Clin Orthop Relat Res (2010) 468:605612

DOI 10.1007/s11999-009-0957-9

CLINICAL RESEARCH

Total Hip Arthroplasty in Patients with Active Tuberculosis

of the Hip with Advanced Arthritis
Devdatta Suhas Neogi MS (Ortho), DNB, MCh.Orth, MRCSEd,
Chandra Shekhar Yadav MS (Ortho),
Ashok Kumar MS (Ortho), Shah Alam Khan MS (Ortho), DNB, MCh.Orth (Liv), FRCS (Glasg),
Shishir Rastogi MS (Ortho), DNB

Received: 2 January 2009 / Accepted: 15 June 2009 / Published online: 30 June 2009
The Association of Bone and Joint Surgeons1 2009

Abstract Osteoarticular tuberculosis (TB) in the hip and

other joints is increasing and patients in developing countries commonly present with advanced joint destruction. We
asked whether TB is reactivated after THA in these patients.
We retrospectively reviewed 12 patients with an average
age of 45 years who had advanced stages of hip destruction
secondary to mycobacterium TB and who were treated with
primary THA and prescribed perioperative antituberculous
medication for 12 to 18 months postoperatively. Diagnosis
in all these patients was confirmed by histopathology and
culture. The minimum followup was 25 months (average,
41 months; range, 2558 months). We observed no reactivation of TB in 11 patients who had Harris hip scores
ranging from 86 to 97. One patient who postoperatively did
not comply with the antituberculous chemotherapy had
reactivation and superimposed infection through a nonhealing sinus tract; that patient underwent component
removal and resection arthroplasty. When the infected
tissue can be debrided and adequate antituberculous therapy
is instituted the outcome of joint arthroplasty may not be
adversely affected. THA in the tuberculous hip has a low
risk of reactivation and produces good functional results.
Each author certifies that he or she has no commercial associations
(eg, consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
Each author certifies that his or her institution has approved the
human protocol for this investigation, that all investigations were
conducted in conformity with ethical principles of research, and that
informed consent for participation in the study was obtained.
D. S. Neogi, C. S. Yadav (&), Ashok Kumar,
S. A. Khan, S. Rastogi
Department of Orthopaedics, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi 110029, India
e-mail: [email protected]

Level of Evidence: Level IV, therapeutic case series (no,

or historical control group). See the Guidelines for Authors
for a complete description of levels of evidence.

Introduction
The World Health Organization estimated the incidence of
TB to be 8.8 million, smear-positive 3.9 million, and
mortality approximately 1.6 million in 2005 [24]. There
has been an increase in the incidence of osteoarticular TB
reported in western countries [18]. The main reasons for
this epidemiologic trend include an increase in immigration
from regions where TB is endemic, an increase in the
number of people with immune suppression, aging of the
population, and development of drug-resistant strains of
mycobacterium tuberculosis (MTB) [18]. Infection of the
musculoskeletal system accounts for 1% to 5% of all
patients with TB, whereas TB of the hip constitutes 10% to
15% of all patients with osteoarticular TB [2, 23].
Socioeconomic constraints and the fear of being a social
outcast in the developing world cause these patients to
delay presentation for treatment, by which time the joint no
longer is able to be preserved. Arthrodesis and resection
arthroplasty are offered to patients in whom hip function is
unsatisfactory [2, 15, 23]. THA has been the accepted
procedure in quiescent TB; however, the reported time for
the hip to become quiescent has varied from 10 to 20 years
[10, 12, 13, 1517]. A history of activity of infection within
10 years, chronic discharging sinus tract, and positive
culture of tissue obtained during surgery reportedly
increase the risk reactivation of infection [1517, 25].
Bacteria adhering to implanted medical devices or damaged tissues can encase themselves in a hydrated matrix of
polysaccharide and protein forming a slimy layer known as a

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Neogi et al.

