Abstract
Background
Total hip arthroplasty (THA) is a well-established procedure to cure tubercular hip arthritis in patients with healed tuberculosis while its role in active tuberculosis is still debatable. The aim of the study is to investigate the functional outcomes of THA in active tuberculosis with advanced hip arthritis. The reactivation of tuberculosis and complications postoperatively has also been assessed.
Materials and methods
The current open-ended prospective cohort study was carried out at a tertiary center from 2018 to 2020. Twenty patients of active tubercular hip arthritis (8 females and 12 males) were taken with a follow-up period ranging from 1 year to 3 years, with a mean of 14 months.
Biochemical investigations were done both preoperatively and postoperatively. Preoperative anti-tubercular therapy (ATT) regimen was administered, as per standard norms, to patients for a minimum period of 6 weeks, and postoperatively for 6 months–12 months. Postero-lateral and Hardinge approaches were employed in all cases. Clinical and radiological parameters were assessed and functional outcomes were evaluated using the Harris Hip score (HHS).
Results
The mean age of patients was 37.6 ± 11.38 years. Biochemical parameters were also found to improve postoperatively (p < 0.0001). The mean flexion, extension, abduction, external and internal rotation were found to increase postoperatively (p < 0.001). The mean flexion deformity in the preoperative period was 12.35 ± 4.716, whereas none of the patients had flexion deformities post operatively. The mean shortening was 2.12 ± 0.60 and 1 ± 0 at preoperative and postoperative respectively. The Total hip arthroplasty implant was found stable in all patients. The mean Harris score increased subsequently throughout the follow-up interval and differences were statistically significant (p < 0.0001). None of the patients had reactivation of tuberculosis infection postoperatively.
Conclusion
Total hip arthroplasty is a reliable option to treat active advanced tubercular hip arthritis and gives good functional outcome with proper preoperative and postoperative ATT regimen.
Keywords: Total hip arthroplasty, Tubercular hip arthritis, Anti-tubercular therapy (ATT), Active tuberculosis
1. Introduction
Tuberculosis, a troublesome disease, has re-emerged as a significant medical concern in the whole world. Globally, an estimated 30 million people are affected with tuberculosis and approximately 1–3% of tuberculosis is associated with the musculoskeletal system.1 In India, it accounts for 1/4th of all patients in the world.2 Hip tuberculosis comprises about 15% of osteoarticular tuberculosis which is the second most prevalent affected bone site.3,4 Most of the patients in developing countries usually have advanced stage tuberculosis and many of them are young. It results in dreadful destruction of bone and cartilage, degeneration of hip eventually leading to painful osteoarthritis of the hip. Treatment of osteoarticular tuberculosis is difficult and technically challenging when initial diagnosis and treatment of tuberculosis is missed.5 Patients with advanced arthritis show different types of radiological appearances. These appearances have been described by Shanmugasundaram, and include travelling/wandering acetabulum, dislocated hip, Perthes type, protrusioacetabuli type, atrophic type and mortar and pestle type.6
Surgical options for patients with tuberculosis induced hip arthritis are arthrodesis, excision arthroplasty and total hip arthroplasty. Usually, excision arthroplasty and arthrodesis are employed to circumvent the pain and infection but the functional outcome of hip is unsatisfactory.3,7 Total hip arthroplasty (THA) is also considered for patients with quiescent tuberculosis.1,8 Studies have shown that THA is a safe treatment option for the tuberculosis of the hip after a complete course of preoperative anti-tuberculosis chemotherapy which requires skillful technical experience.9,10 The treatment of active tuberculosis by THA is a controversial issue owing to the risk of re-infection of tuberculosis. Other issues including preoperative anti-tubercular therapy regimen, surgical time, long-term survival of prosthesis and high complication rate are associated concerns with THA.11in the last few decades the outcomes of THA in active advanced tuberculosis have been promising with preoperative ATT regimen.6,9,12 Hence, the purpose of the current study is to assess the functional outcomes of THA in active tuberculosis with advanced hip arthritis to build evidence globally. Additionally, we also assessed the reactivation of tuberculosis and complications postoperatively.
