What is the management and treatment of ankylosis?

Management and Treatment of Ankylosis

The management of ankylosis requires a tailored approach combining non-pharmacological and pharmacological treatments, with surgical intervention often necessary for severe cases to restore function and improve quality of life. 1

Assessment and Monitoring

• Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation and the ASAS core set 1
• Radiographic monitoring is generally not needed more often than once every 2 years, though exceptions exist for rapidly progressing cases 1
• Assessment should evaluate disease activity/inflammation, pain levels, function, disability, structural damage, and comorbidities 1

Non-Pharmacological Management

Exercise and Physical Therapy

• Regular exercise and physical therapy are cornerstone treatments for ankylosis 1
• Home exercise programs improve function in the short term compared to no intervention 1
• Group therapy shows better patient global assessment outcomes than individual therapy alone 1
• Aquatic exercises in warm water are beneficial as they provide buoyancy to reduce joint loading and facilitate gentle strengthening 2
• Gentle muscle strengthening focusing on isometric exercises that don't require significant movement of the affected joint is recommended 2

Exercise Guidelines

• Start with very light intensity (40-50% of capacity) and gradually progress as tolerated 2
• Use pain response as a guide to appropriate exercise intensity and duration 2
• Incorporate rest periods between exercise sessions to allow recovery 2
• Modify exercises based on day-to-day symptom variation 2

Education and Support

• Patient education about the condition and self-management strategies is essential 1
• Patient associations and self-help groups may provide additional support 1

Pharmacological Management

• NSAIDs are recommended as first-line drug treatment for patients with ankylosis with pain and stiffness 1
• There is convincing level Ib evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over short periods (6 weeks) 1
• For patients with increased gastrointestinal risk, consider either non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor 1
• Analgesics such as paracetamol and opioids might be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 3
• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be beneficial 3
• Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments 1

Surgical Management

Temporomandibular Joint (TMJ) Ankylosis

• Surgical approaches include gap arthroplasty, interpositional arthroplasty, and joint reconstruction 4
• Single-stage operations using virtually designed custom-made implants show promising results with increased mouth opening (from 0.6mm to 25mm) 4
• Lateral arthroplasty (LAP) with temporalis myofascial flap (TMF) is effective for treating traumatic TMJ ankylosis when the medially displaced condylar head and disc are intact 5
• Costochondral graft (CCG) with TMF shows good results for complete bony fusion ankylosis 5

Hip and Spinal Ankylosis

• Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage 1
• Spinal surgery, including corrective osteotomy and stabilization procedures, may be valuable in selected patients 1
• For spinal ankylosis, corrective osteotomy can restore balance and horizontal vision in cases of fixed kyphotic deformity 1
• Fusion procedures should be considered in patients with segmental instability resulting from spinal pseudarthrosis or Andersson lesion 1

Common Pitfalls and Considerations

• Overreliance on imaging findings without correlation to clinical symptoms can lead to unnecessary interventions 3
• Failure to incorporate both pharmacological and non-pharmacological approaches limits treatment effectiveness 3
• Systemic corticosteroids should be avoided for axial disease due to lack of evidence and potential side effects 3
• Be cautious with spinal manipulation, which is contraindicated in conditions with spinal fusion or advanced spinal osteoporosis 2
• Early mobilization and aggressive physiotherapy after surgical intervention are crucial for optimal outcomes 6
• Disease duration is a significant factor in ankylosis management, with longer duration associated with more severe ankylosis 7