Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in female
with AR and bilateral hip arthroplasty

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
AA, 67 year old woman with long history of
rheumatoid arthritis and bilateral hip replacement

1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Personal data

Patient Complaints
Moderate pain and swelling of bilateral shoulders, elbows, knees and ankles
Disabilities of prehension and ADLs, fatigue
Post procedure (total hip arthroplasty consolidation after fall) rehabilitation status

ANAMNESIS (history)
Our 67 year old woman with a 25-year history of rheumatoid arthritis was diagnosed with osteoporosis in 2000,
without adequate treatment. Five years later, in 2005, she was diagnosed with dorsal kyphosis and lumbosacral
spondylosis. She has previous history of Hypertension and Ischemic Heart Disease, gastric ulcer well controlled with
medication. Onset of RA was in 1992, without apparent reason. She mentioned that her hand and leg joints are
progressively disturbedd (painful and swelling) and she has much difficulty in walking and performing ADLs. Since
1993, she performed complete treatment with NSAIDs and disease-modifying antirheumatic drugs (five years
methotrexate 12.5 mg weekly, than leflunomide 20 mg daily until present), regular rehabilitation program for joint
flexibility and adapted daily tasks. The progression of disease in lower limbs occurred over 7 years; her functional
status progressively worse and limiting her daily activity level. Range of all hip and leg movements is impaired,
movement is painful, pain and stiffness when the activity is resumed after resting. In 2014 AM was scheduled for left
total hip arthroplasty, in March 2014 and for right hip arthroplasty in October 2014. The postoperative recovery passed
normally. Our patient was capable of walking with underarm crutches. Last year, she falled and suffered multiple
fractures left elbow, right shoulder and right hip prosthesis dislocation. She was hospitalized at the Clinic of
Orthopedics and Traumatology where it was perfomed the metalic consolidation of prosthesis. After 6 weeks she was
arrived in our Rehabilitation department.
She denied a family history for RA or other connective tissue disease, but her mother had significant dorsal kyphosis
(due to osteoporosis, probably). Also, she denied of vasculitis, pulmonary nodules or pleuropericarditis.
She performed daily activities in standing and walking postures in her professional life.
Personal data
Questions (for assessment detailed answers see next page)

1. Why is important to mention how was the postoperative (for hip replacement) recovery passed ?
a. Because patients with RA are two times more likely to develop postoperative infection after total hip replacement
b. Because the drug treatment of RA reduce the wound healing
c. It is no important
R = a, b

2. How could be explain the complex and multiple fractures of our patient?
a. Her osteoporosis is incorrect treated
b. Our patient refused the treatment because she was diagnosed with gastric ulcer
c. In RA all patients have one or more fractures during their life
R = a, b

3. How can explain the hip pain and limitation of movement in our patient?
a. the inflammation of local synovium can cause the hip pain
b. the muscle destroying through rheumatoid factor can cause the hip movement limitation
c. the evening stiffness and hip osteoarthritis can cause hip pain and limitation of movement
R=a

4. What is missed significant aspect in our patient (female) anamnesis?

a. The age of her menopausal status
b. Her marrital status
c. Her professional profile
R=a
 Personal data
Questions` answers

1. Why is important to mention how was the postoperative (for hip replacement) recovery passed ?
Patients with RA are two times more likely to develop postoperative infection after total hip replacement. Because of
the problem of wound healing in patients with RA, perfect sterile operative technique, careful intra-operative
skin and subcutaneous tissue handling and tight closure of operative wound are essential. Also, patients with RA
have poor bone and soft tissue quality. So, bone loss, osteopenia and acetabular protrusion are real conditions for
the type of prosthesis should be used.

2. How could be explain the complex and multiple fractures of our patient?
Rheumatoid arthritis itself, along with some medications used for treating rheumatoid arthritis, can increase the risk
of osteoporosis. The risk factors for falls were more prevalent in rheumatoid patients compared with the non RA
patients and the risk of falling is common in older women with RA.

