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PubMed1995

Total knee arthroplasty after a previous patellectomy.

We performed a retrospective, matched-control analysis of the results of total knee arthroplasty with cement in twenty-two patients who had had a previous patellectomy for either a fracture of the patella (sixteen patients) or severe patellofemoral osteoarthrosis or chondromalacia patellae (six patients). Nine of the patients were men and thirteen were women. The average age at the time of the total knee arthroplasty was sixty-nine years (range, fifty-nine to seventy-four years). The average time from the patellectomy to the total knee arthroplasty was eight years (range, two to fourteen years). The patients were divided into two groups according to the type of implant that had been used. Group A (nine patients) had had insertion of a posterior stabilized prosthesis (a posterior cruciate-sacrificing implant) and Group B (thirteen patients) had had insertion of a posterior cruciate-sparing implant. Two computer-generated matched groups of patients who had had a total knee arthroplasty with insertion of implants that were identical to those in the study groups but who had not had a previous patellectomy served as controls. Group C consisted of patients who had had insertion of the same type of implant as that used in Group A, and Group D consisted of patients who had had insertion of the same type of implant as that used in Group B. All patients were evaluated before the arthroplasty and five years postoperatively with use of the rating system of the Knee Society.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1995

The role of intraoperative frozen sections in revision total joint arthroplasty.

We performed a retrospective analysis of thirty-three consecutive total hip and knee (twenty-three hip and ten knee) revision arthroplasties during which intraoperative frozen sections were analyzed. Data for the study were collected by means of a review of the charts, radiographic analysis, and evaluation of both frozen and permanent histological sections. The frozen sections, of periprosthetic tissue at the bone-cement interface or the pseudocapsule, were considered positive for active infection if there were more than five polymorphonuclear leukocytes per high-power field in at least five distinct microscopic fields. All patients were available for follow-up, at an average of thirty-six months (range, seventeen to seventy-nine months) after the initial revision operation. The frozen sections from ten patients were positive for infection, and those from twenty-three patients were negative. Comparison of the results of the analyses of the frozen sections (both positive and negative) with those of the analyses of the permanent histological sections of similar tissue showed a correlation of 100 per cent (sensitivity, 1.00; specificity, 1.00; and accuracy, 1.00). Nine patients had positive intraoperative cultures, and all of them had positive frozen sections (sensitivity, 1.00). Of the twenty-four patients who had negative intraoperative cultures, twenty-three had negative frozen sections (specificity, 0.96). Of the nine patients who had positive intraoperative cultures, only two were found to have infection on intraoperative gram-staining. The surgeon's operative assessment regarding the presence of infection, compared with the final pathological diagnosis, demonstrated a sensitivity of 0.70, a specificity of 0.87, and an accuracy of 0.82. All ten patients who had positive frozen sections were managed with excision arthroplasty; six of them subsequently had reimplantation, and the excision was the definitive procedure in the remaining four. One patient who had had a delayed reimplantation had a secondary skin slough and eventually was managed with an arthrodesis of the knee. In the group that had negative frozen sections, eighteen patients had a primary exchange revision arthroplasty and five had a delayed reimplantation. At the time of follow-up, one patient who had had a delayed reimplantation had radiographic loosening of the femoral component and was asymptomatic. One patient who had had a primary exchange arthroplasty was managed with a second revision because of aseptic loosening. There was no clinical recurrence of infection in any patient. The data indicate that analysis of frozen sections of periprosthetic tissue is a reliable predictor of the presence of active infection during revision joint arthroplasty. We recommend its use to differentiate aseptic from septic loosening.

Adult↗
PubMed1996

Granular histiocytosis of pelvic lymph nodes following total hip arthroplasty. The presence of wear debris, cytokine production, and immunologically activated macrophages.

