Survivorship and Outcomes in Patients With Multiple Sclerosis Undergoing Total Joint Arthroplasty

Multiple sclerosis is associated with adverse outcomes following hip and knee arthroplasty: A systematic review and meta-analysis of observational studies

BACKGROUND

The association of multiple sclerosis (MS) with joint diseases has been established. However, the impact of MS on postoperative outcomes following total joint arthroplasty (TJA) remains controversial. Therefore, a systematic review of the literature is warranted to ascertain the relationship between MS and adverse outcomes post-TJA.

METHODS

A systematic literature search of PubMed, Embase, Scopus, and the Cochrane Library from inception to 1 March 2023 was conducted to identify observational studies comparing post-TJA outcomes in MS and non-MS patients. Two investigators independently screened titles, abstracts, and full-text articles for eligibility. A random-effects model was used to calculate odds ratios (OR), mean differences (MD), and corresponding 95% confidence intervals (CI).

RESULTS

Seven retrospective cohort studies published between 2018 and 2022 met the inclusion criteria. Patients with MS had a higher risk of medical, surgical, and overall complications than patients without MS. Similarly, the MS group was more likely to experience an extended hospital stay, non-home discharge, and revision surgery compared to the control group. Joint infection and implant instability were also more common in patients with MS.

CONCLUSION

Although TJA may benefit MS patients, current evidence suggests that their postoperative outcomes may be inferior to those of non-MS patients. Thus, orthopaedic surgeons should inform MS patients of potential risks and perform preoperative optimization individually when considering elective arthroplasty.

Total Hip Arthroplasty in Patients With Neurological Conditions: A Systematic Review

Background

As operative techniques and implant design have evolved over time, total hip arthroplasty (THA) is increasingly being carried out for patients with neurological impairment. This patient group places unique surgical challenges to the arthroplasty surgeon, which may include contractures, instability, and altered muscular tone. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival following THA for patients with neurological conditions affecting the hip. Thus, we aim to support orthopaedic surgeon decision-making when considering and planning THA for these patients.

Methods

A systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed/Medline OVID, Cochrane, and Embase databases. All studies reporting the outcomes of THA in the neurological population which met defined inclusion criteria were included.

Results

From an initial screen of 1820 studies, 45 studies with a total of 36,251 THAs were included in the final selection. All 45 studies reported complication rates, with controls included in 16 for comparison. High complication rates were observed following THA in the neurologically impaired population, most notably dislocation with observed rates up to 10.6%. An improvement was noted in all 36 studies (1811 THAs) which reported upon patient-reported outcomes.

Conclusions

THA may be beneficial in the selected patients with neurological conditions, to reduce pain and improve function. There is an increased risk of complications which require careful consideration when planning the operation and open discussion with prospective patients and caregivers before proceeding with surgery.

Early failure of a highly cross-linked polyethylene inlay after total hip arthroplasty probably due to insufficient irradiation

Highly cross-linked polyethylene (XLPE) is a major advance in total hip arthroplasty (THA), as it suffers from less wear and thus is associated with lower revision rates than standard ultra-high molecular weight polyethylene. Early failures are reported rarely, and associated with specific design or manufacturing issues. We report a case requiring early revision due to adverse reaction to polyethylene particles. Investigations identified insufficient irradiation as the most probable cause of failure. Here are reported the features of a clinical case with determination of the material properties of the retrieved XLPE liner and establishment of the appropriate calibration curves as reference. Periprosthetic joint infection could be ruled out with appropriate sampling as cause for the inflammatory periarticular tumour. Histology identified a massive macrophagic reaction to micrometric polyethylene particles. No component malposition was present, nor any third-body wear. The trans-vinylene index (TVI) indicated insufficient and potentially detrimental irradiation of the polyethylene, while gel content, crystallinity, melting temperature and oxidation index remained within expected ranges. Histologically proven failure of a XLPE THA liner was identifiable despite correct implantation of the components. The cause of failure most probably was an inadequate irradiation, as indicated by determination of the TVI. This case underscores the importance of histologic workup even in aseptic revisions, and of detailed analysis of retrievals. The calibration curves provided are essential for analysis of other retrievals.

The outcomes of total hip arthroplasty in patients with and without multiple sclerosis: a retrospective cohort study

BACKGROUND

Multiple sclerosis (MS) is a neuroinflammatory disease with debilitating manifestations that may predispose patients to hip fracture and osteoarthritis, and may affect recovery from total hip arthroplasty (THA). With increased longevity of MS patients and growth in demand for arthroplasty in this population, it is important to understand outcomes of THA in patients with MS.

AIM

We sought to compare outcomes of THA among persons with MS and without MS.

