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Z. K. Christopher et al.
4.3.2.1 Glucocorticoids
Glucocorticoids are often used in treating the following:
5 RA.
5 Ankylosing spondylitis.
other medication classes. The details of the current recommendations can be found in . Table 4.1 from the
ACR-AAHKS. Biologics should be stopped prior to
surgery.
5 SLE.
5 Psoriatic arthritis.
> The ACR-AAHKS current recommendations are to
4
continue the current daily dose of glucocorticoids in
adults with inammatory arthridities who are undergoing TKA or THA (Goodman et al. 2017).
Supratherapeutic “stress-dosing” is not recommended
in most patients.
> Elective surgery should be scheduled at the end of the
dosing cycle with discontinuation of the medications.
The literature demonstrates that the use of biologics
increases the risk of infection as well as serious adverse
events with odds ratios around 1.5 for both endpoints
(Goodman and Figgie 2013). Furthermore, Goodman
etal. performed a systematic review and meta-analysis
evaluating the use of TNF-α inhibitors in total joint
Jain etal. published evidence suggesting that continuation of steroids does not affect postoperative infection rates, and in fact, stopping them can lead to ares
which can delay rehabilitation (Jain etal. 2002). How-
arthroplasty. Their ndings conrmed that the use of
TNF-α inhibitors resulted in an increased risk of developing a surgical site infection with an odds ratio of 2.47
(95% CI 1.66, 3.68); P<0.0001) (Goodman etal. 2016).
ever, it does distinguish that doses over 15mg/day have
been reported to increase postoperative infection rates
in patients with RA (Somayaji etal. 2013). It is important to note that the current guidelines recommend continuing glucocorticoids at doses <20 mg/day when
possible. At higher doses, consultation with the patient’s
rheumatologist should be considered prior to surgery, as
this may indicate inadequate disease control (ACRAAHKS Guidelines).
4.3.2.4 SLE-Specic Considerations
Medications including mycophenolate mofetil, azathioprine, cyclosporine, and tacrolimus have SLE-specic
indications. The specic dosing intervals in the perioperative period are again found in . Table4.1. The key
difference is whether the medication is being used to
treat severe or non-severe SLE. In patients with severe
SLE, it is recommended to continue these medications,
whereas in non-severe SLE they can be withheld 1week
4.3.2.2 DMARDs
> The current consensus is that disease-modifying anti-
rheumatic drugs (DMARDs) are safe to continue
through the perioperative period.
prior to surgery. Severe SLE is dened as those currently
being treated for severe organ involvement including
lupus nephritis, myocarditis, hemolytic anemia, and central nervous system lupus, among many others.
One of the most signicant studies by Grennan etal.
evaluated methotrexate and early postoperative complications in patients with RA undergoing elective
TJA.They found that continuation of methotrexate did
not increase the risk of infections compared to those
patients who had the medication discontinued, and in
fact continuation of methotrexate may decrease the risk
of ares (Grennan etal. 2001). These authors performed
a 10-year follow-up study and ultimately adhered to
their original conclusions that in the absence of renal
failure or sepsis, methotrexate therapy should be continued (Sreekumar etal. 2011). Similar results have been
demonstrated in hand and wrist surgery (Jain et al.
2002).
4.3.2.3 Biologics
Biologic agents are those medications that use genetically engineered proteins to target specic immune cells
or other cellular proteins to ultimately alter downstream
immune responses. Management of biologics in the
perioperative period is often more nuanced than the
4.3.3 Orthopedic Evaluation
Orthopedic evaluation starts with a thorough history
focusing on the disease process such as duration of disease, medications, and other joint involvement. A thorough physical exam should be conducted with special
attention toward the degree of deformity of the knee,
including xed versus correctible deformities in the coronal and sagittal planes. Further, there is often attenuation of the ligaments in or around the knee; hence
determination of ligamentous stability is critical to evaluate as this inuences implant choice.
> Preoperative knee radiographs including full-length
standing alignment lms are recommended. It is also
important to discuss patient expectations following
TKA in patients with inammatory arthritis.
Outcomes will be discussed further below, but litera-
ture has shown that patients undergoing TKA with
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4
inammatory diseases are on average 10years younger
than those with osteoarthritis (OA) (Lee etal. 2017). Of
patients younger than 45 undergoing TKA, a majority
had either RA or juvenile RA as the primary diagnosis
(Dalury etal. 1995). Fortunately, patient-reported outcome measures in young patients with both OA and
inammatory arthritis are comparable to those in older
age groups (Gill etal. 1997). However, it is critical to
discuss that the risk of requiring revision surgery for any
reason is higher in younger patients. A study published
in 2017 demonstrated that the lifetime risk of revision
increases up to 35% for those in the age of 50–54 undergoing TKA compared with only 5% in patients older
than 70 (Schreurs and Hannink 2017).
4.4 Intraoperative Considerations
With proper preparation, including careful scrutiny of
preoperative imaging and detailed physical examination, the arthroplasty surgeon should be aware of the
bony defects, soft tissue destruction, and ligament stability. Further, the surgeon should be prepared with a
combination of augments, cones, or sleeves, and increasing implant-specic level of constraint to address each
patient’s specic needs. Because of the overall osteopenia and specically the effect of the inammatory process on the subchondral bone, where implant xation is
most critical, cementation is almost exclusively recommended in this patient population.
