America, land of the free, home of the bionic. At least the partially bionic.
According to the results of a study by the Mayo Clinic, by the year 2010 an estimated 7.2 million adults in the U.S. had one or more artificial joint implants. This number may be considerably higher today because the study also noted that about a million joint replacement surgeries are performed in the U.S. each year.
Artificial joints can make a dramatic difference in the lives of people with disabling, often crippling damage to the hips, knees, shoulders, elbows and ankles, alleviating pain and functional limitations and improving overall quality of life. But are they a practical alternative for people with joints ravaged by rheumatoid arthritis?
Generally speaking, the answer is yes.
In the past, it was commonly thought that people with RA fared worse after joint replacement compared with other patients, but studies have not borne this out. On the contrary, the results of joint replacement surgery have mostly been shown to be comparable to those seen in people with osteoarthritis. Both RA and osteoarthritis can cause major joint damage, but they have different mechanisms of action. Damage from osteoarthritis largely occurs though mechanical wear and tear over time and is confined to the joints; RA is an inflammatory autoimmune disease that produces antibodies and inflammation that attack many tissues throughout the body, including the lining of the joints.
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Several factors likely contribute to the success rates seen in people with RA.
“There have been so many improvements in patient preparation, anesthesia use and surgical approach and design, including improvements in the materials, that it is hard to isolate any given factor to explain the improvements in outcomes over the past few decades,” says Dr. Susan Goodman, a rheumatologist and professor of clinical medicine at the Weill Cornell School of Medicine in New York.
The newer RA medications, combined with earlier, more aggressive treatment, may also play a role.
“The widespread use of potent disease-modifying medications has led to great improvements in the health-related quality of life for patients living with RA,” says Goodman, who is also the director of the Integrative Rheumatology and Orthopedic Center of Excellence at the Hospital for Special Surgery in New York.
These medications provide such good control of the disease in so many people with RA that they have even reduced the degree of joint destruction previously seen, to the point where they have decreased the need for arthroplasty, or joint replacement.
“I used to see RA patients weekly, if not daily, in the 1990s and into the 2000s,” says Dr. Seth Leopold, a hip and knee surgeon in Seattle and a professor in the Department of Orthopaedics and Sports Medicine at the University of Washington School of Medicine. “Now it’s more rare to see joints ruined by RA.”
“Patients with RA can expect to improve as much as patients who undergo knee arthroplasty for osteoarthritis,” Goodman says. “Patients undergoing hip replacement also have good outcomes, but they don’t achieve full, functional improvement and pain relief as reliably as patients undergoing hip replacement for osteoarthritis,” Goodman says.
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Ultimately, success depends on the patient’s preoperative condition, according to Leopold.
“Patients who can walk independently, maybe with a cane, likely do better than patients who’ve been in a wheelchair, he says. “Really deconditioned patients who’ve lost a lot of muscle don’t get as much function back.”
Not everyone suffering from RA-related joint damage is a candidate for surgery. Goodman recommends arthroplasty to her patients with RA based on a combination of the patient’s pain and loss of function, as well as X-ray evidence of advanced joint damage.
“The best candidates are patients with severe limiting pain and advanced X-ray damage. When [the] pain seems out of proportion to the X-ray findings, it may indicate that the basic inflammatory disease is poorly controlled, and surgery may not be required,” Goodman notes. “In those cases, the patient might benefit more from an adjustment of their medications.”
Leopold, who is the editor in chief of Clinical Orthopaedics and Related Research , a large, international journal of orthopaedic surgery, uses specific criteria to determine whether individuals with RA should have arthroplasty. First, he suggests that patients with RA be managed by a rheumatologist because they are more likely to have better disease control.
Some medications for RA can suppress the immune system, which increases the risk of infection, or interfere with the drugs prescribed after arthroplasty, so Leopold confers with the patient’s rheumatologist to discuss any necessary, temporary changes in medications before and after surgery. And he asks about any specific issues that may complicate surgery.
“Patients with RA can have problems with the cervical spine in the neck and you may not know that until he or she is on the operating table and the anesthesiologist attempts to move the neck to put in a breathing tube.”
Leopold also assesses what he calls the bio-psych-social profile in all his patients before agreeing to perform joint replacement.
“It’s important to look at the patient as a whole person and not just a hip or knee,” he stresses.
For the bio, or biological, component, he assesses the person’s overall medical condition.
“In some patients, the disease is so well-controlled that you wouldn’t know they had RA. In others, the disease is poorly controlled and patients can have severe complications. The best candidates for surgery are healthier.”
He makes sure that blood pressure and diabetes are under control, and that there are no unaddressed cardiovascular symptoms, such as chest pain or shortness of breath at rest. He also tests for the presence of bacteria, especially methicillin-resistant Staphylococcus aureus, or MRSA. If it is present, he treats it first.
The psych portion of the profile — the psychology of the patient — is equally important.
“Joint replacement is big surgery and the patient has to have a certain amount of resilience,” emphasizes Leopold.
Leopold also assesses prospective patients for depression and anxiety disorder. “Depressed patients don’t fare as well after surgery. So, if depression or anxiety is present, I make sure it’s treated first.”
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For the social part of the profile, Leopold evaluates the person’s living situation.
“Patients need to have someone at home, at least for the first few days after surgery. You can’t send a patient home to an empty house.” Other social factors, such as smoking and alcohol consumption, also factor in to the social profile.
According to Goodman, most RA patients will experience a flare-up of their arthritis after surgery. They may also have to stay in the hospital longer than patients with osteoarthritis.
Overall, though, RA is not an impediment to surgery or recovery.
“In my experience, my RA patients seem to do a little better [than other patients],” Leopold says. “I don’t know why this is. It’s not scientific by any means.”
Kimberly Steinbarger, a physical therapist who suffers from RA herself, agrees. “I find that RA patients do really well really quickly after joint replacement surgery.”
“I don’t know if it’s because they are used to dealing with pain, so the surgical pain doesn’t faze them as much as the general population, or if their preoperative pain was so great that they feel pretty good postoperatively,” adds Steinbarger, who is an academic coordinator of clinical education at the School of Physical Therapy at Husson University in Bangor, Maine.
Still, Leopold advocates delaying surgery as long as possible.
“Try to hold off as long as you can,” he advises. “If you’re still measuring [walking] distance in miles, wait. If you’re measuring distance in blocks, perhaps consider surgery.”
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Should People With Rheumatoid Arthritis Have Joint Replacement Surgery? originally appeared on usnews.com
