What is the treatment for ankylosis?

Treatment of Ankylosis

The treatment of ankylosis depends on the specific type and location, with surgical intervention being strongly recommended for advanced hip arthritis in ankylosing spondylitis (AS) patients, while temporomandibular joint (TMJ) ankylosis typically requires surgical release with interpositional arthroplasty. 1, 2

Ankylosing Spondylitis (AS) Related Ankylosis

Pharmacological Management

• First-line treatment: NSAIDs at maximum tolerated doses

  • Continuous NSAID treatment is conditionally recommended over on-demand treatment 1
  • No particular NSAID is preferred over others 1

• Second-line options (for patients with active AS despite NSAID treatment):

  1. TNF inhibitors (strongly recommended)

     • Options include infliximab, adalimumab, certolizumab, golimumab 1
     • No particular TNFi is recommended as the preferred choice

  2. IL-17 inhibitors

     • Secukinumab or ixekizumab (strongly recommended) 1
     • TNFi are conditionally recommended over IL-17 inhibitors as first biologic 1

  3. Other medications (conditionally recommended for peripheral symptoms)

     • Sulfasalazine, methotrexate, or tofacitinib
     • Should be considered only in patients with prominent peripheral arthritis or when TNFi are not available 1

Non-Pharmacological Management

• Physical therapy and exercise focusing on spinal mobility and posture 2
• Avoidance of spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis (strongly recommended against) 1

Surgical Management

Hip Ankylosis

• Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis 1
  • Provides significant improvements in pain, functioning, and hip range of motion
  • Should be performed by orthopedic surgeons experienced in joint replacement in AS patients 1

Spinal Ankylosis/Deformity

• Spinal osteotomy is conditionally recommended against for most patients with severe kyphosis 1
  • Associated with high risks: 4% perioperative mortality and 5% permanent neurologic sequelae
  • May be considered in highly selected patients with severe kyphosis who lack horizontal vision causing major physical and psychological impairments
  • Should only be performed at specialized centers by surgeons with extensive experience 1

Temporomandibular Joint (TMJ) Ankylosis

Surgical Management

• Interpositional arthroplasty is the primary treatment 3, 4
  • Involves resection of the ankylosed segment and placement of interpositional material
  • Temporal fascia is commonly used as interpositional material to prevent postoperative relapse 5
  • Patient-specific total joint replacement using virtual surgical planning is an advanced option 3

Post-Surgical Management

• Passive mouth-opening exercises are crucial to begin within 7-10 days after surgery 5, 4
• Regular follow-up to monitor progress and prevent relapse
• Failure to perform jaw-opening exercises is the main cause of relapse 6

Dental Ankylosis

• No known treatment to arrest the condition once established 7
• Management focuses on addressing consequences and rehabilitation
• For pre-adolescent patients with ankylosed incisors, monitoring for infraocclusion is important 7

Monitoring and Follow-up

• Disease activity monitoring using validated measures (BASDAI or ASDAS) 2
• Laboratory monitoring: CRP and ESR at regular intervals 2
• Radiographic follow-up generally not necessary more frequently than every 2 years, unless significant clinical changes occur 1
• Regular assessment for complications such as spinal fractures, advanced hip arthritis, and osteoporosis 2

Important Considerations

• Early diagnosis and treatment are crucial to prevent structural deformities 2
• Ankylosis treatment should account for current disease manifestations, symptoms, and prognostic indicators 1
• Surgical interventions carry significant risks and should be performed by specialists with extensive experience 1, 3
• Post-treatment rehabilitation and exercises are essential to prevent relapse 5, 4, 6