UNLABELLED: Infiltration of regional lymph nodes by macrophages has been demonstrated after total joint arthroplasty. Although lymph nodes regulate the immune response, neither cytokine production nor the degree of immunological activation of cells within these nodes after total joint arthroplasty has been investigated. Pelvic lymph nodes were obtained from five patients who had had a total of eleven arthroplasties in seven hips three to twenty years before a pelvic staging procedure for adenocarcinoma (of the prostate in four patients and of the endometrium in one). All lymph nodes had polyethylene or metal debris as well as effacement of the normal nodal architecture by a histiocytic infiltrate. These changes were bilateral in the patients who had had an arthroplasty of one hip. Analysis of specimens from pelvic lymph nodes on the side of the involved hip demonstrated intense immunohistochemical staining of histiocytes for the major histocompatibility complex class-II antigen HLA-DR, a marker of histiocyte immune activation. In contrast, staining was absent in specimens from the contralateral lymph nodes as well as in those from seven patients who had had a prostatectomy but not a hip arthroplasty. Immunohistochemical staining for interleukin-1beta, tumor necrosis factor-alpha, and interleukin-6 demonstrated a much greater expression of these cytokines in the involved lymph nodes. CLINICAL RELEVANCE: Additions improvements in total joint replacement will be facilitated by a more thorough understanding of the biological response to the components and materials of implants. While local biological factors leading to failure of prostheses are currently under intense investigation, the mechanisms and importance of regional and systemic immune responses to wear debris require further study.

Adenocarcinoma↗
PubMed1996

Clinical results of the Mayo total ankle arthroplasty.

Two hundred and four primary Mayo total ankle arthroplasties were performed in 179 patients at the Mayo Clinic from 1974 through 1988. We evaluated the clinical result after 160 arthroplasties in 143 patients who had been followed for two years or more (mean, nine years; range, two to seventeen years). The result was good for thirty-one ankles (19 per cent), fair for fifty-five (34 per cent), and poor for seventeen (11 per cent); fifty-seven arthroplasties (36 per cent) were considered to be a failure (defined as removal of the implant). Adequate preoperative and follow-up radiographs were available for 101 ankles (eighty-nine patients). There was radiographic evidence of loosening of eight tibial components (8 per cent) and fifty-eight talar components (57 per cent), but we found no association between the clinical and radiographic results. Complications occurred after nineteen (12 per cent) of the 160 arthroplasties, and ninety-four additional reoperations were necessary after sixty-six (41 per cent). On the basis of these findings, we do not recommend ankle arthroplasty with a constrained Mayo implant for rheumatoid arthritis or osteoarthrosis of the ankle.

Adult↗
PubMed1999

Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge.

BACKGROUND: Venous thromboembolic disease in the form of deep venous thrombosis and pulmonary embolism is a major risk after a total hip arthroplasty. Enoxaparin, a low-molecular-weight heparin, has been shown to reduce the prevalence of deep venous thrombosis after total hip arthroplasty. Warfarin, an orally administered anticoagulant, has been used historically to reduce the risk of deep venous thrombosis after total hip arthroplasty. METHODS: We compared enoxaparin and adjusted-dose warfarin with respect to their safety and their efficacy in the prevention of clinically important venous thromboembolic disease, defined as distal or proximal deep venous thrombosis or pulmonary embolism, or both, during hospitalization after total hip arthroplasty. We also evaluated the prevalence of complications and mortality from venous thromboembolic disease within three months after discharge. RESULTS: Three thousand and eleven patients at 156 centers were randomly assigned to prophylactic treatment with injection of enoxaparin or oral administration of adjusted-dose warfarin during hospitalization. During the study, fifty-five (3.6 percent) of the 1516 patients who were managed with enoxaparin and fifty-six (3.7 percent) of the 1495 patients who were managed with warfarin had venous thromboembolic disease. Twenty-one patients (0.7 percent), which included four (0.3 percent) of those managed with enoxaparin and seventeen (1.1 percent) of those managed with warfarin (p = 0.0083), had venous thromboembolic disease during hospitalization. After discharge from the hospital, venous thromboembolic disease developed in ninety patients (3.0 percent): fifty-one (3.4 percent) of those managed with enoxaparin and thirty-nine (2.6 percent) of those managed with warfarin. One patient who had been managed with enoxaparin died because of a pulmonary embolism, which was confirmed at autopsy. Three additional patients (one who had been managed with enoxaparin and two who had been managed with warfarin) died, and the deaths were attributed to venous thromboembolic disease; however, no autopsies were performed. Twenty-six patients (0.9 percent) (eighteen managed with enoxaparin and eight managed with warfarin) had clinically important bleeding. CONCLUSIONS: Inpatient programs providing treatment with either enoxaparin (thirty milligrams every twelve hours) or adjusted-dose warfarin for a mean of 7.3 days afforded protection against venous thromboembolic disease, with overall rates of morbidity and mortality of 3.7 and 0.6 percent, respectively, and a very low rate of major bleeding complications (0.9 percent) for three months after total hip arthroplasty. During hospitalization, the patients managed with enoxaparin had a lower rate of venous thromboembolic disease than those managed with adjusted-dose warfarin (p = 0.0083). This benefit was lost after the medication was discontinued, with no difference in the prevalences of venous thromboembolic disease between the two groups at three months after discharge from the hospital.