2. Materials and Methods
The current open ended prospective cohort study was carried out at the tertiary center from July 2018 to July 2020 with a follow up period ranging from 1 year to 3 years, with a mean follow up period of 14 months. Ethical clearance was obtained (97THECM II B- Thesis/P8) from the institutional ethical review board from the university. All patients were carefully observed in the outpatient department. After considering history and clinical examination, all patients were subjected to X-ray chest-PA view, pelvic X-ray of both hips - AP and lateral views and MRI of the involved hip. Patients were classified according to Shanmugasundaram classification.6 "Inclusion criteria of patients were as follows: tubercular arthritis hip with advanced stage - Stage III and IV; Anti tubercular therapy intake for a minimum period of 6 weeks.
Exclusion criteria of patients were as follows: active pulmonary tuberculosis, patients who underwent revision surgery or pre-existing weakness."
Biochemical investigations including Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP) were monitored pre- and post-operatively to evaluate the response to treatment. Patients were administered daily Anti-tubercular therapy regimen, taking into consideration the previous drug intake history of the patients. ATT was given preoperatively for a minimum period of 6 weeks and maximum of 10 weeks, following which they were planned and posted for surgery as per surgical fitness. The standard ATT regimen as per national tuberculosis eradication program was used using 4 drugs (Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E)) for 2 months and 3 drugs (HRE) for 4 months which may extent up to 12 months depending on clinico-radiological and biochemical test. Total hip arthroplasty (THA) was carried out using postero-lateral or Hardinge approach in lateral position.
2.1. Surgical technique
Standard posterolateral and Hardinge approaches were performed. All fibrous tissue and necrotic tissue was removed and hemostasis was achieved. Hip joint was then dislocated-anteriorly in Hardinge approach and posteriorly in posterior approach and an oscillating or reciprocating saw was used to perform the femoral neck cut. Care was taken to keep the hip joint in extension and the knee in flexion to protect the sciatic nerve. The bony acetabulum was exposed with cautious placement of Hohmann retractors and bony defects and cavities were looked for. Intra operatively tissue and fluid samples were taken from multiple sites such as capsule, synovium, labrum and bone for histopathological and microbiological examination. Curettage and bone grafting of cavities was done. Acetabulum was prepared using sequential reaming of acetabulum. Following the preparation of acetabulum, the acetabular component was placed. A higher hip center was constructed in case of a wall defect of the acetabulum and a jumbo cup was employed in the wide acetabulum. After acetabulum cup implantation femoral canal preparation was done as per standard procedure. Box osteotome was set in appropriate anteversion followed by sequential broaching of femoral canal. Size of femoral neck and head were appropriately chosen and trial components were placed. Intra operative stability was assessed by shuck test and measuring leg length discrepancy, which were found to be satisfactory. Following assessment, the trial components are removed and replaced by final implant components. Wound was irrigated and hemostasis was achieved. Myo capsular repair was done with reattachment of external rotators. Wound was closed and dressed under sterile precautions. Out of 20 patients, uncemented THA was done in 10 patients (50%), cemented THA was employed for six patients (30%) and hybrid in 4 patients (20%). Intra-operative parameters including blood loss, surgical time, injury associated with sciatic nerve and gluteal artery were analyzed. Patients were followed postoperatively at 6 weeks, 3 and 6 months then on a biyearly basis. The patients were subjected to standard post-operative rehabilitation protocols. Early toe touch walking for 3 weeks, followed by progressive increase in weight bearing with the help of walker up to 6 weeks followed by full weight bearing with the help of walking stick/walker till 3 months, followed by independent walking. Post-operative clinical outcomes including pain over hip, complaints of difficulty or inability to use lower limb, hip deformity and range of motion were evaluated. Radiological outcomes were evaluated by using pelvic X-ray of both hips – AP and involved hip lateral view to observe position and version of acetabulum and femoral component as well as the radiolucency, osteolysis and implant loosening. Functional outcome was measured by using Harris hip score. Additionally, postoperative complications like infection, discharging sinus, heterotropic ossification were also determined.
