Hip score and disease activity correlation in patients with rheumatoid arthritis after total hip arthroplasty

Association between disease activity of rheumatoid arthritis and risk of complications following total hip arthroplasty: a retrospective cohort study

BACKGROUND

Identifying rheumatoid arthritis patients at higher risk of complications after total hip arthroplasty could make perioperative management more effective. Here we examined whether disease activity is associated with risk of such complications.

METHODS

We retrospectively analyzed data for 337 rheumatoid arthritis patients at our medical center who underwent primary total hip arthroplasty. Rheumatoid arthritis patients were categorized according to the simplified disease activity index (SDAI), the values of which at admission and follow-up were averaged together. Logistic regression was used to examine associations of mean SDAI with rates of dislocation, infection, periprosthetic fracture and aseptic loosening. As controls, 337 osteoarthritis patients who did not have systemic inflammation and who underwent the same procedure were matched across numerous clinicodemographic variables.

RESULTS

Among the 337 rheumatoid arthritis patients, 38 (11.3%) had postoperative complications, the rates of which varied significantly from 0 to 17.5% (p = 0.003) among the four subgroups whose disease activity based on mean SDAI was categorized as high, moderate, low or in remission. Each 1-unit increase in mean SDAI was associated with a significant increase in risk of postoperative complications (OR 1.015, 95% CI 1.001-1.029, p = 0.035). Across all rheumatoid arthritis patients, rate of complications did not differ significantly between patients who received disease-modifying anti-rheumatic drugs or other treatments. Rates of dislocation, of infection or of all postoperative complications combined were significantly lower among osteoarthritis controls than among rheumatoid arthritis patients.

CONCLUSION

Greater mean SDAI is associated with higher risk of dislocation, infection and composite postoperative complications after total hip arthroplasty in rheumatoid arthritis patients. These patients show a significantly higher rate of postoperative complications than osteoarthritis patients, likely reflecting the influence of systemic inflammation. Disease activity should be reduced as much as possible in rheumatoid arthritis patients before they undergo total hip arthroplasty.

Increased bone resorption that outpaces increased bone formation: An important pathology of rapidly destructive coxarthrosis

Rapid joint destruction caused by rapidly destructive coxarthrosis (RDC) can increase surgical complexity and intraoperative blood loss. This single-center retrospective study investigates osteoporosis-related biomarkers for early RDC diagnosis and explores new treatment targets. We included 398 hip joints from patients who underwent total hip arthroplasty, examining medical records for preoperative patient demographics, bone mineral density of the hip and lumbar spine from dual-energy X-ray absorptiometry scans, and osteoporosis-related biomarkers including TRACP-5b, total P1NP, intact parathyroid hormone, and homocysteine. We compared RDC and osteoarthritis (OA) patients, and univariate analysis showed that RDC patients were older (p < 0.001) and had lower serum levels of albumin (p < 0.001) and higher serum levels of TRACP-5b, total P1NP (p < 0.001), and homocysteine (p = 0.006). Multivariable analysis showed that the ratio of serum TRACP-5b to total P1NP had a more significant difference in RDC patients than in OA patients (p = 0.04). Serum TRACP-5b levels were negatively correlated with the time between RDC onset and blood collection, and Japanese Orthopedic Association pain score. Receiver operating characteristic curve analysis revealed that the ratio of serum TRACP-5b to total P1NP had the highest area under the curve value. This study is the first to demonstrate that the ratio of serum TRACP-5b to total P1NP-increased bone resorption that outpaces increased bone formation-is significantly elevated in patients with RDC and that TRACP-5b is higher in the early stages of RDC. Inhibiting serum levels of TRACP-5b, activated osteoclasts, during early RDC may suppress disease progression.

Predictors and complications of blood transfusion in rheumatoid arthritis patients undergoing total joint arthroplasty

PURPOSE

Our research investigated predictors of postoperative blood transfusion rate following total joint arthroplasty (TJA) in patients with rheumatoid arthritis (RA) and evaluated the incidence of complications in the transfusion group and non-transfusion group.

METHODS

The authors retrospectively analyzed risk factors among 320 RA patients who underwent elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2010 to December 2018. Demographic characteristics, laboratory results, medication history, and surgical protocol were gathered from electronic medical records. Univariable and multivariable logistic regression analyses were conducted to measure the impact of relevant variables on the need for transfusions. In addition, we compared the incidence of complications associated with transfusion.

RESULTS

The cohort comprised 320 RA patients, aged 57.4 ± 12.0 years, of whom 137 required postoperative blood transfusions and 183 did not. BMI, type of surgery, duration of surgery, disease activity score 28 (DAS28-CRP), tranexamic acid (TXA) administration, and preoperative hemoglobin (Hb) were all risk factors for transfusion after adjusting for the planned procedure.

