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Ankylosing Spondylitis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyAnkylosing SpondylitisSCE Rheumatology

A 38-year-old man with radiographic axial spondyloarthritis has progressive bilateral hip pain and severe restriction of movement. His axial disease is controlled with secukinumab, but hip symptoms continue to cause substantial impairment of walking and activities of daily living despite physiotherapy and analgesia. Pelvic radiographs show advanced bilateral hip joint-space loss and structural damage. What is the most appropriate additional management?

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Correct answer: E — Refer to orthopaedics for consideration of total hip arthroplasty

The correct answer is E. Total hip arthroplasty should be considered when axial spondyloarthritis has caused radiographic hip damage with persistent pain or disability despite appropriate non-surgical treatment. Young age alone is not a reason to delay referral. Control of axial inflammation with secukinumab does not reverse established structural destruction of the hip, so escalation solely for this purpose is inappropriate. Intra-articular injections may occasionally provide temporary symptomatic relief but are not definitive treatment for advanced bilateral damage. Methotrexate is not an effective substitute for arthroplasty in structurally damaged hips and has no established efficacy for pure axial disease. Orthopaedic assessment should therefore occur while rheumatological treatment continues.

Reference: Ramiro S et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update, recommendation 14. Annals of the Rheumatic Diseases. 2023;82:19-34. https://www.nice.org.uk/guidance/ta304/chapter/2-Clinical-need-and-practice