The posterior cruciate ligament (PCL) provides the
main resistance to posterior translation of the tibia on
the femur and is critical for femoral rollback during
knee exion. Perhaps one of the most debated topics in
patients with inammatory disease undergoing TKA is
the use of posterior stabilized (PS) versus cruciateretaining (CR) implants. Several studies have been published citing good results for either, and mixed results
have been published comparing the two groups
(. Table 4.2). No meta-analyses have been performed
comparing PS and CR TKAs. Some surgeons favor the
use of PS citing a higher risk of complications and
increased revision rate due to eventual PCL incompetence. Laskin etal. compared patients with RA undergoing TKA with CR and PS implants for a minimum of
6-year follow-up. The group with PCL retention (i.e.,
CR knees) was noted to have increased recurvatum and
posterior instability. Similarly, in the revision setting,
patients had a higher incidence of PCL absence (Laskin
and O’Flynn 1997).
In contrast, some surgeons favor the use of CR
implants when the PCL is present and functioning well.
Archibeck etal. demonstrated satisfactory results with
posterior cruciate-retaining implants with a 93% survival rate at 10years. Nine of 72 patients required revision, but 6 of these were related to the metal-backed
patella. Only one patient had radiographic or clinical
evidence of posterior instability (Archibeck etal. 2001).
Similarly, Miller etal. demonstrated a 93% implant survival rate at 20years in patients with CR implants using
posterior instability as the endpoint (Miller etal. 2011).
Ashraf et al. performed a review of the literature and
found “excellent” long-term survivorship and functional
outcomes with up to 25years of follow-up (Ashraf etal.
2017). Notably, this review was not a meta-analysis. In
another study, Hanyu noted good results when selectively using both PS and CR implants in RA patients,
citing a 93% survivorship rate at 10years after adjustment for mortality (Hanyu etal. 1997). These authors
used a CR design in 57 knees and PS in the remaining 31
when the PCL was incompetent. There is a need for a
systematic review with meta-analysis comparing CR
and PS implants to strengthen any recommendations.
> However, if the PCL is found to be decient or absent
intraoperatively, a PS implant is indicated.
Patellar resurfacing in patients with inammatory
arthritis, specically RA, has been investigated. In 1989
Shoji performed a study of 35 patients with bilateral
TKA, one with and one without patellar resurfacing
and found no difference in pain, functional improvement, muscle strength, or range of motion (Shoji etal.
1989). About a decade later, Kajino etal. performed a
study of simultaneous bilateral TKA with patellar resurfacing unilaterally. They noted similar outcomes, however, they found pain on standing and ascending and
descending stairs was noted only in those without patellar resurfacing (Kajino etal. 1997). A more recent study
by Bhan et al. concluded that TKA without patellar
resurfacing yielded satisfactory results in patients with
RA (Bhan etal. 2006).
> There is no consensus on patellar resurfacing in
inammatory arthritis, but surgeons should consider
that these conditions affect the entire joint and the
patellofemoral joint may be frequently involved.
It would stand to reason that in patients with adequate bone stock, patellar resurfacing is an option.
However, if the patella is naturally thin (<20mm thick),
osteopenic, or has signicant bone loss secondary to
erosions or wear, then patellar resurfacing is not advised.
There is limited literature on the use of antibiotic
bone cement in primary total knee arthroplasty in
patients with inammatory arthritis.
42
Z. K. Christopher et al.
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. Table 4.2 Selected studies evaluating PS and CR implants in patients with inammatory arthritis
Year
published
1995 Aglietti etal.
4
1997 Laskin and
1997 Hanyu etal.
2001 Gill and Joshi
2001 Archibeck etal.
2011 Miller etal.
2012 Yamanaka etal.
2015 Lee etal. (
2019 Luo etal.
Authors Prosthesis Findings Conclusion (PS vs. CR)
1995)
(
O’Flynn (
(
1997)
2001
(
2001)
2011)
(
2012)
(
(2019)
PS Cumulative success rate of 96.2% at
13years
PS vs. CR (in
1997))
2015) CR All-cause revision rates: 98.7% at 10years
both RA and
OA)
PS vs. CR 93% implant survival at 10years for all
CR 90.7% survivorship of implant at 19years Good long-term results with CR
CR 95% good to excellent PROMs, 93%
CR At 20years: 69% survival with revision as
CR No loosening, 96.9% survivorship at
PS (multi- vs.
single-radius)
CR implants in RA: Increased recurvatum and posterior instability, 81%
survival rate at 10years
comers, but 31/61 patients died during the
study period
survivorship at 10years, no aseptic
loosening
the endpoint, 93% survival with posterior
instability as the endpoint
12years
and 83.6% at 17years
97.5% implant survival for the SR at
10years and 98.3% for the MR group at
10years
PS implants have excellent results in
patients with RA
PS recommended due to posterior
instability
Both can have excellent results
implants in RA
Excellent results with CR when PCL
was intact and functioning at the time
of surgery
PCL insufciency with instability was
rarely the cause of failure following CR
TKA in patients with RA
CR prosthesis is very effective in RA
patients at 5 to 12years postoperative
Possibility of increased loosening rates
after 10years in CR knees
Single- and multi-radius PS prostheses
yield satisfactory results at 10years
> A 2003 study by Liu reviewed 60 patients with RA
who underwent primary TKA with cefuroximeloaded bone cement in addition to parenteral antibiotic prophylaxis, and demonstrated no deep infections
(Liu etal. 2003).
