Costs and outcomes of total hip and knee joint replacement for rheumatoid arthritis

Total Joint Arthroplasty in the Patient with Inflammatory Arthritis: A Review

Inflammatory arthritis is a family of conditions including rheumatoid arthritis, juvenile inflammatory arthritis, and spondyloarthropathies affecting both the large and small joints. Total joint arthroplasty is commonly used for surgical management of end-stage disease. Preoperative and postoperative considerations as well as perioperative medical management and intraoperative treatment of patients with inflammatory arthritis undergoing total joint arthroplasty are reviewed. Although individualized, multidisciplinary approaches to treatment are necessary due to the complex nature of the disease and the varying levels of severity, patients generally have favorable outcomes with respect to pain scores and functional outcomes.

Factors Associated With Increasing Length of Stay for Rheumatoid Arthritis Patients Undergoing Total Hip Arthroplasty and Total Knee Arthroplasty

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are cost-effective procedures that decrease pain and improve health-related quality of life for patients with advanced symptomatic arthritis, including rheumatoid arthritis (RA). Patients with RA have a longer length of stay (LOS) after THA or TKA than patients with osteoarthritis, yet the factors contributing to LOS have not been investigated. Purpose: We sought to identify the factors contributing to LOS for patients with RA undergoing THA and TKA at a single tertiary care orthopedic specialty hospital. Methods: We retrospectively reviewed data from a prospectively collected cohort of 252 RA patients undergoing either THA or TKA. Demographics, RA characteristics, medications, serologies, and disease activity were collected preoperatively. Linear regression was performed to explore the relationship between LOS (log-transformed) and possible predictors. A multivariate model was constructed through backward selection using significant predictors from a univariate analysis. Results: Of the 252 patients with RA, 83% were women; they had a median disease duration of 14 years and moderate disease activity at the time of arthroplasty. We had LOS data on 240 (95%) of the cases. The mean LOS was 3.4 ± 1.5 days. The multivariate analysis revealed a longer LOS for RA patients who underwent TKA versus THA, were women versus men, required a blood transfusion, and took preoperative opioids. Conclusion: Our retrospective study found that increased postoperative LOS in RA patients undergoing THA or TKA was associated with factors both non-modifiable (type of surgery, sex) and modifiable (postoperative blood transfusion, preoperative opioid use). These findings suggest that preoperative optimization of the patient with RA might focus on improving anemia and reducing opioid use in efforts to shorten LOS. More rigorous study is warranted.

Better clinical outcome of total knee arthroplasty for rheumatoid arthritis with perioperative glucocorticoids and disease-modifying anti-rheumatic drugs after an average of 11.4-year follow-up

Background

Previous evidence suggested that perioperative anti-rheumatic therapy for patients receiving total knee arthroplasty (TKA) helped improve postoperative rehabilitation for rheumatoid arthritis (RA), yet long-term effects and outcomes of perioperative drug therapy in TKA presently remain unclear. This study investigated whether perioperative treatment with glucocorticoids (GC) and disease-modifying anti-rheumatic drugs (DMARDs) can improve clinical outcomes for patients with RA undergoing TKA.

Methods

Patients between January 2000 and December 2011 were allocated into three groups based on perioperative drug therapy: A, control group (no GC or DMARDs), B, DMARD group (DMARDs given without GC), and C, co-therapy group (DMARDs plus GC). The patients were followed up for average 11.4 years. Baseline characteristics, pre- and post-operative Hospital for Special Surgery score (HSS), laboratory parameters, and complications were recorded by follow-up.

Results

Fifty-six RA patients undergoing 91 TKAs were included in this study. Patients who received perioperative GC with DMARDs (group C) achieved larger/increased range of motion (ROM) (C:122.17 vs A:108.31 vs B:108.07, p = 0.001, partial eta squared (η² p) = 0.18) at 1 year, better HSS score (C, 83.01 vs A, 79.23 vs B, 77.35, p = 0.049, η² p = 0.067), pain relief (C, 1.09 vs A, 1.17 vs B, 1.75, p = 0.02, η² p = 0.094), and ROM (C, 130.81 vs A, 112.82 vs B, 113.58, p = 0.001, η²p = 0.142) at latest follow-up comparing with the other treatment groups. No differences were noted in laboratory tests, blood loss, volume of transfusion, or complications among groups.

