TUBERCULOSIS

J. A. B. CAMPBELL,

OF
E. B. HOFFMAN

THE

HIP

IN CHILDREN

From

Maitland

Cottage

Hospital,

Cape

Town,

Republic

of South

Africa

We

have

reviewed

74 tuberculous to From with rifampicin, for nine months

i99i.

hips 1979

in 73

children

either

actively

or with reviewed

continuous 74 hips

passive in 73

motion

(Salter treated

et for

treated from i950 treated 28 patients pyrazinamide given active

this, 46

to 1991 we isoniazid and (series A), using cases. Before

a! 1980). We have tuberculosis This spanned

children

mobiisation

for

the

more

recent

over the 41-year period from two eras of different treatment

1950 and

to 1990. we have

hips had been treated with streptomycin and isoniazid with or without para-aminosalicyclic acid given for a mean of 18 months (series B), and all these patients were immobilised for a mean of 2.2 years. The classified outcome.
59%

therefore reviewed them (series A) our most recent from 1979 to 1990, we pyrazinamide in short

as two series, considering first experience. In series A, treated used rifampicin, isoniazid and and in the later years tended

courses

radiological

appearances

at (i983) normal

presentation predicted type (50% followed by

as the and the

by Shanmugasundaram Most hips were of the of series A and type (25% 9%). There and were i3%) good

B respectively)

dislocating (8% and 93%

poor

and the atrophic type or excellent results in

towards earlier mobilisation. In series B, treated from 1950 to 1978, the methods were prolonged immobilisation and a long course of streptomycin, isoniazid and para-aminosalicylic acid. The aims of our review were to determine whether short drug regimens and early mobilisation altered the outcome, and logical classification dieting the result. to assess the value of Shanmugasundaram of the clinicoradio( 1983) in pre-

of the normal type. All the atrophic type had results. The dislocating type had a poor result if the joint space was narrow after reduction of the hip. Early mobilisation had no effect on the outcome of the normal type of disease. The newer drug but regimens did not allowed for shorter courses of treatment, necessarily give a better outcome.
J Bone Received Joint Surg [Br] 1994; 1995;77-B:319-26. Accepted 24 June /994

PATIENTS
Series A.

AND

METHODS
patients with 28 infected hips

Twenty-seven

presented during the I 2 years were 14 boys and 13 girls; coloured

years

from 1979 to 16 were black age was 5 years

and serial

1990. and ( I year

There 11 of to 13 of open

6 May

race.
1 0 months).

Their

average
All case

records

radiographs

were ESR Before the introduction of chemotherapy, the hip often ended in a fibrous ankylosis Phemister 1937; Ponseti 1948). Streptomycin and isoniazid 1940s, and treatment at that time and prolonged chemotherapy. tuberculosis (Hatcher of and

available, and

as were skin

chest tests.

radiographs All patients

and

the results had had

Mantoux

biopsy. and pyrazinamide immobilised

had been treated with rifampicin. isoniazid and for nine months. The involved hip was either in a spica or on a frame, or was mobilised with or without of the hip continuous at presentation of Shanmugawere assessed
of

were introduced was by prolonged Surgery, however,

in the bed-rest was 1) et or of

actively on skin traction, sive motion (CPM). The radiological

pas-

appearance

advised by some authors. Roberts and Webster ( I 95 performed early extra-articular arthrodesis and Marmor a! (1969) and Wilkinson (1969) used synovectomy with without curettage of the bone lesions. The introduction rifampicin therapy, and in 1967 there allowed was a shorter course of chemoa tendency to earlier mobi!isation,

was recorded by the 1983 classification sundaram (Fig. I ). At review all patients Table I.
the hip, Grading modified Range flexion of results of treatment from Shanmugasundaram of

of tuberculosis (1983)

Grade
Ia J. A. B. Campbell, FCS SA(Orth), Registrar E. B. Hoffman, FCS SA(Orth), Consultant Orthopaedic Surgeon lb

(degrees)
Full
>

Radiography
Normal

Result
Excellent Good Fair

90

Ovoid/irregular Destroyed Fibrous Bony ankylosis ankylosis

Department
Republic

of Orthopaedics,
of South Africa. should Cape

University

of Cape Town.

