Outcome of single-stage total hip arthroplasty in advanced active tubercular arthritis of the hip in Indian patients

Abstract

BACKGROUND

Total hip arthroplasty (THA) is an acceptable method of treatment in healed tubercular (TB) arthritis; however, the role of THA remains debatable in advanced active (stage 3 and 4) TB arthritis of the hip (TB hip) in adults. Single-stage THA in advanced active TB hip is fraught with many challenges, including but not limited to disease reactivation, hip instability, and early revision surgery. These complications may lead to suboptimal clinical outcome in the given patient population.

AIM

To investigate the challenges and clinical outcome of single-stage primary THA in advanced active TB hip in Indian adult patients.

METHODS

In this prospective study, 21 Indian adults having advanced active TB hip without active sinus were treated by single-stage primary THA by posterior approach. The minimum duration of preoperative antitubercular treatment was 6 weeks. Tthe type of THA included cemented (n = 18), cementless (n = 2), and hybrid (n = 1). The mean duration of post-operative antitubercular treatment was 15 months. The mean follow-up period was 30 months. Patients were evaluated for disease reactivation, Harris Hip score, implant loosening, and dislocation.

RESULTS

Intraoperative challenges include increased blood loss 465 ± 48 mL (390-510 mL) in all patients, cortical breach of the femur (n = 1), acetabular reconstruction to prevent a high hip center (n = 1), and conversion from cementless to cemented THA (n = 2). Post-operative complications included disease reactivation at 3 months after surgery (n = 1) and hip dislocation with wound dehiscence (n = 1). There was no neurovascular complication. There was no implant loosening at the time of last follow-up. The preoperative mean Harris Hip score showed a statistically significant improvement at the time of final follow-up [27.38 ± 6.3 (range 20-35) vs 78.47 ± 5.24 (range 78-88); P < 0.001].

CONCLUSION

Single-stage primary THA in advanced TB hip is associated with a relatively high rate of complications in certain selected patients.

Key Words: Hip joint; Infection; Tuberculosis; Arthritis; Surgery; Debridement arthroplasty; Dislocation; Hip replacement

Core Tip: Single-stage primary total hip arthroplasty in patients with advanced active tubercular arthritis of the hip (stages 3 and 4) provides a satisfactory outcome in most patients, with a relatively high risk of complications in certain selected cases. Poor compliance with antitubercular treatment is associated with the risk of disease reactivation, despite adequate preoperative antitubercular treatment and the absence of an active discharging sinus.

INTRODUCTION

Osteoarticular tuberculosis accounts for 2%-3% of all tuberculosis cases[1]. Tuberculosis of the hip, with an incidence of 10%-15%, is the second most common location of osteoarticular tuberculosis after the spine[2,3]. Early diagnosis of tubercular (TB) arthritis of the hip (TB hip) may be missed due to its deep anatomical location and paucibacillary nature of the disease[4]. In developing countries, many patients with TB hip are young and usually present late with advanced active TB arthritis[5,6]. Such patients have severe cartilage and bone destruction with subsequent hip pain, deformity, shortening, and instability[7]. The treatment of such advanced disease is controversial, and the available treatment options include anti-TB treatment (ATT) along with excisional arthroplasty, total hip arthroplasty (THA), or arthrodesis, each having its own merits and demerits[8-10]. THA in healed or quiescent TB hip is a well-established procedure with satisfactory outcome in the majority of cases[11-13]. Performing THA in an active TB hip has several controversies related to the ATT regimen, single- or two-stage surgery[14-18], type of arthroplasty (cemented vs cementless), apprehension for disease reactivation, and implant survival[19-21]. As a result of this, few authors consider THA in patients with TB hip to be a contraindication, whereas others recommend varying time intervals ranging from 10 years to 20 years after the active disease before considering THA[22-24]. The present study evaluated the major challenges and clinico-radiological outcome of single-stage THA in Indian adults with advanced active TB hip.

MATERIALS AND METHODS

It was a single-center, prospective study at a tertiary health care facility. Written informed consent was taken from all of the study participants. Institutional ethical committee clearance was taken before starting the study. Indian adult patients with active TB arthritis (stage 3 and 4) of the hip were included in the study[2]. None of the patients had an active discharging sinus. All patients were given four-drug ATT, including rifampicin, isoniazid, ethambutol, and pyrazinamide for 2 months and three-drug ATT for the remaining duration of treatment depending upon the clinico-radiological progression of the disease. Local administration of ATT into the hip with or without cement was not done in any patient. All patients had a decreasing trend of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) before surgery. Exclusion criteria and diagnostic work for study participants are mentioned in Tables 1 and 2, respectively.

