Michael M. Alexiades, MD, associate attending orthopedic surgeon at Hospital for Special Surgery and associate professor of clinical orthopedic surgery at Weill Cornell Medical College in New York City, met with Rheumatology Advisor to discuss the surgical management of inflammatory arthritides.  This is part 2 of a video series on this topic, to view the first video dealing with timely referral of patients to orthopedic surgeons, please click here. 

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Text Transcript of Video

[For] patients with multijoint disease, very often we have to decide which joint [to operate on] first, which joint are we going to get the most “bang for the buck,” so to speak.  The order in which we do them can have a very big impact on functional outcomes.

For instance, if someone has a bad hip, but they also have a bad ankle that needs an ankle fusion, doing the hip may not benefit them that much if they can’t put weight on the bad ankle.  To [rehabilitate] the hip or knee with a bad ankle, for instance, will be much more difficult because the patient can’t bear weight, [and therefore] they can’t do the normal postoperative exercises.  So, in that case, we would do the ankle fusion first, which is treated in a cast for several weeks after surgery.  There is not any significant amount of rehab required for the fusion itself.  Once that is fully healed, then we can go and [operate on] the hip or the knee.

Probably, one of the more common scenarios is the patient who has involvement of both hips and [underlying] involvement of the knees.  We usually will do the hip replacement first, because if you do the knee replacement first and they have a painful hip above it, the range of motion exercises that you need to do [post-knee surgery] require a painless hip to do it.  So, very often we’ll do the hip first. Even though that may not be the primary and more severe joint, if it is significantly affected enough that it will impede their rehab we do the hip first, and then the knee.

Another unique thing about the [patients with rheumatoid arthritis] is that they may come in for a knee replacement, but it turns out that they have bad elbows or bad shoulders and so you have to decide:  Do you do the upper extremity reconstructions first, or do you do the lower extremity?

In general, most of the joint reconstructions that we do for the upper extremity – shoulder replacement, elbow replacement, wrist replacement, wrist fusions, or hand reconstructions – will impede their ability to use assistive devices after doing lower extremity reconstructions, so they may not be able to use crutches, a walker, or even a cane to help them in their postoperative rehab for the hip or the knee.   In those patients, if we do a shoulder replacement, we are not going to want to put any weight on that shoulder replacement for at least several months.  

An elbow replacement, probably forever you don’t want to put really a lot of weight on it.  So, if we can do the lower extremity reconstructions first, we prefer to do that rather than putting that postoperative load that we do for the lower extremity reconstructions on upper extremity reconstructions that can then damage the implant and negatively affect the longevity of the implant.

There are exceptions.  There are patients in whom the shoulder or the elbow are way too painful, much more so than the lower extremity, so we will do those first, but we will modify the assistive devices to decrease the load on those particular joints.  So, we will use special types of platform walkers, where instead of the patient gripping the handles with their wrist and hand, which will damage the wrist and hand more, we will use platform walkers where they rest the walker with pads so that they put all of their weight on their forearm to take the pressure off of the hand.  And then using axillary crutches, where you put the weight up on the shoulder to take it off the elbow.

The orthopedic surgeon has to take those things into consideration when deciding the staging of a multi-joint involved patient [with rheumatoid arthritis].  Hopefully, most surgeons do know what those staging [procedures] are.  But the fear always is if somebody goes to a hand surgeon because they have hand deformity and the hand surgeon doesn’t look at the elbow or the shoulder, or doesn’t realize that the patient is also going to knee a hip or a knee replacement , and may decide to do a hand reconstruction, which will delay the ability for them to undergo those other reconstructions.

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