Arthroplasty of both hips and both knees in rheumatoid arthritis

Staged replacement of both hips and both knees in patients with rheumatoid arthritis

BACKGROUND

Patients with rheumatoid arthritis (RA) undergoing bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) are an uncommon population, and their outcomes are also difficult to predict. The purpose of this study was to evaluate whether both bilateral cementless THA and cemented posterior-stabilized TKA (PS-TKA) can provide reliable outcomes for RA patients.

METHODS

We retrospectively reviewed 30 RA patients (60 hips and 60 knees) who underwent both elective bilateral cementless THA and cemented PS-TKA, with a minimum follow-up of 2 years. Clinical, patient-reported, and radiographic data were retrospectively analyzed.

RESULTS

The mean follow-up was 84 months (range, 24-156). By the last follow-up, the post-operative range of motion, Harris Hip Score, Knee Society Score (KSS) clinical, KSS functional, Western Ontario and McMaster Universities Index of Osteoarthritis (WOMAC) hip, and WOMAC knee scores were significantly improved compared to the preoperative values. All patients achieved the ability to walk. In addition, overall satisfaction scores on a 100-point scale were 92.5 after THA and 89.6 after TKA. Only one patient underwent revision surgery due to knee joint instability, and all replaced hips and knees were radiographically stable by the assessment of the radiolucent line. The proportion of implants that did not suffer loosening or require revision surgery was 99.2% during the 84-month follow-up, based on Kaplan-Meier analysis.

CONCLUSIONS

Our study suggests that bilateral cementless THA and cemented PS-TKA provides reliable mid-long-term clinical, patient-reported, and radiographic outcomes in RA patients, with high survivorship and patient satisfaction.

Bilateral Total Knee Arthroplasty: Current Concepts Review

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Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days.

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Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others.

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While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA.

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When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart.

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Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.

Bilateral Total Hip and Knee Arthroplasties: Average 10-Year Follow-Up

BACKGROUND

The present study investigates the clinical and radiographic outcomes in patients with all 4 major lower extremity joints replaced.

METHODS

A retrospective review of our institution's database identified 125 patients in whom both hips and both knees were replaced. The mean time between the first and last arthroplasty was 6.6 years. Preoperative diagnoses included osteoarthritis in 80% and rheumatoid arthritis in 20%. The average age at the time of the first arthroplasty was 63.7 years. The mean follow-up for all arthroplasties was 10.5 years (range 2-31 years). Patients were then matched according to age, gender, diagnosis, prosthesis, and follow-up, to patients with single or bilateral total hip or total knee arthroplasty.

RESULTS

There were 11 aseptic hip revisions (4.4%) and 3 aseptic knee revisions (1.2%). At final follow-up, 86% of hips and 83% of knees were rated with no or mild pain, 68% of patients rated walking as unlimited, and 98% of patients were able to satisfactorily negotiate stairs. Aseptic survivorship for all joint arthroplasties was 93.8% at 15 years. No statistical differences were noted in pain, function, stair, and walking scores between the matched groups.

CONCLUSION

This report demonstrated excellent clinical, functional, and radiographic outcomes in patients with all 4 major lower extremity joints replaced. Walking aids were needed in 15% of patients, however. At final follow-up, this selected group of patients appears to fare just as well as patients with single or bilateral hip or knee arthroplasty with respect to pain and function.

Clinical and patient-reported outcomes of patients with four major lower extremity arthroplasties

Few studies report the outcomes of patients treated with total joint arthroplasty of both hips and both knees. We present the outcomes of 14 patients with total joint arthroplasty of both hips and both knees using validated outcome measures. Eleven patients (79%) were satisfied at final review. Ten patients (71%) required revision surgery of at least one joint. Clinical, functional, radiographic, and patient-reported outcomes were consistent with previously reported outcomes in the literature. Mean Timed Up and Go test was 32 seconds (6-158). Mean Berg Balance Scale was 38.5 (4-55). Good outcomes can be achieved in this group of patients with high levels of satisfaction despite the frequent need for revision surgery. Importantly, it was recognized that these patients have a high risk of falls and must be educated in measures for fall prevention.