3. How can explain the hip pain and limitation of movement in our patient?
RA occurs when the immune system attacks the synovium of joint. The synovium thickens, swells, and produces
chemical substances that attack and destroy the articular cartilage covering the bone. The tendons and ligaments
that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment. The
inflammatory synovitis, which has the potential to erode cartilage and destroy joints, leading to pain and loss of
function and often involves the same joint on both sides of the body, so both hips may be affected.

4. What is missed ssignificant aspect in our patient (female) anamnesis?

The menopausal status is important for bone resistance. If our patient would have a younger age of menopausal status
she is expose to higher risk for osteoporosis. RA and osteoporosis are two disorders that sum their disabiliry on
the lower limbs.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

Post hip replacement (2014)

AA was 1.54 m height and a weight of 57 kg, with moderate skin pallor bur without rheumatoid nodules. Pulmonary,
cardiac, digestive and urogenital systems were normal in clinical exam. Mental status was clear. Vertebral spine
dorsal kyphosis, back pain. Both upper limb joints all joints were affected (the shoulders, elbows, wrists and
hands) with a relatively symmetric distribution swelling, tenderness, warmth, and decreased ROM and strength;
both hands with ulnar deviation, boutonniere and swan-neck deformities, with moderate ankylosis and disturbed
prehension. Lower limb with multiple deformities of legs, tendernesss and decreased ROM of both ankles; knee
asymmetrical valgus, passively partial correctable to neutral; right AROM -10 to 90 degrees and left AROM -5 to
100 degrees; both knee effusions and synovial thickening are easily detected; moderate bilateral quadriceps
hypotrophy; no limited motion or pain on motion and weight bearing in both operated hips (skin with nornal
scars). MMT values were 4 for great gluteus, hip stable muscle, -4 for quadriceps, 4 for posterior limb muscles.
Gait was possible with two canes. Neurovascularly of lower limbs were intact.

Actual (2016, post fall and right hip prosthesis dislocation)

AA is 1.51 m height and a weight of 53 kg. Pulmonary, cardiac, digestive and urogenital systems are normal in clinical
exam. Mental status is clear. Vertebral spine dorsal kyphosis, dorsal and back pain. Upper limb joints similar
previous clinical status with difference for left elbow and right shoulder swelling and without functional AROM.
Pain along the lateral side of hip and thight, skin in right hip region with post intervention scars, without any
pathologic aspects; right hip ROM flexion AROM 0 to 75 degrees, PROM 0 to 90 degrees, abduction AROM 0
to 25 degrees, PROM 0 to 30 degrees; MMT values are +3 for great gluteus, -4 for hip stable muscle, -4 for right
quadriceps. For other lower limb joints the previous status was preserved. Gait was possible with underarm
crutches. Neurovascular of lower limbs are intact. Vital Signs: temperature 36.7C, blood pressure 130/60 mmHg,
rhythmic pulse 76 b/min, 16 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. Why is important to assess the swelling and pain of limb joints in our RA patient?
a. Because these symptoms have a significant consequence on the range of motion
b. Because our patient is female
c. It is no important
R=a

2. How can explain the finger deformities in our patient?

a. The boutonniere deformity describes nonreducible flexion at the proxima interphalangeal (PIP) joint along with
hyperextension of the distal interphalangeal (DIP) joint of the finger
b. Swan-neck deformity of the finger describes hyperextension at the PIP joint with flexion of the DIP joint
c. Tightness of intrinsic hand muscles may cause major declines in finger mobility
R = a,b

3. Is hip affected in RA patient?

a. No
b. Yes
c. Sometimes
R=b

4. What is important to perform MMT (manual muscle testing) for all muscles of lower limb?
a. For gait are important both extension and flexion kinetic chains of lower limb
b. For control the knee pain
c. For chose the AINS medication
R=a
 Clinical data
Questions` answers

1. Why is important to assess the swelling and pain of limb joints in our RA patient?
Pain and joint swelling are resulting from thickening of synovial membrane and accumulation of synovial fluid. In
RA, joint swelling is typically spongy or doughy as opposed to firm and knobby (as in osteoarthritis). These
painful and tender to the touch joints will be restricted the range of motion.

