Rheumatoid Arthritis Flares After Total Hip and Total Knee Arthroplasty: Outcomes at One Year

Abstract

ObjectiveMost patients with rheumatoid arthritis (RA) undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) have active RA and report postoperative flares; whether RA disease activity or flares increase the risk of worse pain and function scores 1 year later is unknown.MethodsPatients with RA were enrolled before THA/TKA. Patient‐reported outcomes, including the Hip disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS) and physician assessments of disease characteristics and activity (Disease Activity Score in 28 joints [DAS28] and Clinical Disease Activity Index), were collected before surgery. Patient‐reported outcomes were repeated at 1 year. Postoperative flares were identified using the RA Flare Questionnaire weekly for 6 weeks and were defined by concordance between patient report plus physician assessment. We compared baseline characteristics and HOOS/KOOS scores using 2‐sample t‐test/Wilcoxon's rank sum test as well as chi‐square/Fisher's exact tests. We used multivariate linear and logistic regression to determine the association of baseline characteristics, disease activity, and flares with 1‐year outcomes.ResultsOne‐year HOOS/KOOS scores were available for 122 patients (56 with THA and 66 with TKA). Although HOOS/KOOS pain was worse for patients who experienced a flare within 6 weeks of surgery, absolute improvement was not different. In multivariable models, baseline DAS28 predicted 1‐year HOOS/KOOS pain and function; each 1‐unit increase in DAS28 worsened 1‐year pain by 2.41 (SE 1.05; P = 0.02) and 1‐year function by 4.96 (SE 1.17; P = 0.0001). Postoperative flares were not independent risk factors for pain or function scores.ConclusionHigher disease activity increased the risk of worse pain and function 1 year after arthroplasty, but postoperative flares did not.

‘Should we stop or continue conventional synthetic (including glucocorticoids) and targeted DMARDs before surgery in patients with inflammatory rheumatic diseases?’

“… 21 23 However, using a measure commonly used to assess THA and TKA outcomes, the Hip Disability (HOOS) and Knee Injury OA Outcomes Scores (KOOS), flares in the post-operative period were not an independent risk factor for pain and function measured at 1 year after surgery. 24 Baseline DAS28 predicted 1-year HOOS/KOOS pain and function; each 1 unit increase in DAS28 worsened 1-year pain by 2.41 (SE=1.05, p=0.02) and 1-year function by 4.96 (SE=1.17, p=0.0001), suggesting that active sustained disease is a greater problem than flares. 24 In addition while numerically more flarers used targeted DMARDs, stopping them did not predict flares, and continuing methotrexate in this cohort was not protective.…”

“… 24 Baseline DAS28 predicted 1-year HOOS/KOOS pain and function; each 1 unit increase in DAS28 worsened 1-year pain by 2.41 (SE=1.05, p=0.02) and 1-year function by 4.96 (SE=1.17, p=0.0001), suggesting that active sustained disease is a greater problem than flares. 24 In addition while numerically more flarers used targeted DMARDs, stopping them did not predict flares, and continuing methotrexate in this cohort was not protective. 3 Optimisation prior to surgery should include controlling RA disease activity when possible.…”

“…Moreover, when a patient panel comprised patients with RA and juvenile arthritis were convened to advise the American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) in the formulation of a guideline for perioperative medication management, they were unanimous in their opinion that any potential increase in infection risk was worse than a flare of their disease. 24 25 Taken together, these data suggest that flares in the postoperative period may not be linked to medication management and that patients prioritise the risk of infection over flares after arthroplasty. Table 1 summarises the medications in current use in rheumatology practice and recommendations included in the ACR/AAHKS Guideline.…”

Perioperative management of patients with inflammatory rheumatic diseases

“…Another rationale for continuing treatment is frequent disease relapse within 6 weeks after hip or knee replacement [57]. On the other hand, no effect on function and pain at 1 year has been observed with postoperative relapses [58], so it is debat-able whether postoperative relapses can be tolerated as long as disease activity is not persistently high. A recently published small case-control study reported an increased likelihood of periprosthetic infections after total arthroplasty in 26 patients who continued biologic therapy compared with 58 patients who paused therapy [59].…”

Comparison adductor canal block combined with local infiltration analgesia and adductor canal block alone for pain management after total knee arthroplasty

“…Total knee arthroplasty (TKA) is commonly conducted to address the pain and functional disorder, which attends end-stage osteoarthritis and rheumatoid arthritis. [ 1 , 2 ] In the wake of the aging of the U.S. population, the number of knee arthroplasty is expected to obviously increase by 2030, with the estimated 3.48 million cases each year. [ 3 ] However, postoperative pain remains a major complication, and pain control is an essential component of optimal care in surgical patients.…”