2.2. Statistical analysis
Statistical analysis of the study was performed using student t-test, paired t-test, statistical packages for the social sciences version 23 (SPSS), graph pad etc. software.
3. Results
A total of 20 patients were finally analyzed in the current study, 8 were females (40%) and 12 were males (60%). The mean age of the patient was 37.6 ± 11.38 years ranging from 18 to 65 years. The mean preoperative ATT regimen was 7 weeks ranging from 6 to 10 weeks (Table-1). Postoperatively, the ATT was given from 6 to 12 months and patients were followed up at 6 weeks, 12 weeks, and 6 months and then biyearly with a mean follow-up of 14 months. (Table-1). Preoperative MRI scan findings were suggestive of tubercular infection in all patients. The mean preoperative ESR and CRP were measured along with mean postoperative ESR and CRP levels at 6th week, 3rd month, 6th month and 1 year of follow-up as shown in Table-2. The mean ESR and CRP level decreased subsequently throughout the follow-up interval and differences were statistically significant (p < 0.0001) (Table 3). Twelve patients were operated using the postero-lateral approach and 8 patients were operated using the Hardinge approach. The mean operative time was 91.75 ± 16.49 min with an average blood loss of 447.3 ± 74.15 ml. The mean flexion, extension, abduction and rotational movements showed a significant improvement in the post-operative period and the differences were statistically significant. (Table 3, Table 4). Preoperative Lordosis signs were present in 17 patients and Trendelenburg sign was present in 16 patients. The mean flexion deformity in the preoperative period was 12.35 ± 4.716, none of the patients had flexion deformities post operatively. These signs were not reported postoperatively and the related outcome difference between pre and postoperative periods was found to be statistically significant (p < 0.0001). The mean preoperative Harris hip score was 46.75 and improved post operatively and in the subsequent follow up period to 84.05, 89.0, 91.5, 96.5 (Table 3, Table 4 and Fig. 1). Postoperative mean Harris hip score was found to increase subsequently throughout the follow-up interval and differences were statistically significant (p < 0.0001) (Table 4). Out of 20 patients, two patients had a higher hip center while others had a normal hip center. The mean abduction angle of acetabulum was 41° (30-52°) and mean acetabulum version was 21° (10–32° In all the cases, the mean femoral stem version was 12.53° ± 0.81° (11.78°-13.56°) and position was found to be satisfactory (Fig. 1, Fig. 2, Figure-3, Figure-4). The mean shortening (cm) was 2.12 ± 0.60 and 1 ± 0 at preoperative and postoperative follow-ups respectively and the difference was statistically significant. None of the patients developed signs of reactivation of tuberculosis infection after the preoperative and postoperative ATT regimen treatment. Six patients (30%) were found to be cartridge-based nucleic acid amplification test (CBNAAT) positive and 14 patients (70%) were CBNAAT negative. Seven patients (35%) had Granulomatous Pathology Suggestive of Tuberculosis while two patients (10%) had Granuloma with Caseous Necrosis (Fig. 5a,b). However, eleven patients (55%) did not show any evidence of Granuloma on histo-pathological examination. None of the patients showed any evidence of femoral or sciatic nerve injury. One patient developed intraoperative iatrogenic calcar fracture which was managed by cerclage wire.
Table-1.
Assessment of the variables.
| Variables | Frequency | |
|---|---|---|
| 1. | Age | 37.6 ± 11.38 |
| 2. | Gender: | 12 (60%) |
| Male | 8 (40%) | |
| Female | ||
| 3. | Duration of pre-operative Anti-Tubercular Therapy | 6 weeks |
| 4. | Duration of post-operative Anti-Tubercular Therapy | 6 months–12 months |
| 5. | Intraoperative parameters: | 91.75 ± 16.49 min |
| Mean operative time | 447.3 ± 74.15 ml | |
| Mean blood loss | ||
| 6. | Mean follow-up | 14 months |
Table 2.
