1
|
James WA, Rosenberg AL, Wu JJ, Hsu S, Armstrong A, Wallace EB, Lee LW, Merola J, Schwartzman S, Gladman D, Liu C, Koo J, Hawkes JE, Reddy S, Prussick R, Yamauchi P, Lewitt M, Soung J, Weinberg J, Lebwohl M, Glick B, Kircik L, Desai S, Feldman SR, Zaino ML. Full Guidelines-From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis. J Am Acad Dermatol 2024; 91:251.e1-251.e11. [PMID: 38499181 DOI: 10.1016/j.jaad.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 02/06/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Systemic immunomodulatory agents are indicated in the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis. Perioperative use of these medications may increase the risk of surgical site infection (SSI) and complication. OBJECTIVE To evaluate the risk of SSI and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alfa [TNF-α] inhibitors, interleukin [IL] 12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte-associated antigen-4 costimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine (CsA), and methotrexate [MTX]) undergoing surgery. METHODS We performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery. RESULTS We examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease. CONCLUSION For low-risk procedures, TNF-α inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, MTX, CsA, and apremilast can safely be continued. For intermediate- and high-risk surgery, MTX, CsA, apremilast, abatacept, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab are likely safe to continue; however, a case-by-case approach is advised. Acitretin can be continued for any surgery. There is insufficient evidence to make firm recommendations on tofacitinib, upadacitinib, and deucravacitinib.
Collapse
Affiliation(s)
- Warren A James
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Angela L Rosenberg
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jashin J Wu
- Department of Dermatology, University of Miami Miller School of Medicine, Miami, Florida
| | - Sylvia Hsu
- Department of Dermatology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - April Armstrong
- Department of Dermatology, Keck School of Medicine at University of Southern California, Los Angeles, California
| | | | - Lara Wine Lee
- Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina
| | - Joseph Merola
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sergio Schwartzman
- Department of Dermatology, 72nd Street Medical Associates, New York, New York
| | - Dafna Gladman
- Department of Dermatology, University of Toronto, Toronto, Canada
| | - Clive Liu
- Department of Dermatology, Bellevue Dermatology, Bellevue, Washington
| | - John Koo
- Department of Dermatology, University of California, San Francisco Medical Center, San Francisco, California
| | - Jason E Hawkes
- Department of Dermatology, University of California, Davis, Rocklin, California
| | - Soumya Reddy
- Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Ron Prussick
- Department of Dermatology, Washington Dermatology Center, Frederick, Maryland
| | - Paul Yamauchi
- Department of Dermatology, Dermatology Institute & Skin Care Center, Santa Monica, California
| | - Michael Lewitt
- Department of Dermatology, Illinois Dermatology Institute, LLC, Chicago, Illinois
| | - Jennifer Soung
- Department of Dermatology, Southern California Dermatology, Santa Ana, California
| | - Jeffery Weinberg
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brad Glick
- Department of Dermatology, Glick Skin Institute, Margate, Florida
| | - Leon Kircik
- Department of Dermatology, Physicians Skin Care, Louisville, Kentucky
| | - Seemal Desai
- Department of Dermatology, Innovative Dermatology, Plano, Texas
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mallory L Zaino
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| |
Collapse
|
2
|
Wetzel RM, Ayala GA, Grayson CW, Miranda MA, Simon P, Lyons ST. Risk of Periprosthetic Joint Infection in Patients With Ipsilateral Infected Arthroplasties. Arthroplast Today 2024; 26:101323. [PMID: 39006855 PMCID: PMC11239968 DOI: 10.1016/j.artd.2024.101323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/15/2023] [Accepted: 01/21/2024] [Indexed: 07/16/2024] Open
Abstract
Background The risk of periprosthetic joint infection (PJI) subsequently developing at a second site after an initial PJI has been documented to be approximately 18%-20%. To the best of our knowledge, only a single study has evaluated the incidence in ipsilateral joints and if the risk of infection would be different. While this was the only other study to evaluate this specific subfield, we set to re-evaluate and confirm the incidence of developing a second PJI in the setting of an ipsilateral prosthesis and possible associated risk factors. Methods We retrospectively reviewed all patients treated surgically for lower-extremity PJI at our institution by 5 surgeons from 2015 to 2021. Patients with multiple arthroplasties on the ipsilateral extremity were included. Time between initial and subsequent infection, risk factors for infection, bacterial source, and bacteremia were identified. Results Of 392 patients treated for PJI, 179 (45.6%) had multiple prosthetic joints. Forty-seven of those 179 patients had ipsilateral extremity prosthesis, which made up our study population. Three patients (6.4%) developed a separate infection at an ipsilateral TJA. In total, 10 patients (21.3%) developed a separate PJI. Patients on immunosuppressants had a higher likelihood of developing second PJI on the ipsilateral extremity (P = .02). Conclusions Our study identified the risk of developing an ipsilateral PJI to not be any greater than that in patients with contralateral TJAs. It appears that sharing an extremity with an infected TJA does not pose substantially increased risk of subsequent infection of the un-involved prosthesis. Furthermore, immunosuppressant use may increase the risk of a separate ipsilateral PJI.
