Association of radiological severity of hip involvement with clinical characteristics and sagittal spinopelvic balance in patients with ankylosing spondylitis

INTRODUCTION

This is the first study to analyze the associations between the radiological severity of hip involvement with clinical characteristics and sagittal spinopelvic balance in patients with ankylosing spondylitis (AS).

METHOD

We evaluated 182 patients with AS who were referred to outpatient clinics. Patient demographic data and clinical and radiographic parameters were collected. Patients were divided into three groups based on the Bath Ankylosing Spondylitis Radiology Hip Index. Clinical characteristics and spinopelvic parameters acquired by a low-dose biplanar imaging system were evaluated among these groups.

RESULTS

Patients with more severe hip involvement were older and had longer disease duration and diagnostic delay, with lower Harris Hip Score (p < 0.001) and 12-item Short Form Health Survey Physical Component Score (p < 0.001) and higher Bath Ankylosing Spondylitis Disease Activity Index (p = 0.030) and Functional Index (p < 0.001). Patients with more severe hip involvement had significantly higher sacroiliac grade (p < 0.001) and higher modified Stoke Ankylosing Spondylitis Spinal Score (p < 0.001). Patients with moderate and severe hip involvement had similar lumbar lordosis and spino-sacral angle, whereas patients with severe hip involvement had lower pelvic tilt, pelvic femoral angle, higher sacral slope, and sagittal vertical axis.

CONCLUSIONS

The severity of hip involvement is associated with physical function and is not consistent with the severity of spinal involvement. Severe hip involvement impairs the ability to retrovert the pelvis to accommodate the sagittal deformity, and spinopelvic parameters should be concretely evaluated in preoperative counseling of patients with AS waiting for total hip arthroplasty. Key Points • The severity of hip involvement in patients with AS is associated with physical function. • Severe hip involvement impairs the ability to retrovert the pelvis to accommodate the sagittal deformity.

Total Hip Arthroplasty in Ankylosing Spondylitis: A Case Report of Ankylosed Hip

Ankylosing spondylitis (AS) is a chronic inflammatory arthritic disease that primarily affects the axial skeleton, and its association with the secondary development of osteoarthritis (OA) in peripheral joints, particularly the hips, is increasingly recognized. This case report elucidates the diagnostic and therapeutic challenges encountered in a patient with bilateral hip osteoarthritis secondary to AS. The patient's medical history included AS and a failed attempt at core decompression of the left hip joint. The patient was managed with total hip arthroplasty (THA) on the left side due to persistent symptoms. Total hip arthroplasty on the left side involved a meticulous surgical approach, addressing the unique challenges posed by underlying ankylosis. The procedure was conducted uneventfully, with the implantation of a modular femoral head, uncemented femoral stem, and modular shell. Postoperatively, the patient experienced significant pain relief and improved functionality. Successful rehabilitation and management were integral to the overall positive outcome. This case report highlights the complex interplay between AS and hip osteoarthritis, emphasizing the importance of tailored diagnostic and therapeutic strategies. Successful total hip arthroplasty in the setting of AS-related hip osteoarthritis suggests that joint replacement can be effective, but ongoing research is necessary to optimize surgical planning and long-term outcomes in this patient population.

Regulatory mechanisms of miR-212-3p on the secretion of inflammatory factors in monocyte-macrophages and the directed differentiation into osteoclasts in ankylosing spondylitis

To explore the mechanisms of action of micro ribonucleic acid (miR)-212-3p in the secretion of inflammatory factors in monocyte-macrophages and the directed differentiation into osteoclasts (OCs) in ankylosing spondylitis (AS), proteoglycan was used to establish an AS mouse model. The mouse monocyte-macrophages were cultured in vitro, transfected with miR-212-3p mimic, and added with phosphorylated-extracellular signal-regulated kinase (p-ERK)1/2 agonist Ro67-7476 in vitro. After the cells were transfected with the miR-212-3p mimic in each group, the expressions of p-ERK1/2, matrix metalloproteinase-1 (MMP-1), MMP-3, interleukin-1β (IL-1β), and tumor necrosis factor-α (TNF-α) significantly declined, whereas those of tartrate-resistant acid phosphatase (TRAP), calcitonin, and p-nuclear factor of activated T cell 1 (NFATC1) significantly rose. After Ro67-7476 was added, the protein expressions of p-ERK1/2, MMP-1, MMP-3, IL-1β, and TNF-α were significantly increased in each group, but they displayed decreasing trends in cells transfected with the miR-212-3p mimic. In contrast, the protein expressions of TRAP, calcitonin, and p-NFATC1 declined, but they showed increasing trends in cells transfected with the miR-212-3p mimic. miR-212-3p can, through inhibiting the phosphorylation of p-ERK1/2, prevent the aggregation of macrophages and the secretion of inflammatory factors. It also up-regulates the expression of OC marker proteins to facilitate the differentiation and maturation of OCs, ultimately relieving AS-induced inflammation and new bone growth-induced joint neoplasm.

Revision total hip arthroplasty in patients with ankylosing spondylitis: Mid-term results

BACKGROUND

Few studies have reported on the outcome of revision total hip arthroplasty (THA) for ankylosing spondylitis (AS). Therefore, we sought to investigate the clinical and radiographic outcomes of revision THA in patients with AS.

HYPOTHESIS

The mid-term outcome of revision THA in AS patients was comparable to conventional revision THA.

MATERIALS AND METHODS

Forty-one patients with AS who underwent revision THA (on a total of 51 hips) between April 2004 and June 2018 were included. The mean follow-up duration was 7.5±3.6 years (3.0-15.8 years). Clinical outcomes were assessed using the Bath Ankylosing Spondylitis Functional Index (BASFI), Harris Hip Score (HHS), and the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. Complications were assessed at each follow-up. Radiological outcomes were examined by reviewing postoperative plain radiographs.

RESULTS

Significant improvements were seen in BASFI, HHS, and WOMAC scores (p<0.01). Postoperative combined range of motion (ROM) was 128.9±45.3° (range, 60-300°). Complications included heterotopic ossification, periprosthetic fractures, aseptic loosening, osteolysis, reinfection, residual pain or stiffness, delayed wound healing, numbness, deep vein thrombosis, leg length discrepancy, and posterior dislocation. Five (9.8%) of the 51 hips were treated with re-revision due to aseptic loosening, re-infection, or re-fracture. The incidence of dislocation was 1.9% at 7.5 years. Implant survival for all reasons was estimated to be 96.3% at 5 years, 85.9% at 10 years and 61.0% at 15 years. Forty-two (82.4%) hip revisions were rated "satisfactory" or "very satisfactory" by the patients.

CONCLUSIONS

The mid-term result of revision THA for patients with AS is comparable to conventional revisions in terms of implant survival, despite high complication rates. The benefit-risk ratio of these indications is acceptable but deserves specific information for these patients.

LEVEL OF EVIDENCE

IV; case series.

Stricter correction of leg length discrepancy is required during total hip arthroplasty in patients with ankylosing spondylitis

BACKGROUND

Patients with ankylosing spondylitis often have fusions in the spine and sacroiliac joints, such that it is difficult to compensate for leg length discrepancy (LLD).

METHODS

We retrospectively measured the LLD after total hip arthroplasty (THA) in 89 patients with ankylosing spondylitis from June 2004 to February 2021 at our institute. Patients were divided into two groups based on an LLD of 5 mm. Clinical outcomes were investigated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Harris Hip Score (HHS). In addition, these points are investigated: patient satisfaction with the operation; whether there was a current difference in leg length; and whether there was a limping gait.

RESULTS

The group with an LLD of 5-10 mm rather than < 5 mm had significantly worse WOMAC pain and stiffness. The survey revealed statistically significant differences in patient satisfaction with the operation, limping gait, and whether back pain had improved.

CONCLUSION

For patients with ankylosing spondylitis, reducing the LLD to < 5 mm, which is more accurate than the current standard of < 10 mm, may produce greater improvement in clinical outcomes after hip arthroplasty.

Management of Specific Clinical Profiles in Axial Spondyloarthritis: An Expert's Document Based on a Systematic Literature Review and Extended Delphi Process

INTRODUCTION

The management of specific clinical scenarios is not adequately addressed in national and international guidelines for axial spondyloarthritis (axSpA). Expert opinions could serve as a valuable complement to these documents.

METHODS

Seven expert rheumatologists identified controversial areas or gaps of current recommendations for the management of patients with axSpA. A systematic literature review (SLR) was performed to analyze the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, conventional synthetic, biologic and targeted synthetic disease-modifying antirheumatic drugs (csDMARDs, b/tsDMARDs) in axSpA regarding controversial areas or gaps. In a nominal group meeting, the results of the SLR were discussed and a set of statements were proposed. A Delphi process inviting 150 rheumatologists was followed to define the final statements. Agreement was defined as if at least 70% of the participants voted ≥ 7 (from 1, totally disagree, to 10, totally agree).