Table 1 Exclusion criteria for study participants.

Exclusion criteria
Skeletally immature patient	Immunocompromised status of patients
Stage 1 and 2 involvement of TB hip	Presence of an active discharging sinus
Refused for a surgical intervention due to financial constraints	Revision total hip arthroplasty for tubercular arthritis of the hip
Short follow-up

TB hip: Tubercular arthritis of the hip.

Table 2 Investigations to make preoperative diagnosis of tubercular arthritis of the hip.

Preoperative diagnostic work-up
Thorough clinical history and examination
Radiological examination
Radiographs of the pelvis with both hips, AP view as well as lateral; view of the involved hip; chest X-rays, PA view
MRI pelvis
Complete blood count, ESR, CRP
USG guided hip aspiration-aspirate sent for CBNAAT, Gram staining, culture, and sensitivity for tubercle bacilli in selected cases

AP: Anteroposterior view; CBNAAT: Cartridge-based nucleic acid amplification test; CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; MRI: Magnetic resonance imaging; PA: Posteroanterior view; USG: Ultrasonography.

All of the patients were operated on by a single surgeon having more than 20 years of experience in hip joint reconstruction surgery. All of the patients were operated on under regional or general anesthesia in the lateral decubitus position by posterior approach. Third-generation injectable cephalosporins were given for 3 days in the perioperative period to prevent secondary infection. A thorough joint debridement was done, followed by single-stage primary THA in all the cases. Resected pathological tissue samples from multiple sites were sent for subsequent biopsy, Gram staining, culture and sensitivity for TB bacilli, and cartridge-based nucleic acid amplification test.

Postoperatively, no traction was used, and ambulation and weight-bearing were customized to each patient depending upon the bone quality, need for acetabular reconstruction with bone graft, or any iatrogenic fracture during surgery. Patients were discharged after the first satisfactory wound inspection, usually on the 4^th post-operative day. The first follow-up was done for stitch removal at 2 weeks. Remaining follow-ups were done at 6-week intervals for the initial 6 months and thereafter every 3 months until the last follow-up. All patients received post-operative ATT for a mean duration of 15 months.

Clinico-radiological outcome evaluation was done by an independent observer, who was not directly involved in the surgical intervention of the study participants. Clinical outcome evaluation was done using the Harris Hip score[25]. Radiological outcome evaluation was done for implant osseointegration, fixation stability, and aseptic loosening[26-28]. Disease reactivation was defined as reappearance of clinico-radiological signs and symptoms of active disease along with increasing values of ESR and CRP after 3 months of effective ATT. Effective ATT was defined as a four-drug ATT that improves the clinico-radiological findings along with a decreasing trend in CRP and ESR values. The sample size (n = 21) in the present study was based on consecutive eligible cases during the study period (Figure 1). Given the exploratory nature, post-hoc power analysis was not performed.

Figure 1 Flowchart showing the process of recruitment of study participants. TB: Tuberculosis; THA: Total hip arthroplasty.

Statistical analyses

The normality of data distribution was assessed using the Shapiro-Wilk test, and homogeneity of variance was checked using Levene’s test before applying parametric tests. The assumptions were satisfied. Mean ± standard deviation was used for descriptive data analysis. A paired t-test was used to compare the difference in the mean value of different study parameters before and after the surgery. P < 0.05 was considered statistically significant. The null hypothesis was stated as single stage THA in advance active TB hip does not improve the clinico-radiological outcome, and there is increased risk of disease reactivation. P < 0.05 will reject the null hypothesis in favor of the alternative hypothesis.

RESULTS

There were total of 21 (male: Female = 17:4) patients with a mean age of 51.09 ± 12.22 years (range 27-76 years). Left hip involvement was predominant (n = 12) in the study population. Mean duration of preoperative ATT was 12.09 ± 3.50 weeks (range 6-21 weeks). The mean duration of ATT in the post-operative period was 15.04 ± 2.39 months (range 12-27 months). The mean duration of follow-up was 30.04 ± 7.65 months (range 18-44 months). Mean operative time was 95.43 ± 12.54 minutes (range 80-120 minutes). Mean blood loss was 465.50 ± 65 mL (390-510). Mean preoperative shortening was 3.4 ± 1.11 cm (range 1.5-4 cm). Mean post-operative shortening was 0.60 ± 1.21 cm (range 0.5-1.3 cm).