2. How can explain the finger deformities in our patient?

The boutonniere deformity occurs as a result of synovitis stretching or rupturing the PIP joint through the central
extensor tendon, with concomitant volar displacement of the lateral bands. When the lateral bands have subluxed
far enough to pass the transverse axis of the joint, they become flexors of the PIP joint. Consequences of
boutonniere deformity are loss of thumb mobility and pincher grasp. Swan-neck deformity may be initiated
either by disruption of the extensor tendon at the DIP joint, with secondary shortening of the central extensor
tendon and hyperextension of the PIP joint, or by volar herniation of the PIP joint capsule due to weakening from
chronic synovitis, with subsequent tightening of the lateral bands and central extensor tendon.

3. Is hip affected in RA patient?

The hip is commonly involved in RA; however, because of his deep location, his involvement is not always readily
apparent early in the course of the disease. Limited motion or pain on motion and weight bearing are the
hallmarks of hip involvement. The Patrick maneuver is abnormal in this situation. A flexion deformity may be
demonstrable by conducting a Thomas test.

4. What is important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation program for gait in patient with hip arthroplasty take into consideration the global kinetic exercises,
after analytic kinetic program. The kinetic muscle chains of the lower limb for extension and for flexion are
very important for independence ambulation, so previous kinetic program must do the MMT.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
Imagistic data

Bone densitometry obtained by Dexa scan (DXA) within the previous two weeks prior to the initial visit
demonstrated lumbar and both trochanter osteoporosis, with a T-score of -3.5 (lumbar), -2.7 (left trochanter) and
-3 (right trochanter)
Hands X-ray showed signs of severe arthritis, with two typical deformities of the MCP joints that alter the
alignment of the palmar skeletal arches and the stability of the fingers: volar subluxation and ulnar deviation;
erosions in the interphalangeal joints.; widespread osteoporosis, and marginal erosions affecting the carpal bones
and metacarpal heads.
Hip X-ray after surgical intervention Total bilateral hip arthroplasty with correct position of prostetic
components, cerclage fixation plate for a periprosthetic fracture in the upper third of the right femur.
Imagistic data
Questions (for assessment detailed answers see next page)

1. What is the significant functional aspect resulted after seeing the hand X ray?
a. Our patient had a really disability for prehension, for using walker and performing ADLs
b. Our patient had no disability problem
c. The X ray aspect was not significant for RA
R=a

2. It is important the result of DXA exam in our patient?

a. Yes
b. No
c. Is no necessary
R=a

3. The imagistic findings of standard pelvic and hip X-ray can suggeted the type of used endoprosthesis and
possible complication ?
a. Yes
b. No
c. It is an incorrect hip X ray
R=a

4. Is RMN examination essential for our patient?

a. Yes
b. No
c. It is possible
R=b
Imagistic data
Questions` answers

1. What is the significant functional aspect resulted after seeing the hand X ray?
A severe and extensive destruction of the hand complex, with dissolution of bone, with joints become grossly unstable,
has a significant dysfunctional impact on the ADLs of each patient with RA.

2. It is important the result of DXA exam in our patient?

A score below -2.5 is indicative of osteoporosis by World Health Organization standards). The occurrence, skeletal
distribution, clinical importance and cause of generalised osteoporosis in rheumatoid arthritis remains controversial.
There is now good evidence that bone loss occurs early in RA at the radius, hip and spine, with axial bone loss being
related to disease and physical activity. Technical challenges of performing total hip replacement in patients with RA
are mainly due to bone loss and osteoporosis.

