Pathogenetic and Technical Aspects of Radical Surgical Procedures for Treating Ankylosing Spondylitis

In recent decades, orthopedic science has identified a number of fundamental areas in restoring the functional capabilities of patients based on the use of high-tech methods for treating musculoskeletal pathologies. Arthroplasty has become a key element in solving the problems of late stages of joint diseases,  especially of the lower extremities. However, systemic pathologies, including autoimmune skeletal diseases, especially rheumatoid arthritis (RA) and ankylosing spondylitis (AS), pose unique challenges that require a specialized approach. The importance of endoprosthetics for replacing the hip and knee joint in the complex treatment of AS cannot be overestimated. Radical interventions can relieve pain, restore joint function and improve the quality of life of such a complex group of patients. They play an important role in restoring the patient's physical activity and mitigating the effects of severe skeletal pathology. Without solving the fundamental problem of healing, the method helps to improve the patient's quality of life, which makes it indispensable today. The purpose of the work is to consider treatment options and analyze publications of domestic and foreign authors on the issues of ankylosing spondylitis with an emphasis on surgical correction of late stages of articular manifestations. Source search methodology. To prepare the literature review, the electronic database of scientific literature PubMed (MEDLINE) was used. The literature was searched using the following keywords: ankylosing spondylitis, rheumatoid arthritis, hip replacement The following INCLUSION CRITERIA were used: randomized controlled clinical trials, clinical cases, systematic reviews, meta-analyses. EXCLUSION CRITERIA were articles without a full-text version, duplicate publications. Preference was given to works over the past 5-10 years. 

1. Appel H., Sieper J. Spondyloarthritis at the crossroads of imaging, pathology, and structural damage in the era of biologics. Curr Rheumatol Rep. 2008;10 (5):356-363. doi:10.1007/s11926-008-0058-x

2. Khan M. Update on Spondyloarthropathies. Ann Intern Med. 2002 Jun 18; 136(12):896-907. DOI:10.7326/0003-4819-136-12-200206180- 00011.

3. Balabanova R.M., Erdes Sh.F. THE INCIDENCE AND PREVALENCE OF RHEUMATIC DISEASES IN RUSSIA IN 2012–2013. Rheumatology Science and Practice. 2015;53(2):120-124. DOI:10.14412/1995-4484-2015-120-124

4. Erdes Sh.F., Badokin V.V., Bochkova A.G., Bugrova O.V., Gaidukova I.Z., Godzenko A.A., Dubikov A.A., Dubinina T.V., Ivanova O.N., Korotaeva T.V., Lapshina S.A., Nesmeyanova O.B., Nikishina I.P., Otteva E.N., Raskina T.A., Rebrov A.P., Rumyantseva O.A., Sitalo A.V., Smirnov A.V. ON THE TERMINOLOGY OF SPONDYLOARTHRITIS. Rheumatology Science and Practice. 2015;53(6):657-660. DOI:10.14412/1995-4484-2015-657-660

5. Ramiro S., van der Heijde D., van Tubergen A., et al. Higher disease activity leads to more structural damage in the spine in ankylosing spondylitis: 12-year longitudi- nal data from the OASIS cohort. Ann Rheum Dis. 2014 Aug;73(8):1455-61. DOI: 10.1136/annrheumdis-2014-205178. Epub 2014. May 7

6. Rumyantseva D.G., Erdes S.F. Axial spondyloarthritis: a current look at the concept and evolution of the disease. Sovremennaya Revmatologiya=Modern Rheumatology Journal. 2019;13(4):4-10. DOI:10.14412/1996-7012-2019-4-4-10

7. Lila A.M., Dubinina T.V., Dreval R.O., Lapshina S.А., Zabotina A.N. Medical and social significance and calculation of the economic burden of axial spondyloarthritis in the Russian Federation. Sovremennaya Revmatologiya=Modern Rheumatology Journal. 2022;16(1):20-25

8. Pedersen S.J., Wichuk S., Chiowchanwisawakit P., et al. Tumor necrosis factor inhibitor therapy but not standard ther- apy is associated with resolution of erosion in the sacroiliac joints of patients with axial spondyloarthritis. Arthritis Res Ther. 2014 Apr 22;16(2):R100. DOI: 10.1186/ar4548

9. Sukhareva M.L., Dubinina T.V., Erdes Sh.F., Agasarov L.G. PROBLEMS In the application of principles of evidence-based medicine to the medical rehabilitation of rheumatic diseases. Rheumatology Science and Practice. 2015;53(5):564-567.

10. Karateev A.E., Sukhareva M.V., Lila A.M. Medical rehabilitation in the combination treatment of rheumatic diseases: a review. Rheumatology Science and Practice. 2019;57(5):584-596.

