What is the treatment for tuberculosis of the hip?

Treatment of Tuberculosis of the Hip

The standard treatment for tuberculosis of the hip consists of a 6-month regimen of rifampicin and isoniazid, supplemented with pyrazinamide and ethambutol for the first 2 months, with surgical intervention reserved for cases with neurological compromise, spinal instability, or significant joint destruction. 1

Medical Treatment

First-line Antitubercular Therapy

• The recommended regimen is 2HRZE/4HR: 2 months of isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E), followed by 4 months of isoniazid and rifampicin 1, 2
• Daily dosing is strongly recommended over intermittent regimens to prevent development of drug resistance 1, 3
• Fixed-dose combinations may provide more convenient drug administration and improve adherence 1
• If pyrazinamide cannot be tolerated, treatment should be extended to 9 months 1

Drug Administration Considerations

• Rifampicin should be administered on a daily basis; intermittent therapy is not recommended due to higher incidence of adverse reactions 3
• Patients should be cautioned against interruption of the daily dosage regimen as rare renal hypersensitivity reactions have been reported when therapy is resumed 3
• Directly Observed Therapy (DOT) is recommended to ensure adherence to the treatment regimen 1

Diagnostic Confirmation

• Image-guided aspiration biopsy should be performed to confirm the diagnosis and determine drug susceptibility 1
• Mycobacterial cultures and nucleic acid amplification testing should be performed to identify the organism and guide therapy 1

Surgical Management

Indications for Surgery

• Surgery is indicated for patients with:
  • Large abscess formation 1
  • Failure to respond to medical therapy 1
  • Significant joint destruction 4, 5
  • Neurological compromise 1

Surgical Options

• Simple synovectomy for early disease with minimal joint destruction 4
• Joint debridement for more advanced disease 4
• Total hip arthroplasty (THA) for advanced disease with significant joint destruction, but only after a period of antitubercular therapy 5, 6
• Excision arthroplasty may be preferred in some cases where patients need to squat, sit cross-legged, and kneel 7

Special Considerations

Drug-Resistant Tuberculosis

• For multidrug-resistant TB (MDR-TB): Treatment should be guided by drug susceptibility testing and managed by or in consultation with TB experts 1
• Empirical regimen for suspected drug resistance may include a fluoroquinolone, an injectable agent, and additional oral agents 1
• Never add a single new drug to a failing regimen to prevent further acquired resistance 1

HIV Co-infection

• For HIV co-infected patients, antiretroviral therapy should be initiated within 2 weeks of starting TB treatment 1
• Treatment duration may need to be extended to at least 9 months for HIV-positive patients 8

Monitoring and Follow-up

• Regular clinical assessment for symptom improvement (pain, fever, weight gain) 1, 8
• Radiological follow-up to evaluate response to treatment and detect potential complications 1, 8
• Monitor for drug-related adverse effects, especially hepatotoxicity with isoniazid and rifampicin, and visual disturbances with ethambutol 1
• Liver function tests should be followed up every two to four weeks while receiving antituberculous treatment 9

Adjunctive Therapies

• Nutritional support is essential, especially for malnourished patients 1
• Physiotherapy and rehabilitation are important for improving function and preventing complications 1, 5
• Orthotic devices may be needed to support the joint during healing 1

Prognosis and Outcomes

• With appropriate treatment, TB of the hip can heal with minimal sequelae, especially if diagnosed and treated early 4
• In advanced disease with significant joint destruction, some residual morphological defects may remain despite treatment 4
• Total hip arthroplasty after completion of antitubercular therapy can provide good functional outcomes in cases with advanced joint destruction 5, 6

Common Pitfalls and Caveats

• Adherence to the full 6-month regimen is critical to prevent relapse and development of drug resistance 8
• Total hip arthroplasty should only be considered after a safe period of absolute disease quiescence to minimize risk of reactivation 7
• If performing THA in active tuberculosis, thorough debridement of infected tissues and postoperative antituberculous therapy for at least 12 months are essential 6