194
Major Joint Replacement Surgery for Rheumatoid Arthritis RAYMOND J. NEWMAN, B.Sc., D. Phil., F.R.C.S., F.R.C.S.Ed., F.R.S.H.
Orthopaedic Surgery, University of Leeds; and Honorary Consultant Orthopaedic James’s University Hospital, Leeds
Senior Lecturer in
Surgeon, St
INTRODUCTION
INDICATIONS FOR SURGERY indication for joint surgery is pain unrelieved by conservative therapy. Relative indications are joint instability, deformity and limited range of motion if these conditions are also causing
THE PRINCIPAL
NTIL APPROXIMATELY 25 years ago surgery regarded as having little to offer in the of rheumatoid arthritis. However, the development of prostheses made from biologically compatible materials and based upon mechanically sound designs has changed the scenario (Figure 1). Similarly, the introduction of safer anaesthesia and improved aseptic surgical techniques has transformed surgery to the current situation where it is considered a routine part of the available therapeutic armamentarium.
was management
Figure 1 : Femoral components of hip (left) arthroplasties showing stress fracture of the respectively.
and knee stem and
(right) condyle
sufficient disability.
CONTRA-INDICATIONS TO SURGERY OTHER THAN advanced cardio-pulmonary disease only absolute contra-indication to surgery is sepsis. A well as a clinical screen (see below) routine preoperative urine culture is recommended as many patients have asymptomatic urinary tract infections (especially in the female). Any septic focus should be adequately treated prior to the planned surgery. If there is a significant possibility of a post-operative urinary retention (usually male patients) appropriate surgery to the bladder neck should be performed prior to the planned joint -surgery. This is because postoperative catheterisation leads to an increased infection
th~
rate
(Beddow, 1988).
A relative contra-indication is anaemia and most patients with rheumatoid disease tend to have a chronic anaemia. A haemoglobin level as low as normocytic not unusual but a value below nine usually 9-10 requires a pre-operative blood transfusion.
g/dl is
Rheumatoid arthritis principally affects the musculoskeletal system but there are many extra-articular sites of involvement including the lung, the heart and vessels, the eye and haemato-poietic system. It is therefore not surprising that for optimal care of the rheumatoid patient close co-operation of the rheumatologist and orthopaedic surgeon may be required (Newman et al, 1987). The team is not complete without an anaesthetist, occupational therapist, physiotherapist and an orthotist and appropriate domiciliary support from the general practitioner is also essential. Rheumatic Disease by the Royal Society of Health, the General Infirmary at Leeds - 10th May 1990. Presented
to
the
Conference
on
SURGICAL PRIORITIES IN A polyarthritic disease such as rheumatoid arthritis it may on occasion be difficult to decide the order of priority when several joints simultaneously require surgery. In general it is customary to operate first on.1 the joint which is giving rise to the greatest degree of disability which is usually the most painful one. In most cases lower limb joint involvement produces more disabilities compared to upper limb joints and surgery is therefore more usually indicated first on the lower limb. In lower limb surgery hip joint arthroplasty is generally performed first unless the knee joints have severe deformities which may significantly interfere with rehabilitation following surgery or may predispose to hip dislocation. In such uncommon situations knee arthroplasty is performed first. When ipsilateral hip and knee surgery is indicated the hip should be replaced first followed by the knee though both can be performed during the same anaesthetic resulting in a greater amount of post-operative swelling. Similarly, synchronous bilateral hip
Correspondence : University Department of Orthopaedic Surgery, Clinical Sciences Building, St James’s University Hospital, Beckett Street, Leeds LS9 7rF. Tel: 0532 433144, Ext. 5222.
Downloaded from rsh.sagepub.com at UNIV OF MICHIGAN on July 3, 2015
195
replacement can be peformed without particular intraoperative difficulty although the risks of thromboembolism and cardio-pulmonary complication are higher. In the author’s opinion bilateral replacements of hips or knees should be performed in selected patients only.
Figure 2: Charnley total hip arthroplasty; metal alloy femoral component and high density polyethylene acetabular component.
PRE-OPERATIVE CONSIDERATIONS ANY SEPTIC focus should be identified with the most frequent sites being the teeth, urinary tract and skin. Risk of bone infection in a rheumatoid patient is at least two to three times greater than in an otherwise similar patient with osteoarthrosis (Poss et al, 1984). Steroid dependancy is also assessed and the stability of the cervical spine is checked with lateral radiographs of the neck taken both in flexion and extension. Difficulty in intubation for general anaesthesia should be anticipated and the alternatives considered, i.e. spinal anaesthesia for lower limb surgery and brachial plexus blockade for upper limb procedures. INTRA-OPERATIVE PRECAUTIONS PATIENTS WITH rheumatoid arthritis requiring surgery are usually osteoporotic due to a combmation of factors including the disease itself, steroids, disuse and postmenopausal reasons. Iatrogenic fracture may be caused during surgery and care needs to be taken to obviate this (Barrington et al, 1984). Similarly the disease itself and the administration of steroids render the skin fragile. Lacerations and degloving injuries can occur during the pre-operative exsanguination of a limb using a heavy rubber (Esmark) bandage and simple elevation is recommended or the use of a soft latex (Martin) bandage.
