Total hip arthroplasty in the setting of tuberculosis infection of the hip: a systematic analysis of the current evidence

ABSTRACT

Introduction: Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis, but has been controversial due to concerns of disease reactivation. Over the past several decades, a number of authors have reported outcomes of THA for tuberculosis (TB) infections. However, there is marked heterogeneity in regard to disease activity, surgical approaches, and the use of chemoprophylaxis in these studies.

Areas covered: The purpose of this review was to critically assess: 1) patient characteristics; 2) perioperative planning; 3) clinical outcomes; 4) radiographic outcomes; and 5) complications of THA in the setting of tuberculosis of the hip.

Expert opinion: THA is an effective treatment for post-TB hip arthritis. There has been controversy regarding its safety during the past several decades, as it has been thought to increase the risk of disease reactivation. While studies thus far have shown generally favorable results, they have been limited by small sample sizes and their design as retrospective case series. Comparison of these studies reveals marked heterogeneity in the clinical management of this complex disease. However, synthesis of their findings demonstrates favorable outcomes and low rates of complication, including disease reactivation particularly when perioperative anti-tuberculosis therapy is instituted.

KEYWORDS:

• Tuberculosis
• total hip arthroplasty
• infection
• outcomes
• arthritis

Article highlights

• Previous TB infection of the hipjoint does not preclude THA to restore mobility and function of an arthritic post-tuberculous hip. Current evidence points to a high success rate and low complication rate.

• There is currently inadequate evidence suggesting that longer interval to surgery correlates with better outcomes and lower incidence of disease reactivation. Rather, adequate joint debridement and perioperative prophylactic ATT have been more consistently advocated by experienced surgeons.

• The definition of ‘active disease’ in patients who underwent THA varied among studies. However, most patients who were deemed having active disease mainly showed laboratory and radiographic evidence suggestive of active disease process vs. showing clear clinical evidence such as sinus discharging pus. In patients who showed such clinical signs of active tuberculosis, two-stage procedure was advocated. On the other hand, authors who performed one stage THA did so in patients with active disease based only on laboratory or radiographic signs taking into account good surgical debridement.

• When there is evidence of active local disease, such as draining sinus tract, two-stage procedure with initial debridement followed by implantation may achieve the eradication and avoids a local TB reactivation.

• ATT pre- and post-operatively has been advocated by nearly all authors. What is unclear is the recommended duration. Based on our interpretation of available literature, ATT for 3 months preoperatively and 12 months postoperatively represent a balanced recommendation when THA is undertaken in these patients.

Declaration of interest

MA Mont is a board/committee member for AAOS; an editorial/governing board member for the Journal of Arthroplasty, the Journal of Knee Surgery, Orthopedics, Surgical Techniques International, a paid consultant for Abbott, Cymedica, DJ Orthopaedics Johnson & Johnson, Mallinckrodt Pharmaceuticals, Ongoing Care Solutions, Orthosensor, Pacira, Performance Dynamics Inc., Sage, Stryker, and TissueGene; has received research support from DJ Orthopaedics, Johnson & Johnson, the National Institutes of Health (NIAMS & NICHD), Ongoing Care Solutions, Orthosensor, Stryker, and TissueGene; has received IP royalties from Microport and Stryker; and has stock/stock options from Peerwell. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.