Annals ofthe Rheumatic Diseases 1990; 49: 858-862

Surgical treatment of the rheumatoid hip

I G Kelly

Hip joint disease in rheumatoid arthritis is saidto occur in between 30 and 40% of patients,' 2higher figures being obtained in radiographicallybased studies. This is a considerably lowerincidence of disease than for the knee (60%) orshoulder (70%), and the frequency with whichthe hip joint undergoes surgery is a direct resultof the development of hip joint replacementsurgery.

Patterns of joint diseaseThe inflammatory process within the hip jointinitially leads to a synovitis with an effusion. Toaccommodate the increased volume the hipassumes a flexed, externally rotated, andadducted position. Fixed deformities quicklydevelop and are demonstrable in most patientsat the time of presentation. Certain radiologicalpatterns result from these pathological pro-cesses,2 3the most common being concentricjoint space loss, which may progress witherosion of the acetabular roof and, to a lesserextent, of the femoral head (fig 1). Between 15and 20% of patients will develop protrusioacetabuli (fig 2) and without treatment this will Figure 2 Protrusio acetabuli withfracture ofthe acetabular

floor.

Royal Infifrmary,Glasgow G4 OSFI G Kelly

Figure I Typical concentric disease ofthe hipjoint inrheumatoid arthritis, with erosion ofboth thefemoral headand the acetabulum.

progress and may be complicated by fracture ofthe thin medial acetabular wall.

Indications for surgeryThe patient's major complaint is pain, which isusually localised to the groin, buttock, or lateralthigh but is occasionally limited to the knee,causing diagnostic difficulties when the knee isalso affected. If the pain cannot be controlled byanalgesics or regularly disturbs sleep surgery isindicated. Stiffness or deformity can also providean indication for surgery by threatening thepatient's independence. Although it is wellestablished that young patients have moreproblems with loosening of the prosthesis thanolder patients,4 in my practice youth is nocontraindication if the symptoms cannot berelieved in any other way.

Disease of multiple joints of the leg is notuncommon, and in this situation a plan ofmanagement must be worked out with thepatient and his/her family or carers. If surgery isto be carried out on all of the affected joints thenit is my practice to start with the most painful.The hip will take precedence, however, if thereis a rapidly progressing protrusio or if there isipsilateral disease of the hip and knee. In thissituation correction of the hip deformities

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facilitates the correct alignment of the kneearthroplasty.

Preoperative assessmentBefore surgery, as with other major jointoperations, the patient must be assessed for thepresence of anaemia, impaired renal function,or any sites of active infection, such as unhealedskin lesions. All patients should also have lateralflexion and extension radiographs of their cer-vical spine carried out to detect any significantspinal disease (see p 846, this issue). Theanaesthetist can then be alerted to its presenceand appropriate measures can be taken forintubation, including the use of fibreopticlaryngoscopes. Radiological subluxation in theabsence of symptoms or signs of a myelopathydoes not constitute a contraindication to surgery.

Surgical managementRheumatoid disease at most joints can bemanaged by any one ofsynovectomy, osteotomy,arthrodesis, or arthroplasty according to thestage of the arthritis. At the hip synovectomy isvery difficult to perform adequately and hasfailed to give satisfactory results in the adult.5 Itmay have a role in juvenile chronic arthritis, butin this group its major effect is relief of painwith no significant improvement in mobilityand, like synovectomy at most other sites,continued radiological progression.6 Osteo-tomies around the hip do nothing to tackle therheumatoid pannus and are therefore inappro-priate. Arthrodesis is contraindicated by thepolyarticular nature and potential of the disease.

Total hip replacement is the most valuableform of surgical management for the rheumatoidhip. Developments over the last 30 years haveresulted in a variety of hip-arthroplasties, all ofwhich have a stemmed metal femoral componentand a high molecular weight polyethyleneacetabular component.

Operative approachesMuch of the fundamental work on hip arthro-plasty has been reported by Charnley.7 Hedescribed removal of the greater trochanter withits attached gluteal muscles in the approach tothe hip. Reattachment of this bony fragmentand maintenance of its position can be difficultin the rheumatoid patient because of osteo-porosis (fig 3), and non-union rates of 20% havebeen reported.8 9 Because of these problems Iprefer to avoid the trochanteric approach unlessI require the excellent exposure it affords.

