Case Report Journal of Orthopaedic Case Reports 2016 Nov‑Dec: 6(5):28‑31

Total Hip Arthroplasty Indicated for a Tuberculous Coxitis

Complicating a Controlled Acquired Imunodefficiency
Syndrom Condition: A Preliminary Report Concerning a Case
Handy Eone Daniel1, Jean Emile Bayiha1, Théophyle Chunteng Nana1,
Olivier Kennedy Muluem1, Jean Bahebeck1
What to Learn from this Article?
Implanting total hip arthroplasty in tuberculous hip osteoarthritis is a safe procedure. However, this requires the early
commencement of antituberculous drugs.

Abstract
Introduction: Total hip arthroplasty (THA) remains controversial in active tuberculosis (TB) infection because of the risks of septic
loosening and reactivation of the infection. We present a rare case of THA in a patient positive for the human immunodeficiency
virus (HIV) with active tuberculous coxitis. The aim of this work is to share our experience and our preliminary results.
Case Report: The patient was a 53-year-old Black African woman, positive for the HIV, who was operated for implantation of a THA
via the Hardinge approach indicated for a severe painful hip with restriction of joint movement and limp. A creamy-white liquid was
noticed in the hip joint which was negative for urgent Gram-staining. The surgery was completed with the implantation of a hybrid
THA. The post-operative period was uneventful, and she was put on antituberculous drugs following a positive histology result for
TB, and to continue her antiretroviral drugs. She still has a satisfactory result for 3 years since her surgery.
Conclusion: On condition that the patient is put simultaneously on triple antibiotics and antituberculous drugs, we propose that
THA could be an option in patient presenting with the association of HIV infection and active tuberculous coxitis.
Keywords: Tuberculous coxitis, total hip arthroplasty, human immunodeficiency virus, hip.

Introduction
The principal surgical modalities include arthrodesis [1], resection
Tuberculous coxitis still remains an indication for long-term arthroplasty, and total hip arthroplasty (THA) [2, 3]. Among
antituberculous medications associated with surgical treatment. all these surgical treatments, only the last confers a satisfactory

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Dr. Handy Eone Daniel Dr. Jean Emile Bayiha Dr. Théophyle Chunteng Nana Dr. Olivier Kennedy Muluem Prof. Jean Bahebeck
www.jocr.co.in

DOI: 1
Department of Orthopaedics, Unit of orthopedic surgery and traumatology of the motor apparatus Yaounde Central Hospital.
2250-0685.616

Address of Correspondence
Dr. Handy Eone Daniel,
Service de Chirurgie Orthopédique et de Traumatologie de l’Appareil Moteur, Hôpital Central de Yaoundé, Yaoundé, Cameroon.
E-mail: [email protected]

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Journal of Orthopaedic Case Reports | pISSN 2250‑0685 | eISSN 2321‑3817 | Available on www.jocr.co.in | doi: 10.13107/jocr.2250-0685.616
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non‑Commercial License (http://creativecommons.org/licenses/by‑nc/3.0) which
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functional status; but in an immune compromised terrain, it does
not just expose  to risks of early post-operative infections but also
to short-term septic  loosening. We have not found studies in the
literature reporting the  results  concerning implantation of THA
in human immunodeficiency virus (HIV) positive subjects with
tuberculous  coxitis. However, we sort for its indications in each
infection separately.

The aim of this work is to share our experience and our preliminary
results of a THA implanted on a 53-year-old subject with the acquired
immunodeficiency syndrome (AIDS) who has been on antiretrovirals
(ARV) but having an active tuberculous coxitis.

Case Report

The subject was a 53-year-old housewife, who consulted in December

2013 for inflammatory pain in the right hip evolving for 3  months Figure 1: Pelvic X-ray showing narrowed joint space, without the other signs
controlled with non-steroidal anti-inflammatory drugs, with a walking of coxarthrosis.
distance of about 100 m. The medical history revealed that she is HIV
infected and on triple ARV for 1  year, with a CD4 count of 473/ml,
the viral load was not documented. Evaluation of the right hip showed
flexion/extension of 80/20, abduction/adduction of 40/20, internal
rotation/external rotation of 20/15, a trendelenburg gait, and a limb
length discrepancy of 3 cm. The muscle power of the gluteus medius was
4/5. There was amyotrophy of the right quadriceps muscle. The Merle
d’Aubigne and postel hip score was evaluated to be 9/18. The anterior-
posterior view of the pelvic X-ray (Fig. 1) shows joint space narrowing,
loss of head sphericity, shortened hip length, with no other signs of
coxarthrosis (sclerosis, geodes, osteophytes). These findings coupled
with the patient’s history of immunosuppression were suggestive of a
coxitis, which could be due to tuberculosis (TB) infection. However,
an MRI scan was not done because it was unavailable, and the patient
could not afford to do it due to financial constraints. The full blood count
revealed a hemoglobin level of 13  g/dl, however, the white cell count
was 8000 with 45% lymphocytes and 50% neutrophiles. The rest of the
Figure 2: Per-operative aspect of the cream white liquid.
laboratory investigation was unremarkable.

