Total hip and total knee arthroplasty in juvenile rheumatoid arthritis

Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is indicated for patients with juvenile rheumatoid arthritis (JRA) when marked joint destruction is present and pain or deformity compromises function despite optimal medical therapy. Relief of pain, reduction of the deformity, and dramatic improvement in functional status and quality of life can be achieved in most patients. Functional impairment and deformity rather than pain are usually the primary indications for THA or TKA. When there is both hip and knee involvement, hip arthroplasty should probably be done first. Regional anesthetic appears to be the anesthetic of choice. Careful preoperative planning and the availability of custom and minisized components are essential. Small bone size, osteoporosis, and severe soft tissue disease make the surgery technically demanding. Skeletal immaturity may not contraindicate surgery if the patient is otherwise bedridden with progressive deformity. In the hip trochanteric osteotomy is often necessary for adequate exposure, with the possible exception being a patient with juvenile ankylosing spondylitis who is subject to heterotopic bone formation. Although complete capsulectomy and psoas tenotomy may be necessary to relieve a hip flexion contracture, a soft tissue release that produces leg lengthening may lead to nerve palsy. In the hip component loosening has been less common in patients with JRA than in other young patients who have undergone THA, but it is still the most frequent cause of failure. In the knee preoperative and postoperative serial casts can aid in the correction of severe flexion contracture. Secondary patellar pain has been the most common cause of late failure. Patellar resurfacing should probably be performed at the time of the original knee arthroplasty in all patients with JRA.     

Total knee arthroplasty in juvenile rheumatoid arthritis

BACKGROUND: There is a paucity of reports regarding the long-term results of total knee arthroplasty in patients with juvenile rheumatoid arthritis. The purpose of this study was to evaluate the outcome of total knee arthroplasty in patients with juvenile rheumatoid arthritis who had been followed for a minimum of twelve years. METHODS: Eight consecutive patients (fifteen knees) with juvenile rheumatoid arthritis underwent total knee arthroplasty at an average age of 16.8 years. Clinical evaluation of pain status, range of motion, and the ability to walk and radiographic evaluation of the alignment of the knees and component loosening were performed preoperatively and at a mean of 15.5 years postoperatively. RESULTS: All patients had substantial pain and functional limitation before the surgery, and seven of the eight patients used a wheelchair. At the time of the latest follow-up, which was after revision surgery in three patients, all of the knees were pain-free and six patients were able to walk about the community. The mean arc of motion had increased from 36 degrees to 79 degrees . The final radiographic evaluation showed that thirteen of the fifteen knees were in neutral alignment and two were in valgus. Failure, defined as revision of any of the components or definite loosening as seen radiographically, occurred in three knees. CONCLUSIONS: Good results, in terms of pain relief and restoration of function, were seen at a minimum of twelve years following total knee arthroplasty in our series of patients with juvenile rheumatoid arthritis. This procedure is a reasonable option when nonoperative therapy has been inadequate for patients with severe disability and pain in this relatively young population.     

Total knee arthroplasty in young patients with juvenile rheumatoid arthritis

BACKGROUND: Juvenile rheumatoid arthritis is a disabling and destructive condition that commonly affects the knee during childhood. Total knee arthroplasty occasionally may be necessary for the treatment of end-stage disabling arthritis of the knee in young patients. There is a paucity of available data on the results of total knee arthroplasty in adolescents. We report our experience with total knee arthroplasty in patients under the age of twenty years who had juvenile rheumatoid arthritis. MATERIALS AND METHODS: We reviewed the results of twenty-five consecutive total knee arthroplasties that had been performed at our institution between 1982 to 1997 in thirteen patients (mean age, seventeen years) with juvenile rheumatoid arthritis. The average duration of clinical follow-up was 10.7 years, and the average duration of radiographic follow-up was 6.5 years. RESULTS: The mean Knee Society pain score improved markedly from 27.6 to 88.3 points, and the mean Knee Society function score improved modestly from 14.8 to 39.2 points. There was a slight improvement in the range of motion. Symptomatic and progressive radiolucent lines were noted in two knees, one of which was revised. Two knees (one patient) required exchange of the polyethylene liner at thirteen years. There were four additional reoperations, including manipulation under general anesthesia (two knees in one patient), lysis of adhesions (one knee), and extensor mechanism realignment (one knee). CONCLUSIONS: Despite a substantial number of postoperative complications, total knee arthroplasty provided excellent relief of pain and improvement in function in this group of adolescent patients with juvenile rheumatoid arthritis.     