Laboratory and Functional characteristics of the study population at baseline.
| SN | Statistics | ||
|---|---|---|---|
| 1 | Mean ESR ±SD (Range) mm/hr | 60.95 ± 14.70 (39.0–90.0) | |
| 2 | Mean CRP ±SD (Range) mg/L | 37.90 ± 9.40 (22.0–53.0) | |
| 3 | Mean Harris Hip Score ± SD (Range) | 46.75 ± 13.38 (18.0–67.0) | |
| 4 | Mean Flexion ± SD (Range) | 84.00 ± 12.52 (50.0–100.0) | |
| 5 | Mean Extension ± SD (Range) | 0.0±±0.00 | |
| 6 | Mean Abduction± SD (Range) | 10.50 ± 4.84 (5.0–20.0) | |
| 7 | Mean Adduction± SD (Range) | 10.0 ± 6.28 (0–20) | |
| 8 | Mean Internal Rotation± SD (Range) | 11.50 ± 4.00 (5.0–20.0) | |
| 9 | Mean External Rotation ± SD (Range) | 10.25 ± 3.42 (5.0–15.0) | |
| 10 | Mean Shortening ± SD (Range) | 2.12 ± 0.60 (1.0–3.0) | |
| No. | % | ||
| 11 | Flexion Deformity | 0 | 0.0 (12.35 ± 4.716) |
| 12 | Lordosis | 0 (17 patients) | 0.0 |
Table 3.
Comparison of laboratory parameters at different time intervals (Paired ‘t’-test).
| Parameter | Pre-op vs. 6 weeks | Pre-op vs. 3 months | Pre-op vs. 6 months | Pre-op vs. 12 months | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean Diff. | ‘t’ | ‘p’ | Mean Diff. | ‘t’ | ‘p’ | Mean Diff. | ‘t’ | ‘p’ | Mean Diff. | ‘t’ | ‘p’ | |
| ESR | −34.60 | −10.93 | <0.001 | −41.35 | −13.18 | <0.001 | −47.75 | −14.60 | <0.001 | −49.80 | −14.79 | <0.001 |
| CRP | −33.55 | −16.38 | <0.001 | −35.00 | −16.55 | <0.001 | −35.65 | −9.50 | <0.001 | −35.85 | −17.64 | <0.001 |
Table 4.
Comparison of Harris hip score and range of motion.
| SN | Parameter | Pre-op vs. 6 weeks |
Pre-op vs. 3 months |
Pre-op vs. 6 months |
Pre-op vs. 12 months |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean Diff. | ‘t’ | ‘p’ | Mean Diff. | ‘t’ | ‘p’ | Mean Diff. | ‘t’ | ‘p’ | Mean Diff. | ‘t’ | ‘p’ | ||
| 1 | HHS | 37.30 | 12.27 | <0.001 | 42.25 | 14.29 | <0.001 | 44.75 | 14.75 | <0.001 | 46.00 | 15.66 | <0.001 |
| 2 | Flexion | 14.50 | 4.41 | <0.001 | 21.0 | 28.50 | <0.001 | 24.50 | 5.67 | <0.001 | 26.25 | 6.63 | <0.001 |
| 3 | Abduction | 21.50 | 12.61 | <0.001 | 23.25 | 14.60 | <0.001 | 23.75 | 15.07 | <0.001 | 22.50 | 20.12 | <0.001 |
| 4 | Adduction | 19.75 | 11.49 | <0.001 | 21.25 | 17.32 | <0.001 | 21.75 | 11.48 | <0.001 | 23.00 | 14.78 | <0.001 |
| 5 | Internal Rotation | 0.0 | 0.0 | – | 2.25 | 1.25 | 0.225 | 3.75 | 2.16 | 0.44 | 5.50 | 3.17 | 0.005 |
| 6 | External Rotation | −3.55 | −3.96 | 0.001 | 15.50 | 8.93 | <0.001 | 17.25 | 10.78 | <0.001 | 18.50 | 11.67 | <0.001 |
Fig. 1.
a: Preoperative X-ray of Tubercular hip arthritis, b: Immediate postoperative X-ray of THA, c: Postoperative X-ray of THA at 6 months, d: Postoperative X-ray of THA at 24 months, e: Functional Outcome.
