Lower limb joint replacement in rheumatoid arthritis

Abstract

IntroductionThere is limited literature regarding the peri-operative and surgical management of patients with rheumatoid disease undergoing lower limb arthroplasty. This review article summarises factors involved in the peri-operative management of major lower limb arthroplasty surgery for patients with rheumatoid arthritis.MethodsWe performed a search of the medical literature, using the PubMed search engine (http://www.pubmed.gov). We used the following terms: ‘rheumatoid’ ‘replacement’ ‘arthroplasty’ and ‘outcome’.FindingsThe patient should be optimised pre-operatively using a multidisciplinary approach. The continued use of methotrexate does not increase infection risk, and aids recovery. Biologic agents should be stopped pre-operatively due the increased infection rate. Patients should be made aware of the increased risk of infection and periprosthetic fracture rates associated with their disease. The surgical sequence is commonly hip, knee and then ankle. Cemented total hip replacement (THR) and total knee replacement (TKR) have superior survival rates over uncemented components. The evidence is not clear regarding a cruciate sacrificing versus retaining in TKR, but a cruciate sacrificing component limits the risk early instability and potential revision. Patella resurfacing as part of a TKR is associated with improved outcomes. The results of total ankle replacement remain inferior to THR and TKR. RA patients achieve equivalent pain relief, but their rehabilitation is slower and their functional outcome is not as good. However, the key to managing these complicated patients is to work as part of a multidisciplinary team to optimise their outcome.

Psychological Factors Associated with Response to Treatment in Rheumatoid Arthritis

“…The literature contains few references to the influence of psychological factors on the results of surgical management. A recent systematic review of factors involved in the perioperative management of major lower limb arthroplasty found that RA patients with clinical depression do not improve to the same extent as those without [46].…”

Periprosthetic Fractures

“…Other causes of reduced bone stock (such as rheumatoid arthritis, osteoporosis and steroid use) also increase the risk of periprosthetic fracture [ 9 ]. In studies of joint registries, rheumatoid arthritis increases the risk of periprosthetic fracture by a factor of between 1.5 and 2.1 [ 16 ].…”

Total Knee Arthroplasty Considerations in Rheumatoid Arthritis

“…Surgeons and anesthesiologists alike must be aware of the increased risk to the cervical spine as 80% of patients have atlantoaxial instability [4]. The cervical spine also is at elevated risk of basilar invagination and subaxial instability, and thus preoperative radiographic investigation via flexion and extension images should be obtained, as intubation for surgery can often require hyperextension of the patient's neck, and should be avoided should instability be present [5].…”

“…Controversy exists on whether upper or lower extremity pathology should be addressed first. Clement et al argue that stresses placed on the upper extremity during therapy for TKA may further damage previously repaired joints [4]. Conversely, Chmell et al believe that upper extremity impairment such as severe wrist pain due to RA may impair lower extremity rehabilitation, and thus wrist fusion should be considered prior to TKA.…”