Knee Surgery for Rheumatoid Arthritis.
Last updated Thursday, February 10, 2005
Review of the conditionCharacteristics of rheumatoid arthritis of the knee As with any other joint in the body, the knee joint can be destroyed by rheumatoid arthritis.
This can lead to pain, stiffness, deformity, and disability. Pain is
typically aggravated by weight bearing activity. It often occurs at
rest and interferes with sleep in later stages. Incidence and risk factors Knee involvement by RA is more common than hip involvement.
Approximately 20-30% of patients with RA will have knees affected by
this disease.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. Standard x-rays of the knees with the patient
standing are obtained. 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 knee has set in, there are no specific
exercises that can stop or arrest the development of deformity and
joint 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 knee surgery for rheumatoid arthritis Surgery can reduce the pain and swelling caused by synovitis
associated with RA, and can correct the loss of cartilage and bony
destruction associated with later stages of the disease. Types of surgery recommended
Who should consider knee surgery for rheumatoid arthritis? RA patients who have unrelenting knee pain and destructive arthritis of
their knee joint that does not respond favorably to medical management
should consider total knee replacement. RA patients with knee
involvement in early stages, who do not yet have destructive arthritis,
yet have pain and synovitis that does not respond to medical
managementun should consider knee arthroscopy.What happens without surgery? The best case scenario includes inactivity and decreased mobility in
conjunction with antirheumatic medication and intraarticular steroids
can cause some improvement of symptoms.
A worst case scenario might be severe destruction of the knee joint
and associated osteoporosis and reduced physical capacity potentially
leading to a compromised knee replacement at a later stage with a less
predictable outcome. Surgical options In early stages, arthroscopic or open synovectomy can be of benefit.
In later stages, when the joint space has been destroyed, bony
destruction and deformity has occurred and knee stiffness has set in,
total knee replacement is the optimal and most reliable treatment.Effectiveness Knee replacements in RA are extremely successful. More than 80% of patients will have a satisfactory result for 12-15 years.Urgency Knee 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 Infection, component failure and nerve damage are the most serious
complications. Infection occurs in approximately 4% of patients with RA
which is higher than in the osteoarthritis patient population. This is
thought to be due to systemic immune compromise, frail skin and
impaired wound healing. Peroneal nerve injury can occur with correction
of severely deformed knees. Postoperative stiffness is common and may
be aggravated by generalized muscular weakness and disability.
Managing risk These complications can necessitate a revision knee 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 knee replacement can be done. Wound complications may
require additional surgery. Nerve injuries are managed by special knee
positioning and modified rehabilitation.Costs For the University of Washington systems please contact the Bone & Joint patient coordinators:
- Erin Kerber: (206) 598-6293
- Monette Manio, RN: (206) 598-4288
Surgical team Knee 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
knee RA.
Technical details The knee joint will be exposed surgically by incising the quadriceps
tendon and the inverting the knee cap. The joint surfaces are then
excised and replaced with metallic femoral and tibial components
cemented to the precut surfaces. A polyethylene liner is attached to
the tibia component, and the knee joint is closed.
Anesthetic An epidural anesthetic combined with a light general anesthetic is usually used.Length of knee surgery for rheumatoid arthritis Depending on the complexity of the case, most surgeries last approximately 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 physical therapist starts with a rehabilitation program on day one
post-surgery. Trained nurses observe the patient in the ward. The
surgeon and the surgical team evaluate the surgical incision daily and
the patient normally gets discharged on the 4th day. The epidural
catheter and bladder catheter are normally removed within 24 to 48
hours.
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. Knee range of motion is begun on the second postoperative day, and is combined with quadriceps strengthening exercises. 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 exercises are provided by the physical therapist. The patient is
seen approximately two weeks after surgery to remove staples and
stitches and to check the wound and to make sure the rehabilitation is
going according to plan.Convalescent assistance Most patients go home after 4 days in the hospital, provided that
there is someone to help them with the activities of daily living. 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 Daily active self directed exercise and regular supervised physical
therapy is essential to achieve and maintain good range of motion and
restore muscle strength and mobility in the first 6-8 weeks after
surgery.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 therapists office as
needed. If the patient is unable to travel outside the home, therapy at
home can usually be arranged.
This therapy normally lasts 6-8 weeks and should be continued until
the patient has a satisfactory range of motion and muscular strength is
restored. Returning to ordinary daily activities Patients normally walk unaided by 6 weeks and can comfortably do normal activities at 3 months.Long-term patient limitations Patients are normally encouraged to remain active. Walking,
recreational biking, and swimming or water aerobics are encouraged.
Downhill skiing, running and contact sports are discouraged.Surgery for Rheumatoid arthritis of the knee 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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