The Journal of Bone and Joint Surgery, Vol 65, Issue 8 1071-1080, Copyright © 1983 by Journal of Bone and Joint Surgery, Inc
Total knee arthroplasty in juvenile rheumatoid arthritis
AJ Sarokhan, RD Scott, WH Thomas, CB Sledge, FC Ewald and DW Cloos
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.
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