In 1 patient with a high hip center, acetabular reconstruction with a bone graft and screw was done. There were no major femoral side bone defects. In 2 patients (n = 2), cementless THA was converted to cemented THA. Post-operative hip dislocation along with wound dehiscence was seen in 1 (n = 1) patient. A posteromedial femoral cortical breach was seen in 1 (n = 1) patient. Disease reactivation in the form of a discharging sinus was seen in 1 patient 3 months after surgery. There was no neurovascular injury. There was no implant-related complication until the time of the last follow-up.

A mean preoperative ESR and CRP comparison with post-operative values at 6 weeks, 12 weeks, 6 months, 12 months, and 18 months showed a statistically significant decline (P < 0.05 at all follow-up intervals) (Figure 2 and Table 3). The mean difference between preoperative ESR and at 6 weeks was -40.6, which improved to -45.47 at 18 months follow-up due to a consistent decline in ESR. The mean difference between the preoperative CRP and at 6 weeks was -28.29, which improved to -34.21 at 18 months follow-up. All of these differences were statistically significant.

Figure 2 Diagram showing trends in the mean values of clinico-radiological and lab parameters at different times of follow-up. CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; HHS: Harris Hip score.

Table 3 Comparison of mean Harris Hip score, C-reactive protein, and erythrocyte sedimentation rate. Mean preoperative values are compared with mean values at 6 weeks, 12 weeks, 24 weeks, 48 weeks, and 72 weeks follow-up interval.

Parameter	Pre-operative vs 6 weeks		Pre-operative vs 12 weeks		Pre-operative vs 24 weeks		Pre-operative vs 48 weeks		Pre-operative vs 72 weeks
	Difference between means	P value	Difference between means	P value	Difference between means	P value	Difference between means	P value	Difference between means	P value
HHS	35.61	< 0.04	43.38	< 0.05	49.46	< 0.01	51.53	< 0.01	52.69	< 0.001
ESR	-40.60	< 0.03	-39.7	< 0.04	-43.39	< 0.01	-44.31	< 0.01	-45.47	< 0.001
CRP	-28.29	< 0.02	-30.31	< 0.05	-32.92	< 0.01	-33.31	< 0.01	-34.21	< 0.001

CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; HHS: Harris Hip score.

The Harris Hip score also showed a statistically significant improvement from their preoperative mean values to subsequent postoperative mean values at 6 weeks, 3 months, 6 months, 12 months, and 18 months (Figure 2, Tables 3). The mean difference between the preoperative Harris Hip score and at 6 weeks was 35.61, which improved to 52.69 at 18 months’ follow-up. The prevalence of various co-morbidities in the study population is mentioned in Table 4. There were no significant pharmacological interactions resulting from the concurrent co-morbidities.

Table 4 Prevalence of co-morbidities in the study populations.

Co-morbidities	Number of patients	Pharmacological treatment	Influence on outcome
Hypothyroidism	1	Tablet thyroxine	No effect
Hypertension	1	Tablet amlodipine	No effect
Asthma	1	Salbutamol respules (on and off)	No effect
PCOD	1	Metformin	No effect
Diabetes mellitus	2	Glimepiride, metformin, and insulin	Drug interaction with ATT had indirect effect on dose adjustment. But no effect on outcome

ATT: Antitubercular treatment; PCOD: Polycystic Ovarian Disease.

DISCUSSION

THA in active vs healed disease

Multiple authors, including Kim et al[13], Kim et al[29], and Kim et al[30] have reported that a complete resolution of disease in patients with TB hip may take 10-20 years. Kumar et al[7] have reported a risk of disease recurrence following THA even 2-6 years after effective chemotherapy in these patients. Kushwaha et al[31] believe that providing a functional hip is highly desirable for young patients in developing countries who otherwise may lose a significant part of their productive life.