Other approaches to the hip employ posterioror anterolateral routes and their use dependsalmost entirely on the surgeon's preference. Byavoiding trochanteric detachment they permitmore rapid mobilisation of the patient, thoughthey may make positioning of the prostheticcomponents a little more difficult.

Prosthetic fixationNon-cemented hip arthroplasties have attractedmuch interest over recent years, but rheumatoid

Figure 3 Charnley low frictin arthroplasty unth non-unionofthe greater trochantericfragment andfracture ofthe wires.

arthritis, where there is often osteoporosis andan associated wide femoral medullary cavity,remains a relative contraindication for thismethod. The use of methylmethacrylate bonecement remains the method of choice in therheumatoid patient.

Intraoperative problemsThe effect of rheumatoid disease upon the boneand joint and the patterns of destructionproduced predispose to the occurrence of severalintraoperative problems.

FEMORAL SHAFT FRACTUREDislocation ofthe hip may be difficult, especiallyif there is protrusio acetabuli, and this mayresult in a considerable stress being put upon theosteoporotic femoral shaft, which may fractureas a result. If the hip cannot be dislocateddespite removing the capsule and the anteriorand superior margins of the acetabulum thefemoral neck should be sectioned in situ and thehead removed from the acetabulum separately.

STEM PERFORATIONIt is the osteoporotic bone of the femur whichagain makes this complication more likely thanin osteoarthritis, and it is not always easy torecognise intraoperatively. Patients with juvenilechronic arthritis will have narrow medullarycavities necessitating the use of special pros-theses, and perforation may be difficult toavoid. This type of femur is probably bestprepared by using powered reamers which aredirected by a blunt guide wire using x raycontrol if this is available. Perforation of theshaft can result in persistent postoperative painand contribute towards early loosening.'"

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PROTRUSIO ACETABULIAn acetabular cup allowed to sit in an acetabulumwhere there is protrusio will lie in a superiorposition and will have little or no support fromthe thin or deficient medial wall. The surgeon'saim must be to provide support for the cup to sitin as near to an anatomical position as possible.The medial acetabular wall may be reinforced

by bone cement, bone, wire mesh, or supportrings which bear on the acetabular rim.Charnley suggested that moderate degrees ofprotrusio with an intact medial wall might bemanaged by cement alone, " and the morerecent development of flanged and 'Ogee' cupsfacilitates this method by both sitting on theacetabular rim and providing support and pres-surisation for the cement (fig 4).More severe degrees of protrusio and the

presence of a medial wall defect can necessitatethe use of bone graft. At primary proceduresthis can be obtained by cutting the femoral neckinto slices about 2 mm thick before section ofthe neck. Cement can be applied directly to thesurface of the grafts. Such grafts have beenshown to incorporate and remodelling of themedial wall of the acetabulum has been demon-strated.'2 13

Results of total hip replacementHip arthroplasty gives good results in patientswith rheumatoid arthritis, with excellent painrelief in over 90% of patients. The return ofwalking ability and other lower limb functionsis more difficult to assess because the otherlower limb joints are often affected.8 Simul-taneous arthroplasty of both hips or both kneeshas been recommended in patients withmultiple lower limb joint problems and goodresults have been reported. 14 I have only limitedexperience of this approach but would warn thatthe patient must be made aware of the need forintensive and prolonged rehabilitation measurespostoperatively.

Figure 4 Protrusioacetabuli treated by the useofa flanged cup to pressurisethe cement mantle. Note theescape of the osteoporoticgreater trochanterfrom theintact unres.

Postoperative rehabilitation usually presentsfew problems, though associated arm jointdisease may make the use of walking aidsdifficult. Mobilisation can usually be started onthe third or fourth day after the operation and inmost cases the patient will be discharged fromhospital within two weeks of surgery.

ComplicationsANAEMIAA low haemoglobin concentration is 'normal'for many rheumatoid patients and on occasioneven the moderate blood loss to be expectedduring hip arthroplasty can lower it to such anextent that symptoms ensue. This can have anadverse effect on recovery from the operationboth in terms of mobilisation and woundhealing, and transfusion may be required torestore the haemoglobin to the 'normal' pre-operative concentration.

