Hip Surgery for Rheumatoid Arthritis

Overview

Characteristics of rheumatoid arthritis of the hip

As with any joint in the body the hip joint can be destroyed by rheumatoid arthritis. This can lead to pain stiffness and disability. Pain associated with destruction of the hip joint typically occurs in the groin upper outer thigh and/or buttock. In the early stages of the disease it is aggravated by weight bearing activity. Later it occurs at rest and can interfere with sleep.

Incidence and risk factors

Hip joint involvement by RA is less common and occurs later than other major joints such as the knees.

Diagnosis

A thorough history will determine the patient's overall health and functional capacity. Examination of the spine hips knees ankles and feet for joint range of motion and deformity is done. Radiographs (X-rays) of the involved joints are obtained. These usually include neck X-rays in which the patient is first asked to bend their head forward then backward. Occasionally an MRI scan CAT scan (CT) or Bone-scan may be necessary.

Medications

In early stages of RA anti-inflammatory medications can be effective in decreasing pain and may slow the progression of joint destruction caused by RA.

Exercises

Once joint destruction of the hip has set in there are no specific exercises that can stop or arrest the development and progression of destruction. Regular range of motion exercises and weight bearing activity are important in maintaining muscle strength and overall aerobic (heart and lung) capacity and help prevent the development of osteoporosis which can complicate later treatment.

Possible benefits of hip surgery for rheumatoid arthritis

Total hip replacement very effectively eliminates the pain caused by RA of the hip.

Considering Surgery

Who should consider hip surgery for rheumatoid arthritis?

RA patients who have unrelenting hip pain and destructive arthritis of their hip joint that does not respond favorably to medical management should consider total hip replacement. RA patients with hip involvement in early stages who do not yet have destructive arthritis yet have unexplained debilitating pain should consider hip arthroscopy.

What happens without surgery?

The best case scenario includes inactivity and decreased mobility in conjunction with antirheumatic medication and steroids can cause some improvement of symptoms.

A worst case scenario might be severe destruction of the hip joint and associated osteoporosis and reduced physical capacity potentially leading to a compromised hip replacement at a later stage with a less predictable outcome.

Surgical options

Total hip replacement is the treatment of choice for patient with rheumatoid arthritis with destroyed hip joints. Occasionally hip arthroscopy is indicated in patients with early RA of the hip.

Not all surgical cases are the same, this is only an example to be used for patient education.

Not all surgical cases are the same, this is only an example to be used for patient education.

Effectiveness

More than 80% of patients will have a satisfactory result for 12-15 years after hip replacement surgery.

Urgency

Hip replacement surgery is an elective procedure and should be done only after non-surgical medical management has failed. Once indicated postponing the surgery for an extended period of time (months or years) only leads to increased disability disuse osteoporosis and skeletal complications that can make surgery more difficult and potentially compromise the final result.

Risks

The most common risks of hip replacement surgery for RA are infection dislocation of the hip joint and mechanical failure due to loosening of metal components from the bone. Mechanical loosening occurs in approximately 13% over 12 years and is mostly due to loosening of the metal socket. Infections and dislocations occur in approximately 2% of patients. Infection and dislocation can cause early failure and might prohibit a good result.

Managing risk

These complications can necessitate a revision hip replacement. If an infection occurs then the prosthesis needs to be removed. A six week period of antibiotic treatment is needed and if the infection is cured a revision hip replacement can be done. If the hip dislocates it needs to be relocated in the emergency room with sedation or in the operating room under anesthetic. Recurrent dislocations can lead to revision hip replacement surgery.

Surgical team

Hip replacement in a patient with RA requires an experienced orthopedic surgeon with a strong total joint background and the resources of a large medical center. Patients with RA have complex medical needs and around surgery often require immediate access to a multiple medical and surgical specialties and in-house medical physical therapy and social support services.