ATT regimen

The duration of ATT before surgery ranges from 2 weeks to 1 year[30,32]. Kushwaha et al[31] believe that 6 weeks of pre-operative ATT in the intensive phase can effectively evade the mycobacteria and reduce the risk of disease reactivation. Additionally, a 6-week pre-operative ATT will also improve bone quality and reduce the bacterial count. Based on this notion, the minimum duration of ATT before surgery is 6 weeks in the present study. There is relatively less controversy on the duration of ATT after surgery, ranging from 9 months to 18 months depending upon the serial ESR and CRP values[15,33,34].

Single vs two stages THA

Bhosale et al[33] have shown a satisfactory outcome in the majority of patients with advanced active TB hip treated by single-stage THA. Neogi et al[34] have recommended two-stage THA when there is an active discharging sinus or debridement at the time of surgery is deemed inadequate. Yoon et al[15] and Wang et al[35] even performed a single-stage THA in the presence of an active sinus at the time of surgery (Table 5).

Table 5 Comparison of our study with other similar studies in terms of type of arthroplasty, stage of surgery and revision surgery.

Ref.	Follow up period	Type of arthroplasty	Single vs two stages	Revision surgery	Limitation of study	Direction for future research
Our study	18 months	Cemented/uncemented/hybrid	Single stage	0	Relatively short period of follow-up	Long follow-up is required to comment upon implant longevity
Yoon et al[15]	4.8 years	Cementless	Single stage	0	Retrospective analysis of seven patients	Prospective study with a greater number of patients is desirable
Wang et al[35]	49 months	Cementless/cemented	Single stage	0
Bhosale et al[33]	10.5 years	Cemented/cementless/hybrid	-	7 aseptic loosening	Although patients were evaluated in two phases, there is no patient with an active sinus	A comparative study with and without an active sinus will clarify the impact of sinus on disease recurrence
Zhang et al[44]	41.6 months	-	1/2/3 stage	0	Type of arthroplasty not mentioned	Type of THA (cemented vs cementless) should be clearly mentioned

THA: Total hip arthroplasty.

Cemented vs cementless THA

The heat released during cemented THA is expected to have a bactericidal effect; however, Shen et al[32] and Fang et al[36] have shown that, rather than the type (cemented vs. cementless) of THA, it is the meticulous debridement and an effective ATT that are detrimental to the outcome. In our study of 21 patients, the majority (n = 18) were cemented (Figure 3), and 2 had uncemented THA (Figure 4). Most of the patients in the present study were without health insurance, and financial constraint was the primary reason for performing a cemented THA, although many had satisfactory bone quality at the time of surgery. A brief comparison of our study with similar studies regarding the type of arthroplasty has been shown in tabular form (Table 5).

Figure 3 The imaging information of a 48 years old male with advanced active stage 3 tuberculosis left hip. A: Pre-operative pelvic radiograph (anteroposterior view) of the patient; B: Immediate post-operative radiograph of the patient following cemented total hip arthroplast; C: Follow-up radiograph of the patient at 32 months; D: Satisfactory clinical outcome of the patient at 32 months follow-up.

Figure 4 Imaging information of a 50 years old male with advanced active stage 3 tuberculosis right hip. A: Pre-operative pelvic radiograph (anteroposterior view) of the patient; B: Immediate post-operative radiograph of the same patient following an uncemented total hip arthroplast; C: Follow-up radiograph of the patient at 40 months; D: Clinical outcome of the patient at 40 months follow-up.

Increased blood loss

There is a risk of increased blood loss as well as intra-operative periprosthetic fractures due to ongoing inflammation with resultant hyperemia and poor bone quality. Kushwaha et al[31] found increased blood loss (447.3 ± 74.15 mL) in a prospective review of 20 patients with advanced active TB hip treated by single-stage THA; however, data on blood transfusion are not available. The blood loss in our study was 465 ± 48 mL. Seven patients with preoperative hemoglobin levels less than 10 were given 1 unit of packed red blood cells.