Fig. 2.
a: Preoperative X-ray of Tubercular hip arthritis, b: Immediate postoperative X-ray of THA, c: Postoperative X-ray of THA at 6 months, d: Postoperative X-ray of THA at 24 months, e: Functional Outcome.
Figure-3.
a: Preoperative X-ray of Tubercular hip arthritis, b: Immediate postoperative X-ray of THA, c: Postoperative X-ray of THA at 6 months, d: Postoperative X-ray of THA at 18 months, e: Functional Outcome.
Figure-4.
a: Preoperative X-ray of Tubercular hip arthritis, b: Immediate postoperative X-ray of THA, c: Postoperative X-ray of THA at 18 months, d: Functional Outcome.
Fig. 5.
a: histological image showing necrosis, b: histolological image showing multinucleated giant cells along with epitheloid cells.
4. Discussion
The management of active tuberculosis of hip earlier was predominantly carried out by debridement; Girdlestone excision arthroplasty and arthrodesis in combination with ATT regimen.1,3,13 THA has proven to be a good option to treat post tubercular arthritis of the hips.14,15 Total hip arthroplasty in cases of tuberculosis is challenging and difficult due to joint deformities and contractures leading to disturbed normal anatomy and may hinder adequate surgical exposure and increase risk of bleeding. The bone deformities and cavitary defects, including wandering acetabulum/false acetabulum along with juxta-articular osteoporosis lead to difficult acetabular reconstruction. Accumulating evidence has shown that the re-emergence of tuberculosis infection is a major concern in patients with treatment of post tubercular arthritis of the hip.14,16,17 Use of arthrodesis is infrequent now after the emergence of advanced chemotherapy and it is no longer used in Asia-pacific region.3Girdlestone excision arthroplasty removes the infected tissue thereby providing mobile hip without pain however significant decrease in limb length and instability persist.3,18,19 Several lines of evidence state that though quiescent tuberculosis gets treated successfully by THA but the time period required for complete resolution is very long ranging from 10 to 20 years.8,14,20 Such a long time disturbs the professional and personal lives of the patients. Hertz et al. demonstrated that prevalence of tuberculosis more frequently occurs in male as compared to females.21 A study led by Sidhu et al. found that males (73.9%) were more affected with tubercular hip arthritis.22 Kumar et al. studied that males (69.23%) were more prone to tubercular induced hip arthritis.11 In our study also males (60%) were found to be affected more in comparison to females. Biochemical markers are a part of preliminary examination that defines the health status of the patients. According to the study by Sidhu et al. the preoperative mean ESR and CRP were found to be 69 mm/h (26–88 mm/h) and 37.9 ± 9.407 respectively.22 This study also reported the decline in the ESR and CRP levels. The mean ESR level (mm/hr) at Pre-op, 6th week, 3rd month, 6th month, and 12 months of follow-up were 60.95, 26.35, 19.6, 13.20, and 11.15 respectively. The mean ESR levels decreased throughout the follow-up interval and differences were significant statistically.
