Hip Surgery for Rheumatoid Arthritis.
Last updated Thursday, January 06, 2005
Review of the conditionCharacteristics of rheumatoid arthritis of the hip As with any joint in the body, the hip joint can be destroyed by rheumatoid arthritis.
This can lead to pain, stiffness, and disability. Pain associated with
destruction of the hip joint typically occurs in the groin, upper outer
thigh, and/or buttock. In the early stages of the disease it is
aggravated by weight bearing activity. Later, it occurs at rest and can
interfere with sleep.Incidence and risk factors Hip joint involvement by RA is less common and occurs later than other major joints, such as the knees.Diagnosis A thorough history will determine the patient?s overall health and
functional capacity. Examination of the spine, hips, knees, ankles and
feet for joint range of motion and deformity is done. Radiographs
(X-rays) of the involved joints are obtained. These usually include
neck X-rays in which the patient is first asked to bend their head
forward, then backward. Occasionally, an MRI scan, CAT scan (CT), or
Bone-scan may be necessary.Medications In early stages of RA, anti-inflammatory medications can be effective in decreasing pain and may slow the progression of joint destruction caused by RA.Exercises Once joint destruction of the hip has set in, there are no specific
exercises that can stop or arrest the development and progression of
destruction. Regular range of motion exercises and weight bearing
activity are important in maintaining muscle strength and overall
aerobic (heart and lung) capacity, and help prevent the development of
osteoporosis, which can complicate later treatment. Possible benefits of hip surgery for rheumatoid arthritis Total hip replacement very effectively eliminates the pain caused by RA of the hip. Who should consider hip surgery for rheumatoid arthritis? RA patients who have unrelenting hip pain and destructive arthritis of
their hip joint that does not respond favorably to medical management
should consider total hip replacement. RA patients with hip involvement
in early stages, who do not yet have destructive arthritis, yet have
unexplained debilitating pain should consider hip arthroscopy.What happens without surgery? The best case scenario includes inactivity and decreased mobility in
conjunction with antirheumatic medication and steroids can cause some
improvement of symptoms.
A worst case scenario might be severe destruction of the hip joint
and associated osteoporosis and reduced physical capacity potentially
leading to a compromised hip replacement at a later stage with a less
predictable outcome. Surgical options Total hip replacement is the treatment of choice for patient with
rheumatoid arthritis with destroyed hip joints. Occasionally, hip
arthroscopy is indicated in patients with early RA of the hip.
Effectiveness More than 80% of patients will have a satisfactory result for 12-15 years after hip replacement surgery.Urgency Hip replacement surgery is an elective procedure and should be done
only after non-surgical medical management has failed. Once indicated,
postponing the surgery for an extended period of time (months or years)
only leads to increased disability, disuse osteoporosis, and skeletal
complications that can make surgery more difficult and potentially
compromise the final result.Risks The most common risks of hip replacement surgery for RA are infection,
dislocation of the hip joint, and mechanical failure due to loosening
of metal components from the bone. Mechanical loosening occurs in
approximately 13% over 12 years and is mostly due to loosening of the
metal socket. Infections and dislocations occur in approximately 2% of
patients. Infection and dislocation can cause early failure and might
prohibit a good result.Managing risk These complications can necessitate a revision hip replacement. If an
infection occurs then the prosthesis needs to be removed. A six week
period of antibiotic treatment is needed and if the infection is cured
a revision hip replacement can be done. If the hip dislocates, it needs
to be relocated in the emergency room with sedation or in the operating
room under anesthetic. Recurrent dislocations can lead to revision hip
replacement surgery.Costs For the University of Washington systems please contact the Bone and Joint Clinic and patient coordinators:
- Erin Kerber: (206) 598-6294
- Monette Manio, RN: (206) 598-4288
Surgical team Hip replacement in a patient with RA requires an experienced
orthopaedic surgeon with a strong total joint background and the
resources of a large medical center. Patients with RA have complex
medical needs and around surgery often require immediate access to a
multiple medical and surgical specialties and in-house medical,
physical therapy, and social support services.Finding an experienced surgeon Contact:
- MEDCON (206) 543-5300
- American Academy of Orthopaedic Surgeons: (800) 346-AAOS
