Tuberculous coxitis
Tuberculous involvement of the hip joint (coxitis tuberculosa) is the second most common form of specific arthritis, accounting for about a fifth of all cases. Children aged three to seven years are most susceptible to the disease.
The clinical picture manifests with symptoms of general intoxication and rapid fatigue. The leading local symptom is pain syndrome, which significantly worsens with walking. An important diagnostic feature: pain is localized not only in the hip joint area but also frequently radiates to the knee.
Visual inspection of the patient reveals the following signs:
- Atrophy of the muscular framework of the affected limb.
- Characteristic smoothing of the gluteal and inguinal folds.
- Forced posture: the thigh is adducted and flexed. This posture reflexively relaxes the joint capsule, which helps reduce pain intensity.
In severe cases, the formation of purulent fistulas is possible. X-ray examination shows pronounced osteoporosis, narrowing of the joint space, and destructive changes (destruction of the acetabulum or femoral head).
Tuberculous gonitis: Prearthritic stage
Knee joint involvement (gonitis tuberculosa) ranks third in frequency (15–20% of cases) and is also predominantly diagnosed in young children. The pathology develops in stages.
The prearthritic stage is characterized by the dominance of general symptoms over local ones. The syndrome of general tuberculous intoxication comes to the forefront.
Functional impairments develop gradually:
- The child begins to tire quickly.
- A limp appears.
- During walking, the patient characteristically "drags" the affected leg.
Key feature of this stage: complete absence of pain in the joint itself.
Arthritic stage of gonitis
With the transition to the arthritic stage, the clinical picture changes dramatically, and severe pain appears.
Local status is characterized by a significant increase in the volume of the knee. The joint loses its normal contours: the outlines are completely smoothed out, the skin over it becomes taut, smooth, and shiny. The shape of the affected area becomes typically fusiform. The patient holds the leg in a forced semi-flexed position.
Examination reveals specific symptoms:
- Patellar tapotement (ballottement) test: upon pressure, the patella "sinks" and returns to its original position after the pressure is released. This is a reliable sign of fluid effusion in the joint cavity.
- Alexandrov's sign: thickening of the skin fold on the outer surface of the thigh of the diseased limb compared to the healthy side. This indicates trophic disorders and subcutaneous edema.
Anthropometric measurements confirm an increase in joint circumference against the background of a decrease in thigh circumference due to muscle atrophy. As a complication, rare purulent fistulas may form, from which small bone sequestra can discharge.
X-ray findings in this phase include osteoporosis of the articular ends of the bones, narrowing of the joint space, and, in advanced situations, destruction of the articular surfaces.
Briefly: answers to topical questions
What stages are distinguished in the clinical course of tuberculous gonitis?
Three main stages of pathogenesis are distinguished in the clinical course of tuberculous gonitis.
- Prearthritic stage — formation of the primary tuberculous focus (osteitis) in the bone marrow near the joint. Characterized by general intoxication syndrome and limping in the absence of pain.
- Arthritic stage — transition of specific granulomatous inflammation to the joint (secondary arthritis). Accompanied by pain syndrome, fusiform joint deformation, patellar ballottement sign, and Alexandrov's sign.
- Postarthritic stage — outcome of the disease and process stabilization, characterized by pronounced joint deformation and impaired function.
An intermediate remission stage is also distinguished, when clinical manifestations regress.
What outcomes and residual deformations form in the postarthritic stage of tuberculous gonitis?
In the postarthritic stage, inflammatory phenomena subside, but varying degrees of joint function impairment persist, up to and including ankylosis. The main outcomes and residual changes include:
- Ankylosis — a possible pronounced impairment of joint function and mobility.
- Contractures — mixed myogenic and arthrogenic movement restrictions.
- Frontal deformations — varus or valgus deformity of the limb.
- Secondary deforming arthrosis — with "start-up" pain and pain upon load.
- Joint instability — dislocations and subluxations.
- Change in limb segment length and limb growth lag when the growth plate is affected.
The patellar ballottement sign is easy to remember by imagining a float: due to excess fluid (effusion) in the joint, the patella "floats" and springs when pressed.
What else to study on this topic
- Mechanisms of bone sequestra formation in tuberculous arthritis.
- Trophic tissue changes and the pathogenesis of Alexandrov's sign.
- X-ray presentation of acetabular destruction.
- Pathogenesis of muscle atrophy in specific joint inflammation.
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