Journal of Clinical Orthopaedics and Trauma 17 (2021) 214e217

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Journal of Clinical Orthopaedics and Trauma

journal homepage: www.elsevier.com/locate/jcot

Total hip arthroplasty in tubercular arthritis of the hip e Surgical

challenges and choice of implants
Deepak Gautam a, Vijay K. Jain b, *, Karthikeyan P. Iyengar c, Raju Vaishya d,
Rajesh Malhotra a
a
Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
b
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
c
Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
d
Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, 110076, New Delhi, India

a r t i c l e i n f o a b s t r a c t

Article history: Osteoarticular tuberculosis of the hip joint can be a debilitating disease that can result in severe cartilage
Received 18 January 2021 degeneration, destruction, and eventual painful arthritis of the hip. Usually, a secondary affliction to a
Received in revised form primary lung disease, Tuberculosis (TB) of the hip can be difficult to diagnose due to its indolent natural
20 March 2021
history and deep-seated nature of the hip joint itself. Untreated, ultimately TB hip leads to disabling
Accepted 22 March 2021
arthritis of the hip with limitation of activities of daily living, livelihood, and socio-economic conse-
Available online 28 March 2021
quences. Historic surgical options such as arthrodesis and excision arthroplasty of TB hip have limitations
and several disadvantages. Total hip arthroplasty (THA) is a viable option to restore mobility and relieve
Keywords:
Tuberculosis
pain in patients with severe post-tuberculous arthritis but has been controversial in the past due to the
Hip concerns of disease reactivation. We evaluate the current role of THA in TB of the hip, its various ap-
Arthritis plications in different presenting scenarios with a guide to surgical tips and tricks for managing this
Arthroplasty challenging condition.
Implant © 2021 Delhi Orthopedic Association. All rights reserved.
Cementless
Active disease
Healed disease
Staged surgery
Antitubercular treatment

1. Introduction Tubercular infection of the hip joint constitutes about 15e20% of

all bone and joint TB.3 The disease is secondary to a primary
Hip is the most common site for osteoarticular tuberculosis (TB) infection in the lung. TB affliction of the hip joint undergoes various
after the spine. The cases are not only restricted to endemic regions stages of pathological changes before it complicates to severe
but also present sporadically in other countries where TB is not so arthritis leading to pain and limitation of the activity.4,5 The
prevalent causing a high socioeconomic burden on the population. cornerstone of treatment of TB disease per se is Antitubercular
Osteo-articular TB affects about 2e3% of all such patients every year.1 therapy (ATT). An early diagnosis and the treatment in the initial
Despite advances in research technologies, osteoarticular tubercu- stage with ATT can prevent future complications of advanced
losis is often difficult to diagnose and manage as it is paucibacillary, arthritis. Misdiagnosed, undiagnosed and improperly treated cases
deep-seated infection which is prone to drug resistance and lacks lead to advanced arthritis with or without gross destruction of
definite endpoint of treatment.1,2 Hence delay in diagnosis and femoral head and acetabulum. Left untreated, this may result in
treatment, especially in the weight-bearing joints frequently leads to significant shortening, deformity, instability including subluxation
arthritis and subsequent deformity even after adequate treatment. or dislocation, fibrous ankylosis or osseous ankylosis, sinus for-
mation, and osteopenia.1,3,5
Historically, excision arthroplasty as well as arthrodesis have
* Corresponding author. been described as the modalities of treatment for advanced
E-mail addresses: cmcdeepak@yahoo.com (D. Gautam), drvijayortho@gmail.com arthritis following tuberculosis of hip; however, each method has
(V.K. Jain), kartikp31@hotmail.com (K.P. Iyengar), raju.vaishya@gmail.com its own limitations. In excision arthroplasty, removal of the
(R. Vaishya), rmalhotra62@hotmail.com (R. Malhotra).

