TO THE EDITOR:
I greatly appreciated the excellent article "Current Concepts Review. Tuberculosis of Bones and Joints" (78-A: 288—298, Feb. 1996) by Watts and Lifeso.
Clearly, a short article cannot cover all aspects of a disease, but the authors might have emphasized the very serious complication of sinus formation and how its avoidance should be a primary goal of treatment. This is particularly important in light of the current diminishing effectiveness of all antibiotics. Thus, débridement and drainage need to be performed under scrupulously aseptic conditions and should always be followed by closure of the wound. Drainage sites that are left open almost invariably lead to the terrible sequela of cross-infection.
The risk of sinus formation also needs to be considered when the insertion of a prosthesis into a formerly tuberculous joint is contemplated. One should also remember the value of extra-articular grafting when an arthrodesis is performed.
F. G. St. Clair Strange, F.R.C.S.: Church Hill House, Harbledown, Canterbury CT2 9AB, England
Dr. Watts and Dr. Lifeso reply:
Unfortunately, as Mr. St. Clair Strange mentioned, all aspects of tuberculosis cannot be covered in a short article. In our experience in Saudi Arabia, sinus formation was not a substantial problem either before or after operative treatment. Whether the low prevalence of this complication was related to radical débridement of all avascular material or to a high rate of compliance with multiple-drug therapy directed toward the eradication of tuberculosis, or whether it was strictly a local phenomenon, is not known.
We do not recall ever seeing a persistent sinus after adequate débridement and prolonged antituberculous chemotherapy, but undoubtedly they do occur. We agree that they must be treated vigorously, with radical débridement; closure at the time of the primary operative procedure on the involved joint or bone; and appropriate antibiotics directed toward the underlying tuberculosis infection and also, in many cases, toward the superinfection.
Hugh G. Watts, M.D.: Shriners Hospital for Crippled Children, 3160 Geneva Street, Los Angeles, California 90020
Robert M. Lifeso, M.D.: Erie County Medical Center, 462 Grider Street, Buffalo, New York 14215