Adolescent↗
PubMed2002

Total knee arthroplasty for osteonecrosis.

BACKGROUND: A patient with collapse of a femoral condyle caused by osteonecrosis has few treatment options other than total knee arthroplasty. The purpose of this study was to report the clinical and radiographic outcome of total knee arthroplasty for osteonecrosis. METHODS: Between 1987 and 1996, thirty-two total knee arthroplasties were performed with cement in thirty patients with osteonecrosis of the femoral condyle and/or tibial plateau. The study group included twenty-forty women and five men with a mean age of fifty-four years (range, thirty-one to seventy-seven years) at the time of the arthroplasty. Twenty-two patients had atraumatic osteonecrosis associated with corticosteroid use, and eight had spontaneous osteonecrosis. All patients had a complete clinical and radiographic evaluation at a mean of 108 months (range, forty-eight to 144 months) postoperatively. RESULTS: Overall, thirty-one (97%) of the thirty-two knees had a successful clinical outcome. The mean Knee Society score improved from 54 points preoperatively to 95 points at the time of the latest follow-up. No evidence of progressive radiolucency was found around any prosthetic component. CONCLUSIONS: Previous studies have demonstrated less-than-optimal results following total knee arthroplasty in patients with osteonecrosis. The excellent results found in the present study may have been secondary to the use of cemented implants in all cases and ancillary stems when appropriate.

Adult↗
PubMed1987

Hematogenous infection after knee arthroplasty.

Twenty-five hematogenously infected knee arthroplasties in 20 patients (17 with rheumatoid arthritis and 3 with arthrosis) were followed for 3 years. Staphylococcus aureus was the major infecting organism. Three patients with four arthroplasties died of sepsis. Two patients had removal of the arthroplasty, one of which resulted in an above-the-knee amputation. Four out of five arthrodeses fused. Two knees healed after early debridement and two healed without surgery. Ten knees had successful revision arthroplasty. Rheumatoid arthritis and constrained prostheses increase the risk of hematogenous infection. Any infection and especially cutaneous lesions in a patient with a knee arthroplasty should be treated vigorously.

Adult↗
PubMed1996

The economic impact of failures in total hip replacement surgery: 28,997 cases from the Norwegian Arthroplasty Register, 1987-1993.

The Norwegian Arthroplasty Register was established in 1987. Until January 1994, approximately 200 different implant combinations had been used in total hip replacements (THR) in Norway. About 5,500 THR were performed each year in this period with a total cost of 70 million USD per year. We analyzed the economic consequences related to the use of some inferior primary hip arthroplasties in this period. As the reference arthroplasty, we chose the most commonly used prosthesis in Norway, i.e., the Charnley prosthesis fixed with high viscosity cement containing antibiotic and with systemic antibiotic prophylaxis (n 4,970). We compared this reference group to all other primary THR registered in the same time period (n 24,027), and to the following sub-groups of primary THR: 1) uncemented Ti-Fit/ Bio-Fit (acetabulum/femur) combination (n 173), 2) uncemented Coxa/Femora combination (n 153), 3) THR with low-viscosity cement (n 1,807) and 4) THR with Boneloc cement (n 1,250). We estimated the number of additional revisions compared to the reference arthroplasty after a follow-up of 3-5 years in the different groups, with adjustment for age, sex and diagnosis. The direct extra revision costs were calculated. Compared to the reference arthroplasty, the group of all other primary THR gave an extra revision cost estimated at about 1.7 million USD per year. About 1,000 uncemented Bio-Fit femoral prostheses have been applied in Norway, including those implanted before the registration started (1985-1987). The extra revision costs the first postoperative years for these 1,000 prostheses amount to about 0.7 million USD per year. Corresponding figures in the Coxa/ Femora group were 0.08 million USD, in the group with low-viscosity cement, 0.3 million USD and in the Boneloc group, 0.4 million USD per year.

Aged↗
PubMed1997

Hip and knee arthroplasty infection. In-111-IgG scintigraphy in 102 cases.

