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Introduction: The
knee is one of the most commonly affected joints in patients suffering from
chronic rheumatoid arthritis (20-30%) requiring operative intervention. The
course of rheumatoid arthritis varies from mild disease to severe joint
destructive variant that progress rapidly, leading to unremitting pain and
joint deformity. We conducted this study to evaluate outcomes of total knee
arthroplasty in patients with rheumatoid arthritis of knee.
Materials
and methods: This is a Prospective study of 50 total knee replacements
performed for Rheumatoid Arthritis Knee. Patients having less than 18 months
follow-up, stress fracture tibia, previous unilateral TKR were excluded. The
outcomes were measured by WOMAC and KSS scores. Comparison of outcomes was made
with other similar studies of TKR in RA and OA knee patients.
Results:
Rheumatoid arthritis of knee requiring operative intervention is more common in
females as compared to males (~3:1) with average age at intervention being 63
years. Improvement of 27.5 and 37.75 points were noted in KSS and WOMAC scores
respectively at the end of 18 months following arthroplasty. Complications are
more frequent in patients having RA undergoing TKA when compared to OA group.
Conclusion: Total
Knee Arthroplasty significantly improves functional outcomes of patients with
rheumatoid arthritis of knee. However, complications are more frequent
following the procedure and should be anticipated before operating such cases.
Keywords: Total
knee replacement, Rheumatoid arthritis, Knee joint
Abbreviations: RA:
Rheumatoid Arthritis; OA: Osteoarthritis; TKA: Total Knee Arthroplasty; TKR:
Total Knee Replacement; MHC: Major Histocompatibility Complex; PS: Posterior
Stabilized; KSS: Knee Society Score; WOMAC: Western Ontario and McMaster
Universities Osteoarthritis Index; DMARD: Disease Modifying Anti-Rheumatoid
Drugs
INTRODUCTION/OBJECTIVE
Rheumatoid arthritis
is a chronic inflammatory disease of joints affecting 1% of the population
worldwide. It is an auto-immune condition characterized by hyperplasia of the
synovial lining cells, angiogenesis, and infiltration of mononuclear cells
resulting in pannus formation, cartilage erosion and ultimately joint
destruction [1,2]. This
disease most often affects the distal joints symmetrically, for example, the
small joints of hands, feet; wrists and knees. RA is 2 to 3 times more common
in females than males [3,4]. RA typically manifests with signs in
inflammation, with the affected joints being swollen, warm, painful and stiff,
particularly early in the morning on walking or following prolonged inactivity.
Increased stiffness early in the morning is often a prominent feature of the
disease and typically lasts for more than an hour [5]. A family history of RA
increases risk around three to five times. RA is strongly associated with genes
of the inherited tissue type major histocompatibility complex (MHC) antigen
HLA-DR4, HLA Dw16 are the major genetic factors implicated [6,7].
MATERIALS AND
METHODS
This is a Prospective study of 50 total knee
replacements performed for Rheumatoid Arthritis Knee during March 2016 to March
2017 operated at a tertiary care hospital by single surgeon and his team.
Inclusion criteria
·
Patients having unilateral/bilateral
knee pain with radiographic findings suggestive of arthritis of knee joint
·
Patients fulfilling ACR-EULAR criteria9
for diagnosis of RA with arthritis of knee
·
Patients having documented seropositive
RA with arthritis of knee
Exclusion criteria
·
RA Patients with stress fracture tibia
·
Less than 18 months follow up
post-operatively
·
Patient operated for unilateral TKR
previously
·
Patients with other associated systemic
disease
Prior informed consent was obtained for all
the patients before getting enrolled into the study. After routine
pre-operative fitness, patients were operated for total knee replacement.
DMARDs were modified/continued as per individual drug protocol. Mid
para-patellar approach was used in all the patients with PS (Posterior
stabilized) implants. Patelloplasty was performed in patients in whom patellar
articular surface was found completely eburnated intraoperatively. Post
operatively, patients were followed-up for minimum of 18 months and functional
outcomes measured by KSS and WOMAC scores. Comparison of outcomes was made with
our own data of operated knee replacement patients for osteoarthritis and other
similar studies. Special note of all complications was made and their
management and outcomes were also included in the study (Table 1).
WOMAC score [11]
The Western Ontario and McMaster Universities
Osteoarthritis Index
Scale of difficulty: 0=none, 1=Slight,
2=Moderate, 3=Very, 4=Extremely
Pain
1.
Walking
2.
Stair Climbing
3.
Nocturnal
4.
Rest
5.
Weight bearing
Stiffness
1. Morning
stiffness
2. Stiffness
occurring later in the day
Physical function
1. Descending
stairs
2. Ascending
stairs
3. Rising
from sitting
4. Standing
5. Bending
to floor
6. Walking
on flat surface
7. Getting
in/out of car
8. Going
shopping
9. Putting
on socks
10. Lying
in bed
11. Taking
off socks
12. Rising
from bed
13. Getting
in/out of bath
14. Sitting
15. Getting
on/off toilet
16. Heavy
domestic duties
17. Light
domestic duties
Total Score: ______ / 96 = _______%
RESULTS
There were total of 50 patients enrolled in our study with average age of the patients being 63 years (range-55 to 71 years) at the time of surgery. There were 37 females and 13 males in our study with female to male ratio being 2.85:1. Average duration of hospital stay was 6 days. All the patients were mobilized on 1st post-operative day barring exceptions. Complications our studies are shown in the charts below (Chart 1). Cardiopulmonary complication, wound infection, ICU admission and electrolyte imbalance were the early observed complications while deep infection and revision surgery were the late complications.
