AN ANALYTICAL STUDY OF BONE AND JOINT LESIONS IN RELATION TO CHRONIC PULMONARY TUBERCULOSIS

¹ Department of Medicine and Orthopaedic Surgery, University of California Medical School; University of California Tuberculosis Service of the San Francisco Hospital, San Francisco Department of Public Health

The analysis of the bone and joint tuberculosis encountered in a general tuberculosis hospital during the fifteen years from 1920 to 1935 shows that:

1. Of 4252 tuberculous patients, 160 or 3.76 per cent. had 203 single or multiple tuberculous joint and bone lesions, which were usually secondary to some other tuberculous focus, most frequently in the lungs.

2. Of these 160 patients, 118, or 73.7 per cent., had chronic pulmonary tuberculosis; forty-two, or 26.3 per cent., had no pulmonary involvement but had fifty-three bone and joint lesions, or 26 per cent., of the total orthopaedic lesions. Of these patients with fifty-three lesions, forty-five had manifestations of tuberculosis elsewhere,—in bones and joints, or skin, or as adenitis, polyorrhomenitis, etc. In only eight was one joint the sole focus of tuberculosis.

3. Bone and joint tuberculous disease affects more often the weight-bearing joints in the order indicated in Table II.

4. It is most prevalent in the second and third decades of life.

5. When tuberculous bone and joint lesions are associated with pulmonary disease, the outcome is greatly influenced by the degree of lung involvement and is particularly serious in the moderately advanced and far-advanced stages. Complications were present in the greatest number in the patients with far-advanced pulmonary tuberculosis. The orthopaedic lesions, therefore, should be secondary in importance to the care of the pulmonary disease. Surgery for patients in these advanced stages of the disease must be carefully considered; conservative measures alone are the methods of choice.

6. The prognosis is more serious in patients who have tubercle bacilli in the sputum; in patients in whom there is a draining sinus or multiple abscesses (very often a general toxaemia ensues in the former, and the development of amyloid disease in the latter); and in those with forms of tuberculosis other than pulmonary.

7. The end results show that in 160 patients with 203 bone and joint lesions, thirty-five or 17 per cent. of the lesions were well; forty-two, or 21 per cent., were improved; twenty-six, or 13 per cent., were unimproved; and 100, or 49.3 per cent., were in patients who have died.

8. In a study of bone and joint tuberculosis in a general tuberculosis hospital where far-advanced pulmonary cases constitute a large proportion of the patients, the mortality statistics are necessarily higher than in a service with orthopaedic patients alone. In this series the mortality was highest in the second, third, and seventh decades. It was greater in the pulmonary cases (51 per cent. of the patients with 50 per cent. of the lesions) than in the non-pulmonary cases (38 per cent. of the patients with 45 per cent. of the lesions); and greatest in those with multiple joint lesions. It was also higher in the yellow, mixed, and negro races. This indicates an unusual susceptibility and lowered resistance, and for this reason very careful consideration must be given each patient before surgical procedure is undertaken. Of the patients with positive sputum 79 per cent. died or had lesions which failed to improve; and of ninety-two patients with one or more sinuses, sixty-three died or had lesions which failed to improve.

9. An analysis of the 118 bone and joint lesions treated by rest and immobilization shows that sixty-three, or 53 per cent., were in patients who died; seventeen, or 14 per cent., were unimproved; nineteen, or 16 per cent., were improved; and nineteen, or 16 per cent., were well. Of the eighty-five joints treated by surgery of any kind, thirty-eight, or 44 per cent., were in patients who died; eight, or 9 per cent., were unimproved; twenty-three, or 27 per cent., were improved; and sixteen, or 19 per cent., were well.

10. Because this study has brought out so conclusively the high mortality in bone and joint tuberculosis when associated with pulmonary involvement, the authors wish to emphasize the necessity of a complete physical examination including routine laboratory work and roentgenograms of the chest for every patient.

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