Rapid sequence quadruple joint replacement in a rheumatoid Jehovah's Witness

We report the case of a wheelchair-bound rheumatoid Jehovah's Witness who underwent rapid sequence, staged, simultaneous ipsilateral hip and knee replacements. Using perioperative erythropoietin and postoperative blood salvage, all four joints were reconstructed without homologous blood transfusion. One year following surgery, the patient has achieved an independent functional status, and all four replaced joints remain painless.

Outcomes for patients undergoing one or more total hip and knee arthroplasties

Either total hip arthroplasty (THA), total knee arthroplasty (TKA) or both were performed in 105 patients from 1981 to 1994. These patients were experiencing severe joint destruction in the lower extremities due to rheumatoid arthritis (RA). These patients were followed for more than 2 years after their last operation. Eighty-six patients were alive and 19 patients had died at the time of follow-up. The 86 living patients were divided into four groups based on the number of replaced joints. Their pre- and postoperative conditions, including such factors as pain, mobility and disability for the quality of life (QOL), were compared. All of the four groups showed some reduction in pain and disability, and an improvement in ambulation after the operations. The 19 deceased patients were classified into two groups, one including those with multiple (three or four) arthroplasties and the other, those with only a small number (one or two). The mean age at death was lower (55.7+/-6.2 years) in patients with multiple arthroplasties than that (69.1+/-7.5 years) in patients with only a small number of arthroplasties. Secondary diseases from RA, such as amyloidosis, spinal injury and pulmonary fibrosis, were found to be the primary cause of death in patients with multiple arthroplasties. The most important finding in this study is that although RA patients with multiple arthroplasties in the lower extremities improved their QOL, they were still afflicted with secondary diseases derived from RA and experienced complications that could shorten their lifespan.

Bilateral total hip and knee replacement in rheumatoid arthritis patients

Between 1978 and 1983, 14 patients suffering from rheumatoid arthritis were treated by bilateral total hip and knee replacement. At the time of this follow-up study (32-92 months postoperatively) one patient had died of concomitant disease and was excluded. The postoperative results regarding pain relief, improvement in performing daily activities, and function were studied in the remaining 13 patients. A 200-point rating scale was used, which compared the pre- and postoperative findings at follow-up. All patients showed marked relief from pain, good function and a good functional score. Although walking ability did not always improve, all patients were enthusiastic.

Long-term results of total joint arthroplasty in nonambulatory patients

The authors conducted a long-term follow-up study of 27 patients, all confined to a bed or wheelchair for at least 6 months, who had total joint arthroplasty to relieve rest pain, correct deformity, and enable independent ambulation. The average duration of nonambulatory status before operation was 3 years (mean, 1 1/2 years), with the longest being 15 years. The patients required an average 3-month hospital stay and an average of three major total joint arthroplasties in the lower extremities. All of the patients were ambulatory at the time of discharge but required some sort of aid. After 1 year, 20 patients (74%) were able to launch independently; 9 (33%) could ambulate without aids; and 14 (52%) could ambulate with aids. At follow-up evaluation 3-12.8 years (average, 6.5 years) after operation, nine patients (33%) ambulated without aids, five (19%) required a single crutch or cane, and nine (33%) required bilateral crutches or a walker, for a total success rate of 85%, which did not deteriorate with time.

