NGUYEN TRUNG TUYENOUTCOME EVALUATION OF TOTAL HIP ARTHROPLASTY IN PATIENTS WITH ANKYLOSING SPONDYLITIS Specialty : Orthopedic Surgery Number : 62720129 PHD THESIS SUMMARY HANOI - 2020..
Trang 1NGUYEN TRUNG TUYEN
OUTCOME EVALUATION OF TOTAL HIP ARTHROPLASTY IN PATIENTS WITH ANKYLOSING SPONDYLITIS
Specialty : Orthopedic Surgery
Number : 62720129
PHD THESIS SUMMARY
HANOI - 2020
Trang 2HANOI MEDICAL UNIVERSITY
3 rd Reviewer: Assoc.Prof Dr LE BAO TIEN
The thesis will be defended in front of the School-level Ph.D thesiscoucil at the Hanoi Medical University
Trang 3Ankylosing spondylitis (AS) is a chronic inflammatory disease ofunknown etiology, typically affecting young adults, most commonlymales in the age of 20-30 years, primarily affecting the sacroiliacjoints, spine, hips and, less commonly, the knee joints, causingstiffness, ankyloses, deformities and functional loss i This disease ismanifested by long-term inflammation of the components betweenthe spine and joints, which is associated with a number of factors,one of which can be HLA-B27 antigen The disease progresses inseveral stages, usually accompanies with insidious-onset pain andmovement limitation of the lumbar spine, but it can also start withinflammation of the lower extremities Eventually, the entire spine fusiondisables personal movement, the two hip joints can adhere completely in
a half-contraction position and particularly, the disease can causecardiopulmonary complications such as respiratory failure, chronic heartfailure, tuberculosis, paralysis of the lower extremities
In the late stages, when spinal joints and extremity joints aredamaged, hip replacement is an additional therapy to improve thefunction and physical appearance for patients, enabling relativelynormal activities and fixing deformities for patients However, due tothe complexity of hip injuries in the pathogenesis, hip replacementfor patients with AS is a relatively difficult procedure imposing anumber of risks and needs to be performed by experienced surgeons
at specialized medical facilities In order to increase postoperativeoutcomes, the surgeons need to carefully evaluate a full range offactors such as disease staging, characteristics to the hip and spinaljoints damage as well as soft-tissue involvements around the joints
In addition, because of the epidemiological characteristics oftenoccurring in young people, the selection criteria for specially-designed hip joints with high durability and large range of motion isalso a crucial factor
Trang 4In the world, hip replacement in patients with AS has been firstconducted since 1965 by G P Arden and 1966 by J Harris InVietnam, total hip arthroplasty (THA), as known as total hipreplacement, was first performed in the 1970s, but until the pastdecade THA has gained popularity in several hospitals nationwide.There have been a number of studies on THA, but there have notbeen research deepening into outcome evaluation in patients of AStreated with total hip replacement nationwide Under thecircumstances of increased patient needs, we conducted the project
on the purpose of researching THA procedures for AS and
contributing factors to the treatment results as follows: “Outcome evaluation of total hip arthroplasty in patients with ankylosing spondylitis", with two objectives:
1 Description of clinical and laboratory findings of Ankylosing spondylitis with hip involvements
2 Evaluation of treatment outcome with Total hip arthroplasty in patients with Ankylosing spondylitis
NEW CONCLUSION OF THE THESIS
- 36 patients diagnosed with hip arthritis due to ankylosingspondylitis were included, showing that 42.6% of symptomaticpatients were morbid more than 10 years, 52.8% of patients hadbilateral hip injuries, 95.7% of whom experienced severe pain TheBath AS disease activity index, as known as BASDAI score, was6.03 ± 0.8 and Bath AS functional index, as known as BASFI score,was 6.42 ± 0.66 Particularly, hip movement on the Harris hipfunction scale was 41.76 ± 2.98, graded as poor functional abilities.X-rays showed that the majority of patients were in bilateralsacroiliitis stage II (66.7%) and hip arthritis stage III-IV according toBASRI-h index (89.4%)
Trang 5- 47 artificial hip arthroplasties were performed in 36 patients forthe treatment of AS The results showed that the level of diseaseactivity and functional movement abilities improved gradually overtime, after 36 months, BASDAI score was 2.32 ± 0.36 and BASFIscore was 2.62 ± 0.55 The hip joint function on the HARRIS scale atthe last endpoint was 95.86 ± 0.85, displaying excellent results.Moreover, the patient's quality of life improved significantly, moreobviously from 12th month post-operative, and at the end of follow-
