CASE REPORT Surgical strategies for rheumatoid arthritis

Transcription

1 Hong Kong Journal of Orthopaedic Surgery 2001;5(1): Surgical strategies for rheumatoid arthritis CASE REPORT Surgical strategies for rheumatoid arthritis Tang WM, Ng KH, 1 Chiu KY Division of Joint Replacement Surgery, Department of Orthopaedic Surgery and 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Hong Kong. ABSTRACT Surgical treatment could be considered as one of the most important advances in treating rheumatoid arthritis in the past 30 years. The sequence of surgical treatment for patients with multiple joint involvement, however, is still controversial. This report states the principles of planning surgical strategies in the light of two cases of polyarthritis. Key Words: Arthritis, rheumatoid/surgery; Arthroplasty, replacement, hip; Case-control study; Metatarsophalangeal joint/surgery!!"#$%&'()*+!"#$!%&' PM!"#$%&'()*+,-./ :;<='>,-?@A5BC5!"!"#$%&'()*+,-./ :;<=>?@A* INTRODUCTION Metaphorically, a body suffering from rheumatoid arthritis is a house on fire. Usually this is a lasting fire that can seldom be extinguished completely....it is based on ground pillars that must be saved to avoid its crashing. It has adjoining rooms whose destruction is of less importance. The owner s confidence must be gained if effective action is to be undertaken to save his house. Therefore, the first steps should already be successful. Gschwend 19 Successful surgical treatment, particularly total joint arthroplasty, for patients with rheumatoid, has revolutionised the management of polyarthritis. Surgical intervention is regarded as one of the most valuable therapeutic options that modifies the natural history of rheumatoid arthritis. A review of the outcome for 100 patients with rheumatoid after 10 to 15 years of medical therapy concluded that surgery was superior and it improved outcome. 10 Surgical treatment that re- stores a patient s ability to perform activities of daily living, particularly ambulation, has been considered a major advance in the management of rheumatoid arthritis in the past 30 years. 10 Whereas deciding the type of operation for a particular affected joint may be straightforward (eg arthrodesis for an ankle, arthroplasty for a knee), deciding the priority and sequence of surgical treatment for patients with multiple joint involvement is much harder. Treatment of rheumatoid arthritis has been described as a life-long battle in combating a house on fire a fire that cannot be fully extinguished. 19 The clinician must first understand which part of the house to save first. In this article we present a set of criteria designed to aid in the management of patients presenting to the Queen Mary Hospital with polyarthritis (Table 1). The common goal of treatment for rheumatoid arthritis must be to allow the patient in leading an active, productive life, and to be involved in society. Correspondence: Dr. W.M. Tang, Division of Joint Replacement Surgery, Department of Orthopaedic Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Hong Kong Orthopaedic Association & Hong Kong College of Orthopaedic Surgeons

2 HKJOS Tang WM, Ng KH, Chiu KY Table 1 Criteria for sequence of surgical treatment in patients with polyarthritis Conditions that require urgent/early surgical treatment, eg C1/2 subluxation Patient s preference and expectation The more painful joint first Simple procedure with higher success rate first ( winner procedure), eg arthrodesis of the fist MTPJ for hallux valgus Lower limb before upper limb Lower limb: distal to proximal Upper limb: proximal to distal MTPJ = metatarsophalangel joint CASE REPORTS Case 1 A 35-year-old women presented with a 20-year history of rheumatoid. She had received no regular medical treatment and took only nonprescription analgesics. She was almost bed-bound because of severe involvement of both hips and knees, and the hips were more painful than the knees. Her upper limbs were, however, functionally spared. She could transfer herself from a bed to a chair with help, using her upper limbs. Physical examination revealed a 40 o fixed-flexion contracture of both hips. Her knees were in 20 o fixed valgus and 30 o fixed-flexion deformities. Foot and ankle involvement was slight. X-ray films showed minimal involvement of the cervical spine. Total hip arthroplasty was the first procedure to be performed since the hips were more painful. Since both hips were involved to the same extent, a bilateral hip arthroplasty was performed. Postoperative recovery was uneventful. A bilateral one-stage total knee arthroplasty was performed 3 months later (Fig. 1). Although it is generally recommended to wait 6 months, early mobility was important and could not be achieved without knee arthroplasty. The left knee arthroplasty was, however, complicated by wound dehiscence, which was subsequently settled with repeated debridement. Walking was possible with a walking frame and the patient could transfer herself unaided from bed to chair 6 weeks after the bilateral knee arthroplasty. She required occasional non-steroid anti-inflammatory drugs for pain control. Case 2 A 48-year-old housewife with a history of rheumatoid arthritis was referred to us for treatment of pain in her neck, right wrist, both knees, and both feet. At first presentation, she could walk with a stick for 30 minutes; about 4 weeks later, she became wheelchair-bound due to worsening knee pain. The bilateral hallux valgus were complicated by multiple small ulcers on the big and the second toes, and poor foot hygiene. She had mechanical neck pain with no neurological deficit. Nonsteroid anti-inflammatory drugs and azathioprine, but not steroid, were prescribed, and the patient requested that her knees be first treated. Radiographs, however, demonstrated a C1/2 subluxation (Fig. 2). Thus, despite the declining mobility and the patients request for knee surgery first, the C1/2 was first stabilised by transarticular screw fixation. A bilateral first metatarsophalangeal (MTP) joint fusion and a right wrist fusion were performed simultaneously 4 months later. Knee replacements were performed after a further 8 weeks. Postoperatively she was able to walk on level ground using one stick for 45 minutes without experiencing pain. DISCUSSION Procedures of Higher Priority Although opinions may vary when surgeons are deciding the sequence of surgery for rheumatoid patients with multiple joint involvement, most surgeons would agree that some conditions take priority. Conditions that demand urgent orthopaedic attention include the potentially debilitating and life-threatening atlanto-axial instability, which occurs in 50% to 70% of patients with severe polyarticular disease and basilar invagination. 9,11,26 Other musculoskeletal conditions that demand early surgical treatment include compression neuropathy (eg carpal tunnel syndrome), rupture or pending rupture of a tendon, and infected or painful rheumatoid nodules. 3,8,11 General Principles Common presentation of rheumatoid joints includes pain, deformity, instability, and loss of function. Pain is the most debilitating symptom and should thus be af

