Increased Risk of Complications Following Total Joint Arthroplasty in Patients With Rheumatoid Arthritis

Abstract

Objective. Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are based on patients with osteoarthritis (OA); less is known about outcomes in rheumatoid arthritis (RA). Using a validated algorithm for identifying patients with RA, we undertook this study to compare the rates of complications among THA and TKA recipients between those with RA and those without RA.Methods. In patients who underwent a first primary elective THA or TKA between 2002 and 2009, those with RA were identified using a validated algorithm: a hospitalization with a diagnosis code for RA or 3 physician billing claims with a diagnosis code for RA, with at least 1 claim by a specialist (rheumatologist, orthopedic surgeon, or internist) in a 2-year period. Recipients with diagnostic codes suggesting an inflammatory arthritis, but not meeting RA criteria, were classified as having inflammatory arthritis. All remaining patients were deemed to have OA. Cox proportional hazards models, censored on death, were used to determine the relationship between the type of arthritis and the occurrence of specific complications, adjusting for potential confounders (age, sex, comorbidity, and provider volume).Results. We identified 43,997 eligible THA recipients (3% with RA) and 71,793 eligible TKA recipients (4% with RA). Total joint arthroplasty recipients with RA had higher age and sex-standardized rates of dislocation following THA (2.45%, compared with 1.21% for recipients with OA) and higher age and sex-standardized rates of infection following TKA (1.26%, compared with 0.84% for recipients with OA). Controlling for potential confounders, recipients with RA remained at increased risk of dislocation within 2 years of THA (adjusted hazard ratio [HR] 1.91, P ‫؍‬ 0.001) and remained at increased risk of infection within 2 years of TKA (adjusted HR 1.47, P ‫؍‬ 0.03) relative to recipients with OA.Conclusion. Patients with RA are at higher risk of dislocation following THA and are at higher risk of infection following TKA relative to those with OA. Further research is warranted to elucidate explanations for these findings, including the roles of medication profile, implant choice, postoperative antibiotic protocol, and method of rehabilitation following joint replacement.

Does Chronic Corticosteroid Use Increase Risks of Readmission, Thromboembolism, and Revision After THA?

“…Some studies were single-center analyses limited by relatively small sample sizes and questionable generalizability [4,5,13,15]. Additionally, large-database studies either documented corticosteroid use but did not perform further subanalyses using matched cohort analysis to make inferences regarding complications [16], or they addressed postoperative complications in populations with inflammatory arthritides, who presumably used chronic corticosteroid therapy, but did not further stratify analyses based on corticosteroid use [21]. Therefore, using a large, statewide sample of patients who underwent THA during an 8-year period, we evaluated the risk of common postoperative complications for chronic corticosteroid users versus a matched comparison cohort.…”

“…However, other studies found no increases in the likelihood of readmissions for complications, including periprosthetic joint infection [2] and implant failure [4], after THA in this population. Moreover, the effect of chronic corticosteroid use on venous thromboembolism in this THA population is unknown and has been studied only indirectly in the context of how the specific inflammatory disease affects venous thromboembolism [13,21]. These studies were either single-center analyses limited by relatively small sample sizes and questionable generalizability, or large database studies documenting corticosteroid use but not performing further subanalyses using matched cohorts that make inferences regarding readmission or revision rates or complications like venous thromboembolism [2,4,5,13,15,16,21,22].…”

“…Moreover, the effect of chronic corticosteroid use on venous thromboembolism in this THA population is unknown and has been studied only indirectly in the context of how the specific inflammatory disease affects venous thromboembolism [13,21]. These studies were either single-center analyses limited by relatively small sample sizes and questionable generalizability, or large database studies documenting corticosteroid use but not performing further subanalyses using matched cohorts that make inferences regarding readmission or revision rates or complications like venous thromboembolism [2,4,5,13,15,16,21,22]. We therefore sought to use a large, multihospital, statewide healthcare database to investigate whether chronic corticosteroid use would be associated with an increased risk of complications after THA by casematching patients receiving long-term corticosteroids who underwent THA with patients who were not taking corticosteroids at the time of their hip procedures.…”

Perioperative medical management for patients with RA, SPA, and SLE undergoing total hip and total knee replacement: a narrative review

“…Infection is the most common cause for prosthetic joint failure, and the overall risk of infection is increased in patients with RA, SPA, and SLE [11,[25][26][27][28][29]. The age standardized rate of TKA infection was 1.26% for recipients with RA, compared to 0.84% for recipients with OA, with an adjusted Hazard Ratio (HR) of 1.47, P = 0.03, confirmed in a recent meta-analysis demonstrating a relative risk of 1.7 for patients with RA [11,29].…”

“…The increased utilization of potent disease modifying anti-rheumatic drugs (DMARDs) and biologics like the tumor necrosis factor inhibitors (TNFi) has had a clear impact on quality of life for patients with RA, SPA, and SLE, medication use has not been shown to decrease the incidence of large joint arthroplasty for RA, and most RA, PSA, and SLE patients are receiving these immunosuppressant medications at the time of surgery [6][7][8]. While improvements in pain and function outcomes measured pre and post-operatively are excellent after THA and TKA for patients with RA, SPA, and SLE, adverse events, in particular infection, are increased [9][10][11][12][13][14][15][16][17]. Ninety day readmission, most commonly for infection, is also increased for patients with RA [18].…”