Bilateral simultaneous total knee arthroplasty

One hundred thirty-two patients (264 knees) who had simultaneous bilateral total knee arthroplasty and 77 patients who had unilateral procedures were reviewed for statistical comparison of the two procedures with respect to pain, tibial and femoral radiolucency, and all other complications as well as average hospital stay and hospital costs. Both groups had posterior cruciate condylar total knee prostheses. There were no significant differences except for tibial radiolucency, which was significantly higher in the unilateral group. Bilateral total knee arthroplasty as a single procedure does not increase the risk of postoperative or follow-up complications and decreases the probability of complications such as phlebitis and pulmonary emboli, because only one operation is necessary. The average hospital cost and length of stay were lower in the simultaneous group (decreased by 20% and 46%, respectively), compared with twice that of the unilateral group.

Bilateral hip and knee arthroplasty

Twenty-six severely deformed patients with prosthetic arthroplasty of both hips and both knees because of rheumatoid arthritis (16), juvenile rheumatoid arthritis (6), ankylosing spondylitis (2), osteoarthritis (1), and inflammatory arthritis, cause unknown (1), were followed for a mean of 6.8 years. Severe pain was the primary indication for surgery, and consistent and substantial pain relief was achieved. Most patients also had limited ambulatory and functional improvement. Computer analysis showed that this improvement was related only to preoperative walking and function and a combined hip and knee flexion of at least 190 degrees. All other parameters had no correlation with walking and function improvement. Of the 104 arthroplasties (52 hips and 52 knees), six implants (4 hips and 2 knees) in two patients failed and another seven implants (2 hips and 5 knees) in five patients were revised. Of the remaining 91 implants, 89 were clinically stable, and only two hip implants in two patients appeared destined for revision. However, when radiographic review was included, nine acetabular components, three THA femoral components, and five tibial components in 12 patients had some evidence of impending aseptic loosening, despite low patient activity levels.

Staged versus simultaneous bilateral total knee replacement

Bilateral total knee replacements were reviewed to determine whether any difference exists in the perioperative course between procedures done under one anesthetic (simultaneous) and those done under two anesthetics (staged). There were 29 staged and 18 simultaneous cases, therefore 76 separate procedures and 94 knees done. The total operative time, blood loss, and complications were similar between the two groups. However, the staged replacements had more than twice the hospital days (34.6 +/- 7.7 vs. 16.8 +/- 5.6, P less than .001) and 18% greater hospital bills. In fact, for a given patient, the hospital bill may be greater than 50% higher if a staged rather than simultaneous replacement is done. Therefore, simultaneous replacement is recommended for appropriate patients.

Bilateral joint replacement of hip and knee joints in patients with rheumatoid arthritis

Between 1973 and 1981, bilateral total replacement of hip and knee joints was performed in 22 patients with rheumatoid arthritis. During follow-up, 2 patients died of diseases not directly related to the operation. Besides these patients, there were 2 patients who could not be followed up. The remaining 18 patients constituted the subjects for study. We studied the postoperative results, emphasing improvement in the ability to perform everyday activities. Walking ability was improved in 16 patients. There was an increase in the number of patients able to rise from a chair, go up and down stairs, and get in and out of a car, bus or train. Of the 14 married patients (not including 2 patients who were unable to walk and 5 patients over 60 years of age) 7 were able to perform sexual intercourse as well as they had been able to when healthy. The patients who underwent bilateral total replacement of hip and knee joints often presented various problems, for example with regard to indications, the operative technique to use, as well as complications such as heart disease, pulmonary disease, and secondary amyloidosis. We have found, however, that bilateral total replacement of hip and knee joints can accomplish the operative objectives of eliminating pain and improving the quality of daily life in severely handicapped rheumatoid patients.

Bilateral one-stage total hip replacement in rheumatoid arthritis and SPA

Sixteen cases of bilateral total one-stage hip replacements in patients with rheumatoid arthritis or ankylosing spondylitis are reviewed. Special reference is given to peroperative problems, complications, and indications in a hospital with on intensive care unit. The indications are discussed and the results compared with larger series published earlier in literature. One-stage procedure proves to be a proper alternative in cases with severe bilateral disease. The rate of complications is comparable to that of unilateral procedures. A marked decrease in time consumption can be achieved.