Bone abnormalities in the surgical treatment of patients with rheumatoid arthritis

Profound abnormalities of bone are an important component of the morbidity of rheumatoid arthritis and partly determine the orthopaedic treatment of patients. The principal bone abnormality, which is osteoporosis associated with rapid remodeling, degrades the mechanical properties of the skeleton in juxtaarticular bone, in the diaphyses of long bones, in the pelvis, and in the base of skull. Abnormalities of bone affect clinical decision making in the surgical treatment of patients with rheumatoid arthritis and must be considered for the optimal treatment of these patients. Increased fracture risk and compromised bony fixation complicate fracture treatment. Techniques of surgery must be modified to protect bone from intraoperative fracture. Methods of fixation of implants and other devices must be appropriate to the biomechanics of the bone. Bone healing usually is rapid if not compromised by mechanical instability. Specific patterns of bone deformation and failure can be identified in the evolution of rheumatoid arthritis. Bone graft used in reconstruction of the protruded acetabulum is incorporated rapidly. Bone resorption with joint instability is a common feature of rheumatoid arthritis; however, the opposite pattern of bony ankylosis with stiffness is observed in a smaller percentage of patients. Recognition of the tissue type is necessary for the individualization of surgical procedures to achieve optimal joint stability and mobility. Based on growing understanding of the pathophysiology of bone in patients with rheumatoid arthritis, new pharmacologic therapies may become available for the prevention and treatment of bone abnormalities in patients with rheumatoid arthritis.