RESULTS

Three overarching principles and 17 recommendations were generated. All reached agreement. According to them, axSpA care should be holistic and individualized, taking into account objective findings, comorbidities, and patients' opinions and preferences. Integrating imaging and clinical assessment with biomarker analysis could also help in decision-making. Connected to treatments, in refractory enthesitis, b/tsDMARDs are recommended. If active peripheral arthritis, csDMARD might be considered before b/tsDMARDs. The presence of significant structural damage, long disease duration, or HLA-B27-negative status do not contraindicate for the use of b/tsDMARDs.

CONCLUSIONS

These recommendations are intended to complement guidelines by helping health professionals address and manage specific groups of patients, particular clinical scenarios, and gaps in axSpA.

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and Kmbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5-12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13-16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Radiosynovectomy of the hip joint - preliminary experience

Introduction

Radiosynovectomy (RSV) is a minimally invasive method of treating and controlling joint inflammation refractory to conventional pharmacotherapy. It consist in intraarticular injection of radioactive colloids which irradiate the inflamed synovial membrane to cause its subsequent involution. Despite the fact that hip joint involvement is quite common in systemic inflammatory arthropathies, hip joint RSVs are rarely performed. The aim of this paper is to assess to safety and efficacy of hip joint radioisotope treatment.

Material and methods

We retrospectively analyzed the effects of 21 hip joint RSVs performed in 14 patients (10 female, 4 male; aged 8 to 79; mean age 48 years). Before the RSV, all the patients underwent clinical and ultrasound examination. The radiosynovectomies were performed using rhenium-186 sulfide under ultrasound guidance. Each patient underwent post-therapeutic scintigraphy to assess intraarticular distribution of the radiopharmaceutical. The effects of the treatment were assessed clinically and ultrasonographically during at least 2 follow-up visits 3 and 6 months after the RSV.

Results

In 9 cases, we observed complete resolution of symptoms 3 and 6 months after the RSV. Four patients had only a partial response and required repeated treatment, and all responded well to the second RSV. In 4 patients the treatment had no significant effect, and no repeated treatment attempt was made. All the responders suffered from inflammatory arthropathies; the non-responders had osteoarthritis, with no history of systemic diseases. In all the patients, no significant adverse effects were observed; in particular there were no radiation burns or infections. All post-therapeutic scintigrams showed proper, intraarticular distribution of the radiopharmaceutical.

Conclusions

Radiosynovectomy of the hip joint in systemic joint diseases, especially performed using ultrasound-guidance, is a safe and effective treatment modality.

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and KMbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5~12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13~16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Risk factors of hip joint structural changes following pedicle subtraction osteotomy for ankylosing spondylitis-related thoracolumbar kyphosis: a minimum two-year observation

PURPOSE

To determine the clinical- and surgical-related factors of hip joint structural changes in ankylosing spondylitis (AS) patients with thoracolumbar kyphosis who underwent PSO.

METHODS

Hip involvement was assessed by the Bath Ankylosing Spondylitis Radiology Hip Index (BASRI-h) and defined by a score of at least 2. 52 patients with BASRI-h scores maintained and 78 patients with BASRI-h scores increased during follow-up were retrospectively reviewed. Clinical data were recorded. Radiological assessment was performed preoperatively, postoperatively, and at the final follow-up.

RESULTS

No significant difference existed in age, gender and follow-up time between the groups, but earlier onset of AS, longer disease and kyphotic duration, and worse Bath Ankylosing Spondylitis Functional Index (BASFI) scores at the final follow-up were observed in patients with BASRI-h scores increased (P < 0.05). Besides, global kyphosis (GK), T1-pelvic angle (TPA), pelvic tilt (PT) and anterior pelvic plane angle (APPA) were always larger in patients with BASRI-h scores increased, accompanied with more sacral fixation (P < 0.05). Multivariate logistics regression showed that earlier onset of AS, longer kyphotic duration, larger preoperative GK, sacral fixation and larger APPA during follow-up were independent risk factors.

CONCLUSION

Earlier onset of AS and longer kyphotic duration were the clinical risk factors of hip joint structural changes in AS patients following PSO, while larger preoperative GK, sacral fixation in PSO and larger APPA during follow-up were the surgical-related factors. Surgeons should inform patients with risk factors of the possibility for severe hip joint structural changes after PSO.

Cerebral Tuberculosis in a Patient Following Treatment With Infliximab for Ankylosing Spondylitis: A Case Report

Ankylosing spondylitis (AS) mainly belongs to the group of axial spondylitis. It is a chronic inflammatory disease that primarily affects the spine, but can also affect peripheral joints. It is characterized by inflammatory lower back pain and morning stiffness. Tuberculosis is still a cause of morbidity and mortality in developing countries. Management of patients with AS consists of patient education, spinal mobility exercises, non-steroidal anti-inflammatory drugs (NSAIDs), corticotherapy, and anti-tumor necrosis factor alpha (TNF-α) biological agents. Anti-TNF-α biological agents have changed the prognosis of patients with AS. They contain anti-TNF-α monoclonal antibodies (golimumab, infliximab, adalimumab, certolizumab) and the soluble TNF-α receptor (etanercept). Hip and knee involvement is common in patients with AS, as evidenced in radiographs as bone erosion and joint space narrowing. The patient may have severe pain, stiffness, and loss of mobility, and the treatment involves surgery for joint arthroplasty. We present the case of a 63-year-old patient with axial spondyloarthritis who was treated with infliximab and developed cerebral tuberculosis after three years of biological therapy. The purpose of the study is to determine the possibility of resuming biological therapy at the time of AS reactivation, given the long-term treatment and adverse reactions of cortisone therapy (aseptic necrosis of the femoral head).

The Interleukine-17 Cytokine Family: Role in Development and Progression of Spondyloarthritis, Current and Potential Therapeutic Inhibitors

Spondyloarthritis (SpA) encompasses a group of chronic inflammatory rheumatic diseases with a predilection for the spinal and sacroiliac joints, which include axial spondyloarthritis, psoriatic arthritis, reactive arthritis, arthritis associated with chronic inflammatory bowel disease, and undifferentiated spondyloarthritis. The prevalence of SpA in the population varies from 0.5 to 2%, most commonly affecting young people. Spondyloarthritis pathogenesis is related to the hyperproduction of proinflammatory cytokines (TNFα, IL-17A, IL-23, etc.). IL-17A plays a key role in the pathogenesis of spondyloarthritis (inflammation maintenance, syndesmophites formation and radiographic progression, enthesites and anterior uveitis development, etc.). Targeted anti-IL17 therapies have established themselves as the most efficient therapies in SpA treatment. The present review summarizes literature data on the role of the IL-17 family in the pathogenesis of SpA and analyzes existing therapeutic strategies for IL-17 suppression with monoclonal antibodies and Janus kinase inhibitors. We also consider alternative targeted strategies, such as the use of other small-molecule inhibitors, therapeutic nucleic acids, or affibodies. We discuss advantages and pitfalls of these approaches and the future prospects of each method.

Does the Change of Acetabular Anteversion Result From Lumbar Pedicle Subtraction Osteotomy in Ankylosing Spondylitis-Related Kyphosis After Primary Total Hip Arthroplasty?

STUDY DESIGN

Retrospective study.

OBJECTIVES

To analyze the change in acetabular anteversion (AA) after lumbar pedicle subtraction osteotomy (PSO) in ankylosing spondylitis (AS) patients with thoracolumbar kyphosis who have already undergone total hip arthroplasty (THA).

METHODS

AS patients with thoracolumbar kyphosis following lumbar PSO from January 2005 to January 2020 were retrospectively reviewed. Only the patients performed with THA prior to the PSO were included. AA was measured on the full-length standing posterior-anterior radiographs using the ellipse method.

RESULTS

Twenty patients (34 hips) with a mean age of 36.8 years (range, 22 to 63 years) were included. After lumbar PSO, AA was reduced from 18.59° to 5.85° (P < 0.001). Postoperative change in AA was correlated with the spinal deformity correction. Additionally, the change in AA postoperatively was correlated with pelvic incidence (PI) (R = 0.346, P = 0.045). Although the postoperative change in sagittal vertical axis (SVA) was larger in the patients after L2 or L3 PSO (153.97 mm vs 70.03 mm, P = 0.006), no difference was found in the postoperative change in AA (12.83° vs 10.96°, P = 0.540) compared with the patients following L1 PSO.

CONCLUSIONS

AA was significantly decreased following lumbar PSO and the postoperative change in AA was correlated with the magnitude of spinal deformity correction. Notably, the effect of osteotomy level on the postoperative change in AA was limited in the AS patients underwent 1-level PSO.

Ankylosing spondylitis substantially increases health-care costs and length of hospital stay following total hip arthroplasty - National in-patient database study

Introduction

The outcome following major arthroplasty surgeries in patients with ankylosing spondylitis (AS) has tremendously improved over the past decades, due to substantial amelioration in the medical therapies and sophistication of available surgical modalities. Although various studies have already demonstrated the complication rates and challenges faced in AS patients undergoing THA, there is a substantial paucity of data on the actual healthcare burden associated with this disease, and the diverse factors which may affect it.

Methods

Using the National Inpatient Sample (NIS) database (on the basis of ICD-10 CMP codes), patients undergoing THA between the years 2016 and 2019 were identified. These patients were then classified into two categories: group A: patients with a known diagnosis of AS; and group N: those without. The details regarding demographical information, associated co-morbidities, data pertaining to patients' hospital admissions including expenditure incurred, length of stay and complications encountered, were compared. In addition, propensity-score matching was performed to identify a 1:1 matched sample of THA patients without AS.

