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Young Patient Age, Rheumatoid Arthritis Diagnosis in TKA Require Special Attention
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Total knee arthroplasty performed for osteoarthritis has gradually shown better outcomes in cases with longer follow-up with 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 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) at the EULAR Annual Congress in London. He also addressed some special considerations when performing TKA in young patients and in patients with rheumatoid arthritis (RA).
Proper patient selection is still difficult to execute and the treatment of patients who are young or who have RA is an area with many conflicting opinions on the best indications, he noted.
“You need to be careful in proceeding with knee arthroplasty for degenerative OA in younger patients,” Victor said.
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 the expectations of the patients for the result and outcome of the operation were not met,” he said.
In general, there has been a dramatic and significant decline in orthopaedic joint replacement surgery performed in patients with RA, Victor said. Recent studies into total joint arthroplasty 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 the joints, at one time, it has now shifted to an overall wellness view of the patient and returning him or her to a functional, more independent lifestyle. He urged orthopaedic surgeons to not wait too long to perform TKA in patients with RA and to be prepared to encounter flexion contractures, as well. In patients with RA, physicians should also look for cervical spine problems which can be exacerbated by anesthesia during TKA. At the worst, this problem could be fatal and, at the least, temporomandibular joint stiffness can occur related to the administration of anesthesia.
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.
Disclosure: Victor reports he receives research support from Zimmer Biomet and Corin U.S.A., and receives royalties from Smith & Nephew.