Ankylosing spondylitis (AS) is a progressive multisystem chronic inflammatory disorder. The hallmark of this pathological process is a progressive fusion of the zygapophyseal joints and disc spaces of the axial skeleton, leading to a rigid kyphotic deformity and positive sagittal balance. The ankylosed spine is unable to accommodate normal mechanical forces, rendering it brittle and susceptible to injury. Traumatic hyperextension injury of the cervical spine leading to atlantoaxial subluxation (AAS) in AS patients can often be fatal. We report a non-traumatic mechanism of injury in AS progressing to AAS attributable to persistent hyperextension, which resulted in fatal migration of C2 through the foramen magnum. Cite this article: Bone Joint J 2013;95-B:206–9

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To investigate the correlations among cytokines and regulatory T cells (T-regs) in ankylosing spondylitis (AS) patients, and their changes after anti-tumour necrosis factor-α (TNF-α) treatment.

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Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis.

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A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

To evaluate the efficacy of Vacuum Assisted Closure (VAC) in the management of post surgical spinal sepsis. A retrospective analysis was performed of patients with severe post operative spinal wound infections treated using a combination surgical debridement, antibiotics and VAC therapy. Full records were available for a total of twenty adult all of whom had had prior thoracic or lumbar instrumentation. Comorbidities included disseminated carcinomatosis (25 % of patients), Ankylosing spondylitis (5 %), rheumatoid arthritis (5%) and Polio (5%). In one patient there had been a prior history of irradiation of the surgical field. Most infections treated by this regime were identified within two weeks following surgery. At surgery infection deep to the dorso-lumbar fascia was found in 87 % of cases. It was possible to retain instrumentation in 60 % of cases. An average of three trips to theatre were required prior to wound closure, which was possible in 95 % of cases. The VAC device was left in situ for an average of 11 days. Complications included recurrence of infection necessitating further treatment in 20 % of cases, wound dehiscence necessitating healing by secondary intention in 5%, the need for free flap wound cover in 5 % and death from unrelated causes in 5%. VAC therapy may facilitate the management of wound sepsis following spinal surgery in susceptible patients allowing the maintenance of instrumentation and surgical correction

Protrusio acetabuli can be either primary or secondary. Primary or idiopathic protrusio is a rare condition of unknown etiology. Secondary protrusio may be associated with Rheumatoid Arthritis, Ankylosing spondylitis, osteoarthritis, osteomalacia, trauma and Paget's disease. Challenges in surgery include lack of bone stock, deficient medial support to the cup, difficulty in dislocating the femoral head, and medialisation of the hip joint centre. Several surgical techniques have been described: use of cement alone without bone graft; morsellised impacted autograft or allograft with a cemented cup; metal cages, reinforcement rings, and solid grafts. We describe our technique of impaction grafting using autologous bone and a cementless porous-coated hemispherical cup without the use of acetabular rings or cages in patients with an average age of 46 years. Protrusion was graded depending on distance of medial wall from Kohler's line as mild (1–5 mm medial), moderate (6–15 mm medial) and severe if it was more than 15 mm medial to the Kohler's line. All patients were operated in the lateral position using a modified Hardinge's anterolateral approach. Adductor tenotomy may be required in cases of severely stiff hips. After careful dislocation of the femoral head, it was sectioned in situ into slivers to facilitate obtaining the graft. The periphery was reamed and care was taken to preserve the membrane lining the floor of the defect. Morsellised graft was impacted with hemispherical impactors and the trial cup 1–2 mm larger than the last reamer placed in the desired position. The final socket was then inserted. Femoral preparation was performed in routine fashion. The mean pre-operative Harris hip score of 52 improved to 85 points at a mean follow up of 4 years. The average acetabular inclination angle was 42 degrees. Our results have shown incorporation of the graft in all cases. There was no evidence of progression of the protrusio or cup loosening in any of the cases. Thus far, our hips have not shown osteolytic lesions. The technique described is a satisfactory biological solution of restoring bone stock particularly in young and middle-aged patients