3 Surgical strategies for rheumatoid arthritis Figure 2 Lateral view of cervical spine in flexion showing a 9-mm subluxation (space between arrows) of the atlanto-axial joint. forded the highest priority in treatment. In general, patients wish the most painful joint to be treated first. Pain is considered the most important indication for surgical treatment, closely followed by loss of function. Deformity is not a strong indication for surgery, unless accompanied by pain. 31,32 A severely deformed rheumatoid hand is often not aesthetically acceptable but usually remains functionally sound. Even in the presence of severe volar subluxation and ulnar deviation at the metacarpophalangeal joints, the handgrip can remain remarkably strong. 31,32 Severe pain can, conversely, stop the patient from performing useful tasks. Nevertheless, deformity of the hands may be the main concern for a young rheumatoid patient who may expect that surgery can restore a normal appearance to the hand. Counselling the patient on realistic expectations is important. 11,31,32 Figure 1 Bilateral hip and knee arthroplasty in a 35-year-old rheumatoid patient. Patients with rheumatoid require long-term treatment, thus establishing a good doctor-patient relationship is vital. Moreover, establishing the patients trust in the surgeon will help the patient cope with surgical complications should they occur, such as deep infection of an arthroplasty. One author has suggested that in order to initiate a long-lasting doctor-patient relationship, one should please the new patient by selecting a win