biofilm [22]. Antibiotic resistance of bacteria in the biofilm

mode of growth contributes to the chronicity of infection
[22]. Metal implants have been used in patients with spinal
TB and have been reported to have good results with no
reactivation [7, 9, 21]. In addition, in vitro studies comparing
the adherence and biofilm properties of MTB and staphylococcus epidermidis suggest MTB rarely adheres to a metal
surface and has little or no biofilm formation, thus making it
more susceptible to antibiotic therapy [9, 21].
The in vitro studies of biofilm formation, the success
with using implants [7, 9, 21], and the good functional
results with no reactivation reported for THA in patients
with active TB of the hip [15, 25] prompted us to evaluate
the use of THA in patients with active advanced TB of the
hip particularly in relation to reactivation, function, and
laboratory findings.

Materials and Methods

We retrospectively reviewed all 12 patients with advanced
active TB of the hip treated with a primary one-stage THA
Fig. 1AD Preoperative radiographs show (A) femoral head
destruction and (B) subluxation.
(C) An MR scan shows active
disease with a soft tissue abscess.
(D) A radiograph obtained at the
43-month followup shows no
evidence of osteolysis or disease
reactivation.

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Clinical Orthopaedics and Related Research1

at our institute between January 2003 and June 2006.

Advanced tubercular arthritis was defined as when patients
had clinical features of pain, deformity, restriction of
motion, and wasting with radiographically apparent
destruction of the articular surface and bone on either side,
wandering acetabulum, subluxated or dislocated hip, MR
images of gross destruction and surrounding abscess
(Fig. 1), and supported by hematologic investigations.
Thus, we only included patients with clinically and radiographically advanced Stage III or Stage IV TB in the study
[2, 23]. We excluded patients involved in heavy activity,
those with Stages I and II TB [2, 23], and those with other
sites of involvement. Patients with Stages I and II TB are
known to heal well and have good function after antitubercular chemotherapy (ATT) [2]. THA may not be a good
procedure for people involved in heavy manual labor,
therefore, these patients were excluded. We presumed
involvement of another site signified more immunosuppression, and therefore, we did not offer immediate THA to
these patients. There were seven women and five men with
an average age of 45 years (range, 2663 years) (Table 1).
Pain, deformity, restriction of motion, and limb wasting

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Total Hip Arthroplasty in Active Tuberculosis

were present in all patients; a sinus was present in one. No

patient had any other active focus of TB at presentation.
Two patients had a history of pulmonary TB treated by
ATT for 6 months and both showed a healed focus on their
chest radiograph and were sputum-negative for acid-fast
bacilli (AFB) and MTB. The minimum followup was

Table 1. Patient demographics

Patient

Age
(years)

Gender

Clinical features

ATT before
presentation

50

Female

P/D/RM/W/LW/F

No

62

Female

P/D/RM/W/LW/F

8 weeks

44

Male

P/D/RM/W/LW

No

32

Female

P/D/RM/W/LW/F

No

45

Female

P/D/RM/W/LW/F

No

26

Male

P/D/RM/W/LW/F

4 weeks

7
8

40
63

Male
Male

P/D/RM/W/LW
P/D/RM/W/LW/F

No
No

43

Female

P/D/RM/W/LW/F

No

10

39

Male

P/D/RM/W/LW/F

No

11

52

Female

P/D/RM/W/LW/S

No

12

46

Female

P/D/RM/W/LW/F

No

P = pain; D = deformity; RM = restricted movements; W =

weight loss; LW = limb wasting; F = low grade fever; S = sinus.

