The Rheumatoid Hip. Heiner Thabe. Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona. With 87 Figures and 24 Tables

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2 Heiner Thabe The Rheumatoid Hip With 87 Figures and 24 Tables Translated by Julia and David Roseveare Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona

3 Dr. med. Heiner Thabe Chefarzt der Orthopadischen Abteilung im Rheumazentrum Bad Kreuznach Diakonie-Krankenhaus Ringstral3e D-6550 Bad Kreuznach Translators: Julia and David Roseveare Kleinschmidtstral3e 14 D-6900 Heidelberg ISBN-13: DOl: / e-1sbn-13: Library of Congress Cataloging-in-Publication Data Thabe, Heiner. The rheumatoid hip I Heiner Thabe. Includes bibliographical references (p. ) and index. 1. Rheumatoid arthritis. 2. Rheumatoid arthritis--surgery. 3. Hip joint--diseases. 4. Hip joint--surgery. I. Title. RC933.T '81--dc20 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Verlag Berlin Heidelberg 1990 Softcover reprint of the hardcover I st edition 1990 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2119/ Printed on acid-free paper

4 For Claudia, Tim and Tabea

5 Foreword The inflammatory rheumatoid diseases are still at the fore of experimental and clinical research. To this day, our most varied and intensive endeavours have failed to elucidate the causes conclusively. There are still limitations on diagnosis and treatment imposed by our lack of knowledge of the pathogenesis. In the interest of the many patients who suffer from rheumatoid disease in particular, continuous efforts are necessary to improve their quality of life. Considering the large number of people - nearly 2 million in West Germany alone - with rheumatoid disease, and in view of its sociomedical implications, the need for clarification of diagnostic procedures and treatment cannot be over-emphasized. The inflammatory rheumatoid diseases can affect all synovial joints. We know that the frequency with which individual joints are affected can vary. The hip joint is not one of the joints most involved, but when a hip joint is affected there are important consequences for the function of the lower limbs and for the stability of the spine-pelvis-leg axis. The knee joint has attracted more interest than the hip in rheumatoid arthritis, and for this reason Dr. Thabe is commended for turning his attention to the involvement of the hip joint. This is the first book to give a comprehensive and broad-based account of the rheumatoid hip. Previous publications have all been concerned only with individual aspects of the problem, so that no coherent, scientifically founded evaluation of pathogenesis, diagnosis and therapy has been possible. The section on diagnosis is particularly impressive. On the basis of his thorough investigations Dr. Thabe has succeeded in describing in detail the course of various types of inflammatory rheumatoid disease of the hip joint. The differentiation between dysplastic, protrusion, destructive and degenerative types allows much more precise - and thus more specific - therapeutic intervention. As a result of this a new account is possible of the inflammatory processes in the hip joint. Dr. Thabe's contribution to the therapy of hip joint synovitis with chemical synovectomy is of particular interest. In this field he has been able to demonstrate important methods for treatment by virtue of his thorough and well-founded investigations. Close attention is paid to the problem of operative treatment, which is particularly important in

6 VIn Foreword rheumatoid orthopaedics. Dr. Thabe gives a full account of the various possible operative procedures and, supported by his own wide experience of surgery and experimental investigations, examines the merits of joint-preserving measures, surface replacements and total replacements. Even special individual aspects of this complex subject such as joint resection and the special features of reconstructive intervention in juvenile rheumatoid arthritis are covered scientifically in a thorough and exhaustive manner. This book presents an up-to-date and broad-based synopsis of diagnostic and therapeutic possibilities in inflammatory rheumatoid conditions of the hip. There is no doubt that it will be of great interest to all rheumatologists and orthopaedists. Erlangen, August 1988 Prof. Dr. med. G. Weseloh Representative of the Arbeitsgemeinschaft fur Rheuma-Orthopiidie (ARO) of the Deutsche Gesellschaft fur Orthopiidie und Traumatologie (DGOT)

