Cementless total hip arthroplasty for patients with rheumatoid arthritis: a more than 10-year follow-up

Background/purpose

In this study, cementless THA was performed for RA patients, and its clinical outcomes, as well as radiographic findings and implant survival rates, were examined more than 10 years after surgery in comparison with the outcomes of the same procedure performed for patients with hip osteoarthritis (OA) during the same period.

Method

We studied 28 cases of THA for RA clinically and radiologically at a minimum follow-up duration of 10 years. The patients consisted of 4 males and 22 females, with a mean age at the time of surgery of 53.1. The clinical and radiographic results were compared with an age-matched and sex-matched group of patients who had undergone THA for the diagnosis of primary or secondary OA.

Results

In the RA group, the mean Harris hip score was 48.3 before surgery, and improved to 76.8 at the time of the final survey. In the control group, the score also improved from 46.8 before to 86.5 after surgery, while revealing significant differences between the groups (p = 0.0002). In the RA group, 2 joints required revision THA on the acetabular side due to aseptic loosening, while such revision was not performed on the femoral side despite the presence of more than 2 mm of subsidence in 2 joints. The implant survival rate was 92.9 and 100 % in the RA and control groups, respectively, without significant differences (p = 0.493).

Conclusions

Although its clinical outcomes were significantly different from those for OA, a satisfactory implant survival rate was achieved, at 92.9 % in RA patients.

     

Posterior occipitocervical fusion in rheumatoid arthritis and other instabilities

Occipitocervical fixation remains a surgical challenge. A Y-plate in combination with transarticular screw fixation provides a simple and economically favorable solution to this problem. By integrating the transarticular screws into the Y-plate immediate postoperative reliable stabilization is achieved. Clinical results confirm the reliability and the low rate of pseudarthrosis with this surgical technique. Received for publication on April 16, 1999     

Occipitocervical fusion in patients with rheumatoid arthritis

Instability and deformity of the cervical spine caused by rheumatoid arthritis is a well known entity. Operative intervention is indicated for patients with progressive deformity and when pain is resistant to conservative treatment. In a series of 39 patients who underwent posterior occipitocervical fusion with a Y plate, 22 patients were observed clinically and radiographically at average 41.5 months after surgery. In 35 of the 39 patients the main indication for surgery was pain, and in 30 of the 39 patients additional neurologic deficit (radiculopathy or myelopathy) was present. Thirty-one of the 39 patients had atlantoaxial instability. The atlantoaxial instability was associated with cranial migration of the dens in 19 patients. According to the classification of Conaty and Mongan 77.3% patients had satisfactory results and 22.7% had unsatisfactory results. Of the 30 patients with neurologic deficit, nine patients had a significant improvement. No patient had a worse result after surgery. Solid fusion was seen in all 22 patients at followup. Seven patients experienced complications directly related to the surgical procedure. Posterior fixation combined with anterior decompression in the presence of spinal stenosis represents a useful and safe method to treat instability and deformity caused by rheumatoid arthritis. Early surgical procedures may reduce the complication rate.     

Lumbar fusion outcomes in patients with rheumatoid arthritis

Although outcomes after cervical fusion in rheumatoid arthritis (RA) patients are widely published, outcomes of lumbar fusion in RA patients has not been reported. Ninteen patients with RA, identified using ICD-9 and CPT codes, who underwent instrumented posterolateral lumbar fusion were matched for age, gender, smoking status, date, and level of surgery to a contemporaneous non-RA group. Medical records and radiographs were reviewed by the primary author who had no role in the treatment of these patients. The average age was 64 years in the RA group and 65 years in the non-RA group. The male to female ratio was 2:17 and 1:18, respectively. There were three smokers and two diabetics in each group. An average of 1.5 levels was fused in each group. Average follow-up was 24 and 27 months, respectively. In the RA group, 15 patients were taking DMARDs with 7 of those also taking oral steroids; 4 patients were taking NSAIDs only. There were seven complications (37%) in the RA group versus four (21%) in the non-RA group; wound infections in three patients (16%) in the RA group versus one (5%) in the non-RA group; and non-union in two patients (11%) in the RA group versus three (16%) in the non-RA group. Clinical outcomes were similar between the two groups with 74% of patients achieving good to excellent results in the RA group compared to 63% in the non-RA group (p = 0.692). Surgeons and their RA patients who undergo an instrumented lumbar fusion can expect a slightly higher complication rate than patients without RA which may be related to osteopenia and immunosuppression.     