Observatory

7925.
II Avenue. III IV
<

35 to 9()

Correspondence Newlands 7700,

b sent to Dr E. B. Hoffman at 7 Marne Town, Republic of South Africa. of Bone and Joint Surgery

35

Poor Poor

1995 British Editorial Society 0301 -620X/95/2923 $2.00

Nil

VOL.

77-B.

No. 2, MARCH

1995

319

321)

J. A. B. CAMPBELL.

E. B. HOFFMAN

Type

Normal

Type

Travelling

acetabulum

Type

Dislocating

Type

Perthes

Type

Protrusio-acetabuli

Type

Atrophic

Type

Mortar

and

pestle

Fig. 1

Radiological clinically years and 9 months radiologically (2 years at

types of tuberculosis an average 8 months). follow-up The

of the hip, redrawn of results 3

from Shanmugasundaram

(l983.

to 6 years

were

graded

as shown (1983).

in Table

I, modified

from

Shanmugabeen seen diagnosis at of

sundaram

Series B. From Maitland Cottage tuberculosis

1956 to 1978, 86 patients had Hospital with the presumed No hip had been biopsied,

of the hip.

and only review. Of radiological

46 were considered to be suitable for detailed the 40 hips excluded, 1 1 did not have the

features of tuberculosis and 29 had been treated elsewhere for at least one year before referral. There were I 8 boys and 28 girls; 1 2 were black and 34 were of coloured race. Their average age was 7. 1 years (2 to and been
years

Types
Fig. 2 types in series A.

14). All 46 patients isoniazid,

acid.

had

been with
of

treated the addition

with
(9 to

streptomycin of para-amino24). All had

Distribution of radiological

sometimes
for a mean

salicylic

18 months

immobilised
(1 to 4).

in a spica were not from to

or on a frame available for

for a mean follow-up,

of 2.2 and radiofrom Mantoux skin test was positive in 26 of the 27 patients. All hips had a definite or probable diagnosis of tuberculosis. The presence of acid-fast bacilli on direct micro-

These

patients

assessments were made graphs from admission hospital.

case records and serial the time of discharge

scopy,

or on histological

examination

or positive

Kirschner had

RESULTS Series A. Chest radiographs were positive for active or

culture was recorded for 16 hips. Twenty-six hips histological findings of caseating granulomas. The distribution of the different Shanmugasundaram types is shown in Figure normal -type radiographs. 2. Half seven

of the hips ( 14) showed were of the dislocating

healed pulmonary on admission was

tuberculosis in 42%, and the mean ESR 70 mm in the first hour (25 to 130). The

type and four of the Perthes type. There were no cases showing a travelling acetabu!um or protrusio acetabuli.
THE JOURNAL OF BONE AND JOINT SURGERY

TUBERCULOSIS

OF THE

HIP IN CHILDREN

321

16
14 12 10 8

The
28.5%.

results
fair

were
in 3.5%,

excellent
and poor

in 43%
in 25%

of
(Tables

hips,
I and

good type

in in

II) and

these

are

shown

in relation

to each

radiological

Figure 3. Of the 14 normal-type had been on frames and eight

actively and two by CPM. Eleven

hips (Fig. had been

of these

4) six patients mobilised, six

patients had an

6 4

excellent Of the immobilised, five were

3 4 Types 6 7

result,

two

had

a good

and

one

a poor

result. were other One

2
0

seven dislocating or subluxing hips, two one by spica and one on a frame. The mobilised, four actively and one by CPM.

patient had an excellent poor result. The three had a joint (Fig. 5). space

result, three had a good and three a dislocating hips with poor results all to 3 mm or less after reduction

Fig. 3

reduced

Results

br each radiological

type in series

A.

Radiograph of a 3-year-old girl with the type of tuberculosis of the right hip. showing

normal osteo-

penia and acetabular

result at 2-year

cysts (a). She had an excellent

(b).

follow-up

Table II. by number

Results in series and percentage Series A (n = 28) 12 43 8 28.5 1 3.5

A and

All

the

four

Perthes-type had a good hips, with

hips result joint

(Fig.

