Hip resurfacing arthroplasty for ankylosing spondylitis

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and Kmbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5-12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13-16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and KMbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5~12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13~16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis at total hip arthroplasty (THA) has significant hip stiffness with flexion deformity, restricted mobility, and function. Range of movement (ROM) improvement with good functional outcome is seen following THA in these hips. The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity.

AIM

To assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips.

METHODS

A total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo. All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1^st postoperative day. Modified Harris hip score and ROM were assessed during follow-up. Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at follow-up. SPSS 22.0 was used for statistical analysis. The correlation of ROM and functional score change was performed using Pearson’s correlation coefficient.

RESULTS

Sixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range. The mean flexion in 69 hips improved from 29.35 ± 31.38 degrees to 102.17 ± 10.48 degrees. The mean difference of 72.82 with a P value < 0.0001 was significant. In total, 45 out of 69 hips had flexion deformity, with 13 hips having a deformity above 30 degrees. The flexion during the follow-up was below 90 degrees in 3 hips. Eleven hips had flexion of 90 degrees at follow-up, while the remaining 55 hips had flexion above 100 degrees. Modified Harris hip score improved from 17.03 ± 6.02 to 90.66 ± 7.23 (P value < 0.0001). The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11, very good in 20, good in 5, fair in 3, and poor in 1. The mean mental health score was 84.10 ± 11.58. Pain relief was good in all 69 hips. Altogether, 28/40 patients (70%) had no pain, 9 patients (22%) had occasional pain, and 3 patients (8%) had mild to moderate pain with unusual activity. Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips.

CONCLUSION

Modified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM, Harris hip score, and quality of life indicated by the 36-item and 12-item short form health surveys.

Total hip arthroplasty in fused hips with spine stiffness in ankylosing spondylitis

Ankylosing spondylitis (AS) is characterized by involvement of the spine and hip joints with progressive stiffness and loss of function. Functional impairment is significant, with spine and hip involvement, and is predominantly seen in the younger age group. Total hip arthroplasty (THA) for fused hips with stiff spines in AS results in considerable improvement of mobility and function. Spine stiffness associated with AS needs evaluation before THA. Preoperative assessment with lateral spine radiographs shows loss of lumbar lordosis. Spinopelvic mobility is reduced with change in sacral slope from sitting to standing less than 10 degrees conforming to the stiff pattern. Care should be taken to reduce acetabular component anteversion at THA in these fused hips, as the posterior pelvic tilt would increase the risk of posterior impingement and anterior dislocation. Fused hips require femoral neck osteotomy, true acetabular floor identification and restoration of the hip center with horizontal and vertical offset to achieve a good functional outcome. Cementless and cemented fixation have shown comparable long-term results with the choice dependent on bone stock at THA. Risks at THA in AS include intraoperative fractures, dislocation, heterotopic ossification, among others. There is significant improvement of functional scores and quality of life following THA in these deserving young individuals with fused hips and spine stiffness.

Cementless total hip arthroplasty for three different degrees of hip involved secondary to ankylosing spondylitis: an analysis of 195 hips

Background

Hip involved secondary to ankylosis spondylitis (AS) had a huge influence on hip function. Cementless total hip arthroplasty (THA) can improve hip function. However, no previous study compared the outcomes of THA for AS patients with three different degrees of hip involvement.

Methods

The 195 hips were retrospectively analyzed and divided into non-ankylosed group (group A, 94 hips), fibrous ankylosed group (group B, 49 hips), and bony ankylosed group (group C, 52 hips). postoperative range of motion (ROM), harris hip scores (HHS), the short-form 12 health survey (SF-12), length of stay (LOS), cost, radiological assessments, and complications were compared.

Results

The follow-up time was (79.4 ± 29.5) months for group A, (80.6 ± 28.9) months for group B, and (79.1 ± 28.9) months for group C (P = 0.966). Group A had the best postoperative hip ROM (P < 0.001), while group A and B can realize better HHS than group C (P < 0.001). The three groups had similar SF-12 postoperatively. For group A, LOS and cost for unilateral procedure were the least than that for group B and C (P = 0.003 and P = 0.001). Similar radiological assessments were achieved for three groups. 1 hip in group A encountered delay union of wound. 1 hip in group C encountered delay union of wound and dislocation and another patient encountered femoral fracture intraoperatively. 12 hips (12.8%) in group A, 6 hips (12.2%) in group B, and 6 hips (11.5%) in group C encountered asymptomatic heterotopic ossification (P = 0.977).