11. Tang M., Xue L., Shen Y., et al. Efficacy of long-term nonsteroidal antiinflammatory drug treatment on magnetic resonance imag- ingdetermined bone marrow oedema in early, active axial spondyloarthritis patients. Clin Rheumatol. 2018 Jan;37(1):245-50. doi: 10.1007/s10067-017-3666-x. Epub 2017 May 11

12. Bochkova A.G.Rol’ glyukokortikoidovv lechenii spondiloartritov. Sovremennaya Revmatologiya Modern Rheumatology Journal. 2011;5(1):76-79.

13. Xi Y., Jiang T., Chaurasiya B. et al. Advances in nanomedicine for the treatment of ankylosing spondylitis. Int J Nanomedicine. 2019 Oct 29;14:8521-42. doi: 10.2147/ IJN.S216199

14. Stovall R., Peloquin C., Felson D., Neogi T., Dubreuil M. Relation of NSAIDs, DMARDs, and TNF Inhibitors for Ankylosing Spondylitis and Psoriatic Arthritis to Risk of Total Hip and Knee Arthroplasty [published correction appears in J Rheumatol. 2021 Dec;48(12):1892. DOI: 10.3899/jrheum. 200453.

15. Erdes S.F. Recent advances and prospects of axial spondyloarthritis / ankylosing spondylitis treatment. Sovremennaya Revmatologiya=Modern Rheumatology Journal. 2021; 15(2):94-105.

16. Al-Lami M.A.D.,. Akhtyamov I.F., Nuriakhmetova T.Yu., Lapshina S.A. Assessment of the effectiveness of the replacement of hip joints in patients with spondyloarthritis 2024:2: 9-14 DOI: 10.33454/1728-1261-2024-2-9-14.

17. MacKay K., Brophy S., Mack C., Doran M., Calin A. The development and validation of a radiographic grading system for the hip in ankylosing spondylitis: the bath ankylosing spondylitis radiology hip index. J Rheumatol. 2000;27(12):2866-2872.

18. Vander Cruyssen B., Muñoz-Gomariz E., Font P. et al. Hip involvement in ankylosing spondylitis: epidemiology and risk factors associated with hip replacement surgery. Rheumatology (Oxford). 2010;49(1):73-81. doi:10.1093/rheumatology/kep174

19. Brooker A.F., Bowerman J.W., Robinson R.A., Riley L.H. Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973; 55(8): 1629–32

20. Rudwaleit M. et al. Low T cell production of TNFalpha and IFNgamma in ankylosing spondylitis: its relation to HLA-B27 and influence of the TNF-308 gene polymorphism. Ann. Rheum. Dis. 2001;60:36–42 DOI:10.1136/ard.60.1.36.).

21. Faham M. et al. Discovery of T cell receptor beta motifs specific to HLA-B27-positive ankylosing spondylitis by deep repertoire sequence analysis. Arthritis Rheuma. 2017;69:774–784. DOI:10.1002/art.40028.

22. Bowness P. et al. Th17 cells expressing KIR3DL2+ and responsive to HLA-B27 homodimers are increased in ankylosing spondylitis. J. Immunol. 2011;186:2672–2680. DOI:10.4049/jimmunol.1002653.

23. Ward M.M. Increased Rates of Both Knee and Hip Arthroplasties in Older Patients with Ankylosing Spondylitis. J Rheumatol. 2019;46(1):31- 37. DOI:10.3899/jrheum.171316

24. Hawley S., Sacks S., Bowness P., Prieto-Alhambra D. Incidence of Total Hip and Knee Replacement in UK Patients with Ankylosing Spondylitis. J Rheumatol. 2018;45(9):1334-1336. DOI:10.3899/jrheum.171387

25. Di Martino A., Ursini F., Bordini B. et al. Perioperative treatment with TNF inhibitors does not affect survival of total hip arthroplasty in inflammatory arthritis: A registry-based cohort study. Semin Arthritis Rheum. 2023; 60: 152201. DOI:10.1016/j.semarthrit.2023.152201.

26. Tsay P.J., Hsu S.W., Peng H.C. et al. Trachway intubating stylet for tracheal intubation in an ankylosing spondylitis patient undergoing total hip replacement under general anesthesia. Acta Anaesthesiol Taiwan. 2011; 49(4): 159–61. DOI:10.1016/j.aat.2011.11.005

27. Chung B.C., Stefl M., Kang H.P. et al. Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis. Hip Int. 2023; 33(6): 1026–34. DOI:10.1177/11207000221126968. PMID: 36192824.

