Introduction

Tuberculous arthritis of the hip (coxitis tuberculosa) is the second most common form of osteoarticular tuberculosis in children, representing 15-20% of cases. The condition is particularly significant due to its potential for severe disability and growth disturbance.

Anatomical Considerations

• Common Sites of Involvement:
  • Femoral head epiphysis
  • Acetabulum
  • Synovial membrane
  • Metaphyseal region
• Pathological Changes:
  • Synovial hypertrophy
  • Cartilage destruction
  • Bone erosion
  • Capsular distension

Classification (Shanmugasundaram)

1. Stage I (Synovial Stage):
   • Early synovitis
   • Preserved joint space
   • No bone destruction
2. Stage II (Early Arthritis):
   • Joint space narrowing
   • Focal erosions
   • Minimal head deformation
3. Stage III (Arthritis):
   • Significant destruction
   • Early subluxation
   • Acetabular changes
4. Stage IV (Advanced Arthritis):
   • Severe destruction
   • Dislocation
   • Pathological subluxation

Clinical Features

Early Manifestations

• Insidious onset pain
• Limping gait
• Restricted hip movements
• Night cries
• Referred knee pain

Late Manifestations

• Fixed deformities
• Apparent limb shortening
• Muscle wasting
• Abscess formation
• Sinus tract development

Diagnostic Approach

Clinical Examination

• Gait Assessment:
  • Antalgic gait
  • Trendelenburg gait
  • Short limb gait
• Deformity Pattern:
  • Flexion
  • Adduction
  • Internal rotation
• Special Tests:
  • Thomas test
  • FABER test
  • Trendelenburg test

Imaging Studies

• Radiographic Findings:
  • Phemister's triad
  • Wandering acetabulum
  • Perthes-like changes
  • Protrusio acetabuli
• MRI Features:
  • Synovial enhancement
  • Bone marrow edema
  • Joint effusion
  • Cartilage status
  • Abscess delineation

Laboratory Investigations

• Blood Tests:
  • Elevated ESR/CRP
  • CBC with differential
  • Liver function tests
• Specific Tests:
  • Mantoux test
  • IGRA (Quantiferon TB Gold)
  • Joint fluid PCR
  • Culture studies

Treatment Protocol

Conservative Management

• Anti-tubercular Therapy:
  • Initial Phase (3 months):
    • HRZE regimen with weight-based dosing
    • Regular monitoring of drug toxicity
  • Continuation Phase (9-15 months):
    • HR combination
    • Duration based on clinical response
• Joint Protection:
  • Traction in early stages
  • Abduction splinting
  • Non-weight bearing protocol

Surgical Interventions

• Early Disease:
  • Synovectomy
  • Debridement
  • Joint lavage
• Advanced Disease:
  • Arthrodesis
  • Joint replacement
  • Girdlestone arthroplasty

Rehabilitation Program

Phase-wise Protocol

• Phase I (Protection):
  • Joint unloading
  • Pain management
  • Static exercises
• Phase II (Motion):
  • Passive movements
  • Active assisted exercises
  • Muscle strengthening
• Phase III (Functional):
  • Gait training
  • Balance exercises
  • ADL training

Complications

• Early Complications:
  • Subluxation/dislocation
  • Abscess formation
  • Sinus tract formation
• Late Complications:
  • Growth disturbance
  • Leg length discrepancy
  • Hip stiffness
  • Ankylosis
  • Secondary osteoarthritis

Monitoring and Follow-up

• Clinical Monitoring:
  • Monthly assessment of:
    • Pain status
    • Range of motion
    • Deformity progression
    • Functional improvement
• Investigation Follow-up:
  • ESR/CRP monthly
  • X-rays quarterly
  • MRI as indicated
  • Growth monitoring

Prevention of Complications

• Early diagnosis and treatment
• Regular monitoring
• Appropriate immobilization
• Compliance with medication
• Regular rehabilitation
• Growth monitoring