POST-OPERATIVE CONSIDERATIONS OPERATED JOINTS are generally rested in a splint for a day or two following surgery. During this time it is important that the non-operated joints should be mobilised to prevent the development of stiffness or contractures.
Thrombo-embolism frequently occurs after lower limb joint surgery and this will be discussed below. SURGERY OF SPECIFIC JOINTS
theoretically amenable to some form of surgery but this review will include only the hip, knee, shoulder and elbow. Most surgical time is spent on the hip and therefore this section will be appropriately ALL JOINTS are
expanded. SURGERY OF THE HIP INVOLVEMENT OF hip by rheumatoid arthritis is frequent and reports vary between 10% and 40% (Duthie and Harris, 1969) with the interval between onset of the disease and surgery being more than 10 years (Reece and Bedow, 1988). Once the hip becomes clinically involved with pain and limitation of motion it deteriorates rapidly. The resulting disability is more severe as compared with the knee and surgery is usually indicated earlier rather than later. It is generally accepted that there is hardly any role for synovectomy, soft tissue releases and osteotomy or unipolar, bipolar and double cup arthroplasties as these operations have not proved to be durable. The place for non-cemented total hip replacement is not yet proven in this condition and the cemented total hip arthroplasty is taken to be the gold standard for most patients with rheumatoid arthritis (Figure 2).
There are several reports documenting good to excellent results in patients with rheumatoid arthritis. Pain relief obtained by cemented total arthroplasty is achieved in approximately 95% of patients (Welch and Chamley, 1970) with complete pain relief in 85%. An increased range of motion is found almost universally and may be as much as 100°. The combination of pain relief and increased range of motion leads to increased mobility and independence. A recent review by Ranawat (1989) in patients with total hip arthroplasty for rheumatoid arthritis with an average follow-up of 12 years showed that more than 80% of patients have satisfactory results. The revision rate due to mechanical failure and infection was 17% and the revision rate for mechanical loosening alone was 13%. The latter principally affected the acetabular rather than the femoral component. The complications of total hip arthroplasty are very similar to those of other major joint arthroplasties and will be discussed for ease in this particular section. Ling (1984) reviewed 13 publications involving 15,000 hip replacements (for all diagnoses) and found an overall mortality rate of 1.07% in the first month. There is no evidence to suggest that rheumatoid arthritis carries a higher risk of peri-operative mor-
tality.
z
Deep infection of a hip prosthesis is two to four times
more common in rheumatoid arthritis than in osteo,arthrosis (Van Niekerk and Charnley, 1977; Poss et al, 1984) and it is late infection by haemotogenous spread from distant sites which accounts for the higher incidence (Ainscow and Denham, 1984). Similarly steroid therapy increases the susceptibility to infection
~(Nixon,
1988).
In addition to screening all patients for sepsis other modalities used to minimise the risk of infection include confining all procedures to a special clean air enclosure exhaust for the surgeon, the use of with bacteriologically impermeable operating gowns by the surgeons and drapes for the patient, the intraoperative use of prophylactic antibiotics (the author’s current regime is 1.5 grams of Cefuroxime with induction of the anaesthetic and 750 mg tds for two days). Antibiotic loaded cement (usually gentamicin) may also be used. Hip arthroplasty carries a high risk of thromboreview of published series found an embolism overall instance of deep vem thrombosis of approximately 50%, pulmonary embolism in approximately
personal body
and a
Downloaded from rsh.sagepub.com at UNIV OF MICHIGAN on July 3, 2015
196
1984) and fatal pulmonary embolism in 6%1%-2% (Sikovski, (Hull and Raskob, 1986). Rheumatoid arthritis
carries a lower risk of thrombo-embolic disease than osteoarthrosis (Welch and Chamley, 1970). The prophylactic use of anti-coagulants such as heparin, warfarin and dextran remains controversial and the effects of this treatment must be balanced against the increased risk of haemorrhage, haematoma and subsequent wound infection. Hydroxychloroquine may have a beneficial effect on the incidence of fatal pulmonary embolism without significant haematological side effects (Wroblewski, 1989) and in addition to using this pre- and post-operatively the author uses anti-embolism stockmgs and early mobilisation to prevent thrombo-embolic disease. D,islocation following total hip arthroplasty occurs in 3% of cases (Coventry et al, 1974) with the up principal risk being in the first four to six weeks following surgery. Loosening can occur due to sepsis or because of mechanical reasons and the latter is a greater potential problem in the younger patients. Wound healing is impaired in rheumatoid arthritis can be minimised by the use of straight but problems incisions, the avoidance of undermining and meticulous skin closure. Total hip replacement is one of the most satisfactory operations used in the treatment of rheumatoid arthritis and patient satisfaction may be as high as 96% seven years following surgery (Poss et al,
hip above.
There are relatively few reports in the literature on the results of total knee arthroplasty solely in patients with rheumatoid arthritis but is clear that a deformity can be overcome, the range of active flexion increased and significant pain relief given (Abernethy, 1989). However the pain relief score deteriorates with time and the incidence of radiolucent lines which may indicate loosening also increases.
fixed flexion
Figure 3: Fully constrained, (hinged) all metal, total knee arthroplasty (left) and contemporary, unconstrained, two part, metal on polyethylene total knee arthroplasty (right).
to
1984).