We studied indium-111-labeled immunoglobulin G (In-111-IgG) scintigraphy for evaluation of total hip and knee arthroplasty infection in 100 patients (102 arthroplasties) where infection was suspected (85 total hip and 17 total knee replacements, 23 of which proved to be infected, all but 2 late infections). The sensitivity of In-111-IgG scintigraphy for infection was 1.0, for hip and knee arthroplasties the specificities were 0.8 and 0.5, respectively. False-positive results for infection occurred in cementless total hip arthroplasties up to 14 months after implantation. Aseptic inflammation due to formation of ectopic ossification and foreign-body response, following wear of the polyethylene socket, was responsible for false-positive results. The images should be read in conjunction with radiographs, which reduces the rate of false-positive results. In-111-IgG is a highly sensitive and fairly specific tool for detecting of late infection of total hip and total knee arthroplasties.

Adult↗
PubMed1995

Infected Total Hip Arthroplasty: Diagnosis and Treatment.

The diagnosis of a deep infection complicating total hip arthroplasty is not difficult in most patients. When the diagnosis is not evident on the basis of the medical history, physical examination, routine blood work, and plain radiographs, indium-111-labeled leukocyte scintigraphy can be diagnostic. New immunologic techniques may allow differentiation of aseptic loosening from septic loosening of a painful total hip arthroplasty. Once the diagnosis of a deep infection about a total hip arthroplasty has been established, there are several treatment options. Oral antimicrobial therapy combining rifampin with a fluoroquinolone may prove to be an attractive alternative to surgical intervention in the treatment of some staphy-lococcal infections. If the causal microorganism is considered to be less virulent and does not elaborate glycocalyx, a one-stage procedure for reconstructing the hip with a cemented total hip arthroplasty incorporating antibiotics that are cidal to the microorganism has been successful in as many as 90% of patients. If the causal microorganism is considered to be virulent, a two-stage procedure with a prolonged interval between the Girdlestone resection arthroplasty and the second-stage reconstructive procedure is the treatment of choice.

Journal Article↗
PubMed1993

Efficacy and cost of low-molecular-weight heparin compared with standard heparin for the prevention of deep vein thrombosis after total hip arthroplasty.

PURPOSE: To compare the efficacy, safety, and cost-effectiveness of low-molecular-weight heparin with standard heparin for the prevention of deep vein thrombosis after total hip arthroplasty. DATA IDENTIFICATION: Studies were identified by MEDLINE search and review of bibliographies of retrieved articles. Hospital resources used in treating deep vein thrombosis and bleeding complications after total hip arthroplasty were estimated using retrospectively collected data from 447 patients who participated in a recently completed randomized controlled deep vein thrombosis prophylaxis trial at our center. STUDY SELECTION: Randomized controlled trials directly comparing a low-molecular-weight heparin preparation with standard heparin for the prevention of deep vein thrombosis after total hip arthroplasty were potentially eligible for the meta-analysis. DATA EXTRACTION: Data from eligible studies were extracted independently by two of the authors. Multiple regression analysis of data from the patient cohort was used to estimate the effect of deep vein thrombosis and bleeding on length of hospital stay. A hypothetical North American price for low-molecular-weight heparin was determined based on the ratio between low-molecular-weight heparin and standard heparin in France. Costs were based on weighted per-diem hospital expenditures and physician fees for procedures and reported in 1992 U.S. dollars. RESULTS OF DATA SYNTHESIS: Meta-analysis of six eligible trials determined that low-molecular-weight heparin was significantly more effective than standard heparin at preventing deep vein thrombosis after total hip arthroplasty (common odds ratio, 0.72; 95% CI, 0.53 to 0.95). However, this benefit was restricted to the prevention of proximal deep vein thrombosis (common odds ratio, 0.40; CI, 0.28 to 0.59). No significant differences were found in the rates of distal deep vein thrombosis or total, major, or minor bleeding between the two groups. Based on a 2.6 to 1 price ratio between low-molecular-weight heparin and standard heparin, use of low-molecular-weight heparin would save the health care system about $50,000 per 1000 patients treated. Sensitivity analysis shows that if the low-molecular-weight heparin/standard heparin price ratio exceeds 3.7 (the threshold value lies between 0.8 and 5.5 based on the extremes of the 95% CI of the common odds ratios for deep vein thrombosis and bleeding complications), use of low-molecular-weight heparin is more expensive. At a price ratio of 10, it would cost more than $250,000 to treat 1000 patients with low-molecular-weight heparin compared with standard heparin or about $5000 for each additional deep vein thrombosis prevented with low-molecular-weight heparin. CONCLUSIONS: Low-molecular-weight heparin is more effective and is at least as safe as standard heparin for the prevention of deep vein thrombosis after total hip arthroplasty. Based on the current French price ratio of low-molecular-weight heparin to standard heparin, the use of low-molecular-weight heparin in North America would result in overall savings in cost; however, the relative cost-effectiveness is critically dependent on the price ratio between the two drugs. Further research is needed to compare the cost-effectiveness of low-molecular-weight heparin with other prophylactic regimens and postoperative deep vein thrombosis management strategies.

