Hip replacement surgery in patients with ankylosing spondylitis

Construction of a predictive model for blood transfusion in patients undergoing total hip arthroplasty and identification of clinical heterogeneity

A precise forecast of the need for blood transfusions (BT) in patients undergoing total hip arthroplasty (THA) is a crucial step toward the implementation of precision medicine. To achieve this goal, we utilized supervised machine learning (SML) techniques to establish a predictive model for BT requirements in THA patients. Additionally, we employed unsupervised machine learning (UML) approaches to identify clinical heterogeneity among these patients. In this study, we recruited 224 patients undergoing THA. To identify factors predictive of BT during the perioperative period of THA, we employed LASSO regression and the random forest (RF) algorithm as part of supervised machine learning (SML). Using logistic regression, we developed a predictive model for BT in THA patients. Furthermore, we utilized unsupervised machine learning (UML) techniques to cluster THA patients who required BT based on similar clinical features. The resulting clusters were subsequently visualized and validated. We constructed a predictive model for THA patients who required BT based on six predictive factors: Age, Body Mass Index (BMI), Hemoglobin (HGB), Platelet (PLT), Bleeding Volume, and Urine Volume. Before surgery, 1 h after surgery, 1 day after surgery, and 1 week after surgery, significant differences were observed in HGB and PLT levels between patients who received BT and those who did not. The predictive model achieved an AUC of 0.899. Employing UML, we identified two distinct clusters with significantly heterogeneous clinical characteristics. Age, BMI, PLT, HGB, bleeding volume, and urine volume were found to be independent predictors of BT requirement in THA patients. The predictive model incorporating these six predictors demonstrated excellent predictive performance. Furthermore, employing UML enabled us to classify a heterogeneous cohort of THA patients who received BT in a meaningful and interpretable manner.

Revision total hip arthroplasty in patients with ankylosing spondylitis: Mid-term results

BACKGROUND

Few studies have reported on the outcome of revision total hip arthroplasty (THA) for ankylosing spondylitis (AS). Therefore, we sought to investigate the clinical and radiographic outcomes of revision THA in patients with AS.

HYPOTHESIS

The mid-term outcome of revision THA in AS patients was comparable to conventional revision THA.

MATERIALS AND METHODS

Forty-one patients with AS who underwent revision THA (on a total of 51 hips) between April 2004 and June 2018 were included. The mean follow-up duration was 7.5±3.6 years (3.0-15.8 years). Clinical outcomes were assessed using the Bath Ankylosing Spondylitis Functional Index (BASFI), Harris Hip Score (HHS), and the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. Complications were assessed at each follow-up. Radiological outcomes were examined by reviewing postoperative plain radiographs.

RESULTS

Significant improvements were seen in BASFI, HHS, and WOMAC scores (p<0.01). Postoperative combined range of motion (ROM) was 128.9±45.3° (range, 60-300°). Complications included heterotopic ossification, periprosthetic fractures, aseptic loosening, osteolysis, reinfection, residual pain or stiffness, delayed wound healing, numbness, deep vein thrombosis, leg length discrepancy, and posterior dislocation. Five (9.8%) of the 51 hips were treated with re-revision due to aseptic loosening, re-infection, or re-fracture. The incidence of dislocation was 1.9% at 7.5 years. Implant survival for all reasons was estimated to be 96.3% at 5 years, 85.9% at 10 years and 61.0% at 15 years. Forty-two (82.4%) hip revisions were rated "satisfactory" or "very satisfactory" by the patients.

CONCLUSIONS

The mid-term result of revision THA for patients with AS is comparable to conventional revisions in terms of implant survival, despite high complication rates. The benefit-risk ratio of these indications is acceptable but deserves specific information for these patients.

LEVEL OF EVIDENCE

IV; case series.