METHODS

International Classification of Diseases, Ninth Revision Procedure Coding System (ICD-9-PCS) codes for hip arthroplasty (815.1) were used to identify all patients in the New York Statewide Planning and Research Cooperative System (SPARCS) database who underwent THA between 2000 and 2014. Patients with MS, the primary exposure, were identified using ICD-9-Clinical Modification (CM) code 340. The study outcomes of length of stay (days), discharge disposition, index admission mortality, 90-day readmission, 1-year revision arthroplasty, and 1-year all-cause mortality were evaluated using multivariable regression analyses inclusive of basic demographics, admission source, disposition, payer, comorbidity, and socioeconomic status (SES).

RESULTS

Compared to patients without MS, those with MS had marginally longer lengths of stay (mean ratio [MR] 1.05; 95% confidence interval [CI], 1.01-1.10; p = 0.0142), higher risk for institutional discharge disposition (odds ratio [OR] 2.03; 95% CI, 1.54-2.70; p < 0.0001) and higher risk of readmission for revision hip arthroplasty (OR 2.60; 95% CI, 1.07-6.35; p = 0.035). However, MS patients had similar risk for 90-day readmission and one-year all-cause mortality as compared with non-MS patients.

CONCLUSIONS

Although patients with MS who underwent THA had a 90-day complication risk that was similar to those without MS, the risk for requiring revision surgery was more than 2-fold higher. Additional studies are needed to understand the reasons for revision surgery and for developing strategies to mitigate the risk of complications.

Patients with neuromyelitis optica spectrum disorder (NMOSD) are associated with adverse outcome after total hip arthroplasty: a matched case-control study

Background

Neuromyelitis Optica Spectrum Disorders (NMOSD) are rare inflammatory diseases of the central nervous system that cause transverse myelitis and optic neuritis. Steroids are commonly administered in NMOSD patients. The use of steroids may lead to osteonecrosis, which makes some of the NMOSD patients candidate for total hip arthroplasty (THA). To date, the clinical outcome of THA in NMOSD patients have not been investigated.

Aim

Investigate the patient reported outcome measures (PROM), radiographic outcome and complication in NMOSD patients after THA, compared with that of non-NMOSD patients.

Methods

Patients from Jan. 2016 to October. 2020 were identified in our database. 12 NMOSD cases which met the inclusion criteria were matched to non-NMOSD cases in a ratio of 1:2 based on age, sex, Charlson Comorbidity Index (CCI) and surgical date. Relevant outcome were analyzed and compared between the two groups.

Results

There was a significantly increased risk of dislocation in NMOSD patients. Post-operative HOOS score was similar between the two groups even though the pre-operative HOOS score is significantly higher in the non-NMOSD group. NMOSD patients had poor performance in EQ-5D and EQ-VAS. The cups were placed more anteverted in NMOSD cases (P = 0.01).

Conclusion

There is a significantly increased risk of dislocation after THA in NMOSD patients. However, satisfactory improvement in functional outcome of the hip was achieved. Due to the natural process of NMOSD, rehabilitation and hip precaution should be patient-specific and time-specific.

Role of real-world digital data for orthopedic implant automated surveillance: a systematic review

INTRODUCTION

Data collection automation through the reuse of real-world digital data from clinical data warehouses (CDW) could represent a great opportunity to improve medical device monitoring. For instance, this approach is starting to be used for the design of automated decision support systems for joint replacement monitoring. However, a number of obstacles remains, such as data quality and interoperability through the use of common and regularly updated terminologies, and the use of a Unique Device Identifier (UDI).

AREAS COVERED

To present the existing models of automated surveillance of orthopedic devices, a systematic review of initiatives using real-world digital health data to monitor joint replacement surgery was performed following the PRISMA 2020 guidelines. The main objective was to identify the data sources, the target populations, the population size, the device location, and the main results of studies on such initiatives.

EXPERT OPINION

Analysis of the identified studies showed that real-world digital data offer many opportunities for improving the automation of monitoring in orthopedics. The contribution of real-world data, especially through natural language processing, UDI use in CDW and the integration of device databases, is needed for automated and more robust health surveillance.

A Systematic Review of Total Knee Arthroplasty in Neurologic Conditions: Survivorship, Complications, and Surgical Considerations

BACKGROUND

Patients with neurologic disorders present a unique set of challenges for knee surgeons because of contractures, muscle weakness, spasticity, and ligament instability. The primary purpose of this review was to report the outcomes of total knee arthroplasty (TKA) in these patients, including survivorship, complications, and surgical considerations.

METHODS

We performed a systematic review of articles using PubMed, Cochrane Central, EMBASE, and Google Scholar. All studies reporting outcomes of TKA in patients with Parkinson disease, multiple sclerosis, poliomyelitis, Charcot joint, spina bifida, stroke, and cerebral palsy were included.

