Goals, Indications, Preoperative and Intra operative considerations for doing a hip replacement in Ankylosing spndylitis

1. TIPS & TRICKS OF THR IN
ANKYLOSING SPONDYLITIS
DR SABYASACHI BARDHAN
Joint Replacement & Trauma Surgeon

2. INTRODUCTION
• Autoimmune inflammatory multisystem disorder
• 16.7/10000 population in Asia
(Global prevalence of ankylosing spondylitis Linda E. Dean, Gareth T. Jones, Alan G. MacDonald,
Christina Downham, Roger D. Sturrock, Gary J. Macfarlane Rheumatology, Volume 53, Issue 4, April
2014, Pages 650–657, https://doi.org/10.1093/rheumatology/ket387)
• M:F 3:1
• Sacroiliac joints and Axial Spine
• Peripheral joints: Hip most common (30-50%,
Most are bilateral)
• 88% is HLA B27 positive

3. GOAL
• Painfree stable hip
• Correction of deformity
• Increase mobiilty
• Improve posture

4. Indication
• Pain and deformity severe enough to
interfere with ADL
• Cannot go to school/college
• Cannot go to office
• Failure of medical management

5. ASSESSMENT
Clinical: ROM of Spine, Sterno-mental distance, Modified Schober,
Hip ROM and Deformities

6. Zheng et al recommend :
Spinal osteotomy be performed before THR
1)AS patients with a severe kyphotic deformity have the potential risk of
anterior dislocation of the prosthesis, as pelvic hyperextension to
compensate for a kypkotic spine brings the cup to a more open
position with an exaggerated anteversion.
2)Hyperextension of immobile spine during THR could lead to intra-op
thoracic vertebral body extension fractures with resultant acute traumatic
paraplegia

7. ASSESSMENT
Radiological assessment
1. Xray pelvis with both hip joints: Ap & Lateral
2. Standing Xray of pelvis with lumbar spine: lateral
3. Lumbar spine: Ap

8. Pre anaesthetic Check up
• Management of the upper airway: stiff flexed
cervical spine may need fiber optic intubation
• Presence of pulmonary restriction: May need
PFT
• Cardiac involvement: ECG and
Echocardiography
• Access to the neuroaxis
• ICU backup

9. INTRA OPERATIVE CONSIDERATIONS
Patient Positioning
• Can be challenging
• Contra lateral hip deformity can prevent pelvis
to be horizontal
• Proper support to spine
• Better to do it yourself!!

10. INTRA OPERATIVE CONSIDERATIONS
Approach
• Individual choice and experience
• Posterior approach: Difficult in abducted externally
rotated hips
• Dual approach
(Total hip arthroplasty using a combined anterior and posterior
approach via a lateral incision in patients with ankylosed hips
Jian Li, MD,*† Zhiwei W et al)

11. INTRA OPERATIVE CONSIDERATIONS
Hip Dislocation
• Very challenging
• Osteotomy of neck in situ
• Nibbling out the head or in situ reaming
• Fluroscopic guidance

12. INTRA OPERATIVE CONSIDERATIONS
Acetabular Cup Placement
Decreased Anteversion and increased inclination to
counter chance of anterior dislocation due to
loss/absence of spino pelvic movement

13. INTRA OPERATIVE CONSIDERATIONS
Acetabular Cup Placement
Cup inclination changes if pelvis is
not horizontal to the table

14. INTRA OPERATIVE CONSIDERATIONS
Adequate soft tissue release
1. Adductor tenotomy
2. Iliopsoas release
3. Capsulotomy

15. INTRA OPERATIVE CONSIDERATIONS
Choice of Implants
• Uncemented
• Cemented

16. COMPLICATIONS
• Intraoperative: Neuro vascular injury
Periprosthetic fracture
Blood loss
• Postoperative: Dislocation
Poor functional recovery

17. CONCLUSION
• Very challenging
• Proper selection of patients
• Preoperative assessment is crucial: Clinically
and Radiologically
• PAC is a must
• Correct cup placement is crucial

18. THANK
YOU