Increased Risk of Common Orthopedic Surgeries for Patients with Rheumatic Diseases in Taiwan

Background and Objectives: Rheumatic diseases, including rheumatoid arthritis, ankylosing spondylitis, psoriasis, and systemic lupus erythematosus (SLE), are characterized by chronic arthritis or spondyloarthritis, which can lead to joint and spine destruction. Our previous studies showed that the risk of common orthopedic surgeries, including total knee replacement (TKR), total hip replacement (THR), or spine surgery, was increased in patients with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and SLE. The aim of this review was to summarize the risk of TKR, THR, cervical spine, and lumbar spine surgery on the basis of studies conducted using data from Taiwan’s National Health Insurance Research Database (NHIRD). Materials and Methods: The risk of TKR, THR, cervical spine surgery, and lumbar spine surgery in patients with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and SLE was summarized from the results of our previous studies and unpublished findings based on NHIRD data. Results: Patients with rheumatoid arthritis and psoriasis and men with ankylosing spondylitis showed an increased risk of TKR. Patients with rheumatoid arthritis, ankylosing spondylitis, and women with SLE showed an increased risk of receiving THR. Only patients with ankylosing spondylitis had an increased risk of cervical spine surgery, and patients with rheumatoid arthritis or ankylosing spondylitis showed an increased risk of lumbar spine surgery. Although the risk of THR, TKR, or spine surgery in these patients has declined in the era of biologics use, direct evidence for the effects of biologics agents is not yet available. Conclusions: There was an increased risk of common orthopedic surgery in patients with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and SLE. Clinicians should be vigilant to reduce the increased risk of TKR and THR in young and middle-aged patients with rheumatoid arthritis, THR in young patients with ankylosing spondylitis, and young female patients with SLE, as well as cervical spine surgery in young patients with ankylosing spondylitis.

The second decade of anti-TNF-a therapy in clinical practice: new lessons and future directions in the COVID-19 era

Since the late 1990s, tumor necrosis factor alpha (TNF-α) inhibitors (anti-TNFs) have revolutionized the therapy of immune-mediated inflammatory diseases (IMIDs) affecting the gut, joints, skin and eyes. Although the therapeutic armamentarium in IMIDs is being constantly expanded, anti-TNFs remain the cornerstone of their treatment. During the second decade of their application in clinical practice, a large body of additional knowledge has accumulated regarding various aspects of anti-TNF-α therapy, whereas new indications have been added. Recent experimental studies have shown that anti-TNFs exert their beneficial effects not only by restoring aberrant TNF-mediated immune mechanisms, but also by de-activating pathogenic fibroblast-like mesenchymal cells. Real-world data on millions of patients further confirmed the remarkable efficacy of anti-TNFs. It is now clear that anti-TNFs alter the physical course of inflammatory arthritis and inflammatory bowel disease, leading to inhibition of local and systemic bone loss and to a decline in the number of surgeries for disease-related complications, while anti-TNFs improve morbidity and mortality, acting beneficially also on cardiovascular comorbidities. On the other hand, no new safety signals emerged, whereas anti-TNF-α safety in pregnancy and amid the COVID-19 pandemic was confirmed. The use of biosimilars was associated with cost reductions making anti-TNFs more widely available. Moreover, the current implementation of the “treat-to-target” approach and treatment de-escalation strategies of IMIDs were based on anti-TNFs. An intensive search to discover biomarkers to optimize response to anti-TNF-α treatment is currently ongoing. Finally, selective targeting of TNF-α receptors, new forms of anti-TNFs and combinations with other agents, are being tested in clinical trials and will probably expand the spectrum of TNF-α inhibition as a therapeutic strategy for IMIDs.

Trends in orthopaedic surgery for spondyloarthritis: outcomes from a National Hospitalised Patient Registry (MBDS) over a 17-year period (1999-2015).TREND-EspA study

Objective

To assess the incidence of orthopaedic surgery (OS) (including total hip arthroplasty (THA), total knee arthroplasty, upper limb arthroplasty, arthrodesis and spinal surgery) and associated trends in patients with spondyloarthritis (SpA) over a long period (17 years).

Methods

An observational, retrospective, population-based, serial cross-sectional study was conducted. All hospital admissions of patients with SpA reported between 1999 and 2015 were analysed, and a control group was selected and matched by age, sex and year of admission. Incidence rates for OS (and subtypes) were calculated. Generalised linear models were used to analyse trends; unconditional logistic regression models were used to calculate crude and adjusted ORs (aORs) with the aim of evaluating the association between OS and SpA.

