Strategizing Simultaneous Spinal Osteotomy and Total Hip Replacement in Ankylosing Spondylitis

Abstract

Objective: Ankylosing spondylitis (AS) is a debilitating rheumatic condition that significantly impairs mobility and quality of life through chronic inflammation and spinal fusion. The aim of this study is to investigate the optimal sequencing of spinal osteotomy and total hip replacement (THR) as treatment options, a topic that remains a subject of debate among medical professionals.

Methods: In a retrospective cohort study spanning from 2017 to 2021, we assessed adult patients with AS who underwent both spinal osteotomy and THR, outcome measures involved radiographic assessments like Global Cobb angle, thoracolumbar kyphosis (TLK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS), as well as clinical metrics such as the Harris hip score. For the same surgical group, paired t-tests were performed for pre- and postoperative data, while independent sample t-tests were used for comparing different surgical groups. The study aims to elucidate the optimal sequencing of these surgical procedures based on these comprehensive metrics.

Results: Among the 14 patients included, demographic and clinical variables were comparable between the two procedural groups. At the 3-month follow-up, all major metrics showed significant postoperative improvements. Specifically, the Global Cobb angle reduced from 98.88 ± 38.54 to 54.48 ± 18.14 (p = 0.018), and the Harris hip scores, evaluated at the 3-month follow-up, dramatically increased from 15.14 ± 10.12 to 72.57 ± 14.12 (p = 0.001). Furthermore, the Spine First Group exhibited more pronounced changes in pelvic parameters (p = 0.009), albeit at the expense of longer operation times and increased blood loss. No major complications were encountered.

Conclusions: Contrary to the prevalent belief that spinal osteotomy should precede THR, our study argues that under certain conditions, opting for hip surgery first can be both viable and advantageous. This approach may mitigate the risk of complications and even facilitate subsequent spinal surgery. Surgical decisions must be highly tailored, focusing on patient-specific needs and anatomical considerations. The ultimate goal remains consistent: to improve patients’ functional abilities in daily activities and thereby enhance their overall quality of life.

Keywords

Ankylosing Spondylitis / Deformity / Spinal Osteotomy / Surgical Sequencing / Total Hip Replacement

References

[1] Taurog JD, Chhabra A, Colbert RA. Ankylosing spondylitis and axial Spondyloarthritis. N Engl J Med. 2016; 374(26): 2563–2574.

[2] Lubrano E, Astorri D, Taddeo M, Salzmann A, Cesarano E, Brunese L, et al. Rehabilitation and surgical management of ankylosing spondylitis. Musculoskelet Surg. 2013; 97(Suppl 2): S191–S195.

[3] Fan X, Qi B, Ma L, Ma F. Screening of underlying genetic biomarkers for ankylosing spondylitis. Mol Med Rep. 2019; 19(6): 5263–5274.

[4] Rashid T, Ebringer A, Wilson C. The link between Klebsiella and ankylosing spondylitis in worldwide geographical locations. Curr Rheumatol Rev. 2016; 12(3): 223–231.

[5] Joshi AB, Markovic L, Hardinge K, Murphy JCM. Total hip arthroplasty in ankylosing spondylitis: an analysis of 181 hips. J Arthroplasty. 2002; 17(4): 427–433.

[6] Healey EL, Haywood KL, Jordan KP, Garratt AM, Packham JC. Patients with well-established ankylosing spondylitis show limited deterioration in a ten-year prospective cohort study. Clin Rheumatol. 2013; 32(1): 67–72.

[7] Vander Cruyssen B, Muñoz-Gomariz E, Font P, Mulero J, de Vlam K, Boonen A, et al. Hip involvement in ankylosing spondylitis: epidemiology and risk factors associated with hip replacement surgery. Rheumatology (Oxford). 2010; 49(1): 73–81.

[8] Gerscovich EO, Greenspan A, Montesano PX. Treatment of kyphotic deformity in ankylosing spondylitis. Orthopedics. 1994; 17(4): 335–342.