DEEP VENOUS THROMBOSISDeep venous thrombosis is a common compli-cation of hip arthroplasty with an overallincidence in excess of 50% and an incidence ofpulmonary embolism of 6%. ' Patients withrheumatoid arthritis are said to have a low riskof thromboembolic disease, however. 16 Avoid-ing the trochanteric approach to the hip is alsosaid to be beneficial, and there is some evidencethat the use of spinal rather than generalanaesthesia will halve the incidence of majorthrombi.Although venous thrombosis itself can have

serious after effects, the low incidence of fatalpulmonary embolism (about 1%) and theproblems of haematoma and wound infectionencountered during the routine use of anti-coagulant drugs"7 "I make it difficult to recom-mend a regimen of routine drug prophylaxis.Hydroxychloroquine has been reported to beeffective and to have no serious side effects, '9though patients not infrequently experienceshort lived nausea. The results of a large doubleblind study of this agent are awaited. Gradedcompression stockings have also been shownto be of value20 and are widely used, and intra-operative calfcompression also has its advocates.Whatever method is used early mobilisation isessential.

INFECTIONInfection, especially deep infection, is usuallyincompatible with survival of the arthroplasty,and deep infection occurs four times morecommonly in rheumatoid arthritis than in osteo-arthritis.2' This is usually a late event andsuggests haematogenous infection from adistant site such as a skin ulcer. The use ofsystemic steroids also increases the risk ofinfection.22

Antibiotic prophylaxis is now almostuniversal with arthroplasties, and it has beensuggested that this eliminates any differencesbetween rheumatoid and osteoarthritic patientsin the early postoperative period.23 Because ofthe risk ofhaematogenous infection prophylacticantibiotics should be used to cover any episode

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of infection at any time postoperatively and allpatients should be screened for the presence ofoccult infection, especially in the urinary tract,preoperatively.

LOOSENINGLoosening may be purely mechanical or have aninfective cause; differentiating the two can bevery difficult. In infective loosening theorganism is often oflow pathogenicity (Staphylo-coccus epidermidis or diphtheroids), there willbe no clinical signs of infection around the hip,there may be no leucocytosis, and the sedi-mentation rate or C reactive protein concen-tration, or both, may be difficult to interpret.Radiographs will show lucent lines at the bone-cement junction around the prosthesis and theremay be endosteal erosions (fig 5). These signscan be present without infection, however.Bone scanning with both technetium-99m andgallium-67 citrate can be very helpful because,although both types of loosening will show anincreased uptake of technetium, only infectedhips will show an increased uptake of gallium.24This method is not infallible, however, andaspiration of the hip on one or more occasionswith the use of special bacteriological tech-niques should be used before carrying out anyrevision surgery. The organisms with lowpathogenicity and even Staphylococcus aureuscan usually be controlled sufficiently withsystemic antibiotics and antibiotic loaded bonecement, making revision of the arthroplasty toanother hip replacement possible in one or twostages provided that the bone stock is sufficient.Gram negative bacteria and other more difficultorganisms are usually incompatible with this

. {

FigureS Gross loosening ofboth components ofthearthroplasty. Thefemoral component has subsided into thefemoral canal with resorption ofthe bonefrom the calcar.Note the lucency between the cement and bone and theendosteal erosions, which are most marked medially. Theacetabular component has migrated into the pelvis. Onceagain note the radiolucent zone between the cement and thebone.

method of management and removal of thearthroplasty is usually necessary (see below).

Mechanical loosening is often thought to bemore prevalent in rheumatoid patients becauseof the poor quality of the bone and the commonacetabular abnormalities. Beddow, however,considers that this is not proved and suggeststhat the lighter frame and the limited activitiesof most of these patients counter the potentialproblems with prosthetic fixation.25 Studies ofyounger patients in a variety of diagnosticgroups4 26 suggest that aseptic loosening mayoccur in as many as 57% by five years afteroperation. Young patients with rheumatoidarthritis had a better prognosis than othergroups, again probably because of their limitedactivities.

Excision arthroplasty of the hipExcision arthroplasty27 has little place in theprimary management of the rheumatoid hip,though it can be useful for the relief of pain andthe correction of severe deformity in a chair-bound patient. It has a role as a salvageprocedure for failed arthroplasty when re-implantation cannot be considered because ofthe nature of the infecting organism or the lackof bone stock. It will provide good pain reliefbut, because of the resulting instability andshortening, walking is likely to be difficult evenwith the use of a shoe raise and a walking aid.

ConclusionThe excellent pain relief and the good long termresults make total hip replacement a 'winner' inthe surgical management ofrheumatoid arthritis.No other surgical procedure on the hip canmatch the results it achieves.