The patient was operated for implantation of a THA via the Hardinge
approach. During surgery, an incident was encountered while dislocating
the hip to resect the femoral head. There was a cream-white liquid that was
oozing out of the hip joint (Fig. 2). A sample was rapidly collected per-
operative and sent for urgent bacteriological analysis. The gram coloration
was negative, the rest of the liquid was then sent for microbiological,
mycobacteriological and histological analyses. The debris from reaming
and the femoral head (Fig. 3) were also sent for analysis. The surgery
was continued and completed with the implantation of a hybrid THA
due to the fragile acetabulum; the stem was uncemented while the
acetabulum was cemented (Fig. 4). The anatomopathological findings
showed an active TB infection (Fig. 5). At the end of the surgery, the limb
length discrepancy was corrected. The wound healing was normal, and
rehabilitation commenced 24 h after surgery with isometric contractions
of the gluteal and quadriceps muscles in bed. She was then verticalized the
second day following surgery and walking was assisted using crutches. The
Figure 3: Femoral head after resection.
patient thence continued with her ARV the same day of surgery and 10 days
triple antibiotics initiated. She had a fixed combination of antituberculous
29 Discussion
drugs (isoniazid, rifampin, pyrazinamide, and ethambutol) to be taken for
12 months. 3 years after the surgery we have not noticed any relapse of the This write up reports a case of THA with favorable short-term evolution in
infection or any loosening. a 53-year-old female black African, with a tuberculous coxitis complicating

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Campbell and Hoffman [7] found that patients with HIV disease are more
susceptible to postoperative complications like delayed wound healing,
and worsening of their disease condition, however, our patient did not
have any wound complications and healed by primary intention.

Some authors have reported that implantation of prosthetic implants

in active TB is controversial for fear of disease reactivation, but recent
findings showed that metals could be safely used in tuberculous
lesions [3, 8]. Oztürkmen et al. [9] did not observe any reactivation
of disease in his 9  cases after an average follow-up of 5.6  years, all the
femoral and acetabular components did not show signs of loosening. After
3 years of follow-up our patient presented with adequate bone ingrowth
on X-ray films and no signs of loosening. Similarly, Wang et al. [3] had
no case of hip dislocation and loosening. Other authors made similar
observations [10, 11]. We carried out thorough debridement of infected
tissues and post-operative antituberculous therapy as recommended by
Figure 4: Hybrid total hip arthroplasty, uncemented stem and a Wang et al. [3] thereby lowering the risk of reactivation.
cemented acetabulum.
Many authors have indicated and reported favorable results of THA on
tuberculous coxitis [3, 10, 12], associated with long-term antituberculous
drugs. Bahebeck et al. [13] and Harrison et al [14] have also reported
favorable results of THA on HIV-positive subjects on condition that
they are simultaneously on triple ARV and long-term peri-operative
antibiotics. Because of the results obtained in the studies mentioned
above, our experience on caseous necrosis, and a per-operative negative
gram stain, we therefore decided not to do a Girdlestone resection
arthroplasty but implant a THA. The histological findings comforted
us as we instituted antituberculous drugs. The short- and medium-term
results are satisfactory.

Conclusion

While awaiting a series of similar subjects which is difficult to assemble due

to the rare nature of this association, THA could be a good surgical option
on HIV-infected individuals having TB coxitis on condition that the
Figure 5: Histology showing a caseous necrosis in the middle and peripheral subject is simultaneously placed on triple antibiotics and antituberculous
grannulomtosis with giant cells characteristic of tuberculosis. drugs.

an AIDS condition on triple ARV. To the best of our knowledge, this is the Authors Contributions
first case reported in contemporary literature. For this reason, and despite
All the above-listed authors did actively participate in this work.
the fact that it is the only case, reporting it to the scientific community is a
warranty. It should be noted that arthropathy has been found to be among
the most common orthopedic pathology in HIV-positive patients [4] and
could be either related to HIV-induced immunodeficiency, or due to side
Clinical Message
effects of antiviral drugs [5].
It is possible to do a THA in active tuberculous coxitis in HIV-
Although bacterial infection rates according to the literature are increased
infected patients on the condition that the patient receives long-
in HIV-infected patients who receive surgical treatment [6], our patient
term antituberculous drugs and ARVs.
did not show any post-operative sepsis.

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How to Cite this Article

Conflict of Interest: Nil
Source of Support: None Daniel HE, Bayiha JE, Nana TC, Muluem OK, Bahebeck J. Total
Hip Arthroplasty Indicated for a Tuberculous Coxitis Complicating
a Controled Acquired Imunodefficiency Syndrom Condition: A
Preliminary Report Concerning a Case. Journal of Orthopaedic Case
Reports 2016 Nov-Dec;6(5):28-31.

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Journal of Orthopaedic Case Reports | Volume 6 | Issue 5 | Nov - Dec 2016 | Page 28-31