[9] Ma S, Zhou Z, Yu H, Wu C, Deng W, Cao K. Two-level pedicle subtraction osteotomy in lateral position for an ankylosing spondylitis patient with severe thoracolumbar kyphosis and hip flexion contracture: a case report. Oper Neurosurg (Hagerstown). 2022; 23(1): e72–e76.

[10] Moll JM. New criteria for the diagnosis of ankylosing spondylitis. Scand J Rheumatol Suppl. 1987; 65: 12–24.

[11] Song K, Zheng G, Zhang Y, Zhang X, Mao K, Wang Y. A new method for calculating the exact angle required for spinal osteotomy. Spine. 2013; 38(10): E616–E620.

[12] Le Manach Y et al. Outcomes after hip fracture surgery compared with elective Total hip replacement. JAMA. 2015; 314(11): 1159–1166.

[13] Tsai SHL, Lau NC, Chen WC, Chien RS, Tischler EH, Fu TS, et al. Total hip arthroplasty has higher complication rates in stiff spine patients: a systematic review and network meta-analysis. J Orthop Surg Res. 2022; 17(1): 353.

[14] Iwai C, Fushimi K, Nozawa S, Kato K, Miyagawa T, Takigami I, et al. Surgical Management of Thoracolumbar Scoliosis Secondary to hip joint Ankylosis and severe pelvic obliquity. Cureus. 2021; 13(11): e19744.

[15] Tang WM, Chiu KY. Primary total hip arthroplasty in patients with ankylosing spondylitis. J Arthroplasty. 2000; 15(1): 52–58.

[16] Zheng GQ, Zhang YG, Chen JY, Wang Y. Decision making regarding spinal osteotomy and total hip replacement for ankylosing spondylitis: experience with 28 patients. Bone Joint J. 2014; 96-b(3): 360–365.

[17] Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, et al. The assessment of SpondyloArthritis international society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009; 68 Suppl 2: ii1.

[18] Haddas R, Belanger T. Clinical gait analysis on a patient undergoing surgical correction of kyphosis from severe ankylosing spondylitis. Int J Spine Surg. 2017; 11(3): 18.

[19] Allouch H, Shousha M, Böhm H. Surgical management of ankylosing spondylitis (Bechterew’s disease). Zeitsch Rheumatol. 2017; 76(10): 848–859.

[20] Kawahara N, Tomita K, Baba H, Kobayashi T, Fujita T, Murakami H. Closing-opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Spine. 2001; 26(4): 391–402.

[21] Chang KW, Cheng CW, Chen HC, Chang KI, Chen TC. Closing-opening wedge osteotomy for the treatment of sagittal imbalance. Spine (Phila Pa 1976). 2008; 33(13): 1470–1477.

[22] Qian BP, Wang XH, Qiu Y, Wang B, Zhu ZZ, Jiang J, et al. The influence of closing-opening wedge osteotomy on sagittal balance in thoracolumbar kyphosis secondary to ankylosing spondylitis: a comparison with closing wedge osteotomy. Spine (Phila Pa 1976). 2012; 37(16): 1415–1423.

[23] Zhang W, Yin W, Cui X, Chai Z, Zheng G, Ding Y, et al. Operative strategies for ankylosing spondylitis-related thoracolumbar kyphosis: focus on the cervical stiffness, coronal imbalance and hip involvement. BMC Musculoskelet Disord. 2023; 24(1): 723.

[24] Luan H, Liu K, Kahaer A, Wang Y, Sheng W, Maimaiti M, et al. Pedicle subtraction osteotomy for the corrective surgery of ankylosing spondylitis with thoracolumbar kyphosis: experience with 38 patients. BMC Musculoskelet Disord. 2022; 23(1): 731.

[25] McMaster MJ. A technique for lumbar spinal osteotomy in ankylosing spondylitis. J Bone Joint Surg Br. 1985; 67(2): 204–210.

[26] Lee ML. Orthopaedic problems in ankylosing spondylitis. Rheumatism. 1963; 19: 79–82.

[27] Obeid I, Boissière L, Vital JM, Bourghli A. Osteotomy of the spine for multifocal deformities. Eur Spine J. 2015; 24(Suppl 1): S83–S92.

RIGHTS & PERMISSIONS

2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.