Approach To Inflammatory Arthritis – Hip Arthritis

Modern Study Review (AI-Generated)

High-Yield Summary

Inflammatory arthritis of the hip, particularly rheumatoid arthritis (RA) and ankylosing spondylitis (AS), leads to distinctive patterns of joint destruction and presents unique challenges in arthroplasty. Progressive erosive changes and bone quality issues complicate implant fixation and healing. Modern management prioritizes cemented total hip arthroplasty (THA) with tailored perioperative infection prophylaxis and heterotopic ossification (HO) prevention strategies to optimize pain relief and function.

Key Diagnostic Findings

Current Gold Standard Treatment

• Non-operative:
• Disease-modifying antirheumatic drugs (DMARDs) and biologics to control systemic inflammation.
• NSAIDs and physical therapy for symptom control.

• Operative:
• Total Hip Arthroplasty (THA) with cemented fixation is the gold standard due to poor bone quality and unreliable osseointegration in RA.
• Avoid osteotomies; femoral neck osteotomy may be required in situ due to soft bone and protrusio.
• Internal fixation of femoral neck fractures in RA is contraindicated unless completely undisplaced; THA preferred.
• Prophylactic antibiotics perioperatively and before procedures with bacteremia risk.
• HO prophylaxis (radiation or NSAIDs) in ankylosing spondylitis patients undergoing THA.

Modern Complications & Outcomes

• Complications:
• Higher rates of aseptic loosening due to poor bone quality and increased bone turnover.
• Increased infection risk, necessitating stringent perioperative antibiotic protocols.
• Nonunion risk with trochanteric osteotomies; thus, these are avoided or used cautiously.
• High incidence of HO in ankylosing spondylitis, requiring prophylaxis.

• Outcomes:
• Cemented THA provides durable fixation and improved function in inflammatory arthritis.
• Early and aggressive medical management of systemic disease improves surgical outcomes.
• Vigilant infection prevention and HO management are critical to optimize long-term results.

Classic Clinical Notes

Approach to Inflammatory Arthritis – Hip Arthritis

• Rheumatoids get concentric wear with erosive changes, and end up with protrusio which tends to be progressive.
• Bone turnover has been shown to be higher in the peri-articular area – be wary of trying non-cemented techniques, because you may not be able to depend on bone ingrowth.
• In general, rheumatoids have shown increased rates of loosening of the femoral and acetabular components.
• They also have increased risk of infection.

• There is NO ROLE FOR OSTEOTOMY in this patient population.
• Technically, be wary of the protrusio – may have to do in-situ osteotomy of the femoral neck; be careful about dislocating the bone – it is very soft and is at risk of fracture; be careful about doing trochanteric osteotomies or slides – the bony healing is not optimal in the rheumatoids and you may precipitate a nonunion.
• The gold standard is cemented fixation, just because their bone is kinda hard to depend on for bony ingrowth.
• DO NOT ATTEMPT INTERNAL FIXATION OF RHEUMATOID FEMORAL NECK FRACTURES UNLESS COMPLETELY UNDISPLACED – they DO NOT heal reliably and are better served with THA.

• Beware high incidence of HO in ank sponds – be prepared for XRT or NSAIDS postop.
• Be wary of infection postop – these patients should all get prophylactic antibiotics before dental work, colonoscopy, or other procedures that may involve transient bacteremia.
• Kephlex – 500 mg 1 hour preop, then 1 hour postop.
• Clindamycin if PCN allergic.

Last Updated on January 24, 2026 by orthonet