Results

Overall, 367,890 patients underwent THA; among whom, 501 (0.14%) were known AS patients (group A). Group A included a substantially higher proportion of patients belonging to younger age group (58.6 ± 13.4 versus 65.9 ± 11.4 years; p < 0.001), male sex (67.1% in group A vs 44.1% in group N; p < 0.001), and Asian ethnicity (p < 0.001). Group A patients had a substantially higher risk for longer duration of hospital stay (p < 0.03) and higher overall healthcare expenditure incurred (p < 0.001). As compared to group N, AS patients had a significantly higher risk for developing post-operative anemia [21.8% (group A) vs 11.8% (group N); p < 0.02]; and higher rate of periprosthetic infections [2.4% (group A) vs 1.0% (group N); p < 0.007].

Conclusion

Patients with AS require a significantly longer duration of hospital stay and higher admission-related expenditure following THA, as compared to the general population. These enhanced early health care-associated costs can be attributed to higher complication rates in AS patients. AS patients are prone to higher rates of anemia and peri-prosthetic infections during the early post-THA period.

A Cross-Sectional Study on Gluteal Muscles in Patients with Ankylosing Spondylitis at Different Stages of Hip Involvement

Hip involvement in ankylosing spondylitis (AS) is associated with severe functional impairment, and early diagnosis can improve the disease prognosis. We investigated gluteal muscle cross-sectional area (CSA) and radiodensity at different stages of hip involvement and their associations with AS-related clinical and laboratory parameters. This cross-sectional study included 83 patients with AS and 83 age- and sex-matched controls. Patients with AS were divided into three groups according to the Bath Ankylosing Spondylitis Radiology Hip Index system. The CSA and radiodensity of the gluteus maximus, medius, and minimus muscles were measured using computed tomography images. Muscle parameters were compared, and their relationships with clinical and laboratory parameters were evaluated. For the gluteus maximus, patients with AS had a lower CSA than controls, regardless of the degree of hip involvement. For the gluteus medius and minimus, patients with moderate/advanced hip involvement had significantly lower CSA and radiodensity than those with mild to no hip involvement. The severity of hip involvement was negatively associated with muscle parameters. CSA of the gluteus maximus decreased in early-stage hip involvement without any changes in radiographs, while radiodensity decreased in the later stages. Muscle parameters on computed tomography may be a more sensitive indicator than radiographic findings.

Predisposing factors for allogeneic blood transfusion in patients with ankylosing spondylitis undergoing primary unilateral total hip arthroplasty: a retrospective study

BACKGROUND

The transfusion rate is relatively high in patients with ankylosing spondylitis (AS) undergoing total hip arthroplasty (THA). However, relevant studies focusing on the predisposing factors for transfusion with a large sample size are lacking. This study aimed to investigate the incidence of and risk factors for allogeneic blood transfusion in patients with AS undergoing primary unilateral THA.

METHODS

This retrospective study included 331 patients with AS who underwent primary unilateral THA between 2011 and 2021. Relevant parameters were collected through a chart review. Multivariate logistic regression analysis was conducted to identify possible factors associated with perioperative allogeneic blood transfusion.

RESULTS

A total of 113 (34.1%) patients received perioperative allogeneic blood transfusions. Factors related to receiving an allogeneic blood transfusion included prolonged operative duration (odds ratio [OR] per 10 min = 1.139, P = 0.047), increased estimated intraoperative blood loss (OR per 100 mL = 1.348, P < 0.001), and increased postoperative drainage volume (OR per 100 mL = 1.235, P = 0.024). A higher body mass index (BMI) (OR = 0.914, P = 0.012), perioperative tranexamic acid (TXA) use (OR = 0.166, P < 0.001), and a higher preoperative hemoglobin level (OR per 1 g/dL = 0.744, P = 0.004) decreased the risk of transfusion.

CONCLUSIONS

In patients with AS undergoing THA, prolonged operative duration, increased estimated intraoperative blood loss, and increased postoperative drainage volume were found to be risk factors for transfusion, whereas a higher BMI, perioperative TXA use, and a higher preoperative hemoglobin level were protective factors. These results may aid in developing a better perioperative management strategy, ultimately reducing the need for transfusion.

ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update

OBJECTIVES

To update the Assessment of SpondyloArthritis international Society (ASAS)-EULAR recommendations for the management of axial spondyloarthritis (axSpA).

METHODS

Following the EULAR Standardised Operating Procedures, two systematic literature reviews were conducted on non-pharmacological and pharmacological treatment of axSpA. In a task force meeting, the evidence was presented, discussed, and overarching principles and recommendations were updated, followed by voting.

RESULTS

Five overarching principles and 15 recommendations with a focus on personalised medicine were agreed: eight remained unchanged from the previous recommendations; three with minor edits on nomenclature; two with relevant updates (#9, 12); two newly formulated (#10, 11). The first five recommendations focus on treatment target and monitoring, non-pharmacological management and non-steroidal anti-inflammatory drugs (NSAIDs) as first-choice pharmacological treatment. Recommendations 6-8 deal with analgesics and discourage long-term glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs (DMARDs) for pure axial involvement. Recommendation 9 describes the indication of biological DMARDs (bDMARDs, that is, tumour necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i)) and targeted synthetic DMARDs (tsDMARDs, ie, Janus kinase inhibitors) for patients who have Ankylosing Spondylitis Disease Activity Score ≥2.1 and failed ≥2 NSAIDs and also have either elevated C reactive protein, MRI inflammation of sacroiliac joints or radiographic sacroiliitis. Current practice is to start a TNFi or IL-17i. Recommendation 10 addresses extramusculoskeletal manifestations with TNF monoclonal antibodies preferred for recurrent uveitis or inflammatory bowel disease, and IL-17i for significant psoriasis. Treatment failure should prompt re-evaluation of the diagnosis and consideration of the presence of comorbidities (#11). If active axSpA is confirmed, switching to another b/tsDMARD is recommended (#12). Tapering, rather than immediate discontinuation of a bDMARD, can be considered in patients in sustained remission (#13). The last recommendations (#14, 15) deal with surgery and spinal fractures.

CONCLUSIONS

The 2022 ASAS-EULAR recommendations provide up-to-date guidance on the management of patients with axSpA.

Intraoperative picture of hip joint lesion in ankylosing spondylitis: data from a retrospective analysis

In population of Russian patients with ankylosing spondylitis (AS), the frequency of clinical manifestations (pain and limitation of functions) of coxitis reaches 56%. Total hip arthroplasty (THA) can be considered as the only alternative that can relieve the suffering of the patient. Radiography and magnetic resonance imaging are widely used methods for assessing structural damage to the hip joint in AS. However, at the moment these methods can’t allow us to fully describe the lifetime changes of these joints. The aim of the study: to analyze the external changes of the femoral heads (HF) and acetabulums during the THA in patients with AS. Materials and methods. The retrospective study included 170 patients with a reliable diagnosis of AS, who met the modified New York criteria of 1984, who were treated in the traumatological and orthopedic department of the V.A. Nasonova Research Institute of Rheumatology in the period from 1998 to 2020, all patients underwent THA as planned. Most of them were male (80.6%). The average age of patients was 38.1±11.3 years and the average duration of the disease since the onset of the first symptoms was 17.0±8.5 years. The duration of pain in hip joints before performing THA is 7.4±4.8 years. The assessment of macroscopic changes in the FH and acetabulum was performed intraoperatively. Results and discussion. Acetabulum protrusion was detected in 108 (63.5%) patients, bone cysts – in 65 (38.2%). Filling of acetabulum with granulation tissue was recorded in 155 (91.2%) patients, presence of osteophytes on its edges – in 153 (90%). Cartilage in the acetabulum was completely absent in 122 (71.8%) patients. FH deformation was detected in 98.2% of cases, erosion in 46.4%. Cartilage on FH was completely absent in 130 (76.5%) patients. In 119 (70%) patients, macroscopic signs of osteonecrosis of FH were found. 79 (46.4%) patients had ankylosis of the hip joint, including fibrous ankylosis – in 77.2% of patients and bone ankylosis – in 22.8%. Conclusion. In patients with AS, the necessity for THA occurs on average after 7.4±4.8 years from the moment of the appearance of first clinical signs of coxitis. In 70% of cases, the macroscopic picture of hip joint lesion was characterized by the development of Avascular necrosis of the femur head (AVNFH), in most patients there was no cartilage in the most loaded segments of acetabulum and FH, in almost half of cases – ankylosis of hip joint and mainly fibrous (77.2%).

Cost and Complications in Rheumatoid Arthritis Patients Undergoing Primary Hip Arthroplasty: A National Inpatient Sample-Based Study

INTRODUCTION

Rheumatoid arthritis (RA) is an autoimmune disease that affects multiple synovial joints in the body, including the hip. Hip involvement in RA patients is fairly common, but the current literature is lacking large-scale studies on the surgical outcomes of RA patients undergoing total hip arthroplasty (THA). The aim of the study is to examine the outcomes and hospital costs associated with THA in patients with RA and compare them to patients without RA using the National Inpatient Sample (NIS) database.