6) were

mobilised Both poor was

9.

Result Excellent Good Fair Poor

Series B (n = 46) 19 41 9 3 /9.5 6.5

actively; three atrophic-type results (Fig.

and one a poor result. spaces 3 mm, had hip

in Figure

7). The

single

mortar-and-pestle-type (Fig. 8). are shown type (27/46). hip. I and

immobilised and had a fair result Series B. The radiological types Again. most were of the normal the dislocating type (6/46) and type. There was one Perthes-type The results, as shown in Tables

with

six of

six of the mortar-and-pestle II, were excellent in

7 25

15 33

VOL.

77-B.

N.

2. MARCH

1995

322

J. A. B. CAMPBELL.

E. B. HOFFMAN

Fig.

Sa

Radiograph of a 6-year-old boy with the dislocating type of disease (a). After open biopsy and relocation, a radiograph in abduction traction shows a normal joint space (b). The final result was good.

Fig.

Sb

41% these Most

hips,

of hips, are
with

good

in 19.5%, for
poor

fair

in 6.5% were seen

and type

poor

in 33%; 10. -type

and

were

of the

normal

type: hip one scan,

all but the femoral five

three

had head

excellent is sclerotic with cold this

or at type hips poor

shown
most

each
results

radiological
in dislocating,

in Figure
atrophic,

excellent

or good types.

results

in normal

good results. In the Perthes-tvpe presentation; had cular. an isotope only bone

of our

patients appeared three

mortar-and-pestle

which reported

or avaswith

Shanmugasundaram

Perthes-type all
true

DISCUSSION We have confirmed the ( I 983) that the radiological sentation accurately predicts findings of appearance the final Shanmugasundaram of the hip at preoutcome.

all in patients under five years of age, and results; he stated that the distinction from disease Four year good
sis

Perthes

may be extremely of our five patients

difficult. with Perthes-type

hips

(aged

The normal type of disease has mainly synovial involvement. There may be cysts or cavities in the femoral head, neck, or acetabulum, but there is no gross destruction Shanmuof 3 1 in had
(55%)

9 months to 8 years 4 months at presentation) had results. Because of the high prevalence of tuberculoin South Africa we perform ESR and Mantoux tests on

of subchondral gasundaram children excellent under

bone and the joint space is normal. had eight such hips in his series 14 years result. of age; In our six series of the eight

an

all patients suspected of Perthes disease. Our tuberculous Perthes-type hips all had radiological features which differentiated them from true Perthes disease: the whole head was always involved, but there were none of the metaphyseal changes seen in true Perthes
OF BONE

or good

41 of 74 hips

disease
AND JOINT

(Catterall
SURGERY

THE JOURNAL

TUBERCULOSIS

OF THE

HIP IN CHILDREN

323

Radiograph Fig. 6a

of a 2-year-old

boy

with

Perthes

type

of

disease

(a). An isotope
there (b).

bone
is coxa

scan

showed
with

a cold
good

hip. At two years range of movement

magna

Fig. 6b

1 97 1 ). Acetabular

Perthes an ovoid
with did not

disease femoral
state a tendency

osteopenia and cysts are not seen in true (Fig. 6a). Those with good results all had head
to

pestle

suggesting
revascularisation. his patients

recurrent
had open

vascular
biopsies,

insults
but he

Shanmugasundaram

tratelling-acetabulum, protrusio, and ?nortar-andtype hips result from erosion of subchondral bone. The travelling-acetabulum hip was common in Shanmugasundarams series (9 of 3 1 hips). We saw only two cases

The

whether

and

did suggest patients had

some

that surgery provided an open biopsy, which

of the hip.

little may

benefit. All have resulted

our in in to

as in his study they The mortar-and-pestle sundaram only in adults, early in series We have
as good or excellent,

both had a poor result. type was seen by Shanmugabut we had seven such hips, most classified
good range

decompression

B. Shanmugasundaram
because of the

his
of

results
move-

In the dislocating series A was seen capsular mulation six cases

series

type, the dislocation in all cases at open

or subluxation biopsy to be due

ment.