Studies evaluating high-risk patients suggest that
there may be benets in using low-dose antibioticloaded bone cement (ALBC). Chiu et al. randomized
340 patients undergoing primary TKA to cefuroximeimpregnated cement versus a control and showed no
deep infection in the ALBC group versus ve infections
in the control group. It is important to note that all ve
infections occurred in a higher risk group with diabetes
(Chiu etal. 2002).
In a 2006 current concepts review, Jiranek etal. recommended the use of low-dose ALBC in high-risk
patients (. Fig.4.4) (Jiranek etal. 2006). Two large retrospective registry studies demonstrated a statistically
signicant decrease in rates of revision (HR 0.85)
(Jameson etal. 2019) and odds for early postoperative
infection (OR 0.89) (Chan etal. 2019).
> Extrapolating these data, we recommend consider-
ation of either manual or commercially mixed ALBC
in patients with inammatory diseases who are inherently at higher risk for infection.
4.5 Postoperative Considerations
4.5.1 Medications
As discussed previously, medication management is the
mainstay of treatment for these systemic diseases.
Restarting any medications that were discontinued prior
to surgery is important to minimize symptoms, maintain
control of the condition, and prevent are of the disease. The risk and benets of disease control versus
complications must be carefully balanced and it is
important to work closely with the patient’s rheumatol-
Use of Antibiotic-Loaded Bone Cement
1.0-2.0 g of antibiotic
•C
•C
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Prophylaxis Treatment
43
4
Low-Dose ALBC
(0.5-1.0 g of antibiotic
per 40 g cement)*
emented Revision THA / TKA
emented Primary THA / TKA
- High-Risk Patients
. Fig. 4.4 Use of antibiotic-loaded bone cement. (Jiranek etal. 2006)
ogist in decision-making. The recommendations from
the ACR-AAHKS publication can be found in
. Table4.1 and should serve as a guide to therapy.
4.5.2 Complications
Patients with inammatory arthropathies are well
known to have higher complication rates, particularly
infection, compared to those with OA. This is likely due
to a combination of chronic inammation, immune dysfunction, and long-term use of immune-suppressing
medications. By the time these patients present for evaluation by an arthroplasty surgeon, they have usually
been taking immune-modulating medications including
DMARDs, steroids, or biologics for an extended time
period. Although historical studies reported infection
rates after joint replacement to be as high as 17%(Stern
et al. 1989) in patients with inammatory conditions,
more recent data suggest that the rate of infection in
patients with inammatory arthritis following TKA is
approximately 2%, which is nearly double that of the
general population (Cancienne etal. 2016). Despite several studies evaluating the timing of medication management in the perioperative period, infection risk still
remains high in this patient population (Schrama etal.
2010; Bongartz etal. 2008; Ravi etal. 2012).
Bongartz etal. showed that RA patients had a three-
»
fold increased infection rate at 5 years compared to
patients with OA. They recommended that surgeons
High-Dose ALBC
ALBC Spacers /
Beads /
PROSTALAC*
>3.6 g of antibiotic
per 40 g cement**
should strongly consider the use of antibioticimpregnated cement in this patient population (Bongartz etal.
2008).
Prosthesis
Fixation at time of
Reimplantation
per 40 g cement**
Similarly, we agree that it is reasonable to use ALBC
in this context, however, there is no evidence that it prevents indolent inoculum or late hematogenous infection.
Although many of the common medications used in
managing inammatory arthritis have dramatically
improved the quality of life in patients aficted with
these disorders, these medications can also have detrimental effects in the immediate postoperative period. As
the primary effect of many of these drugs is to decrease
inammation and the local immune response, this has
direct implication on wound healing.
In their review article, Busti etal. thoroughly outline
the normal process of wound healing and how therapeutic medications can disrupt this healing (Busti etal.
2005). They outline that during the acute phase of
wound healing, often termed the inammatory phase,
growth factors such as platelet-derived growth factor
(PDGF) and eicosanoids (e.g., prostaglandins, leukotrienes, and thromboxanes) stimulate chemotaxis, cell permeability, and proliferation of the various cells
responsible for wound healing, including macrophages,
monocytes, and neutrophils. Further, in both the inammatory and proliferative phases of wound healing,
broblasts and smooth muscle cells are drawn to the
wound bed to continue to supplement wound healing.
In the nal phase of wound healing (maturation or
remodeling phase), deposition of bronectin, hyaluronic
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Z. K. Christopher et al.
acid, proteoglycans, and collagen takes place over weeks
to months to provide the ultimate strength and integrity
of the wound.
Each medication used to treat inammatory arthridities can affect this pathway in some way. For example,
NSAIDs disrupt the synthesis of prostaglandins and
leukotrienes thereby blunting the inammatory phase
and limiting cell permeability/chemotaxis (Karukonda
4
etal. 2000). Corticosteroids have been shown to inhibit
broblast proliferation, vascular proliferation, and
wound contraction (Busti et al. 2005; Pollack 1982).