3. The imagistic findings of standard pelvic and hip X-ray can suggeted the type of used endoprosthesis and
possible complication ?
THA is an extremely successful operation, and rates for complications and adverse events are low. However, significant
complications may occur, such as venous thromboembolism (VTE), infection, dislocation and death. Patients with
RA were at increased risk for dislocation, migration and rotation after total hip arthroplasty. At two years in
rheumatoid arthritis patient population has been identified to have a higher baseline risk of infectious diseases
compared with the general population. In addition, the immunosuppressive drugs used in the treatment of RA may
further increase the risk of infection.

4. Is RMN examination essential for our patient?

Due to metalic components of the hip replacement the RMN exam can not be performed.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assess, in accordance with ICF:

impairments of body functions - pain, muscle weakness, and restricted hip and hand flexibility;
changes in body structures - synovial panus in upper and lower limb joint, fractures and the new hip joints have damaged
several proprioceptors because of:
capsular excision,
injured some muscles because of splitting or detaching them, followed by suturing and reattaching them;
activity limitation - failure to cover short distances, limited walking ability and various problems with ADLs;
participation restrictions failure to participate to leisure activities and in household chores;
the changes in the patients level of function over the hip replacement.

We used:
easily reproducible physical performance measures for activity limitation and participation restriction
6 Minute Walk = 220 meters before rehabilitation program; 360 meters after rehabilitation program
Timed Up and Go = 34 seconds before rehabilitation program; 22 seconds after rehabilitation program
scales for condition-specific health status measures
WOMAC (with 3 subscales measuring pain - 5 items, stiffness - 2 items, physical function - 17 items;
lower score indicates a better outcome) = 79 before hospitalization; 56 after rehabilitation program
HAQ (the Health Assessment Questionnaire for disability assessment about dressing, arising, eating, walking,
hygiene, reach, grip, and activities; disability is scored 0 = normal function to 3.0 = unable to do most activities of
daily living) = 21 before hospitalization; 15 after rehabilitation program
SF-36 (the lower the score the more disability - a score of zero is equivalent to maximum disability; the higher the
score the less disability a score of 100 is equivalent to no disability) = 23 before hospitalization; 44 (after the
rehabilitation program)
 Functional data
Questions (for assessment detailed answers see next page)

1. Although the painful and dysfunction hip joints have been replaced by endoprothesis, previous impairments in
body function of our patient still carry with her?
a.No
b.Yes
c.Is no important to mention
R=b

2. The changes in body structures that appeared from surgery may explain?
a.A further disturbance in the neuromuscular status
b.Optimal balance and gait
c.Back pain and lumbar stifness
R=a

3. The final score of the WOMAC scale and HAQ index in our patient are in concordance for disability status ?
a.Yes
b.No
c.It is no possibility to compare the two score scales
R=a

4. It is important to assess the lower limb disability in our patient with the test Timed Up and Go?
a.Yes
b.No
c.Probably
R=a
Functional data
Questions` answers

1. Although the painful and dysfunction hip joints have been replaced by endoprothesis, previous impairments in
body function of our patient still carry with her?
Yes. Two of the consequences of RA are decline in functional status and daily activities disability. The domain of
disability is assessed by the eight categories of dressing, arising, eating, walking, hygiene, reach, grip, and common
activities. A compensatory movement pattern may have become a habit after years of volitional unloading of the
painful limbs, and this problem may sustain after replacement.

2. The changes in body structures that appeared from surgery may explain?
Additionally, the changes in body structures that appeared from surgery may explain the picture of a further disturbance
in the neuromuscular status.

3. The final score of the two scales used for our patient WOMAC and HAQ index are in concordance for
disability status ?
Yes. The potential candidates for total joint replacement are defined as patients who have a summed WOMAC score
39, and no absolute contraindication to total joint replacement. HAQ index is a functional disability index that is
widely used throughout the world and has become a mandated outcome measure for clinical trials in rheumatoid
arthritis; higher score is a frame of more disability. We must take into consideration that patients with RA have a
longer length of hospital stay with slower functional improvement than patients undergoing joint replacement surgery
for primary osteoarthritis.