Conclusions

Compared with the other perioperative anti-rheumatic treatments, the combination of GC and DMARDs results in improved HSS score, better function, larger range of motion, and reduced postoperative pain for TKA patients with RA in the long term. Further investigation is warranted to look for a better understanding of more specific medication effects and strike a good balance between the benefits and complications for long-term pharmacotherapy.

PROFILE OF PATIENTS RECEIVING TOTAL KNEE ARTHROPLASTY: A CROSS-SECTIONAL STUDY

OBJECTIVE

To describe the epidemiological profile, presented deformities, associated comorbidities, and impact on quality of life in patients with knee osteoarthritis. This study was conducted in a philanthropic hospital in Fortaleza from 2014 to 2015.

METHODS

Data were collected from medical records, epidemiological forms, and by applying the Lequesne index questionnaire, which contains several questions related to pain, discomfort and functional limitation to assess the severity of symptoms.

RESULTS

Females were more prevalent (76.7%), as were patients over 65 years of age (61.6%) and non-whites (81.6%). As for comorbidities, 83.3% had hypertension and 31.7% had diabetes. Of the total, 76.5% cases were genu varum, and 23.5% genu valgum. According to the Lequesne index findings, 61.6% cases were "extremely severe," and women had higher scores.

CONCLUSION

Females were more prevalent and whites were less prevalent. The most frequent comorbidity was hypertension. Female and elderly patients have more severe disease according to Lequesne index score, and these findings were statistically significant. Level of Evidence II, Prospective Study.

Comparison of total hip and knee joint replacement in patients with rheumatoid arthritis and osteoarthritis: a nationwide, population-based study

INTRODUCTION

Patients with rheumatoid arthritis (RA) and osteoarthritis (OA) may require total hip replacement (THR) or total knee replacement (TKR). The present study aimed to compare the demographic characteristics and medical costs of RA and OA patients from Taiwan who underwent either THR or TKR.

METHODS

The medical records of patients who had undergone THR or TKR from 1 January 1996 to 31 December 2010 were obtained from the Taiwan National Health Insurance Research Database (NHIRD). In all, we found 49 and 146 RA patients who received THR and TKR, respectively, and 1,191 and 6,574 OA patients who received THR and TKR, respectively. The gender, age, Charlson comorbidity index (CCI), hospital grade, age at registration in the catastrophic illness dataset, and medical utilisation costs of the different groups were compared.

RESULTS

There were statistically significant differences in age, CCI score, drug costs and surgery costs between RA and OA patients. Joint replacement incidence was lower in RA patients than in OA patients, and among patients who underwent THR, total medical costs incurred were higher for RA patients than OA patients. RA patients who underwent THR incurred a significantly greater total medical utilisation cost in the outpatient department (3 months before surgery and 12 months after surgery) than OA patients who underwent THR.

CONCLUSION

Analysis of Taiwan NHIRD with regard to patients who had undergone either THR or TKR indicated that RA patients were younger than OA patients, and that significantly more medical resources were used for RA patients before, during and after hospitalisation for these procedures.

Systemic effects of surgical intervention on disease activity, daily function, and medication in patients with rheumatoid arthritis

OBJECTIVES

Although tight control of rheumatoid arthritis (RA) has been achieved through the development of effective medication, surgical intervention is still required for a certain subpopulation of patients. To examine the systemic effects of orthopaedic surgery, we evaluated improvements in disease activity, daily function, and medication after surgery.

METHOD

A prospective cohort study was conducted in 196 cases of elective orthopaedic surgery in 150 patients with RA from January 2011 to March 2014 in our institution. The 28-joint count Disease Activity Score based on erythrocyte sedimentation rate (DAS28-ESR) and modified Health Assessment Questionnaire (mHAQ) scores just before surgery and at 6 and 12 months after surgery were examined prospectively. Concomitant medications were also investigated.

RESULTS

Significant improvement was seen in the DAS28-ESR and mHAQ scores for replacement surgery in both the upper and lower extremities, and for arthroplasty/arthrodesis in the upper extremities at the 12-month follow-up. Partial mHAQ scores for the lower extremities were significantly reduced in lower replacement surgery, and partial mHAQ scores for the upper extremities were significantly reduced in upper arthroplasty/arthrodesis surgery. Although the use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) did not decrease after surgery, the dose of prednisolone (PSL) decreased significantly at 12 months after surgery, especially in the well-controlled group and in surgical procedures in the lower extremities.

CONCLUSIONS

Elective orthopaedic surgery improves both systemic disease activity and general functional impairment. Orthopaedic surgery is effective in reducing the amount of medication required postoperatively.

