Total hip arthroplasty for tuberculosis: a case series

Introduction

Tuberculosis (TB) is a significant global medical problem. It is one of the top 10 causes of mortality worldwide and the chief cause of death from a single infectious pathogen. Globally, an estimated 10 million people (range, 9.0–11.1 million) contracted TB in 2018, with an estimated 1.2 million (range, 1.1–1.3 million) TB deaths among HIV-negative people (1). TB of the hip accounts for approximately 10–15% of osteoarthritic TB (2,3), and is second only to the spine for tuberculous involvement sites (4). With a timely diagnosis and regular treatment using first-line antibiotics, most TB patients can be cured. However, without early diagnosis, advanced stage TB can lead to joint destruction, and management of the disease can become technically demanding (5-8).

Besides the pre- and post-operative anti-tubercular therapy (ATT), the surgical options for advanced tubercular hip include resection arthroplasty, arthrodesis, and total hip replacement (THR). Resection arthroplasty and arthrodesis can provide pain relief and infection control, and adversely abnormal gait, difficulty of conversion to THR. However, resection arthroplasty can result in instability and leg length discrepancy (9-11), and arthrodesis can lead to hip immobility, adjacent joint degeneration, lower back pain, and probable non-union (12).

The demands for quality of life among patients are increasing, especially since many patients are relatively young and have several decades of active life remaining. Thus, they require a painless, stable, and functional hip joint. However, THR for TB of the hip still involves many controversial issues related to infection reactivation, surgical timing, perioperative ATT regime, long-term survival of prosthesis, etc. The purpose of our research was to investigate the feasibility and outcome of different treatment options through a review of the clinical data of seven patients between November 2014 and September 2018. We hope that our study provides some insight into the clinical treatment of TB of the hip.

We present the following article in accordance with the AME Case Series reporting checklist (available at http://dx.doi.org/10.21037/apm-20-2544).

Methods

Seven patients with TB of the hip were treated with total hip arthroplasty (THA) in the Orthopaedic Department of Guizhou Provincial People’s Hospital from November 2014 to September 2018. Of these, five were men and two were women, with a mean age of 34.3 years (range, 20–75 years). Three patients were in the active phase and four patients were in quiescence. Two patients suffered right hip infection, while the remaining five patients had left hip infection. One patient was accompanied with obsolete pulmonary TB and pneumothorax, and one patient had lumbar TB. One patient had sinus tract drainage and tested positive for mixed infection of Staphylococcus aureus, while another patient had three healed sinus tracts (Table 1).

Table 1 Demographic characteristics of seven hip tuberculosis patients
Full table

All patients received anti-tubercular chemotherapy [isoniazid (300 mg/d), rifampicin (450 mg/d), ethambutol (750 mg/d), and pyrazinamide (750 mg/d)] preoperatively for an average of 3.4 weeks (range, 2–6 weeks), and postoperatively for an average of 16.7 months (range, 12–18 months). Inflammatory indicators, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), had decreased significantly before surgery in all active patients (Table 2).

Table 2 Treatments and results of seven hip tuberculosis patients
Full table

The patient with sinus tract and mixed infection received three-stage surgery. The first stage surgery involved radical debridement, sinus tract resection, and implantation of a vancomycin-loaded cement spacer, while the second stage surgery involved cement spacer replacement and was conducted 2 months after the first surgery due to spacer breakage resulting from poor compliance. Final implantation of the hip prosthesis was completed 6 months later (Figure 1). The remaining six patients received one-stage surgery involving thorough debridement and prosthesis implantation. All patients were allowed weight-bearing 1 day after THA (Figure 2). All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by institutional ethics committee of Guizhou provincial people’s hospital (No.EC-20201026-1017) and informed consent was taken from all the patients.

Figure 1 A 57 years old man was diagnosed active hip tuberculosis with sinus tract drainage. Preoperative X-ray (A), CT scan (B) and MRI (C) showed joint destruction and cold abscess. (D) Postoperative radiograph of first-stage surgery (sinus tract resection, radical debridement and implantation of vancomycin-loaded cement spacer). (E) Two months postoperatively, spacer breakage occurred due to poor compliance. (F) The patient received second-stage surgery (debridement and replacement of cement spacer). (G,H) Eight months postoperatively, the final metal prosthesis was implanted. (I) Seventy months postoperatively, the final follow-up radiograph showed good position and growth-up of prosthesis.

