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Wheeless' Textbook of Orthopaedics

Ankylosing Spondylitis



- See: Spondyloarthropathies

- Discussion:
    - affects young men (ages 15 to 25 years), but may also begin in middle-aged men;
           - disease is often more severe when it occurs early in life;
    - disease characterized by insidious onset of pain and stiffness in lower back associated w/ gradual loss of spinal mobility;
    - illness may cause inflammation in uveal tract (iritis in 25%) & in intima of aorta;
    - symptoms are typically worse in the morning and in the middle of the night;
    - note: that in women, the symptoms of ankylosing spondylitis often first present during pregnancy;
    - labs: HLA-B27 (may be present in up to 8% of unaffected white population);
           - may also be present in Reiter's syndrome;


- Spine in Ankylosing Spondylitis:
    - disorder has a tendency to progress slowly, w/ diminished mobility of the spine and sacroiliac joints;
    - early diagnosis can often be made with a CT scan of the sacroiliac joints;
    - cervical spine in ankylosing spondylitis:
         - acute neck pain in pt w/ AS is usually caused by frx thru ankylosed spine;
         - frx involves all columns & may be assoc w/ dramatic change in neck alignment;



- Peripheral Arthritis:
    - may involve hips, knees, ankles, toes, (rare upper extremities).
    - these may precede the back pain by several years;
    - arthritis is acutely painful but rarely chronic or destructive;
    - hip joint:
           - is affected in up to 50 % of patients with AS, and when it occurs it is often bilateral;
           - protrusio and hip flexion contractures are common;
           - heterotopic ossification may follow THR;
           - total hip replacement:
                   - hetertopic ossification;
                          - occurs in 20-40 % of hip replacements and is more common w/ trochanteric osteotomy;
                   - to avoid heterotopic ossification consider insertion of a cemented acetabular component followed by 750 rads around the component;

- Childhood AS:
    - AS may develop in children & resembles pauciarticular JRA;
    - usually boys over 8 years of age
    - asymmetric peripheral arthritis of lower extremities.
    - must be differentiated from DISH;


- Management:
    - NSAIDS: patients should be placed on indocin as soon as the diagnosis is made;
    - tumor necrosis factor inhibitors:
          - Treatment of Ankylosing Spondylitis by Inhibition of Tumor Necrosis Factor
    - sulfasalazine:
          - may attenuate the inflammatory exacerbations;
                  - effect starts within the first 2 to 3 months;
                  - dose can be gradually decreased after 6 months, and then slowly stopped;
                  - begin with full dose (2 g/day) or start with 500 mg/day weekly increasing the dose to 1 g/bid;
                  - dose can be increased up to 3 g/day;
          - less effective in chronic cases


References 

Disorders of the sacro-iliac joint in children.

Total hip replacement for patients who have ankylosing spondylitis. The importance of the formation of heterotopic bone and of the durability of fixation of cemented components.

The Shoulder Girdle in Ankylosing Spondylitis.

Ankylosing spondylitis: experience in surgical management of 21 patients

The clinical spectrum of ankylosing spondylitis.

Long term results of total hip replacement in young patients who had ankylosing spondylitis. Eighteen to thirty year results with survivorship analysis.
     

Alternatives to Total Knee Replacement: Autologous Hamstring Resurfacing Arthroplasty



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, August 21, 2012 4:09 pm