Cost-Benefit Analysis↗
PubMed1991

The effect of miscellaneous invasive procedures on subsequent total knee arthroplasty.

Invasive orthopedic procedures were performed on 112 joints that underwent total condylar knee arthroplasty between November 1975 and February 1987. These knees were divided into six categories based on the most traumatic surgical procedure the patients had experienced. The six classifications were total knee arthroplasty, proximal tibial osteotomy, fracture fixation, patellectomy, arthroscopy, and debridement. Each group of knees was compared with the 579 primary arthroplasties performed during the same time period. The only group in which results were significantly less favorable than those of the virgin joints was the previous total arthroplasty category. All other surgical classification groups had knee scores, radiolucency frequencies, and ranges of motion comparable with those of the primary replacement surgeries. When surgical techniques are modified to insure proper soft tissue alignment, patients who have undergone previous invasive procedures on their knees can expect highly favorable results from total joint arthroplasty.

Arthroscopy↗
PubMed1995

Surgical options in the treatment of arthritis of the shoulder: alternatives to prosthetic arthroplasty.

Reconstructive options for glenohumeral arthritis revolve around the timing and success of hemi-joint arthroplasty and total joint arthroplasty techniques. The purpose of this article is to discuss the alternative treatment options of shoulder arthritis. Specific options include arthroscopic debridement, synovectomy, capsular release, osteotomy, resection arthroplasty, interposition arthroplasty, and arthrodesis. In the early stages of the arthritic process, arthroscopic debridement, synovectomy and capsular release, may delay the onset of more severe symptoms and degenerative changes requiring a prosthetic reconstruction. However, their role as a definitive procedure is limited. The use of resection arthroplasty and arthrodesis represent salvage procedures used when an implant has failed or become infected. However, function will be predictably diminished.

Arthritis↗
PubMed2000

Total hip arthroplasty in young patients. 8- to 13-year results using an uncemented stem.

One hundred eight uncemented total hip arthroplasties were performed in 91 patients who were 50 years of age or younger using the Taperloc femoral component. The average age of the patients at time of surgery was 37 years (range, 20-50 years). The mean followup was 10.2 years (range, 8-13 years). No patient was lost to followup. Seven patients (eight hips) died before obtaining the minimum time of 8 years for inclusion in this study. All seven died with their femoral components in place. Of the remaining 100 total hip arthroplasties, no femoral component required revision for aseptic loosening. One femoral component was revised to correct a leg length discrepancy, and one well-fixed femoral component was revised for sepsis. In the 98 total hip arthroplasties that had not undergone femoral component revision, complete radiographic and clinical followup was obtained. Radiographically, 96 (98%) femoral components were determined to have fixation by bone ingrowth, two (2%) femoral components showed stable fibrous ingrowth, and no femoral component was unstable. Femoral cortical osteolysis occurred in seven (7%) hips; major lysis was present in only one (1%). Clinically, 91 (93%) total hip arthroplasties were rated good or excellent; six (6%) were rated fair, and one (1%) was rated poor. Thirty-nine patients with 47 total hip arthroplasties (48%) were engaged in moderate to strenuous manual labor. These results indicate that excellent fixation and minimal lysis can be achieved with an uncemented femoral component in young and active patients at 10 years.

Adult↗
PubMed1992

Evaluation of the painful total hip arthroplasty.