Figure 2 A 45-year-old woman suffered left hip tuberculosis. (A,B) The X-ray showed affected left hip. (C,D) After anti-tubercular chemotherapy for six months. (E) The patient received total hip arthroplasty. (F) The follow-up X-ray two months postoperatively. (G) The follow-up X-ray 26 months postoperatively.

Results

The mean follow-up time was 41.6 months (range, 25–71 months), and no reactivation was detected. The average Harris score increased from 40.0 (range, 15–58) preoperatively to 89.4 (range, 8–98) at the final follow-up. The ESR of the three active TB of the hip cases decreased from 143.7 mm/L (range, 94–221 mm/L) at the time of diagnosis to 6.7 mm/L (range, 2–10 mm/L) at the final follow-up. The CRP of the three active TB of the hip cases decreased from 80.01 mg/L (range, 37.34–136.92 mg/L) at the time of diagnosis to 1.91 mg/L (range, 1.05–2.57 mg/L) at the final follow-up. The ESR and CRP of all patients had returned to a normal level at the final follow-up. No prosthesis dislocation, loosening, or neurovascular injury was observed (Table 2).

Discussion

Staged surgery is the gold standard treatment for severe infectious destruction of the skeletal and joint systems. First stage surgery involves radical debridement and curettage of inflammatory and necrotic tissue, with or without implantation of an antibiotic-loaded cement spacer. Second stage surgery is carried out after the infection is under control, and involves once more debridement and implantation of the metal prosthesis. The necessity of staged surgery results from adherence to the metal surface as well as the biofilm-forming characteristics of common bacteria. Bacteria coated with biofilm have strong resistance to antibiotics and host immune attack, which can ultimately lead to serious surgical failure (13). Some authors have suggested that staged surgery with anti-TB chemotherapy could minimize the reactivation of TB. Li et al. (6) held the view that it is difficult to achieve thorough debridement of advanced hip infection diffused to the thigh or pelvis, and recommended two-staged surgery.

In contrast to common pyogenic pathogens, TB bacilli have unique biological characteristics, including that they are slow-growing, they do not adhere to metal surfaces, and have scarce biofilm-formation (13-15). Encouraged by the success of one-staged surgery with metal implantation for active spinal TB (16,17), an increasing number of surgeons have applied one-staged surgery for the treatment of TB of the hip, with satisfactory results (8,15,18,19).

However, in addition to the anti-TB chemotherapy, the quiescence before THA reported by different authors varied from immediately to 20 years (8,18-21). There have also been some cases of reactivation reported after a very long time of quiescence. Johnson et al. (22) encountered two patients who had TB of the hip in childhood and had no manifestation of infection for 42 and 37 years, respectively. Reactivation of TB emerged 1 year after THA for two ankylosing hips. These two patients were treated in childhood with conservative immobilization only (i.e., without anti-TB chemotherapy). In our retrospective cases, the quiescence before THA was not taken into consideration when deciding the surgical timing. Also, the standard first-line anti-TB chemotherapy, including isoniazid, rifampicin, pyrazinamide, and ethambutol, was applied for every patient for between 2 and 6 weeks preoperatively and between 12 and 18 months postoperatively.

Many authors hold the opinion that sinus tract drainage is contraindicated in one-staged surgery for treating TB of the hip (6,15,23). Sinus tract drainage is often accompanied by mixed infection with other common pyogenic pathogens including multi-drug resistant super-bacteria. Li et al. (6) reported a series of four TB of the hip cases with sinus tract; they selected two-staged surgery with regular anti-TB chemotherapy, and ultimately achieved a satisfactory result. In our study, we chose three-staged treatment for cases with sinus tract, with anti-TB chemotherapy and intravenous administration of sensitive antibiotics.

Conclusions

THA is an effective and safe option for TB of the hip. The essentials for good surgical outcomes include early diagnosis, regular perioperative anti-TB chemotherapy, radical debridement of inflamed tissue and necrotic bone, as well as staged-surgery if necessary.

Acknowledgments

Funding: (I) National Natural Science Foundation of China (No. 81960401); (II) Guizhou Province Science and Technology Project ([2019]1429).

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at http://dx.doi.org/10.21037/apm-20-2544

Data Sharing Statement: Available at http://dx.doi.org/10.21037/apm-20-2544

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/apm-20-2544). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by institutional ethics committee of Guizhou provincial people’s hospital (No.EC-20201026-1017) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: A. Kassem)