Akahoshi, Yoshihiko

Kirita, Yoshito

Kondo, Eishi

Yamada, Kengo

Yoshimine, Yasuo

Õtani, Midori

Kyoto University Research Information Repository

Title END-RESULT STUDY OF DEBRIDEMENT OF BONE-JOINT TUBERCULOUS FOCI (Intermediary Report)Author(s)Kondo, Eishi; Yamada, Kengo; Kirita, Yoshito; Yoshimine,Yasuo; Akahoshi, Yoshihiko; Õtani, MidoriCitation日本外科宝函 (1954), 23(4): 306-309Issue Date1954-07-01URL http://hdl.handle.net/2433/206108RightType Departmental Bulletin PaperTextversionpublisherKyoto University306 END-RESULT STUDY OF DEBRIDEMENT OF BONE-JOINT TUBERCULOUS FOCI (Intermediary Report) by EISHI KONDO ＆ KENGO YAMADA・YOSHITO KIRIT A・YASUO Y OSHIMINE Y OSHIHIKO AKAHOSHI・MIDORIOTANI From the Orthopedic Division, Kyoto University Medical Schol. Five years have passed since the first introduction of our form of operation, debridement of bone-joint tuberculous foci performed under the administration of streptomycin. The form of operation advocated in 1951 by us, met with more or les apprehension from authorities, but nowadays, with the recognition of freedom from danger and good primary results obtained in the operation, physicians who apply this form of operation have increased in number. Moreover, some of them are advocating the necessity of using this method. Thus, at the present moment, when this form of operation shows great tendencies to spread throughout Japan and abroad, it seems to be most important to discuss precisely the results of the operation, and to determine the proper indications for the operation. Here, the authors will try, on the grounds of clinical experience with several cases, to make a strict discussion of the idea of our debridement of bone-joint tuberculous foci ; i.e. the operative promotion and assistance of the natural healing process, self-purifica-tion in the affected foci. There are at present over 200 operated cases in our clinic, but the prsesent paper will report only on an evalu-ation of th巴 intermediaryend-results of 108 out of 176 cases, which have been ob-served for one to 自veyears. Anatomical distribution of the lesions is shown in Table I. Table. I Location of lesions Cases observed Spinal caries 32 of ・5 cases Hip joint tuberculosis 19 of 36 cases Foot joint・ tuberculosis 22 of 30 cases Knee joint ・1uberculosis 10 of 18 cases Sacroiliac joint tuberculosis 13 of 14 cases and others 12 of '23 cases Total number of lesions 108 of 176 cases (61.4%) The authors investigated statistically the results, in regard to the clinical and radiological findings, as well as the modus of present life of the cases. The criteria for the evaluation of the results are as follows ・ 1) Excellent : convalescence completed and no restriction of social activities. 2) Good : great improvement of local and general conditions, being stil kept in convalescence. 3) Unimproved : degradation or recurr~nce of disease. 4) Death. END-RESULT STUDY OF BQNE JOINT TUBERCULOSIS 307 Table. I Results obtained are shown Results obtained Cases Per cent in Table I, and are favo-Excellent: 58 rable in 90.8% (sum of Ex-Good: 40 37. 90.8 cellent 53.7% and Good Unimproved: 8 7.4 37.1%). Death: 2 1.8 One of the two cases who died was a child with hip joint tuberculosis, who died from post-operative shock, and the other was an adult with spinal caries complicated by epidural abscess, who died from tuberculous meningitis five months after operation. Both of them were in a florid stage of the disease, which should be a contra-indication for the operation. The results arranged in the post自operativeperiod, as shown in Table III, reveal that the longer the post-operative course, the better become the results. Table. III Results obtained Post-operative course 3 years 2 years I year Excellent: IO (91.0%) 22 (73.4%) 23 (49.0%) 3 (15.0%) Good: I ( 9.0%) 4 (13.3拓） 19 ( 40.0%) 16 (80.0%) Unimproved : 4(13.3%) 4 ( 8.5%) Death: I( 2.1%) I ( 5.0%) Total number of the cases [ 11 30 47 20 And also the results arranged in location of the lesions, as shown in Table IV, reveal that the results obtained in the treatment of small joints are in general very favorable, and the most di伍cultis the treatment of the spinal caries, the results of which are excellent in 31.2%, good in 56.3%, unimproved in '9.4%, death in 3.1%. Table. IV Results obtained Excellent Good Unimproved Death 、 、 ， ， ， 、 、 ， ? 