Results

The study database contained data on 214 280 hospital admissions (SpA/non-SpA 1:1 ratio). In the SpA cohort, 5 382 admissions (5.02%) had undergone OS compared with 3 533 in the non-SpA cohort (3.29%) (AOR 1.64; 95% CI 1.57 to 1.72). OS rates increased for both cohorts (+4.92% per year vs +8.41%). The trend in OS, THA, arthrodesis and spinal surgery decreased or stabilised in patients under age 60 in the SpA cohort, while the non-SpA cohort remained stable. In the SpA cohort, the mean age was 53.68 years (SD 13.65) in 1999, increasing to 62.76 years (SD 12.74) in 2015. In the non-SpA cohort, the mean age remained stable at around 63 years.

Conclusions

A 9-year difference in the age of patients undergoing OS was observed in patients with SpA. The incidence of OS, THA and arthrodesis decreased in patients under age 60, and the incidence of spinal surgery decreased in patients under age 40. Our findings suggest that these patients are increasingly able to defer surgical interventions.

Hip Replacement in Ankylosing Spondylitis Patients with Advanced Hip Involvement: Factors Associated with Bilateral Total Hip Arthroplasty

Background

This study aimed to compare the clinical data of ankylosing spondylitis (AS) patients who underwent unilateral and bilateral total hip arthroplasty (THA) due to advanced hip involvement. Furthermore, to determine the factors associated with bilateral THA.

Methods

Utilizing a single-institution database, we selected 373 consecutive AS patients undergoing primary THA from 2012 to 2017 and compared the clinical characteristics and anti-tumor necrosis factor (TNF) therapy of the patients who underwent unilateral and bilateral THA. Logistic regression was used to identify factors associated with bilateral THA.

Results

Bilateral THA was performed in 67.3% (n=251) of the patients. Male patients had a higher frequency of undergoing bilateral THA compared with female ones (P<0.05). The proportion of the patients who had bilateral onset in hips, administration of TNF inhibitors, flexion contracture in the hip, and a BASRI-hip score of 4 was significantly higher in patients with bilateral THA than that with unilateral THA (P<0.05). Patients with bilateral THA experienced longer disease duration than those with unilateral THA (P<0.05). The results of the logistic regression showed that factors related to bilateral THA were bilateral onset in hips, administration of TNF inhibitors, a BASRI-hip score of 4, and an erythrocyte sedimentation rate (ESR) level (P<0.05).

Conclusion

Bilateral THA is more common in AS patients with advanced hip involvement. Bilateral onset in hips, a BASRI-hip score of 4, and a higher level of ESR are risk factors associated with bilateral THA, while anti-TNF therapy is a protective factor reducing the progression of hip involvement to bilateral THA.

Relation of NSAIDs, DMARDs, and TNF Inhibitors for Ankylosing Spondylitis and Psoriatic Arthritis to Risk of Total Hip and Knee Arthroplasty

OBJECTIVE

Ankylosing spondylitis (AS) and psoriatic arthritis (PsA) often affect the hip and/or knee. If effective, treatments might reduce risk of total hip or total knee arthroplasty (THA/TKA). We evaluated risk of THA/TKA related to use of medical therapies in AS/PsA.

METHODS

We conducted a nested case-control study using 1994-2018 data from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims, laboratory results, and enrollment records for commercial and Medicare Advantage enrollees. Among those with AS/PsA, THA/TKA cases were matched up to 4 controls by sex, age, AS/PsA diagnosis, diagnosis year, insurance type, obesity, and prior THA/TKA. We assessed AS/PsA treatment 6 months prior to THA/TKA, including disease-modifying antirheumatic drugs (DMARDs) and tumor necrosis factor inhibitors (TNFi), alone or in combination, stratified by nonsteroidal antiinflammatory drug (NSAID) use. We evaluated the relation of treatment to risk of THA/TKA using conditional logistical regression with adjustment for confounders.