Challenges in joint reconstruction

Gautam et al[4] have reported varying degrees of acetabular bone defects and advised a preoperative computed tomography scan as well as an intraoperative assessment for exact characterization of these defects for successful restoration of normal hip biomechanics. The femoral side may be less affected due to the active disease; however, due to recumbency resulting from painful, joint destruction, there might be generalized osteopenia of the femoral shaft. Contrary to this, 1 of our patients had good proximal femur bone stock; the exact reason for this remains unknown. In addition, 1 of our patients with a high hip center required acetabular reconstruction using a bone graft and screw to restore normal hip biomechanics. Another important finding in our study was the conversion of uncemented THA into cemented THA in 2 patients. Both patients were females in their 7^th decade with generalized osteoporosis and further compromise in bone quality due to the active disease. The acetabular component did not have a press fit, resorting to a cemented THA. The authors are unaware of any similar reporting in the literature.

Periprosthetic fracture

Liu et al[37] observed juxta-articular osteoporosis due to ongoing active disease as well as generalized osteoporosis resulting from prolonged recumbency due to advanced joint destruction; this could be a risk factor for periprosthetic fracture in these patients. One of our patients (a 27-year-old female) had an intraoperative breach of the posteromedial aspect of the femur, which was only noticed on postoperative radiographs (Figure 5). The patient was reluctant to undergo an immediate revision; she was advised 4 weeks of bed rest before ambulation. One must be cautious while applying THA components in these patients; intraoperative use of an image intensifier is advisable to detect untoward periprosthetic fractures.

Figure 5 Imaging information of a 27 years old female with advanced active stage 3 tuberculosis left hip. A: Pre-operative pelvic radiograph (anteroposterior view) of the patient; B: Immediate post-op radiograph of the patient following hybrid total hip arthroplasty, showing breach in the femoral cortex; C: Radiograph of the patient at the time of last follow-up; D: Tuberculosis hip confirmed on light microscopy, hematoxylin and eosin-stained section from the biopsy material shows clusters of epithelioid histiocytes along with Langhans giant cells in a background of chronic inflammatory infiltrate and foci of caseous necrosis (100 ×). Blue arrow (downfacing): Langhans giant cells, blue arrow (right facing): Epithelioid histiocyte, blue arrow (left facing): Necrosis.

Joint dislocation

Eskola et al[38] have reported prosthesis dislocation in these patients and advise management depending upon the stability of THA components. One of our patients (a 55-year-old male) developed hip dislocation with wound dehiscence following a slip on the ground in the early postoperative period. The implant was stable; dislocation was reduced, and the wound was managed conservatively with a satisfactory outcome (Figure 6).

Figure 6 Imaging information of a 55-year-old male with advanced active stage 4 tuberculosis left hip. A: Pre-operative pelvic radiograph (anteroposterior view) of the patient; B: Immediate post-operative radiograph of the same patient following cemented total hip arthroplasty; C: Patient developed hip dislocation; D: Wound dehiscence in the early post-operative period following a slip on the ground. Closed reduction was done, and the wound was managed conservatively; E and F: Showing satisfactory outcome at 28 months follow-up.

Disease reactivation

Zheng et al[19] in a recent systematic review and meta-analysis of THA in TB hip has reported a 4% rate of disease reactivation. According to Kim et al[13] the causes of recurrence include failure to comply with ATT, drug resistance, or inadequate dosage and duration of ATT. The presence of active sinus at the time of surgery is itself a risk factor for disease reactivation; however, Wang et al[21] did not report any disease recurrence following THA in such patients. There is no account of a superimposed pyogenic infection in these studies. Neogi et al[34] reported recurrence in 1 of his patients, who had a discharging sinus with superimposed pyogenic infection. He treated this patient with resection arthroplasty. Zhang and Ding[39] advised prolonged ATT in patients with disease reactivation due to poor compliance or drug resistance.

In our study, 1 patient developed disease reactivation in the form of an active discharging sinus 3 months after surgery due to poor compliance with ATT. There was no drug resistance. ATT for another 18 months healed the infection successfully without the need for revision surgery. A brief tabular representation of the risk of disease recurrence and duration of follow-up has been done in Table 6.

Table 6 Incidence of disease reactivation compared with other similar studies.