Long-term results of the thrust plate prosthesis in patients with rheumatoid arthritis: a minimum 10-year follow-up

Background  

The thrust plate prosthesis (TPP) is a hip prosthesis with metaphyseal fixation to the femur. Because the bone quality is reduced in patients with rheumatoid arthritis, this kind of fixation may have a higher failure rate than conventional stemmed endoprostheses in these patients. The aim of this investigation was to analyze the long-term results obtained with the TPP in patients with rheumatoid arthritis.     

A radiologic parameter that could be applied in the development of sleep apnea in rheumatoid arthritis patients undergoing occipitocervical fusion

BackgroundThe prevalence of sleep apnea in rheumatoid arthritis (RA) patients with occipitocervical lesions was 79%. Occipitocervical fusion (OCF) could incur sleep apnea or worsen this condition. Recent studies reported that this complication is caused by stenosis of the oropharyngeal airway accompanying a decrease in the occipitoaxial angle (O–C2a). However, there are several limitations to the application of the O–C2a, which decreases its effectiveness. Therefore, we aimed to evaluate the association between a new radiologic parameter, the CVT/NSL angle (CVT: craniocervical inclination in the second and fourth vertebrae; NSL: Nasion-Sella line), and sleep apnea in RA patients accepting OCF.MethodsA total of 35 patients who underwent OCF due to upper cervical lesions secondary to RA and had sleep apnea before surgery were analyzed. Those who have a postoperative apnea–hypopnea index (AHI) < 15 and a ΔAHI ≥50% were considered “responders”; patients were otherwise considered “non-responders.” They were analyzed whether pre- and postoperative radiologic parameters and their differences in plain lateral radiographs were correlated to the parameter related to sleep apnea.ResultsThe included patients have a mean AHI of 21.9 (range, 10 to 52) before surgery. The mean postoperative CVT/NSLa, ΔCVT/NSLa, andΔO-C2a in complete responders were significantly greater compared with non-responders (p < 0.05). Both the changes in the CVT/NSLa and O–C2a were linearly correlated within patients. However, the R² value for the CVT/NSLa was greater compared with the O–C2a (0.403 vs. 0.203).ConclusionsThe usefulness of the new craniovertebral angle, CVT/NSLa, as an intraoperative indicator during OCF, is more valuable in comparison with the conventional method of measuring the O–C2a. Measuring the craniovertebral angle is extremely important in the planning of surgical treatment for the development of sleep apnea in rheumatoid arthritis patients undergoing occipitocervical fusion.     

Sleep apnea in rheumatoid arthritis patients with occipitocervical lesions: the prevalence and associated radiographic features

Since sleep apnea is a risk factor for high mortality of rheumatoid arthritis (RA) patients, this study examined the prevalence in RA patients with occipitocervical lesions, and the associated radiographic features. Twenty-nine RA patients requiring surgery for progressive myelopathy due to occipitocervical lesions (3 males, 26 females, average age 65 years) were preoperatively evaluated. Twenty-three (79%) had sleep apnea defined as apnea–hypopnea index >5 events per hour measured by a portable monitoring device, and all of them were classified as the obstructive type. Among gender, age, bone mass index (BMI), and radiographic parameters related to occipitocervical lesions: atlantodental interval (ADI), cervical angles (O/C1, C1/2, and C2/6), and cervical lengths (O–C2 and O–C6), the ADI and cervical lengths were shown to be significantly associated with the presence of sleep apnea by parametric statistical analysis. Since there were positive correlations between the ADI and cervical lengths by Pearson’s test, we performed a multivariate logistic regression analysis after adjustment for confounding factors and found that small ADI was the principle parameter associated with sleep apnea. We therefore conclude that the prevalence of sleep apnea is higher than that in a general RA population that was reported previously, and believe that occipitocervical lesions are an independent risk factor for this condition. Small ADI and short neck, secondary to the vertical translocation by RA, may cause obstructive sleep apnea, probably through mechanical or neurological collapse of the upper airway.     