Collapse
Affiliation(s)
- Robert M Wetzel
- Florida Orthopaedic Institute, Adult Reconstruction Service, Temple Terrace, FL, USA
| | - Giovanni A Ayala
- Foundation for Orthopaedic Research and Education, Research Department, Tampa, FL, USA
| | - Christopher W Grayson
- Florida Orthopaedic Institute, Adult Reconstruction Service, Temple Terrace, FL, USA
| | - Michael A Miranda
- Florida Orthopaedic Institute, Adult Reconstruction Service, Temple Terrace, FL, USA
| | - Peter Simon
- Foundation for Orthopaedic Research and Education, Research Department, Tampa, FL, USA
| | - Steven T Lyons
- Florida Orthopaedic Institute, Adult Reconstruction Service, Temple Terrace, FL, USA
| |
Collapse
|
3
|
de Araujo LCT, Westerholt A, Sandiford AN, Gursche A, Kendoff D. Periprosthetic joint infections in patients with rheumatoid arthritis are associated with higher complication and mortality rates. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05248-y. [PMID: 38502248 DOI: 10.1007/s00402-024-05248-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/17/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) remains the most devasting complication after total joint arthroplasty (TJA). There has been a significant focus on this topic in recently-published medical literature. However, relatively little has been published about PJI in patients with rheumatoid arthritis (RA), which are often physiologically frail and immunocompromised. A better understanding of PJI in this patient population is therefore crucial. The main aims of this paper are to (1) report complication and mortality rates in a cohort of PJI-RA patients; and (2) clinically characterize them. METHODS Medical and surgical records of all RA PJI patients treated surgically from 2003 to 2020 were retrospectively reviewed. Medical history, physical examination, reactive protein (CRP) level, procalcitonin, white blood cell (WBC) count, joint aspiration results, and cultures were used to determine PJI. RESULTS 54PJIs, 49 of them chronic, were treated in 53RA patients. Mean patient age was 65 yrs. (range = 32-88); 33females and 20 males (one bilateral hip). The overall mortality rate was 18.9%(n = 10), with five deaths directly attributed to PJI. Staphylococci accounted for 34 infections (63%), while 11(20.4%) had multiorganism infections and six culture-negative PJI. At the end of treatment 79.6%(n = 43) still had an implanted TJR, 7.4% (n = 4) had spacers, 5.6%(n = 3) had undergone resection arthroplasty, 3.7%(n = 2) arthrodesis, and one each amputation and exarticulation. CONCLUSIONS Mortality and specially complication rates were (are) high in this RA patients group presenting PJI. Delays to diagnosis and treatment may explain some of these poor outcomes. LEVEL OF EVIDENCE A cohort level III retrospective study.
Collapse
Affiliation(s)
- Lucio Cappelli Toledo de Araujo
- Department of Orthopaedic Surgery, ENDO Klinik Buch, Berlin, Germany.