SURGERY OF THE KNEE BECAUSE SYNOVITIS is the earliest pathological lesion it is not unreasonable to suppose that synovectomy might eradicate the disease. This operation was the end of the 19th century but the expectations of the procedure have not been fulfilled. This is probably the joint cannot be totally synovectomised surgically with 85% clearance being the practical goal. Similarly it has been shown that synovium can regenerate and with the passage of time the regenerated tissue becomes almost indistinguishable from that seen in acute rheumatoid arthritis. There have been several retrospective series and the results of surgical synovectomy are clearly time dependant. Though in continental Europe synovectomy is still in vogue, within the United Kingdom and the USA the operation plays a much less important part in the management of rheumatoid patients. It is reserved for the younger patient with a radiologically well preserved knee joint, hypertrophic synovitis and persistent pain and swelling unrelieved by medical treatment. Chemical and radio-isotope synovectomy have also been attempted with mixed results. Total knee arthroplasty is the operation of choice for with advanced disease but sadly the operation patients has a poor reputation since most patient’s and surgeon’s minds are coloured by the results of arthroplasty using the restrained prostheses of the last two decades (Figure 3). On purely biomechanical principles which have subsequently been described these implants were doomed to failure and the recent introduciton of unconstrained prostheses has revolutionised the results of knee arthroplasty with recent results of this operation shoving a similar result to that seen following hip
introduced at
because
(hinged)
arthroplasty (Ritter et al, 1989). The operation can be complicated by extensive bone loss principally affecting the tibial condyles which may require bone grafting procedures. Otherwise the complications are broadly similar to those outlined for the
SURGERY OF THE SHOULDER THE SHOULDER is composed of at least five functionally inter-related sub-units all of which can be affected
synchronously or metachronously to varying degrees by rheumatoid arthritis. These
are
the sterno-clavicular
joint, the acromio-clavicular joint, the sub-acromial region and bursa, the gleno-humeral joint and the scapulo-thoracic functional joint. It is mandatory that prior to treatment being suggested the exact site of pain i.e.
whether it be extrinsic
or
intrinsic to the
truel
gleno-humeral joint should be accurately localised. It its classically taught that an accurate history and physical examination will allow symptoms arising from these
different functional units to be differentiated but this is, not true in patients with advanced disease. The diagnostic technique of choice is selective injection of local anaesthetic and this has been well described (Newman, 1989a). This author has experienced several cases that may have been diagnosed as gleno-humeral arthritis on the basis of clinical and radiological examination but have been found on sensory testing to have no more than acromio-clavicular arthritis or sub-acromial involvement as the principal sites of pain. A subsequent course of steroid injections to these regions together with physiotherapy is effective and localised surgery can be offered for any failures. In most series over 70% of patients demonstrate involvement of the acromio-clavicular joint by rheumatoid arthritis with isolated disease only occurring in a
Downloaded from rsh.sagepub.com at UNIV OF MICHIGAN on July 3, 2015
197
minority (Newman, 1989b). Most cases respond to intra-articular steroid injections and failures can be dealt with by excision of the outer end of the clavicle. Similarly, sub-acromial impingement syndrome can be treated by injection treatment with decompression by anterior acromioplasty being left for the failures.
Gleno-humeral involement, i.e. the ’true’ shoulder is commonly affected by rheumatoid arthritis with severe functional impairment. The place for synovectomy as an isolated procedure is debateable and though it may be indicated in the young patient or in the uncommon instance of marked synovial hypertrophy with minimal articular involement it generally has no application. Arthrodesis (fusion) has been peformed in the past but it is an unsatisfactory option when other upper limb joints may be affected at the same time or in the future. Total shoulder arthroplasty is the procedure of choice (Figure 4) and in the most recent review solely dedicated to a cohort of 42 patients with rheumatoid arthritis, Kelly et al, found
joint,
(1997)
Figure
4: Neer total shoulder
arthroplasty;
metal
alloy
humeral
component and high density polyethylene glenoid component, both with polymethyl methacralate cement mantles.
almost 90% to have no significant pain. Flexion and extension were both improved by approximately 30° and internal and external rotation improved by a similar amount. Though all patients experienced an improvement in their functional abilities leading to greater personal independence none could use their hand above shoulder level. Shoulder arthroplasty should be considered as an operation which gives pain relief rather than increases the range of motion. This is because the rotator cuff is invariably involved with the rheumatoid process and is often almost functionless. (This is unlike the situation of primary osteoarthrosis or trauma when the rotator cuff is functional and the post-operative range of motion so much better). However, rotator cuff deficiency should not be considered a contra-indication to arthroplasty since pain relief is brought about by the procedure and this facilitates scapulo-thoracic rotation. Glenoid bone erosion occurs in gleno-humeral rheumatoid arthritis and may be marked prejudicing the fixation of the glenoid component. An alternative approach is to manage these shoulders without using a glenoid component i.e. hemi-arthroplasty only. Few publications have compared the results of total with hemi-arthroplasty in a controlled manner but it is probable that the total joint replacement fares superior to
hemi-arthroplasty (Marmar, 1977; Gschwend, 1988).