607

25 months (average, 41 months; range, 2558 months). No

patients were lost to followup.
All patients were counseled regarding the procedure and
preoperative and postoperative therapy, and informed
consent was obtained. After obtaining ethical board clearance, we reviewed patients records to identify the
presentation, treatment details, operative details, and
implants used (Table 2). Preoperatively, a thorough history
of diagnosis for past tuberculous infection or for any history of contact with a patient with tuberculous infection
was obtained routinely. We obtained chest, spine and
radiographs of other bones in all patients when symptomatic to rule out any other osteoarticular active foci of
infection because we thought this may increase operative
risks. Sputum for detection of AFB and culture was sent for
microbiologic examination in all patients. We performed a
hemogram, enzyme-linked immunosorbent assay for HIV,
hepatitis B antigen, and routine biochemical investigations
(ie, serum blood chemistry for sugar, urea, and creatinine)
to rule out lowered immune status and for preoperative
fitness.
Preoperatively, ATT was started with four drugs: 5 mg/
kg isoniazid, 10 mg/kg rifampicin, 15 mg/kg ethambutol,
and 25 mg/kg pyrizinamide daily for at least 4 weeks
accompanied by domiciliary traction. THA was performed
in all patients. Perioperatively, cephalosporin cover was
given for 3 days. The average duration of preoperative
ATT was 5 weeks. Patient 11 had a sinus that healed with

Table 2. Management
Patient Preoperative
number investigations
Chest ESR Xray/
xray (mm) MRI

Preoperative Procedure Postoperative

Therapy
ATT
investigations
compliance
(weeks)
Biopsy HistoPCR
culture pathology

55

De, A

UC-THA

2
3

N
HF

60
45

De, A
De, Dl, A

6
4

H-THA
UC-THA

35

Sb, De, A 4

UC-THA

80

De, A

UC-THA

60

De, A

UC-THA

Postoperative Additional
ATT
procedures
(months)

Ty

Nd

Yes

12

No

Ty
ATy

+
+

Yes
Yes

18
12

No
No

Ty

Nd

Yes

12

No

Ty

Nd

Yes

12

No

ATy

Yes

12

No

64

Sb, A

UC-THA

Ty

Nd

Yes

18

No

HF

52

De, A

UC-THA

Ty

Yes

18

No

43

De, A

UC-THA

Ty

Yes

12

No

10

50

Sb,De, A

UC-THA

Ty

Yes

12

No

11

45

De, A

H-THA

Ty

Nd

No/
Persistence
+ SA

18

2 Debridements,
later implant
removal

12

48

De, A

UC-THA

Yes

12

No

Ty

st

N = normal; HF = healed focus; ESR = erythrocyte sedimentation rate at end of 1 hour in mm; De = destruction of hip on both sides;
Sb = subluxation; Dl = dislocation; A = abscess; UC-THA = uncemented THA; H-THA = hybrid THA; Ty = typical; ATy = atypical;
PCR = polymerase chain reaction; N = not done; SA = superadded Staphylococcus aureus infection.

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Neogi et al.

ATT by 6 weeks and was prescribed an additional 2 weeks

therapy until the index procedure.
All THAs were performed using a posterior approach.
After splitting the gluteus maximus, we found delineation
of the short external rotators difficult owing to surrounding
fibrosis. Given osteoporotic bones, we took extra care when
dislocating the hip. During reaming we ensured the reamer
was in the center to minimize the risk of cortical perforation. We curetted cavities in the acetabulum when present.
Owing to the presence of inflammation, soft tissue bleeding
tended to be greater; we therefore ensured adequate
hemostasis and availability of blood replacement when
needed. Abscesses detected on preoperative scans were
drained. Necrotic tissue, when present, needed adequate
debridement. All patients had cementless fixation on the
acetabular side; on the femoral side 10 patients had
cementless fixation and two patients had cemented fixation.
The AML plus femoral stem (DePuy, Warsaw, IN, USA),
Durolac shell (DePuy), and liner with a 28-mm metal head
(DePuy) were used in four patients; the Corail femoral
stem (DePuy, Leeds, UK), Pinnacle acetabulum cup and
liner (DePuy [USA]), and 28-mm head (DePuy [USA])
were used in three patients; the CPT femoral stem

Fig. 2AE A preoperative radiograph shows (A) femoral head

destruction and a large acetabular
cavity (arrow) with periarticular
osteopenia. (B) Anteroposterior
and (C) lateral radiographs show
the hips after THA and reconstruction of an acetabular
defect with morselized allograft
bone grafting (arrow). Followup
(D) anteroposterior and (E)
lateral radiographs obtained at
45 months show good incorporation of the allograft (arrow), and
no evidence of osteolysis or
reactivation.