METHODS

We analyzed the NIS database to identify patients undergoing THA between 2016 and 2019 using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes. Multiple variables including demographics, medical comorbidities, total hospital costs, length of stay, and perioperative complication rates were then compared between patients with and without RA. Further, the two groups were matched for demographic differences, if any, using a 1:1 propensity match algorithm.

RESULTS

Patients with RA undergoing THA were significantly younger and predominantly female when compared to patients without RA. There was also a lower incidence of obesity and the percentage of elective THA procedures were smaller in the RA group. The RA group had a longer length of stay and increased incidences of blood loss anemia, blood transfusion, and periprosthetic fractures. These differences persisted despite matching the two groups for demographic differences, elective procedures, diabetes, obesity, and tobacco usage.

CONCLUSION

THA in RA is associated with an increased incidence of blood loss anemia, blood transfusion, and periprosthetic fractures, as well as a longer length of stay in THA patients.

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis at total hip arthroplasty (THA) has significant hip stiffness with flexion deformity, restricted mobility, and function. Range of movement (ROM) improvement with good functional outcome is seen following THA in these hips. The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity.

AIM

To assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips.

METHODS

A total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo. All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1^st postoperative day. Modified Harris hip score and ROM were assessed during follow-up. Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at follow-up. SPSS 22.0 was used for statistical analysis. The correlation of ROM and functional score change was performed using Pearson’s correlation coefficient.

RESULTS

Sixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range. The mean flexion in 69 hips improved from 29.35 ± 31.38 degrees to 102.17 ± 10.48 degrees. The mean difference of 72.82 with a P value < 0.0001 was significant. In total, 45 out of 69 hips had flexion deformity, with 13 hips having a deformity above 30 degrees. The flexion during the follow-up was below 90 degrees in 3 hips. Eleven hips had flexion of 90 degrees at follow-up, while the remaining 55 hips had flexion above 100 degrees. Modified Harris hip score improved from 17.03 ± 6.02 to 90.66 ± 7.23 (P value < 0.0001). The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11, very good in 20, good in 5, fair in 3, and poor in 1. The mean mental health score was 84.10 ± 11.58. Pain relief was good in all 69 hips. Altogether, 28/40 patients (70%) had no pain, 9 patients (22%) had occasional pain, and 3 patients (8%) had mild to moderate pain with unusual activity. Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips.

CONCLUSION

Modified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM, Harris hip score, and quality of life indicated by the 36-item and 12-item short form health surveys.

Age and Symptoms at Onset of Ankylosing Spondylitis in Japanese Patients

OBJECTIVE

To examine the age at onset and initial symptoms as clinical features of ankylosing spondylitis (AS) in Japanese patients.

METHODS

This retrospective study included 60 Japanese patients diagnosed with AS at our institute between January 2004 and June 2021. Initial symptoms were considered pain in axial joints and/or extra-axial joints. If a patient had initial symptoms at multiple sites, each site was counted. We assessed trends for the number of patients and sites of initial symptoms according to age at onset.

RESULTS

Mean age (± standard deviation) at onset was 28.9 (± 14.3) years. Approximately one-third of patients experienced onset before age 20. The back was the most common site of initial symptoms (36.7%), followed by the hip (26.7%), knee (15%), buttocks (15%), neck (10%), finger (6.7%), shoulder (3.3%), and others (including overlapping sites). Thirty-two (53.3%) and 25 (41.7%) patients had initial symptom only in axial joints and only in extra-axial joints, respectively. The proportion of patients with initial symptoms only in extra-axial joints significantly decreased with increasing age (p=0.024).

CONCLUSION

Sites of initial symptoms were frequently the back, hip, knee, and buttocks, and 41.7% had initial symptom only in extra-axial joints. Younger onset patients frequently had extra-axial involvement.

Total hip arthroplasty has higher complication rates in stiff spine patients: a systematic review and network meta-analysis

Background

Ankylosing spondylitis (AS) and spinal fusion (SF) classified as stiff spines have been associated with the increased rate of complications following total hip arthroplasty (THA). However, the differences between the two cohorts have inconsistent evidence.

Methods

We searched for studies comparing complications among stiff spine patients, including SF and AS, who underwent THA in PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus until March 2021. Studies detailing rates of mechanical complications, aseptic loosening, dislocation, infection, and revisions were included. We performed network meta-analyses using frequentist random-effects models to compare differences between cohorts. We used P-score to rank the better exposure with the lowest complications.

Results

Fourteen studies were included in the final analysis. A total of 740,042 patients were included in the systematic review and network meta-analysis. Mechanical complications were highest among SF patients (OR 2.33, 95% CI 1.86, 2.92, p < 0.05), followed by AS patients (OR 1.18, 95% CI 0.87, 1.61, p = 0.82) compared to controls. Long Spinal Fusions had the highest aseptic loosening (OR 2.33, 95% CI 1.83, 2.95, p < 0.05), dislocations (OR 3.25, 95% CI 2.58, 4.10, p < 0.05), infections (OR 2.14, 95% CI 1.73, 2.65, p < 0.05), and revisions (OR 5.25, 95% CI 2.23, 12.32, p < 0.05) compared to AS and controls. Our results suggested that SF with longer constructs may be associated with higher complications in THA patients.

Conclusions

THAs following SFs have higher mechanical complications, aseptic loosening, dislocations, and infections, especially with longer constructs. AS patients may have fewer complications compared to this cohort.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03237-8.

Fourth‐Generation Ceramic‐on‐Ceramic THA in Patients with Ankylosing Spondylitis: A Minimum 10‐Year Follow‐Up

Objective

To report the long‐term outcomes of total hip arthroplasty (THA) with fourth‐generation ceramic‐on‐ceramic (CoC) bearing in patients with ankylosing spondylitis (AS).

Methods

We retrospectively identified 180 primary THAs performed in 110 patients with AS, including 100 (90.9%) men and 10 women (9.1%), from 2009 to 2011.The mean age of the patients at surgery was 33 years (range, 16 to 65 years). Cementless prostheses with fourth‐generation CoC bearings were used in all patients. Survivorship of the implants and postoperative complications were calculated. Functional improvement was assessed by the hip flexion‐extension range of motion (ROM) and Harris hip score (HHS). A special noise assessment questionnaire was performed at the last follow‐up. The cumulative incidence of noise was calculated by the Kaplan–Meier method with 95% confidence intervals (CIs). Clinical characteristics and functional outcomes were compared in the hips with noise to those without noise.

Results

The mean follow‐up was 11 years (range, 10 to 12 years), and survivorship of the implants was 99.4% at the most recent follow‐up. The complications included dislocation (one hip, 0.6%), periprosthetic joint infection (one hip, 0.6%), mild to moderate pain (five hips, 2.8%), heterotopic ossification (12 hips, 6.7%), and noise (52 hips, 28.9%). The flexion‐extension ROM improved significantly with a median from 10° (range, 0 ~ 130°) to 100° (30 ~ 130°) after THA (p < 0.001), and the HHS increased significantly from 41 ± 20 to 90 ± 8 (p < 0.001). The cumulative incidence of noise at 0.5, 5, and 10 years was 6.1% (95% CI, 2.6 ~ 9.6), 16.7% (95% CI, 11.2 ~ 22.1), and 28.9% (95% CI, 22.2 ~ 35.5), respectively, and that of squeaking at 0.5, 5, and 10 years was 4.4% (95% CI, 1.4 ~ 7.4), 13.3% (95% CI, 8.4 ~ 18.3), and 23.9% (95% CI, 17.6 ~ 30.1), respectively. None of the patients with noise generation in the hip reported it affecting daily activities or causing dissatisfaction. No differences in age, sex, BMI, disease duration, bilateral THA, the frequency of bony ankylosis, the proportion of using a 36‐mm‐diameter femoral head, pre/postoperative flexion‐extension ROM, or pre/postoperative HHS were found between hips with noise and those without noise (p > 0.05).

Conclusion

THAs with fourth‐generation CoC bearings exhibit excellent long‐term survival and clinical outcomes in patients with AS, with a very low dislocation rate. The incidence of noise associated with CoC bearings in THA performed in patients increases over time, but it does not affect postoperative hip function or daily activities.

Influence of lumbar sagittal profile on pelvic orientation and pelvic motion during postural changes in patients with ankylosing spondylitis-related thoracolumbar kyphosis following pedicle subtraction osteotomy

OBJECTIVE

The objective of this study was to investigate the impact of the lumbar sagittal profile on pelvic orientation and pelvic motion during postural changes in patients with ankylosing spondylitis (AS) and thoracolumbar kyphosis and to evaluate the potential risk of prosthetic dislocation after total hip arthroplasty (THA) following pedicle subtraction osteotomy (PSO).

METHODS

Seventy-two patients with AS-related thoracolumbar kyphosis following spinal osteotomy were retrospectively reviewed, and 21 healthy volunteers were recruited as a control group. Pre- and postoperative 2D full-body images in standing and sitting positions were obtained to evaluate the anterior pelvic plane angle (APPA), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), proximal femur angle (PFA), and femoroacetabular flexion during postural changes. Patients with AS were categorized in either a lordotic or kyphotic group based on the lumbar sagittal profile.