DMARDs have numerous mechanisms of action but in
general all function to decrease inammation (Busti
the issue of prolonged or increased wound drainage may
be more commonly encountered in this population.
Saleh etal. showed that prolonged wound drainage is a
signicant risk factor for surgical site infection (Saleh
etal. 2002). Further, Johnson etal. demonstrated wound
edge hypoxia with excessive knee exion immediately
postoperatively (Johnson etal. 1991). For these reasons,
in our clinical practice, if signicant drainage is noted or
there is concern preoperatively that a patient may suffer
from prolonged healing and/or increased drainage, we
recommend a brief period of immobilization following
surgery until we are satised that the wound is sealed
with no drainage.
et al. 2005). Although each of these medications has
theoretical disadvantages with respect to local wound
healing, they simultaneously play a role in mitigating the
4.5.3 Implant Survivorship
deleterious systemic effects of the inammatory process.
For this reason, extensive clinical studies have been performed to determine which medications should be withheld and the optimal timing. As outlined earlier in the
> Results of TKA in patients with inammatory condi-
tions have been shown to be satisfactory, but slightly
inferior to patients undergoing TKA for OA.
chapter, the American College of Rheumatology and
the American Association of Hip and Knee Surgeons in
2017 extensively reviewed available and pertinent literature (Goodman etal. 2017).
Ravi etal. performed a systematic review and metaanalysis comparing complications and outcomes of
total joint arthroplasty for RA and OA (Ravi et al.
2012). They report a slightly higher odds ratio of revi-
> In general, they recommend continuing current doses
of glucocorticoids, continuing DMARDs, and holding biologics in the perioperative period. The importance of involving the rheumatologist, especially in
patients with multiple medications and/or higher dosing regimens, cannot be understated.
sion at less than 5years (OR 1.24, 95% CI: 1.10–1.40).
At 6–10years and>10years, there were no differences
in revision rates in cemented TKA. Similarly, Hernigou
compared matched groups of patients with RA and OA
undergoing revision TKA and found no difference in rerevision rates at 10-year follow-up. All implants in this
study were posterior stabilized and cemented (Hernigou
Please see . Table4.1 for more extensive breakdown
of each medication recommendation.
Most of the research surrounding inammatory
arthritis and joint replacement have been performed on
etal. 2017). The patients with RA had lower pre- revision
functional scores, but similar postoperative scores, hence
a greater change in functional scores compared to the
OA revision group.
RA, however recent publications have shed light on
other conditions. Cancienne etal. reviewed over 1.7 million patients who underwent primary TKA including
4.6 Conclusion
153,531 with RA, 7918 with psoriatic arthritis, and 4575
with ankylosing spondylitis. Infection, revision at all
time points, and readmission rates were all signicantly
higher in these patients compared to those with OA
(Cancienne et al. 2016). Schasner et al. showed that
patients with juvenile rheumatoid arthritis also have a
higher risk of wound dehiscence (Schnaser etal. 2015).
In the same study, they demonstrated an increased risk
of perioperative periprosthetic fracture in patients with
inammatory arthridities. With the exception of psoriatic arthritis, they demonstrated that all inammatory
conditions had signicantly more medical as well as
orthopedic complications (Schnaser etal. 2015).
As inammatory arthritis is a risk factor for delayed
wound healing,(Doran etal. 2002; Bernatsky etal. 2007)
Inammatory arthridities are systemic conditions that
often symmetrically affect knees and can lead to severe
impairment in daily function. Patients undergoing
cemented TKA for inammatory arthridities can expect
good long-term survivorship with excellent improvement in outcome scores. Surgeons should work closely
with the patient’s rheumatologist especially with regard
to perioperative medication management. The decision
for PS versus CR implants remains controversial, but
when the PCL is decient or absent, PS components
should be utilized. Arthroplasty surgeons should counsel their patients on the increased perioperative risks
during and after TKA, with particular emphasis on
infection. Cemented TKA is an appropriate procedure
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4
for patients with inammatory disorders who have endstage knee arthritis. The arthroplasty surgeon should be
well versed in the surgical and nonsurgical considerations of the disease in order to provide excellent outcomes for these patients.
Take-Home Messages
5 Inammatory arthritis has complicated local
and systemic disease manifestations. Attention
to detail of both is critical for successful outcomes.
5 These patients require a multidisciplinary team
to achieve optimal outcomes.
5 High-quality cementation technique is impor-
tant, secondary to poorer quality of the subchondral bone.
5 The addition of prophylactic antibiotics to the
cement is recommended in this patient population.
5 Manual (e.g., cefuroxime) or commercially (e.g.,
gentamicin/tobramycin) mixed antibiotics may
be used.
5 If the PCL is intact, the surgeon can consider
using CR implants with good reported results.
5 Patellar resurfacing may result in activity-related
pain reduction, though resurfacing should be
reserved for patients with adequate bone stock.
5 Not all rheumatological medications require dis-
continuation prior to surgery. Guidelines have
been established to aid in decision-
making for
perioperative medication management.
