Total hip and total knee arthroplasty in juvenile rheumatoid arthritis.

Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is indicated for patients with juvenile rheumatoid arthritis (JRA) when marked joint destruction is present and pain or deformity compromises function despite optimal medical therapy. Relief of pain, reduction of the deformity, and dramatic improvement in functional status and quality of life can be achieved in most patients. Functional impairment and deformity rather than pain are usually the primary indications for THA or TKA. When there is both hip and knee involvement, hip arthroplasty should probably be done first. Regional anesthetic appears to be the anesthetic of choice. Careful preoperative planning and the availability of custom and minisized components are essential. Small bone size, osteoporosis, and severe soft tissue disease make the surgery technically demanding. Skeletal immaturity may not contraindicate surgery if the patient is otherwise bedridden with progressive deformity. In the hip trochanteric osteotomy is often necessary for adequate exposure, with the possible exception being a patient with juvenile ankylosing spondylitis who is subject to heterotopic bone formation. Although complete capsulectomy and psoas tenotomy may be necessary to relieve a hip flexion contracture, a soft tissue release that produces leg lengthening may lead to nerve palsy. In the hip component loosening has been less common in patients with JRA than in other young patients who have undergone THA, but it is still the most frequent cause of failure. In the knee preoperative and postoperative serial casts can aid in the correction of severe flexion contracture. Secondary patellar pain has been the most common cause of late failure. Patellar resurfacing should probably be performed at the time of the original knee arthroplasty in all patients with JRA.

Total knee arthroplasty in juvenile rheumatoid arthritis.

From 1971 to 1981, total knee arthroplasty was performed on forty-eight knees in twenty-eight patients with juvenile rheumatoid arthritis at the Robert Breck Brigham (now Brigham and Women's) Hospital. Seventeen of these patients, with twenty-nine knee-replacement arthroplasties, were followed for from two to eleven years (average, five years) and are the basis for this study. The patients' ages at operation ranged from thirteen to thirty-nine years (average, twenty-three years). Six patients had undergone total hip arthroplasty prior to admission for total knee replacement, and five patients had a total hip replacement performed while they were hospitalized for the knee arthroplasty. Thirteen patients (twenty-one knees) had significant preoperative pain but only three (five knees) had severe discomfort. Four patients were unable to walk, three were household walkers, and ten were limited community walkers. Preoperative deformities of the knees ranged from 20 degrees of varus angulation to 35 degrees of valgus angulation. The average preoperative flexion deformity was 23 degrees and the arc of motion averaged 45 degrees. At follow-up, twenty of the twenty-one knees that had been significantly painful preoperatively were completely relieved of discomfort. The average arc of motion increased by 34 degrees, while in all but one knee the angular deformity had been corrected to zero to 10 degrees of valgus angulation. All but one patient became a limited or full community walker. Complications included one late deep infection and one posterior tibial subluxation. Four knees required subsequent resurfacing of the patella for treatment of pain. We now routinely resurface the patella in all patients with juvenile rheumatoid arthritis who have a total knee replacement. To date no prosthesis has required revision for loosening. Radiolucency of one millimeter or less about the prosthesis was noted at follow-up in eight (30 per cent) of the knees. As custom-made components were required in twelve of the twenty-nine knees, it is obvious that preoperative planning is crucial in the treatment of these patients. Our recent experience has shown that the use of preoperative and postoperative serial casts aids greatly in the correction of severe flexion deformity of the knee. Postoperative manipulation was required for twenty-one of the twenty-nine knees. Skeletal immaturity was not an absolute contraindication to surgery. We think that our results, which showed a marked improvement in both knee function and in quality of life, make the short and long-term risks of knee-implant surgery well worth taking in this patient population.

Volkmann's ischemia.

The posttraumatic syndrome of Volkmann's ischemia and infarction is the end result of compromise of muscle perfusion within the osteofascial compartments of the forearm. The "closed space" arrangement as well as the particular neurovascular anatomy make the flexor forearm muscles particularly susceptible to the cyclic derangement of blood flow, which ultimately results in muscle ischemia and infarction. Only strong clinical awareness will allow appropriate early diagnosis and treatment by surgical decompression. Fasciotomy and epimysiotomy serve to interrupt the cycle. The successful treatment of Volkmann's ischemia requires an understanding of the pathophysiologic mechanisms at work, an appreciation of the subtleties of the clinical presentation, and strong grounding in the details of forearm anatomy and techniques of surgical decompression.