Surgery of the rheumatoid knee

Thromboembolic disease in patients with rheumatoid arthritis undergoing joint arthroplasty: Update on prophylaxes

The risk of venous thromboembolism (VTE) in rheumatoid arthritis (RA) and the higher incidence of RA patients undergoing major orthopedic surgery is well recognized. The objective of the present study is to describe the incidence of VTE and discuss the correct prophylaxis in RA patients undergoing knee or hip replacement. A systematic review of studies on thromboprophylaxis in RA patients undergoing major orthopedic surgery was performed. Detailed information was extracted to calculate the rate of VTE in RA orthopedic patients and analyze the thromboprophylaxis performed and bleeding complications. Eight articles were eligible for full review. No difference in the overall rate of VTE was observed between RA patients and controls. No significant differences were found in RA patients in terms of bleeding complications. The data on the optimal prophylaxis to be used in RA patients were insufficient to recommend any of the several options available. In the absence of dedicated guidelines for the care of RA patients undergoing orthopedic surgery, management must be individualized to obtain favorable patient outcome, weighing up all the factors that might put the patient at risk for higher bleeding and thrombotic events.

Cementless total knee arthroplasty in chronic inflammatory rheumatism

INTRODUCTION

We report a short-term monocentric retrospective evaluation of cementless total knee arthroplasty (TKA) in a population suffering from chronic inflammatory rheumatism.

MATERIALS AND METHODS

We have reviewed 23 patients (34 knees) with an average age of 55 years (range 26-78), bearing a TKA for chronic inflammatory rheumatisms with a 6-year follow-up (range 3-12); 78% suffered from rheumatoid arthritis and 15% from juvenile rheumatoid arthritis. We used a cementless total prosthesis sacrificing the posterior cruciate ligament and bearing an ultra-congruent rotational tibial insert, the Natural Knee (NK2™) (Zimmer(®), Warsaw, IN, USA). At last follow-up, an independent surgeon performed a clinical assessment for pain, function and quality of life using International Knee Documentation Committee score, International Knee Society (IKS) score and Devane's score. A radiographic study evaluated secondary fixation according to the radiographic index of the Knee Society and according to Ewald's score.

RESULTS

The mean postoperative IKS score was 83 points (range 40-100) for the knee score and 74 points (range 20-100) for the function score. Radiographic assessment came across only one case of loosening, concerning the tibial component on an asymptomatic patient. We came across the following complications: 1 early infection, 2 important postoperative flessum deformity having needed an arthrolysis, 1 supracondylar fracture of the femur and 1 fracture of the patellar component. Survival rate at 6-year follow-up is 97% taking into account one case of revision.

CONCLUSION

Non-cementation of this implant in chronic inflammatory rheumatism does not result in a higher rate of loosening. In this series, patients own satisfaction, function of the knee and survival rate are rather good.

LEVEL OF EVIDENCE

Retrospective, no control group, Level IV.

Joint lavage for treating recurrent knee involvement in patients with juvenile idiopathic arthritis

OBJECTIVE

To retrospectively evaluate the benefits of knee joint lavage with intraarticular glucocorticoid injection in patients who have juvenile idiopathic arthritis with knee involvement unresponsive to repeated intraarticular glucocorticoid injections.

PATIENTS

Seventeen knees in 10 children (eight girls and two boys) were treated from 1997 to 2000. Mean age was 14 years 9 months and mean disease duration was 7.2 years. The diagnoses were juvenile oligoarthritis (n = 6, including two with extended disease), systemic arthritis (n = 2), juvenile spondyloarthropathy (n = 1), and juvenile dermatomyositis (n = 1). Repeated intraarticular triamcinolone hexacetonide injections had been performed in all the patients, the mean number of injections being 2.2 per patient within the last 30 months. Plain radiographs were normal in six of the eight patients. Mean erythrocyte sedimentation rate was 21.7 mm/h and mean C-reactive protein level was 20.6 mg/l. Joint fluid was obtained from 10 knees and had a mean cell count of 12?660 mm(-3). Second-line therapy was with methotrexate alone or combined with cyclosporine or azathioprine. Oral glucocorticoids and/or nonsteroidal antiinflammatory drugs were used for symptom relief. TREATMENT PROCEDURE: Lavage was performed under strict aseptic conditions with simple analgesia, on a day-hospital basis. After aspiration of the joint, lavage was performed with saline, and a delayed-action glucocorticoid was injected. The knee joint was immobilized in the extended position for 48 h. Efficacy criteria were presence of effusion, presence of pain, and presence of a systemic treatment-sparing effect.

RESULTS

Freedom from effusion and pain was noted in all 17 knees after 1 month, in eight (47%) knees after 6 months, and in seven (41%) knees after 12 months. The patients with the longest lasting improvements had systemic polyarthritis. After joint lavage, second-line treatment was reduced in two patients and oral glucocorticoid therapy was stopped in two others. None of the variables studied (age, sex, disease duration, inflammatory syndrome, or joint fluid cytology) predicted a good response. No adverse effects were recorded.

CONCLUSION

These preliminary results show that joint lavage with glucocorticoid injection is safe in children. The improvements were modest, but the patients had a history of arthritis refractory to multiple triamcinolone hexacetonide injections. Thus, joint lavage may have a place in the treatment pyramid just before synovectomy.

Cataract surgery in patients with dry eyes

PURPOSE

To evaluate the potential causes of postoperative complications and the visual outcome after surgery for age-related cataract in dry eyes.

SETTING

Tertiary-care multidisciplinary referral medical institution.

METHODS

The records of 15 patients (21 eyes) with age-related cataract, a Schirmer value of 5.0 mm or less in 5 minutes, and a tear-film breakup time of 5 seconds or less having complications after cataract surgery were reviewed. Patients were assigned to 1 of 2 groups: dry eye with probable secondary Sjögren's syndrome (Group 1); dry eye without connective tissue disorders (Group 2). The surgical procedure, preoperative and postoperative medications, postoperative complications, and final visual outcome were analyzed.

RESULTS

Ten eyes (8 patients) in Group 1 and 11 (7 patients) in Group 2 had cataract surgery. In Group 1, postoperative endophthalmitis developed in 3 eyes and peripheral keratolysis in 4; 5 eyes attained a visual acuity between 6/60 and 6/18 2 years after surgery. In Group 2, filamentary keratitis developed in 6 eyes and peripheral keratolysis in 2 eyes; 6 eyes achieved a visual acuity of 6/12 or better 2 year after surgery. A significant decrease in visual acuity occurred between 3 months and 2 years postoperatively in both Group 1 (P = .010) and Group 2 (P = .0005).

CONCLUSION

Cataract surgery in dry eyes had fewer complications and better visual outcome in patients who did not have connective tissue disease than in those who did.