Finding an experienced surgeon

Contact:

• MEDCON (206) 543-5300
• American Academy of Orthopedic Surgeons: (800) 346-AAOS
• Washington State Medical Society: (206) 441-9762 (Will connect to local County Medical Society)

Facilities

A large hospital usually with academic affiliation and equipped with state of the art radiologic imaging equipment and Intensive Medicine Care Unit is clearly preferable in the care of patients with hip RA.

Technical details

The surgeon will expose the affected area of the hip through an incision over the bony prominence at the upper outer thigh. This allow for dislocation of the hip removal of the head of the femur and cleaning of the destroyed socket without damaging the major hip muscles. After being machined to a perfect hemisphere the socket is replaced by a metal cup fixed directly to bone. A special plastic liner is inserted into the cup. A metallic femoral component is then fitted directly to bone or alternatively cemented into the femur. A metal or ceramic ball is then fit onto the femoral component and the new hip joint is reduced and the surgical incision closed.

Anesthetic

Typically an epidural anesthetic with a general anesthetic is used for this type of surgery.

Length of hip surgery for rheumatoid arthritis

Depending on the complexity of the case most surgeries last 2 hours.

Recovering from surgery

Pain and pain management

Analgesics administered through the epidural catheter placed for surgery are very effective for controlling postoperative pain and are used for approximately 48 hours. Patient controlled intravenous narcotics can be used as a substitute for or supplement to epidural analgesics. By the third postoperative day oral narcotics are usually sufficient for pain relief and are quickly tapered according to individual patient needs. After that oral narcotics are administered and provided for the first two to four weeks after the patient has been discharged.

These medications are very effective in relieving the pain associated with total hip replacement. Dryness in the mouth sleepiness lightheadedness and constipation are the most frequent side effects of narcotic medications. The most serious side effect is suppression of respiration.

Hospital stay

The patients are cared for in the hospital by trained nurses and doctors. Mobilization begins immediately after surgery in the hospital bed. Surgical wound dressings are changed daily beginning on the second postoperative day.

Recovery and rehabilitation in the hospital

90% of recovery takes place within the first six weeks. Rehabilitation begins on the first postoperative day. It starts with sitting or standing at the bedside and progresses to walking with assistance and stair climbing. Precautions to prevent dislocation of the hip are taught. Instruction in the use of assistive devices is given.

Hospital discharge

The patient is discharged with oral narcotics to ensure comfort at home. Patients are usually ambulatory with a walker and independently mobilize from bed to walking. Physical activity and joint range of motion limitations are clearly provided by the physical therapist mainly to prevent dislocation of the hip. The hip can only be flexed up to 60 degrees the patient has to sleep with a pillow between the legs and is not allowed to cross the legs for the first six weeks after surgery.

Convalescent assistance

Most patients go home after 4-5 days. In the hospital they do though need some help for basic care especially those people with multiple joint involvement. If they do not have help at home then a short stay at a rehabilitation/convalescent facility will be necessary until they can resume independent living.

Physical therapy

Very little physical therapy is required after total hip arthroplasty. Therapists reinforce hip precautions supervise ambulation and provide muscle strengthening.

Rehabilitation options

Physical therapy begins with the inpatient rehabilitation described above. After returning home physical therapy can continue with the therapist coming to the patients home or in the therapist's office as needed. Most people do not require any physical therapy outside the home.

Only a small number of patients need therapy after 6 weeks--mostly to help them achieve a normal gait.

Returning to ordinary daily activities

At 6 weeks most of the hip dislocation precautions can be stopped. Patients can then can sit with hips flexed at 90 degrees sleep without a pillow between the legs and can walk without a walking aid. Most ordinary daily activities can be resumed.

Long-term patient limitations

We do not recommend high impact activities like down hill skiing running and jumping. The patient should always avoid putting shoes on with the hip in flexion and internal rotation and should avoid sitting on low stools. Lifetime prophylactic antibiotic therapy is recommended prior to dental procedures or any invasive diagnostic procedure (i.e. colonoscopy).