[Monitoring the functional capacity of patients with rheumatoid arthritis for three years]

OBJECTIVE

To quantify modification of functional capacity in a three year period in a group of patients with rheumatoid arthritis (RA) using HAQ and EPM-ROM inventories.

METHODS

Forty patients with RA on methotrexate (MTX) as disease-modifying anti rheumatic drug (DMARD) were followed for up to three years. The functional status was assessed at the beginning and end of the period by HAQ and EPM-ROM.

RESULTS

Thirty two patients were retrieved, with initial HAQ score of 1.14±0.49 (mean±SD) and EPM-ROM score of 5.8±2.75. After an average period of three years, the HAQ score was 1.13±0.49 and EPM-ROM score, 6.81±3.66. In the subgroup of seven patients submitted to orthopedic surgery, HAQ score decreased from 0.84±0.72 to 1.64±0.56 and the EPM-ROM score, from 5.8±1.80 to 8.3±0.74. In the subgroup of non-operated patients, HAQ score varied from of 1.2±0.45 to 1.07±0.70 and EPM-ROM score, from 5.7±3.06 to 6.4±3.90.

CONCLUSION

In a group of RA patients in use of only MTX as DMARD, there was little change on HAQ score and EPM-ROM scores over the average period of three years. Worsening functional capacity was observed in the group of operated patients in comparison to the not operated ones. This fact alerts us to the need for use of broader therapeutic regimens availability of musculoskeletal surgeries in a timely manner in patients with RA.

Patients with Rheumatoid Arthritis Are More Likely to Have Pain and Poor Function After Total Hip Replacements than Patients with Osteoarthritis

Objective.

Total hip replacement (THR) outcomes have been worse for patients with rheumatoid arthritis (RA) compared with those who have osteoarthritis (OA). Whether this remains true in contemporary patients with RA with a high use of disease-modifying and biologic therapy is unknown. The purpose of our study is to assess pain, function, and quality of life 2 years after primary THR, comparing patients with RA and patients with OA.

Methods.

Baseline and 2-year data were compared between validated patients with RA and patients with OA who were enrolled in a single-center THR registry between May 1, 2007, and February 25, 2011.

Results.

There were 5666 eligible primary THR identified, of which 193 were for RA. RA THR had worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (44.8 vs 53.2, p < 0.001) and function (38.7 vs 49.9, p < 0.001) compared with OA. These differences remained after surgery: pain (88.4 vs 94.0, p < 0.001) and function (82.9 vs 91.8, p < 0.001). Patients with RA were as likely to have a significant improvement as patients with OA (Δ WOMAC > 10) in pain (94% vs 96%, p = 0.35) and function (95% vs 94%, p = 0.69), but were 4 times as likely to have worse function (WOMAC ≤ 60; 19% vs 4%, p < 0.001) and pain (12% vs 3%, p < 0.001). In multivariate logistic regression controlling for multiple potential confounders, RA increased the odds of poor postoperative function (OR 4.32, 95% CI 1.57–11.9), and in patients without a previous primary THR, worse postoperative pain (OR 3.17, 95% CI 1.06–9.53).

Conclusion.

Contemporary patients with RA have significant improvements in pain and function after THR, but higher proportions have worse 2-year pain and function. In addition, RA is an independent predictor of 2-year pain and poor function after THR, despite high use of disease-modifying therapy.

The use of biologic DMARDs identifies rheumatoid arthritis patients with more optimistic expectations of total knee arthroplasty

BACKGROUND

Preoperative expectations of total knee arthroplasty (TKA) correlate with postsurgical satisfaction, and are linked to outcomes. Rheumatoid arthritis (RA), and other chronic diseases, may lower expectations, although new biologic medications have greatly enhanced patients' quality of life.

QUESTIONS/PURPOSES

The purpose of this study is to compare preoperative expectations of RA to those of matched osteoarthritis (OA) patients undergoing TKA, and examine the subset of RA on biologic DMARD therapy.

METHODS

For a cross-sectional study, RA and OA identified from an institutional TKA registry were matched on age, sex, prior TKA, and preoperative function. Expectations were measured using the Hospital for Special Surgery (HSS) Knee Expectations Survey. Expectations and quality of life measures were assessed preoperatively and scores were compared between RA and OA.

