Total hip arthroplasty in ankylosing spondylarthritis patients

Ankylosing spondylarthritis (AS) belong to the group of rheumatic diseases, which underlying pathology is systemic progressive soft tissue disorganization with pronounced autoimmune changes in the organism, chronic course of pathological process with joint involvement and development of stable limbs deformities which are the cause of locomotor system malfunction, disability and severe invalidism of patients.

In AS the peripheral joints are involved more than in a half of the patients and about one third of patients develops hip joints lesions.

The restoration of hip joint mobility is possible only with help of surgical interventions. Lately the patients with AS have been undergone the total hip arthroplasty more often [1 — 5 ].

PATIENTS AND METHODS

At the Ukrainian Centre of Joint Replacement 29 total hip arthroplasties were performed in 23 patients with AS with a mean age of 36,5 years (range: 22 to 62). There were 20 men and 3 women. 6 patients had bilateral arthroplasty. The arthroplasty of another joint was performed 3—5 months after postoperative wound healed, the patient began to walk independent with full weight bearing on operated limb and joint mobility of the operated limb had been restored.

In 19 cases prostheses of the firm «Biomet» were inserted, in 10 cases prostheses of Ukrainian Research Institute design.

RESULTS

Total hip arthroplasty long term results were studied from 1 to 7 years. The outcome was considered to be good when the discordant lower limb deformity was eliminated, the joint function was restored within 90 degrees and more in the sagittal plane and 30—50 degrees in the frontal plane in full limb extension without pain both while walking and resting.

When the joint function was restored not less than within 30—45 degrees in lower limb extension or a small tendency to extensive contracture of 5—10 degree and movements in the frontal plane were preserved within 20—30 degree and the hip joint was free of pain the outcome was considered to be satisfactory.

The outcome was regarded as poor when there was a deformity recurrence with significant function reduction or full failure of that and the operated hip joint was painful.

In 22 cases of the total 29 the results were good. The operated hip joints were painless both in rest and load, the range of movement increased significantly: flexion to 90 degree, abduction to 25 degrees.

In 7 cases patients had satisfactory outcomes.

5 patients developed a complication in form of postoperative hematoma. The hematomas were drained, the inflammatory process was stopped within 4—6 weeks. These complications did not have any effect on the treatment results.

DISCUSSION

On base of our clinical experience we have determined some features which should be taken into account in this patients category while performing total joint arthroplasty, such as: — at early disease stages in the bones surrounding the joint local osteoporosis begins developing, over time it becomes generalized, what is associated with appearance of aseptic joint inflammation, decrease in range of movement and weight bearing capability of the limb, antiflammatory drug usage as well as soft tissue metabolopathy; — the influence of deformities, contractures or ankyloses in other joints on the locomotor system biomechanics; — acetabulum protrusion development.

Taking into account all mentioned above we worked out indications for total hip arthroplasty in this patients category.

The surgical indications were: — significant destructive changes in the proximal femur and acetabulum with durable pain syndrome; — limbs deformities because of flexion-abduction contractures of the hip joint; — hip joint stiffness or ankylosis.

While preparing for the surgery the muscle condition was payed attention to, especially in patients who because of high general pathological process intensity had to keep bed for a long time or who had hip joint ankylosis. That is why several months before the surgery, depending on the locomotor system condition the massage, physical therapy — myostimulation, amplipulse, therapeutic exercises were performed to restore the muscle tonus. The drug therapy was aimed at the decrease in inflammatory process intensity.

The surgery was performed according to the conventional operative technique. The hip joint arthroplasty in AS patients had a peculiarity: in most cases, in particular in AS, the patient agreed to the surgery only when in the hip joint true or true and false ankylosis had developed. In such cases after the capsule incision over anterior hip joint surface it is usually hard to luxate the femur head into the wound. That is why at first neck femur osteotomy was performed and with help of a gouge the femur head was fragmentated and removed from the acetabulum. In the course of surgical intervention the hip joint capsule was carefully resected and if necessary myotomy of adductors was performed.

Taking into account local and general osteoporosis the prosthesis components both acetabulum and stem were inserted with use of cement. In the postsurgical period the second rehabilitation stage started. The therapeutic excercises training was introduced on the second day after surgery. From the third day the patients were allowed to be up, to stand using crutches near the bed with partial loading on the operated limb. In cases when the acetabulum plasty had been performed the regimen was more conservative. About two weeks after surgery only passive motion in bed was allowed and 3—4 weeks later the active movements could be performed. During 4—6 weeks the patients could walk with partial weight bearing on the operated limb and full weight bearing was allowed from the 12th week. As physical therapy methods in the postsurgical period myostimulation and amplipulse were used.

So, in surgical intervention planning in total hip arthroplasty the changes developed in the patients locomotor system in the course of durable disease and the patterns of pathological process process must be taken into account.

The total hip arthroplasty in AS patients with use of cement permits restoring the hip joint function and obtaining the supportable limb.

REFERENCES

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2. Brinker M. R., Rosenberg  A. G., Kull  L., Cox  D. D. Primary noncemended total hip arthroplasty in patients with ankylosing spondylitis. Clinical and radiographic results at an average follow-up period of 6 years. //Journal of Arthroplasty. 1996. Okt. 11(7):802—12.
3. Gualtieri G, Gualtieru I, Hendriks M ect (1992) Comparison of cemented ceramic and metal-polyethylene coupling hip prostheses in ankylising spondylitis. Clinical Orthopaedics Related Research 282:81—85
4. Lukoschek M., Simank  U. G., Brocai  D. R. (1998 ) Cementless hip prosthesis in inflammatory rheumatic diseases. Orthopade Jun; 27 ( 6 ): 392 — 5.
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Gerasymenko S., Polulyakh M V.Vaida, V. Maiko, J. Pavlischen Total hip arthroplasty in ankylosing spondylarthritis patients. Central Europen Orthopedic Congress. Book of Abstracts. -Zagreb. — 2002. — p. 92.