28. Debarge R., Demey G., Roussouly P. Radiological analysis of ankylosing spondylitis patients with severe kyphosis before and after pedicle subtraction osteotomy. Eur Spine J. 2010; 19(1): 65–70

29. Jacob M.K., Reddy P.K., Kuruvilla R.S., John C.V., Poonnoose P.M., Oommen A.T. Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis. World J Orthop. 2022;13(8):714-724. Published 2022 Aug 18. DOI:10.5312/wjo. v13.i8.714.

30. Song L., Yu J., Zhang T. Therapeutic effect of artificial total hip arthroplasty on flexion regidity of hip joint in ankylosing spondylitis. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009; 23(2): 205–8.

31. Zhu X.B., Yuan L.L., Han G.S. et al. Short term effect of total hip arthroplasty through direct anterior approach for the treatment of ankylosing spondylitis with hip flexion deformity. Zhongguo Gu Shang. 2019; 32(2): 141–45. DOI:10.3969/j.issn.1003-0034.2019.02.009

32. Li L., Fu J, Xu C. et al. Fourth-Generation Ceramic-on-Ceramic THA in Patients with Ankylosing Spondylitis: A Minimum 10-Year FollowUp. Orthop Surg. 2022;14(5):860-867. . DOI:10.1111/os.13259

33. Owen A.R., Markos J.R., Mabry T.M., Taunton M.J., Berry D.J., Abdel M.P. Contemporary Primary Total Knee Arthroplasty is Durable in Patients Diagnosed With Ankylosing Spondylitis. J Arthroplasty. 2020;35(11):3161-3165. DOI:10.1016/j.arth.2020.06.033

34. Man S., Ji X., Zhang L., Hu Z., Lv Y., Zhou Y., Song H., Huang F. Effects of types and degrees of ankylosing spondylitis hip structural damages on post-total hip arthroplasty outcome measurements. Medicine (Baltimore). 2020 Nov 13;99(46):e23174. PMID: 33181692; PMCID: PMC7668424. DOI: 10.1097/MD.0000000000023174

35. Im C.J., Lee C.Y., Beom J.Y., Kim M.G., Yoon T.R., Park K.S. Stricter correction of leg length discrepancy is required during total hip arthroplasty in patients with ankylosing spondylitis. BMC Musculoskelet Disord. 2023;24(1):781. Published 2023 Oct 3. DOI:10.1186/s12891-023-06908-7

36. Ward M.M. Complications of Total Hip Arthroplasty in Patients With Ankylosing Spondylitis. Arthritis Care Res (Hoboken). 2019;71(8):1101-1108 DOI:10.1002/acr.23582

37. Lian Q., Lian Y., Li K. et al. Complications of primary total hip arthroplasty among patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and primary osteoarthritis. BMC Musculoskelet Disord. 2022;23(1):924. Published 2022 Oct 19. DOI:10.1186/s12891-022-05891-9

38. Bukowski B.R., Clark N.J., Taunton M.J. et al. Primary total hip arthroplasty in patients with ankylosing spondylitis. J Arthroplasty. 2021; 36(7S): S282–S289. DOI:10.1016/j.arth.2021.01.054. PMID: 33602587.

39. Miller L.L., Prieto-Alhambra D., Trela-Larsen L. et al. Revision and 90-day mortality following hip arthroplasty in patients with inflammatory arthritis and ankylosing spondylitis enrolled in the National Joint Registry for England and Wales. Hip Int. 2022; 32(3): 371–78. DOI:10.1177/1120700021990592. PMID: 33601915

40. Hu Y., Jiang W.Z., Pan C.L., Wang T. Active ankylosing spondylitis increases blood loss during total hip arthroplasty for a stiff hip joint. BMC Musculoskelet Disord. 2020;21(1):243. Published 2020 Apr 15 DOI:10.1186/s12891-020-03278-2

41. Mekkawy K.L., Rodriguez H.C., Mercadal G. et al. Ankylosing spondylitis in patients undergoing total hip arthroplasty increases the risk of medical and implant-related complications: A case control analysis. Hip Int. 2024; 34(5): 602–7. DOI:10.1177/11207000241267706

42. Li L., Fu J., Xu C. et al. Factors associated with blood loss in ankylosing spondylitis patients with hip involvement undergoing primary total hip arthroplasty: a cross-sectional retrospective study of 243 patients. J Orthop Surg Res. 2020;15(1):541. Published 2020 Nov 18. DOI:10.1186/s13018-020-02064-z

43. Li J., Zhao J., He C., Tong W., Zou Y., Xu W. Comparison of Blood Loss After Total Hip Arthroplasty Between Ankylosing Spondylitis and Osteoarthritis. J Arthroplasty. 2016;31(7):1504-1509. DOI:10.1016/j.arth.2015.12.049