up period, ASQoL questionnaire score fell to 1.09 ± 0.37, achievingpatients’ satisfaction
THESIS LAYOUT
The thesis consists of 115 pages (excluding the references andappendices) There are 4 chapters, 26 tables, 33 figures, 6 charts.Introduction: 2 pages; Overview: 46 pages; Materials and methods:
19 pages; Results: 20 pages; Discussion: 25 pages; Conclusion: 2pages; Recommendations: 1 page; 124 references (36 in Vietnameseand 88 in English)
CHAPTER 1: OVERVIEW 1.1 Ankylosing spondylitis
Ankylosing spondylitis (AS) is the most common chronic arthritis
in the sero-negative group, which is closely related to HLA-B27human leukocyte antigen (80-90%) of the histocompatibilitycomplex AS is common in males (80-90%) and young (patientsunder 30 years old account for 80%) The etiology of AS is currentlystill unknown
1.1.1 Clinical symptoms
1.1.1.1 Early stage
Initial signs: Hip pain, sciatica, Achille tendonitis Thesesymptoms last for several months, years
Trang 61.1.1.2 Late stage
Pain, swelling, movement limitation in multiple joints, muscleatrophy with rapid deformities Arthritis is usually symmetrical withincreasing pain at night
- Joints in the extremities: Hip joints: 90% unilateral arthritis, thenbilateral involvement Knee joints: 80% have knee joint effusion
- Spinal joints: Symptoms usually appear later than joints in theextremities Lumbar spine: 100% of patients experienced continuousand dull pain, movement limitation, perispinal muscle atrophy…
- Sacroiliac joint: Sacroiliitis is an early and specific sign mainlyshown on X-rays Patients may experience pelvic pain extending tothighs, gluteal muscle atrophy Pelvic floor relaxation test (+)
1.1.1.3 Progression
- Generally, symptoms of AS exacerbates over time, causing jointinvolvement and deformities If not treated early and properly, thepatient may have malpositions and multiple disabilities
- Complications: respiratory distress, chronic heart failure,pulmonary tuberculosis, bilateral limb paralysis due to spinal cordand nerve root entrapments
- Poor prognosis in patients with younger age, peripheralpolyarthritis, fever, weight loss Better prognosis in patients whoseonset develops after 30 years old, most common manifested in spine.50% of patients with AS progress continuously, 10% of whomprogress rapidly
1.1.2 Laboratory findings
1.1.2.1 Blood tests
- Basic blood tests refer to low diagnostic values: increased ESR(90%), increased Fibrinogen level (80%); Immunoassay demonstratesthat Waaler Rose antibodies, Antinuclear antibodies (ANA),Hargraves cells are mostly negative and they have no diagnosticvalues
Trang 7- B27 (1973): There is a close relationship between B27 and AS It is found that in AS, 75-95% of patients are carriers (inVietnam: 87%), compared to that only 4-8% of normal population areHLA-B27 carriers (in Vietnam: 4%)
HLA-1.2.2.2 Radiologic findings
Radiology of the sacroiliac (SI) joint:
Bilateral sacroiliitis is the mandatory criterion to the definitivediagnosis of AS, because sacroiliitis is the earliest and most commonsign recognised in AS Radiologic findings of SI joints are classifiedinto 5 grades as follows:
- Grade 0: normal
- Grade 1: suspicious changes
- Grade 2: minimal definite changes: circumscribed areas witherosions or sclerosis with no changes of the SI joint space
- Grade 3: distinctive changes, sclerosis, change of joint space(decrease or widened), partial ankylosis
- Grade 4: ankylosis
Radiology of the hip joint:
Radiologic findings of hip joints are classified into 5 grades ofBASRI-h index
On X-ray, there are two typical features: osteoporosis with bonespurs around the femoral necks and acetabular erosions The mostwidely used and validated indicator to evaluate the severity andprogression of hip involvement is BASRI-h index
Hip replacement is indicated at stage 3-4 or stage 1-2 with severepain, which greatly affects hip functions
Radiology of the spine and ligaments:
- X-rays of spinal column and ligaments is specific for diagnosis
of AS but only visible until late stages of AS
- At the early stages, nonspecific changes are easily omitted.+ Loss of spinal curvature with ossification of perispinalconnective tissue
Trang 8+ “Bamboo spine” signs.