Assessment of liver fibrosis by transient elastography in rheumatoid arthritis patients treated with methotrexate

ObjectiveThis study was designed to assess the degree of liver fibrosis with transient elastography and noninvasive biochemical methods in rheumatoid arthritis patients treated with methotrexate.MethodsWe reviewed the medical records of rheumatoid arthritis patients who were administered methotrexate for more than 3 years. Transient elastography was performed and serological markers of liver fibrosis were evaluated by prospectively and was compared with the result of healthy control group. A correlation of the cumulative dose of methotrexate with the elastography value (kPa) or the level of serological markers was assessed. Two subgroups of patients were compared; patients who received a cumulative dose of methotrexate of less than 4000 mg (group 1) and more than 4000 mg (group 2). A total of 177 consecutive rheumatoid arthritis patients were evaluated.ResultsThe mean cumulative dose of methotrexate was 3988 ± 1566 mg with doses ranging from 652.5 to 10,415 mg. The mean elastography value of all patients was 4.01 ± 0.77 kPa. The kilopascal values and levels of biochemical markers did not correlate with the cumulative dose of methotrexate, but did correlate with the AST to ALT ratio, AST to platelet ratio index, haptoglobin level. Mean kilopascal values were not statistically different for group 1 and group 2 patients. For rheumatoid arthritis patients treated with a high cumulative dose of methotrexate, significant liver fibrosis is rare and is not accurately detected in patients with liver enzyme abnormalities.ConclusionTaking into account the risk and benefit of a liver biopsy, transient elastography can be recommended as an additional diagnostic option.     

15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis

In 25 patients with rheumatoid arthritis, 36 cases of cemented Kinematic total knee arthroplasty were reviewed clinically and radiographically at 13 to 19 years after surgery. The mean age at the time of surgery was 51.6 +/- 8.9 years. According to the follow-up results evaluated with the Hospital for Special Surgery knee scoring system, 28 knees (77.7%) were classified as good or excellent. The mean flexion angle at follow-up evaluation was 99 degrees +/- 24 degrees (10 degrees -140 degrees ). At the tibial or femoral bone-cement interfaces, a radiolucent line was seen in 10 of 36 knees (27.8%) at follow-up evaluation. The survival rate of prostheses with revision as the endpoint was estimated to be 93.7% at 15 years. Kinematic total knee arthroplasty in rheumatoid arthritis patients provided a good long-term outcome.     

Shoulder rheumatoid arthritis associated with chondromatosis, treated by arthroscopy

We present a case of rheumatoid arthritis that affected the right shoulder and was associated with chondromatosis and multiple loose body formation. The arthritis was treated arthroscopically with satisfactory results after a follow-up period of 15 months. In our case, arthroscopic debridement and partial synovectomy not only relieved the pain but also improved the range of motion the night after surgery. The multiple loose bodies irritating the synovium and causing effusion, crepitus, and locking were also removed. One may need to change portals of the scope and suction cannula to remove loose bodies in different joint spaces. The subacromial space must be searched for loose bodies. Thorough cleaning, lavage, and synovectomy are important parts of this surgery. The continuous passive motion (CPM) machine in the immediate postoperative period was helpful.     