RESULTS

In total 38 studies were included: 22 studies (461 patients) reported patient-reported outcome measures and 24 studies (510 patients) reported survivorship. All 38 studies reported complication rates. TKA resulted in an improvement in functional outcome in all series. Complication rate was higher in patients with neurologic conditions. Of studies reporting survivorship, mean follow-up ranged from 1 to 12 years with survivorship from 66% to 100%. All levels of implant constraint were reported without consensus. Limited rehabilitative data exist.

CONCLUSION

TKA in patients with neurologic disorders improves symptoms and function but carries significant risk. This review helps surgeons preoperatively counsel their patients in an informed manner. Careful planning, perioperative care, and appropriate implant selection may mitigate risk of complication.

Patients With Multiple Sclerosis are at Increased Risk for Postoperative Complications Following Total Hip and Knee Arthroplasty

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease affecting the central nervous system. Patients with MS are living longer due to improved medical therapy and thus the demand for arthroplasty in this population will increase. The objective of this study is to evaluate MS as a potential risk factor for postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Patients with a diagnosis of MS who underwent THA or TKA from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visits, infection, revision, and dislocation (for THA) or stiffness (for TKA) were calculated, in addition to cost and length of stay. MS patients were then compared to a matched control population.

RESULTS

In total, 3360 patients who underwent THA and 6436 patients who underwent TKA with a history of MS were identified and compared with 10:1 matched control cohorts without MS. The MS group for both TKA and THA had significantly higher incidences of hospital readmission (THA odds ratio [OR] 2.05, P < .001; TKA OR 1.99, P < .001), emergency room visits (THA OR 1.41, P < .001; TKA OR 1.66, P < .001), and infection (THA OR 1.35, P = .001; TKA OR 1.32, P < .001). MS patients who underwent THA had significantly higher rates of revision (OR 1.35, P = .001) and dislocation (OR 1.52, P < .001). Diagnosis of MS was also associated with significantly higher costs and hospital length of stay for patients undergoing both TKA and THA.

CONCLUSION

A diagnosis of MS is associated with increased risk of postoperative complications and higher costs following both THA and TKA.

Inhospital Complications of Patients With Neuromuscular Disorders Undergoing Total Joint Arthroplasty

INTRODUCTION

Orthopaedic surgeons are wary of patients with neuromuscular (NM) diseases as a result of perceived poor outcomes and lack of data regarding complication risks. We determined the prevalence of patients with NM disease undergoing total joint arthroplasty (TJA) and characterized its relationship with in-hospital complications, prolonged length of stay, and total charges.

METHODS

Data from the Nationwide Inpatient Sample from 2005 to 2014 was used for this retrospective cohort study to identify 8,028,435 discharges with total joint arthroplasty. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify 91,420 patients who had discharge diagnoses for any of the NM disorders of interest: Parkinson disease, multiple sclerosis, cerebral palsy, cerebrovascular disease resulting in lower extremity paralysis, myotonic dystrophy, myasthenia gravis, myositis (dermatomyositis, polymyositis, and inclusion-body myositis), spinal muscular atrophy type III, poliomyelitis, spinal cord injury, and amyotrophic lateral sclerosis. Logistic regression was used to estimate the association between NM disease and perioperative outcomes, including inpatient adverse events, length of stay, mortality, and hospital charges adjusted for demographic, hospital, and clinical characteristics.

RESULTS

NM patients undergoing TJA had increased odds of total surgical complications (odds ratio [OR] = 1.21; 95% confidence interval [CI], 1.17 to 1.25; P < 0.0001), medical complications (OR = 1.41; 95% CI, 1.36 to 1.46; P < 0.0001), and overall complications (OR = 1.32; 95% CI, 1.28 to 1.36; P < 0.0001) compared with non-NM patients. Specifically, NM patients had increased odds of prosthetic complications (OR = 1.09; 95% CI, 0.84 to 1.42; P = 0.003), wound dehiscence (OR = 5.00; 95% CI, 1.57 to 15.94; P = 0.0002), acute postoperative anemia (OR = 1.20; 95% CI, 1.16 to 1.24; P < 0.0001), altered mental status (OR = 2.59; 95% CI, 2.24 to 2.99; P < 0.0001), urinary tract infection (OR = 1.45; 95% CI, 1.34 to 1.56; P < 0.0001), and deep vein thrombosis (OR = 1.27; 95% CI, 1.02 to 1.58; P = 0.021). No difference of in-hospital mortality was observed (P = 0.155).

DISCUSSION

Because more patients with NM disease become candidates of TJA, a team of neurologists, anesthesiologists, therapists, and orthopaedic surgeon is required to anticipate, prevent, and manage potential complications identified in this study.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.