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Posterior-Stabilized Total Knee Replacement In Rheumatoid Arthritis

  Almeida F*,  Martin J M**, Silvestre A ***, Gomar F #.

* Consultant Orthopaedic Surgeon
*** Consultant Orthopaedic Surgeon
# Director Department of Orthopaedics, Clinic University Hospital, Valencia. Spain

Address for Correspondence:  
Fernando Almeida Herrero.
Av Cortes Valencianas 41 61. 46015.
Valencia. Spain.
Tel: +34606609925.
: +34963987651.     


We retrospective compared the outcomes of 42 total knee replacements in 28 patients with rheumatoid artritis, after an average follow-up of 7.5 years. Revision was necessary in nine knees (21.4%). No revision for deep infection was done. Four patients died and two patients (with bilateral replacement) had a follow-up less than two years, so they are not included in this serie. The mean Hospital for Special Surgery score was 79.6 and the mean clinical and functional Knee Society score were 83 and 61, respectively. The mean flexion angle at follow-up evaluation was 97.8º+18.4. The rate of survival at eight years was 81% with femoral or tibial revision for any reason as the end point. Total knee arthroplasty is a good option in patients with rheumatoid arthritis in the medium term follow-up, even though it is not free of complications.

J.Orthopaedics 2008;5(3)e3

Arthroplasty; Knee; Rheumatoid arthrtitis

Total knee arthroplasty (TKA) provides good pain relief and functional recovery in patients with impaired walking ability and persistent knee pain caused by chronic rheumatoid arthritis.

Patients with rheumatoid arthritis are on average approximately 10 years younger than patients with osteoarthritis at the time of total knee arthroplasty. [1] Assuming the patient has a normal life span, a total knee arthroplasty in a patient with rheumatoid arthritis will have to be good functioning for a longer time so we should take into account this for late complications such as infection, loosening, component wear, and osteolysis.

The aim of this retrospective study was to review our clinical and radiological mid-term results (mean follow-up of 7 years) after total knee arthroplasties in patients with rheumatoid arthritis.  

Preoperative patient evaluation

Before performing a total knee replacement on a patient with rheumatoid arthritis, a careful preoperative assessment is crucial.

 Systemic nature of the disease and long-term therapies with corticoisteroids and immunosuppressive drugs can modify the immune system of these patients. Approximately 10% of patients with RA at the time of total knee arthroplasty are taking maintenance corticosteroids.[1,2] These drugs and the patient´s nutritional status can affect the rate of wound healing and the incidence of infection, in the immediate post-op and in the long run. The incidence of infection after joint replacement surgery in patients with RA is three times greater than in the general population.[1]

As well as corticosteroids and immunosuppressive therapies, nonsteroidal anti-inflammatory drugs are a mainstay in the treatment of rheumatoid symptoms. These drugs have influence on deep venous thrombosis prophylaxis, anesthesia and postoperative pain management. Aspirin and ibuprofen harmfully influence the coagulation profile of the patients, so the use of warfarin or low-molecular-weight heparin together with these nonsteroidal anti-inflammatory drugs is contraindicated.  

The knee is among the most commonly affected joint in rheumatoid arthritis. Indeed, it is estimated that up to 90% of these patients will eventually have involved one or both knees.[3] Polyarticular involvement of rheumatoid arthritis requires careful planning in order to optimize the patient´s overall function. As much as 50% of patients with rheumatoid disease of the knee have concomitant hip involvement.[4] Hip replacement should be done before knee replacement when both are indicated in the same leg for several reasons. Pain from an unhealthy hip may be referred to the knee, so hip arthroplasty may delay the need for total knee prosthesis. On the other hand, rehabilitation after hip arthroplasty is possible in the presence of knee arthritis but the opposite situation is quite hard. Finally, the overall experience of undergoing hip arthroplasty is easier from patient´s perspective in terms of pain and rehabilitation and therefore will set up patient confidence in the use of these devices more promptly.