RESULTS

Significant increases in the SS and decreases in the APPA, PT, and LL were observed postoperatively in both the standing and sitting positions (p < 0.001 for all). Significantly higher APPA, PT, LL, and ΔPT, and lower SS, ΔSS, and ΔSS+ΔPFA were observed in the kyphotic group (p < 0.05). After undergoing PSO, ΔPT and ΔSS significantly decreased while femoroacetabular flexion significantly increased in both AS groups (p < 0.05), and no significant difference was present between the two groups (p > 0.05). Bath Ankylosing Spondylitis Radiology Hip Index scores in the kyphotic group were significantly worse than those in the lordotic group pre- and postoperatively (p < 0.05). No significant difference in parameters concerning pelvic motion (ΔAPPA, ΔPT, and ΔSS) was found when PSO was performed in the thoracolumbar or lumbar spine.

CONCLUSIONS

Lumbar sagittal profiles greatly affect pelvic orientation and pelvic motion in AS. When THA is performed before PSO, AS patients with lumbar kyphosis are at higher risk of anterior prosthetic dislocation, while those with lordotic lumbar sagittal profiles are at higher risk of posterior dislocation. PSO should be performed prior to THA. After PSO, further decreased pelvic motion indicated a potential risk of posterior prosthetic dislocation after sequential THA, whereas theoretically patients with preoperative lumbar kyphosis are at higher risk of THA dislocation. The site where PSO was performed (thoracolumbar or lumbar spine) does not influence the risk of THA dislocation.

The correlation between volumetric bone mineral density and morphological parameters of the proximal femur and clinical outcomes in ankylosing spondylitis patients with hip involvement

Background

To measure volumetric bone mineral density (vBMD) with quantitative computed tomography (QCT) in the proximal femur of ankylosing spondylitis (AS) patients with hip involvement and analyze their correlations with radiographic and clinical parameters.

Methods

Sixty-five AS inpatients were enrolled in this study. The bone mineral density was measured by QCT and dual-energy x-ray absorptiometry (DXA), respectively. The morphological parameters of the proximal femur were measured on digital anteroposterior (AP) radiographs of the pelvis. The correlations between them were analyzed by SPSS software.

Results

The average trabecular vBMD measured at the femoral neck was 136.38 ± 25.58 mg/cm³. According to the BASRI-Hip score, group A consisted of 39 hips (0–2 score) and group B consisted of 26 hips (3–4 score). There were significant differences regarding trabecular CTXA equivalent T-score between group A and B at the femoral neck (p = 0.004); intertrochanteric region (p < 0.001) and greater trochanter (p = 0.001). The trabecular CTXA equivalent T-score at femoral neck had a negative correlation with disease duration (r = − 0.311, p = 0.012) and with CBR (r = − 0.319, p = 0.010).

Conclusions

The low trabecular bone density at the site of the hip was associated with the duration of disease progression and degree of hip involvement. Meanwhile, it had a correlation with hip function status although we failed to confirm a significant relationship between hip vBMD and disease activity.

Risk Factors for Spinal Structural Damage in a Chinese Cohort With Ankylosing Spondylitis

OBJECTIVES

A cross-sectional study was conducted in 270 Chinese patients with ankylosing spondylitis (AS) in order to identify potential risk factors for severity of spinal structural damage.

METHODS

Two hundred seventy AS patients fulfilled the Modified New York Criteria. Computed tomography (CT) was used to scan sacroiliac and hip joints, and radiography was used to scan anteroposterior and lateral lumbar spine, as well as lateral cervical spine. Bath Ankylosing Spondylitis Radiology Index and modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) were scored in duplicate.

RESULTS

One hundred eighty-three patients had low mSASSS (mSASSS, <10), and 87 patients had high mSASSS (mSASSS, ≥10). Univariate analysis revealed that AS age of onset, body mass index (BMI), smoking duration, duration of symptoms, diagnostic delay, hip involvement, and sacroiliitis grade were significantly associated with the risk of having high mSASSS after adjustment (all p's < 0.05). Hip involvement interacted significantly with BMI and smoking duration in a graded manner. Particularly, relative to patients with low BMI-negative hip involvement, those with high BMI-negative hip involvement, low BMI-positive hip involvement, and high BMI-positive hip involvement had a 1.94-fold, 3.29-fold, and 5.07-fold increased risk of high mSASSS (95% confidence interval, 0.84-4.47, 1.37-7.89, and 1.97-13.06, p = 0.118, 0.008, and 0.001, respectively). Finally, a nomogram graph based on 7 significant risk factors was generated with substantial prediction accuracy (concordance index, 0.906).

CONCLUSIONS

We have identified 7 potential risk factors for the severity of spinal structural damage in Chinese AS patients. Importantly, positive hip involvement, combined with high BMI or long smoking duration, was associated with a remarkably increased risk of having severe spinal structural damage.

Total hip arthroplasty in fused hips with spine stiffness in ankylosing spondylitis

Ankylosing spondylitis (AS) is characterized by involvement of the spine and hip joints with progressive stiffness and loss of function. Functional impairment is significant, with spine and hip involvement, and is predominantly seen in the younger age group. Total hip arthroplasty (THA) for fused hips with stiff spines in AS results in considerable improvement of mobility and function. Spine stiffness associated with AS needs evaluation before THA. Preoperative assessment with lateral spine radiographs shows loss of lumbar lordosis. Spinopelvic mobility is reduced with change in sacral slope from sitting to standing less than 10 degrees conforming to the stiff pattern. Care should be taken to reduce acetabular component anteversion at THA in these fused hips, as the posterior pelvic tilt would increase the risk of posterior impingement and anterior dislocation. Fused hips require femoral neck osteotomy, true acetabular floor identification and restoration of the hip center with horizontal and vertical offset to achieve a good functional outcome. Cementless and cemented fixation have shown comparable long-term results with the choice dependent on bone stock at THA. Risks at THA in AS include intraoperative fractures, dislocation, heterotopic ossification, among others. There is significant improvement of functional scores and quality of life following THA in these deserving young individuals with fused hips and spine stiffness.

Gender Differences in Ankylosing Spondylitis Patients with Advanced Hip Involvement: Results from A Matched Retrospective Cohort Study

Objective

To determine the gender differences in ankylosing spondylitis (AS) patients with advanced hip involvement.

Methods

We retrospectively analyzed the 373 consecutive AS patients with advanced hip involvement from 2012 to 2017 and divided them into two groups by sex with 340 men and 33 women. Research data on hip involvement in the patients were obtained from medical records and radiographs. The severity of radiographic hip involvement was evaluated by the Bath Ankylosing Spondylitis Radiology Hip Index (BASRI‐hip) scoring system. The data on clinical characteristics, radiographic hip involvement, and laboratory values were compared between the two groups. The comparison was performed again between the two groups after adjusting for the onset age and disease duration by propensity score matching (PSM).

Results

Men underwent total hip arthroplasty earlier than women in the patients, with a median age of 31 years (range, 19–67 years) vs 36 years (range, 23–67 years), respectively (P < 0.05). Hip involvement was found to be younger in men than that in women, with a median age of 18 years (range, 7–56 years) vs 23 years (range, 5–55 years) (P < 0.05), and men with bilateral onset in hips had a higher frequency than women with that (66.2% vs 39.4%) (P < 0.05). There was no gender difference in the proportion of bilateral advanced hip involvement (85.3% vs 72.7%) (P > 0.05). The proportion of the patients who had spinal involvement (89.1% vs 69.7%), flexion contracture in the hip (43.8% vs 24.2%), hip range of motion =0° (53.5% vs 30.3%), and an elevated level of C‐reactive protein (CRP) (69.1% vs 51.5%) was significantly higher in men than that in women (P < 0.05). After adjusting for the onset age and disease duration by PSM (1:1), men with bilateral onset in hips still had a higher frequency than women with that (76.7% vs 40.0%), and the proportion of the patients who had spinal involvement (90.0% vs 66.7%) and an elevated level of CRP (80.0% vs 53.3%) was significantly higher in men than that in women (P < 0.05).

Conclusions

The disease pattern of hip involvement in AS has gender differences, with bilateral onset being the dominant pattern in men and unilateral onset being more common in women. However, the frequency of bilateral advanced hip involvement has no gender difference eventually. The higher prevalence of spinal involvement in men with AS may be responsible for the more severe functional impairment compared with women.

B Cell Involvement in the Pathogenesis of Ankylosing Spondylitis

Extensive research into ankylosing spondylitis (AS) has suggested the major role of genetics, immune reactions, and the joint-gut axis in its etiology, although an ultimate consensus does not yet exist. The available evidence indicates that both autoinflammation and T-cell-mediated autoimmune processes are actively involved in the disease process of AS. So far, B cells have received relatively little attention in AS pathogenesis; this is largely due to a lack of conventional disease-defining autoantibodies. However, against prevailing dogma, there is a growing body of evidence suggestive of B cell involvement. This is illustrated by disturbances in circulating B cell populations and the formation of auto-reactive and non-autoreactive antibodies, along with B cell infiltrates within the axial skeleton of AS patients. Furthermore, the depletion of B cells, using rituximab, displayed beneficial results in a subgroup of patients with AS. This review provides an overview of our current knowledge of B cells in AS, and discusses their potential role in its pathogenesis. An overarching picture portrays increased B cell activation in AS, although it is unclear whether B cells directly affect pathogenesis, or are merely bystanders in the disease process.