Aim of the study: To assess the results of the uncemented oblong shaped Bofor cup in acetabular revision. Methods & materials: A prospective study from January 2001 to July 2006.15 cases of acetabular revision in 14 patients is studied. Paprosky classification for the acetabular defects is used. Final outcome assessed clinically and radiologically. Both Harris hip and Oxford hip functional scoring is used to assess the patients. None of the cases are lost in follow up. Results: The average follow-up was 36 months (range 8–52 months). All the cases were of aseptic loosening. 1case of type 2a, 6 cases of type 2b, 5 cases of type 2c, 3cases of type 3 defect and 4 cases with medial wall defect were noted. Stem was revised in 8 cases. In 4 cases auto graft from iliac crest was used. allograft was not used in any cases. In 12 cases 15 degree hooded insert was used. Average HHS improved from 30 points (range 20–38) to 84 points (range 70–90). Average OHS improved from 24 points (range 18–40) to 82 points (range 74–92). There were no cases of dislocation& infection.1 patient had sciatic nerve neuropraxia.1 case of severe Ankylosing spondylitis failed which was revised. Conclusion: Assemytical shape and design of the Boforcup makes it an useful cup for segmental and cavitatory acetabular defects. Pre operative classification of acetabular defects is inconsistent and unreliable. Allograft usage is not essential for these defects

Introduction: Pseudoarthrosis in Ankylosing spondylitis is often misdiagnosed as infection. It is a slow progressing lesion resulting in a kyphosis and slow onset weakness of the lower limbs. We are presenting our strategy and experience in treating 9 patients with such a lesion. Method: 9 patients age range from 40–55 years who presented with pseudoarthrosis of the ankylosed spine underwent back-front surgery during 2001–204. 6 patients had dorsal spine lesion, 2 had dorso-lumbar junctional lesion and 1 had cervico-dorsal junctional lesion. 8/9 patients had insidious onset with progressive weakness of both lower limb. 1 patient had an acute onset with deformity. 7/9 patients had neurodeficit (Frankel C) 1/9 had complete paraplegia. All patients underwent posterior kyphosis correction and decompression of the spinal cord. During posterior decompression 8/9 patients had an incidental dural tear due to adherence fractured lamina. The dura was repaired primarily or patch graft. 5/9 patients had single stage back and front surgery. The rest of the patients had staged surgery. The front surgery was excision of the tough fibrotic psuedoarthosis and reconstruction using strut graft/cage. Results: Average duration of surgery was 4 ½ hours (3 ½ to 6 hours). Blood loss was 800 ml (600–1300 ml). All patients required blood transfusion. Primary dural repair was done in 7/8 cases, patch graft in 3/8 cases, ceiling with fusion glue and fat graft in 1 patient. 5 patients who had less that 1000 ml blood loss during posterior surgery had same stage anterior reconstruction. Rest of the patient had 2 staged surgery. 4/9 patients had previous THR B/L. All patients showed rapid improvement in the neurological status and at 3 months follow up all were Frankel E. Conclusion: The surgical outcome of the ankylosing spondylitis patients with Andersson lesion with neurological deficit is encouraging. Excision of the pseudoarthroses anteriorly and posterior spinal stabilization resulted in full recovery of the deficit. However there were difficulties encountered during the posterior decompression due to adhesions of the posterior elements to the dura

Purpose: Ankylosing spondylitis and Forestier hyperosteosis produces a fused vertebral column. The fused vertebrae can be considered like a “spine-bone” which has particular features different from those of the mobile spine. The purpose of this retrospective analysis was to investigate the clinical and radiological particularities of the spine-bone in order to reduce the delay to diagnosis. Material and results: Forty-eight spinebone fractures were observed over a 17-year period by one practitioner. Twenty of the patients (mean age 62 years) had ankylosing spondylitis and 28 (mean age 81 years) had hyperosteosis. All of the patients were men. Twenty-five were victims of falls, eleven victims of traffic accidents, and six victims of sports accidents (all with ankylosing spondylitis). No notion of trauma could be identified for six patients. Sixteen fractures were diagnosed within 1 to 28 days. Forty-four patients had cord injury including 16 cases which developed secondarily. Four types of fracture were identified:. - type I = anterior opening fracture: 30 patients,. - type II = “sawbone” fracture: 4 patients,. - type III = “rasp line” fracture: 8 patients,. - type IV = fractures comparable to other fractures of the vertebral column: 6 patients. Fractures diagnosed late were four anterior opening fractures, eight “rasp line” fractures, and four “sawbone” fractures. A CT scan was obtained in all cases and an MRI in 30. Three compressive spinal extradural haematomas were diagnosed. Thirty-two patients died, 31 patients with spinal injuries due to decubitus-related complications and one by rupture of an aneurysm of the aorta. Discussion: This series illustrates several points. Fracture without trauma is frequent. Diagnosis is made late. Fractures gone undiagnosed lead to neurological complications or nonunion. Diagnosis of “rasp line” fractures cannot be made on standard x-rays, leading us to order a scanner and/or an MRI in all patients with a painful ankylosed spine even if the standard x-ray does not show any fracture. Neurological and extradural haematoma are serious complications. Mortality is high in these debilitated patients. Knowledge of these exceptional fractures of the vertebral column is necessary to improve diagnosis and prognosis

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The aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate.

