Theodore Fields, MD: I am Dr. Ted Fields at the Hospital for Special Surgery and I am here today with Dr. Brian Nestor, one of our Orthopaedic surgeons. Brian works with us in the comprehensive arthritis clinic, which combines the skills of the rheumatologist and Orthopaedist in the care of patients with arthritis. Brian, what do you feel the important features are with having a team approach to the management of patients particularly rheumatoid arthritis?
Bryan Nestor, MD: Well, as you know, Ted, the comprehensive arthritis program really started in the mid 1960's. We think a comprehensive approach is necessary because of the complexity of this disease. It affects both the musculoskeletal system, as well as the significant extraskeletal involvement. As well, 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 all 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.
Dr. Fields: What are some of the special risks involved in managing a patient with rheumatoid arthritis that you can think about preoperatively?
Dr. Nestor: Well, in terms of surgical risk, there is no question but that patients with inflammatory arthritis and rheumatoid arthritis are at increased risk for infection, both acute as well as late. This is in part due to the disease and in part due to the many remitive agents used the disease. Additionally, other problems with bone quality arise. These patients have significant osteopenias intolerance, which can make obtaining fixation a problem, and also increases their risk for late problem such as periprosthetic fracture. Wound healing and bone quality all put the patient at some increased risk.
Dr. Fields: From a rheumatologist's point of view, we spend a lot of time preoperatively evaluating patients as to whether they may have an unstable cervical spine. How is that a problem for the Orthopaedic and anesthesia management of the patient?
Dr. Nestor: What is important to recognize is that cervical spine involvement 30 to 40 percent of patients will have some type of involvement, and half the time it may be asymptomatic. Therefore, it is important to always consider in the patient careful neurological examination and appropriate radiographs when indicated. The impact it has on the surgical care, if there is significant stability present or neurological change, then the patient even require a operation for stabilization before considering other reconstructive procedures. More commonly, it just simply requires care in the operating room. Regional anesthesia is preferred over a general anesthesia. If there is concern about airway management, we think that intubation will be necessary, then generally, that is done under a very controlled environment, with the patient sedated, and using fiberoptic intubation.
Dr. Fields: When a rheumatologist has a patient with rheumatoid arthritis with polyarticular disease, that we are referring onto the Orthopaedic surgeon, we often wonder which joint will the Orthopaedic surgeon decide to operate on first. It is a problem with the lower extremity, and we also wonder how you think about that in the upper extremity. What is your approach?
Dr. Nestor: In general, we operate on the most involved joint first. When there is bilateral disease-both hips, both knees involved-when possible we prefer to do both joint replacements at the same time under the same anesthesia. 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 and I think the reasons for that primarily are the functional return that we get with elbow replacement, compared to shoulder replacement. Probably, also due to the fact that shoulder arthritis seems to be better tolerated by patients with rheumatoid arthritis. In the lower extremity, the same principles apply. We precede with foot and ankle reconstruction when indicated first, in order for the patient to ambulate. Second is probably the hip, and the reasons for that are that it is an easier rehabilitation. Probably more importantly, successful rehabilitation following knee replacement requires pain-free hip range of motion, so the knee is reconstructed following hip replacement.
Dr. Fields: Brian, what is the state of the art of cemented versus uncemented replacement in the hips, particularly, and what about in other joints?
Dr. Nestor: In terms of types of fixation-which is the first choice the surgeon really has to consider in hip replacement in inflammatory arthritis-probably the preferred method of fixation today for most patients is what we call a hybrid total hip replacement. It takes advantage of uncemented fixation in the acetabulum, which has shown some clear advantages over cemented sockets, and cemented fixations in the femoral component, which still remains the gold standard today. However, in younger patients, we consider using uncemented types of implants, particularly patients with juvenile rheumatoid arthritis and in-patients less than forty with reasonable bone stock. The advantages of an uncemented stem may well come, not so much from the superior fixation, which seems to be as least as good as cement, but no necessarily better, but from long-term considerations. Implant loosening: It may be easier to revise an uncemented component. There may be less bone loss. That is our primary consideration in that age group.
Dr. Fields: The patient in the office of a rheumatologist will often say to us, "I am thinking of having a total joint replacement, but I am afraid that I shouldn't wait until it is too late." They may hear this from friends or even from their primary care doctor. What does an Orthopaedist think about that? When is it too late, or is it ever too late?
Dr. Nestor: Well, for the most part, I think that we are operating to relieve pain and also to restore motion and decrease deformity, thereby improving function. But I think that the patients for the most part have to be comfortable with that decision, and it is based on pain and functional deficit. When I advise patients, I tell them that for the most part those are the considerations. There are some other considerations, for example, extensive bone loss resulting from prolonged disease, but that is something that can be monitored with serial radiographs if there is a concern. Usually those things are slow to progress over several years.
Dr. Fields: What is the state of the art of total elbow replacement today, both in terms of the longevity of the prosthesis, infection rate, and the ability to fix a problem once it develops in the elbow.
Dr. Nestor: Total elbow replacement, I think, has come a long way. Its history, of course, is tarnished with a type of implant that was hinged and was very constrained. It led to loosening rates as high as 50 percent in three to four years. I think more contemporary designs, whether they are unconstrained designs or what we call semi-constrained so-called sloppy hinge, have enjoyed much improved success. Certainly, the functional improvement in these patients is significant. In general, we are looking at ten years survival of 90 percent. The risk of infection does remain higher than in other joints, such as the hip or knee, and that is in part due to the subcutaneous location of the joint as well. The majority of the patients we operate on are with rheumatoid arthritis, which puts them at risk. The salvage of that difficult problem is also being addressed with consideration of reimplantation in a staged manner, similar to what we do in the hip and knee and/or resection arthroplasty.
Dr. Fields: As our final question, let me give you a chance at some broad-ranging comments. Say something about the future of joint replacement: What things can be done to make these prostheses last longer, have less incidence of infection. What are some of things that are going on now?
Dr. Nestor: 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. We know that the biological problem begins with wear debris, which is generated and the body's reaction to that. I think that as we move forward, we will continue to try to improve fixation, either through coatings of the implants or improvement in design and technique. There is also a big effort today improve the bearing surfaces to try to reduce the very wear debris that causes the problem of loosening. There are alternative bearing surfaces being at in the hip, ceramic-on-ceramic, metal-on-metal, and I think that those are some of the advances in the future that will lead to improvement in the longevity of total joint replacement. Additionally, medical management of the problem of osteolysis also holds some promise for the future.
Dr. Fields: Thank you very much.
Dr. Nestor: Thank you, Ted.
Dr. Nestor was interviewed by Dr. Theodore R. Fields, Internet Project Director, HSS Division of Rheumatology, Director, HSS Rheumatology Faculty Practice Plan, Associate Professor of Clinical Medicine, Weill Medical College of Cornell University