Total knee arthroplasty in rheumatoid arthritis

The course of rheumatoid arthritis varies from mild disease to severe joint destructive variant that progresses rapidly, eventually leading to unremitting pain and joint deformity. In advanced disease, total knee arthroplasty has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients. However, as rheumatoid arthritis patients carry additional potential for late complications, many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients.     

Total hip arthroplasty in juvenile rheumatoid arthritis. Two to eleven-year results

From 1971 to 1980, forty-five patients with juvenile rheumatoid arthritis had eighty-three cemented total hip replacements at The Hospital for Special Surgery and North Carolina Memorial Hospital. Thirty-four of these patients, with sixty-two involved hips, returned for examination and radiographs. The average age of these thirty-four patients at the time of surgery was twenty-six years, and twenty-seven of them, with forty-nine involved hips, were thirty years old or less. The average length of follow-up was six years (range, two to eleven years), with forty-one hips having been followed for five to eleven years. According to The Hospital for Special Surgery hip-rating system, thirty hips were rated excellent; nineteen, good; nine, fair; and four, poor. Of the four hips with a poor result, two (in the same patient) had severe heterotopic ossification with ankylosis postoperatively, and two had required revision: one for acetabular loosening six years after replacement and the other for a broken stem of the femoral component ten years postoperatively. Radiographic review of the sixty-two hips demonstrated progressive radiolucencies or migration of 26 per cent of the acetabular components and 8 per cent of the femoral components. The frequency of acetabular migration or progressive radiolucencies was related to the postoperative position of the component relative to the position of the true acetabulum. These results were somewhat better than those in other reports on cemented total hip replacement in young patients. The difference is probably related to the lower average weight and decreased activity level of patients with juvenile rheumatoid arthritis.     

Total knee arthroplasty in juvenile rheumatoid arthritis. A seven-year follow-up study

Total knee arthroplasty (TKA) for preservation of ambulation is indicated in young adults with juvenile rheumatoid arthritis (JRA). The bony deformities of JRA require special measures to adequately seat the prosthesis. Thirteen patients with 25 knee arthroplasties were followed an average of 61 months. Prior surgical operations did not affect the outcome of this procedure. A 55% reduction in pain plus an average 30-point gain on Jergesen's functional assessment scale reflected the overall improvement attributable to TKA. To date, no revisions, infections, or loosenings have occurred in this series of patients.     

Total knee replacement in juvenile rheumatoid arthritis

In general, longer operative times and in some cases increased blood requirements can be expected with TKA in patients with juvenile rheumatoid arthritis. Complications also are more frequent. Pain relief is usually good to excellent, and function and deformity are significantly improved. Range of motion after TKA for juvenile rheumatoid arthritis is usually less than that obtained in osteoarthritis, but still allows for dramatic improvements in performing activities of daily living (Figure 3).     

Results of bilateral combined hip and knee arthroplasty in very young patients with juvenile rheumatoid arthritis

Introduction We evaluated the long-term outcomes for combined, bilateral total knee and hip arthroplasty performed on a group of very young patients with juvenile rheumatoid arthritis. Materials and methods Six consecutive patients with a mean age of 14 years at the time of hip replacement and 16 years at knee replacement were analyzed. Five of the six patients were wheelchair dependent pre-operatively. All knee components had uncemented fixation, while the hip replacements were a mixed group of cemented and uncemented prostheses. Results Clinical and radiographic follow-up at a mean duration of 13.8 years for the hips and 17.3 years for the knees demonstrated four of the six patients were unlimited community ambulators, one a limited community ambulator and the remaining patient a household ambulator. Failure, defined as revision of any of the components or definite radiographic loosening, occurred in three knees (two patients) and five hips (three patients). Conclusions These good long-term functional results in a relatively very young population indicate that an early and aggressive approach to multiple joint disease is an appropriate option at a young age for patients with juvenile rheumatoid arthritis with severe disability and pain refractory to conservative management. Source: Surgery originally performed at the Shrine Hospital, Minneapolis, MN, USA.     