References
Aglietti P, Buzzi R, Segoni F, Zaccherotti G (1995) Insall-Burstein
posterior-stabilized knee prosthesis in rheumatoid arthritis. J
Arthroplast 10(2):217–225. https://doi.org/10.1016/S0883-
5403(05)80131- 7
Archibeck M, Berger R, Barden R etal (2001) Posterior cruciate
ligament-retaining total knee arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Am Vol 83(8):1231–1236
Ashraf M, Sharma OP, Priyavadhana S, Sambandam SN,
Mounasamy V (2017) Rationale of cruciate retaining design in
rheumatoid arthritis: a review of clinical analysis and its role in
rheumatoid arthritis. Open Orthop J 11:1023–1027. https://doi.
org/10.2174/1874325001711011023
Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D
(2012) Risk of incident cardiovascular events in patients with
rheumatoid arthritis: a meta-analysis of observational studies.
Ann Rheum Dis 71(9):1524–1529. https://doi.org/10.1136/
annrheumdis- 2011- 200726
Bernatsky S, Hudson M, Suissa S (2007) Anti-rheumatic drug use
and risk of serious infections in rheumatoid arthritis.
Rheumatology (Oxford) 46(7):1157–1160.
org/10.1093/rheumatology/kem076
Bhan S, Malhotra R, Eachempati KK (2006) Total knee arthroplasty
without patellar resurfacing in patients with rheumatoid arthri-
tis. Publ Assoc Bone Joint Surg® | CORR® 450:157–163. https://
doi.org/10.1097/01.blo.0000229277.74194.bf
Bongartz T, Halligan CS, Osmon DR etal (2008) Incidence and risk
factors of prosthetic joint infection after total hip or knee
replacement in patients with rheumatoid arthritis. Arthritis
Rheum 59(12):1713–1720. https://doi.org/10.1002/art.24060
Boutry N, Morel M, Flipo R-M, Demondion X, Cotten A (2007)
Early rheumatoid arthritis: a review of MRI and sonographic
ndings. Am J Roentgenol 189(6):1502–1509. https://doi.
org/10.2214/AJR.07.2548
Busti AJ, Hooper JS, Amaya CJ, Kazi S (2005) Effects of periopera-
tive antiinammatory and immunomodulating therapy on surgi-
cal wound healing. Pharmacotherapy 25(11):1566–1591. https://
doi.org/10.1592/phco.2005.25.11.1566
Cancienne JM, Werner BC, Browne JA (2016) Complications of pri-
mary total knee arthroplasty among patients with rheumatoid
arthritis, psoriatic arthritis, ankylosing spondylitis, and osteoar-
thritis. J Am Acad Orthop Surg 24(8):567–574.
org/10.5435/JAAOS- D- 15- 00501
Chan JJ, Robinson J, Poeran J, Huang H-H, Moucha CS, Chen DD
(2019) Antibiotic-loaded bone cement in primary total knee
arthroplasty: utilization patterns and impact on complications
using a national database. J Arthroplasty 34(7S):S188–S194.e1.
https://doi.org/10.1016/j.arth.2019.03.006
Chiu F-Y, Chen C-M, Lin C-FJ, Lo W-H (2002) Cefuroxime-
impregnated cement in primary total knee arthroplasty: a pro-
spective, randomized study of three hundred and forty knees. J
Bone Joint Surg Am 84(5):759–762
Dalury DF, Ewald FC, Christie MJ, Scott RD (1995) Total knee
arthroplasty in a group of patients less than 45 years of age. J
Arthroplast 10(5):598–602. https://doi.org/10.1016/S0883-
5403(05)80202- 5
Doran MF, Crowson CS, Pond GR, O’Fallon WM, Gabriel SE
(2002) Frequency of infection in patients with rheumatoid arthri-
tis compared with controls: a population-based study. Arthritis
Rheum 46(9):2287–2293. https://doi.org/10.1002/art.10524
Gill GS, Joshi AB (2001) Long-term results of Kinematic Condylar
knee replacement. J Bone Joint Surg 83(3):4
Gill GS, Chan KC, Mills DM (1997) 5- to 18-year follow-up study of
cemented total knee arthroplasty for patients 55 years old or
younger. J Arthroplast 12(1):49–54. https://doi.org/10.1016/
S0883- 5403(97)90046- 2
Goodman SM, Figgie M (2013) Lower extremity arthroplasty in
patients with inammatory arthritis: preoperative and perioper-
ative management. J Am Acad Orthop Surg 21(6):355–363.
https://doi.org/10.5435/JAAOS- 21- 06- 355
Goodman SM, Menon I, Christos PJ, Smethurst R, Bykerk VP (2016)
Management of perioperative tumour necrosis factor α inhibitors
in rheumatoid arthritis patients undergoing arthroplasty: a sys-
tematic review and meta-analysis. Rheumatology (Oxford)
55(3):573–582. https://doi.org/10.1093/rheumatology/kev364
Goodman SM, Springer B, Guyatt G etal (2017) 2017 American
College of Rheumatology/American Association of Hip and
Knee Surgeons Guideline for the Perioperative Management of
Antirheumatic Medication in Patients With Rheumatic Diseases
Undergoing Elective Total Hip or Total Knee Arthroplasty. J
Arthroplast 32(9):2628–2638. https://doi.org/10.1016/j.
arth.2017.05.001
Grennan DM, Gray J, Loudon J, Fear S (2001) Methotrexate and
early postoperative complications in patients with rheumatoid
https://doi.
https://doi.
