Theodore Fields, MD: Why is a team approach so valuable in patient management, especially for patients with rheumatoid arthritis?
Bryan Nestor, MD: A comprehensive approach is necessary because of the complexity of this disease. It affects both the musculoskeletal system, as well as the significant extra-skeletal involvement. There is a need for coordinated care, not only between the Orthopaedist from the surgical side, and the rheumatologist from the medical side, but nursing care, physical therapy, occupational therapy. The patients themselves really are part of the team. It is through this team approach that we are able to effectively deal with the complex nature of rheumatoid and inflammatory arthritis.
Theodore Fields, MD: What are some of the special risks involved in managing a patient with rheumatoid arthritis that you can think about before surgery?
Bryan Nestor, MD: Patients with rheumatoid arthritis are at increased risk for infection – due to both the disease and the many medications used to treat it. They also may have problems with wound healing. In addition, problems with bone quality may arise. People with rheumatoid arthritis may have significant loss of bone density, which can make fixing a joint replacement difficult. It also increases their risk for later fracture around the replacement.
Theodore Fields, MD: Rheumatologists carefully evaluate whether a patient may have an unstable cervical spine. How might that be a problem during orthopedic surgery?
Bryan Nestor, MD: About 30% to 40% have some type of cervical spine involvement, and half the time it causes no symptoms. It's important to assess this before surgery with careful neurological examination and, sometimes, X-rays. If there is significant instability or neurological change, the patient may even require an operation for stabilization before considering other reconstructive procedures. More commonly, it just simply requires special care in the operating room. For example, we are more likely to use regional anesthesia rather than general anesthesia. If we do general anesthesia, special care is taken.
Theodore Fields, MD: When a patient has problems with multiple joints, how do you decide which join to operate on first?
Bryan Nestor, MD: In general, we operate on the most involved joint first. When there is bilateral disease – both hips and or both knees have problems – when possible, we prefer to do both joint replacements at the same time. This makes rehabilitation easier for the patient. In terms of which joint to do first, if we think of the upper extremity, the function of the shoulder and elbow are to position a functional hand in space. So, reconstruction of the hand and wrist take precedence over reconstruction of the shoulder and elbow. Second is probably the elbow because of the improved function provided by elbow replacement, compared to shoulder replacement. In addition, shoulder arthritis seems to be better tolerated by patients with rheumatoid arthritis. In the legs, the same principles apply. We precede with foot and ankle reconstruction when indicated first, in order for the patient to be able to walk. Second is probably the hip because it is an easier rehabilitation. Successful rehabilitation following knee replacement requires pain-free hip range of motion, so the knee is reconstructed after hip replacement.
Theodore Fields, MD: Sometimes you cement the joint replacement into the bone. Sometimes you don't cement them, using porous replacements that allow new bone to grow into the replacement. What is the state of the art these different types of fixation?
Bryan Nestor, MD: The preferred method for in hip replacement for patients with inflammatory arthritis is a hybrid total hip replacement. We use uncemented fixation in the part that gets implanted into the pelvic bone (at the acetabulum); this has shown some clear advantages over cemented sockets. Then we use cemented fixation in the part that gets inserted into the top of the leg (the femoral component), which still remains the "gold standard." However, in younger patients, we consider using totally uncemented types of implants, particularly patients with juvenile rheumatoid arthritis and in those under forty with reasonably dense bone. In younger patients who need their implants to last longer, there seems to be less risk of loosening with uncemented fixation – and if a revision surgery is eventually needed, it may be easier with an uncemented component. There
Theodore Fields, MD: Some patients say "I am thinking of having a total joint replacement, and I am afraid that I shouldn't wait until it is too late." When is the right time?
Bryan Nestor, MD: Patients have to be comfortable with their decision, and it should be based on pain and problems with daily function. We operate to relieve pain, to restore motion, and to decrease deformity, thereby improving function. There are some other considerations, such as extensive bone loss resulting from prolonged disease, but they can be monitored with X-rays. Usually those things are slow to progress over several years and, if spotted in time, need not prevent joint replacement.
Theodore Fields, MD: What is the state of the art of total elbow replacement today?
Bryan Nestor, MD: Total elbow replacement has come a long way. Its history was tarnished by an older type of implant that did not have good function and often loosened within a few years. Today's designs have enjoyed much improved success. Certainly, the functional improvement in these patients is significant – and the implant last at least 10 years in 90% of patients.
Theodore Fields, MD: What's the future of joint replacement? What can be done to make them last even longer?
Bryan Nestor, MD: Well, the number one problem facing us in total joint replacement today is implant loosening. There is a lot that we understand about implant loosening. Today we know that it is both a mechanical and a biological problem. I think that we will continue to try to improve fixation, either through coatings of the implants or improvement in design and technique and other advances. These improvements will lead to increased longevity for total joint replacement.