Upper-extremity involvement of the disease must also be assessed prior to undertaking total knee arthroplasty in rheumatoid patients. Often, the involvement of the shoulders, elbows or wrists hinders the use of canes which are necessary for walking in the weeks following knee replacement. Up to 105º of knee flexion is required to rise from a seated position without the help of the upper extremities. Hence, any surgical technique should attempt to restore plenty knee flexion in order to maintain independent function in patients with upper-extremity disease.[5]

Finally, the use of disease-modifying agents in the perioperative period has been of great concern for orthopaedic surgeons. Use of methrotrexate should finish just about 2 weeks before surgery and in the immediate postoperative period because of fluid-balance disturbances and the possibility of infections.[6,7] However, larger prospective clinical trials are required to ascertain the precise effects of these disease-modifying agents on the TKA population.

Material and Methods :

Between February 1990 and May 2005, 42 cemented primary posterior-stabilized total knee arthroplasty were performed in 28 patients with rheumatoid arthritis at our Hospital.  Four cemented posterior-stabilized designs were included: Hermes (Osteal-Ceraverâ), Performance (Biometâ), Link (Linkâ) and Interax (Strykerâ) (Figure 1). The Hermes implant was mainly use in 16 knees while the Link and Interax implant was used only in one case respectively.

Fig. 1. Main posterior-stabilized designs used. Hermes (Osteal-Ceraverâ), Performance (Biometâ)

Four patients (8 knees) died during the follow-up, two patients (4 knees) have not included in the group because the follow-up was less than two years and revision surgery was done in five patients (9 knees), so they have also been excluded. None of the patients who died underwent revision surgery or reported complications related to their knees while they were alive. Therefore 21 knees in 17 patients have been included in our group for clinical and X-ray evaluation. The end of the follow-up was July 2007, so all patients had a minimum of two years record (mean 7.4; 2 to 12).

The study included 16 female and one male with a mean age of 62 years (range 28-80 years) at the time of their replacement. Four patients had bilateral surgery. A previous operation, open synovectomy, had been performed in only one patient.

A midline skin incision with a medial parapatellar splitting of the quadriceps was used in all the patients. The distal femur was then excised to achieve a tibiofemoral alignment of 5º of valgus in the coronal plane. After achieving ligamentous balance, the proximal tibia was resected in order to get a surface perpendicular to the shaft of the tibia in coronal plane. Careful awareness to match gaps and to the correct any pre-operative flexion contracture was paid. The patella was resurfaced in all cases.

Patients began active and passive motion of their knees and started walking with aids about two days, after surgery. We used in our hospital continuous passive motion machines for the rehabilitation program. 

            The patients were evaluated clinically using the rating systems of the Hospital for Special Surgery (HSS) [8] and the Knee Society (KS).[9] In the KS rating system, two scores were assigned: one for knee score (pain, range of motion, and stability) and another for function score (walking, stair climbing, and use of walking aids).

In the early post-operative and final follow-up standing anteroposterior and lateral radiographs were assessed for radiolucency at bone-implant interfaces, lateral and medial joint spaces, measurement of angles a,b,d and g, change in the position of the components and osteolysis, according to the method of the Knee Society.[9] Radiolucencies at the bone-cement interface were evaluated in 7 zones in the anteroposterior view of the tibial component, 3 zones in the lateral view of the tibial component and 5 zones in the lateral view of the femoral component. Patients were reviewed by two senior physicians, independently of the surgeon performing the procedure.

Survivorship analysis was performed using the Kaplan-Meier method with the end-point being removal or revision of a component for any reason. [10]

Results :

The average Hospital for Special Surgery score was 79.6+10.2 at the final follow-up assessment. The mean clinical and functional Knee Society in knee score were 83 (41 to 99) and in the function score were 61 (0 to 100) at the end of the follow-up. All the patients were included in category type C with multiple arthritis and medical infirmity.[9] At this time 14 knees (66.6%) were pain-free, four knees (19.1%) were somewhat painful during long walks, two knees (12.2%) were fairly painful during stair climbing and a knee (2.1%) was hardly painful while walking. No one was painful at rest. Twelve patients (70.5%) did not require a cane for walking, two (11.8%) needed a cane only for long walks, two (11.8%) used a cane full-time, and one of them (5.9%) was forced to use a walker.