SURGERY OF THE ELBOW INVOLVEMENT OF the elbow with rheumatoid arthritis is much more frequent than is often realised with approximately 50% of patients with long standing rheumatoid disease showing evidence (Souter, 1989). The pathology varies from rheumatoid nodules or olecranon bursae through synovitis to bone destruction. Two procedures are available for this joint; synovectomy and total joint arthroplasty. Synovectomy is often performed in conjunction with excision of the radial head and the first report of this operation was by Lane and Vanio in 1969. The operation is reliable with regard to initial pain relief but the results with regard to movement are variable though gains in flexion and extension have been reported by some to be up to 55% (Stein et al, 1975). The complication rate is low and the risks of sustaining a significant loss of movement no more than 10%. The operation does not appear to arrest radiological deterioration and the recurrence of synovitis is not uncommon. For example Summers et al (1987) found in a review of 50 patients that although 84% were clear of pain at six months only 54% were within this category at five years. Furthermore, recurrent synovitis occurred in almost 40% of patients. This is also the opinion of Souter (1989). In the light of these observations it is probably prudent to regard synovectomy not as a definite solution to the rheumatoid elbow but rather than a delaying procedure before more radical surgery is required. It should be reserved solely for those elbows in the earlier grades of severity unresponsive to conservative treatment. The surgical management of the elbow with advanced disease is by arthoplasty and the design of prostheses has changed dramatically over the course of the last two decades (this is very similar to what has happened with knee arthroplasty described above). From fully constrained implants with long stemmed fixation designs have changed to unconstrained prostheses. Several patterns are currently available but a recent 10 year review of the Souter-Strathclyde prosthesis has shown that whereas pre-operatively 85% of the patients experienced severe elbow pain, 92% had no pain or only occasional twinges of discomfort one year after surgery and this gratifying result was maintained at five years later. Pronation and supination are improved by this procedure, flexion is usually increased but fixed flexion deformity is almost irremovable (Souter, 1989). The complications specific to elbow arthroplasty are ulnar neuronathy which occurs in at least 15% and dislocation 1989) which is usually associated with medial collateral ligament insufficiency.
(stouter,
SUMMARY AND CONCLUSION THE RESULTS of total joint arthroplasty
are exciting but certainly they are not yet good enough to warrant complacency. Further advances in design and materials are required. It is also clear that there is a positive relationship between the technical expertise with which the surgery is performed and the long term functional results (especially with regard to the knee). Nonethe-
less, the benefits that this type of surgery can confer on the severely afflicted rheumatoid patient with regard to relief and function pain little hesitation in
are
such that there should be
offering this form of treatment to all
patients
who fail conservative treatment. However, it
Downloaded from rsh.sagepub.com at UNIV OF MICHIGAN on July 3, 2015
198
has always to be remembered that the results of even the most sophisticated surgery can be improved by an intensive rehabilitation programme including pre- and post-operative occupational therapy and physiotherapy, the prescription of appropriate appliances and the optimisation of medical therapy. REFERENCES ..
- ...
ABERNETHY F. J.
-.....’11. -.
Surgery
-
..
W’.
__
- ,..,
for rheumatoid artnntis; 2. Lower Limb (ii)
, 150-156, 1989. surgery of knee. Curr. Orthop., 3 AINSCOW D. A. P. AND DENHAM R. A. The risk of haematogenous infection in total joint replacements. J. Bone Joint Surg., 66B , 580-582, 1984. BARRINGTON T. W., JOHANSSON J. E. and MC BROOM R. Fractures of the femur complicating total hip replacement. In: Complications of Total Hip Replacement ed R. S. M. Ling, Churchill Livingstone, Edinburgh, 1984. BEDDOW F. H. Surgical management of rheumatoid arthritis. Butterworth Y. Co. London, 1988. COVENTRY M. B., BECKENBAUGH R. D., NOLAN D. R. et al. 2012 total hip arthroplasties: a study of post-operative course and early complications. J. Bone Joint Surg., 56A, 273-284, 1974. DUTHIE R. B. and HARRIS C. M. A radiographic and clinical survey of the hip joint in seropositive rheumatoid arthritis. Acta Orthop. Scand., 40, 346-364, 1969. GSCHWEND N. Is glenoid component necessary for rheumatoid patients? Proc. 2nd Cong. Europ. Shoulder Elbow Soc., Berne, Switzerland, 1988. HULL R. D. and RASKOB G. E. Prophylaxis of venous thrombo-embolic disease following hip and knee surgery. J Bone Joint Surg., 68A, 146-150, 1986. KELLY I. G., FOSTER R. S., FISHER W. D. Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint. Surg., 69B, 723-726, 1987. LAINE V. and VAINIO K. Elbow in rheumatoid arthritis. In, Early Synovectomy in rheumatoid arthritis ed, Hijams W., Paul W. D. and Herschel H, Excerpta Medica Foundation, Amsterdam, p. 112-116,1969. LING R. S. M. Systemic and miscellaneous complications. In, Complications of Total Hip Replacement ed, Ling, R. S. M., Churchill Livingstone, Edinburgh, 1984. MARMOR L. Hemi-arthroplasty for the rheumatoid shoulder joint. Clin.
Orthop., 122,201-203,1977.
NEWMAN R. J. Chronic shoulder
J., 299, 530,1989a.
tables were inadvertently omitted from the paper on Child Feeding by Nigerian Mothers during Acute Diarrhoeal Illness by E. E. Ekanem and C. O. Akitoye which appeared on pp164 of the October issue.
THE FOLLOWING
pain in rheumatoid arthritis.
*n
=
the number of responses for each food item.
(per cent in
parenthesis).
Brit. Med.