modified

his classification.

however,

(Table

laxity and synovial hypertrophy and not to accuof pus. Shanmugasundaram had poor results in all in children. Four of the seven dislocating hips in
excellent or good results, but in series B only

I), regarding movement

hips had

a destroyed femoral head with a good range of as a fair result (2 of the 7 hips). The other five
fibrous ankylosis and therefore poor results. We

A had A were

had in

no hips

of the protrusio-acetabuli reported seen

hips

type. poor exclusively

under

two
series

of the six hips

probably

had traction 3 mm)

a good
due

result.

The

better

results
hip,

Shanmugasundaram
atrophic-type saw six

results
14 years

for

the We a

to open

relocation

of the

as

hip,
atrophic-type

almost

in adults.

opposed to frame after reduction ( that

VOL.

in series predicted

B. A narrow a poor result,

joint space suggesting

in patients

of age,

there
77-B.

was

also

an atrophic
1995

element.

and had poor results joint space of 3 mm

in all six. Initial radiographs or less, but at open biopsy

showed the cartilage

No. 2. MARCH

324

J. A. B. CAMPBELL,

E. B. HOFFMAN

-.

g-

Fig.

7a

Radiograph of a 10-year-old boy showing an atrophic type of hip at presentation, with the joint space almost obliterated (a). A radiograph at two years shows fibrous ankylosis (b).

Fig. 8 Radiograph pestle type of a 6-year-old of disease of the girl with left hip. mortar-and-

looked normal and examination of the suggests pannus, space

glistening. cartilage

In one case histological was normal (Fig. 7). This

by vigorous active movement, supports the supposition that Shanmugasundaram symptoms in normal
types varied from
,

with there

CPM in later is subchondral

cases; this erosion.

that articular cartilage is not destroyed by surface but by subchondral erosion which appears as jointnarrowing on radiographs, as reported by Phemister

reported that the mean duration of Perthes, dislocating and atrophic 4 to 7 months, and for the travellingWe had and mortar-and-pestle an accurate record
AND JOINT SURGERY

(1925) and Phemister and Hatcher inevitably progress to fibrous ankylosis

( 1933).

These hips despite treatment

acetabulum, types, for

protrusio-acetabuli 10 to 14 months.
THE

of

JOURNAL

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TUBERCULOSIS

OF THE

HIP IN CHILDREN

325

ible

for

the

atrophic

hip

and

possibly
,

for mortar-and-

the

travelling-acetabulum, protrusio-acetabuli pestle types. The closely similar results in our series II) confirm that the newer drugs rifampicin,

and

A and B (Table isoniazid and than the and paraimproved

the treat-

pyrazinamide allow shorter courses of treatment older drug regimes using streptomycin, isoniazid aminosalicyclic acid, but do not necessarily give
results. Similar findings have been reported for

ment

of tuberculosis

of the

spine

(MRC

1973,

1993).

Both Marmor et al (1969) and Wilkinson improved results for synovectomy with

( 1969) reported or without curethas no major of the hip. In almost invariopen

diagtissue the

Types
Fig. 9 Distribution of radiological types of disease in series B.

tage

of bony

lesions.

We consider

that

surgery

role in the early management the normal type of disease ably

biopsy nosis;

of tuberculosis chemotherapy result.

an to accurate

gives
in this

a good
all may

or excellent
to help provide also

We do advocate

patients

30 25 20 15 10

decompress

avascular

Perthes-type

hip and

to relocate

the dislocating

type.

In the and has

atrophic, travelling-acetabulum, mortar-and-pestle types of disease, occurred The i!isation,

series

protrusio-acetabuli irreversible damage as opposed !4 normal

traction

before presentation. influence of mobilisation, can be compared in the

A. All were treated

to immobtype hips in
for at least

in abduction

Types
Fig. 10 The results br each radiological type in series B.

two months, but after this in the later cases active movement was encouraged and CPM was added, once the initial pain of the open biopsy had settled. Of these 14 hips, seven were immobilised and seven actively mobilised: there was no difference Conclusions. bus hip outcome. in the outcome. The radiological appearance of the tubercupredicts the and dislocatwill will have

at presentation Hips of normal

with a normal joint

almost invariably type. Perthes type

space after reduction types

duration of symptoms for 20 of the 28 patients in our series A. Normal Perthes, dislocating and atrophic types
.

ing

type

a good

result.

