Surgery for Rheumatoid Arthritis—Timing and Techniques: The Lower Extremity

¹ An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons

In the patient with early rheumatoid involvement of the knee, synovectomy is the procedure of choice, and in the patient with late involvement, joint débridement, patelloplasty, patellectomy, arthroplasty, proximal tibia1 osteotomy, and finally arthrodesis should be considered.

In the management of rheumatoid arthritis of the hip, results are not as succcessful as with pure degenerative joint disease, and frequent revisions are probable. When possible, the first procedure should be arthroplasty with a large, loose-fitting cup in association with synovectomy of the hip. When changes in the femoral head are such that a cup cannot be accepted, then an initial prosthetic replacement should be considered. After resorption of the femoral head beneath the cup, a prosthetic revision can be performed. Should it fail, the prosthetic revision can be converted into a resection type of excisional artroplasty. With severe, progressive arthritic involvement of both hips, bilateral excisional arthroplasties should be considered initially. In this regard, my colleagues and I are not yet definite in our feelings. Treatment of a totally ankylosed hip joint may include either excisional arthroplasty or cup or prosthetic arthroplasty, whichever seems most feasible under the circumstances. The frequent bilaterality of disease involvement creates one of the most severe problems in orthopaedics, and one of the most demanding since management of both hips may involve additional revisions of one or both hips. Each situation must be considered individually, with the understanding that, if excisional arthroplasty must be done eventually on one hip, differences in leg length will create additional problems in walking.

In the rheumatoid foot, surgery on the fore part of the foot basically involves excisional arthroplasty, whereas that of the hind part involves bone stabilization by arthrodeois. Flexion deformities of the toes can easily be corrected manually by osteoclasis, or if the joints of only are toe are involved, the proximal joint can be resected or it can be fused by the use of an intramedullary Kirsehner wire.

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