44. Shi D., Xu X., Song K. et al. Comparison of venous thromboembolism after total hip arthroplasty between ankylosing spondylitis and osteoarthritis. Biomed Res Int. 2014;2014:712895. DOI:10.1155/2014/712895

45. Chung B.C., Stefl M., Kang H.P. et al. Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis. Hip Int. 2023;33(6):1026-1034. DOI:10.1177/11207000221126968

46. Katakam A., Bedair H.S., Melnic C.M. Do All Rigid and Unbalanced Spines Present the Same Risk of Dislocation After Total Hip Arthroplasty? A Comparison Study Between Patients With Ankylosing Spondylitis and History of Spinal Fusion. J Arthroplasty. 2020;35(12):3594-3600. DOI:10.1016/j.arth.2020.06.048

47. Bukowski B.R., Clark N.J., Taunton M.J., Freedman B.A., Berry D.J., Abdel M.P. Primary Total Hip Arthroplasty in Patients With Ankylosing Spondylitis. J Arthroplasty. 2021;36(7S):S282-S289. DOI:10.1016/j.arth.2021.01.054

48. Ran T.F., Ke S., Li J. et al. Relieved Low Back Pain after Total Hip Arthroplasty in Patients with Both Hip Osteoarthritis and Lumbar Degenerative Disease. Orthop Surg. 2021;13(6):1882-1889. DOI:10.1111/os.13135

49. Jacob M.K., Reddy P.K., Kuruvilla R.S., John C.V., Poonnoose P.M., Oommen A.T. Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis. World J Orthop. 2022;13(8):714-724. Published 2022 Aug 18. DOI:10.5312/wjo.v13.i8.714

50. Chen L., Zhou Y., Zhang L., Huang Y., Tang H. Revision total hip arthroplasty in patients with ankylosing spondylitis: Mid-term results. Orthop Traumatol Surg Res. 2023;109(7):103504. DOI:10.1016/j.otsr.2022.103504

51. Aissaoui N., Rostom S., Hakkou J. et al. Fatigue in patients with ankylosing spondylitis: prevalence and relationships with disease-specific variables, psychological status, and sleep disturbance. Rheumatol Int. 2012;32(7):2117-2124. DOI:10.1007/s00296-011-1928-5

52. Sağ S., Nas K., Sağ M.S., Tekeoğlu İ., Kamanlı A. Relationship of work disability between the disease activity, depression and quality of life in patients with ankylosing spondylitis. J Back Musculoskelet Rehabil. 2018;31(3):499-505. doi:10.3233/BMR-169657

53. Аkland G., Gran J.T., Nossent J.C. Increased mortality in ankylosing spondylitis is related to disease activity. Ann Rheum Dis. 2011;70(11):1921– 1925. DOI: 10.1136/ard.2011.151191

54. Van Eijk I.C., Peters M.J., Serné E.H., et al. Microvascular function is impaired in ankylosing spondylitis and improves after tumour necrosis factor alpha blockade. Ann Rheum Dis. 2009;68(3):362-366. DOI:10.1136/ard.2007.086777

55. Klingberg E., Lorentzon M., Mellstrom D., Geijer M., Gothlin J., Hilme E. et al. Osteoporosis in ankylosing spondylitis - prevalence, risk factors and methods of assessment. Arthritis Res Ther. 2012;14(3):R108. DOI: 10.1186/ar3833.

56. Lapshina S.A., Akhtyamov I.F., Gilmutdinov I.Sh., Al-Lami M.A.J. Hip arthroplasty in patients with ankylosing spondylitis. Practical medicine. 2019;17(6):35-38.

57. Novikov Yu.O., Bogachev A.A., Tsykunov M.B. Differential diagnostics of musculoskeletal pain in spondyloarthrosis and osteoarthrosis using magnetic resonance imagraphy. N.N. Priorov Journal of Traumatology and Orthopedics. 2024;31(3):325−336.

58. Tsykunov M.B. Rehabilitation diagnosis in the pathology of the musculoskeletal system using categories of the international classification of functioning. N.N. Priorov Journal of Traumatology and Orthopedics. 2019;1:58-66.

59. Podryadnova M.V., Balabanova R.M., Urumova M.M., Erdes Sh.F. Correlation between clinical characteristics of ankylosing spondylitis and work capacity and productivity. Rheumatology Science and Practice. 2014;52(5):513–519.

60. Ward M.M., Deodhar A., Gensler L.S. et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America. Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Care Res (Hoboken). 2019 Oct; 71(10):1285- 99. DOI: 10.1002/acr.24025. Epub 2019 Aug 21.