Aim <p>Effective treatment of tuberculous arthritis depends on strict adherence to anti-tuberculous therapy to achieve cure and reduce mortality. This study aimed to investigate the impact of treatment adherence on mortality risk in patients with tuberculous arthritis.</p> Methods <p>A retrospective cohort of 391 patients diagnosed with tuberculous arthritis between 2001 and 2016 was analyzed. Patient demographics, body mass index, co-morbidities, and treatment details were collected. Adherence was defined as treatment persistence, measured from initiation to discontinuation of anti-tuberculous therapy. Mortality outcomes were recorded, and Cox proportional hazards models were used to assess the association between adherence and mortality risk, adjusting for potential confounders.</p> Results <p>Among 391 patients (mean age 65.9 ± 14.13 years; 42.5% female), 87 deaths occurred during follow-up. Overall adherence rate was 45.8%, significantly lower in the deceased group (31%) compared to survivors (50%, <i>p</i> = 0.002). Multivariate Cox regression demonstrated that adherence to anti-tuberculous therapy was independently associated with a 56% reduction in mortality risk (HR 0.44; 95% CI 0.28–0.71).</p> Conclusion <p>Adherence to anti-tuberculous therapy markedly decreases mortality risk in tuberculous arthritis patients. Targeted interventions to improve treatment adherence are essential to enhance clinical outcomes in this population.</p> Clinical trial <p>This is not clinical trial.</p>