- Washington State Medical Society: (206) 441-9762 (Will connect to local County Medical Society)
Facilities A large hospital, usually with academic affiliation and equipped with
state of the art radiologic imaging equipment and Intensive Medicine
Care Unit is clearly preferable in the care of patients with hip RA.Technical details The surgeon will expose the affected area of the hip through an incision over the bony prominence at the upper outer thigh. This allow for dislocation of the hip, removal of the head of the femur and cleaning of the destroyed socket without damaging the major hip muscles. After being machined to a perfect hemisphere, the socket is replaced by a metal cup fixed directly to bone. A special plastic liner is inserted into the cup. A metallic femoral component is then fitted directly to bone or alternatively cemented into the femur. A metal or ceramic ball is then fit onto the femoral component and the new hip joint is reduced, and the surgical incision closed.Anesthetic Typically an epidural anesthetic with a general anesthetic is used for this type of surgery.Length of hip surgery for rheumatoid arthritis Depending on the complexity of the case, most surgeries last 2 hours.Pain and pain management Analgesics administered through the epidural catheter placed for
surgery are very effective for controlling postoperative pain and are
used for approximately 48 hours. Patient controlled intravenous
narcotics can be used as a substitute for or supplement to epidural
analgesics. By the third postoperative day oral narcotics are usually
sufficient for pain relief, and are quickly tapered according to
individual patient needs. After that oral narcotics are administered
and provided for the first two to four weeks after the patient has been
discharged.
These medications are very effective in relieving the pain
associated with total hip replacement. Dryness in the mouth,
sleepiness, lightheadedness and constipation are the most frequent side
effects of narcotic medications. The most serious side effect is
suppression of respiration. Hospital stay The patients are cared for in the hospital by trained nurses and
doctors. Mobilization begins immediately after surgery in the hospital
bed. Surgical wound dressings are changed daily beginning on the second
postoperative day.Recovery and rehabilitation in the hospital 90% of recovery takes place within the first six weeks. Rehabilitation
begins on the first postoperative day. It starts with sitting or
standing at the bedside and progresses to walking with assistance and
stair climbing. Precautions to prevent dislocation of the hip are
taught. Instruction in the use of assistive devices is given.Hospital discharge The patient is discharged with oral narcotics to ensure comfort at
home. Patients are usually ambulatory with a walker and independently
mobilize from bed to walking. Physical activity and joint range of
motion limitations are clearly provided by the physical therapist,
mainly to prevent dislocation of the hip. The hip can only be flexed up
to 60 degrees, the patient has to sleep with a pillow between the legs
and is not allowed to cross the legs for the first six weeks after
surgery.
Convalescent assistance Most patients go home after 4-5 days. In the hospital they do though
need some help for basic care especially those people with multiple
joint involvement. If they do not have help at home then a short stay
at a rehabilitation/convalescent facility will be necessary until they
can resume independent living.
Physical therapy Very little physical therapy is required after total hip arthroplasty.
Therapists reinforce hip precautions, supervise ambulation, and provide
muscle strengthening.Rehabilitation options Physical therapy begins with the inpatient rehabilitation described
above. After returning home, physical therapy can continue with the
therapist coming to the patients home or in the therapist's office as
needed. Most people do not require any physical therapy outside the
home.
Only a small number of patients need therapy after 6 weeks--mostly to help them achieve a normal gait. Returning to ordinary daily activities At 6 weeks most of the hip dislocation precautions can be stopped.
Patients can then can sit with hips flexed at 90 degrees, sleep without
a pillow between the legs and can walk without a walking aid. Most
ordinary daily activities can be resumed.Long-term patient limitations We do not recommend high impact activities like down hill skiing,
running and jumping. The patient should always avoid putting shoes on
with the hip in flexion and internal rotation, and should avoid sitting
on low stools. Lifetime prophylactic antibiotic therapy is recommended
prior to dental procedures or any invasive diagnostic procedure (i.e.
colonoscopy).
Surgery for rheumatoid arthritis of the hip at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.
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