The mean active range of motion of the knees was 97º (15º to 130º). Flexion contracture less than 15º was seen in five knees (24%). However, flexion less than 90º was observed in five knees (24%) at follow-up evaluation.

            Femorotibial alignment of 5.5º of valgus (range, 3.1º to 12º) was measured on the postoperative radiograph in the standing position. The mean position of the components was 94º (range, 79.5º-100.8º) for the femoral (alfa), and 87.9º (range, 84º-92º) for the tibial one (b). Flexion of the femoral component (g) was 5.9º (range, 0º-27.9º), and the slope of the tibial component (d) was 89.6º (range, 83.6º-94.5º) (Figure 2).

Fig.2. Roentgenographic evaluation. Measurements of knee alignment (femorotibial angle) and position of components (position -a-, angle -g- of the femoral component and position -b-, angle -d- of the tibial component).

Radiographs of 10 knees (48%) showed radiolucent lines at the bone-cement interface during the follow-up. Nine knees (43%) had radiolucent lines around the femoral component, three in zone 1, six in zone 2, one in zone 3 and three knees in zone 4. Ten knees (48%) had radiolucent lines related to the tibial component. In the anteroposterior view of the tibial implant we observed nine radiolucent lines in zone 1, eight in zone 2, five in zone 3 and seven in zone 4 at the tibial bone-cement interface while in the lateral view detected eight knees with radiolucent lines in zone 1, five in zone 2 and one in zone 3. No relationship was remarked between radiolucency and variables such as age, body weight, type of component, and alignment (Figure 3).  

Fig.3. Radiographs showed radiolucencies at the bone-cement interface in tibial and femoral components

Nine knees (21.4%) underwent revision surgery performed 7.5 years after the primary joint arthroplasty (range, 2-18 years). Two knees were revised for clinical symptomatic instability after three and four-years of follow-up being change to a modular rotating hinge design. The other seven had revision for PE wear 14 years after surgery (range, 12 to 18 years) in four cases, aseptic loosening in two cases (4 and 9 years after surgery) and for pain of unknown source after 23 months of the surgery. There were no revisions for septic loosening.

Survivorship was calculated using the method of Kaplan and Meier.[10] Removal or revision of a component for any reason was set up as an endpoint. With these criteria, there was a survival rate of 81% at 8 years (Figure 4).         

Fig.4. Survival curve with a revision as the end point shows 81% survival rate at 8 years follow-up.


Discussion :

Functional status of rheumatoid patients after total knee arthroplasty remained far below that of patients with osteoarthritis treated with knee arthroplasty.[11] This was believed to be caused by polyarticular involvement of the disease and the steadily declining functional status than can occur in the long term.[12] In our serie, 11 patients underwent surgery in other joints, however excellent or good results in the Hospital for Special Surgery score were achieved in 81% of our patients after a mean follow-up of 7.5 years.

The pain score and range of motion are usually beyond the influence of other maladies. In our cases, 18 of 21 knees (85.7%) had no pain or were slightly painful. Van Loon et al reported that 48 of 52 knees (92%) had no pain or occasional pain.[13] Malkani et al stated no pain in 70% of knees [14] and Laskin warned that knees with low pain score had malalignment or malpositioning of the components, mainly the tibia.[15]

                        While debates within the orthopedic community focus on issues as the value of preserving the posterior cruciate ligament, recent studies support the fact that with modern total knee designs, excellent functional improvement and long-term prosthesis survivorship should be expected. Schai et al evaluated 81 patients who had received a posterior cruciate retaining implant and reported a prosthesis survivorship of 93.7% after 11 years of follow-up with a mean of 95 points in the Knee Society score.[16] On the other hand, Laskin and O´Flynn assessed 116 patients with a posterior cruciate ligament retaining prosthesis and showed a 50% incidence of late posterior instability.[17] Eleven patients underwent revision surgery because of instability. In a large multicenter Swedish survey, reviewing more than 1900 cruciate retaining knee replacements in patients with rheumatoid arthritis, only 0.5% of revision surgeries were performed for posterior instability.[18] Scuderi et al studied cruciate sacrificing and posterior stabilized total knee arthroplasties and found an overall survivorship of 97.3% at 10 years and 90.6% at 15 years.[19]