https://doi.org/10.1016/j.jcot.2021.03.018
0976-5662/© 2021 Delhi Orthopedic Association. All rights reserved.
D. Gautam, V.K. Jain, K.P. Iyengar et al. Journal of Clinical Orthopaedics and Trauma 17 (2021) 214e217

diseased head resulted in removal of infection and control of pain underwent THA for tubercular arthritis of the hip.18 These patients
but leads to instability of the joint, shortening, and huge dissatis- underwent surgery at the range of 2e6 years of completion of ATT.
faction to the patient. The arthrodesis on the other hand provides THA was performed under the ATT coverage of one week before
pain relief and improves quality of patient’s life compromised due surgery and continued for 6 months postoperatively. There were no
to advanced arthritis but at the cost of loss of motion at the hip, implant-related complications, however, two patients developed
abnormal gait and marked shortening. These patients go on to recrudescence of tuberculosis which were treated with ATT only.18
develop degenerative arthritis of the spine, ipsilateral knee and It is suggested immunocompromised patients with Human Im-
contralateral hip as well adding to morbidity. munodeficiency Virus (HIV) and advanced tubercular arthritis
Total hip arthroplasty (THA) has emerged as a viable option for should be considered for antiretroviral therapy along with ATT
healed cases of tuberculosis providing good functional outcomes before undergoing THA.
with restored biomechanics. In addition, THA provides both sta-
bility and mobility along with pain relief. Liu et al.6 compared 1.3. Choice of implants and fixation techniques for total hip
methods of treatment in TB hip. Authors concluded that arthro- arthroplasty in tuberculosis of the hip joint patients
plasty is superior to hip arthrodesis (HA) in the treatment of TB hip.
They found less operative time and blood loss in the arthrodesis The choice of implants depends on the age, bone quality, and/or
group, but the pain scores and clinical and functional score were bone defect as the consequence of tubercular infection. There is no
better in the THA group as compared to the HA group. When stable established fact to suggest that any implant choice is a responsible
hip arthroplasty is done early in active tuberculosis, ambulation factor for the reactivation of disease. We as authors, prefer a
and weight-bearing improve periarticular osteopenia which cemented hip arthroplasty in the elderly patient and cementless
developed preoperatively due to reduced ambulatory activities.7 total hip arthroplasty in younger patients. However, patients with
Despite a good outcome, these patients are, however, not im- late presentation and bone defects in the acetabulum or proximal
mune to complications. Although, the spinal instrumentation in femur may require modular implants. From our own experience of
Pott’s spine has shown that reactivation of TB disease does not treating many patients in the endemic region, we recommend the
occur as the tubercular bacilli rarely adhere to the metal surface or following implants and fixation techniques as a guide in a different
form biofilm-like the pyogenic infections, there are reports of scenario of patients presenting with TB Hip pathology in Table 1.
reactivation of tubercular infection after the THA.8 Currently available literature shows good results with cement-
This article aims to discuss the role of THA in different clinical less total hip arthroplasty in tubercular arthritis of the hip.18e22 The
scenarios of TB hip. We explore choice of implants with suggestions authors have no preference on the choice of articulation; however,
including surgical tips and pearls for managing this challenging we prefer a ceramic-on-ceramic articulation in younger patients
condition. and ceramic on polyethylene for elderly patients (Fig. 1 A & B).

