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2013 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd

GUIDELINE

Consensus of Chinese Orthopaedic Experts on

Diagnosis and Treatment of Ankylosing Spondylitis
Bin Shen, MD1, Zhan-jun Shi, MD2, Hou-shan Lv, MD3, Jian-zhong Xu, MD4, Shi-gui Yan, MD5, Ke Zhang, MD6,
Zi-rong Li, MD7, Qing-ming Yang, MD8, Hui-lin Yang, MD9, Yong-gang Zhou, MD10, Yu Zhao, MD11, Xi-sheng Weng, MD11,
Wen Yuan, MD12, Yong-cheng Hu, MD13, Fu-xing Pei, MD1, Gui-xing Qiu, MD11
1
Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, 2Department of Orthopaedic Surgery, Nanfang Hospital,
Guangzhou, 3Arthritis Clinic & Research Center, Peking University Peoples Hospital, Beijing, 4Department of Orthopaedics, Southwest Hospital,
Third Military Medical University, Chongqing, 5Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang
University, Hangzhou, 6Department of Orthopaedics, Peking University Third Hospital, Beijing, 7Center for Osteonecrosis and Joint Preserving &
Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, 8Department of Orthopaedics, Ruijin Hospital,
Shanghai Jiaotong University School of Medicine, Shanghai, 9Department of Orthopaedics, First Affiliated Hospital and Orthopaedic Institute of
Soochow University, Suzhou, 10Department of Orthopaedics, General Hospital of Chinese Peoples Liberation Army, Beijing, 11Department of
Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing,
12
Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, and 13Department of Bone Oncology,
Tianjin Hospital, Tianjin, China

Introduction Diagnostic Criteria for Ankylosing Spondylitis

A nkylosing spondylitis (AS) is a connective tissue disease

that affects mainly the sacroiliac, spinal and peripheral
joints and paraspinal soft tissue. It can also cause extra-
articular symptoms and signs. Patients with severe AS can have
spinal deformity and joint stiffness. According to a preliminary
survey, the prevalence rate of AS is about 0.3% in China with
about a 23:1 male:female ratio. In women, the course of the
disease is slower and the manifestations less severe. The age of
onset is usually between 13 and 31 years, the peak age of onset
being 20 to 30 years. Onset older than 40 or younger than 8
years is rare1.
A type of seronegative spondyloarthropathy, AS is char-
acterized by onset in the sacroiliac joints, then progression
slowly upward along the spine or downward to affect the hips
and knees bilaterally; upper limb joints are rarely involved. The
earliest pathological manifestation is typically sacroiliitis and
the latest bamboo-like change in the spine2. Usually, it takes
from 5 to 10 years from onset of chronic symptoms of AS to
diagnosis. Key measures for controlling the progress of the
disease and reducing disability are early diagnosis and reason-
able and timely treatments.
T he New York criteria, which were last revised in 1984, are
often used to diagnose AS (Table 1). However with more
extensive AS research, especially regarding development of
more effective therapy (such as tumor necrosis factor [TNF]
inhibitor), limitations of the revised New York criteria are
becoming increasingly apparent. The classification criteria for
axial spondyloarthritis (Fig. 1) that the Assessment of Spondy-
loArthritis international Society (ASAS) published in 2009
can help with early diagnosis of AS and identification of the
appropriate treatment programs3. These classification criteria
specify that a definite diagnosis of AS can be made when a
radiologic criterion (Table 2) is associated with at least one
clinical criterion.
Treatment of Ankylosing Spondylitis
T he goals when treating AS are as follows: (i) to eliminate or
alleviate symptoms such as back and joint pain, morning
stiffness and fatigue; (ii) to prevent and correct deformities by
slowing down the destructive process in the spine and joints
and correcting rigidity or severe deformities of the large joints