4 HKJOS Tang WM, Ng KH, Chiu KY ner procedure, that is, a simple procedure with which the surgeon is familiar and which has a high success rate. 8,31,32 A number of winner procedures have been suggested; perhaps surgery for hallux valgus is the classic one. Arthrodesis of the first MTP joint is a relatively simple procedure with a high success rate (>90%) and a zero recurrence rate once the joint is successfully fused. More importantly the procedure relieves pain not just over the first MTP joint, but also the lateral side of the foot because it restores the ability of the big toe to bear weight on walking. 2,5,23 Another important issue is the unrealistic expectations of many patients with regard to surgery; some may be over-optimistic, others may believe that surgery will be no help at all. In Hong Kong, patients with rheumatoid are often referred to orthopaedic surgeons at a late stage of their disease. Most of the patients have had the disease for many years, have been seen by many doctors, and have received a number of therapies. It is therefore not surprising that they are severely depressed and either have no confidence in surgical treatment, or see it as a cure-all. Such unrealistic expectations can severely hamper the clinical outcome of a surgical procedure to an extent that some orthopaedic surgeons might refuse to operate. 11 The orthopaedic surgeon must therefore first understand what the patient wants and expects before making any surgical decisions. Helping the patient to develop reasonable expectations is the key to postoperative satisfaction. 11,31,32 The patient, preferably with his or her family, should be involved in decision-making. Upper Extremity Versus Lower Extremity The authors suggest a higher priority for lower limb reconstruction over upper limb surgery. The lower limb joints, which are weight-bearing structures, can cause more pain and dysfunction than does the joints of the upper extremity. 7,27,30 Virtually all patients would agree that the ability to walk independently preserves their dignity because they no longer need to depend on someone else. Because of the pain and the loss of mobility, patients usually request that their lower limb joints be treated first. For the surgeon, the predictable results of hip and knee arthroplasties make them good winner procedures. The use of walking aids during rehabilitation will also put unnecessarily stress on the delicate upper limb reconstructions if they were performed first. 11 As a result, lower limb reconstruction usually precedes upper limb surgery. Avoiding wheelchair dependency should also be of high priority because a return to ambulation after 6 months of wheelchair confinement is rare. 11 Lower Extremity In the orthopaedic surgery unit where this study was taken, surgery is usually performed in the order of foot, ankle, hip, and lastly, knee. It is important to appreciate the inter-relationships of the mechanical alignment of the weight-bearing lower joints in patients with rheumatoid. Change of alignment at one joint will expose adjacent joints to higher stress; a vicious circle ensues. The valgus deformity of a rheumatoid knee can force the hind foot into pes planovalgus, and lead to collapse of the longitudinal arch of the foot, as well as increase the pronation of the forefoot. On the other hand, a painful and deformed foot can pose extra stress on the proximal joints of the lower extremity, which leads to a change in the mechanical alignment of the lower limb. 14 Dunbar and Alexiades 5,7,11 emphasized the importance of a stable and plantigrade foot and ankle. A deformed foot can be a source of bacteraemia if there is a pressure ulcer; 33 and deserves priority in treatment before reconstruction of the proximal joints. In the presence of a severe valgus deformity of the knee, however, the deformed knee should be realigned prior to reconstruction of the ipsilateral ankle and foot. 5,14 A first MTP joint arthrodesis for hallux valgus is regarded as one of the winner procedures that should be performed as an overture to gain the patient s confidence and to initiate a good doctor-patient relationship. Having a fusion rate up to 95%, arthrodesis of the first MTP joint offers excellent pain relief and good restoration of the weight-bearing ability of the hallux that may reduce lateral metatarsalgia. 5,23 The knee is much more commonly involved than the hip in rheumatoid arthritis. Knee joint involvement is recognised as the single most important reason for loss of walking ability. 8,15,30 Hip destruction necessitating arthroplasty in patients with rheumatoid, which include those with steroid induced avascular necrosis of the femoral head, is uncommon compared with the incidence of knee destruction. 6 If ipsilateral hip and knee are equally involved, however, it is debatable whether hip reconstruction should precede that of the knee. Hip arthroplasty is more of a winner procedure than knee reconstruction 8,11 because rehabilitation following total knee arthroplasty generally demands more cooperation 68 67