1.1. THA in active tubercular disease of the hip 1.4. Two stage vs single stage THA in TB hip- rationale

The role and success of THA in active cases of tuberculosis is There has been a paradigm shift in performing THA from a
controversial. There are few studies supporting THA under ATT staged procedure to a single setting. Single-stage procedure under
cover in patients with good immunity status but the control of ATT coverage has proven safe and effective in most of the cases.7
infection and retention of implant in a structurally weak and Staged procedure is reserved for cases of advanced active disease
diseased bone is a matter of concern.9e12 The Antitubercular ther- with discharging sinus or in case of the extensive disease not
apy should be started preoperatively and continued in the post- amenable to a single stage procedure.13 Li et al.23 reported good
operative period till completion of course.13 There is no consensus outcome with two-stage THA in 9 patients where each patient
on the duration of ATT prior to surgery. Kim et al.14 and Sidhu et al.15 underwent removal of the abscess and joint debridement after
agree on the safety of three months ATT before the surgery. There initial antitubercular antibiotics of two weeks. The patients were
have also been reports suggesting at least 2 weeks of ATT before the followed to an average of 4.2 months. During the second stage, THA
surgery.9 One of the long-term follow-up studies by Bhosale et al. was undertaken with monitoring of wound healing and serum
advocate 3e6 months of preoperative and 9e18 months post- markers viz. Erythrocyte Sedimentation Rate (ESR) and the C-
operative ATT therapy for patients undergoing THA in active Reactive Protein (CRP). The ATT was continued for another 6e9
advanced tuberculosis.7 The authors believe that effective pre- months postoperatively.
operative ATT followed by THA should be undertaken according
to the clinical presentation and radiological advancement of the 1.5. THA in previous girdle stone arthroplasty, ankylosed hip, or
disease. Accordingly, an elderly patient with disabling tuberculosis conversion arthroplasty of a previous hip arthrodesis
of the hip with radiological signs of arthritis can be operated on
early after a minimum of two weeks of ATT. The authors prefer a Tubercular infection of the hip usually heals by fibrous anky-
cemented hip arthroplasty in such cases. It is suggested patients losis; however, a long-standing treated case may present with bony
with mild to moderate clinical severity and younger age group can ankylosis. Historically performed girdle stone arthroplasty or hip
undergo THA later after completing at least three months of ATT. arthrodesis are being replaced these days to give a mobile and
stable hip as per the patient’s increased expectations. The technical
1.2. THA in healed tubercular disease of the hip challenge in converting a girdle stone arthroplasty to THA lies in the
search of the native acetabulum as it is filled with fibrous tissues as
THA has been observed to be safe in healed cases of tuberculosis well as significant over riding of femur. On the other hand, in the
and there are gradually increasing global reports that metal im- case of a stiff hip with fibrous ankylosis, the loss of movement may
plants can be safely used in tuberculous lesions. THA is indicated hinder in dislocation of the hip intraoperatively. An arthrodesis of
when the patient develops painful disabling end-stage arthritis the hip or bony ankylosis poses a different test due to previous
and/or ankylosis of the hip secondary to infection.16,17 hardware (if any), loss of normal anatomical structures, difficulty in
Excellent outcomes without any recurrence of infection have locating the acetabular boundaries, and hence a challenge for
been reported at an average follow up of 8.3 years in patients who proper cup placement.24 In addition, previous surgical scar, atrophy
215
D. Gautam, V.K. Jain, K.P. Iyengar et al. Journal of Clinical Orthopaedics and Trauma 17 (2021) 214e217

Table 1
Authors recommendations on the use of orthopaedic implant and fixation techniques for Total Hip Arthroplasty in Tuberculosis of the hip joint.

Tuberculosis of the hip with associated scenario Author’s recommendation on the type of implants and fixation technique

1 Poor bone quality (elderly) Conventional Cemented total hip arthroplasty

2 Good bone quality (younger patient) Conventional Cementless total hip arthroplasty
3 Sclerotic acetabular margin Modern porous coated metal cups
4 Acetabular defect with adequate head preserved Bone Grafting with resected head and modern porous coated metal cup
5 Acetabular defect with loss of femoral head Trabecular metal shell with Trabecular metal augments as and when required
6 Preserved neck in a younger patient Neck preserving stems and/or short tapered wedge stems
7 Loss of femoral head but preserved calcar Modular stem prosthesis
8 Subluxation or dislocation of the femoral head Modular stem prosthesis and dual mobility cup at the native acetabulum
9 High up ridden and/or deformed femur Modular stem prosthesis with or without subtrochanteric osteotomy
10 Childhood disease and late presentation with the narrow femoral canal Modular stem prosthesis with or without subtrochanteric osteotomy

adequately before internally rotating the femur to prevent inad-

vertent femoral fracture intraoperatively. Often a complete capsular
release may suffice to correct the deformity, but it may warrant an
adductor tenotomy to gain the abduction movement as well as limb
length equalization. Cases of severe flexion contracture may require
a psoas tenotomy as well. Rarely the cases with hip stiff in extension
and abduction with external rotation will require modified Z-plasty
of the Iliotibial band.

