Can Total Hip Replacement (THR) be performed in patients with active Tuberculosis (TB)?

Total Hip Replacement in Active Tuberculosis of the Hip

Total hip replacement (THR) can be safely performed in patients with active tuberculosis of the hip when combined with appropriate antituberculous therapy and thorough surgical debridement.

Preoperative Management

• Antituberculous therapy: Must be initiated at least 2-3 weeks before surgery 1, 2

  • Standard regimen: Isoniazid, rifampicin, pyrazinamide for first 2 months, followed by isoniazid and rifampicin 3
  • For drug-resistant TB: Follow MDR-TB protocols with at least 5 effective drugs in intensive phase and 4 drugs in continuation phase 4

• Preoperative assessment:

  • Confirm TB diagnosis through histological examination 1, 2
  • Monitor inflammatory markers (ESR, CRP) to assess disease activity 5
  • Evaluate extent of joint destruction through imaging

Surgical Approach Options

Single-Stage THR

• Indications: Most cases of active TB without extensive destruction or sinus tracts 1, 6
• Procedure:
  • Thorough debridement of all infected and necrotic tissues
  • Implantation of prosthesis in same operation
  • Uncemented prostheses preferred (used in 72.8% of cases) 5

Two-Stage THR

• Indications: Cases with 7:
  • Extensive joint destruction difficult to debride in one operation
  • Presence of sinus tracts
• Procedure:
  • First stage: Thorough debridement after at least 2 weeks of antituberculous therapy
  • Interval treatment: Continue antituberculous therapy for 3-4 months
  • Second stage: Implant prosthesis when ESR and CRP normalize and wound is well healed

Postoperative Management

• Antituberculous therapy: Continue for 6-15 months postoperatively 1, 2, 7

  • Total duration of therapy should be at least 12 months from initiation 7
  • For drug-resistant TB, follow appropriate extended regimens 4

• Monitoring:

  • Regular clinical evaluation for signs of reactivation
  • Monitor inflammatory markers (ESR, CRP)
  • Assess liver function tests to detect medication toxicity
  • Evaluate functional outcomes using Harris Hip Score

Outcomes and Prognosis

• Infection reactivation: Very low risk (1-3%) when proper protocol followed 1, 6, 5
• Functional outcomes: Excellent improvement in most patients
  • Mean Harris Hip Score improvement from 35-37 preoperatively to 88-92 postoperatively 5, 7
• Complications: Similar to standard THR when proper protocols followed

Pitfalls and Caveats

• Non-compliance with antituberculous therapy is the primary risk factor for reactivation 1
• Inadequate debridement increases risk of persistent infection
• Premature surgery before adequate preoperative antituberculous therapy may lead to higher failure rates
• Drug resistance must be identified early and treated appropriately to prevent treatment failure 4
• Hepatotoxicity from antituberculous medications requires regular monitoring of liver function

Special Considerations

• HIV co-infection: Requires careful monitoring and possibly extended treatment 4

  • ART should be initiated within 2-8 weeks of TB treatment depending on CD4 count
  • Monitor for immune reconstitution inflammatory syndrome (IRIS)

• Drug-resistant TB: Follow specialized protocols with individualized drug regimens 4

  • For MDR-TB: At least 5 drugs in intensive phase, 4 in continuation phase
  • Extended treatment duration (15-24 months after culture conversion)

The systematic evidence shows that THR in active TB of the hip is safe and effective when combined with appropriate medical therapy and surgical technique, providing significant improvement in pain and function with low risk of reactivation.