Comparison of KSS and WOMAC score observed in our study were as shown in Table 2 [10,11].
DISCUSSION
This is a prospective study of 50 total knee
arthroplasty performed in patients with RA knee. The average age of patients in
our study at the time of intervention was 63 years. Out of the 50 patients in
our study 37 were females and 13 were males, stressing on the fact that more of
the females ultimately get the total knee replacement done than male. All the
patients were mobilized on 1st post-operative day barring few restrictions
like, lack of confidence on patient’s behalf, ICU admissions.
All the patients in our study underwent a thorough preoperative investigations – ECG, chest X-ray, 2D echo, all the relevant blood investigations, medical and surgical advises taken in case of respective comorbidities. Bilateral knee anteroposterior (standing) lateral radiographs were taken. Pre op evaluation of deformity was done by measuring tibiofemoral angle and Hip knee axis (Table 3). When such radiographs were not feasible, pelvic radiographs were used to determine the distal femoral valgus cut. Valgus deformity was more common occurrence in RA when compared to OA which is similar to findings of other studies [12]. All the patients were given antibiotic prophylaxis preoperatively. Protocols we followed for DMARDs is described in table below [13].
The results obtained in our study are
compared with various previous established studies [14,15] (Table 4).
Reddy
et al. [15] study did not show any complication while our study showed a few
complications described above. Wound complications and infection in RA patients
were noted to be one of the most common and statistically significant
complications in our study over OA patients (p<0.05). Apart from it,
hemoglobin level was lesser in this group and required more average units of
transfusion. Bone was found comparatively weaker in RA patients as compared to OA
patients intra-operatively and skin of RA patients was observed to be thinner
and more fragile than OA patients as per authors’ observation. However, no
quantifiable measurement could be stated for the same. Though we did not
replace patella in most of the patients, it was observed by the authors that
patella was shallower in RA patients and there can be higher chances of
fracture due to this attribute. RA also is associated with the increased risk
of peri-prosthetic fracture [16], but no such case was observed in our study.
However, as many as 21 patients were put on AK-BK brace post-operatively for
walking to have added support while walking. Other complications in our study
included cardiopulmonary, electrolyte imbalance. However, their occurrence was not
statistically significant over OA patients.
Average KSS score at the 18 months follow-up
was 72.5 with average improvement of 27.5 points over pre-operative scoring.
Average WOMAC score at the 18 months follow-up was 42 with average improvement
of 37.75 points over pre-operative scoring. Both these improvements were noted
to be statistically significant (p<0.05) when compared to pre-operative
status suggesting improved quality of life of RA patients post-TKR.
CONCLUSION
Total Knee Arthroplasty significantly improves functional outcomes in patients of RA knee. Complications like wound complications and infection, though less, are more common following TKA when compared to OA. So appropriate patient counselling along with properly performed operative procedure are advisable for TKA in RA knee patients.
1. Gibofsky
A (2014) Epidemiology, pathophysiology and diagnosis of rheumatoid arthritis: A
synopsis. Am J Manag Care 20: S128-135.
2. Grassi
W (1998) The clinical features of rheumatoid arthritis. Eur J Radiol 27:
S18-24.
3. van
Vollenhoven RF (2009) Sex differences in rheumatoid arthritis: more than meets
the eye. BMC Med 7: 12.
4. Linos
A, Worthington JW, O'Fallon WM, Kurland LT (1980) The epidemiology of
rheumatoid arthritis in Rochester, Minnesota: A study of incidence, prevalence
and mortality. Am J Epidemiol 111: 87-98.
5. Sierakowski
S, Cutolo M (2011) Morning symptoms in rheumatoid arthritis: A defining
characteristic and marker of active disease. Scand J Rheumatol 125: 1-5.
6. Choy
E (2012) Understanding the dynamics: Pathways involved in the pathogenesis of
rheumatoid arthritis. Rheumatology Oxford 51: v3-11.
7. Grassi
W, De Angelis R, Lamanna G, Cervini C (1998) The clinical features of
rheumatoid arthritis. Eur J Radiol 27: 18-24.
8. Schäfer
VS, Schmidt WA, Backhaus M, Hartung W (2016) Arthritis of the knee joint in
rheumatoid arthritis. Open Rheumatol J 10: 81-87.
9. Aletaha
D, Neogi T, Silman AJ (2010) Rheumatoid arthritis classification criteria: An
American College of Rheumatology/European League against Rheumatism
collaborative initiative. Arthritis Rheum 62: 2569-2581.
10. Insall
JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical
rating system. Clin Orthop Relat Res 248: 13-14.
11. Bellamy
N (1995) WOMAC osteoarthritis index user guide. London (Ontario, Canada):
University of Western Ontario.
12. Lee
JK, Choi CH (2012) Total knee arthroplasty in rheumatoid arthritis. Knee Surg
Relat Res 24: 1-6.
13. Howe
CR, Gardner GC, Kadel NJ (2006) Perioperative medication management for the
patient with rheumatoid arthritis. J Am Acad Orthop Surg 14: 544-551.
14. Memon
MN, Noor SS, Najjad MK, Zia OB, Ghilzai AK (2016) Functional outcome of total
knee replacement in patients with rheumatoid arthritis. J Pak Ortho Assoc 28:
67-70.
15. Reddy
AK, Rao AS, Reddy AVG (2013) Functional outcome of total knee replacement in
patients with rheumatoid arthritis – A prospective study. Journal Medical
Thesis 1: 20-22.
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Table 1 -
Table 2
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Table 3
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Table 4
-
Table 5
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