46
https://t.me/medicina_free
Z. K. Christopher et al.
arthritis undergoing elective orthopaedic surgery. Ann Rheum
Dis 60(3):214–217. https://doi.org/10.1136/ard.60.3.214
Hanyu T, Murasawa A, Tojo T (1997) Survivorship analysis of total
knee arthroplasty with the kinematic prosthesis in patients who
have rheumatoid arthritis. J Arthroplast 12(8):913–919. https://
doi.org/10.1016/S0883- 5403(97)90161- 3
Henchie TF, Gravallese EM, Bredbenner TL, Troy KL (2019) An
image-based method to measure joint deformity in inammatory
arthritis: development and pilot study. Comput Methods
4
Biomech Biomed Engin 22(10):942–952. https://doi.org/10.1080/
10255842.2019.1607315
Hernigou P, Dubory A, Potage D, Roubineau F, Flouzat- Lachaniette
CH (2017) Outcome of knee revisions for osteoarthritis and
inammatory arthritis with postero-stabilized arthroplasties: a
mean ten-year follow-up with 90 knee revisions. Int Orthop
41(4):757–763. https://doi.org/10.1007/s00264- 016- 3319- 8
Jain A, Witbreuk M, Ball C, Nanchahal J (2002) Inuence of ste-
roids and methotrexate on wound complications after elective
rheumatoid hand and wrist surgery. J Hand Surg Am 27(3):449–
455. https://doi.org/10.1053/jhsu.2002.32958
Jameson SS, Asaad A, Diament M et al (2019) Antibiotic-loaded
bone cement is associated with a lower risk of revision following
primary cemented total knee arthroplasty: an analysis of 731,214
cases using National Joint Registry data. Bone Joint J 101B(11):1331–1347. https://doi.org/10.1302/0301- 620X.101B11.
BJJ- 2019- 0196.R1
Jiranek WA, Hanssen AD, Greenwald AS (2006) Antibiotic-loaded
bone cement for infection prophylaxis in total joint replacement.
JBJS 88(11):2487–2500. https://doi.org/10.2106/JBJS.E.01126
Johnson DP, Eastwood DM, Bader DL (1991) Biomechanical factors
in wound healing following knee arthroplasty. J Med Eng Technol
15(1):8–14. https://doi.org/10.3109/03091909109015442
Kajino A, Yoshino S, Kameyama S, Kohda M, Nagashima S (1997)
Comparison of the results of bilateral total knee arthroplasty
with and without patellar replacement for rheumatoid arthritis.
A follow-up note*. JBJS 79(4):570–574
Karukonda SR, Flynn TC, Boh EE, McBurney EI, Russo GG,
Millikan LE (2000) The effects of drugs on wound healing–part
II.Specic classes of drugs and their effect on healing wounds.
Int J Dermatol 39(5):321–333. https://doi.
org/10.1046/j.1365- 4362.2000.00949.x
Krause ML, Matteson EL (2014) Perioperative management of the
patient with rheumatoid arthritis. World J Orthop 5(3):283–291.
https://doi.org/10.5312/wjo.v5.i3.283
Kwek TK, Lew TWK, Thoo FL (1998) The role of preoperative cer-
vical spine X-rays in rheumatoid arthritis. Anaesth Intensive
Care 26(6):636–641. https://doi.org/10.1177/03100
57X9802600604
Laskin RS, O’Flynn HM (1997) The Insall Award. Total knee
replacement with posterior cruciate ligament retention in rheumatoid arthritis Problems and complications. Clin Orthop Relat
Res 345:24–28
Lee JK, Kee YM, Chung HK, Choi CH (2015) Long-term results of
cruciate-retaining total knee replacement in patients with rheumatoid arthritis: a minimum 15-year review. Can J Surg
58(3):193–197. https://doi.org/10.1503/cjs.012014
Lee D-K, Kim H-J, Cho I-Y, Lee D-H (2017) Infection and revision
rates following primary total knee arthroplasty in patients with
rheumatoid arthritis versus osteoarthritis: a meta-analysis. Knee
Surg Sports Traumatol Arthrosc 25(12):3800–3807. https://doi.
org/10.1007/s00167- 016- 4306- 8
Lereim P, Goldie IF (1975) Relationship between morphologic fea-
tures and hardness of the subchondral bone of the medial tibial
condyle in the normal state and in osteoarthritis and rheumatoid
arthritis. Arch Orthop Unfallchir 81(1):1–11. https://doi.
org/10.1007/BF00417022
Lereim P, Goldie I, Dahlberg E (1974) Hardness of the subchondral
bone of the tibial condyles in the normal state and in osteoar-
thritis and rheumatoid arthritis. Acta Orthop Scand 45(1–
4):614–627. https://doi.org/10.3109/17453677408989184
Lindhardsen J, Ahlehoff O, Gislason GH et al (2011) The risk of
myocardial infarction in rheumatoid arthritis and diabetes mel-
litus: a Danish nationwide cohort study. Ann Rheum Dis
70(6):929–934. https://doi.org/10.1136/ard.2010.143396
Liu H-T, Chiu F-Y, Chen C-M, Chen T-H (2003) The combination of
systemic antibiotics and antibiotics impregnated cement in pri-
mary total knee arthroplasty in patients of rheumatoid arthritis-
-evaluation of 60 knees. J Chin Med Assoc 66(9):533–536
Lopez-Olivo MA, Andrabi TR, Palla SL, Suarez-Almazor ME
(2012) Cervical spine radiographs in patients with rheumatoid
arthritis undergoing anesthesia. J Clin Rheumatol 18(2):61–66.