RESULTS

Among 16,748 adults with AS, there were 444 THA/TKA cases and 1613 matched controls. Among 34,512 adults with PsA, there were 1003 cases and 3793 controls. Adjusted ORs for treatment category and THA/TKA ranged from 0.60 to 1.92; however, none were statistically significant. Results were similarly null in several sensitivity analyses.

CONCLUSION

Odds of THA/TKA were not reduced with any combinations of NSAIDs, DMARDs, or TNFi among persons with AS or PsA. Given current utilization patterns in this population of US adults with AS and PsA, these medical therapies did not appear to be associated with less end-stage peripheral joint damage.

Primary Total Hip Arthroplasty in Patients With Ankylosing Spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a common inflammatory spondyloarthropathy with hip involvement in 40% of patients. With the renewed interest in the hip-spine interplay, this study aimed to define long-term outcomes of primary total hip arthroplasty (THA) in the setting of AS.

METHODS

We identified 309 hips (219 patients) with AS treated with primary THA from 1969 to 2018. Mean age was 49 years, 80% were males, and mean body mass index was 28 kg/m². Cumulative incidences of any revision, reoperation, and dislocation were calculated utilizing a competing risk analysis. Harris Hip Scores and complications were also reported. Mean follow-up was 16 years.

RESULTS

The cumulative incidence of any revision after primary THA was 2.3% at 5 years and 17.5% at 20 years. The most common reasons for revision (n = 73) were aseptic loosening (41%), osteolysis/polyethylene (PE) wear (30%, all with conventional PE), and femoral component fracture (8%). The cumulative incidence of dislocation was 1.9% at 5 years and 2.9% at 20 years. Younger age was associated with increased risk of revision (hazard ratio (HR) = 1.3, P < .01) and reoperation (HR = 1.2, P < .01), but not dislocation (HR = 0.7, P = .1). Twenty-eight hips (9%) experienced a postoperative complication not requiring reoperation. The mean Harris Hip Score improved from 51 to 76 after THA (P < .001).

CONCLUSION

In this series of 309 primary THAs in patients with AS, the 20-year cumulative incidence of any revision after primary THA was 17.5%. Aseptic loosening, osteolysis/PE wear, and femoral component fracture were the most common reasons for revision. Notably, the cumulative incidence of dislocation at 20 years was only 2.9%.

LEVEL OF EVIDENCE

Level IV.

Efficacy of needle-knife combined with etanercept treatment regarding disease activity and hip joint function in ankylosing spondylitis patients with hip joint involvement: A randomized controlled study

This study aimed to assess the efficacy of needle-knife (NK) combined with etanercept (NKCE) in attenuating pain, inflammation, disease activity, and improving hip joint function in ankylosing spondylitis (AS) patients with hip joint involvement.Totally, 90 patients with active AS involving unilateral hip joint were enrolled and randomly assigned in 1:1:1 ratio to receive NKCE, NK or conventional drugs (control). The ESR, CRP, hip joint pain Visual Analogue Scale (VAS) score, bath ankylosing spondylitis disease activity index (BASDAI), bath ankylosing spondylitis functional index (BASFI), modified Harris hip score (mHHS), and range of motion (ROM) of affected hip joint were assessed at baseline (W0), after 1-week treatment (W1) and after 24-week treatment (W24).ESR and CRP were decreased in NKCE group compared with NK and control groups, while was not attenuated in NK group compared with control group. Regrading pain and disease activity, NKCE group presented a reduction in hip pain VAS score and BASDAI compared with NK and control groups, and NK group showed a decrease in hip pain VAS score and BASDAI compared with control group. Besides, BASFI was lowered in NKCE and NK groups compared with control group, but similar between NKCE and NK groups. mHHS and hip ROM were raised in NKCE and NK groups compared with control group, but similar between NKCE and NK groups.NKCE decreases hip pain, inflammation, disease activity and improves hip joint function in AS patients with hip joint involvement.

Clinical and MRI response to dose reduction of an etanercept-biosimilar for hip arthritis in patients with ankylosing spondylitis: an observational, retrospective cohort study

OBJECTIVES

Hip arthritis plays a critical role in the prognosis of ankylosing spondylitis (AS). Dose reduction of tumor necrosis factor inhibitors preserves general improvement of AS, so this study attempted to examine the equivalence between Yisaipu® tapering and conventional therapy for hip arthritis in AS patients, using clinical parameters and magnetic resonance image (MRI).

