The Journal of Arthroplasty Vol. 20 No. 7 2005
Immediate Cementless Total Hip Arthroplasty for the Treatment of Active Tuberculosis Taek Rim Yoon, MD, Sung Man Rowe, MD, Setyagung Budi Santosa, MD, Sung Taek Jung, MD, and Jong Keun Seon, MD
Abstract: We report the results of a primary total hip arthroplasty (THA) in 7 patients with advanced active tuberculous arthritis of the hip and had lost the chance of preserving the hip without replacement surgery. Tuberculosis was confirmed in all cases by the culture or histological examination. All patients were treated with primary THA followed by antituberculous medications for 1 year. Cementless stems and sockets were used in all patients. The average follow-up period was 4.8 years. The reactivation of the infection was not detected in all cases. The result was excellent in all patients according to the Harris Hip Score. Total hip arthroplasty in the tuberculous hip is a safe procedure and produces superior functional results compared with resection arthroplasty or arthrodesis. The results of primary THA in the selected patients was satisfactory as they rapidly recover from the disease. Key words: active tuberculosis of the hip, total hip arthroplasty. n 2005 Elsevier Inc. All rights reserved.
patient with current infection or wait until the infection treatment is completed [1,2,5-8,10-12]. A few cases of THA in patients with active tuberculosis have been reported. Kim et al [6-8] reported several successful Charnley low friction arthroplasties in patients with tuberculosis of the hip, including 8 cases with active disease. This paper presents a review of 7 cases of active advanced tuberculosis of the hip treated by immediate THA. The details of the patients’ history and clinical results are described.
Tuberculosis of the hip constitutes approximately 15% of all cases of osteoarticular tuberculosis. Progressive hip destruction occurs if patients are untreated [1,2]. Treatment must be instituted early with the aim of salvaging the hip. If the disease is diagnosed after considerable bone destruction, surgical treatment such as resection arthroplasty, arthrodesis, or arthroplasty is required [3-10]. Resection arthroplasty or arthrodesis may relieve the pain and control infection, but function of the hip is unsatisfactory. Total hip arthroplasty (THA) has been well established as a successful form of treatment, but it is unclear whether THA should be performed in a
Patients and Methods Seven patients with advanced active tuberculous of the hip treated by THA were analyzed retrospectively. At the diagnosis, their mean age was 46.4 years ranging from 23 to 58. Two (29%) of the patients were males, and 5 (71%) of the patients had involvement of the left hip. Two patients had associated pulmonary tuberculosis, and 1 patient had spine tuberculosis. One patient had hypertension (Table 1). For the management of active tuberculosis of the hips, all patients underwent primarily THA
From the Department of Orthopaedic Surgery and Research Institute of Medical Science, Chonnam National University Hospital, Gwangju, South Korea. Submitted June 30, 2003; accepted August 20, 2004. No benefits or funds were received in support of the study. Reprint requests: Taek Rim Yoon, MD, Department of Orthopaedic Surgery, Chonnam University Hospital, 8 Hak Dong, Gwangju, 501-757, South Korea. n 2005 Elsevier Inc. All rights reserved. 0883-5403/04/1906-0004$30.00/0 doi:10.1016/j.arth.2004.08.002
90 40 No 9 Positive No growth
T11-12 debridementcurettage and bone graft. Primary THA Primary THA Not done 1 (after THA)
97 98 93 45 39 31 No No No 7 2 2 Positive Positive Positive M. tuberculosa M. tuberculosa No growth Not done 5 (after THA) Not done 4 (after THA) Not done 8 (after THA) Primary THA
Not done Not done Not done
96 97 39 35 No No 2 4 Positive Positive M. tuberculosa M. tuberculosa Not done 5 (after THA) Not done 1 (after THA) Primary THA Primary THA
Not done Not done
96 30 No 2 Positive M. tuberculosa Not done 4 (after THA) Positive
followed by postoperative antituberculous medication for 1 year. To prevent additional infection, cephalosporins were given before surgery as well as postoperatively to all patients for 5 days. Patients were treated daily with the following antituberculous medications: isoniazid (5 mg/kg), rifampicin (10 mg/kg), ethambutol (15 mg/kg), and pyrazinamide (20 mg/kg). The mean follow-up duration after THA was 4.8 years ranging from 2 to 9 years. Immediate cementless THA was considered for patients with serious disability of the hip joint because of pain or limited motion of the involved hip, or both. Inflammatory tissues and caseous materials were confined within the joint in all cases. Patients with sinus tract into the pelvis or thigh may not be a contraindication of primary THA for tuberculosis of hip, but we chose resection arthroplasty with a 2-stage operation because of the possibility of tuberculosis reactivation in the case of incomplete debridement. The inflamed soft tissues and the destroyed bones were completely curetted out at the time of the operation. Total hip arthroplasty was performed using cementless press fit fixation of the stem and the socket (Fig. 1). Out of 7 patients, Wagner conical stems (Centerpulse, Barr, Switzerland) were used in 5 cases, the CLS (Centerpulse) in 1 case, and the Anatomique Benoist Girard (Howmedica, Europe) in 1 case. Regarding the type of socket and the bearing articulation, Armor socket (Centerpulse) with the metal on metal articulation was used in 6 cases and the Anatomique Benoist Girard socket with the metal on polyethylene bearing was used in 1 case. Additional screw fixation of socket was performed in 4 cases. The average size of the socket was 55 mm ranging from 52 to 60. An additional adductor tenotomy was performed in 2 patients. The sputum examination was positive in 1 of the 2 cases with associated pulmonary tuberculosis. The histological preparations of the resected tissue were stained with hematoxylin and eosin, and Ziehl-Neelsen stain to obtain evidence of a caseating granuloma and acid-fast bacilli. In all cases, the diagnosis was confirmed by a histological examination.