CONCLUSION

Previously published predictors, such as BMI, low preoperative hemoglobin, duration of surgery, procedure type (THA), were also identified in our analysis. Moreover, TXA administration and the DAS28-CRP showed the potential to influence risk. The incidence of postoperative complications was increased in patients who received blood transfusions compared to non-transfusion group. Our findings could help to identify RA patient population requiring blood transfusions, to ensure the necessary steps are adopted to limit blood loss and improve blood management strategies. Key Points • The risk factors for blood transfusion in rheumatoid arthritis patients undergoing total joint arthroplasty were BMI, the type of surgery, duration of surgery, TXA administration, DAS28-CRP, and preoperative hemoglobin. • The incidence of postoperative complications was increased in patients who received blood transfusions compared to non-transfusion group.

Minimum 10-Year Results of Modular Metal-On-Metal Total Hip Arthroplasty

Background: this study aimed to assess the long-term outcomes of (a minimum of 10-years) total hip arthroplasty with a metal-on-metal acetabular prosthesis. Methods: Eighty-nine primary total hip arthroplasties (82 patients) were performed using a Pinnacle modular metal-on-metal acetabular prosthesis. Clinical hip function outcomes were evaluated using the Japanese Orthopaedic Association hip score preoperatively and at the final follow-up. Radiological analysis was performed at the final follow-up and magnetic resonance imaging in all hips postoperatively. Results: Out of 82 patients, 17 were excluded who were followed up for <10 years. Of the remaining 65 patients (70 hips), 19 (20 hips) developed pseudotumors during 2−10 years postoperatively. After 10 and 13 years, the survival rates of revision endpoint were 93.6% and 90.4%, respectively. Clinical hip function outcomes had improved significantly at the final follow-up. In the radiological analysis, the mean cup angle of inclination and mean ratio of femoral offset on the operated hip to the contralateral hip was highest in patients with revision surgery for adverse reactions to metal debris. Conclusions: This study showed a 29.0% prevalence of pseudotumors. Some cases required revisions even after 10 years following surgery. Regular clinical surveillance is recommended for the early detection of adverse reactions to metal debris.

Short stature and short distance between the anterior acetabular rim to the femoral nerve are risk factors for femoral nerve palsy following primary total hip arthroplasty using the modified Watson-Jones approach

BACKGROUND

Nerve palsy following total hip arthroplasty (THA) critically impacts patient clinical function. However, few studies have focused on femoral nerve palsy (FNP) following THA via the modified Watson-Jones approach. Previous reports have suggested that THA, regardless of the approach, is associated with several FNP risk factors, including female gender, hip dysplasia, revision surgery, and short stature. Magnetic resonance imaging (MRI) has suggested that a shorter distance between the femoral nerve and the anterior acetabular edge (dFN) is related to FNP after THA. The purposes of this study were: 1) to determine the presumed risk factors through a retrospective investigation of FNP clinical courses, and 2) to identify the relationships between FNP occurrence and the short dFN following primary THA via the modified Watson-Jones approach.

HYPOTHESIS

Short stature is a risk factor for femoral nerve palsy following THA. i.e. a significant difference in dFN exists between patients with and without FNP.

PATIENTS AND METHODS

This retrospective case-control study was performed at a single university hospital. From January 2016 to December 2020, 676 THAs were performed via the modified Watson-Jones approach at our institution. These included 495 THAs performed in the supine position and 181 in the lateral position. In this study, FNP was defined as weakness of the quadriceps femoris (manual muscle test<grade 3) with or without sensory disturbance over the anteromedial aspect of the thigh. The incidence of FNP was calculated. Patient background factors (age, sex, preoperative diagnosis, surgical position, height, weight, body mass index, surgeon experience, type of components, the method of anesthesia, leg lengthening during the surgery, and operation time) were compared between the FNP group and a non-FNP control group. The dFN was measured in T1-weighted MRI axial images at the level of the hip center. The distance between the femoral nerve and the anterior acetabular edges, where retractors are commonly placed during surgery, was also measured and compared between the FNP group and the non-FNP control group. The FNP group and non-FNP control group were extracted by 1:4 matching of patient height and weight. All data were statistically evaluated using the Mann-Whitney U test, and p values less than 0.05 were considered statistically significant.

RESULTS

FNP occurred in 6 out of 676 joints (0.88%) following primary THA via the modified Watson-Jones approach. In all 6 cases, the motor deficit recovered completely within a year. Patient height was significantly shorter in the FNP group than in the non-FNP control group (148.4±3.3cm vs. 155.4±8.1cm [p=0.01]). The dFN was significantly shorter in the FNP group (16.3±4.1mm vs. 21.5±4.0mm [p=0.034]).