NEWMAN R. J. Surgery for rheumatoid arthritis: 1. upper limb. Surgery of the shoulder. Curr. Orthop., 3, 4-8, 1989b. NEWMAN R. J., BELCH J., KELLY I. G. and STURROCK R. D. Are combined orthopaedic and rheumatology clinics worth while? Brit. Med. J., 294, 1392-1393, 1987. NIXON J. E. Failure patterns after total hip relacement. Brit. Med. J., 286,
*n
=
the number of responses for each food item.
(per cent in
parenthesis).
166-170,1983.
POSS R., MALONEY J. P., EWALD F. C., et al. Six to eleven year results of total hip arthroplasty in rheumatoid arthritis. Clin. Orthop 182, 109-116, 1984. RANAWAT C. S. Surgery for rheumatoid arthritis: 2. lower limb. Surgery of the hip, Curr. Orthop., 3 , 146-149, 1989. REES D. and BEDDOW F. H. Surgical management of the rheumatoid hip. In, Surgical Management of Rheumatoid Arthritis, Butterworth & Co, London, 1988. RITTER M. A., KEATING E. M. and PARIS P. M. Design features and clinical results of the anatomic graduated components (AGC) total knee
, 641-647, 1989. replacement. Contemporary Orthop, 19
SIKOVSKI J. M. Thrombo-embolic complications. In, Complications of Total Hip Replacement ed, Ling R. S. M., Churchill 1984. SOUTER W. A. Surgery for rheumatoid arthritis: 1. upper limb. Surgery of the elbow. Curr. Orthop., 3, 9-13, 1989. STEIN H., DICKSON R. A. and BENTLEY G. Rheumatoid arthritis of the elbow. Pattern of joint involvement, and results of synovectomy with excision of the radial head. Ann. Rheum. Dis., 34, 403-408,1975. SUMMERS G. D., WEBLEY W. and TAYLOR A. R. Synovectomy and excision of the radial head in rheumatoid arthritis: a short term palliative Clin. Expt. Rheumatol, 5, Suppl 2, 115 (Abst.),1987. procedure. VAN NIEKERK G. A. and CHARNLEY J. Post-operative infection after Charnley low friction arthroplasty of the hip. Internal Publication No. 68, Centre for Hip Surgery, Wrightington Hospital, 1977. WELCH R. B. and CHARNLEY J. Low friction arthroplasty of the hip in rheumatoid arthritis and ankylosing spondylitis. Clin. Orthop., 72, 22-32, 1970. WROBLEWSKI, personal communication, 1989.
Edinburgh,
Livingstone,
~
*n
~
~~
-------
the number of responses for each food item. (per cent in =
parenthesis).
Downloaded from rsh.sagepub.com at UNIV OF MICHIGAN on July 3, 2015
Major Joint Replacement Surgery for Rheumatoid Arthritis RAYMOND J. NEWMAN, B.Sc., D. Phil., F.R.C.S., F.R.C.S.Ed., F.R.S.H.
Orthopaedic Surgery, University of Leeds; and Honorary Consultant Orthopaedic James’s University Hospital, Leeds
Senior Lecturer in
Surgeon, St
INTRODUCTION
INDICATIONS FOR SURGERY indication for joint surgery is pain unrelieved by conservative therapy. Relative indications are joint instability, deformity and limited range of motion if these conditions are also causing
THE PRINCIPAL
NTIL APPROXIMATELY 25 years ago surgery regarded as having little to offer in the of rheumatoid arthritis. However, the development of prostheses made from biologically compatible materials and based upon mechanically sound designs has changed the scenario (Figure 1). Similarly, the introduction of safer anaesthesia and improved aseptic surgical techniques has transformed surgery to the current situation where it is considered a routine part of the available therapeutic armamentarium.
was management
Figure 1 : Femoral components of hip (left) arthroplasties showing stress fracture of the respectively.
and knee stem and
(right) condyle
sufficient disability.
CONTRA-INDICATIONS TO SURGERY OTHER THAN advanced cardio-pulmonary disease only absolute contra-indication to surgery is sepsis. A well as a clinical screen (see below) routine preoperative urine culture is recommended as many patients have asymptomatic urinary tract infections (especially in the female). Any septic focus should be adequately treated prior to the planned surgery. If there is a significant possibility of a post-operative urinary retention (usually male patients) appropriate surgery to the bladder neck should be performed prior to the planned joint -surgery. This is because postoperative catheterisation leads to an increased infection
th~
rate
(Beddow, 1988).
A relative contra-indication is anaemia and most patients with rheumatoid disease tend to have a chronic anaemia. A haemoglobin level as low as normocytic not unusual but a value below nine usually 9-10 requires a pre-operative blood transfusion.
