Two-stage total hip arthroplasty for patients with advanced active tuberculosis of the hip

Abstract

BackgroundTreatment of advanced active tuberculosis (TB) of the hip is confronted with great challenges. Although one-stage total hip arthroplasty (THA) is considered as a safe procedure for most patients by some authors, there are still exceptions. The purpose of this paper was to investigate the feasibility and effectiveness of two-stage THA for selected patients with advanced active TB of the hip.MethodsNine consecutive patients with advanced active tuberculous arthritis of the hip were reviewed in this study. Out of these nine patients, the hips of five were destroyed extensively with difficulties of thorough debridement at one operation, and the hips of the other four were detected of sinus tracts. Nine patients received the two-stage total hip arthroplasty (THA) protocol and the perioperative antituberculous medication between January 2008 and December 2013. During the first stage, a debridement was carried out after at least 2 weeks of antituberculous chemotherapy to remove abscesses and infected and necrotic tissues as thoroughly as possible, followed by antituberculous chemotherapy for a minimum of 3 months (average 4.2 months). During the second stage, hip prosthesis was implanted if the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) were normal and the wound was well healed. Antituberculous chemotherapy was continued for 6–9 months postoperatively to constitute a total duration of a minimum of 12 months after the first operation. The patients were then evaluated based on the reactivation of infection, the Harris hip score system, X-ray, ESR, and CRP.ResultsThe average follow-up was 40 months (range, 18–72 months). No reactivation of TB or superimposed infection was observed in all patients. The ESR and CRP returned to the normal level with no liver injury. The average Harris hip score was increased from 35 (range, 15–55) preoperatively to 91.5 (range, 83–97) at the final follow-up. The X-ray film showed no prosthesis shift or loosening.ConclusionsTwo-stage THA is an alternative treatment option for patients with advanced active tuberculosis of the hip under some difficult conditions. The hip with sinus tracts or destroyed extensively with difficulties of thorough debridement at one operation may be regarded as indications.

Artroplastia total de cadera posterior a una infección por Tuberculosis: Caso clínico y revisión de la literatura

“…El compromiso de la cadera es el segundo más frecuente después de la columna, 2 y su tratamiento presenta controversias en relación a su manejo médico y quirúrgico. 5 El caso presentado muestra un paciente con una tuberculosis activa de la cadera que determinó una destrucción articular avanzada. Se describe entonces como se realizó su manejo médico y posterior ATC en 2 tiempos como una alternativa de tratamiento efectiva para ese complejo escenario.…”

“…10 Algunos autores recomiendan un largo periodo de quiescencia antes de la cirugía, siendo utilizados intervalos desde ATC inmediata hasta 20 años posterior al inicio de la enfermedad. 5,10,11 En pacientes con infección activa, el tratamiento quirúrgico con una ATC de forma primaria en un tiempo es controversial por el riesgo potencial de reactivación de la enfermedad. No obstante, la reactivación de la TBC ocurre en pacientes en que no se diagnosticó la etiología inicialmente, en aquellos sin tratamiento preoperatorio o que no presentaron una adherencia adecuada.…”

“…Se recalca en este trabajo, así como en la mayoría de los autores, la recomendación de realizar la ATC en dos tiempos en el caso de la presencia de trayectos fistulosos o de no lograr un debridamiento adecuado. 2,5,10 El tiempo de duración del tratamiento antituberculoso para el manejo de la tuberculosis extra pulmonar también es tema de debate. Se ha administrado quimioterapia en periodos variables tanto en el pre y postoperatorio, que van desde 2 semanas a tres meses, en el primero, y 6 a 15 meses, en el segundo, sin presentar reactivaciones, mejorando la funcionalidad y obteniendo los mismos resultados que en nuestro paciente.…”

“…Al igual que lo reportado por Yoon y cols., 10 nuestro paciente se trató con artroplastia total no cementada, en dos tiempos, debido a la presencia de fistula, manteniéndose con espaciador hasta la cirugía definitiva. 5 En esa situación, se optó por quimioterapia antituberculosa por una duración de 6 meses, en base a la recomendación a la sociedad americana de enfermedades infecciosas, 15 mostrando la ausencia de reactivación en el seguimiento de 12 meses posterior a la reconstrucción definitiva.…”

Two-stage total hip arthroplasty for primary advanced septic arthritis of the hip in adults: comparison of debridement versus femoral head resection with spacer implantation

“…Subsequent report has found that the use of antibiotic-loaded spacers in two-stage THA may be considered as a suitable method for the treatment of primary SA in adults [8]. In addition, Li et al [9] have reported that twostage THA using debridement or femoral head resection with antibiotic-loaded spacer implantation is effective in the treatment of advanced active tuberculosis of the hip and have demonstrated that the outcomes of two procedures are consistent. Therefore, it is necessary for us to further demonstrate the treatment of between debridement and antibiotic-loaded spacer implantation in two-stage of THA in adults.…”