Briana Baldino Clinical Problem Solving I November 5, 2014 Does a History of Juvenile Rheumatoid Arthritis Affect Functional Outcomes After a Total Hip Arthroplasty? Briana Baldino Clinical Problem Solving I November 5, 2014

Patient Demographics 50 year old male College education Engineer-mostly computer work Married with 2 young children One story house with a ramp Seen in acute care s/p THA

Medical History Polyarticular juvenile rheumatoid arthritis (JRA) Hip dysplasia Osteoarthritis notecard

Prior Level of Function Ambulated independently for 1 block with single point cane Bilateral Trendelenburg with antalgia Independent with ADLs and IADLs Bilateral hip and knee pain (7/10) Decreased hip range of motion Right: 70o flexion, 5o internal/external rotation Left: 60o flexion, 5o internal/external rotation

History of Present Illness Total hip arthroplasty (THA) -posterolateral approach Corrected hip dysplasia secondary to JRA Posterolateral hip precautions Additional precautions: no straight leg raise, no active abduction, slowly begin to flex hip and extend knee notecard

Physical Therapy Exam Observation Shortened upper extremities with bilateral wrist deformities Leg length discrepancy (right>left) Sensation Absent in right thigh and medial leg Range of Motion/Strength Unable to perform active heel slide on the uninvolved side Limited extension in elbows Unable to perform right quad set Mobility Required assistance from multiple therapists for bed mobility and for sit to stand transfer Light touch testing- intact everywhere else. R heel slide not tested 2nd to precautions

Assessment and Treatment Patient has difficulty with bed mobility and transfers secondary to THA, his anatomy, and lack of sensation and motor control in right lower extremity. Prognosis is fair. 50 years old and had good strength prior to THA JRA has caused deterioration in multiple joints Patient was seen for bed mobility, transfer training, and gait training. Adaptive equipment was utilized to assist patient. Pt is a 50 year old male with a history of JRA POD1 for R THA. Pt has limited mobility in BUE due to anatomy which makes bed mobility and transfers more difficult. Pt has deficits in functional mobility secondary to arthritis and also limited today due to lack of sensation and motor control in RLE

Does a history of juvenile rheumatoid arthritis affect functional outcomes after a total hip arthroplasty? notecard

Influence of Preoperative Functional Status on Outcome after Total Hip Arthroplasty Roder, C., Staub, L., Eggli, S., Dietrich, D., Busato, A., & Muller, U. (2007). Influence of Preoperative Functional Status on Outcome After Total Hip Arthroplasty. The Journal Of Bone And Joint Surgery, 89(1), 11-17. Patient has decreased preoperative status secondary to his history of JRA

Methods Retrospective cohort study International Documentation and Evaluation System (IDES) hip registry 65 hospitals in 8 European countries 1965-2002 IDES collects data with a consistent survey that categorizes patients

Methods cont. 12,925 patients 6467 females, 6458 males Mean age 68.6 years (female) and 66.3 years (male) Mean of 2 follow-up visits (range 1-9) Mean duration of follow-up is 4.3 years (range 29 days- 10 years)

Prognostic Factors Walking capacity restriction Hip pain >60 minutes, 31-60 minutes, 10-30 minutes, <10 minutes/not possible Hip pain None/mild, moderate, severe/intolerable Active hip flexion >90°, 71° to 90°, 30° to 70°, or <30°/stiff

Pain notecard

Walking Capacity notecard

Hip Flexion notecard

Results No significant difference in outcome in pain categories Significant differences in outcome in the walking capacity and hip flexion categories

Study Strengths and Limitations Controlled for covariables of age, gender, and follow- up year Large population from different countries and settings over 40 years Limitations Varying component designs and fixation methods Surgeons with varying experience Loss of data on patients that did not follow-up or attend follow-up at primary center

Conclusion Poor preoperative mobility and function are predictive of less postoperative recovery of function. Preoperative pain levels are not predictive of long term postoperative pain.

As Related to Case Preoperative hip flexion (70o) 68% that he will have >90 hip flexion in 10 years Preoperative walking capacity(estimated <10 minutes) 39% that he will be able to ambulate >60 minutes in 10 years

Early Results of Total Hip Arthroplasty in Patients with Developmental Dysplasia of the Hip Compared with Patients with Osteoarthritis Boyle, M., Frampton, C., & Crawford, H. (2012). Early Results of Total Hip Arthroplasty in Patients With Developmental Dysplasia of the Hip Compared With Patients With Osteoarthritis. The Journal of Arthroplasty, 27(3), 386-390.  While patient does not have DDH, he does have dysplasia resulting from the JRA and it has caused similar problems

Methods Retrospective study-New Zealand National Joint Registry 2 Populations Developmental dysplasia of the hip (DDH) n=1,205 (mean age 49.3 years) Osteoarthritis (OA) n=40,589 (mean age 67.6 years) Primary Outcomes 6 month Oxford Hip Score (OHS), revision rate, 6 month mortality rate Secondary Comparisons (controlled for through multivariate analyses) Age, sex, operative characteristics notecard

Results- Primary Outcomes DDH OA Corrected Comparison P Number of Patients 1205 40589 OHS 41.5 40.8 Mean Difference .25 (-.54-1.03) .54 Revision Rate 42 1031 Hazards Ratio 1.08 (.75-1.55) .674 Mortality Rate 6 (.5%) 312(.8%) Odds Ratio 2.83 (1.21-6.61) .016 Patients age, sex, and operative approach had significant effect on revision rate. notecard

Study Strengths and Limitations Controlled for covariables Limitations Disparity in group sizes OHS was not assessed preoperatively Limit of 6 month follow-up Severity of DDH not assessed

Conclusions Patients with developmental dysplasia of the hip can have comparable functional outcomes and revision rates to patients with a primary diagnosis of osteoarthritis.

Does a history of juvenile rheumatoid arthritis affect functional outcomes after a total hip arthroplasty?

Patient Prognosis Fair Prognosis Boyle et al. found that patients with DDH had comparable outcomes to those with OA Age and sex have more of an effect on outcome Roder et al. found that preoperative mobility and motion have a significant impact on functional outcome Patient had decreased motion and ability to ambulate

Conclusion Juvenile rheumatoid arthritis causes joint deterioration which can lead to a decrease in mobility and motion. This decreased preoperative function can be predictive of lower functional outcomes after a total hip arthroplasty.

In the Future Similar treatment approach Different expectations Emphasis on regaining functional mobility and the ability to ambulate Provide adaptive equipment to facilitate progress Different expectations Expected patient to improve more than he did while in acute care- decreased preoperative function has a significant effect on postoperative gains

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