F F F 4 5 6
58 36 55
M F 2 3
Age at Case Sex diagnosis
Pulmonary TB DM Pulmonary TB Hypertension None Spondylitis tbc T11-12
HHS Length of ESR normal Culture after follow-up (mo) Aspiration THA Histology (y) Reactivation Preoperative Postoperative Before THA
Concurrent medical problem
Table 1. Summary of the Treatment
924 The Journal of Arthroplasty Vol. 20 No. 7 October 2005
The mean Harris Hip Score (HHS) was 37 preoperatively ranging from 30 to 45 and at 94.9 at the last follow-up ranging from 89 to 98. The erythrocyte sedimentation rate became normal below 15 mm/h 4 months after THA ranging
THA in Active Tuberculous of the Hip ! Yoon et al 925
Fig. 1. (A) A preoperative radiograph of a 51-year-old woman with tuberculosis of the hip revealing bony destruction with a narrowing of the joint space. (B) A postoperative radiograph. (C) Nine years after surgery, bone ingrowth into the stem and mild stress shielding were observed in Gruen zones 1 and 7.
from 1 to 8 months. The C-reactive protein was normal below 0.5 mg/dL after 3 months ranging from 1 to 6 months. Within the average follow-up of 4.8 years, reactivation of tuberculosis was not detected. We assessed the stability of the femoral prosthesis by the Engh and Bobyn classification . All 7 patients revealed stability by bone ingrowth on both the socket and femoral stem. Heterotopic ossification greater than grade I according to Brooker et al  was not detected. No patient demonstrated postoperative dislocation, neurological, or vascular complications. At the last follow-up, all patients ambulated without walking aids.
Discussion Total hip arthroplasty in a hip with current tuberculous infection is a controversial issue due to the potential risk of reactivation of tuberculosis. Charnley advised against it because he believed the risks were too high . Some authors also recommended a long interval between the treatment of the active infection and arthroplasty [2,5,12,16]. Kim et al  and Jupiter et al  reported a lower reactivation rate when THA was performed 10 years after the tuberculosis treatment. They suggested that if the interval between the active infection and the surgery is shorter than 10 years, preoperative antibiotic therapy should be given for
at least 3 months, followed by 18 months of postoperative treatment, if there is persistent histological evidence of active disease. In contrast, Johnson et al  emphasized that the length of time of the inactive infection should not be a decisive factor and that there may always be the risk of tuberculosis reactivation. In all cases that we studied, the patients were successfully treated with primary THA and antituberculous chemotherapy. The infection was limited to the hip joint without sinus tract formation into the pelvis or deep into the thigh. The infected tissues could be curetted out or debrided effectively to eradicate the disease. Postoperative antituberculous chemotherapy was used to control the residual foci [5,17,18]. Tuberculous reactivation was not affected by the use of cemented prosthesis or cementless prosthesis. Kim et al  reported that the prevalence of reactivation of infection in the hips with the cemented prosthesis is comparable with the cementless prosthesis, which indicates that the thermal reaction from the cement is irrelevant to the reactivation. In our study, the tuberculous reactivation in patients with the uncemented implants was not detected. Kim et al [6-8] reported that although THA in the infected hips relieves the pain and improves walking ability, the improvement of the range of motion was modest. By applying the Charnley hip rating system, they reported that THA increased the mean
926 The Journal of Arthroplasty Vol. 20 No. 7 October 2005 score from 7.1 to 13 in 20 hips previously infected with tuberculosis. Jupiter et al  reported that THA increased the mean HHS from 57 to 91, showing 5 excellent and 2 good results. Eskola et al  reported an improvement in the mean flexion arc of the hip from 408 (range 08-908) to 868 (range 558-1208). They reported 15 good or excellent results, 2 fair, and 1 poor result in a patient with a subsequent deep infection that was treated with resection arthroplasty. Primary THA was suitable for treating advanced active tuberculosis of the hip in our series. During the operation, the destroyed bone was completely curetted out and although there were many small cavitary defects in the acetabulum, the bone graft was not performed to lessen the possibility of the reactivation. The radiological examination during the follow-up showed the healing of the defects with the formation of a new bone. The level of functional activity improved because they were treated directly by the primary THA. Early functional recovery was possible and the HHS was satisfactory. We believe that THA in advanced active tuberculosis of the hip is a safe procedure providing symptomatic relief and functional improvement. Patients with infected sinus tracts extended into the pelvis or deep into the thigh may not be a good indication for immediate THA because the reactivation may occur if the infected tissues cannot be completely debrided. In such cases, 2-stage operation may be preferable. Cement spacer may be used for facilitation of the second-stage operation. However, the use of antituberculous drugs with bone cement is not well established.
Acknowledgment No benefits in any form have been received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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