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TKA in patients with young age, rheumatoid arthritis requires special attention
Despite improvements in TKA, indications remain narrow for young patients and patients with rheumatoid arthritis, according to a presenter.
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LONDON — Total knee arthroplasty performed for osteoarthritis has gradually shown better outcomes with longer follow-up and an endpoint of implant revision. Much of that progress is due to an improved surgical technique and more orthopaedic surgeons who are better skilled in performing total knee arthroplasty, according to orthopaedic surgeon Jan Victor, MD, PhD.
Victor, who is chairman of the Department of Orthopaedics at Ghent University Hospital in Ghent, Belgium, presented the results of total knee arthroplasty (TKA) in patients with end-stage osteoarthritis (OA) and addressed some special consideration when performing TKA in young patients and patients with rheumatoid arthritis (RA) in a presentation at the EULAR Annual Congress, here.
He noted proper patient selection is still difficult to execute and treatment of patients who are young or who have RA is an area in which there are many conflicting opinions on the best indications.
“You need to be careful in proceeding with knee arthroplasty for degenerative OA in younger patients,” Victor said.
Be aware of expectation levels
Regarding younger patients who undergo TKA, Victor said, “If you look in all honesty to the data of outcomes and revision, it is clear the single most important common denominator for early revision is young age, with dissatisfaction being the main driver.”
Victor cited a study by Bourne and colleagues that found dissatisfaction with the results of TKA performed for degenerative OA in 20% of patients in their cohort.
“The strongest predictor of dissatisfaction was the fact [that] the expectations of the patients for the result and outcome of the operation were not met,” he said.
According to data from the Australian Orthopaedic Association National Joint Replacement Registry, which Victor discussed in his presentation, young patients also did not achieve good results with unicompartmental knee arthroplasty (UKA).
“Young patients fare a lot worse than the older patients, with revision rates up to 25% at 12 years” after UKA, he said.
RA findings
In general, there has been a dramatic and significant decline in orthopaedic total joint arthroplasty (TJA) performed in patients with RA, Victor said, noting arthroscopic synovectomy and soft tissue procedures for contractures are now rarely done in patients with RA.
Furthermore, recent studies into TJA in patients with RA “clearly show the advent of [disease-modifying antirheumatic drugs] DMARDs and biological drugs has steeply declined the need for orthopaedic interventions,” he said.
In addition, where the focus of treatment for patients with RA was once solely on the joints, it has now shifted to an overall wellness view with the goal of returning patients to a functional, more independent lifestyle.
Timing of surgery is critical
Should TJA be indicated for a patient with RA, Victor said, “If you wait too long in this group, you can have major disasters.”
He noted joint dislocation, severe joint deterioration and deformity may be avoided when there is timely and careful decision-making regarding TJA in patients with RA.
“Infection is our greatest enemy in rheumatoid patients” and that complication, which is best treated prophylactically, can affect the short-term and long-term outcomes in this population, Victor said.
He also urged physicians to look for cervical spine problems that can be exacerbated by anesthesia during TJA surgery in patient with RA.
“If they go unnoticed, complications can be devastating. Even death can result if you do not know about a condition of the cervical spine,” Victor said.
Temporomandibular joint stiffness can also occur in patients with RA related to the administration of surgical anesthesia, he noted. – by Susan M. Rapp
- References:
- Bourne RB, et al. Clin Orthop Relat Res. 2010;doi:10.1007/s11999-009-1119-9.
- Victor J. Joint replacement for end-stage osteoarthritis: The holy grail?! Presented at: EULAR Annual Congress; June 8-11, 2016; London.
- For more information:
- Jan Victor, MD, PhD, can be reached at Ghent University Hospital, Chairman of Orthopaedics, De Pintelaan 185, 9000 Ghent, Belgium; email: j.victor@skynet.be.
Disclosure: Victor reports he receives research support from Zimmer Biomet and Corin U.S.A., and he receives royalties from Smith & Nephew.