Mechanism of Hip Arthropathy in Ankylosing Spondylitis: Abnormal Myeloperoxidase and Phagosome

Background

The pathogenesis of Ankylosing spondylitis (AS) has not been elucidated, especially involving hip joint disease. The purpose of this study was to analyze the proteome of diseased hip in AS and to identify key protein biomarkers.

Material and Methods

We used label-free quantification combined with liquid chromatography mass spectrometry (LC–MS/MS) to screen for differentially expressed proteins in hip ligament samples between AS and No-AS groups. Key protein was screened by Bioinformatics methods. and verified by in vitro experiments.

Results

There were 3,755 identified proteins, of which 92.916% were quantified. A total of 193 DEPs (49 upregulated proteins and 144 downregulated proteins) were identified according to P < 0.01 and Log|FC| > 1. DEPs were mainly involved in cell compartment, including the vacuolar lumen, azurophil granule, primary lysosome, etc. The main KEGG pathway included Phagosome, Glycerophospholipid metabolism, Lysine degradation, Pentose phosphate pathway. Myeloperoxidase (MPO) was identified as a key protein involved in Phagosome pathway. The experiment of siRNA interfering with cells further confirmed that the upregulated MPO may promote the inflammatory response of fibroblasts.

Conclusions

The overexpression of MPO may contribute to the autoimmune inflammatory response of AS-affected hip joint through the phagosome pathway.

Hip Replacement in Ankylosing Spondylitis Patients with Advanced Hip Involvement: Factors Associated with Bilateral Total Hip Arthroplasty

Background

This study aimed to compare the clinical data of ankylosing spondylitis (AS) patients who underwent unilateral and bilateral total hip arthroplasty (THA) due to advanced hip involvement. Furthermore, to determine the factors associated with bilateral THA.

Methods

Utilizing a single-institution database, we selected 373 consecutive AS patients undergoing primary THA from 2012 to 2017 and compared the clinical characteristics and anti-tumor necrosis factor (TNF) therapy of the patients who underwent unilateral and bilateral THA. Logistic regression was used to identify factors associated with bilateral THA.

Results

Bilateral THA was performed in 67.3% (n=251) of the patients. Male patients had a higher frequency of undergoing bilateral THA compared with female ones (P<0.05). The proportion of the patients who had bilateral onset in hips, administration of TNF inhibitors, flexion contracture in the hip, and a BASRI-hip score of 4 was significantly higher in patients with bilateral THA than that with unilateral THA (P<0.05). Patients with bilateral THA experienced longer disease duration than those with unilateral THA (P<0.05). The results of the logistic regression showed that factors related to bilateral THA were bilateral onset in hips, administration of TNF inhibitors, a BASRI-hip score of 4, and an erythrocyte sedimentation rate (ESR) level (P<0.05).

Conclusion

Bilateral THA is more common in AS patients with advanced hip involvement. Bilateral onset in hips, a BASRI-hip score of 4, and a higher level of ESR are risk factors associated with bilateral THA, while anti-TNF therapy is a protective factor reducing the progression of hip involvement to bilateral THA.

The Clinical and MRI Effect of TNF-α Inhibitors in Spondyloarthritis Patients With Hip Involvement: A Real-World Observational Clinical Study

Objectives

Hip involvement is an important cause of disability and poor prognosis in patients with spondyloarthritis (SpA). Tumor necrosis factor (TNF)-α inhibitor treatment has been demonstrated to be effective in SpA patients with hip arthritis; however, quantitative assessment using MRI in long-term follow-up needs further application and observation.

Methods

A total of 239 patients were involved in this study. Methotrexate and sulfasalazine were given as basic treatment. In total, 165 patients received TNF-α inhibitors plus basic treatment, and 74 received basic treatment only, as controls. Clinical symptoms were assessed at baseline and at weeks 12, 24, and 52. MRI performances of hip arthritis, including bone marrow edema (BME) and synovitis, were quantitatively assessed using the Hip Inflammation MRI Scoring System (HIMRISS).

Results

The clinical values of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Harris hip score, and Ankylosing Spondylitis Disease Activity Score (ASDAS)-ESR in both groups showed significant clinical remission at week 52 (p < 0.001). However, the change in disease activity levels at week 52 in the control group was significantly worse than in the TNF-α inhibitor group. At week 52, MRI showed a significant remission trend in the TNF-α inhibitor group versus baseline, and total HIMRISS scores were significantly decreased (26.49 ± 10.37 vs. 20.59 ± 9.41, p < 0.001); the control group only had slight improvement (p < 0.05).

Conclusions

TNF-α inhibitors could significantly improve clinical and MRI manifestations of hip involvement in patients with SpA. Quantitative MRI assessment combined with clinical assessment can be used to accurately evaluate the treatment effect of TNF-α in SpA patients with hip involvement to help guide targeted treatment.

Automatic segmentation and grading of ankylosing spondylitis on MR images via lightweight hybrid multi-scale convolutional neural network with reinforcement learning

Objective.Ankylosing spondylitis (AS) is a disabling systemic disease that seriously threatens the patient's quality of life. Magnetic resonance imaging (MRI) is highly preferred in clinical diagnosis due to its high contrast and tissue resolution. However, since the uncertainty and intensity inhomogeneous of the AS lesions in MRI, it is still challenging and time-consuming for doctors to quantify the lesions to determine the grade of the patient's condition. Thus, an automatic AS grading method is presented in this study, which integrates the lesion segmentation and grading in a pipeline.Approach. To tackle the large variations in lesion shapes, sizes, and intensity distributions, a lightweight hybrid multi-scale convolutional neural network with reinforcement learning (LHR-Net) is proposed for the AS lesion segmentation. Specifically, the proposed LHR-Net is equipped with the newly proposed hybrid multi-scale module, which consists of multiply convolution layers with different kernel sizes and dilation rates for extracting sufficient multi-scale features. Additionally, a reinforcement learning-based data augmentation module is utilized to deal with the subjects with diffuse and fuzzy lesions that are difficult to segment. Furthermore, to resolve the incomplete segmentation results caused by the inhomogeneous intensity distributions of the AS lesions in MR images, a voxel constraint strategy is proposed to weigh the training voxel labels in the lesion regions. With the accurately segmented AS lesions, automatic AS grading is then performed by a ResNet-50-based classification network.Main results. The performance of the proposed LHR-Net was extensively evaluated on a clinically collected AS MRI dataset, which includes 100 subjects. Dice similarity coefficient (DSC), average surface distance, Hausdorff Distance at95thpercentile (HD95), predicted positive volume, and sensitivity were employed to quantitatively evaluate the segmentation results. The average DSC of the proposed LHR-Net on the AS dataset reached 0.71 on the test set, which outperforms the other state-of-the-art segmentation method by 0.04.Significance. With the accurately segmented lesions, 31 subjects in the test set (38 subjects) were correctly graded, which demonstrates that the proposed LHR-Net might provide a potential automatic method for reproducible computer-assisted diagnosis of AS grading.

Automatic quantification and grading of hip bone marrow oedema in ankylosing spondylitis based on deep learning

OBJECTIVE

This study has developed a new automatic algorithm for the quantificationy and grading of ankylosing spondylitis (AS)-hip arthritis with magnetic resonance imaging (MRI).

METHODS

(1) This study designs a new segmentation network based on deep learning, and a classification network based on deep learning. (2) We train the segmentation model and classification model with the training data and validate the performance of the model. (3) The segmentation results of inflammation in MRI images were obtained and the hip joint was quantified using the segmentation results.

RESULTS

A retrospective analysis was performed on 141 cases; 101 patients were included in the derived cohort and 40 in the validation cohort. In the derivation group, median percentage of bone marrow oedema (BME) for each grade was as follows: 36% for grade 1 (<15%), 42% for grade 2 (15-30%),and 22% for grade 3 (≥30%). The accuracy of 44 cases on 835 AS images was 85.7%. Our model made 31 correct decisions out of 40 AS test cases. This study showed that THE accuracy rate 85.7%.

CONCLUSIONS

An automatic computer-based analysis of MRI has the potential of being a useful method for the diagnosis and grading of AS hip BME.

MRI Assessment of Extra-axial Findings at Pelvic Sites in a Group of Axial-SpA Patients

Introduction

MRI allows a better evaluation of inflammatory and structural lesions of the sacroiliac joints and spine in patients with axial spondyloarthritis (axial SpA), so MRI plays an important role in the classification and diagnosis of axial SpA. The aim of our study was to assess extra-axial MRI findings at pelvic sites and their possible associations with clinical indices in patients with axial SpA.