1.7. Treatment of recrudescence of infection after total hip

arthroplasty in TB hip

Fig. 1. Radiograph of pelvis with both hips in Anteroposterior view showing post- It is not uncommon to have reactivation of tubercular infection
tubercular arthritis of right hip in a 24-year-old patient. The patient underwent following total hip arthroplasty. Recrudescence is common espe-
cementless total hip arthroplasty with modern porous metal cup and short femoral
cially in immunocompromised patients and patients with associ-
neck preserving stem and Ceramic on Ceramic articulation (A) Post-operative follow
up radiograph of pelvis with both hips showing stable total hip arthroplasty prosthesis
ated inflammatory disease. The disease has been reported to recur
in situ at 4 years follow up (B). or have recrudescence in patients taking biologicals for the in-
flammatory disorder.25 The disease may also recur in non-
compliant cases where the patient deliberately discontinues ATT
of the abductors, the proximity of sciatic nerve, and loss of proximal before completing its course. In all the cases re-institution for a
femoral anatomy add to the difficulty in the safe execution of total complete course of ATT and patient counseling remains the main-
hip arthroplasty and providing a stable hip at the end. stay of treatment. There has been reporting of successful treatment
of recrudescence of tuberculosis with ATT only without the need of
1.5.1. Strategies in such scenarios that can be considered any surgical intervention.26
Any previous hardware warrants a partial or complete removal Bhosale et al.7 have reported 7 cases (3.6%) (2 cemented, 5
depending on the implant chosen. An in-situ femoral neck osteot- cementless) of aseptic loosening in THA undertaken for active TB.
omy remains a technical tip in all such cases. It is advisable to keep These do not appear to be related to underlying tuberculosis pa-
the limb in extension with the knee flexed to keep the sciatic nerve thology. These patients were managed by removal of the implant/s,
away from the field of acetabular preparation. The abductors need extended trochanteric osteotomy, and use of Wagner stem in
to be protected with a retractor while performing the femoral cementless stem and CPT long stem in cemented stem loosening.
preparation. There is always a risk of avulsion of greater trochanter Authors mention the need of obtaining tissue samples from 5
so one should be precautious especially when hardware is removed different sites from the hip joint, including acetabulum, femoral
from the proximal femur. The authors prefer a modern porous- canal, and inferior part of the acetabulum, and evaluating them for
coated acetabular shell in such cases unless the stability is an bacteriological, histopathological culture and Polymerase Chain
issue due to abductors where the choice of implant would be a dual reaction (PCR) tests to rule out aseptic loosening due to tubercular
mobility cup. A modular stem prosthesis serves an option for reactivation.
addressing issues related to stability as well as metaphysio-
diaphyseal mismatch in cases of childhood tuberculosis where 2. Tips and surgical pearls in performing THA in TB hip
the patient presents with a narrow femoral canal. The limb length
discrepancy is always an issue that can be addressed only to an 2.1. Preoperative planning
extent where the sciatic nerve is not compromised. The patient
needs to be counseled regarding the same pre-operatively. Majority of the cases of post-tubercular arthritis fall under the
category of complex primary total hip arthroplasty as they invari-
1.6. Total hip arthroplasty in patients with severe deformity ably present with deformity. As a rule of thumb, all such cases
should also be treated like septic sequelae because of infective
In endemic countries, it is not uncommon for the patient to pathology. Inflammatory markers for infection viz. ESR and CRP
present with severe deformity. Usually, advanced tubercular should be done in all patients prior to surgery to rule out any re-
arthritis presents with a deformity of flexion, adduction, and in- sidual infection. Routine radiographs are sufficient for operative
ternal rotation. The soft tissue releases during the surgery need to planning in cases with no bone defect whereas a Computed
be titrated accordingly. While performing the THA via a posterior Tomogram (CT) may be required when the bone loss is to be located
approach, the gluteus maximus attachment should be released and quantified precisely for the need of additional implants.
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D. Gautam, V.K. Jain, K.P. Iyengar et al. Journal of Clinical Orthopaedics and Trauma 17 (2021) 214e217

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