- Ossification of spinal ligaments, as known as enthesitis (trolleytrack and dagger signs)
- Lateral X-ray findings: loss of spinal curvature, calcification ofthe posterior portion and interspinous ligaments
Spinal involvements are graded as 0-4 on the basis of BASRI-sindex
- Limitation of lumbar spine in sagittal and frontal planes
-Limitation of chest expansion (relative to normal valuescorrected for age and sex)
* Radiologic criteria
Bilateral grade 2-4 sacroiliitis and/ or unilateral 3-4 sacroiliitisRequirement for definitive diagnosis of AS is at least one clinicalcriterion AND at least one radiologic criterion
In order to diagnose and follow-up during its progression, furthertests of the inflammatory response such as ESR, reactive protein Ctests are required
In the early stages of AS to assist definitive diagnosis, HLA-B27tests can be utilized if possible (HLA-B27 antigen test can bepositive in more than 80% of cases), MRI of the SI joint
Trang 9status and disease stage Instruct the patient to practice breathing,correct their postures Physiotherapy if possible.
1.1.4.2 Medications
Analgesics Nonsteroidal anti-inflammatory drugs (NSAIDs) release medications for basic treatment Corticoids Novel biologics:monoclonal antibodies against tumor necrosis factor TNF-α
Slow-1.1.4.3 Surgical treatment
- Supratrochanteric femoral neck incision to form pseudojoint
- Voss’s operation in hip osteoarthritis
- Hip replacement is the surgical treatment that brings the bestoutcomes
1.2 Research results of hip replacement for AS worldwide
In the world, most of the studies have demonstrated theimprovement of movement abilities of patients with AS after THA,even in symptomatic patients as preoperative hip stiffness, reported
by Walker and Sledge (1991), Sochart and Porter (1997)
A number of research on assessment of the durability of artificialhip joints in patients with AS have been collected The average lifeexpectancy of artificial joints after the first THA in patients with ASshowed similar outcomes to that in patients with osteoarthritis,reported by Lehtimaki (2001), Joshi (2002)
These studies also show that long-term outcomes after THA inpatients with AS were relatively good, reported by Shih (1995), Lee(2017), and Tyim SJ (2018) These studies show that assessmentduring long-term follow-up period, the patient's postoperative Harrisscore greatly improved, pain levels decreased and quality of lifeimproved
1.3 Research results of hip replacement for AS in Vietnam
Total hip replacement for AS was initially performed in Vietnam
in 1973 by Tran Ngoc Ninh et al Since then, a number of authorshave researched on this issue, such as Tran Quoc Do (1980), Doan
Trang 10Viet Quan and Doan Le Dan (2000), Do Huu Thang (2002), TonQuang Nga (2004), Nguyen Huu Tuyen (2004), Tran Dinh Chien(2010), Ngo Van Toan (2011), Pham Van Long (2014), Mai Dac Viet(2015), Ngo Hanh (2015), Pham Duc Phuong (2015) Nationwidestudies have shown that there are a number of advantages in artificialTHA in hip-involved patients with AS, including early return tonormal walking postoperative, improvement of ROM, pain reductionand quality of life enhancement However, this is still a difficultsurgery and there are many perioperative and postoperative risks.