、 、 ， ， ， ， 、 、 ， ，?????????????????? 、?? ， ，?、 ， ，? 、 ， ，? 、 ， ，? 、， 、 、 ? ?? ??????Hip joint 9(47.4%) 8(42.2%) I( 5.2%) I( 5.2%) Location of lesions Foot joint Knee joinnt 16(72.7%) 5(50.0%) 5(22.7%) 5(50.0%) I( 4.6%) ?? 、?? 、?? 、 』??????? ?? ???????????????? 、?、?? 、????? ー 、 、 ， ? 、 ? 』 ? 、 、 』 ?? ? ???????? ?????、?， 、?? 、??Total number I of cases I 32 19 '22 10 13 12 In regard to the general condition : tuberculosis of lung developed only in 1.8% post-operatively and in most of the cases was much improved or remained in the similar state as before. Pre-operatively the erythrocyte sedimentation rate was elevated in a majority of the cases, but at present most of them are normal (Table V.). These facts reveal that the operation can improve the general condition of the patients. 308 日本外科宝曲第23巻第4号Table. V Erythrocyte sedimentation凶 e I P伶 operative 一生!_J>~竺ntElevated (over 30mm) I , 55.0% 、 .9.9%Moderate ( 15～ 29 mm) I 23.0% 28.8% Normal ( 0～ 14 mm) I 22.0% 61.7拓In regard to local signs, abscesses were complications in 51.0% of the cases in the pre-operative period, but most of them have healed and are present only in 6.4 拓ofthe cases. Also sinuses were complications in 33.0拓 ofthe cases in the pre-operative period, but now they are present in only 2.8% of the C回目． In th~ heal-ing state of operative wounds, primary closure occured in 75.0% of the cases and secondary closure in 25.0%, but none of the cases showed a transition to permanent sinus formation. The operative wounds for foot and knee joint tuberculosis show a greater tendency to close secondarily than those in other areas (Table VI). Table. VI Closure of the operated wounds Spine Hip joint Foot joint Knee joint Sacroiliac joint Others ~~is7:r~ry 2ゆ 0.0%）附9.5%）附5.5%）叫60.0%) 11(84.似）附3.3%)Secondary closure Number of total cases 5(10.0%) 32 2(10.5%) 12(54.5%) 4(40.0%) 19 22 IO 2(15.4%) 2(16.7%) 13 12 So special care should be taken in operations on the foot and knee joint. In regard to the radiological healing of this disease in the post-operative period, spinal caries showed block formation of vertebrae in 66.6%, which became more marked in proportion to the length of time after the operation, sklerosing around the foci or formation of osteophytes were present in 34.4% of the cases, but deve-loping destruction or sequester formation could be observed in 6.6% of～the cases. Therefore, the procedure of debridement should be performed completely. In tuber・ culosis of other joints, bone atrophy was observed in only 1.0%, developing destruc-tion or sequester formation in 4.2% of the cases. A majority of the cas白（94.8%)showed marked sklerosing around the foci, and 39.0拓 amongthem complete bony ankylosis. Mobile joints without recurrence of the disease were‘observed in only 1.2%. During the post-operative treatment, the number of cases treat疋dby immobiliza・Table. VII Post-operative course I to 2 years 2 to 3 years 3 to 4 years 4, to 5 years Immobilized Percent with brace 一 一長rミ示王両一両面~~or plaster cast wearing brace or cast 78.0 % 22.0 % 41.0 % 59.0 % 17.0 % 8・3.0 % 0 100.0% Fig. 1 S. S., male, age 20 years. Before operation 12 months after operation Complications: Abscesses ( +) Er!.throcyte sedimentation 23.25mm rate Fig. 2 S. 0., female, age 3l years. 時、（一）11.5mm Before operation 13 months after operation Complications: Abscesses ( +) Erythrocyte sedimentation 39.0mm rate 1凸.OmmFig. 3 S. S., male, age 25 years. Before operation 15 months after operation [' Fig. 4 I. Y., female, age 23 years. Before operat10n 17 months after operation Complications: Abscesses ( +) Er!.throcyte sedimentation rate Sini ( + J Bl.25mm （ー）（ー）22.0mm E. KONDO I Fig・. 5 M. S., male, ag~ 22 years. Befor巴operat:o:1 3 years after opてrationFig・. 6 ]. M., male, age 15 years. Before operation Complications: Abscesses ( +) Sini ( +) Erythrocyte sedimentation 35.Smm rate 12 months after operation （一）（ー）8.0mm Fig・. 7 Y. H., female, age 21 years. まBefore operation 13 months after operation Fig. 8 M. A., male, age 14 years. Before operation 12 months after operation Complications: Abscesses ( +) （』）｛ー）Sini ( +l E. KONDO H Fig. 9 A. M., femal号， age25 years. Before opf!ation 29 months after operation Fig・. 