METHODS

AS patients received this etanercept-biosimilar injections (50 mg/week) in the first 12 weeks. Participants in the tapering group were treated with this reagent 50 mg every other week from week 13 to week 24, while the control group kept undergoing full-dose therapy. Clinical and laboratory parameters were assessed at baseline, week 12 and week 24. MRI examination of hip was performed at baseline and week 24.

RESULTS

One hundred and thirty-six patients were enrolled, and 80 of them were in the tapering group. Linear mixed model revealed that main effects of tapering group with control group as reference in disease activity parameters were insignificant (p > 0.05). Main effects of baseline with week 24 as reference were significant (p < 0.05), but main effects of week 12 with week 24 as reference were not (p > 0.05). Prevalence of acute inflammatory change in MRI significantly decreased in the tapering group (76.88% vs 20.00%, p < 0.05) and control group (76.79% vs 19.64%, p < 0.05). Influence of both treatments on acute inflammatory change was equivalent (p > 0.05).

CONCLUSION

Efficacy of Yisaipu® tapering treatment is comparable to the full-dose therapy for hip arthritis in AS patients. Both treatments maintain remission of hip arthritis after patients achieved low disease activity.

Incidence and Predictive Factors for Orthopedic Surgery in Patients with Psoriatic Arthritis

Objective.

To investigate the incidence of orthopedic procedures in patients with psoriatic arthritis (PsA), and how patient characteristics, time of diagnosis, and treatment affect the need for surgery.

Methods.

We reviewed the medical history of 1432 patients with possible PsA at Haukeland University Hospital in Bergen, Norway. There were 590 patients (mean age 49 yrs, 52% women) who had sufficient journal information and a confirmed diagnosis of PsA, and who were included in the present study. Relevant orthopedic procedures were obtained from the hospital’s administrative patient records. Survival analyses were completed to evaluate the effect of different factors such as year of diagnosis, age, sex, radiographic changes, disease activity, and treatment, on the risk of surgery.

Results.

There were 171 procedures (25% synovectomies, 15% arthrodesis, and 53% prostheses) performed on 117 patients. These factors all increased the risk of surgery: female sex [relative risk (RR) 1.9, p = 0.001], age ≥ 70 years at diagnosis (RR 2.4, p = 0.001), arthritis in initial radiographs (RR 2.2, p = 0.006), and maximum erythrocyte sedimentation rate 30–59 mm/h (RR 1.6, p = 0.026). Time period of diagnosis had no effect on the outcome. In a subanalysis of surgery exclusive of hip and knee arthroplasty, diagnosis in earlier years (1954–1985 vs 1999–2011) was a risk factor (RR 2.1, p = 0.042). Antirheumatic treatment changed significantly over time.

Conclusion.

There were 20% of patients with PsA who needed surgery. We found that the prognosis of patients with PsA did not change regarding the risk of orthopedic surgery, despite the change in treatment. A possible explanation is the increase in large joint replacements in the general population.

A Literature Review of Total Hip Arthroplasty in Patients with Ankylosing Spondylitis: Perioperative Considerations and Outcome

Ankylosing spondylitis is a spondyloarthropathy affecting the sacro-iliac joints with subsequent progression to the spine and the hip joints. The hip joints are affected by synovitis, enthesial inflammation, involvement of medullary bone, progressive degeneration and secondary osteoarthritis. Clinical presentation is usually in the form of pain and stiffness progressing to disabling fixed flexion contractures and in some instances, complete ankylosis. Hip arthroplasty should be considered for hip pain, postural and functional disability, or pain in adjacent joints due to hip stiffness. We conducted a literature review to determine peri-operative considerations and outcome in ankylosing spondylitis patients undergoing hip arthroplasty. In this review, we have discussed pre-operative surgical planning, thromboprophylaxis, anaesthetic considerations and heterotopic ossification. Outcomes of arthroplasty include range of movement, pain relief, survivorship and complications.