Hips
and

of atrophic,
mortar-and-pestle

travelling-acetabulum.
have

proa

showed that

a mean duration of

duration symptoms

from may

2 to S months. be a factor:

This

suggests

trusio-acetabuli

in travelling-

acetabulum, types with

local similar

protrusio-acetabuli a longer duration,

bone destruction of symptoms,

there

and mortar-and-pestle is time for significant

to occur. Patients present with with a a may

poor result. The newer treatment, Surgery

biopsy

drug

regimes not necessarily presentation

of

allow

for

shorter better limited

hip.

periods

of

subchondral duration

but do at initial
and the

produce should be
a dislocated

outcome. to open
Prolonged

however,

relocation

normal type of hip and have a good outcome. or with an atrophic hip and have a poor outcome. In a normal hip, the disease is mainly localised to the synovium. Pannus does not proliferate over the area of joint contact and
caseation disease contrast, is there a form is of 1925: significant local control and subchondral and necrosis erosion of 1933). in the By the (Phemister Phemister Hatcher

immobilisation appears come of the radiologically

This

to have no influence on the normal type of disease.

out-

atrophic hip. It is now accepted

culosis destroying may either hypersensitivity

study was made possible by a research grant from the Chairmans Fund Educational Trust of the Anglo-American Corporation of South Africa. The authors would like to thank Mrs V. Barrow kr the typing and Mr M. Wyeth for preparing the illustrations. No benefits in any form have been received or will be received froni a commercial party related directly or indirectly to the subject of this article.

that
confer

the immune
protection (Ainslie

mechanism
or and lead Bateman to

in tubertissue1991).
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Protective immunity is related to granuloma formation is seen in the normal, synovial type of tuberculous
disease. sensitivity,
VOL. 77-B.

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hyper-

It

seems causing

possible subchondral
1995

that

tissue-destroying erosion, may be

respons-

Nu. 2. MARCH

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J. A. B. CAMPBELL,

E. B. HOFFMAN

Hatcher CH, Phemister

sis of the Marmor losis hip joint. L, Chan of the hip

DB.
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The primary Gynec Obstet

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in tuberculoof tubercu-

Ponseti
Obstet

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hip.

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Gynec

KP, Ho KC,
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Justin M. Surgical treatment Clin Orthop 1969:67:133-42.

MRC.

Roberts hip Salter

WM, Webster FS.

in children. Surg

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of tuberculosis

of the

A controlled trial of ambulant out-patient treatment and in-patient rest in bed in the management of tuberculosis of the spine in young Korean patients on standard chemotherapy. J Bone Joint Surg (Br] 1973;55-B:678-97. MRC. Controlled trial of short-course regimens of chemotherapy in the ambulatory treatment of spinal tuberculosis: results at three years of a study in Korea. J Bone Joint Surg [Br] 1993;75-B:240-8.

RB, Simmonds
continous passive articular cartilage: Joint Surg [Am]

DF, Malcolm BW, et at. The biological effect of motion on the healing of full-thickness defects in an experimental investigation in the rabbit. J Bone 1980:62-A: 1232-S 1. TK.
Bone and joint tuberculosis. Madras: Kothan-

Phemister DB. Changes in the articular surfaces in tuberculous arthritis. Bone Joint Surg 1925:7:835-47. Phemister DB, Hatcher CH. Correlation of pathological and roentgenological findings in diagnosis of tuberculous arthritis. Am J Roentgeno! 1933:29:736-52.

Shanmugasundaram daram & Co.

1983. and knee treated by a follow-up study. chemoJ Bone

Wilkinson MC. Tuberculosis of the hip therapy, synovectomy and debridement: Joint Surg [Am] 1969:Sl-A:1343-59.

THE

JOURNAL

OF BONE

AND

JOINT

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