1 Duthie R B, Harris C M. A radiographic and clinical surveyof the hip joint in seropositive rheumatoid arthritis. ActaOrthop Scand 1969; 40: 346-64.

2 Hastings D E, Parker S M. Protrusio acetabuli in rheumatoidarthritis. Clin Orthop 1975; 108: 76-83.

3 Welch R B, Charnley J. Low friction arthroplasty of the hipin rheumatoid arthritis and ankylosing spondylitis. ClinOrthop 1970; 72: 22-32.

4 Dorr L D, Takei G K, Conaty J P. Total hip arthroplasties inpatients less than forty five years old. J Bone joint Surg[Am] 1983; 65: 474-9.

5 Conaty J P. Surgery of the hip and knee in patients withrheumatoid arthritis. J Bone joint Surg [Am] 1973; 55:301-14.

6 Mogenson B, Brattstrom H, Ekelund L, Svantesson H,Lidgren L. Synovectomy of the hip in juvenile chronicarthritis. J Bone joint Surg [Br] 1982; 64: 295-9.

7 Charnley J. Low frictwon arthroplasty of the hip: theory andpractice. Berlin: Springer, 1979.

8 Colville J, Raunio P. Charley low friction arthroplasties ofthe hip in rheumatoid arthritis. J Bone joint Surg [Br]1978; 60: 498-503.

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10 Talab Y A, States J D, Evarts C Mc C. Femoral shaftperforation: a complication of total hip reconstruction. ClinOrthop 1979; 141: 158-65.

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12 McCallum D E, Nunley J A, Harrelson J M. Bone grafting intotal hip replacement for acetabular protrusion. J BoneJoint Swrg [Am] 1980; 62: 1065-73.

13 Mayer G, Hartseli K. Hip replacement in acetabular pro-trusion. Acta Orthop Scand 1985; 56: 461-3.

14 McDonald I. Bilateral replacement of the hip and knee inrheumatoid arthritis. J Bone joint Surg [Br] 1982; 64:465-8.

15 Sikorski J M. Thromboembolic complications. In: LingR S M, ed. Complicatins oftotal hip replacement. Edinburgh:Churchill Livingstone, 1984.

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16 Sikorski J M, Hampson W G, Staddon G E. The naturalhistory and aetiology of deep vein thrombosis after total hipreplacement.I BoneJointSurg [Br] 1981; 63: 171-7.

17 Harris W H, Salzman E W, Athanasoulis C, Waltman A C,Baum S, De Saudis R W. Comparison of warfarin, lowmolecular weight dextran, aspirin and subcutaneous heparinin prevention of venous thromboembolism following totalhip replacement. J7 Bone Joint Surg [Am] 1974; 56:1552-62.

18 Hull R D, Raskob G E. Prophylaxis of venous embolicdisease following hip and knee surgery. Bone Jtoint Surg[Am] 1986; 68: 146-50.

19 Johnson R, Loudon J R. Hydroxychloroquine prophylaxisfor pulmonary embolus for patients with low frictionarthroplasty. Clin Orthop 1986; 211: 151-3.

20 Ishak M A, Morley K D. Deep venous thrombosis after totalhip arthroplasty: a prospective controlled trial to determinethe prophylactic effect of graded pressure stockings. BrSurg 1981; 68: 429-32.

21 Fitzgerald R H, Nolan D R, Ilstrup D M. Deep wound sepsisfollowing total hip arthroplasty. Bone Joint Surg [Am]1977; 59: 847-55.

22 Nixon J E. Failure patterns after total hip replacement. BrMed 1983; 286: 166-70.

23 Poss R, Ewald F C, ThomasW H, Sledge C B. Complicationsof total hip replacement arthroplasty in patients withrheumatoid arthritis. Bone Joint Surg [Am] 1976; 58:1130-3.

24 Klenerman L. The management of the infected prosthesis.J Bone Joint Surg [Br] 1984; 66: 645-51.

25 Beddow F H. Surgical management of rheumatoid arthritis.London: Butterworth, 1988.

26 Chandler H P, Reineck E T, Wixson R L, McCarthy J C.Total hip replacement in patients younger than thirtyyears old. J Bone joint Surg [Aml 1981; 63: 1426-34.

27 Girdlestone G R. Arthrodesis and other operations fortuberculosis of the hip. Bonejoint Surg (Birthday Volume)1928.

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