https://doi.org/10.1097/RHU.0b013e318247bb0d
Luo Z, Zhou Z, Pei F (2019) Long-term results of total knee arthro-
plasty with single-radius versus multi- radius posterior-stabilized
prosthesis in rheumatoid arthritis. Orthopaedic Proceedings
101-B(SUPP_4):47. https://doi.org/10.1302/1358-
992X.2019.4.047
Meune C, Touze E, Trinquart L, Allanore Y (2009) Trends in cardio-
vascular mortality in patients with rheumatoid arthritis over 50
years: a systematic review and meta-analysis of cohort studies.
Rheumatology 48(10):1309–1313. https://doi.org/10.1093/rheu-
matology/kep252
Miller MD, Brown NM, Della Valle CJ, Rosenberg AG, Galante JO
(2011) Posterior cruciate ligament-retaining total knee arthro-
plasty in patients with rheumatoid arthritis: a concise follow-up
of a previous report: *. JBJS 93(22):e130. https://doi.org/10.2106/
JBJS.J.01695
Ogdie A, Yu Y, Haynes K etal (2015) Risk of major cardiovascular
events in patients with psoriatic arthritis, psoriasis and rheuma-
toid arthritis: a population-based cohort study. Ann Rheum Dis
74(2):326–332. https://doi.org/10.1136/annrheumdis-
2014- 205675
Pollack SV (1982) Systemic medications and wound healing. Int J
Dermatol 21(9):489–496. https://doi.org/10.1111/j.1365- 4362.1982.
tb01189.x
Ravi B, Escott B, Shah PS etal (2012) A systematic review and meta-
analysis comparing complications following total joint arthro-
plasty for rheumatoid arthritis versus for osteoarthritis. Arthritis
Rheum 64(12):3839–3849. https://doi.org/10.1002/art.37690
Saleh K, Olson M, Resig S etal (2002) Predictors of wound infection
in hip and knee joint replacement: results from a 20 year surveil-
lance program. J Orthop Res 20(3):506–515. https://doi.
org/10.1016/S0736- 0266(01)00153- X
Schnaser EA, Browne JA, Padgett DE, Figgie MP, D’Apuzzo MR
(2015) Perioperative complications in patients with inamma-
tory arthropathy undergoing total knee arthroplasty. J
Arthroplast 30(9 Suppl):76–80. https://doi.org/10.1016/j.
arth.2014.12.040
Schrama JC, Espehaug B, Hallan G etal (2010) Risk of revision for
infection in primary total hip and knee arthroplasty in patients
with rheumatoid arthritis compared with osteoarthritis: a pro-
spective, population-based study on 108,786 hip and knee joint
arthroplasties from the Norwegian Arthroplasty Register.
Arthritis Care Res 62(4):473–479. https://doi.org/10.1002/
acr.20036
Schreurs BW, Hannink G (2017) Total joint arthroplasty in younger
patients: heading for trouble? Lancet 389(10077):1374–1375.
https://doi.org/10.1016/S0140- 6736(17)30190- 3
Inammatory Arthritis
https://t.me/medicina_free
47
4
Shoji H, Yoshino S, Kajino A (1989) Patellar replacement in bilateral
total knee arthroplasty. A study of patients who had rheumatoid
arthritis and no gross deformity of the patella. J Bone Joint Surg
Am 71(6):853–856
Somayaji R, Barnabe C, Martin L (2013) Risk factors for infection follow-
ing total joint arthroplasty in rheumatoid arthritis. Open Rheumatol
J 7:119–124. https://doi.org/10.2174/1874312920131210005
Sreekumar R, Gray J, Kay P, Grennan DM (2011) Methotrexate and
post operative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery–a ten year follow-up.
Acta Orthop Belg 77(6):823–826
Stern SH, Insall JN, Windsor RE, Inglis AE, Dines DM (1989) Total
knee arthroplasty in patients with psoriasis. Clin Orthop Relat Res
248:108–110; discussion 111. https://doi.org/10.1097/00003086-
198911000- 00018
Sudoł-Szopińska I, Jans L, Teh J (2017) Rheumatoid arthritis: what
do MRI and ultrasound show. J Ultrason 17(68):5–16. https://
doi.org/10.15557/JoU.2017.0001
Yamanaka H, Goto K, Suzuki M (2012) Clinical results of Hi-tech
Knee II total knee arthroplasty in patients with rheumatoid ath-
ritis: 5- to 12-year follow-up. J Orthop Surg Res 7(1):9. https://
doi.org/10.1186/1749- 799X- 7- 9
Yang J-P, Bogoch ER, Woodside TD, Hearn TC (1997) Stiffness of
trabecular bone of the tibial plateau in patients with rheumatoid
arthritis of the knee. J Arthroplast 12(7):798–803. https://doi.
org/10.1016/S0883- 5403(97)90011- 5
Osteonecrosis
https://t.me/medicina_free
HythamS.Salem, BrandonH.Naylor, KevinK.Mathew,
andMichaelA.Mont
Contents
5.1 Introduction – 50
5.2 Case Examples – 51
5.2.1 Case Report #1 – 51
5.2.2
Case Report #2 – 51
5.3 Published Outcome Data – 52
5.4 Conclusion – 54
References – 55
49
5
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_5
50
https://t.me/medicina_free
H. S. Salem et al.
5.1 Introduction
femoral condyle (Mears etal.