CHAPTER 2 MATERIAL AND METHODS
2.1 Study design: A retrospective and prospective, descriptive study 2.2 Study subjects
36 patients (6 retrospective and 30 prospective) diagnosed withhip involvements, with 47 hip joints treated with THA in Viet DucUniversity Hospital from January 2010 to December 2015, wereincluded
2.3 Inclusion criteria
Patients who meet the requirement for definitive diagnosis of AS,which is at least one clinical criterion AND at least one radiologiccriterion taken from 1984 Modified New York Criteria for AS:
* Clinical criteria
- Low back pain during over 3 months, improved by exercises andnot relieved by rest
- Limitation of lumbar spine in sagittal and frontal planes
- Limitation of chest expansion (relative to normal valuescorrected for age and sex)
* Radiologic criteria
Bilateral grade 2-4 sacroiliitis and/ or unilateral 3-4 sacroiliitis
Trang 11- Patient diagnosed with hip involvement grade 2 on BASRI-hindex
- Patients without contraindications to THA such as high age,weak health condition, local joint or systemic infection, medicalhistory not suitable for general or local anesthesia
2.4 Exclusion criteria
- Patients not previously treated for AS or patients during the active stage
of AS, patients not well-controlled with BASDAI index score over 8
- Patients underwent previous surgery to the inflamed hip joint,including total hip replacement with or without cement
- Patients without etiologies that cause muscle hypercontraction ormovement limitation of the knee joint
- Patients with mental disorders, or epileptic disorders, motorneurological dysfunction
- Patients with unclear medical records or addresses, missingpreoperative and postoperative X-rays
2.5.2 Prospective study
This clinical uncontrolled cross-sectional study was conductedstep by step from January 2013 to December 2015 as follows:
Trang 12- Selected patients, completed medical records and laboratorytests and follow-up sheets.
- Recorded radiologic scans of femur and hip joints, lumbar spine
- Treated chronic diseases if present or comorbidities if indicated
- Performed THA If the patient had a bilateral hip replacement,the interval between 2 hip arthroplasties was at least 3 months
- Conducted postoperative follow-up, Xray after surgery
- Instruct patients to practice after surgery
- Checked-up patients after surgery as scheduled
Evaluation timelines: T0 - before surgery; T1- 1 month aftersurgery; T3- 3 months after surgery; T6- 6 months after surgery; T12
- 12 months after surgery; T24- 24 months after surgery; T3 - 36months after surgery
2.6 Data analysis
Data collected from the study were processed according tocomputerized medical statistical algorithms using SPSS softwareversion 16.0
CHAPTER 3 RESULTS
3.1 Clinical and laboratory findings of the study subjects
3.1.1 General data
3.1.1.1 Age distribution
The average age of the study patients was 37 (range 18-67) years;the majority of patients belonged to the age group of 21-40 years old(47.2%) The youngest patient undergoing a hip joint replacementwas 18 years old and the oldest patient was 67 years old
Trang 133.1.1.2 Gender distribution
The study patients were 34 males (accounting for the majority at94.4%, 11 of whom had bilateral surgeries), 2 females (accounting for5.6%, one of whom had bilateral surgery)
3.1.1.3 The diagnosis-to-surgery duration
The duration from diagnosis of joint involvements to replacementwas more than 10 years, accounting for 42.6% (until significantdecreases of ROM that the patients underwent surgeries)
3.1.1.4 Hip involvements
Mostly bilateral hip joints (52.8%) Unilateral hip jointinvolvement was less common
3.1.1.6 Clinical criteria for diagnosis of AS
On our study patients: 100% of subjects had lumbar spinemovement limitation in sagittal and frontal planes, 97.2%experienced lumbar pain which lasted for more than 3 months, 58.3%with reduced chest expansion 100% of subjects were previouslydiagnosed with AS and treated
3.1.2 Outcome measures
3.1.2.1 BASDAI index
Table 3.1 BASDAI index (n=36)