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Clinical Orthopaedics and Related Research1

(Zimmer, Warsaw, IN, USA), Trilogy acetabular system

(Zimmer), and 28-mm head (Zimmer) were used in two
patients; and the Accolade femoral stem (Stryker Orthopaedics, Mahwah, NJ, USA), Trident shell and
polyethylene liner (Stryker Orthopaedics), and 36-mm
femoral head (Stryker Orthopaedics) were used in two
patients. On the acetabular side, we used one to three
cancellous screws in all patients. Morselized allograft bone
grafting was used on the acetabular side in one patient
(Fig. 2). Medium-sized cavities (12 cm) in two patients
were filled with iliac crest autograft and small cavities (less
than 1 cm) were left unfilled. During reduction of the
prosthesis, difficulty owing to preexisting contractures was
encountered, and therefore psoas release was performed in
three patients and adductor release in nine patients. In all
patients, the material obtained was sent for staining, culture, and histopathologic examination. We performed
polymerase chain reaction for the presence of the mpt64 [2]
gene of MTB in seven patients.
All patients wore graduated compression stockings and
used foot pumps for postoperative thromboprophylaxis.
Traction was used for 1 to 2 weeks. In-bed mobilization
was started on the second day. Toe-touch weightbearing

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Total Hip Arthroplasty in Active Tuberculosis

609

into three zones, as described by DeLee and Charnley [4].

The Engh and Bobyn classification system [5] for implant
fixation based on radiographic inspection was used to
assess the cementless femoral components.

and crutch walking were allowed from the tenth day and
continued for up to 8 to 12 weeks; full weightbearing was
allowed only after that.
All patients were prescribed ATT with isoniazid, rifampicin, ethambutol, and pyrizinamide postoperatively for
the first 4 months; isoniazid, rifampicin, and pyrizinamide
were prescribed for an additional 4 months; and isoniazid
and rifampicin were prescribed for another 4 to 10 months.
Thus patients whose ESR and CRP were normal by the
fifth month were given postoperative ATT for a total of
1 year, whereas for patients whose values remained above
normal, the decision was made to continue ATT up to
18 months.
Patients were seen for followup every 4 weeks after
discharge for the first 6 months and evaluated with the
Harris hip score (HHS) [11], erythrocyte sedimentation rate
(ESR), C-reactive protein (CRP), and liver function tests.
We obtained anteroposterior and lateral radiographs every
8 weeks. From 6 months to 1 year, patients were called
once in 8 weeks and all the previous parameters were
tested, whereas during the second year, patients were followed up every 3 months for the first 6 months and
thereafter were called once in 6 months, with all the previous parameters. The radiographic techniques were
standardized across all patients and for each radiographic view. Anteroposterior and lateral radiographs were
assessed by the senior authors (CSY, SAK) by comparing
them with previous radiographs for change in overall bone
density, any new and progressive radiolucent lines or
cavities, and implant subsidence and migration. The femoral component and associated interfaces were divided into
seven zones, as described by Gruen et al. [8], whereas the
acetabular component and surrounding bone were divided

Results
One patient had reactivation of the infections. She was
noncompliant with ATT and was lost to followup 2 months
postoperatively. After 4 months, she returned with infection and a discharging sinus. She underwent two
debridements. Cultures showed a superinfection with
Staphylococcus aureus, and the patient subsequently
underwent implant removal and resection arthroplasty.
MTB culture sensitivity was obtained from surgical specimens that showed sensitivity to all first-line drugs, which
were continued for 18 months under supervision. No
reactivation was seen in other patients at last followup.
There was no postoperative dislocation or any neurologic
or vascular complications in the remaining patients.
The preoperative pain score (component of HHS)
improved from a mean of 5 (SD = 5) to a mean of 30
(SD = 0) by 1 month postoperative. The HHS improved
from a mean of 38 (SD = 6) to a mean of 88 (SD =
11) by the last followup (Table 3). Range of movement
in the flexion-extension plane improved from an average of
35 (range, 1550) to an average of 108 (range, 70
120). Eleven patients did not use a walking aid at followup.
Culture specimens were positive for five patients; histopathologic analysis was positive for all patients, with
typical epithelioid granuloma with or without caseation
seen in 10 patients and poorly formed granuloma in two