Similarly, the mean CRP level (mg/L) at Pre-op, 6th week, 3rd month, 6th month, 12 months of follow-up were 37.9, 4.35, 2.9, 2.25, and 2.05 respectively. The mean CRP level decreased subsequently throughout the follow-up interval and differences were significant statistically (p < 0.0001*). Li et al. reported a rise in the ESR and CRP levels which decreased after THA with a mean duration of 3.3 and 1.6 months respectively.23 In this study, we also observed a decrease in the levels of biochemical markers postoperatively which was statistically significant. The ATT regimen is very important to control tuberculosis infection. Several articles have employed the preoperative ATT regimen either for 3 weeks or for more than one year prior to THA surgery.10,20 In our study, patients were given ATT regimen preoperatively for a minimum of 6 weeks prior to THA because six weeks are required to evade the bacteria in intensive phase and predict less recurrence. In this study, MRI findings of all cases were suggestive of Tubercular pathology. A recent study also reported that tuberculosis infection on MRI is correlated with biochemical markers (ESR and CRP) in active tuberculosis hip arthritis.23 Several previous studies have employed the postero-lateral approach for THA in tubercular hip arthritis.9, 10, 11 In this study, the Postero-lateral and Hardinge approaches were employed as the surgical teams had expertise in both approaches. The surgeonstook advantage of the Hardinge approach to release tight anterior capsular structure. Several articles on tubercular hip arthritis treated with THA show that postoperative ATT regimen can be used from 6 to 12 months.12, 16, 24, 25 In this study, all patients received preoperative ATT for 6 weeks and postoperative ATT for 6–12 months depending upon the levels of biochemical markers. A retrospective study conducted by Neogi et al. reported an improvement in range of motion in the flexion-extension plane from 35° (preoperative) to 108° (postoperative).9 A recent study by Chanet al. found that the flexion-extension range of motion was 93.6° + 12.1°.26 They reported that ROM was significantly improved after THA in contrast to the range of motion in preoperative period of 38.2° + 10.5°. In our study, we also observed an increase in flexion-extension range of motionfrom 85° pre-operatively to 108° postoperatively 12 months follow-up. A study led by Chan et al. and Morsi et al. showed improvement in mean external rotation at hip.26, 27 In our study, we also observed an improvement in external rotation from 10.25° to 28.75° and internal rotation from 11.5° to 17.0°. Several studies have also shown that none of the patients develop postoperative osteolysis or implant loosening.6, 9, 25 In our study, one patient developed intraoperative iatrogenic fracture at calcar while using uncemented THR, which required fixation using double looped cerclage wire at the level of lesser trochanter. None of the patients developed postoperative osteolysis or implant loosening within the period of follow up. Follow-up period was less in this study so it's early to conclude about implant loosening and osteolysis. One of the studies showed that preoperative and postoperative mean Harris hip score was 38 (27–56) and 91 (86–95) respectively after the THA surgery in patients with tubercular hip arthritis.10 A study performed by Kumar et al. showed that preoperative and postoperative mean Harris hip scores were 27 and 91 respectively.11 In this study, the mean Harris hip score improved in the post operative period. The value at pre-op was 46.75 (poor), which improved at 6th week to 84.05 (good), 3rd month to 89.0 (good), 6th month to 91.5 (excellent) and at 12 months to 96.5 (excellent). The mean Harris hip scores increased subsequently throughout the follow-up interval and the difference was found to be significant (p < 0.0001*)and the mean difference in Harris Hip scores between the pre-operative period and at 6 weeks, 3 months, 6 months, and 12 months showed significant difference and were 37.30, 42.25, 44.75 and 46 respectively (Fig. 1, Fig. 2, Figure-3, Figure-4). Correction of limb length discrepancy (LLD) is very important for patient satisfaction and anticipation. Sidhu et al. reported preoperative average limb length discrepancy of 3.8 cm, ranging from 3 to 5.5 cm, which decreased postoperatively (1.3 cm).22 Morsi et al. showed that mean preoperative LLD was 3.4 cm (1.5–6.5 cm) while mean postoperative LLD was 1.6 cm (2–2.5 cm).27 In this current study, the mean preoperative shortening was 2.12 cm ranging from 1 to 3 cm. Only six patients had shortening of limb length postoperatively. One patient developed superficial infection which was resolved by debridement and a longer period of intravenous antibiotics. None of the patients reported any complication