Artroplastia total de rodilla en pacientes con artritis reumatoide

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Abstract

Introducción: La articulación de la rodilla se halla afectada en un 90% de los pacientes que padecen artritis reumatoide (AR). El propósito de este estudio es evaluar retrospectivamente el resultado de las artroplastias totales de rodilla (RTR) en pacientes con artritis reumatoide y analizar el rendimiento de los diferentes diseños utilizados. Materiales y métodos: De 590 RTR realizadas entre 1997 y 2006, se evaluaron 51 (9,5%) artroplastias efectuadas en 39 pacientes con diagnóstico de AR, con un seguimiento promedio de 3,48 años. El promedio de edad fue de 59 años. Los implantes utilizados fueron 21 nacionales monoblock (Insall), 13 de origen importado, modulares: 9 PFC variedad "Sigma" (J & J Depuy,Waesaw, Indiana EE.UU.) y 4 Scorpio (Stryker Howmedical Osteonic). Las restantes 17 fueron de base tibial de polietileno PFC tipo all poly (J & J Depuy, Warsaw, IN. EE.UU.). En 4 pacientes (8%) fue necesaria la utilización de vástagos femorales y tibiales. Para la evaluación objetiva se utilizó el análisis de la Knee Society, que consiste en la evaluación radiográfica de las rodillas. Resultados: Todos los pacientes presentaron una buena evolución clínica y radiológica durante el seguimiento, sin observarse diferencias significativas entre los diferentes implantes utilizados. Las complicaciones fueron dos casos de infección (4%) y una dehiscencia del aparato extensor. Conclusiones: Resulta interesante la alternativa de utilizar un implante importado, de base tibial de polietileno, monoblock, el cual es más económico que los modulares importados. En su elección es importante tener en cuenta la posibilidad, en casos de AR, de necesitar componentes modulares para adosar vástagos o cuñas metálicas, por la mala calidad ósea de estos pacientes.

Translated abstract

Background: The knee joint is involved in about 90 % of the patients with rheumatoid arthritis (RA). The main purpose of this study was to evaluate the outcome of a total knee arthroplasty (TKR) in patients with rheumatoid arthritis, and analyze the performance of different designs used. Methods: 590 TKR were performed between 1997 and 2006, we evaluated 51 (9.5%) arthroplasties in 39 patients with RA diagnosis, followed up for an average of 3.48 years. Average age was 59 years. The implants used were 21 monoblock (Insall), national make, and thirteen modular, foreign design. (9 PFC "Sigma" J & J Depuy, Warsaw, Indiana USA and 4 Scorpio Stryker Howmedical Osteonic). The remaining 17 were PFC polyethylene tibial type "All Poly" (J & J Depuy, Warsaw, IN. USA). In four patients (8%) femoral and tibial stems were required. Results: All patients had a good clinical and radiological outcome, without significant differences between different implants. There were 2 cases of infection (4%), and an extensor mechanism rupture. Conclusions: It is an interesting option to use an all-polyethylene tibial component in patients with RA, because it is more economical than modular ones. The surgeon should take into account poor bone quality and the need to insert pins or metallic wedges.

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Most cited references 24

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The patellofemoral joint in total condylar knee arthroplasty. Pros and cons based on five- to ten-year follow-up observations.

Amar Ranawat (1986)

In this report, 100 knees in 77 patients, with an average age of 65, were followed for a period between five and 10 years. Rheumatoid arthritis was the diagnosis in 43 patients and osteoarthritis in 34 patients. The majority had varus, valgus, and biplane deformities. Twenty-one patients underwent bilateral procedures; all but one had patellar replacement. Over 90% of the knees were rated good to excellent according to The Hospital for Special Surgery Knee Disability Score Sheet. Of the 34 osteoarthritic patients (40 knees), 24 or 71% could walk ten blocks and beyond. Ten patients, or 29%, could walk between one and ten blocks. Further ambulation was restricted only by overall poor health and age (most were 74 years of age or older). Twenty-four patients, or 71%, could ascend and descend stairs without support, while six (18%) relied on bannister support when descending stairs. Four patients (11%) required bannister support for both ascending and descending stairs. Among the complications seen in this series were one loose patella and another with osteonecrosis of the anterior surface. No dislocations occurred, but 14 patellae showed tilt on skyline view roentgenograms, indicating a tight lateral retinaculum. In view of the good to excellent results achieved in the majority of patients, and the low morbidity associated with replacement, it is recommended that the patellofemoral joint be replaced in the course of total knee arthroplasty. When careful attention is paid to technical details, this procedure improves the quality of the arthroplasty.

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Indications for patellar resurfacing in total knee arthroplasty.

Dan Burnett, Christina R. Bourne (2003)

The management of the patella in total knee arthroplasty (TKA) traditionally has been one of three options: always resurface, never resurface, or selectively resurface the patella. Historically, implant design and surgical technique did not completely address the patellofemoral articulation. Increased understanding of patellofemoral anatomy, biomechanics, implant design, and surgical technique have led to an improvement in the previously reported high rate of patellofemoral complications associated with TKA. Traditional indications for patellar resurfacing, including age, weight, gender, patellar anatomy, quality of articular cartilage, radiographic findings, and the presence of rheumatoid arthritis deformity and preoperative anterior knee pain continue to be debated. Anterior knee pain before and after TKA must not always be presumed to be secondary to a patellofemoral resurfacing/nonresurfacing etiology, and other factors may play a role in the dynamic development of anterior knee pain after TKA. The decision to resurface the patella in TKA remains controversial, and the results of longer-term randomized controlled trials will improve understanding of this complex issue in the future.

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The patellofemoral joint after total knee arthroplasty without patellar resurfacing.

James Welch, K McGann, G Picetti (1990)

One hundred total knee replacements with a total condylar prosthesis and without patellar resurfacing were followed for a minimum of two years. Eighty-four per cent of the knees were affected by osteoarthrosis. Graded according to the knee-rating system of the Hospital for Special Surgery, there were eighteen excellent, fifty-three good, eighteen fair, and eleven poor results. At the most recent follow-up, twenty-nine knees (29 per cent), nine of which were affected by rheumatoid arthritis, were still painful in the patellofemoral area. The height and weight of the patient definitely influenced the amount of patellofemoral pain postoperatively. Small patients who had osteoarthrosis were exceptionally free of pain, regardless of sex, age, or level of activity. It seems that the best approach to patellofemoral replacement includes resurfacing of the patella in all patients who have rheumatoid arthritis and in patients who have osteoarthrosis if they have preoperative patellofemoral pain, are more than 160 centimeters tall, weigh more than sixty kilograms, and have advanced changes in the patella at the time of the operation.