Conclusion

For AS patients with hip involvement, THA can improve hip ROM and function. THA for the non-ankylosed hip can realize the better hip function and postoperative ROM than ankylosed hip.

Does the Femoral Head Size Influence Outcomes After Uncemented Total Hip Arthroplasty for Fused Hips? A Prospective Study in Ankylosing Spondylitis

BACKGROUND

Uncemented total hip arthroplasty (THA) with large size femoral heads have shown greater advantage with good stability, range of motion and decreased dislocation rate in ankylosing spondylitis (AS). Meticulous planning is needed to address the unique surgical challenges in such patients with fused hip and spinal deformity.

MATERIALS AND METHODS

Thirty fivefused hip joints in twenty-five AS patients who underwent uncemented THA (April 2014 to December 2016) were included in our prospective study and were followed up for a minimum period of 36 months. Pain relief, functional improvement and patient satisfaction were statistically assessed using "Visual Analogue Score" (VAS), "Harris Hip Score" (HHS) and "AJRI 10-Point Satisfaction Score" (A10PSS), respectively.

RESULTS

The overall mean preoperative VAS improved from 6.9 ± 1.5 to 1.5 ± 1, HHS improved from 50.0 ± 12 to 88.4 ± 7.8 and A10PSS improved from 2.2 ± 1.2 to 7.6 ± 0.8. Our study results were significant with zero dislocation and good functional score in comparison to the other available studies in literature. First subdivision study in AS patients with bilateral THA performed better than unilateral THA. Second subdivision study showed no significant statistical difference in terms of VAS, HHS, A10PSS and dislocation rate in relation to femoral head size between 32 mm, 36 mm and 40 mm.

CONCLUSION

Uncemented THA with large size femoral head equal or greater than 32 mm provides better stability and good functional outcome with less dislocation rate in comparison to older studies of literature with femoral head size less than 32 mm.

LEVEL OF EVIDENCE

A Level II study. (Data collected from the ongoing prospective study) (https://www.spine.org/Documents/LevelsofEvidenceFinal.pdf).

2018 APLAR axial spondyloarthritis treatment recommendations

INTRODUCTION

Despite the availability of axial spondyloarthritis (SpA) recommendations proposed by various rheumatology societies, we considered that a region-specific guideline was of substantial added value to clinicians of the Asia-Pacific region, given the wide variations in predisposition to infections and other patient factors, local practice patterns, and access to treatment across countries.

MATERIALS AND METHODS

Systematic reviews were undertaken of English-language articles published between 2000 and 2016, identified from MEDLINE using PubMed, EMBASE and Cochrane databases. The strength of available evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Recommendations were developed through consensus using the Delphi technique.

RESULTS

Fourteen axial SpA treatment recommendations were developed based on evidence summaries and consensus. The first 2 recommendations cover non-pharmacological approaches to management. Recommendations 3 to 5 describe the following: the use of non-steroidal anti-inflammatory drugs as first-line symptomatic treatment; the avoidance of long-term corticosteroid use; and the utility of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) for peripheral or extra-articular manifestations. Recommendation 6 refers to the indications for biological DMARDs (bDMARDs). Recommendation 7 deals specifically with screening for infections endemic to Asia, prior to use of bDMARDs. Recommendations 7 to 13 cover the role of bDMARDs in the treatment of active axial SpA and include related issues such as continuing therapy and use in special populations. Recommendation 14 deals with the utility of surgical intervention in axial SpA.

CONCLUSION

These recommendations provide up-to-date guidance for treatment of axial SpA to help meet the needs of patients and clinicians in the Asia-Pacific region.

Complications of Total Hip Arthroplasty in Patients With Ankylosing Spondylitis

OBJECTIVE

To compare the risks of complications of primary total hip arthroplasty (THA) between patients with ankylosing spondylitis (AS) and those without AS.

