[Evaluation of treatment outcomes in tuberculosis of knee and hip joints in 2005-2012]. / Srovnání výsledku lécby tuberkulózy kolene a kycle z období 2005-2012.

PURPOSE OF THE STUDY: Tuberculosis (TB) in a joint region presents high risk of damage to the joint. Consequences of a late diagnosis and inadequate therapy may be serious particularly in the large joints of lower extremities. Tuberculosis of knee and hip joints accounts for about 25% to 35% of osteoarticular tuberculosis (OAT). The aim of this study was to evaluate the objective and subjective results of tuberculosis treatment in knee and hip joints. MATERIAL AND METHODS: Of 258 OAT patients treated at the Specialised Treatment Centre Jevícko between January 2005 and September 2012, tuberculosis of the hip joint was diagnosed in 31 patients in whom three hips were treated by incision and drainage and 10 by total hip replacement; 18 patients had tuberculosis of the knee joint with the following treatment: puncture in seven knees, incision and drainage in eight, excochleation of a tuberculous focus in the proximal tibia in two, removal of a bursa in one, arthrodesis in four and total knee replacement in four patients. The patients continued to be followed up at the Jevícko Centre. The scale of 1 to 5 (best to worst) was established for evaluation of objective and subjective results of the treatment. The data were analysed using the basic statistical characteristics and compared. RESULTS: The objective evaluation was better for the hip joint; the sums of relative frequencies of marks 1 to 3 were 72.22% in the knee and 80.65% in the hip. In the knee more than 50% of the cases fell in the interval <1.304; 4.252>, in the hip this was <1.296; 3.672>. The hip joint was better subjectively evaluated, it had a higher sum of relative frequencies of marks 1 to 3, i.e., 96.77% as compared with 88.89% for the knee. In the knee more than 50% of the cases had marks in the interval <0.767; 3.122>; in the hip this was <0.869; 2.680>. The hip joint was better evaluated both objectively and subjectively. DISCUSSION: An early diagnosis allows for the treatment of synovitis, which has a better prognosis than an arthritic disease. The subjective perception of treatment results showed a better evaluation than its objective correlate. Many patients were satisfied with the results, even with an immobilised joint (in arthrodesis). Total joint replacement in OAT patients does not always provide expected results in either knee or hip joints. Arthrodesis also has its indications related to health condition, age and social status of the patient. In periprosthetic TB infections, a careful consideration should be given to removal of the prosthesis and its re-implantation in relation to all circumstances associated with each particular case. CONCLUSIONS: Tuberculosis of large weight-bearing joints is a rare entity in the countries with low TB prevalence, including the Czech Republic. It is necessary to pay attention to diagnosis and therapy and make them more effective even at higher costs associated with total hip replacement in TB or post-TB patients in order to maintain or restore joint function. At the time of borders open for citizens from countries with higher TB prevalence, the diagnosis of OAT should be considered.

[Total hip replacement after tuberculous coxitis. Twenty-seven-year experience (1980-2007)]. / 27leté zkusenosti s endoprotetikou po tuberkulózní koxitide (1980-2007).

PURPOSE OF THE STUDY: Tuberculous hip arthritis accounts for about 15 % of all orthopaedic forms of tuberculosis and ranks third after spinal and knee joint tuberculosis. The aim of this study was to present the results of total hip arthroplasty (THA) for treatment of post-infectious arthritis or ankylosis, or previous arthrodesis. MATERIAL: A group of patients, 16 women and 10 men, treated at the 1st Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague, between 1980 and 2007, was evaluated. All patients had tuberculous hip arthritis in their history and subsequently underwent THA. The average age at the time of THA was 65 years. METHODS: Indications for THA following tuberculous coxitis were secondary post-infectious arthritis in 20 patient, ankylosis (fibrous or osseous) in four and conversion from arthrodesis in two. Intra-operative samples were taken for microbiological examination, polymerase chain reaction (PCR) and histological examination. Anti-tuberculous drugs (rifampicin and isoniazid) and cephalosporin were administered intra-operatively following the sample collection and continued post-operatively. Cephalosporin was discontinued on post-operative day 11, rifampicin and isoniazid were administered for further 3 to 5 months with regular laboratory tests. RESULTS: The average post-operative values for flexion ranged from 0 to 90 degrees, for abduction from 0 to 35 degrees and for both internal and external rotation from 0 to 30 degrees. At the end of treatment all patients walked without aid and with full weight-bearing on the operated leg. No complications were recorded. Intra-operative findings of microbiological, PCR and histological examinations were negative. No recurrent tuberculous disease was found. DISCUSSION: A total joint replacement in any post-infectious condition is a complex issue. The average time between achieving a steady state o tuberculous arthritis and the THA procedure was approximately seven years. The outcome was evaluated as good by 75 % of the patients, who would be willing to undergo the surgery again. The clinical picture and radiographic and laboratory findings were within norms at regular follow-ups, which is in agreement with the literature data. Our system of intra- and post-operative administration of anti-tuberculous drugs and antibiotics proved very efficient. CONCLUSIONS: In contrast to arthrodesis or Girdlestone resection arthroplasty, THA results in a marked improvement of painless joint motion. Before any patient is indicated for THA, a thorough medical history with laboratory, internal and pulmonary (including heart and lung radiographs) examination is necessary. When there is more than one tuberculous disease in the patient's medical history, other organ systems such as urinary or reproductive tracts should also be examined. In addition to conventional radiography, examination by computed tomography or magnetic resonance imaging is indicated. The priority is an individual approach of the phthisiology orthopaedist to the indications ensuing from this comprehensive examination, with assessment of both physical and psychic state of the patient in view of post-operative rehabilitation.