g/dl is
Rheumatoid arthritis principally affects the musculoskeletal system but there are many extra-articular sites of involvement including the lung, the heart and vessels, the eye and haemato-poietic system. It is therefore not surprising that for optimal care of the rheumatoid patient close co-operation of the rheumatologist and orthopaedic surgeon may be required (Newman et al, 1987). The team is not complete without an anaesthetist, occupational therapist, physiotherapist and an orthotist and appropriate domiciliary support from the general practitioner is also essential. Rheumatic Disease by the Royal Society of Health, the General Infirmary at Leeds - 10th May 1990. Presented
to
the
Conference
on
SURGICAL PRIORITIES IN A polyarthritic disease such as rheumatoid arthritis it may on occasion be difficult to decide the order of priority when several joints simultaneously require surgery. In general it is customary to operate first on.1 the joint which is giving rise to the greatest degree of disability which is usually the most painful one. In most cases lower limb joint involvement produces more disabilities compared to upper limb joints and surgery is therefore more usually indicated first on the lower limb. In lower limb surgery hip joint arthroplasty is generally performed first unless the knee joints have severe deformities which may significantly interfere with rehabilitation following surgery or may predispose to hip dislocation. In such uncommon situations knee arthroplasty is performed first. When ipsilateral hip and knee surgery is indicated the hip should be replaced first followed by the knee though both can be performed during the same anaesthetic resulting in a greater amount of post-operative swelling. Similarly, synchronous bilateral hip
Correspondence : University Department of Orthopaedic Surgery, Clinical Sciences Building, St James’s University Hospital, Beckett Street, Leeds LS9 7rF. Tel: 0532 433144, Ext. 5222.
Downloaded from rsh.sagepub.com at UNIV OF MICHIGAN on July 3, 2015
195
replacement can be peformed without particular intraoperative difficulty although the risks of thromboembolism and cardio-pulmonary complication are higher. In the author’s opinion bilateral replacements of hips or knees should be performed in selected patients only.
Figure 2: Charnley total hip arthroplasty; metal alloy femoral component and high density polyethylene acetabular component.
PRE-OPERATIVE CONSIDERATIONS ANY SEPTIC focus should be identified with the most frequent sites being the teeth, urinary tract and skin. Risk of bone infection in a rheumatoid patient is at least two to three times greater than in an otherwise similar patient with osteoarthrosis (Poss et al, 1984). Steroid dependancy is also assessed and the stability of the cervical spine is checked with lateral radiographs of the neck taken both in flexion and extension. Difficulty in intubation for general anaesthesia should be anticipated and the alternatives considered, i.e. spinal anaesthesia for lower limb surgery and brachial plexus blockade for upper limb procedures. INTRA-OPERATIVE PRECAUTIONS PATIENTS WITH rheumatoid arthritis requiring surgery are usually osteoporotic due to a combmation of factors including the disease itself, steroids, disuse and postmenopausal reasons. Iatrogenic fracture may be caused during surgery and care needs to be taken to obviate this (Barrington et al, 1984). Similarly the disease itself and the administration of steroids render the skin fragile. Lacerations and degloving injuries can occur during the pre-operative exsanguination of a limb using a heavy rubber (Esmark) bandage and simple elevation is recommended or the use of a soft latex (Martin) bandage.
POST-OPERATIVE CONSIDERATIONS OPERATED JOINTS are generally rested in a splint for a day or two following surgery. During this time it is important that the non-operated joints should be mobilised to prevent the development of stiffness or contractures.
Thrombo-embolism frequently occurs after lower limb joint surgery and this will be discussed below. SURGERY OF SPECIFIC JOINTS
theoretically amenable to some form of surgery but this review will include only the hip, knee, shoulder and elbow. Most surgical time is spent on the hip and therefore this section will be appropriately ALL JOINTS are
expanded. SURGERY OF THE HIP INVOLVEMENT OF hip by rheumatoid arthritis is frequent and reports vary between 10% and 40% (Duthie and Harris, 1969) with the interval between onset of the disease and surgery being more than 10 years (Reece and Bedow, 1988). Once the hip becomes clinically involved with pain and limitation of motion it deteriorates rapidly. The resulting disability is more severe as compared with the knee and surgery is usually indicated earlier rather than later. It is generally accepted that there is hardly any role for synovectomy, soft tissue releases and osteotomy or unipolar, bipolar and double cup arthroplasties as these operations have not proved to be durable. The place for non-cemented total hip replacement is not yet proven in this condition and the cemented total hip arthroplasty is taken to be the gold standard for most patients with rheumatoid arthritis (Figure 2).
There are several reports documenting good to excellent results in patients with rheumatoid arthritis. Pain relief obtained by cemented total arthroplasty is achieved in approximately 95% of patients (Welch and Chamley, 1970) with complete pain relief in 85%. An increased range of motion is found almost universally and may be as much as 100°. The combination of pain relief and increased range of motion leads to increased mobility and independence. A recent review by Ranawat (1989) in patients with total hip arthroplasty for rheumatoid arthritis with an average follow-up of 12 years showed that more than 80% of patients have satisfactory results. The revision rate due to mechanical failure and infection was 17% and the revision rate for mechanical loosening alone was 13%. The latter principally affected the acetabular rather than the femoral component. The complications of total hip arthroplasty are very similar to those of other major joint arthroplasties and will be discussed for ease in this particular section. Ling (1984) reviewed 13 publications involving 15,000 hip replacements (for all diagnoses) and found an overall mortality rate of 1.07% in the first month. There is no evidence to suggest that rheumatoid arthritis carries a higher risk of peri-operative mor-
tality.
z
Deep infection of a hip prosthesis is two to four times
more common in rheumatoid arthritis than in osteo,arthrosis (Van Niekerk and Charnley, 1977; Poss et al, 1984) and it is late infection by haemotogenous spread from distant sites which accounts for the higher incidence (Ainscow and Denham, 1984). Similarly steroid therapy increases the susceptibility to infection
~(Nixon,
1988).