of postoperative Sciatic nerve injury and heterotopic ossification. A meta-analysis conducted by Tiwari et al. reported that tuberculosis infection is confirmed by histo-pathological examination and microbiological examination by using intraoperative tissue samples.28 Another study reported tuberculosis in 28 patients (54 %) followed by suggestive tuberculous lesions in 23 patients (44%) and inconclusive in one patient (2%).29Neogi et al. reported the positive histo-pathologic findings for tuberculosis in the form of typical epithelioid granuloma with/without caseous necrosis in ten patients and poorly formed granuloma in 2 patients.9 In this current study, seven patients (35%) had granulomatous pathology suggestive of Tuberculosis followed by granuloma with caseous necrosis in two patients (10%) while no evidence of granuloma/malignancy infection was found in 11 patients (55%). A study performed at a tertiary center reported positive CBNAAT test in 11 patients (68.75%) while one patient was found to be sensitive to Rifampicin.29 A study conducted by Li et al. reported positive CBNAAT in four patients (44.44%).23 In this current study, a positive CBNAAT test was found in six patients (30%) and all were Rifampicin sensitive while 14 (70%) patients were CBNAAT negative. Re-occurrence of the tuberculosis infection is a major concern after the THA in patients with tubercular induced hip arthritis. A meta-analysis conducted by Tiwari et al. reported that one patient with an uncemented implant and one with hybrid implant developed reactivation of infection after preoperative (2–5 weeks) and postoperative ATT regimen (6–12 months).28 In this current study, none of the patients developed signs of reactivation of tuberculosis infection with 6 weeks of preoperative and 6–12 months of postoperative ATT regimen. As shown in the retrospective study conducted by Arora et al. where 23 patients underwent THA along with ATT, it was found that THA is a viable option and provides mobile, stable hip in tubercular hip arthritis even in active TB hip patients. The authors state that ATT is important in the management and prevention of reactivation of the disease.30 These results were in accordance with the results in our study. In a systematic review, by Viswanathan VK et al., THA was found to be a safe and effective surgical intervention in patients with active and advanced TB arthritis of hip and should be performed under cover of multi-drug anti-tubercular regimen. They found significant improvements in clinical, radiological and functional outcome (as assessed by HHS) after THA in these patients.31, 32 In this study also THA was found to be a very effective solution for tubercular arthritis when done with ATT, resulting in improvement in Harris Hip scores post operatively.
The limitation of the present study is a short follow-up and a small sample size.
5. Conclusion
Total hip arthroplasty is a technically challenging procedure in advanced tubercular arthritis, requiring careful preoperative planning including clinical, laboratory and radiological evaluation with judicial use of anti-tubercular regime to achieve satisfactory results and return to better-quality of life. Future longer prospective studies, multicenter randomized control trials and meta-analysis with larger sample sizes are warranted to further investigate, validate and improve the understanding of the outcomes.
Source(s) of support
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Presentation at a meeting
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Conflicting interest (if present, give more details)
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Contribution details (to be ticked marked as applicable)
Contributor 1; Concepts, Design, Definition of intellectual content, Literature search, Clinical studies, Experimental studies, Data acquisition, Data analysis, Statistical analysis, Manuscript preparation, Manuscript editing, Manuscript review, Guarantor, Contributor 2; Design, Definition of intellectual content, Literature search, Contributor 3; Literature search, Clinical studies, Experimental studies, Contributor 4; Clinical studies, Experimental studies, Data acquisition, Manuscript preparation, Contributor 5; Data acquisition, Data analysis, Statistical analysis, Manuscript preparation, Contributor 6; Definition of intellectual content, Literature search, Clinical studies, Experimental studies, Functional Outcome of Total Hip Arthroplasty in Tubercular Hip Arthritis: A prospective study.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgement
none.
Contributor Information
Narendra Singh Kushwaha, Email: nskortho@gmail.com.
Dharmendra Kumar, Email: dharmendra00715@gmail.com.
Ravindra Kumar Gupta, Email: ravindra.17dr@gmail.com.
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