Wheelchair to Walking: Quadruple Arthroplasty of Hip and Knee Joints in a Patient with Severe Ankylosing Spondylitis.

INTRODUCTION

Ankylosing spondylitis (AS) is a chronic inflammatory disease that can lead to progressive joint ankylosis, most commonly affecting the spine and hips. Severe cases may result in functional autoarthrodesis of multiple lower extremity joints, significantly impairing mobility and quality of life. Although total hip and knee arthroplasty are well-described individually in AS, management of simultaneous multi-joint ankylosis in extreme flexion deformity is rarely reported.

CASE REPORT: We report the case of a 23-year-old male with advanced AS resulting in bilateral hip and knee autoarthrodesis fixed in severe flexion, rendering him wheelchair-bound for 3 years. He underwent four staged arthroplasty procedures over the course of 1 year, consisting of bilateral total hip arthroplasties followed by bilateral total knee arthroplasties, with approximately 8-week intervals between procedures. Significant intraoperative challenges included absent normal joint anatomy, extreme flexion deformities (hips 80-85° and knees 70-75°), and complex patient positioning. The hips were addressed through an anterolateral approach, and the knees through a medial parapatellar approach with adjunctive osteotomies and soft-tissue releases as needed. Postoperatively, the patient underwent intensive rehabilitation and subsequent manipulation under anesthesia to improve the range of motion. Functional outcome measures demonstrated substantial improvement, with hip disability and osteoarthritis outcome score increasing from 6.9 to 61.3, Harris Hip Score from 15 to 63, and knee injury and osteoarthritis outcome score from 9 to 41.

CONCLUSION

Staged total hip and knee arthroplasty in severe AS with autoarthrodesis can result in meaningful functional recovery. Careful pre-operative planning, staged reconstruction, and tailored rehabilitation are essential to optimize outcomes and minimize complications in these complex cases.