Address for correspondence Fu-xing Pei, MD, Department of Orthopaedics, West ChinaHospital, Sichuan University, Chengdu, China 610041 Tel:
0086-28-85553329; Fax: 0086-28-85423438; Email: shenbin71@hotmail.com. Yong-cheng Hu, MD, Department of Bone Oncology, Tianjin
Hospital, Tianjin, China 300211 Tel: 0086-22-28334734; Fax: 0086-22-28241184; Email: yongchenghu@yahoo.com.cn. Gui-xing Qiu, MD,
Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing
100730 Tel: 0086-10-65296114; Fax: 0086-10-65124875; Email: qiugx@medmail.com.cn
Disclosure: The authors declare no conflict of interest. No benefits in any form have been, or will be, received from a commercial party related directly
or indirectly to the subject of this manuscript.
Received 22 October 2012; accepted 1 November 2012

Orthopaedic Surgery 2013;5:15 DOI: 10.1111/os.12016

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TABLE 1 Modified New York criteria for ankylosing spondylitis
(1984)
Clinical criteria
a) Low back pain and stiffness for more than 3 months that improves with
exercise, but is not relieved by rest
b) Limitation of motion of the lumbar spine in both the sagittal and frontal
planes
c) Limitation of chest expansion relative to normal values corrected for age
and sex
Radiologic criterion
Sacroiliitis grade 2 bilaterally or sacroiliitis grade 34 unilaterally.
(hips or knees) and spine; and (iii) to improve function by
maximizing recovery of the patients physical and mental func-
tioning, for example by improving spinal mobility, social skills
and the ability to work.
The principles of treatment are to use medical treatment
in the early stages and reserve surgical treatment for managing
rigidity and severe deformities of the large joints (hips or
knees) in the end stages.
Non-surgical Treatment
Non-pharmacological Interventions
Education of Patients. Patients and their families should be
provided with sufficient information and education to enable
Fig. 1 2009 ASAS classification criteria for axial spondyloarthritis SpA, axial spondyloarthritis.
Diagnosis and Treatment of AS
TABLE 2 Radiographic grading of sacroiliac changes in anky-
losing spondylitis
Grade Appraisal
0 Normal
1 Suspicious
2 Sclerosis, some erosion
3 Severe erosions, widening of the
joint space, some ankylosis
4 Complete ankylosis
them to understand the disease. The long-term treatment plan
should include social psychology and rehabilitation counseling
of patients.
Posture and Alignment. Patients should be taught to maintain
optimal functional postures during their daily activities to
prevent deformities of the spine and joints. This includes
standing erect, keeping the chin up, facing forward and sleep-
ing on a hard board in a supine position to avoid postures that
could promote contorted or malaligned body positions.
Patients should use a thin pillow unless the upper thoracic or
cervical vertebrae are involved, in which case it is recom-
mended that no pillow be used. Large joints of the limbs
should be kept in functional positions to avoid stiffening into
non-functional positions.
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Functional Exercises. Regular physical exercises for at least
30 min each day and at least five days a week are the basis of
successful treatment of AS. Deep breathing and coughing can
increase pulmonary expansion. Other exercises designed to
enhance the strength of the paraspinal muscles, increase lung
capacity, maintain mobility of the joints and prevent or miti-
gate disability are recommended.
Proper Physical Therapy. This is necessary for any inflamed
joints and tissues.
General Measures. Adequate rest, diet that is rich in calcium,
vitamins and nutritional value and eating more fruit is recom-
mended during the active stage. It is also necessary to quit
smoking and drinking.
Pharmacological Interventions
Non-steroidal Anti-inflammatory Drugs (NSAIDs). NSAIDs
can quickly mitigate low back pain and morning stiffness,
relieve joint swelling and pain and increase the range of activity
of AS patients. Thus, they can be used as first-line drugs for
early or late treatment of symptoms. Long-term continuous
use of appropriate doses of NSAIDs can both prevent and stop
further new bone formation in AS patients. This is especially
true of the selective COX-2 inhibitors, which not only have
strong anti-inflammatory effects, but also can prevent and stop
progression as shown by imaging4.
When prescribing NSAIDs, physicians should be aware
of the risk of cardiovascular, gastrointestinal and renal damage.
Compared with non-selective NSAIDs, long-term selective
COX-2 inhibitors are safer because they are less toxic to the
gastrointestinal tract.
Sulfasalazine. This drug can mitigate joint pain, swelling and
