1. 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

2. 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

3. Medical History Polyarticular juvenile rheumatoid arthritis (JRA)
Hip dysplasia
Osteoarthritis
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4. 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

5. 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
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6. 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

7. 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

8. Does a history of juvenile rheumatoid arthritis affect functional outcomes after a total hip arthroplasty?
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9. 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),
Patient has decreased preoperative status secondary to his history of JRA

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

11. 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)

12. Prognostic Factors Walking capacity restriction Hip pain
>60 minutes, minutes, 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

13. Pain
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14. Walking Capacity
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15. Hip Flexion
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16. Results No significant difference in outcome in pain categories
Significant differences in outcome in the walking capacity and hip flexion categories

17. 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

18. 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.

19. 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

20. 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),  
While patient does not have DDH, he does have dysplasia resulting from the JRA and it has caused similar problems

21. 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
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22. Results- Primary Outcomes
DDH OA
Corrected Comparison P
Number of Patients
1205
40589
OHS
41.5
40.8
Mean Difference .25
( )
.54
Revision Rate 42
1031
Hazards Ratio 1.08
( )
.674
Mortality Rate
6 (.5%)
312(.8%)
Odds Ratio 2.83 ( )
.016
Patients age, sex, and operative approach had significant effect on revision rate. notecard

23. 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

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

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

26. 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

27. 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.

28. 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

29. Questions?