Methods

Axial-SpA patients who were classified according to the ASAS criteria and consecutively attended our clinic were assessed with pelvic MRI. The main clinical and demographic characteristics of all patients, including age, sex, BMI, presence of HLA-B27 and type of axial SpA (radiographic or nonradiographic), were evaluated. The main indices of disease activity and joint function were assessed, including BASDAI, ASDAS-PCR, BASMI and BASFI. Finally, the presence/absence of inflammatory/structural lesions at extra-axial structures (the hip joints, pubic symphysis, greater and lesser trochanters, ischial tuberosity, iliac spines and iliac crest) was evaluated.

Results

35 patients (21 males and 14 females) with a mean age (SD) of 47 (12.7) years and a mean duration of symptoms of 5 (2.1) years were enrolled. Hip abnormalities were found in 14 (40%) patients. Trochanteric enthesopathy/bursitis and pubic osteitis were found in 2 patients (5.7%) and 1 patient (2.8%), respectively. No other abnormalities were found at other sites. We found significant associations between the presence of extra-axial alterations, disease activity and joint function.

Conclusions

Our study demonstrated the presence of extra-axial abnormalities in more than one-third of patients with axial SpA, suggesting that MRI evaluation should be extended to the entire pelvis.

Risk factors for radiological hip involvement in patients with ankylosing spondylitis

OBJECTIVE

Our study aimed to explore the potential risk factors for radiological hip joint involvement in patients with ankylosing spondylitis (AS).

METHODS

This cross-sectional convey collected the clinical data, laboratory indicators, and radiographic data of patients with AS. Radiographic hip joint involvement was defined as a Bath Ankylosing Spondylitis Radiology Hip Index (BASRI-hip) score ≥2. Multivariate logistic regression analyses were conducted to explore the potential risk factors for radiological hip involvement in patients with AS.

RESULTS

Based on BASRI-hip score, all enrolled 386 patients with AS were classified as patients involving with radiological hip joint involvement (BASRI-hip ≥2; n=203) and those without it (BASRI-hip ≤1; n=183). Mean age of enrolled patients with AS were 36.7±11.9 years, and 320 (82.9%) patients were male. Mean course of disease was 10.7±8.3 years, and 349 (90.4%) patients were with a positive HLAB27. Multivariate analyses indicated that Juvenile onset (onset age ≤16 years) (odds ratio [OR]=4.159, 95% confidence interval [CI], 1.779-9.721, p<0.001), body mass index (BMI) <18.5 kg/m2 (OR=1.986, 95%CI 1.187-3.323, p=0.009), continuous nonsteroidal anti-inflammatory drug (NSAID) use (OR=0.351, 95%CI 0.155-0.794, p=0.012), and bone mass below the expected range for age (Z score ≤-2) (OR=2.791, 95%CI 1.456-5.352, p=0.002) were independently associated with radiological hip joint involvement in patients with AS.

CONCLUSIONS

The potential risk factors for radiological hip joint involvement were juvenile onset, lower BMI, and bone mass below the expected range for age. Furthermore, continuous NSAID use was the protective factor for radiological hip joint involvement in these population.

Prevalence and distribution of peripheral musculoskeletal manifestations in spondyloarthritis including psoriatic arthritis: results of the worldwide, cross-sectional ASAS-PerSpA study

OBJECTIVES

To characterise peripheral musculoskeletal involvement in patients with spondyloarthritis (SpA) including psoriatic arthritis (PsA), across the world.

METHODS

Cross-sectional study with 24 participating countries. Patients with a diagnosis of axial SpA (axSpA), peripheral SpA (pSpA) or PsA according to their rheumatologist were included. The investigators were asked which diagnosis out of a list of six (axSpA, PsA, pSpA, inflammatory bowel disease-associated SpA, reactive arthritis or juvenile SpA (Juv-SpA)) fitted the patient best. Peripheral manifestations (ie, peripheral joint disease, enthesitis, dactylitis and root joint disease), their localisation and treatments were evaluated.

RESULTS

A total of 4465 patients were included (61% men, mean age 44.5 years) from four geographic areas: Latin America (n=538), Europe plus North America (n=1677), Asia (n=975) and the Middle East plus North Africa (n=1275). Of those, 78% had ever suffered from at least one peripheral musculoskeletal manifestation; 57% had peripheral joint disease, 44% had enthesitis and 15% had dactylitis. Latin American had far more often peripheral joint disease (80%) than patients from other areas. Patients with PsA had predominantly upper limb and small joint involvement (52%).Hip and shoulder involvement was found in 34% of patients. The prevalence of enthesitis ranged between 41% in patients with axSpA and 65% in patients with Juv-SpA. Dactylitis was most frequent among patients with PsA (37%).

CONCLUSION

These results suggest that all peripheral features can be found in all subtypes of SpA, and that differences are quantitative rather than qualitative. In a high proportion of patients, axial and peripheral manifestations coincided. These findings reconfirm SpA clinical subtypes are descendants of the same underlying disease, called SpA.

A single center experience: physician related diagnostic delay and demographic and clinical differences between patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis

Background. A large number of comparative studies have been conducted for ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA), including disease burden, treatment modalities and patient characteristics. The aim of this study was to compare physician related diagnostic delay time between patients with AS and nr-axSpA. Methods. In our retrospective study we included 266 patients with axSpA. Patients were classified into two subgroups, AS and nr-axSpA. The time from back pain onset until diagnosis of axSpA was defined as the diagnostic delay. The first specialist referred to and the first diagnosis for each patient was noted in detail. Patient characteristics, clinical manifestations and laboratory and imaging results at diagnosis were also compared between subgroups. Results. The diagnostic delay time was significantly longer for AS patients [6 ± 8.14 years vs 1.62 ± 2.54 years]. 40.9% of all patients were initially consulted by specialists in physical therapy and rehabilitation, followed by 29.7% consulted by a neurosurgeon and 19.9% by a rheumatologist. The most common initial diagnosis was fibromyalgia, 52.6% (140), followed by ankylosing spondylitis, 28.9% (77), and lumbar disc hernia, 12.7% (34). Conclusion. The vast majority of patients were initially evaluated by healthcare providers other than rheumatologists and mostly diagnosed with fibromyalgia. Efforts to increase awareness and to educate first healthcare providers may shorten the diagnostic delay time.

Assessment of hip involvement in patients with ankylosing spondylitis: reliability and validity of the Hip Inflammation MRI Scoring System

Background

This study aimed to test the reliability and validity of the Hip Inflammation MRI Scoring System (HIMRISS) in assessing hip involvement of AS patients with AS at different stages of the bath ankylosing spondylitis radiology index (BASRI-hip) scoring system.

Methods

Fifty-two outpatients with ankylosing spondylitis (AS) were included in this study. The subjects’ data includes demographics, clinical characteristics, disease activity score, and functional index. Based on the Harris hip scoring (HHS) of involved hip and BASRI-hip score, we devided these patients into no hip involvement group((HHS ≥ 80 and BASRI ≤ 1) (Group A), mild hip involvement subgroup (BASRI = 2 or BASRI ≤ 1 and HHS ≤ 79) (Group B), and moderate to advanced hip involvement subgroup (BASRI ≥ 3) (Group C). Data was analyzed statistically by SPSS software.

Results

In total of 44 patients (88 hips), group A consisted of 21 hips, group B consisted of 42 hips and group C consisted of 25 hips. The test–retest intraclass correlation coefficients (ICCs) in four raters were 0.955 ~ 0.977 and interrater ICC was 0.993. HIMRISS correlated moderately with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (r = 0.540, p < 0.001), the Bath ankylosing spondylitis functional index (BASFI) (r = 0.540, p < 0.001), the Bath Ankylosing Spondylitis Functional Index (BASFI) (r = 0.581, p < 0.001), ASDAS-ESR (r = 0.604, p < 0.001), and Ankylosing Spondylitis Disease Activity Score (ASDAS)-C reactive protein (CRP) (r = 0.575, p < 0.001). HIMRISS in groups B and C was significantly higher than that in group A: 29.38 (17.00, 40.94) vs. 14.50 (11.38, 22.25), p = 0.009; 38 (31.13, 64.38) vs 14.50 (11.38, 22.25), p < 0.001.

Conclusions

HIMRISS applied to patients with AS demonstrated a satisfactory reliability, meaning it is a reliable quantitive assessment tool for evaluating early hip involvement in patients with AS.

Primary Total Hip Arthroplasty in Patients With Ankylosing Spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a common inflammatory spondyloarthropathy with hip involvement in 40% of patients. With the renewed interest in the hip-spine interplay, this study aimed to define long-term outcomes of primary total hip arthroplasty (THA) in the setting of AS.

METHODS

We identified 309 hips (219 patients) with AS treated with primary THA from 1969 to 2018. Mean age was 49 years, 80% were males, and mean body mass index was 28 kg/m². Cumulative incidences of any revision, reoperation, and dislocation were calculated utilizing a competing risk analysis. Harris Hip Scores and complications were also reported. Mean follow-up was 16 years.

