Lower Limb Joint Replacement in Patients with Rheumatoid Arthritis - Perioperative management considerations for patients with RA who need a total hip, knee, or ankle replacement
Rheumatoid arthritis (RA) is a chronic systemic connective tissue disease, and it is the third most common indication for lower limb joint replacement in Northern Europe and North America.  The etiology of the disease remains unclear, but there are strong associations with human leukocyte antigens (DRB1).  The prognosis is poor, with 80% of patients being disabled 20?years from primary diagnosis.  The medical treatment of RA has improved during the last 25?years, which is reflected by a 40% decrease in the rate of hip and knee surgery since a peak that was observed in the mid 1990s.  Anemia, raised erythrocyte sedimentation rate, and a high disease activity score have all been identified as risk factors for the need for large joint arthroplasty. 
Seventeen percent of patients with RA undergo an orthopaedic intervention within 5?years of initial diagnosis.  More than one third of patients will need a major joint replacement, of which the majority will receive a total hip or knee replacement (THR, TKR).  This review article summarizes factors involved in the perioperative management of major lower limb arthroplasty surgery for patients with RA.
Sledge CB: Introduction to surgical management of patients with arthritis. In Kelly’s Textbook of rheumatology. Edited by Saunders WB. Philadelphia; 2001. PubMed Abstract
Macgregor AJ, Snieder H, Rigby AS, Koskenvuo M, Kaprio J, Aho K, Silman AJ: Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins. Arthritis Rheum 2000, 43:30-37.
Scott DL, Symmons DP, Coulton BL, Popert AJ: Long-term outcome of treating rheumatoid arthritis: results after 20 years. Lancet 1987, 1:1108-1111.
Louie GH, Ward MM: Changes in the rates of joint surgery among patients with Rheumatoid Arthritis in California, 1983–2007. Ann Rheum Dis 2010, 69(5):868-871.
James D, Young A, Kulinskaya E, Knight E, Thompson W, Ollier W, Dixey J: Orthopaedic intervention in early rheumatoid arthritis. Occurrence and predictive factors in an inception cohort of 1064 patients followed for 5 years. Rheumatology (Oxford) 2004, 43:369-376.
Wilkinson JM, Stanley D, Getty CJM: Surgical management of the rheumatoid patient. Curr Orthop 2004, 18:357-370.
Conlon PW, Isdale IC, Rose BS: Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 1966, 25:120-126.
Roche CJ, Eyes BE, Whitehouse GH: The rheumatoid cervical spine: signs of instability on plain cervical radiographs. Clin Radiol 2002, 57:241-249.
Takatori R, Tokunaga D, Hase H, Mikami Y, Ikeda T, Harada T, Imai K, Nishimura T, An HS, Inoue N, Kudo T: Three-dimensional morphology and kinematics of the craniovertebral junction in rheumatoid arthritis. Spine 2010, 35:1278-1284.
Anstead GM: Steroids, retinoids, and wound healing. Adv Wound Care 1998, 11:277-285.
Weinblatt ME, Maier AL, Fraser PA, Coblyn JS: Longterm prospective study of methotrexate in rheumatoid arthritis: conclusion after 132 months of therapy. J Rheumatol 1998, 25:238-242.
Grennan DM, Gray J, Loudon J, Fear S: Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis 2001, 60:214-217.
Chen YF, Jobanputra P, Barton P, Jowett S, Bryan S, Clark W, Fry-Smith A, Burls A: A systematic review of the effectiveness of adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis in adults and an economic evaluation of their cost-effectiveness. Health Technol Assess 2006, 10(iii-xiii):1.
Bibbo C, Goldberg JW: Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int 2004, 25:331-335.
Kawakami K, Ikari K, Kawamura K, Tsukahara S, Iwamoto T, Yano K, Sakuma Y, Tokita A, Momohara S: Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-alpha blockers: perioperative interruption of tumour necrosis factor alpha blockers decreases complications? Rheumatology (Oxford) 2010, 49(2):341-347.
Guidance on the use of metal on metal hip resurfacing arthroplasty. London: National Institute for Clinical Excellence; 2002. http://www.nice.org.uk/nicemedia/pdf/HipResurfacing-FinalGuidance.pdf.
Chmell MJ, Scott RD, Thomas WH, Sledge CB: Total hip arthroplasty with cement for juvenile rheumatoid arthritis. Results at a minimum of ten years in patients less than thirty years old. J Bone Joint Surg Am 1997, 79:44-52.
Creighton MG, Callaghan JJ, Olejniczak JP, Johnston RC: Total hip arthroplasty with cement in patients who have rheumatoid arthritis. A minimum ten-year follow-up study. J Bone Joint Surg Am 1998, 80:1439-1446.
Eskelinen A, Paavolainen P, Helenius I, Pulkkinen P, Remes V: Total hip arthroplasty for rheumatoid arthritis in younger patients: 2,557 replacements in the Finnish Arthroplasty Register followed for 0–24 years. Acta Orthop 2006, 77:853-865.
Havelin LI, Hallan G, Dybvik E: Cemented verses uncemented femoral stems in rheumatoid arthritis patients in th Norwegian arthroplasty register. European Federation of National Associations Of Orthopaedics and Traumatology (8th Congress) 2007, Vol. Florence(91-B ed):89-90.
Sotelo-Garza A, Charnley J: The results of Charnley arthroplasty of hip performed for protrusio acetabuli. Clin Orthop Relat Res 1978, 12:8.
Hirst P, Esser M, Murphy JC, Hardinge K: Bone grafting for protrusio acetabuli during total hip replacement. A review of the Wrightington method in 61 hips. J Bone Joint Surg Br 1987, 69:229-233.
Laskin RS, O’Flynn HM: The Insall Award. Total knee replacement with posterior cruciate ligament retention in rheumatoid arthritis. Problems and complications. Clin Orthop Relat Res 1997, 24:8.
Goldberg VM, Figgie MP, Figgie HE, Heiple KG, Sobel M: Use of a total condylar knee prosthesis for treatment of osteoarthritis and rheumatoid arthritis. Long-term results. J Bone Joint Surg Am 1988, 70:802-811.
Kristensen O, Nafei A, Kjaersgaard-Andersen P, Hvid I, Jensen J: Long-term results of total condylar knee arthroplasty in rheumatoid arthritis. J Bone Joint Surg Br 1992, 74:803-806.
Gill GS, Joshi AB: Long-term results of retention of the posterior cruciate ligament in total knee replacement in rheumatoid arthritis. J Bone Joint Surg Br 2001, 83:510-512.
Meding JB, Keating EM, Ritter MA, Faris PM, Berend ME: Long-term followup of posterior-cruciate-retaining TKR in patients with rheumatoid arthritis. Clin Orthop Relat Res 2004, 146:52.
Morgan H, Battista V, Leopold SS: Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg 2005, 13:515-524.
Sculco TP: The role of constraint in total knee arthroplasty. J Arthroplasty 2006, 21:54-56.
Rodriguez JA, Saddler S, Edelman S, Ranawat CS: Long-term results of total knee arthroplasty in class 3 and 4 rheumatoid arthritis. J Arthroplasty 1996, 11:141-145.
Shoji H, Yoshino S, Kajino A: Patellar replacement in bilateral total knee arthroplasty. A study of patients who had rheumatoid arthritis and no gross deformity of the patella. J Bone Joint Surg Am 1989, 71:853-856.
Kajino A, Yoshino S, Kameyama S, Kohda M, Nagashima S: Comparison of the results of bilateral total knee arthroplasty with and without patellar replacement for rheumatoid arthritis. A follow-up note. J Bone Joint Surg Am 1997, 79:570-574.
Michael JM, Golshani A, Gargac S, Goswami T: Biomechanics of the ankle joint and clinical outcomes of total ankle replacement. J Mech Behav Biomed Mater 2008, 1:276-294.
Jensen NC, Linde F: Long-term follow-up on 33 TPR ankle joint replacements in 26 patients with rheumatoid arthritis. Foot Ankle Surg 2009, 15:123-126.
Hobson SA, Karantana A, Dhar S: Total ankle replacement in patients with significant pre-operative deformity of the hindfoot. J Bone Joint Surg Br 2009, 91:481-486.
Wood PL, Crawford LA, Suneja R, Kenyon A: Total ankle replacement for rheumatoid ankle arthritis. Foot Ankle Clin 2007, 12:497-508.
Raut VV, Siney PD, Wroblewski BM: Cemented revision Charnley low-friction arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br 1994, 76:909-911.
Mont MA, Domb B, Rajadhyaksha AD, Padden DA, Jones LC, Hungerford DS: The fate of revised uncemented acetabular components in patients with rheumatoid arthritis. Clin Orthop Relat Res 2002, 140:8.
Schreurs BW, Thien TM, de Waal Malefijt MC, Buma P, Veth RP, Slooff TJ: Acetabular revision with impacted morselized cancellous bone graft and a cemented cup in patients with rheumatoid arthritis: three to fourteen-year follow-up. J Bone Joint Surg Am 2003, 85-A:647-652.
Garcia RM, Hardy BT, Kraay MJ, Goldberg VM: Revision total knee arthroplasty for aseptic and septic causes in patients with rheumatoid arthritis. Clin Orthop Relat Res 2010, 468:82-89.
Nguyen-Oghalai TU, Ottenbacher KJ, Caban M, Granger CV, Grecula M, Goodwin JS: The impact of rheumatoid arthritis on rehabilitation outcomes after lower extremity arthroplasty. J Clin Rheumatol 2007, 13:247-250.
Stanley D, Stockley I, Getty CJ: Simultaneous or staged bilateral total knee replacements in rheumatoid arthritis. A prospective study. J Bone Joint Surg Br 1990, 72:772-774.
Lindahl H, Malchau H, Oden A, Garellick G: Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br 2006, 88:26-30.
Sarvilinna R, Huhtala HS, Puolakka TJ, Nevalainen JK, Pajamaki KJ: Periprosthetic fractures in total hip arthroplasty: an epidemiologic study. Int Orthop 2003, 27:359-361.
Bongartz T, Halligan CS, Osmon DR, Reinalda MS, Bamlet WR, Crowson CS, Hanssen AD, Matteson EL: Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 2008, 59:1713-1720.
Chotanaphuti T, Ongnamthip P, Songpatanasil T, Veerapan P, Deeprecha K: Risk factors of deep vein thrombosis (DVT) after total knee arthroplasty (TKA) at Phramongkutklao Hospital. J Med Assoc Thai 2007, 90:485-491.
Guan ZP, Lu HS, Chen YZ, Song YN, Qin XL, Jiang J: Clinical risk factors for deep vein thrombosis after total hip and knee arthroplasty. Zhonghua Wai Ke Za Zhi 2005, 43:1317-1320.
Matta F, Singala R, Yaekoub AY, Najjar R, Stein PD: Risk of venous thromboembolism with rheumatoid arthritis. Thromb Haemost 2009, 101:134-138.
Benjamin A, Helal B: Surgical repair and reconstruction in rheumatoid disease. London: The Macmillan Press; 1980.
Ethgen O, Kahler KH, Kong SX, Reginster JY, Wolfe F: The effect of health related quality of life on reported use of health care resources in patients with osteoarthritis and rheumatoid arthritis: a longitudinal analysis. J Rheumatol 2002, 29:1147-1155.
How to Cite
Copyright (c) 2014 Nicholas Clement, Stephen Breusch, Leela Biant
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright and License Agreement:
Authors who publish with the Reconstructive Review agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work. Reconstructive Review follows the Creative Commons Attribution-NonCommercial CC BY-NC. This license allows anyone to download works, build upon the material, and share them with others for non-commercial purposes as long as they credit the senior author, Reconstructive Review, and the Joint Implant Surgery & Research Foundation (JISRF). An example credit would be: "Courtesy of (senior author's name), Reconstructive Review, JISRF, Chagrin Falls, Ohio". While works can be downloaded and shared they cannot be used commercially.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.