A 46-year-old male (body weight 69 kg, ASA status II) was scheduled for right total hip arthroplasty (THA). He suffered from ankylosing spondylitis for 20 years. Physical examination indicated that the cervical and lumbar spine was rigid and the right hip joint was immobilized. The bamboo-like changes of spine were found in the spinal anterioposterior and lateral radiographs (Fig. ). X-ray and CT examination indicated degenerative osteoarthrosis of bilateral hip joints and sacroiliitis on the right side. The patient appeared potentially difficult to be intubated as the examination of airway revealed that the interincisor distance was 2 cm and a Mallampati class III. The preoperative visual analog scale (VAS) score of this patient was 4. This patient received ultrasound-guided lumbar SNRB plus T12 paravertebral and sacral plexus blocks, and 25 mL of 0.4% ropivacaine was used. Pinprick test was used to confirm the success of these blocks. The time of surgery was 1 hour and 26 minutes. He also did not complain any painful during surgery and in PACU. With the PCA, the postoperative VAS scores were 0 to 1. This patient discharged on the second day after surgery. No postoperative complication was reported with him.
Case 1: A 38-year-old male (weight 75 kg, ASA status III) was scheduled for right total hip arthroplasty (THA) due to severe bilateral rigid and sore hip joints. He had a history of ankylosing spondylitis for more than 18 years. Despite a long term usage of sulfasalazine and “painkiller”, the patient developed a rigid kyphotic and scoliotic deformity. An overall physical examination revealed rheumatoid arthritis involved most articles in the body resulting in limited movement and swelling of interphalangeal joints, metacarpophalangeal joints, elbow joints, shoulder joints, and ankle joints, with rigid bilateral hip and knee joints preventing any walk. The airway assessment revealed a Mallampati class III, interincisor distance of 3 cm, and rigid neck incapable of any movement. X-ray of his cervical, thoracic and lumbar vertebrae and pelvis revealed a loss of physiological curvature of the vertebral column, kyphosis, hyperplasia at the edge of the vertebrae, “bamboo” like bony bridge, blurred facet joints, and calcification of ligament, a fusion of both sacroiliac joints, rough articular face and narrowed articular cavity and hyperplasia of both hip joints (Fig. ). After administration, he received immunosuppressive therapy, with prednisone 20 mg per day, and methotrexate 10 mg once per week, and anti-TNF therapy with etanercept (TNF receptor fusion protein) 25 mg i.h. twice per week, and anticoagulation therapy with low-molecular-weight heparin 4000 U per day.