CONCLUSION

Short stature and short dFN are risk factors for FNP after THA using the modified Watson-Jones approach.

LEVEL OF EVIDENCE

III, case-control study.

Primary Sjögren's syndrome is not associated with poor outcomes after total hip arthroplasty: a retrospective case-control study with a matched cohort of osteoarthritis patients

Introduction

The number of patients with primary Sjögren’s syndrome (PSS) requiring total hip arthroplasty (THA) is expected to increase, but few studies have detailed their outcomes. The purpose of this study was to evaluate a THA cohort of patients with avascular necrosis of the femoral head (ANFH) who had PSS and to compare their outcomes with those of matched patients with osteoarthritis.

Method

A case–control study using data from a single-institution arthroplasty registry was performed. Forty-two THAs in 32 patients undergoing THA with a diagnosis of PSS were identified and were matched with 84 THAs in 64 patients with osteoarthritis (1:2 ratio). Functional and health-related quality of life (QoL) evaluations were performed, and complications were recorded at the last follow-up. Logistic regression was used to determine factors associated with reaching the transfusion trigger of hemoglobin < 8 g/dL (TT8) in PSS patients.

Results

After a mean 5-year follow-up, both cohorts had similar hip function and health-related QoL outcomes. The incision complications and reaching TT8 were greater in the PSS group. No differences were observed in the rate of 90-day readmission, reoperation, or overall revision. By multivariate analysis, the influencing factors for reaching TT8 in PSS patients were lower preoperative hemoglobin (OR = 0.842, 95% CI [0.741–0.958], P < 0.05).

Conclusion

Our study demonstrated PSS patients who received THA due to ANFH could achieve clinical outcomes similar to those of non-PSS patients. Improving preoperative Hb level can reduce the risk of transfusion.

Key Points • THA significantly improved hip function and health-related quality of life in PSS patients with osteonecrosis of the femoral head. • Patients with PSS were more likely to reach the transfusion trigger and higher rates of incision complications after THA. • Improving preoperative Hb level can reduce the risk of transfusion for PSS patients who underwent THA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10067-022-06256-2.

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

OBJECTIVE

Most 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.

METHODS

Patients 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.

RESULTS

One-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.

CONCLUSION

Higher disease activity increased the risk of worse pain and function 1 year after arthroplasty, but postoperative flares did not.

Mid-term clinical outcome of constrained condylar knee prosthesis for patients with rheumatoid arthritis

Objectives: This study retrospectively investigated the mid-term outcome of Legacy constrained condylar knee (LCCK) prosthesis in patients with rheumatoid arthritis (RA) having severe varus/valgus deformity, instability, and/or bone loss. Methods: Between January 2000 and December 2015, LCCK prostheses had been performed in 32 knees of 25 patients with RA, and 23 knees of 17 patients of the postoperative follow-up minimum 2 years were analyzed in this study (Primary: 14 knees, Revision: 9 knees). The average of follow-up duration was 6.9 ± 2.7 years, all were female, and the average of age and RA duration at the surgery was 59.0 ± 9.5 years and 26.6 ± 13.5 years, respectively. Clinical result was analyzed by Knee Society Score (KSS) knee and function at preoperative time and final visit. Imaging outcome was investigated by femoral tibial angle (FTA), four component alignment angles, and radiolucent line at pre-/postoperative time. Results: KSS knee/function scores and radiographic FTAs were improved after operation. Radiolucent lines around components were seen in 17 knees (73.9%), of which only one knee (4.3%) has shown aseptic loosening. The seven-year Kaplan-Meier survivorship analysis resulted in 91.7%. Conclusion: LCCK prosthesis in RA patients was achieved to the excellent mid-term clinical and radiographic result.

Total knee arthroplasty improves both knee function and disease activity in patients with rheumatoid arthritis

OBJECTIVE

This study evaluated the effect of TKA with capsulosynovectomy on disease activity and knee function in patients with RA.

METHODS

Seventy-six RA patients who underwent primary TKA with more than two years of follow-up were retrospectively reviewed to assess postoperative knee function and disease activity.

RESULTS

Postoperative knee function was significantly improved in all clinical scores, and maintained up to 24 months after surgery. RA disease activity was significantly decreased in DAS28-CRP, CDAI, and serum CRP level, and maintained up to 24 months after surgery. Postoperative knee function was negatively correlated with RA disease activity.

CONCLUSIONS

TKA improves both knee function and disease activity in patients with rheumatoid arthritis.