2009). In fact, it has been
shown that 94% of SPONK lesions are located in medial
Total knee arthroplasty (TKA) is primarily indicated in
the elderly population with end-stage arthritis. However,
a subset of patients who undergo TKA has an underlying diagnosis of osteonecrosis.
condyle (al-Rowaih etal. 1993). Some authors have postulated that this is due to relatively limited intraosseous
blood supply of the medial versus lateral condyle (Reddy
and Frederick 1998). Conversely, other authors argue
that unlike other forms of osteonecrosis, ischemia is not
> The knee is the second most common site for osteone-
crosis to develop.
the primary factor that leads to SPONK (Yamamoto
and Bullough 2000). Rather, it has been found that subchondral insufciency fracture with extravasation of
5
It is generally categorized into three distinct types:
5 Secondary
uid into the bone may represent the inciting pathogenic
mechanism (Yamamoto and Bullough 2000).
5 Spontaneous
5 Post-arthroscopic (Jones and Mont 2019)
Due to the propensity for some forms of knee osteo-
necrosis to manifest at a younger age than osteoarthritis,
> This hypothesis is supported by evidence that SPONK
is most commonly seen in female patients older than
60years, and that low bone mineral density is a risk
factor in these patients (Akamatsu etal. 2012).
maximizing the survivorship of TKA implants is
increasingly important.
Secondary osteonecrosis of the knee is more likely to
present earlier in life, typically affecting patients younger
than 45years (Mont etal. 2000). Secondary osteonecrosis is associated with multiple factors including the following:
5 Corticosteroid use
5 Excessive alcohol intake
5 Sickle-cell disease
5 Gaucher’s disease
5 Myeloproliferative disorders
Patients who have SPONK typically present with
acute onset medial knee pain with tenderness over the
medial femoral condyle (Lotke etal. 1982).
A rare form of knee osteonecrosis occurs following
arthroscopic knee surgery. Studies have shown that postarthroscopic knee osteonecrosis occurs after meniscectomy or chondroplasty in 0.2–4% of patients who
undergo these procedures (Cetik etal. 2009; Di Caprio
etal. 2017; Pruès-Latour etal. 1998). While some theories for the etiology of post-arthroscopic osteonecrosis
have been proposed, its exact pathogenic mechanism
remains poorly understood. The use of radiofrequency
> The two most common risk factors are corticosteroid
use and alcohol abuse (Mont etal. 2000).
for chondral debridement has been posited as a risk factor, however, recent studies have refuted this theory
(Cetik etal. 2009; Turker etal. 2015). Post-arthroscopic
Both corticosteroid use and alcohol abuse have
been shown to increase bone marrow adipogenesis
leading to increased intraosseous pressure, and consequently, hypoperfusion of bone (Wang etal. 2003; Yin
et al. 2006). Secondary knee osteonecrosis involves
both femoral condyles in greater than 80% of cases
and can involve the epiphyseal, metaphyseal, and
diaphyseal regions of the distal femur, while proximal
tibia involvement is seen in 22% to 36% of patients
(Mears et al. 2009; Mont et al. 2000). Patients who
have secondary knee osteonecrosis typically describe
an insidious onset of knee pain and may also complain
of additional joint pain due to the propensity for multiple joint involvement in up to 90% of patients (Mears
etal. 2009).
Conversely, spontaneous osteonecrosis of the knee
(SPONK) is more commonly diagnosed in the elderly
population. Its prevalence has been estimated to be 3.4%
in patients older than 50years and 9.4% in those greater
than 65years of age (Pape etal. 2002). SPONK is most
likely to occur as a focal epiphyseal lesion in the medial
knee osteonecrosis most commonly affects the medial
femoral condyle and tends to correspond with the location of preexisting knee pathology (Pape et al. 2007).
The time between arthroscopic surgery and the onset of
symptoms is typically 6 to 8weeks (Karim etal. 2015).
Similar to SPONK lesions, those associated with an
arthroscopic surgery present with a sudden onset of
pain over the affected region.
Regardless of etiology, TKA may be the only treatment option for patients who have post-collapse knee
osteonecrosis and have failed conservative treatment
measures. Among the three forms of this condition,
TKA for steroid-induced knee osteonecrosis tends to be
the most problematic due to two main distinctive factors. As previously mentioned, it is more common in
younger patients. Secondly, a more diffuse pattern of
necrosis is typically observed when compared to other
etiologies (Seldes etal. 1999). For this reason, patients
who undergo TKA for steroid-induced knee osteonecrosis may have diminished bone stock potentially compromising component xation. For example, cases where
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