The Charnley total hip arthroplasty in juvenile rheumatoid arthritis patients

A follow up of 27 consecutive total hip arthroplasties in 16 patients with juvenile rheumatoid arthritis was performed. The mean age at surgery was 18 years, and the average follow-up period was 64 months. No serious early complications were recorded, but three deep infections developed from 6 to 18 months after the arthroplasty, all requiring revision. The clinical results were good at follow up, as 20 hips were free of pain and 7 had only slight pain. Most of the patients had improved their walking ability and the range of motion in the hip as well. A poor correlation was, however, shown between the clinical and the roentgenographical results, as there was one femoral implant that was definitely loose and four more hips that had components which were probably loose. The frequency of infections might have been reduced by using antibiotic prophylaxis during surgery in all the cases; the frequency of aseptic loosening might also have been reduced by improved cementing techniques. Because of high loosening rate without clinical symptoms, it is recommended to follow the patients roentgenographically to make revision surgery possible while the bone stock still is sufficient.     

人工膝关节表面置换治疗类风湿性关节炎屈膝畸形

目的探讨人工全膝关节置换术治疗类风湿性关节炎屈膝畸形的临床效果。方法选用后稳定型钴合金假体对21例类风湿性关节炎屈膝畸形患者进行人工全膝关节置换术,其中单侧膝关节置换5例,双侧膝关节置换16例,手术前后对患者的膝关节功能进行评分。结果随访1~5年,术前患者平均膝评分(22.84±6.06)分,平均功能评分(12.86±16.09)分;术后2周平均膝评分(70.16±2.71)分,平均功能评分(58.10±8.14)分;术后12周随访平均膝评分(86.14±3.12)分,平均功能评分(89.05±3.01)分。结论人工全膝关节置换术能显著纠正类风湿性关节炎屈膝畸形患者膝关节的畸形,解除疼痛,改善患膝的功能。     

Total knee arthroplasty in young adults who have rheumatoid arthritis

At the Mayo Clinic, between 1978 and 1982, forty-four total knee arthroplasties were performed with cement in twenty-six adults who had rheumatoid arthritis. The age at operation ranged from nineteen to thirty-nine years old. The twenty-six patients were followed for two to eight years (average, five years). At the time of final follow-up, thirty-nine knees were free of pain and five were mildly painful during weight-bearing. The Hospital for Special Surgery knee score improved from a mean of 52 points preoperatively to 84 points postoperatively. There were twenty-four excellent, fourteen good, six fair, and no poor results. Radiographic analysis revealed an incomplete radiolucent line that was more than one millimeter in width adjacent to five tibial and four femoral components in eight knees (18 per cent). The positions of the components had not changed. Postoperatively, there was one transient peroneal palsy and two knees required patellar resurfacing. No revisions were performed for loosening of a prosthesis. We concluded that use of a cemented total knee prosthesis in a patient who has rheumatoid arthritis and is less than forty years old provides a satisfactory result and that the component will not loosen after an average of five years.     

类风湿性关节炎全膝关节置换的临床疗效观察

目的:观察人工全膝关节置换术治疗严重类风湿性关节炎的临床疗效.方法:我院2003年3月-2005年12月对11例严重类风湿关节炎患者行人工全膝关节置换术,平均随访13个月,按美国特种外科医院膝关节评分系统(HSS)进行疗效评定.结果:所有患者没有一例行翻修手术,X线显示所有置换假体植入位置满意,没有假体松动、移位现象出现.11个膝关节的术后情况比较满意.HSS评分平均指数从术前的41分提高到术后的90分.结论:人工全膝关节置换术可作为类风湿性关节炎患者保存关节功能,改善疼痛的一种有价值的治疗方法.     