RESULTS

One hundred fourteen RA cases, 46.5% on biologics, were matched to 228 OA cases. The average expectations score was not significantly lower for RA compared to OA (72.9 ± 20.7 vs. 77.2 ± 18.3, p = 0.040. RA on biologics had expectations similar to OA (total expectation score 76.3 ± 18.1 vs. 77.4 ± 17.4, p = 0.71), while RA not on biologics had expectations that were significantly lower (69.9 ± 22.4 vs. 77.1 ± 19.0, p = 0.03).

CONCLUSION

Use of biologics in RA patients was associated with higher expectations, similar to those of OA patients, but the effect on outcomes is not known. Further studies should assess the effect of higher expectations in RA patients on outcomes.

Medical technology as a key driver of rising health expenditure: disentangling the relationship

Health care spending has risen steadily in most countries, becoming a concern for decision-makers worldwide. Commentators often point to new medical technology as the key driver for burgeoning expenditures. This paper critically appraises this conjecture, based on an analysis of the existing literature, with the aim of offering a more detailed and considered analysis of this relationship. Several databases were searched to identify relevant literature. Various categories of studies (eg, multivariate and cost-effectiveness analyses) were included to cover different perspectives, methodological approaches, and issues regarding the link between medical technology and costs. Selected articles were reviewed and relevant information was extracted into a standardized template and analyzed for key cross-cutting themes, ie, impact of technology on costs, factors influencing this relationship, and methodological challenges in measuring such linkages. A total of 86 studies were reviewed. The analysis suggests that the relationship between medical technology and spending is complex and often conflicting. Findings were frequently contingent on varying factors, such as the availability of other interventions, patient population, and the methodological approach employed. Moreover, the impact of technology on costs differed across technologies, in that some (eg, cancer drugs, invasive medical devices) had significant financial implications, while others were cost-neutral or cost-saving. In light of these issues, we argue that decision-makers and other commentators should extend their focus beyond costs solely to include consideration of whether medical technology results in better value in health care and broader socioeconomic benefits.

Joint replacement and rapid mobilization: a clinical perspective on rapid arthroplasty mobilization protocol

Rapid arthroplasty mobilization protocol (RAMP) is a multimodal approach that has been trialed and implemented over the past 9 years in an Australian hospital, on patients undergoing either a total hip or knee arthroplasty. The aim strongly focuses on improving patient outcomes, by alleviating many of the postoperative problems associated with total joint arthroplasty, such as pain control, early mobilization, nausea and vomiting, deep vein thrombosis, and increased length of hospital stay. In addition, RAMP is aimed at accelerating wellness to encourage a rapid return to optimum function within the individual. Key elements of this procedure are good communication and an understanding of the protocol by the patient, together with a clear understanding and knowledge of the postoperative care required by the orthopaedic nurses.

Health-related quality of life after total joint arthroplasty: a scoping review

A scoping review was completed to summarize the change in health status after THA and TKA. Although a recent study has performed a systematic review of functional recovery after THA,(61) we reviewed a broad topic of HRQL changes after total joint arthroplasty. This scoping review was not restricted by study design; however, the majority of studies were prospective single group, observational studies so that change over time could be reported. A variety of HRQL measures were used, including disease-specific, generic, and utility measures. We reported on 33 studies that met our inclusion criteria. Most studies’ primary outcomes were disease-specific measures. Not surprisingly, MCIDs were reported with recovery both short term and long term. These clinically relevant changes were accompanied with large effect sizes for pain and function using disease-specific measures such as the WOMAC. In general, smaller changes were reported with joint stiffness; however, this may also be related to inherent measurement properties of the WOMAC in that it uses two questions to evaluate stiffness. Overall, large effect sizes, in excess of 1.0, were seen not only short term but also long term, that is, more than a year after surgery. The changes may also be reflected in the low rate of complications reported with total joint arthroplasty.(62) The generic health measures showed a smaller magnitude of change, which is to be expected given the construct of these measures evaluate overall health and includes the effect of other health conditions. That being said, the largest changes were seen in those domains that were primary to total joint arthroplasty, pain and physical function. A challenge of evaluating change of health status after total joint arthroplasty is that each measure has individual strengths and limitations. This review introduced the measures and the MCIDs when available to evaluate clinical change. The derived MCIDs should be considered carefully because these values are dependent on a number of features such as the study setting, methodology used to derive the values, baseline scores, and severity of the disease.(63) Change over time was also presented by the effect sizes. The effect size provided another perspective to measuring recovery after total joint arthroplasty in which comparison across measures can be made. Regardless of the type of outcome measure, large effect sizes are seen with total joint arthroplasty both over short-term and long-term outcomes. Because a number of HRQL measures are used to evaluate the outcomes after total joint arthroplasties, comparisons can be challenging. This review summarized published findings to help place the magnitude of change seen with total joint arthroplasty in perspective. Changes seen with HRQL are one aspect of evaluating outcomes from a patient perspective; however, recovery is a complex concept(64) that needs many clinical and research-oriented measures to evaluate the full spectrum of recovery.