In addition to screening all patients for sepsis other modalities used to minimise the risk of infection include confining all procedures to a special clean air enclosure exhaust for the surgeon, the use of with bacteriologically impermeable operating gowns by the surgeons and drapes for the patient, the intraoperative use of prophylactic antibiotics (the author’s current regime is 1.5 grams of Cefuroxime with induction of the anaesthetic and 750 mg tds for two days). Antibiotic loaded cement (usually gentamicin) may also be used. Hip arthroplasty carries a high risk of thromboreview of published series found an embolism overall instance of deep vem thrombosis of approximately 50%, pulmonary embolism in approximately
personal body
and a
Downloaded from rsh.sagepub.com at UNIV OF MICHIGAN on July 3, 2015
196
1984) and fatal pulmonary embolism in 6%1%-2% (Sikovski, (Hull and Raskob, 1986). Rheumatoid arthritis
carries a lower risk of thrombo-embolic disease than osteoarthrosis (Welch and Chamley, 1970). The prophylactic use of anti-coagulants such as heparin, warfarin and dextran remains controversial and the effects of this treatment must be balanced against the increased risk of haemorrhage, haematoma and subsequent wound infection. Hydroxychloroquine may have a beneficial effect on the incidence of fatal pulmonary embolism without significant haematological side effects (Wroblewski, 1989) and in addition to using this pre- and post-operatively the author uses anti-embolism stockmgs and early mobilisation to prevent thrombo-embolic disease. D,islocation following total hip arthroplasty occurs in 3% of cases (Coventry et al, 1974) with the up principal risk being in the first four to six weeks following surgery. Loosening can occur due to sepsis or because of mechanical reasons and the latter is a greater potential problem in the younger patients. Wound healing is impaired in rheumatoid arthritis can be minimised by the use of straight but problems incisions, the avoidance of undermining and meticulous skin closure. Total hip replacement is one of the most satisfactory operations used in the treatment of rheumatoid arthritis and patient satisfaction may be as high as 96% seven years following surgery (Poss et al,
hip above.
There are relatively few reports in the literature on the results of total knee arthroplasty solely in patients with rheumatoid arthritis but is clear that a deformity can be overcome, the range of active flexion increased and significant pain relief given (Abernethy, 1989). However the pain relief score deteriorates with time and the incidence of radiolucent lines which may indicate loosening also increases.
fixed flexion
Figure 3: Fully constrained, (hinged) all metal, total knee arthroplasty (left) and contemporary, unconstrained, two part, metal on polyethylene total knee arthroplasty (right).
to
1984).
SURGERY OF THE KNEE BECAUSE SYNOVITIS is the earliest pathological lesion it is not unreasonable to suppose that synovectomy might eradicate the disease. This operation was the end of the 19th century but the expectations of the procedure have not been fulfilled. This is probably the joint cannot be totally synovectomised surgically with 85% clearance being the practical goal. Similarly it has been shown that synovium can regenerate and with the passage of time the regenerated tissue becomes almost indistinguishable from that seen in acute rheumatoid arthritis. There have been several retrospective series and the results of surgical synovectomy are clearly time dependant. Though in continental Europe synovectomy is still in vogue, within the United Kingdom and the USA the operation plays a much less important part in the management of rheumatoid patients. It is reserved for the younger patient with a radiologically well preserved knee joint, hypertrophic synovitis and persistent pain and swelling unrelieved by medical treatment. Chemical and radio-isotope synovectomy have also been attempted with mixed results. Total knee arthroplasty is the operation of choice for with advanced disease but sadly the operation patients has a poor reputation since most patient’s and surgeon’s minds are coloured by the results of arthroplasty using the restrained prostheses of the last two decades (Figure 3). On purely biomechanical principles which have subsequently been described these implants were doomed to failure and the recent introduciton of unconstrained prostheses has revolutionised the results of knee arthroplasty with recent results of this operation shoving a similar result to that seen following hip
introduced at
because
(hinged)
arthroplasty (Ritter et al, 1989). The operation can be complicated by extensive bone loss principally affecting the tibial condyles which may require bone grafting procedures. Otherwise the complications are broadly similar to those outlined for the
SURGERY OF THE SHOULDER THE SHOULDER is composed of at least five functionally inter-related sub-units all of which can be affected
synchronously or metachronously to varying degrees by rheumatoid arthritis. These
are
the sterno-clavicular
joint, the acromio-clavicular joint, the sub-acromial region and bursa, the gleno-humeral joint and the scapulo-thoracic functional joint. It is mandatory that prior to treatment being suggested the exact site of pain i.e.
whether it be extrinsic
or
intrinsic to the
truel
gleno-humeral joint should be accurately localised. It its classically taught that an accurate history and physical examination will allow symptoms arising from these
different functional units to be differentiated but this is, not true in patients with advanced disease. The diagnostic technique of choice is selective injection of local anaesthetic and this has been well described (Newman, 1989a). This author has experienced several cases that may have been diagnosed as gleno-humeral arthritis on the basis of clinical and radiological examination but have been found on sensory testing to have no more than acromio-clavicular arthritis or sub-acromial involvement as the principal sites of pain. A subsequent course of steroid injections to these regions together with physiotherapy is effective and localised surgery can be offered for any failures. In most series over 70% of patients demonstrate involvement of the acromio-clavicular joint by rheumatoid arthritis with isolated disease only occurring in a
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197
minority (Newman, 1989b). Most cases respond to intra-articular steroid injections and failures can be dealt with by excision of the outer end of the clavicle. Similarly, sub-acromial impingement syndrome can be treated by injection treatment with decompression by anterior acromioplasty being left for the failures.