Table 3. Followup
Patient
number

Followup
(months)

1
2

Harris hip score

Total range of movement

(flexion extension)

Reactivation

Preoperative

Postoperative

58

31

88

105

No

54

40

97

115

No

45

43

96

120

No

43

28

92

115

No

44

41

88

100

No

42

44

86

105

No

7
8

40
25

40
36

88
92

110
120

No
No

29

46

96

115

No

10

33

38

90

105

No

11

35

30

56

70

Yes

12

42

35

86

105

No

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Neogi et al.

patients. Polymerase chain reaction for the mpt64 gene [3]

was positive in all seven patients tested. Laboratory
parameters of ESR and CRP returned to normal in eight
patients by the fifth month and in the sixth to seventh
months of ATT in four patients. None of our patients
experienced changes in liver function, drug intolerance, or
hypersensitivity reactions. At followup, none of the
patients had progressive radiolucent lines or cavities
around the prosthesis. It took 18 to 24 months for the bone
density to appear similar on both sides.

Discussion
THA in patients with active TB is controversial [10, 12, 13,
1517, 23]. However studies showing favorable microbiologic properties of MTB after ATT, and clinical success
after implant use in patients with spinal TB with hip
arthritis, prompted us to perform THA in patients with
active TB and study their reactivation, laboratory findings,
and clinical results [7, 9, 15, 16, 25].
The study limitations were that this is a small series with
short-term followup and the retrospective design means
diagnostic criteria, surgical approaches, and medical
management were not standardized. All patients in this
study were diagnosed on the basis of clinical, biochemical,
and radiographic findings, which are quite accurate in
places endemic for TB, and the microbiologic diagnosis
was established after study of the tissue obtained at surgery
[2, 23]. However in the emergence of drug-resistant TB, we
now routinely perform preoperative CT-guided biopsy,
with specimens undergoing culture and sensitivity testing.
THA in a patient with quiescent TB of the hip is an
established procedure [10, 12, 13, 1517, 23]. However
there is lack of consensus regarding the definition of a hip
with quiescent TB. Some authors consider TB to be quiescent after 10 years of successful treatment [13, 15],
others 20 years after a sinus stops draining or 10 years
after an ankylosed hip [10], and others indicate the length
of time of the inactive infection should not be a decisive
factor and there always might be the risk of TB reactivation
[12]. In two small case series reporting THA in patients
with active TB, the patients had no recurrences, and the

authors emphasized adequate surgical debridement and

ATT for a successful outcome (Table 4) [15, 25]. Several
authors recommend preoperative chemotherapy from 1 to
4 weeks to as much as 3 months before any surgery in the
presence of active infection [15, 23], and we empirically
treated all patients a minimum of 4 weeks before surgery.
This period allows stabilization of the lesion, improvement
in soft tissue contractures with traction, and better planning
of the reconstructive procedure. Postoperative chemotherapy is essential to control residual foci of TB [15, 23, 25].
Although the first-line drugs for ATT have been standardized, there still is no consensus regarding the duration.
WHO guidelines recommend 6 months for extrapulmonary
TB [24], whereas The Centers for Disease Control recommend 6 to 9 months for osteoarticular TB [1]. We
followed the protocol at our institute for skeletal TB. If the
patients general condition shows marked improvement
and the ESR and CRP return to normal by the fifth month,
then we continue ATT until 1 year; however, if the ESR
and CRP take more than 5 months to return to normal, we
continue ATT until 18 months.
The presence of cemented or cementless implants
seemingly has no influence on reactivation [15, 25]. Our
preference was uncemented prostheses for the femoral and
acetabular sides, but in two patients older than 60 years, we
preferred a cemented femoral component because we were
not satisfied with the stability of the femoral uncemented
prosthesis. In studies of THA in patients with quiescent TB
[11, 17], reported reactivation rates were similar for
cemented and cementless THAs, which indicates thermal
reaction from cement is irrelevant to reactivation. In our
study, one patient with cemented arthroplasty had reactivation owing to noncompliance with ATT. Insufficient
research has been performed regarding the use of antituberculous drugs impregnated in cement, with studies on
Table 5. Comparison of ROM in active and quiescent TB
Study