10 R. M., female, age 21 y_句rs.Before operation Er:i:throcyte sedimentation rate 37.25mrn 40 months after operation 35.0mm Fig. 11 H. S., male, age 12 years. Before operation 22 months after operation ＼ ＼ ． Complications: Sini ( +) (-) E. KONDO JIFig. 12 S. S., female, age 2 years. Before operation 51 months after operation 、L Fig・. 13 T. U., female, age 25 years. Before operatio日 2a montb after operation CompEcations: Absccssc~ ( +) （ー）E. KONI)() IV END-RESULT STUDY OF BONE-JOINT TUBERCULOSIS 309 tion with brace or plaster cast decreased in proportion to the length of time after the operation (Table VII). This fact reveals that immobilization becomes unnec回目sary with the period of the post-operative course and greatly encourages us. From the above, our focal debridement combined with streptomycin is, as far as operative indications can be strictly observed, a quite safe and rational operation, great developments in which can be expected in the future. Results obtained in several cases treated by focal debridement are illustrated in the following pictures: (Fig.1-13). REFERENCES 1) Bosworth D. M., and Levine J., Tuberculosis of Spine-Analysis of Cases Treated Surgically. J. Bone ゐ JointSurg., 31・A,267:274, 1949 2) Bosworth D. M. and Wright H.A., Streptomy-cin in Bone and Joint Tuberculosis. J. Bone & Joint Surg., 3i・A,255-266, 1952 3) Erlacher P. J., The Radical Operative Treatment of Bone and Joint Tuberculosis. J. Bone ゐ JointSurg., 17, 536. 1953 4) Evans E. T., Tuberculosis of the Bone and Joints with Special Reference to the Influence of StreptomyCin ap_d the Application of Radical Surgical Techniques to Certain E任巴ct,and Complications of the Tuberculous Lesions. J. Bone & Joint Surg., 34・A,1952 5) Finkelstein H., Greenberg, B.B., Jahss S. A. and Mayer L., Operative and Conservative Treatment of Tuber-culosis of the Spine. J. A. M.A., 110, 480, 1938 6) HaJlock H. and Tourney J.W. Jr., Hip Joint Tuberculosis Treated by Fusion Operation; End-Result Study of 170 Unselected Cases. J. A. M.A., 103, 1836, 1934 7) Harris R.I. and Coulthard H.S., Prognosis in Bone and Joint Tuberculosis; Analysis of Results of Treatment and Consider-ation of Factors Which Influence End Results J. Bone & Joint Surg., 24, 382, 1942 8) Harris R.I., Coulthard H. S. and Dewer F. P., Strepto-mycin in the Treatment of Boneぬ JointTuber-culosis. J. Bone & Joint Surg., 34・A,279-287, 1952 9) Hibbs R. A. and von Lackum H. L., End Results in Treatment of Knee Joint Tuberculosis. J.A.M.A., 85, 1289, 1925 JO) Hibbs RA. and Risser J.C., Treatment of Vertebral Tuberculosis by the Spine Fusion Operation; A Report of 286 Cases. J. Bone & Joint Surg., 10, 805, 1928 11) Jaffe K., Ueber Knochentuberkulose. Deutsche Ztschr. Chir., 18, 432-458, 1883 12) Katayama R., Oya K. and Otsuka S., Experience of Treat-ment with Streptomycin to Bone-Joint Tubercu-losis. J. Japan. Orthop. Soc., 24, 200-202 1950 13) Katayama R円。yaK. and Itami Y., Che-motherapy of Bone and Joint Tuberculosis. J. Japan. Orthop. Surg. Soc., 25, 238-239, 1951 14) Kondo E. and Yamada K., On the Operative Cleansing of Foci of Bone-Joint Tuberculosis. J. Japan. Orthop. 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Chir., 162, 388-477, 1930 21) Taniguchi T., Surgical Treatment of Bone and Joint Tuberculosis Securing Post-operative ”Dynamic”Function, Especially on the Arthrec-tomy and Arthroplasty. J. Japan. Orthop. Surg. Soc., 26, 304 305, 1952 22) Yamada K., Ueber die Prognose der Senkungsabszesse bei Spondylitis tuberculosa. Arch. f. Japan・Chir.,18, 624-631, 1941 23) Yamada K. and Kasai J., Indication of Operative Cleansing against Tuberculous Foci in Bone and Joint. J. Japan. Orthop. Surg. Soc., 24, 202-203, 1950 24) Yamada K., Kirita Y., Otuka T. and Otani H., Investigations of the Indications for the Operative Treatment of Bone-Joint Tuberculosis. J. Japan. Orthop. Surg. Soc., 26, 305-306. 1952 25) Yasuda I., Kato T. and Hara 0., Our Surgical Treatment in Tuberculo-sis of Bone and Joint. J. Japan. Orthop. Surg. Soc., 24, 203-204, 1950 

END-RESULT STUDY OF DEBRIDEMENT OF BONE-JOINT TUBERCULOUS FOCI (Intermediary Report)

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END-RESULT STUDY OF DEBRIDEMENT OF BONE-JOINT TUBERCULOUS FOCI (Intermediary Report)

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