Regarding long term component stability in relation to the posterior cruciate ligament, an early predictor of late implant loosening may be the presence of radiolucencies at bone-cement interface. The prevalence of radiolucent lines is reported to be between 20% and 60%, the higher rates observed in studies with more than ten-year follow-up.[14,20-22] Uematsu et al studying 616 knees with a maximum follow-up period of 7 years, reported 7% of radiolucent lines on the femoral side and 20% on the tibial side.[20] Eward et al reported that 18% of 124 consecutive cases had radiolucent lines at the tibial bone-cement interface.[21] Ito et al described a prevalence of 27.8% at 13 years or more after surgery in 36 cases.[22] Malkani et al had an incidence of 60% at a mean of 10 years after surgery.[14] Sharma et al for 63 cases informed of 32% of significant radiolucent lines at 16 years after surgery. In our cases, prevalence of radiolucent lines was 48% at a mean of 7.5 years follow-up, similar to other reports in literature.[23]             

Whether or not malalignment of the knees influences clinical results or radiolucent lines are an important fact, especially in the long term results, it is an evidence that the prevalence of radiolucent lines was significantly higher in cases with a varus-positioned tibial component than in those with neutral placement. Conversely, the incidence of radiolucent lines around the femoral component was not related with the placement of the femoral component.[21] In rheumatoid knees, Laskin indicated that varus positioning of the tibial component was significantly correlated with radiolucency at the bone-cement interface in a 10-year follow-up study.[15]

Infection perhaps is the most important complication after total knee replacement in patients with rheumatoid arthritis. Rates of infection have been reported to be about three times larger than in patients with osteoarthritis.[24,25] Reasons for these are multifactorial, but the use of immunosuppressive drugs, mainly corticosteroids, is the main factor. Steroids not only influence the immune response system of the patients, but also have tendency to render the skin atrophic and easily injured.

Other complication after total knee arthroplasty apart from aseptic loosening and infection is peri-prosthetic fracture.[22,26,27] Restricted range of motion could be a risk factor for supracondylar fracture of the knee. Nerve palsy, deep vein thrombosis, skin necrosis, breakage of the metallic tray [28] and granulomatosis reaction are also complications that could appear.[29]

Total knee prosthesis for rheumatoid arthritis and for osteoarthritis are not similar in terms of the activity of patients, osteoporosis around the implant, disorders of other joints, and age of surgery. Hence, the data of follow-up results and survival rate are not exactly comparable if prosthesis designs, disease of the population and age at surgery are not considered.

In long term studies, the number of patients often decreases because of death from natural causes. Higher mortality rates have been registered in patients with rheumatoid arthritis than in cases of osteoarthritis.[30] Sharma informed of mortality rates of 23.4% [23] and Ito reported rates of 40.8% at 15 years.[22] In our study four patients had died (14.2%) at the follow-up evaluation.


Rheumatoid arthritis concerns about 1% of the population. Most of the patients with long-standing rheumatoid arthritis have at least one, and often both knees affected.[31] When there is joint deformity or cartilage destruction, total knee replacement is the main therapeutic alternative. Unycondilar prosthesis and osteotomy do not diminish inflammation and the constant damage of the residual joint cartilage of the knee joint. Despite the difficulties related to the surgery in rheumatoid population, a well-timed, well-executed total knee replacement has been proven to enhance quality of life for people with disabling rheumatoid of the knee.

Reference :

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This is a peer reviewed paper 

Please cite as : Almeida F : Posterior-Stabilized Total Knee Replacement In Rheumatoid Arthritis

J.Orthopaedics 2008;5(3)e3





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