A different disease with a similar name.
Osteoarthritis is a disorder of the joint as a mechanical structure. Inflammatory arthritis is a systemic disease in which the immune system attacks the synovium, the lining of the joint. The synovium thickens, produces excess fluid and releases enzymes that destroy cartilage and erode bone. The joint damage is the consequence of the disease, not the disease itself.
The distinction is not academic. Osteoarthritis is managed with exercise, load management and, eventually, surgery. Inflammatory arthritis is managed with medication that suppresses the immune process, and it is managed by a rheumatologist. Delay in starting that treatment causes damage that cannot be undone.
How it differs.
- Morning stiffness. Prolonged, typically more than an hour, and it eases with movement. Osteoarthritic stiffness lasts minutes.
- Pattern. Usually several joints, often symmetrically, and frequently including the small joints of the hands and feet.
- Response to activity. Often improves with gentle use; osteoarthritis typically worsens.
- Systemic features. Fatigue, and in some conditions skin, eye, bowel or lung involvement.
- Age. Can begin at any age including in young adults.
Anyone with this pattern should be assessed by a rheumatologist promptly, through their GP. That is more urgent than a surgical opinion.
Joint replacement in inflammatory arthritis.
Medical therapy has changed this picture considerably. Effective disease-modifying and biologic drugs mean fewer joints are destroyed than in previous decades, and rates of joint replacement for rheumatoid arthritis have fallen. Where a joint has already been damaged before treatment took hold, replacement remains an excellent operation.
Several things need specific planning in this group:
- Immunosuppression. Biologic and some conventional agents raise infection risk and are usually withheld around surgery on a schedule agreed with your rheumatologist, timed to the dosing interval of the specific drug.
- Bone quality. Often poorer, from the disease and from long-term corticosteroid use. This affects fixation and the choice of implant.
- Other joints. Rehabilitation after a knee replacement is harder if the shoulders and wrists cannot take weight through a frame. The order in which joints are replaced is planned deliberately.
- The cervical spine. Long-standing rheumatoid arthritis can affect the upper cervical spine, which matters to the anaesthetist during intubation. It is screened for before surgery.
- Skin. Psoriatic plaques near an incision raise infection risk and are best treated beforehand.
Outcomes after hip and knee replacement in inflammatory arthritis are generally good, with a slightly higher rate of infection than in osteoarthritis, which is why the perioperative medication plan is made carefully rather than casually.
Where this practice fits.
Professor Rodda's practice is focused on hip and knee replacement. He does not perform joint-preserving surgery such as arthroscopy or osteotomy. If your condition is at a stage where preservation surgery is the right option, you will be told that and referred to a colleague who does it, within Sunshine Coast Orthopaedic Group or elsewhere. Where the joint has reached the point that replacement is the reasonable option, that is the work done here.
Common questions.
What is the difference between osteoarthritis and rheumatoid arthritis?
Osteoarthritis is mechanical wear of the joint surface, usually affecting one or two joints, with stiffness lasting minutes. Rheumatoid arthritis is an autoimmune disease attacking the joint lining, usually affecting several joints symmetrically, with morning stiffness lasting an hour or more and systemic features such as fatigue.
Do I need to stop my biologic before surgery?
Usually yes, and the timing depends on the specific drug and its dosing interval. This is planned with your rheumatologist rather than decided unilaterally, because stopping for too long risks a disease flare and stopping for too short a period raises infection risk.
Is joint replacement riskier with inflammatory arthritis?
The infection rate is modestly higher, and bone quality is often poorer. Both are manageable with planning. Outcomes are generally good and the operation is well established in this group.
Which joint should be replaced first?
It is planned around rehabilitation. If your upper limbs cannot take weight through crutches or a frame, that may need addressing first. Where both a hip and a knee on the same leg need replacing, the hip is usually done first.
Should I see a rheumatologist or a surgeon?
A rheumatologist, and promptly, through your GP. Inflammatory arthritis is treated medically, and early treatment prevents damage that surgery can only then work around. Surgery is for joints already damaged.
References.
- Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol. 2017;69(8):1538-1551.
- Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. Adelaide: AOA.
This page provides general information about a medical condition and a surgical procedure. It is not individual medical advice and does not replace consultation with a qualified practitioner. Outcomes vary between individuals and all surgery carries risk. A referral is needed for a consultation with Professor Daevyd Rodda; without one, you can start with the practice nurse practitioner, who can provide it.