morning stiffness and reduce serum concentrations of IgA and
other laboratory indicators. However, it is less effective for
treating axis symptoms than NSAIDs. The recommended daily
dose is 2.0 g orally 2 to 3 times a day. The maximum pharma-
cological effect is usually achieved 4 to 6 weeks after beginning
the medication. In order to offset its delayed and less pro-
nounced anti-inflammatory effects, combination with a rapid
onset NSAID is recommended5.
Glucocorticoids. Glucocorticoids do not stop progression of
AS and have severe adverse effects. Neither oral nor intrave-
nous glucocorticoids are recommended for treatment of AS.
Intractable tendon disease and persistent synovitis can
responds well to local glucocorticoids. Injection of joints with
glucocorticoids is indicated for intractable peripheral joint
arthritis (such as in the knee) that has not responded well to
systemic drug administration; generally, this should be per-
formed no more often than 2 or 3 times a year.
Biological Therapy. Biological preparations are novel drugs
used to control AS that have strong anti-inflammatory effects.
They can prevent progression of the disease. Thus far, there is
Diagnosis and Treatment of AS
only one category of such biological preparations that has
proven effectiveness in AS, namely tumor nuclear factor-a
(TNF-a)_inhibitors6. TNF-a inhibitors include etanercept
(25 mg/vial, Pfizer, New York, NY, USA), infliximab (100 mg/
vial, Xian-Janssen, Titusville, NJ, USA) and adalimumab
monoclonal antibody (40 mg/vial, Abbott, Champaign, IL,
USA). Their overall success rate is 50%75%. Treatment with
TNF-a inhibitors is characterized by rapid onset of beneficial
effect, significant inhibition of bone destruction, mitigation of
central axis and peripheral symptoms and good patient toler-
ance If a 12-week trial of TNF-a inhibitor treatment is effec-
tive, then it is recommended that the treatment continue. If
one TNF-a inhibitor does not produce satisfactory results,
another can be substituted.
Biological agents may cause injection site or infusion
reactions and can increase the risk of tuberculosis, hepatitis
virus activation and tumor. Because etanercept does not cause
destruction of the immune cells which express transmembrane
TNF, it is associated with less risk of inducing tuberculosis and
tumor than are the other available TNF-a inhibitors7. Before
commencing TNF-a treatment, it is necessary to screen for
tuberculosis and hepatitis and exclude active infection and
tumor. During treatment, the hemogram and liver and kidney
function should be reviewed regularly818.
Surgical Treatment
The Goals of Surgical Treatment
The goals of surgical treatment of AS are to correct deformi-
ties, improve function and relieve pain.
Indications for Surgery
When there is significant disability, such as severe kyphosis or
ankylosis or severe pain and limited mobility of the hip or
knee, accompanied by X-ray findings of structural damage,
spine orthopedic surgery or joint arthroplasty should be con-
sidered. The effects of surgery are long-term, stable and
reliable. However, before surgery patients should be informed
that the purpose of the surgery is to treat deformities of the
spine and dysfunction of joints rather than to treat the AS
itself19.
Preoperative Preparation
The following considerations are important.
Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein
(CRP). The ESR and CRP concentrations of AS patients are
generally higher than in normal subjects. They are indicators
of the activity of the disease. Preoperative concentrations of
CRP several times higher than normal may increase the risk of
postoperative infection after joint arthroplasty.
Osteoporosis. Because of the lack of stress stimuli in the pres-
ence of spine rigidity, patients with AS characteristically have
osteoporosis. Careful consideration should be given to the
difficulties of achieving firm fixation in the presence of
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TABLE 3 Perioperative use of therapeutic medications
Medications Comments
NSAIDs Traditional NSAIDs should be discontinued five
half-lives before surgery and recommenced 48 hours
after surgery
Selective COX-2 inhibitors can be continued during
the perioperative period
Leflunomide Continue during the whole perioperative period
Corticosteroids Continue to use. 100150 mg hydrocortisone can be
administered i.v. on the day of surgery, the
decreased by 50 mg per day in 12 days, tapering to
the preoperative oral dose
TNF antagonists Discontinue the drug two half-lives before surgery. If
the wound heals well and there is no sign of
infection, the drug can be recommenced*
*Half-lives of these drugs: etanercept, 70 h; infliximab, 7.79.5 days;
adalimumab, 14 days.