7 Preface Rheumatoid surgery has considerably broadened the spectrum of treatment for those suffering from rheumatoid disease. Surgical intervention alone, though, is not sufficient. More than in any other disease the patient must rely on effective cooperation by a great number of therapists, as the full range of treatment can seldom be handled by one therapist alone. Every therapist must be aware of the recent developments when deciding what treatment to offer. This book is based on my 15 years of experience in the active treatment of rheumatoid patients. When I began working at the Bad Bramstedt Hospital for Rheumatoid Diseases, where treatment is based on interdisciplinary cooperation, treatment concepts were already very advanced for most joints. In the mid-1970s, due to lack of facilities, patients with rheumatoid hips had to be referred to neighbouring hospitals. Principles following the "arthrosis concept" proved to be less satisfactory in treating the rheumatoid hip. My teacher, Karl Tillmann, taught me the fundamental principles of an exact and scientific approach. He further equipped me excellently for the operative treatment of rheumatoid arthritis. I would like to thank him sincerely at this point for his support and the motivation he gave me to carry out my own work in this complex area. The concept presented in this book is thus based on our cooperation in Bad Bramstedt. At that time there was also close and fruitful cooperation with Mr. Arnold Keller and Waldemar Link Co., who worked rapidly and efficiently to help us solve specific problems in the care of the rheumatoid hip. From this cooperation emerged the cementless hip system presented here, which was originally developed to cope with the poor quality of the bone in rheumatoid patients. The open and intense discussion in the Arbeitsgemeinschaft fur Rheumaorthopadie (Study Group on Rheumatoid Orthopaedics) confirmed the validity of our methods. In other centres similar methods that had been developed for varying reasons were also successful. After my move to the Diakonie Hospital at Bad Kreuznach interdisciplinary cooperation became a logical consequence. My thanks also go to Gerd Weseloh, who encouraged me to publish my work. I am grateful to Vlf Droste for his assistance in checking and

8 X Preface correcting the sections concerning internal medicine. I would like to thank Springer-Verlag, Dr. Graf-Baumann and Mrs. Bohlen for their willingness to publish this book, Julia and David Roseveare for their proficient translation from the German, and finally Prof. Ian Goldie, whose expert comments and corrections provided the finishing touch. Bad Kreuznach, August 1990 H. Thabe

9 Contents Diagnosis in Rheumatoid Joint Diseases Morphology. Clinical Aspects Chemical Analysis Haematology Synovial Analysis Radiography Histology Differential Diagnosis The Rheumatoid Hip Dysplasia Protrusio Destructive Degenerative Radiography Differential Diagnosis of Arthritic Diseases of the Hip. Arthroscopy Treatment for Chronic Inflammatory Disease of the Hip..... General Medical Treatment Non-Steroidal Antiinflammatory Drugs Glucocorticoids Disease-Modifying Antirheumatic Drugs Special Features of Treatment of Juvenile Rheumatoid Arthritis Special Physiotherapy. Remission

10 XII Contents Exacerbation Balneotherapy Intraarticular Injection Treatment Local Treatment with Corticosteroids Intraarticular Enzyme Treatment Treatment with Aprotinin Therapy with Orgotein Chemical Synovectomy Treatment with Varicocid Treatment with Osmic Acid Use of Silicon Oil Radiosynoviorthesis Surgical Problems - General Requirements Social Problems Anaesthetic Problems Special Problems with Rheumatoid Involvement of the Cervical Spine Perioperative Cortisone Therapy Peri operative Therapy with Non-Steroidal Antiinflammatory Drugs and Disease-Modifying Antirheumatic Drugs Thrombosis Prophylaxis. 77 A.7 Antibiotic Prophylaxis Preparation for Surgery Surgical Approach Surgical Procedures Joint-Preserving Operations Bursectomy Tenotomy Synovectomy Osteotomy Replacement: Cup Arthroplasty Total Hip Replacement Total Replacement with Bone Cement Cementless Replacement Other Interventions Remobilization Arthrodesis Resection 148

11 Contents XIII Secondary Hip Operations Special Features of the Reconstructive Care in Juvenile Rheumatoid Arthritis Postoperative Management Summary References.. Subject Index