RESULTS

The cumulative incidence of any revision after primary THA was 2.3% at 5 years and 17.5% at 20 years. The most common reasons for revision (n = 73) were aseptic loosening (41%), osteolysis/polyethylene (PE) wear (30%, all with conventional PE), and femoral component fracture (8%). The cumulative incidence of dislocation was 1.9% at 5 years and 2.9% at 20 years. Younger age was associated with increased risk of revision (hazard ratio (HR) = 1.3, P < .01) and reoperation (HR = 1.2, P < .01), but not dislocation (HR = 0.7, P = .1). Twenty-eight hips (9%) experienced a postoperative complication not requiring reoperation. The mean Harris Hip Score improved from 51 to 76 after THA (P < .001).

CONCLUSION

In this series of 309 primary THAs in patients with AS, the 20-year cumulative incidence of any revision after primary THA was 17.5%. Aseptic loosening, osteolysis/PE wear, and femoral component fracture were the most common reasons for revision. Notably, the cumulative incidence of dislocation at 20 years was only 2.9%.

LEVEL OF EVIDENCE

Level IV.

Analysis of Bone Strength and Bone Turnover Markers in Ankylosing Spondylitis with Radiological Hip Involvement

Background

Limited clinical data are available on bone loss in ankylosing spondylitis (AS) patients with hip involvement, especially for bone strength. The purpose of this study was to analyze bone strength and bone turnover markers in AS patients with hip involvement.

Material/Methods

The stiffness index (SI) calculated by quantitative ultrasound (QUS) was used to compare the bone strength between patients with AS with radiographic hip involvement (RHI-AS, BASRI-hip ≥2) and those without radiographic hip involvement (WORHI-AS, BASRI-hip ≤1). The Spearman correlation test was used to evaluate the association between SI and bone turnover markers [TP1NP, OC, β-CTx, 25(OH)VD3, and PTH].

Results

RHI-AS (BASRI-hip ≥2) patients accounted for 52.2% (177/339) of all patients. There was no significant difference in most of the basic clinical features between RHI-AS and WORHI-AS patients, except for age and BMI. After adjusting for confounding factors (age and BMI), the stiffness index (SI) of RHI-AS patients was significantly lower than that of WORHI-AS patients (OR_adj=0.982, 95% CI_adj=0.968~0.997, P_adj=0.017). The Z scores calculated by SI were lower in RHI-AS patients (OR_adj=0.802, 95% CI_adj=0.679~0.949, P_adj=0.01). Among the 5 bone turnover markers in the RHI-AS patients, only 25(OH)VD3 had a correlation with SI (rho=0.279, P=0.001).

Conclusions

AS patients have lower bone strength once the disease progresses to include radiologic hip involvement. Treatment of vitamin D deficiency may be an effective way to improve bone strength in AS patients with hip involvement.

Root Joint Involvement in Spondyloarthritis: A Post-hoc Analysis from the International ASAS-PerSpA Study

OBJECTIVES

Primary objective was to compare the clinical characteristics of spondyloarthritis (SpA) patients with and without root joint disease (RJD+ and RJD-). Secondary objectives were to compare the prevalence of RJD across various SpA subtypes and in different world regions, to compare the SpA axial severity and SpA burden between RJD+ and RJD-.

METHODS

This is a post-hoc analysis of the ASAS-PerSpA study (PERipheral involvement in SpondyloArthritis), which included 4,465 patients with SpA (axial (axSpA), peripheral (pSpA), psoriatic (PsA), inflammatory bowel disease, reactive and juvenile) according to the rheumatologist's diagnosis. RJD was defined as the "ever" presence of hip or shoulder involvement related to SpA, according to the rheumatologist. The patient's characteristics were compared between RJD+ and RJD-. Multivariable stepwise binary logistic regression analyses were conducted to identify factors associated with "RJD", "hip" and "shoulder" involvement.

RESULTS

RJD was significantly associated with the SpA main diagnosis (highest in pSpA), a higher prevalence of HLA-B27 positivity, enthesitis, tender and swollen joints, CRP, cs-DMARDs, loss of lumbar lordosis and occiput-wall distance > 0. RJD was more prevalent in Asia, and occurred in 1,503 patients (33.7%), with more hip (24.2%) than shoulder (13.2%) involvement. Hip involvement had a distinct phenotype, similar to axSpA (including younger age at onset, HLA-B27 positivity), whereas shoulder involvement was associated with features of pSpA (including older age at onset).

CONCLUSION

RJD+ SpA patients had a distinctive clinical phenotype compared with RJD-. Hip involvement, based on the rheumatologist's diagnosis, was more prevalent than shoulder involvement and was clinically distinct.

A Comprehensive Assessment of Hip Damage in Ankylosing Spondylitis, Especially Early Features

Ankylosing spondylitis (AS) is most common in adolescents and the ultimate result is disability, which places a huge burden on patients and society. Therefore, the key to improve the prognosis of AS is the early diagnosis of hip injury. To examine if AS patients whose hip pain is either absent or minimal might already have observable MRI and X-ray hip changes. Clinical and imaging hip data were systematically analyzed in 200 healthy controls (HC) and 300 AS with varying degrees of hip pain. Forty-four patients with early hip osteoarthritis (OA) served as positive imaging controls. In MRI images, BME lesions in the STIR sequence were much more frequent in AS (62%) compared to HC (2%) (p < 0.0001). Most importantly, 42% of AS with no or minimal hip pain had one or more MRI lesions. This was much more frequent compared to the 2% in HC (p < 0.05). These lesions in AS were observed singly or in combination in the trochanters (8%), femoral heads (12%), and acetabula (13%). Parallel finding that X-ray changes were present in patients with minimal or no hip pain was also observed with X-ray. Based on the normal hip width of HC, joint space narrowing was observed in 94.3% of the entire AS cohort, and importantly 56.7% of AS patients with no or mild hip pain. In these latter patients, functional activities of the hips such as walking were normal. At least 40% of AS patients with minimal or no hip pain might already show MRI and X-ray changes.

Evaluating the strength of spinal and proximal girdle muscles in patients with axial spondyloarthritis: Correlation with activity, disability, and functionality

AIM

To compare the muscle strength of muscle groups in axial spondyloarthritis (axSpA) patients with the muscle powers of healthy volunteers and to examine the relationship of muscle strengths with disease activity, functionality, and disability.

METHOD

One hundred males (50 axSpA, 50 healthy) were included in the study. Bath Disease Activity Index (BASDAI), Functional Index (BASFI), and Health Assessment Questionnaire-Disability Index (HAQ-DI) scores were recorded. The maximum (max) and mean cervical flexion, extension, lateral flexion (CF, CE, CLF), truncal flexion, extension (TF, TE), root joint flexion, extension, abduction, internal and external rotation (SF, SE, SAB, SIR and SER for the shoulder; HF, HE, HAB, HIR and HER for the hip) muscle strengths of the patients in both groups were measured by a handheld dynamometer. Total muscle strength (CT, TT, ST, HT) was found according to the sum of the max and mean values for each region.

RESULTS

All muscle strengths were lower in the axSpA group compared to the healthy volunteers. The symptom duration was found to have a weak-moderate negative correlation with CT, TT, ST, HT and all individual muscle strengths except for the TE, CF, HIR, and HER. BASDAI and HAQ-DI had weak-moderate negative correlations with HIR and HER. BASFI had a weak-moderate negative correlation with cervical measurements, TE, TF, SF, SER, SIR, and hip measurements.

CONCLUSION

All muscle strengths were lower in patients compared to healthy volunteers. Strengthening specific muscle groups for the desired goal can be a reasonable strategy. The study is prospectively registered and available at www.clinicaltrials.gov (NCT04435860).

Female with Ankylosing Spondylitis from the 7th–6th century BCE Lori Berd burial (Armenia)

A female skeleton from the Lori Berd archaeological cemetery, located near the city of Stepanavan (Lori Province of Armenia) is described. Palaeopathological analysis revealed a variety pathology (ankylosis of the sacroiliac joints, ankylosis of the vertebrae, syndesmophytes, ankylosed of the costovertebral and costotransverse joint fusions, kyphosis, lordosis, fracture of the anterior inferior iliac spine and traumatic lesions). This paper reports a new case of ankylosing spondylitis in a skeleton and a differential diagnosis performed to determine the etiology of the condition. The vertebral bodies remodel and together with the associated syndesmophytes form a continuous, smooth bone surface that is sometimes referred to as “bamboo spine”. In this skeleton changes in the spine, ribs, the sacrum, acetabulum, head of the femur and greater trochanter, as well as the anterior inferior iliac spine are typical of ankylosing spondylitis in advanced stage. Addtionally, there were signs of a traumatic death with injuries sustained to the scapula and vertebra. Using osteological markers in combination with the reconstruction of the archaeological context, the burial pattern suggests that the pathology the female suffered was likely due to her physical deficiencies.

[Inflammatory changes of the hip joint]

Die Osteoarthrose ist die häufigste Ursache für den Hüftschmerz des Erwachsenen. Daher wird anderen Ursachen wie z. B. Entzündungen weniger Beachtung für den Gelenkschmerz in der Erstdiagnose geschenkt. Dieser Artikel gibt eine Übersicht von unterschiedlichen rheumatologischen Erkrankungen der Hüfte und deren Interpretation in der Bildgebung. Die Vor- und Nachteile der einzelnen bildgebenden Verfahren werden anhand der pathologischen Befunde für die rheumatologischen Erkrankungen erläutert.