osteoporosis. Because joint ankylosis is often complicated by
osteoporosis, surgeons should be wary of periprosthetic frac-
tures when performing joint arthroplasties.
Respiratory Function. In AS patients, limited thoracic expan-
sion is typically associated with decreased respiratory func-
tional reserve. In addition to cough and expectoration
training, routine lung function monitoring should also be per-
formed. For patients undergoing general anesthesia, the forced
expiratory volume in the first second should be >40% of the
predicted volume, maximum ventilator volume/minute >50%
of the predicted volume and lung function >35%. Patients who
do not meet these criteria should not undergo surgery until
they have received training and physical therapy to improve
their pulmonary function.
Anesthesia. An anesthetist should be consulted about anesthe-
sia techniques before surgery. Because cervical ankylosis can
cause difficulty in intubation, the need for intubation tools
such as fiberoptic bronchoscopes should be anticipated and
prepared for preoperatively.
Medical Management. During the perioperative period,
patients with AS usually require medications. The need for
withdrawal should be assessed according to the nature of each
medication (Table 3). Finding a balance between reducing sur-
gical complications and maintaining drug efficacy is important
in facilitating postoperative rehabilitation of patients with
AS20,21.
Surgical Procedures
The most commonly used surgical procedures are spinal
osteotomy and hip and knee arthroplasty. Lumbar spinal
osteotomy can correct lumbar deformities. Hip and knee
arthroplasties can be performed for stiffness, pain and
Diagnosis and Treatment of AS
impaired function of the hip and knee that is accompanied by
X-ray findings of structural damage.
Sequence of Surgical Procedures. Spinal or joint surgery, which
one should be performed first? In principle, the region in
which there is the most severe deformity or most severe impact
on function should be operated on first; however, the position
required for the surgical procedure should also be taken into
consideration. Hip or knee surgery, which one should be per-
formed first? Usually, hip arthroplasty should be performed
first to determine the rotational center of the hip. Bilateral hip
arthroplasty should be performed first in patients with bilat-
eral hip and knee ankylosis, following which bilateral knee
arthroplasty can be performed. Also, ipsilateral hip and knee
arthroplasties can be performed first; two-stage surgery on the
other side is also acceptable. Postoperative functional exercises
are helpful.
Spinal Osteotomy. Smith-Peterson annex wedge osteotomy,
multi-segment vertebral arch wedge osteotomy and transfo-
raminal wedge osteotomy are the most commonly used types
of spinal osteotomy. Because of concentration of stress at the
osteotomied stage and limited space to avoid spinal cord
caused by spinal stiffness and confinement of the spinal cord,
particular attention should be paid to avoid spinal cord and
nerve root injuries, vascular injury and spinal instability
during the surgery. During surgery, the spinal cord, blood pres-
sure, respiration, pulse rate, and lower extremity sensory and
motor function should be closely monitored.
Hip Arthroplasty. Patients who undergo hip arthroplasty at an
early stage of hip stiffness typically achieve much better results
than those who undergo surgery at a later stage. Age should not
be a limitation for patients with AS who need hip arthroplasty
for flexion ankylosis deformities. Patients with severe ankylosis
deformities of the hips are encouraged to undergo early
surgery because this is helpful for improving joint function
and their quality of life. Although early surgery may lead to
long-term complications such as loosening of prostheses, this
is becoming less problematic with advances in prosthesis
design and technology.
Knee Arthroplasty. Patients with AS usually have associated
osteoporosis. Therefore, the surgeon should be wary of
periprosthetic fracture during surgery. For those with flexion
deformities of more than 60, surgeons should also guard
against stretch injuries of the popliteal vessels and peroneal
nerve during surgery22.
Postoperative Management
Functional Rehabilitation. Rehabilitation should be focused
on increasing muscle strength, improving joint range of
motion, controlling pain and improving coordination of
motor and sensory capabilities. Initiation of early and positive
training is recommended.
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Analgesia and Prevention of Deep Vein Thrombosis. Please refer
to the guidelines of the orthopaedic branch of the Chinese
Medical Association23,24.
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