清热活血方药治疗类风湿关节炎1年后双手X线变化临床观察

目的：通过观察双手腕X线1年后所见,评估清热活血方药治疗类风湿关节炎（RA）的作用。方法：2007年7月至2009年3月将86例辨证属湿热瘀阻证的活动期RA患者随机分为中药组和中西药组,各43例。中药组使用清热活血方药治疗（药物组成：黄柏、赤芍、萆薢、丹参、莪术、青风藤、生黄芪、金银花、土茯苓、蜈蚣、蜂房、生薏苡仁）,每剂水煎400ml,每日分2次口服;中西药组在中药基础上加甲氨蝶呤治疗,疗程12个月。对中药组和中西药组其中各21例进行X线评估,中药组21例,女19例,平均年龄（43.0±11.3）岁,病程2（1,3）年;中西药组女18例,平均年龄（44.5±14.0）岁,病程3（1.7,5）年。于疗前和治疗12个月分别收集患者双手X线片,对读片者隐藏时间先后顺序和临床数据,以Sharp/vanderHeijde方法对X线片进行评分。结果：评分达到较高一致性,观察者内相关系数达0.95。中药组和中西药组1年时点放射学所见的双手骨侵蚀及关节间隙狭窄等改变与治疗前差异以及组间差异均无统计学意义（P〉0.05）。2组不同进展程度的病例数也相似（P=0.46）,无放射学进展者中药组7例,中西药组8例;放射学进展较明显者,中药组3例,中西药组1例。结论：中药组和中西药组RA患者的骨破坏进展程度相似,提示中药治疗RA中远期具有潜在的骨保护作用。     

Clinical evaluation of a cohort of patients with rheumatoid arthritis treated with anti-TNF-alpha in the community

OBJECTIVES: TNF-alpha inhibitors have been effective in randomized controlled studies for the treatment of RA. The purpose of this study was to evaluate the clinical, laboratory, and radiological responses in a cohort of unselected patients with RA treated with TNF-alpha inhibitors in the community. METHODS: Using the Swiss Clinical Quality Management in Rheumatoid Arthritis, a centralized system of data gathering for RA patients, we obtained the following information regarding patients treated with a TNF-alpha inhibitor in the Geneva Canton before 02/2003: demographics; clinical data (disease activity, functional status, treatments received and type of TNF-alpha inhibitor used); laboratory and radiographic data. RESULTS: A total of 66 patients (mean age = 60.5 years) with long-standing disease (mean duration = 12.5 years) were analyzed. Sixteen patients (24%) discontinued anti-TNF-alpha, half within the first 6 months of the study. Mean DAS score decreased from 4.8+ /- 0.4 to 3.8 +/- 0.4 (P < 0.01); HAQ scores (mean = 1.35) remained unchanged; pain, evaluated on a 10-point scale, decreased from 5.0 at baseline to 3.3 (P < 0.001). CRP values decreased steadily from 17.9 at baseline to 5.6 at 20 months or later. The progression of radiographic damage decelerated in 30 patients, accelerated in 12, and remained unchanged in one. CONCLUSIONS: The responses of this community-based group of patients with severe, long-standing RA to TNF-alpha inhibitors revealed a reassuring similarity to those of patients enrolled in controlled clinical trials.     

类风湿关节炎行关节置换术围手术期管理的研究进展

类风湿关节炎是最常见的炎性关节病,尽管目前类风湿关节炎缓解药物不断改进,药效却只能延缓关节功能障碍的进展。人工膝或髋关节置换术现已成为晚期类风湿关节炎患者的惟一选择,经手术治疗后患者的关节功能及畸形问题可得到不同程度改善。但类风湿关节炎的病程持续进展直接影响术后的远期效果,如何完善围手术期管理,将关节置换术与药物治疗有效结合逐渐成为临床工作者关注的重点。本文拟通过对行关节置换术类风湿关节炎患者的术前药物使用、术中手术技巧、假体选择、术后治疗、康复锻炼及并发症等国内外管理现状加以概括总结,为提高此类患者远期疗效及生活质量提供有益帮助。