Average ROM
in flexion/extension plane

Eskola et al. [6]

86.1

Current study

108

ROM = range of motion.

Table 4. Review of case series

Study

Cases

Age (years)

Preoperative ATT

Type of THA

Followup (months)

HHS at followup

Reactivation

Kim et al. [15]

33.3

Yes

C-THA

33

86

None

Yoon et al. [25]

46.4

No

UC-THA

57.6

95

None

45

Yes

10-UC-THA
2-Hybrid THA

41

88

Current study

12

C-THA = cemented THA; UC-THA = uncemented THA; ATT = Antitubercular therapy; HHS = Harris hip score.

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streptomycin, kanamycin, vancomycin, and rifampicin [14,

15, 17, 20]. Nevertheless, recommendations regarding their
use cannot be made based on these few reports. Isoniazid,
rifampicin, and ethambutol are heat-stable, but the risk of
toxicity and poor elution preclude their use until further
research is performed [19].
In one of our patients with a large acetabulum (Fig. 2),
we performed morselized allograft bone grafting after
thorough curettage and debridement. At 46 months followup, the graft is well incorporated and the patient has no
reactivation. Small cavitary defects, as reported in another
study [25], also were left unfilled in our patients, and at
followup these showed healing with new bone formation.
Use of fresh-frozen allografts in patients with TB of the
spine has shown incorporation and remodeling with no
cases of collapse or reinfection [7].
Studies have reported that THA in the quiescent hip
relieves pain and improves walking ability but improvement in range of movement was modest (Table 5) [6, 15,
17]. Yoon et al. [25] reported an improvement in HHS in
their patients from 37 preoperatively to 95 at their last
followup. In our patients, the HHS improved from an
average of 38 to 88. The slightly lower average score of our
patients compared with the average score reported by Yoon
et al. [25] was the result of one patient with a poor result
who was noncompliant with ATT and followup protocol,
resulting in persistence and reactivation of TB and sinus
formation. She also had a pyogenic superinfection with
Staphylococcus aureus and underwent implant removal and
resection arthroplasty.
In the majority of patients with TB of the hip, the
treatment comprising drug therapy, traction, and supervised mobilization produces good results, especially during
the early stages of the disease. In patients who do not
respond favorably to nonoperative treatment, joint clearance surgery (a combination of synovectomy and joint
debridement) should be performed before the hip is
destroyed and the hip should be immobilized in a functional position in a spica cast for 6 to 8 weeks followed by
rehabilitation [2]. If unacceptable functional results are
seen after adequate treatment, then depending on the
amount of destruction and extent of fibrous ankylosis, we
offer resection arthroplasty or THA to our patients. THA in
active disease with advanced destruction is offered to a
small proportion of patients who fulfill strict inclusion
criteria.
Our experience with these patients allows us to believe
THA is a safe procedure in active TB providing symptomatic relief, functional improvement, and early return to
activity. We recommend preoperative culture and sensitivity and, in the absence of drug resistance to first-line
drugs, to proceed with a single-stage procedure accompanied by thorough debridement to decrease the disease load

Total Hip Arthroplasty in Active Tuberculosis

611

in patients with advanced disease, followed by a complete

course of ATT. Patient counseling regarding compliance
with the ATT regimen and postoperative protocol is very
important in ensuring success.

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