METHODS

In this population-based study, we examined data from 1999 to 2013 of US Medicare beneficiaries (ages <75 years old) with AS and a comparison group without AS who had undergone primary THA. Complications were based on the Centers for Medicare & Medicaid Services 2013 THA Complication Measure, which included myocardial infarction, pneumonia, or sepsis within 7 days; surgical site bleeding, pulmonary embolus, or venous thrombosis within 30 days; or mechanical complications or local infection within 90 days. Mortality within 90 days, revision arthroplasty within 1 year, long length of stay, discharge to a care facility, and readmission within 90 days were also examined.

RESULTS

The study included 2,773 patients with AS and 107,341 patients without AS who had THA. Perioperative complications, 30-day complications, and local infections were rare in both groups (<1%). Mechanical complications and revision arthroplasty were uncommon in both groups. Ninety-day mortality was lower among patients with AS than those without AS (0.36% versus 0.7%). Patients with AS were more likely to be discharged to a care facility, and slightly more likely to have a long length of stay. Likelihood of a long stay was lower at hospitals that performed ≥100 THAs per year, but other complications were not associated with hospital volume.

CONCLUSION

Complications after primary THA are uncommon in patients with AS and similar in frequency to those without AS. Ninety-day mortality was lower among patients with AS.

Hip resurfacing arthroplasty for patients with inflammatory arthritis: a systematic review

INTRODUCTION

Modern metal-on-metal hip resurfacing arthroplasty has led to decreased revision rates and high implant survival rates as compared to prior generations of resurfacing. Many of the series that report on resurfacing outcomes focus upon patients treated with a diagnosis of osteoarthritis. Patients with inflammatory arthritis such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are also treated in these series, however, their outcomes following resurfacing are underreported. The aim of this study was to determine complications that may occur following hip resurfacing in patients with inflammatory arthritis. A secondary aim was to determine functional outcomes following resurfacing.

METHODS

A search was performed in MEDLINE (PubMed/OVID), Cochrane Library, and Google Scholar. 5 studies met eligibility criteria. This review includes 196 hips; 120 had a diagnosis of AS or seronegative spondyloarthropathy and 76 had a diagnosis of RA or juvenile RA. 8 revisions were reported at a mean time of 64.2 (8.67-275.58) weeks.

RESULTS

Femoral neck fracture was the most common indication for revision, occurring in 3.06% of all hips at 34.5 weeks (16.0-52.0). 2 infections, 2 reports of acetabular radiolucency, and no dislocations were reported. The University of California at Los Angeles score, Harris Hip Score, and Range of Motion were the most common functional outcomes measured, which increased in the majority of studies following resurfacing.

CONCLUSIONS

Femoral neck fracture was the most common reason for revision in patients with inflammatory arthritis following resurfacing and there were no dislocations reported. Following resurfacing, these patients have improved functional outcomes.

A Literature Review of Total Hip Arthroplasty in Patients with Ankylosing Spondylitis: Perioperative Considerations and Outcome

Ankylosing spondylitis is a spondyloarthropathy affecting the sacro-iliac joints with subsequent progression to the spine and the hip joints. The hip joints are affected by synovitis, enthesial inflammation, involvement of medullary bone, progressive degeneration and secondary osteoarthritis. Clinical presentation is usually in the form of pain and stiffness progressing to disabling fixed flexion contractures and in some instances, complete ankylosis. Hip arthroplasty should be considered for hip pain, postural and functional disability, or pain in adjacent joints due to hip stiffness. We conducted a literature review to determine peri-operative considerations and outcome in ankylosing spondylitis patients undergoing hip arthroplasty. In this review, we have discussed pre-operative surgical planning, thromboprophylaxis, anaesthetic considerations and heterotopic ossification. Outcomes of arthroplasty include range of movement, pain relief, survivorship and complications.