4. It is important to assess the lower limb disability in our patient with the test Timed Up and Go?
Yes. The Timed Up and Go Test (TUG) is a test of balance that is commonly used to examine functional mobility in
community-dwelling, frail older patients. The test requires a patient to stand up, walk 3 m, turn, walk back, and sit
down. Time taken to complete the test is strongly correlated to level of functional mobility and has a high degree of
inter- and intra-rater validity.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

Previous bilateral hip replacement

After clinical assessment, we performed lab (complete blood test - tests for rheumatoid factor (RF) and anti-cyclic
citrullinated peptide antibodies - anti-CCP, liver function tests, urine test), electrocardiogram and imagistic exam, for
complete diagnosis. We respected the 2010 ACR / EULAR classification criteria for RA.
Complete diagnosis for our patients is:
1. Rheumatoid arthritis positive RF and antibodies - anti-CCP, DAS 28 (scale, 0-9.4) = 2.9, stage III (severe
progression), functional class III able to perform usual self-care activities but limited in vocational and avocational
activities
2. Anemia and Osteoporosis
3. Hypertension and Ischemic Heart Disease (medication controlled)

Differential diagnosis must take into consideration the following: osteoarthritis, polymyalgia rheumatica, inflammatory
arthritis, hip osteonecrosis,, tumoral disease, post traumatic hip status

Actual (post total hip replacement, multiple osteoporotic fractures and metalic consolidation in right side)
1. Rheumatoid arthritis positive RF and antibodies - anti-CCP, DAS 28 (scale, 0-9.4) = 2.8, stage III (severe
progression), functional class IV - limited in ability to perform usual self-care, vocational, and avocational activities
2. Total bilateral hip arthroplasty (THA)
3. Anemia and Osteoporosis. Dorsalgia.
4. Hypertension and Ischemic Heart Disease (medication controlled)
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What is the initial and the most important risk factor in our patient for requirement of large joint arthroplasty?
a. anemia
b. high disease activity score
c. compromised biomechanical properties of rheumatic bone
R=c

2. Our patient had not followed corticotherapy. This is a positive or negative aspect in THA life?
a. Positive
b. Negative
c. It is not important for THA life
R=a

3. Why is a significant difference between DAS 28 value and functional class in our patient ?
a. Because her disease is early diagnosed
b. Because she has multiple fractures
c. Because she mentioned a long period of hip pain and disability of lower limb
R=b

4. We must mentioned in complete diagnosis all patients disorders? Why?

a. No, it is not an important aspect
b. Yes, because the disorders have an important conditioning for rehabilitation program goals and methods
c. Yes, but not important for rehabilitation program
R=b
Complete diagnosis
Questions` answers

1. What is the initial and the most important risk factor in our patient for requirement of large joint
arthroplasty?
Anaemia, raised erythrocyte sedimentation rate and a high disease activity score have all been identified as risk factors for
requirement of large joint arthroplasty, but the most important risk factor is compromised biomechanical properties
of rheumatic pelvic bone, caused by inflammatory diseases and medication. This leads to many questions with regard
to the practice of implanting artroplastic components in rheumatic bone.

2. Our patient had not followed corticotherapy. This is a positive or negative aspect in THA life?
Today, THA modular hip prostheses - is extremely successful operation in RA patient, and rates for complications and
adverse events are generally low. Corticosteroids, which are frequently used in RA, clearly increase overall infection
risk. The effect on infection risk for corticosteroid is highest with current use, but cumulative and absolute dose also
influence the risk.

3. Why is a significant difference between DAS 28 value and functional class in our patient ?
DAS28 (ESR) (Low/minimal disease, 2.6 or more to less than 3.2; moderate disease, 3.2 or more to 5.1 or less;
high/severe disease greater than 5.1) is a laboratory composite tools. In functional classification we consider global
joint disability and pain with daily life. Affected joints can become deformed, and the performance of even ordinary
tasks may be very difficult or impossible; these factors can severely affect patients quality of life. In addition, RA is
a systemic disease that can affect other parts of the body in addition to joints.