Total hip arthroplasty in rheumatoid arthritis. A long-term follow-up study

This study was undertaken to assess the clinical and radiographic results of total hip arthroplasty in rheumatoid arthritis patients with a minimum of 10 years of follow-up evaluation. Eighty-three hips in 51 of the original 104 patients were available for follow-up study an average of 12.1 years following surgery. The average age of the patients at the time of surgery was 39.9 years (range, 14-72 years). Fourteen hips were revised, 11 for mechanical loosening and 3 for late infection. The overall revision rate is 16.7%; the revision rate for mechanical loosening was 13.3%. According to Merle D'Aubigne-Postel hip rating scores in the 69 hips that did not require revision, 19 hips were excellent (28%), 37 were good (54%), 11 were fair (15%), and 2 were poor (3%). Therefore, 67 of 83 hips (80.7%) were satisfactory on follow-up study. Radiographic evidence of loosening in nonrevised hips was found in 11 acetabular and 2 femoral components.     

Total knee arthroplasty in patients with rheumatoid arthritis. An overview

Total knee arthroplasty in patients with rheumatoid arthritis presents several unique challenges. Patients with rheumatoid arthritis often have additional medical, anesthetic, and global musculoskeletal problems that are not present in the patient with osteoarthritis. In terms of the knee, these patients usually have osteopenia and may present with an array of bone and soft tissue deformities, each of which can impact the initial success and long term durability of a total knee replacement. Despite these potential difficulties, the early and long term results of total knee arthroplasty in patients with rheumatoid arthritis have proven to be excellent.     

Bipolar hip arthroplasty in rheumatoid arthritis

Bipolar hip arthroplasty with bone grafting was performed on 25 joints with rheumatoid arthritis from 1981 to 1985. The results and roentgenographical progress of the grafted bone were followed for a minimum of two years, the longest follow-up examination occurring six years after the operation. The clinical score was assessed by the hip rating score of the Japanese Orthopaedic Association, which assigns a maximum of 100 points. The preoperative clinical score ranged from 22 to 59 points (mean, 42.6). The postoperative score improved to a range of 65-92 points (mean, 72.8). Of 24 hips examined, 21 (87.5%) were painless. As measured serially from the roentgenograms made immediately after the operation, the overall distance of central migration in 24 hips was 0-8.5 mm (average, 2.7 mm). The overall distance of superior migration in 24 hips was 0-10 mm (average, 3.7 mm). A single massive bone graft using extracted femoral head was considered to be better than bone fragments as the procedure for acetabular reconstruction during bipolar hip arthroplasty in rheumatoid arthritis.     

Total hip arthroplasty in children with juvenile chronic arthritis: long-term results

From 1984 to 2002, 20 total hip arthroplasties in children with juvenile chronic arthritis were performed in the authors' department. All patients had polyarticular disease. Average age of patients was 15.8 (range 13-24) years. Early onset of the disease occurred at an average age of 7.3 (4-10) years. In six patients the physes were open at the time of surgery. All patients had complete loss of joint space and various combinations of subchondral sclerosis, flattening of the femoral head, and anterior inclination of the neck. All patients used crutches for walking and joint function was very restricted. All patients were operated on under general anesthesia. One of them was supported additionally with laryngeal mask because of cervical spine involvement. No intra- or postoperative complications occurred. Mobilization of the patients started immediately after surgery, followed by a special rehabilitation program. Follow-up examination was based on the Merle d'Aubigne et Postel scale as modified by Charnley. Patients were followed at 6 weeks and 3 months after surgery and thereafter every 6 months with clinical and radiologic examination. Average follow-up was 9.2 (2-20) years. All patients had no pain and full functional ability. Although total hip arthroplasty is technically difficult in this age, it should be performed in specialized centers because pain relief, decreased deformity, and improved quality of life can be achieved in most patients. The only disadvantage is wear of the prosthesis.