Page 366 - Medicine and Surgery

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362 Chapter 8: Musculoskeletal system

Surgicalmanagementaimstohelpwithsymptomcon- due to discordance in identical twins. Suggested agents

trol and maximise joint function. Procedures include include bacterial infection (such as Klebsiella).
the following:
1 Synovectomy, which is the removal of excessive syn- Pathophysiology
ovial swelling from joints and tendons, may help to There is an inflammatory reaction at the site of liga-
reduce pain and stiffness in early disease. ment to bone attachment (enthesopathy), which then
2 Tendon repair and transfer is used particularly in progresses to ligamentous ossification. Microscopically,
the wrist and hand. there is oedema and inflammation, especially in the ad-
3 Excision arthroplasty (limited joint excision) or jacent bone marrow. Synovitis of the spine and large
arthrodesis (joint fusion) may be performed for in- joints may occur, and there is both synovitis and enthe-
tractable pain at the elbow or wrist; however, there sopathy at the sacroiliac joints. The outer layer of the
is an inevitable loss of function. Atlantoaxial sub- intervertebral disc becomes calcified and forms a bony
luxation may require surgical stabilisation. bridge between vertebral bodies (syndesmophytes). As
4 Joint replacement has significant postoperative these extend up the spine, calcification causes rigidity
morbidity but can be an effective longer term treat- and a typical ‘bamboo’ appearance on X-ray.
ment.
Clinical features
Prognosis Patients develop a gradual onset of episodic low-back
The disease generally progresses insidiously in the ma- painandmorningstiffness.Thereisalossofnormallum-
jority of cases although most patients experience periods barlordosisduetomusclespasmandsacroiliacjointten-
of exacerbation and quiescence. derness. Movement of the spine is restricted in all planes
and a limitation of chest expansion may occur. Late in
the disease there is a severe kyphosis (see Fig. 8.2) with
Seronegative arthritides marked limitation of movement or complete rigidity of
(spondyloarthropathies) the spine. Acute anterior uveitis, aortic regurgitation and
apical lung fibrosis are known extra-articular features.

Ankylosing spondylitis

Definition
Ankylosing spondylitis is a chronic inflammatory arthri-
tis predominantly affecting the axial skeleton, causing
pain and progressive stiffness.

Prevalence
0.2% of the population.

Age
Usual onset at 16–40 years.

Sex
5M : 1F, overt disease.

Aetiology
HLAB27ispresentinover90%ofCaucasianswithanky-
losing spondylitis. Environmental factors are implicated Figure 8.2 Question mark spine in ankylosing spondylitis.