5 Surgical strategies for rheumatoid arthritis and effort of the patient. Intraoperatively, total knee arthroplasty usually requires a fair amount of hip flexion. Postoperatively, rehabilitation of the knee generally demands a much more functional range of movement of the ipsilateral hip than that required of the knee after hip arthoplasty. 11 Good hip motion is therefore a pre-requisite to arthroplasty as well as adequate rehabilitation of the ipsilateral knee. 11,29 For these reasons, a hip-first approach is more likely to satisfy the patient than a knee-first approach. An exception occurs when there is a severe fixed flexion contracture of the knee that, left untreated, can lever on the ipsilateral hip arthroplasty and result in dislocation. 3,11 Concern has been expressed about dislocating the hip prosthesis during the process of ipsilateral total knee arthroplasty because extreme hip flexion might be required during the procedure. 21 Thus knee arthroplasty should be done no less than 6 months after an ipsilateral hip arthroplasty. However, hip flexion during the process of total knee arthroplasty is mainly along a plane with minimal abduction or adduction, and it rarely exceeds 90 o. The risk of dislocating a correctly performed total hip arthroplasty is therefore more theoretical than actual. Upper Extremity The nondominant side reconstruction should precede that of the dominant side unless the latter is more severely affected. 4 Most surgeons adopt a proximal to distal approach. The shoulder and elbow position the hand in space, and therefore ipsilateral painful, weak, stiff, or unstable proximal joints may hinder the rehabilitation of hand reconstruction. Deformity of the hand and wrist, however, do not technically affect surgery of the proximal joints and their rehabilitation. 11 For these reasons, reconstruction of proximal joints usually precedes that of the ipsilateral hand and wrist. As with the lower extremities, it is arguable whether shoulder reconstruction should have priority over ipsilateral elbow arthroplasty. Neer 24,25 supported the shoulder-first approach. A mobile and stable shoulder will eliminate the referred pain to the elbow, and free the subsequent total elbow arthroplasty from unnecessary torque in compensation for the ipsilateral stiff shoulder. He also held that shoulder reconstruction should be performed in an early stage so as to prevent insurmountable rotator cuff and glenoid destruction. Others have favoured an elbow-first approach. Total elbow arthroplasty, done before total shoulder arthroplasty, can buy patients significantly more time between the two arthroplasties (45 months compared with 13.4 months). 13,16 In these studies, two thirds of patients claimed that the elbow had caused greater functional limitation than the shoulder. Three quarters of patients obtained a better functional improvement from the elbow reconstruction than from the shoulder arthroplasty. Other workers have argued that a stable, painfree elbow is required not only to allow a proper rehabilitation of the ipsilateral shoulder arthroplasty, 13,20 but to facilitate the correct insertion of the humeral component during total shoulder arthroplasty. 11,22 Ruptured or pending rupture tendon is considered an orthopaedic emergency and requires urgent exploration. In line with the general principle that a proximal (wrist) deformity can lead to distal (hand and digits) involvement, it is generally accepted that the damaged wrist should be repaired first, even if it is not too symptomatic. Restoration of wrist alignment is crucial in maintaining the alignment and balance of distal digits. A painful, deformed wrist will impair hand function regardless of the status of the digits. Metacarpophalangeal joint reconstruction should closely follow wrist re-alignment procedures because metacarpophalangeal joints provide the foundation for digital function. 11 Combination of Surgery Performing more than one joint reconstruction in one surgical session has the advantages of shortening patient suffering, saving operating time and facilitating rehabilitation, especially in polyarthritic patients. 1,11,12,22,28 A number of procedures can be combined in one operation, for instance reconstructing ipsilateral shoulder and elbow, 22 or one-stage bilateral total knee arthroplasty. 1,12 A one-stage arthroplasty of the ipsilateral shoulder and elbow has been described. 22 The elbow operation should be performed first because more accurate positioning of the humeral component can be achieved in the presence of a stable ipsilateral elbow. Others have suggested that in the presence of severe involvement of the ipsilateral shoulder and the elbow, replacing both joints in one operation is required to obtain optimal functional and clinical outcomes. 17,18 Symmetrical involvement of both knees is common in patients with rheumatoid. A contralateral painful knee will jeopardise rehabilitation of the replaced knee if they 69 68

6 HKJOS Tang WM, Ng KH, Chiu KY are not replaced together. 1,12 One-stage bilateral total knee arthroplasty can shorten the overall rehabilitation period and allow earlier ambulation. Since 1995, onestage bilateral knee arthroplasty for patients with rheumatoid and bilateral knee involvement has been performed routinely in the Queen Mary Hospital. REFERENCES 1. Alfaro Adrian J, Bayona F, Rech JA, Murray DW. One- or two-stage bilateral total hip replacement. J Arthroplasty 1999;14: Beauchamp CG, Kirby T, Rudge SR, Worthington BS, Nelson J. Fusion of the first metatarsophalangeal joint in forefoot arthroplasty. Clin Orthop 1984;190: Benjamin A, Hetal B, Copeland S, Edwards J. Selection. In: Surgical repair and reconstruction in rheumatoid disease. 2nd ed. London: Springer Verlag; 1993: Blair WF. An approach to complex rheumatoid hand and wrist problems. Hand Clin 1996;12: Burra G, Katchis SD. Rheumatoid arthritis of the forefoot. 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Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty 1998;13: Scott RD, Sarokhan AJ, Dalziel R. Total hip and total knee arthroplasty in juvenile rheumatoid arthritis. Clin Orthop 1984;182: Sculco TP. The knee joint in rheumatoid arthritis. Rheum Dis Clin North Am 1998;24: Souter WA. General principles of surgical management. In: Lamb DW, Hooper G, Kuczynski K, eds. The practice of hand surgery. Oxford: Blackwell 1981: Souter WA. Planning treatment of the rheumatoid hand. Hand 1979;11: Thomas BJ, Moreland JR, Amstutz HC. Infection after total joint arthroplasty from distal extremity sepsis. Clin Orthop 1983;181: The Authors TANG Wai-Man, FRCSE, FHKAM (Orth Surg), Assistant Professor, Division of Joint Replacement Surgery, Department of Orthopaedic Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong. NG Ka-Ho, FRCSE, FHKAM (Orth Surg), Medical Officer, Department of Orthopaedics and Traumatology, Department of Orthopaedic Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong. CHIU Kwong-Yuen, FRCSE, FHKAM (Orth Surg), Associate Professor and Chief, Division of Joint Replacement Surgery, Department of Orthopaedic Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong