The Hip: Preservation, Replacement and Revision

Hip Joint in Rheumatoid Arthritis

- See: rheumatoid arthritis

- Discussion:
    - rheumatoid cervical spine:
           - ensure that anesthesia is prepared for possible need for bronchoscopic intubation;
    - total hip arthroplasty in rheumatoid arthritis: (see total hip replacement);
           - protrusio acetabuli is common and is often progressive;
           - many authors recommend stopping methotrexate 2 weeks before surgery although this may be controversial;
           - most of these patients will be on a NSAID and/or steroids;
                  - these medications may both interfere with bone growth, and therefore they should be held for 6 weeks postop when patients 
                         are to receive a press fit stem;
                         - withholding NSAIDS or steroids in a RA patient, however, often will provoke a serious arthritic flare;
                  - if a cemented component is to be used, NSAIDS and steroids need not be discontinued;
           - cemented implants:
                  - in the study by Creighton et al. 1998, 103 hips were followed for a minimum of 10 years.
                         - 7% of hips were revised (due to infection, dislocation, or loosening (2 patients));
                         - 8% of hips showed acetabular loosening and 2% showed femoral loosening.
           - references:
                  - Total hip arthroplasty with cement in patients who have rheumatoid arthritis. A minimum ten year follow up study
                  - Total hip arthroplasty in protrusio acetabuli of rheumatoid arthritis
                  - Should methotrexate be discontinued before elective orthopaedic surgery in patients with rheumatoid arthritis?  
                  - Local infectious complications following large joint replacement in rheumatoid arthritis patients treated with methotrexate versus those not treated with methotrexate.  
    - juvenile rheumatoid arthritis:
           - references:
                  - Total hip arthroplasty in juvenile rheumatoid arthritis. Two to eleven-year results.
                  - Total hip and knee arthroplasty in juvenile rheumatoid arthritis.
                  - Total hip arthroplasty in juvenile rheumatoid arthritis.

- Management of Femoral Neck Frx in RA:
    - indicated for patients w/ rheumatoid arthritis and/or concomitant hip arthrosis;
    - patients should be aware of a relatively high complication rate (10% will dislocate);
    - risk of dislocation was dramatically reduced using the Hardinge approach (3/40 hips) versus the posterior approach (4/17 hips);
    - references:
         - A comparison of total hip arthroplasty and hemiarthroplasty for treatment of acute fracture of the femoral neck.
         - Secondary total hip replacement after fractures of the femoral neck.
         - Total hip arthroplasty after acute displaced femoral neck fractures.
         - Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement.
         - Total hip arthroplasty following failed internal fixation of hip fractures.
         - Treatment of intracapsular hip fractures with total hip arthroplasty in rheumatoid arthritis.
         - The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison.
         - Treatment of acute femoral neck fractures with total hip arthroplasty.
         - Failure of internal fixation of displaced femoral neck fractures in rheumatoid arthritis.
         - Total hip arthroplasty for the treatment of an acute fracture of the femoral neck: long-term results.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, May 14, 2012 3:02 pm