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Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

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The management of acetabular defects at the time of revision hip arthroplasty surgery is a challenge. This study presents the results of a long-term follow-up study of the use of irradiated allograft bone in acetabular reconstruction.

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We present a minimum 20-year follow-up study of 382 cemented Exeter Universal total hip arthroplasties (350 patients) operated on at a mean age of 66.3 years (17 to 94).

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The aim of this study is to introduce and investigate the efficacy and feasibility of a new vertebral osteotomy technique, vertebral column decancellation (VCD), for rigid thoracolumbar kyphotic deformity (TLKD) secondary to ankylosing spondylitis (AS).

Cardiac disease in patients with ankylosing spondylitis (AS) has previously been studied but not in patients with a kyphosis or in those who have undergone an operation to correct it.

The aim of this study was to measure the post-operative changes in cardiac function of patients with an AS kyphosis after pedicle subtraction osteotomy (PSO).

The original cohort consisted of 39 patients (33 men, six women). Of these, four patients (two men, two women) were lost to follow-up leaving 35 patients (31 men, four women) to study. The mean age of the remaining patients was 37.4 years (22.3 to 47.8) and their mean duration of AS was 17.0 years (4.6 to 26.4). Echocardiographic measurements, resting heart rate (RHR), physical function score (PFS), and full-length standing spinal radiographs were obtained before surgery and at the two-year follow-up.

The mean pre-operative RHR was 80.2 bpm (60.6 to 112.3) which dropped to a mean of 73.7 bpm (60.7 to 90.6) at the two-year follow-up (p = 0.0000). Of 15 patients with normal ventricular function pre-operatively, two developed mild left ventricular diastolic dysfunction (LVDD) at the two-year follow-up. Of 20 patients with mild LVDD pre-operatively only five had this post-operatively. Overall, 15 patients had normal LV diastolic function before their operation and 28 patients had normal LV function at the two-year follow-up.

The clinical improvement was 15 out of 20 (75.0%): cardiac function in patients with AS whose kyphosis was treated by PSO was significantly improved.

Cite this article: Bone Joint J 2015;97-B:1405–10.

The widespread use of MRI has revolutionised the diagnostic process for spinal disorders. A typical protocol for spinal MRI includes T1 and T2 weighted sequences in both axial and sagittal planes. While such an imaging protocol is appropriate to detect pathological processes in the vast majority of patients, a number of additional sequences and advanced techniques are emerging. The purpose of the article is to discuss both established techniques that are gaining popularity in the field of spinal imaging and to introduce some of the more novel ‘advanced’ MRI sequences with examples to highlight their potential uses.

Cite this article: Bone Joint J 2015;97-B:1683–92.

The April 2014 Spine Roundup³⁶⁰ looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?

Few studies have examined the order in which a spinal osteotomy and total hip replacement (THR) are to be performed for patients with ankylosing spondylitis. We have retrospectively reviewed 28 consecutive patients with ankylosing spondylitis who underwent both a spinal osteotomy and a THR from September 2004 to November 2012. In the cohort 22 patients had a spinal osteotomy before a THR (group 1), and six patients had a THR before a spinal osteotomy (group 2). The mean duration of follow-up was 3.5 years (2 to 9). The spinal sagittal Cobb angle of the vertebral osteotomy segment was corrected from a pre-operative kyphosis angle of 32.4 (SD 15.5°) to a post-operative lordosis 29.6 (SD 11.2°) (p < 0.001). Significant improvements in pain, function and range of movement were observed following THR. In group 2, two of six patients had an early anterior dislocation. The spinal osteotomy was performed two weeks after the THR. At follow-up, no hip has required revision in either group. Although this non-comparative study only involved a small number of patients, given our experience, we believe a spinal osteotomy should be performed prior to a THR, unless the deformity is so severe that the procedure cannot be performed.

Cite this article: Bone Joint J 2014;96-B:360–5.

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.