Ref.	Follow-up	Disease reactivation	Study limitation	Direction for future research
Our study	18 months	1	Advance work-up to rule out pulmonary tuberculosis was not done	Co-existing pulmonary TB should be effectively ruled out
Neogi et al[34], 2010	41 months	1	Retrospective case series. Cause of reactivation not mentioned	A prospective study with detailed work-up of the cause of disease reactivation is needed
Wang et al[35], 2010	49 months	0	Retrospective study with small sample size	Prospective study with larger sample size would be more helpful to generalize the study outcome
Bhosale et al[33], 2020	10.5 years	0	Retrospective case series, includes only patient without an active sinus. Exact duration of disease not mentioned	Prospective study including patients with active sinus would better help to assess the impact of sinus on disease recurrence
Chen et al[43], 2021	32.1 months	Aseptic loosening = 0; dislocation = 0; recurrence = 0	Retrospective study, duration of disease highly variable (9 months to 12 years)	Prospective study with lesser variation in duration of disease will be more useful
Kushwaha et al[31], 2024	14 months	0	Short follow-up period	A longer follow-up period will be more helpful in assessing implant longevity

TB: Tuberculosis.

Implant longevity

According to Sidhu et al[40] and Li et al[41] implant survival in patients with THA is a matter of debate. In our study, none of the patients had any implant loosening; all patients had well-fixed implants at the time of last follow-up. Many studies report good implant survival following THA in TB hip. Since the follow-up period in the present study is relatively short, it will be premature to comment on long term implant longevity.

Bhosale et al[33] retrospectively reviewed 52 patients with advanced active tuberculosis of the hip treated by single-stage THA, with a mean follow-up of 10.5 years. He reported aseptic loosening in 7 (13%) patients unrelated to TB arthritis. All 7 patients underwent revision THA. Arora et al[42] have reported stem loosening with revision arthroplasty in 1 patient. A brief comparison of our study with other similar studies in terms of the rate of revision has been shown in tabular form (Table 5).

CRP and ESR

Shen et al[32] and Yoon et al[15] showed a consistent decline in ESR and CRP following an effective ATT, attaining normalized values between 3-6 months following commencement of treatment. Clinical outcome assessment using the Harris Hip score has been extensively done in the given patient population with consistent outcomes. The present study compared the mean difference between preoperative ESR, CRP, and Harris Hip score with values at 6 weeks, 12 weeks, 6 months, 12 months, and finally at 18 months using a paired t-test. The values were statistically significant (P < 0.05). Radiologically, there was no evidence of an infective lesion. Therefore, the null hypothesis is rejected in favor of the alternative hypothesis.

Sex-based analysis of outcome

The literature is scarce in sex-based analysis of outcomes in these patients. This is an area that requires special attention to develop a sex-specific approach for THA in TB hip. Chen et al[43] compared functional and radiological outcomes between males and females, indicating no inherent sex-based difference in the effectiveness of the procedure itself. Present study's findings in terms of clinico-radiological outcome in male and female patients are aligned with this study.

Strengths and limitations

Strengths: Being a prospective study, the present work avoids the recall bias associated with a retrospective study, as multiple similar studies are retrospective[15,34,35,43]. Assessment of the clinico-radiological outcome by an independent observer is another strength of the present study.

Limitations: A small sample size was one of the limitations of the present study. A small sample size could be attributed to financial constraints, even though many patients are eligible for a THA. The sample size in the present study (n = 21) was more than or equal to the sample size (n = 7 to 20) in other similar studies[15,31,34,44]. Few authors have presented a relatively large sample size with long-term follow-up[33]. Another limitation was the relatively short follow-up period, which is insufficient to comment upon implant longevity. Maximum follow-up in the present study was 3 years, which may be sufficient to detect an early recurrence of disease; however, it may not be appropriate to comment upon implant survival and long-term disease reactivation. One of the important causes of disease reactivation could be pulmonary tuberculosis. We did not do anything more than a chest radiograph and sputum smear examination to rule out pulmonary tuberculosis in 1 of our patients who developed disease reactivation. This could be a confounding factor in the present study. Since patients with active discharging sinuses were excluded from the present study, it could introduce an element of bias in terms of reduced risk of disease reactivation in the given patient population. A randomized control trial with a large sample size, a standardized ATT regimen, and long-term follow-up is required to satisfactorily answer the remaining queries regarding the role of single stage primary THA in advanced active TB arthritis of the hip.

CONCLUSION

Despite many surgical challenges, single-stage THA in active advanced TB hip without discharging sinus provides satisfactory clinico-radiological outcome in most patients. However, there is a risk of early disease recurrence in patients having poor compliance with ATT.

ACKNOWLEDGEMENTS

We are grateful to Mohd Faizan for his valuable contribution to the statistical analyses for the research.