Gleno-humeral involement, i.e. the ’true’ shoulder is commonly affected by rheumatoid arthritis with severe functional impairment. The place for synovectomy as an isolated procedure is debateable and though it may be indicated in the young patient or in the uncommon instance of marked synovial hypertrophy with minimal articular involement it generally has no application. Arthrodesis (fusion) has been peformed in the past but it is an unsatisfactory option when other upper limb joints may be affected at the same time or in the future. Total shoulder arthroplasty is the procedure of choice (Figure 4) and in the most recent review solely dedicated to a cohort of 42 patients with rheumatoid arthritis, Kelly et al, found
joint,
(1997)
Figure
4: Neer total shoulder
arthroplasty;
metal
alloy
humeral
component and high density polyethylene glenoid component, both with polymethyl methacralate cement mantles.
almost 90% to have no significant pain. Flexion and extension were both improved by approximately 30° and internal and external rotation improved by a similar amount. Though all patients experienced an improvement in their functional abilities leading to greater personal independence none could use their hand above shoulder level. Shoulder arthroplasty should be considered as an operation which gives pain relief rather than increases the range of motion. This is because the rotator cuff is invariably involved with the rheumatoid process and is often almost functionless. (This is unlike the situation of primary osteoarthrosis or trauma when the rotator cuff is functional and the post-operative range of motion so much better). However, rotator cuff deficiency should not be considered a contra-indication to arthroplasty since pain relief is brought about by the procedure and this facilitates scapulo-thoracic rotation. Glenoid bone erosion occurs in gleno-humeral rheumatoid arthritis and may be marked prejudicing the fixation of the glenoid component. An alternative approach is to manage these shoulders without using a glenoid component i.e. hemi-arthroplasty only. Few publications have compared the results of total with hemi-arthroplasty in a controlled manner but it is probable that the total joint replacement fares superior to
hemi-arthroplasty (Marmar, 1977; Gschwend, 1988).
SURGERY OF THE ELBOW INVOLVEMENT OF the elbow with rheumatoid arthritis is much more frequent than is often realised with approximately 50% of patients with long standing rheumatoid disease showing evidence (Souter, 1989). The pathology varies from rheumatoid nodules or olecranon bursae through synovitis to bone destruction. Two procedures are available for this joint; synovectomy and total joint arthroplasty. Synovectomy is often performed in conjunction with excision of the radial head and the first report of this operation was by Lane and Vanio in 1969. The operation is reliable with regard to initial pain relief but the results with regard to movement are variable though gains in flexion and extension have been reported by some to be up to 55% (Stein et al, 1975). The complication rate is low and the risks of sustaining a significant loss of movement no more than 10%. The operation does not appear to arrest radiological deterioration and the recurrence of synovitis is not uncommon. For example Summers et al (1987) found in a review of 50 patients that although 84% were clear of pain at six months only 54% were within this category at five years. Furthermore, recurrent synovitis occurred in almost 40% of patients. This is also the opinion of Souter (1989). In the light of these observations it is probably prudent to regard synovectomy not as a definite solution to the rheumatoid elbow but rather than a delaying procedure before more radical surgery is required. It should be reserved solely for those elbows in the earlier grades of severity unresponsive to conservative treatment. The surgical management of the elbow with advanced disease is by arthoplasty and the design of prostheses has changed dramatically over the course of the last two decades (this is very similar to what has happened with knee arthroplasty described above). From fully constrained implants with long stemmed fixation designs have changed to unconstrained prostheses. Several patterns are currently available but a recent 10 year review of the Souter-Strathclyde prosthesis has shown that whereas pre-operatively 85% of the patients experienced severe elbow pain, 92% had no pain or only occasional twinges of discomfort one year after surgery and this gratifying result was maintained at five years later. Pronation and supination are improved by this procedure, flexion is usually increased but fixed flexion deformity is almost irremovable (Souter, 1989). The complications specific to elbow arthroplasty are ulnar neuronathy which occurs in at least 15% and dislocation 1989) which is usually associated with medial collateral ligament insufficiency.
(stouter,
SUMMARY AND CONCLUSION THE RESULTS of total joint arthroplasty
are exciting but certainly they are not yet good enough to warrant complacency. Further advances in design and materials are required. It is also clear that there is a positive relationship between the technical expertise with which the surgery is performed and the long term functional results (especially with regard to the knee). Nonethe-
less, the benefits that this type of surgery can confer on the severely afflicted rheumatoid patient with regard to relief and function pain little hesitation in
are
such that there should be
offering this form of treatment to all
patients
who fail conservative treatment. However, it
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198
has always to be remembered that the results of even the most sophisticated surgery can be improved by an intensive rehabilitation programme including pre- and post-operative occupational therapy and physiotherapy, the prescription of appropriate appliances and the optimisation of medical therapy. REFERENCES ..
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Edinburgh,
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~
*n
~
~~
-------
the number of responses for each food item. (per cent in =
parenthesis).
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