Risk factors for poor hip flexion after total hip arthroplasty for the treatment of ankylosing spondylitis a multivariate analysis

The purpose of this study is to investigate the clinical and radiographic results of total hip arthroplasty (THA) for the treatment of ankylosing spondylitis (AS) and to evaluate the effects of patient, prosthesis design, and surgical technique-related risk factors on postoperative functional results. We retrospectively reviewed the clinical and radiographic results of THA performed in 167 hips for 100 patients with AS. The average follow-up period was 54.8 months (range, 32-129 months). The hip passive-flexion arc averaged only 0 ° (0-40.0 °) before surgery, compared with 100.0 ° (85.0-110.0 °) at the most recent follow-up examination (P < 0.001). Multivariate regression demonstrated that significant variables for postoperative hip flexion were degree of preoperative flexion contracture, preoperative level of C-reactive protein, use of a 32-mm femoral head, and postoperative heterotopic ossification. In patients with AS with severe pain, limited motion and posture, as well as deformity, the overall outcomes after THA were found to be favorable with an encouraging midterm prosthetic survivorship, a low complication rate and a high level of patients' satisfaction. It seemed these patients were particularly predisposed to relative poor range of motion of the involved hips after THA which was closely related to patients' satisfaction. The surgeons should pay careful attention to all possible risk factors perioperatively and develop a comprehensive treatment regimen.

Decision making regarding spinal osteotomy and total hip replacement for ankylosing spondylitis

Few studies have examined the order in which a spinal osteotomy and total hip replacement (THR) are to be performed for patients with ankylosing spondylitis. We have retrospectively reviewed 28 consecutive patients with ankylosing spondylitis who underwent both a spinal osteotomy and a THR from September 2004 to November 2012. In the cohort 22 patients had a spinal osteotomy before a THR (group 1), and six patients had a THR before a spinal osteotomy (group 2). The mean duration of follow-up was 3.5 years (2 to 9). The spinal sagittal Cobb angle of the vertebral osteotomy segment was corrected from a pre-operative kyphosis angle of 32.4 (SD 15.5°) to a post-operative lordosis 29.6 (SD 11.2°) (p < 0.001). Significant improvements in pain, function and range of movement were observed following THR. In group 2, two of six patients had an early anterior dislocation. The spinal osteotomy was performed two weeks after the THR. At follow-up, no hip has required revision in either group. Although this non-comparative study only involved a small number of patients, given our experience, we believe a spinal osteotomy should be performed prior to a THR, unless the deformity is so severe that the procedure cannot be performed.

Cite this article: Bone Joint J 2014;96-B:360–5.

Hip resurfacing arthroplasty in inflammatory arthritis a 3- to 5-year follow-up study

The success of hip resurfacing in younger patients with primary osteoarthritis has paved the way for the trial of the procedure in patients with secondary osteoarthritis of the hip. We retrospectively reviewed the clinical and radiologic results in a cohort of 23 patients (32 hips) with inflammatory arthritis who were chosen for hip resurfacing after normalizing vitamin D levels and ruling out proximal femoral osteopenia using dual-energy x-ray absorptiometry. At a minimum follow-up of 3 years, there was failure in only 1 hip due to fracture of the femoral neck attributable to osteonecrosis of the remnant head. The clinical outcome was evaluated using Harris hip score and was found to be good to excellent in 30 of 31 hips. Hip resurfacing is a promising alternative in carefully chosen patients with inflammatory arthritis.

Bilateral synchronous total hip arthroplasty for ankylosed hips

PURPOSE

We investigated the effect of bilateral total hip replacement (THR) for patients with ankylosed hip joints caused by late ankylosing spondylitis (AS) and to discuss its related pre- and postoperative problems.

METHODS

Data of 12 patients with ankylosed hip joints caused by late AS who underwent THR (24 hips) were reviewed. Each patient had both hips replaced at the same time. We assessed joint pain, range of motion (ROM) and Harris hip score (HHS) to determine postoperative results.

RESULTS

Mean follow-up was 4.2 years; all hip-joint function improved, and flexion deformity was corrected. Flexion ranges were 75-105°(average 84. 4°) extension 10°~20°(average 18. 7°). HHS ranged from 15.21 points preoperation to 86.25 points postoperation. No patient experienced hip pain postoperatively, and presurgery knee and lower back pain were clearly relieved postoperatively.

CONCLUSION

Bilateral THR is an effective treatment for the ankylosed hip joint caused by late ankylosing spondylitis. When considering this procedure, attention to related pre- and postoperative problems must be considered.