Total hip arthroplasty is a common technique for the surgical management of degenerative hip disease. Because of the increasing number of patients and the variety of prostheses and fixation modalities available to the surgeon, the evaluation of the patient with a painful arthroplasty has become an increasingly complex endeavor. The growing number of patients who undergo multiple revision surgeries further complicates the evaluation of the painful arthroplasty. Other complicating factors include the lack of absolute sensitivity and specificity of the variety of diagnostic techniques and the difficulty of differentiating pain caused by septic verses aseptic loosening. This report reviews the recent literature concerning the evaluation of the painful total hip arthroplasty and provides a clinical rationale for the assessment of the painful total hip arthroplasty.

Diagnosis, Differential↗
PubMed1991

Intermittent pneumatic compression versus coumadin. Prevention of deep vein thrombosis in lower-extremity total joint arthroplasty.

One hundred forty-nine consecutive patients requiring lower extremity total joint arthroplasty were randomized to either coumadin (52 patients) or intermittent pneumatic compression (48 patients) as prophylaxis against deep vein thrombosis (DVT). Forty-nine patients were excluded. When fully ambulatory, the presence or absence of DVT was diagnosed by ascending venography (90% of patients), nuclear venography, venous dopplers, or impedence plethysmography. The two groups were similar in average age (64 years), indication for arthroplasty (pain because of arthritis in 90%), gender (98% male), and average number of risk factors (2.4). Twenty-five percent of patients on coumadin and 25% of patients on intermittent pneumatic compression (IPC) developed DVT. IPC was more effective than coumadin following primary total hip arthroplasties (THAs) (16% versus 24% incidence DVT); coumadin was more effective than IPC following primary total knee arthroplasties (TKAs) (19% versus 32% incidence of DVT). DVT developed in 36% of patients following revision arthroplasty. Seventy-five percent of all thrombi were proximal. Both IPC and coumadin were found to be safe; there was no increased perioperative bleeding in the coumadin group. Of three postoperative deaths, one was possibly due to pulmonary embolism (PE).

Adult↗
PubMed1991

Effect of time of onset and depth of infection on the outcome of total knee arthroplasty infections.

The treatment results of 24 infected total knee arthroplasties with a minimum follow-up period of two years are presented. The most common pathogens were coagulase-positive staphylococci (50%), coagulase-negative staphylococci (29.2%), and enterococci (12.5%). Eleven patients with early postoperative infections (occurring within one month of prosthesis implantation) were treated with debridement, retention of the prosthesis, and intravenous antibiotics. Treatment was successful in all five patients with superficial infections not extending into the joint. In six patients with deep infections, treatment was successful in only two (33%), despite a longer course of antibiotic therapy (four to six weeks) and the use of tobramycin-impregnated polymethylmethacrylate beads. Three patients continued to have recurrent drainage, and one patient was subsequently successfully treated with a delayed exchange arthroplasty. Thirteen patients were diagnosed with late infections. One patient with a late, superficial infection and another with an acute (hematogenous seeding), deep infection were successfully managed with debridement and intravenous antibiotics. Prosthesis removal was not required. Eleven patients presented with late, deep infections. Of three patients who were treated without removal of the prosthesis, infection was arrested in only one. The remaining eight patients were treated with debridement, intravenous antibiotics, tobramycin-impregnated polymethylmethacrylate beads, and delayed exchange arthroplasty. The median interval to reimplantation was eight weeks (range, seven to 25 weeks). Treatment was successful in six cases (75%). The overall success rate in the treatment of total knee arthroplasty infections was 71%. In 19 patients with deep infections, treatment success was seen in 78% of patients treated with delayed exchange arthroplasty, but this value was only 40% in patients who were not treated with prosthesis removal.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Total hip and knee arthroplasty in juvenile rheumatoid arthritis.

Total hip or knee arthroplasty is indicated in patients with juvenile rheumatoid arthritis when there is marked functional impairment and/or severe disabling pain from advanced structural hip or knee joint involvement. Relief of pain and dramatic improvement in function can be achieved in most patients. When both the hip and knee are involved, hip arthroplasty should probably be done first. Regional anesthesia is preferable. Careful preoperative planning is essential because custom prostheses are often required. Small bone size, osteoporosis, and soft-tissue contractures make the surgery technically demanding. Skeletal immaturity is not an absolute contraindication to surgery. Component loosening is the most frequent late complication in hip arthroplasty. It is less common in condylar metal-to-plastic knee arthroplasty in which patellar complications predominate. Cementless arthroplasty has an evolving role in the patient with juvenile rheumatoid arthritis and, to date, is more often used in the hip than in the knee.

Arthritis, Juvenile↗