4. We must mentioned in complete diagnosis all patients disorders? Why?

Rehabilitation program for total hip replacement typically reclaim kinetic exercises. In cardiac patient all kinetic program
must respect the intensity, duration and frequency in accordance with cardiac status. Also, the osteoporotic fractures
of upper limbs had an important conditioning in rehabiliation program goals and sessions.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Rehabilitation program (RP)

1. Objectives of RP in our patient:

painful status control;
controlling the residual inflammatory process;
control of joint damage - regaining stability and mobility of the lower limb joint, muscle and ligament balance,
restoring balance to the muscle groups serving the entire hip" complex;
correcting abnormal walking scheme, with recovery of normal walking;
keeping the hip in the economy of the limb biomechanics;
maintenance of normal daily activities;
maximization of quality of life.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics, anti-osteoporosis and chondroprotective drugs, LFN 10 mg/daily
non-pharmacological modalities, especially for THA:
- educational, dietary and hygienic,
- posture (activity modification),
- physical (thermotherapy - paraffin legs; electrotherapy - magnetodiaflux, TENS, ultrasound for knees, legs, hands) -
decreased joint swelling and pain will reduce chances of developing complications during the rehabilitation process;
- massage classic and special massage (Cyriax),
- kinetic correct posture of lower limb (with abduction of lower limbs), disto-proximal lower limb joint mobilization
(assistive active and active range of motion), stretching and strengthening in all muscles (early quadriceps and hip
stable muscles retraining and strength training), gait training with supporting walker or both canes
- orthoses for legs and hands.
 Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why is indicated hip arthroplasty in our patient?

a. Because her hip joints were destroyed in rheumatoid process
b. Because patient wanted to make the intervention
c. Because we established a high RF concentration
R=a

2. Our patient had multiple secondary fractures. One of this is located in the right femur.
Is an important factor for RP in our patient?
a. No
b. Yes
c. It is not important
R=b

3. Is kinetic program a opportune choice in RP for our patient ?

a. No
b. It is no important
c. Yes
R=c

4. The pain and dysfunction in upper limb joint in our patient can be well controlled in RP?
a. Partial
b. Yes
c. No
R=a
 Rehabilitation program
Questions` answers

1. Why is indicated hip arthroplasty in our patient?

Surgical repair may be considered if medications and other treatments fail to prevent or slow damage to the joints. This
option can reduce pain, correct deformities and help restore the ability to move the affected joint. The hip joint is
affected in 15% to 30% of all RA patients. In the end 10 to 25% of all RA patients undergo THA. Total hip
replacement is one of the most successful and cost-effective of surgical procedures with the primary goals of pain
relief and restoration of function. By alleviating pain and disability, it has helped patients to return to active life.

2. Our patient had multiple secondary fractures. One of this is located in the right femur. Is an important factor for
RP in our patient?
Yes. THA in RA is associated with an increased risk of fractures. One of the most severe but rare fractures is that of
the shaft of the femur, often necessitating extra extensive surgery, like in our patient. The risk of osteoporosis appears
to be higher than average in patient with RA who are older than 60 years. All fractures had a severe impact into the
function status.

3. Is kinetic program a opportune choice in RP for our patient ?

Yes. A guided exercise program can improve quality of life and muscle strength in patients with RA. Results of
randomized controlled trials support physical exercise to improve quality of life and muscle strength in patients with
RA. Exercise training programs have not been shown to have deleterious effects on RA disease activity, pain scores,
or radiographic joint damage. The role of kinetic program is complex: maintaining the range of motion, strengthening
of muscles, prevent contractures, prevent other deformities, maintain activities of daily living.

4. The pain and dysfunction in upper limb joint in our patient can be controlled in RP?
Partial. Affected upper limb joints were deformed, and the performance of even ordinary tasks was very difficult or
impossible; these factors severely affected patients quality of life. Pain is partial controlled with TENS and joint
protection rules.