Elsevier

Seminars in Arthroplasty

Volume 19, Issue 4, December 2008, Pages 261-266
Seminars in Arthroplasty

Juvenile Rheumatoid Arthritis and Total Hip Arthroplasty

https://doi.org/10.1053/j.sart.2008.10.003Get rights and content

Juvenile rheumatoid arthritis (JRA) is the most common rheumatic disease of childhood. Hip joint involvement is the most significant factor impacting mobility and independence of the child. The persistent synovitis can lead to physeal growth injury and cartilage destruction. The first line of treatment involves anti-inflammatory medications, physiotherapy, and intra-articular injections. Surgical treatment options include soft tissue release of contractures, synovectomy, and joint arthroplasty. The results of joint replacement in this population are encouraging however there are many anatomical challenges in this population. The optimal method of fixation remains yet unclear.

Section snippets

Conservative Management

In the early stages of hip involvement, the medical treatment of the disease is critical. Traditionally, nonsteroidal anti-inflammatory drugs (NSAIDS) or selective COX-II inhibitors are effective at controlling the level of joint synovitis and inflammation.11 Unfortunately about 30% of patients will continue to have symptomps that are refractory to NSAIDS and will require disease-modifying antirheumatic drugs (DMARDS).11

Chemotherapeutics such as corticosteroids and methotrexate are effective

Perioperative Considerations

A multidisciplinary approach to the perioperative care of these patients should include the expertise of a social worker, physiotherapist, rheumatologist, anesthesiologist, and orthopedic surgeon. Cervical spine instability may preclude the use of a general anesthestic and affect patient positioning during surgery. Mandibular hypoplasia can lead to difficulties around the jaw while temporomandibular joint inflammation can impair visualization of the trachea during intubation.14

Patients often

Surgical Considerations

A wide surgical exposure during joint replacement surgery is critical considering the significant joint contractures and altered anatomy that is normally present in these patients. A wide capsulotomy combined with a soft tissue release anterior and posterior is recommended to limit the risk of fracture during dislocation. In a series of 75 patients, Ruddlesdin and coworkers15 noted a significant number of cases required an in situ femoral neck osteotomy for bony ankylosis or protrusion

Conclusion

The care of the child with JRA involves awareness of both the physical and psychosocial impacts of the disease. Conservative management with NSAIDS and DMARDs can be effective at controlling joint synovitis and effusions. Concurrent physiotherapy is essential to prevent joint contractures that can severely limit a child's level of physical function. Surgical treatment options of joint capsule and muscle contracture release may be effective at improving patient quality of life and function;

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