Reason for revision influences early patient outcomes after aseptic knee revision

BACKGROUND

Revision TKA less consistently produces improvements in clinical function and quality of life when compared with primary TKA. The reasons for this difference are unclear.

QUESTIONS/PURPOSES

We determined differences in patient-reported outcomes and rates of satisfaction between primary and revision TKAs, and determine whether the reason for revision influences patient-reported outcomes after revision TKA.

METHODS

We retrospectively analyzed prospectively collected patient-reported outcome measures (PROMs) for 24,190 patients (23,393 TKAs; 797 aseptic revision TKAs). We compared patient-reported outcomes using the Oxford Knee Score (OKS), EuroQol (EQ-5D), and patient satisfaction between primary TKA and revision TKA, and for subsets of the revision TKA cohort. The followup data were collected between 6 and 12 months (7 months average) postoperatively.

RESULTS

Improvements in the OKS (10) and EQ-5D (0.231) were smaller after revision when compared with primary TKA (OKS, 15; EQ-5D, 0.303). Patients who had revision TKA were less satisfied (66% versus 83%). Revisions for aseptic loosening or lysis were associated with the best patient outcomes (OKS improvement = 11; EQ-5D improvement = 0.232; satisfaction = 72%). Revisions for stiffness had the worst results (OKS improvement = 6; EQ-5D improvement = 0.176; satisfaction = 47%).

CONCLUSIONS

The early improvements in knee function and general health after revision TKA are only 69% to 76% of those observed for primary TKA. Levels of patient-reported knee function, general health, and satisfaction after revision are varied and related to the reason for revision. Even the best revision group does not approach the levels of function and satisfaction observed after primary TKA at a mean of 7 months postoperatively. Longer-term followup would be required to determine whether conclusions from these early data will need to be modified.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Patient-reported outcome after rheumatoid arthritis-related surgery in the lower extremities: a report from the Swedish National Register of Rheuma Surgery (RAKIR)

BACKGROUND AND PURPOSE

Although decreasing with the development of effective pharmacological regimes, joint surgery has improved the function and quality of life of patients with rheumatoid arthritis (RA). Few studies have assessed patient-reported outcomes after RA surgery to the lower extremities. Here we report patient-relevant outcome after RA-related surgery based on the first data from the Swedish National Register of Rheuma Surgery (RAKIR).

PATIENTS AND METHODS

258 RA patients (212 women) who had joint surgery performed at the Department of Orthopaedics, Spenshult Hospital between September 2007 and June 2009 were included. Mean age at surgery was 64 (20-86) years. The patients completed the SF-36 and HAQ questionnaires preoperatively and 6 months postoperatively, and 165 patients completed them after 12 months.

RESULTS

Improvement was seen as early as at 6 months. At 12 months, 165 patients (141 women)-including hip (n = 15), knee (n = 27), foot (n = 102), and ankle (n = 21) patients-reported statistically significant improvements from preoperatively to 12 months postoperatively in HAQ (mean change: -0.11) and SF-36 subscales physical function (11), role physical (12), bodily pain (13), social functioning (6.4), and role emotional (9.4). Hip and knee patients reported the greatest improvements.

INTERPRETATION

Orthopedic RA-related surgery of the lower extremities has a strong effect on pain and physical function. Improvement is evident as early as 6 months postoperatively and remains after 12 months.

Total hip and knee joint replacement: perioperative clinical aspects

ABSTRACT Objective: To understand the profile of patients undergoing hip and knee replacement during two years, and to compare the data obtained with the literature. Methods: A total of 323 medical records were reviewed to analyze the perioperative data of patients submitted to hip and knee replacement. Results: Osteoarthritis was the main indication for both procedures and male patients were heavier than females (p < 0.05). Hypertension was the prevalent disease among patients. Blood loss was more frequent in knee surgery than in the hip. Conclusions: The profile of patients undergoing total arthroplasty improved substantially over the past decade due to shorter hospital stay, lower risk of thromboembolic events and no infection as compared to previous reports.