- Regional Hospital Dr. Homero Miranda Gomes, São José, Santa Catarina, Brazil.
| | - Anette Westerholt
- Department of Orthopaedic Surgery, ENDO Klinik Buch, Berlin, Germany
| | | | - Angelika Gursche
- Department of Orthopaedic Surgery, ENDO Klinik Buch, Berlin, Germany
| | - Daniel Kendoff
- Department of Orthopaedic Surgery, ENDO Klinik Buch, Berlin, Germany
| |
Collapse
|
4
|
Nishitani K, Ito H, Murata K, Kuriyama S, Nakamura S, Matsuda S. Postoperative function of patients with rheumatoid arthritis after total knee arthroplasty in the last decade was comparable in the unadjusted cohort but inferior in the propensity score matched cohort with that of patients with osteoarthritis. Knee 2024; 47:228-238. [PMID: 38447350 DOI: 10.1016/j.knee.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/27/2023] [Accepted: 12/07/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND The perioperative pain and function of total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA) approach those in patients with osteoarthritis (OA). This study aimed to evaluate whether the clinical outcomes, especially functions, of patients with RA reached those of OA, utilizing a background-matched cohort. METHODS Patients who underwent TKA between 2013 and 2021 were enrolled. Preoperative and minimum 2-year postoperative scores, specifically the Original Knee Society Score (OKSS) and New Knee Society Score (2011KSS), between RA and OA were compared. Clinical assessments were performed on unadjusted and propensity-score matched cohorts, ensuring age, sex, body mass index, and valgus deformity rate parity. RESULTS In an unadjusted cohort involving 98 patients with RA and 560 patients with OA, patients with RA demonstrated inferior preoperative OKSS-Function Score (FS) but similar postoperative functional scores to OA patients. In the matched cohort of 83, patients with RA displayed lower preoperative OKSS- FS (median difference: 20, P < 0.001) and 2011KSS functional activities (difference: 9, P = 0.01) beyond minimum clinically important differences than patients with OA. Patients with RA improved more in OKSS-FS, yielding no postoperative difference compared with patients with OA. However, postoperative 2011KSS functional activities remained lower in patients with RA (difference: 9.5, P = 0.03), especially in advanced functions, than in those with OA. CONCLUSION Postoperative function showed no difference between patients with RA and OA in the unadjusted cohort; within the background-matched cohort, postoperative function, especially advanced function, was inferior in patients with RA to those with OA.
Collapse
Affiliation(s)
- Kohei Nishitani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Hiromu Ito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Advanced Medicine of Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichi Murata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Advanced Medicine of Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Kuriyama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
5
|
Liu X, Wei C, Wang J, Li M. Effect of tumour necrosis factor-a inhibitors exposure on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery: A meta-analysis. Int Wound J 2024; 21:e14538. [PMID: 38272825 PMCID: PMC10788641 DOI: 10.1111/iwj.14538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 01/27/2024] Open
Abstract
A meta-analysis investigation was executed to evaluate the effect of tumour necrosis factor-a inhibitor exposure on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery. A comprehensive literature investigation till October 2023 was applied, and 82 470 individuals with orthopaedic surgery were in the chosen investigations' starting point. Odds ratio (OR) in addition to 95% confidence intervals (CIs) was utilized to compute the value of the effect of tumour necrosis factor-a inhibitors exposure on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery by the dichotomous approaches and a fixed or random model. Tumour necrosis factor uses had significantly higher surgical site infections (OR, 1.65; 95% CI, 1.21-2.25, p = 0.001) compared with tumour necrosis factor non-use in rheumatoid arthritis patients undergoing elective orthopaedic surgery. However, no significant difference was found between discontinued and continued tumour necrosis factor on surgical site infections (OR, 0.61; 95% CI, 0.35-1.05, p = 0.07) in rheumatoid arthritis patients undergoing elective orthopaedic surgery.Significantly higher surgical site infections was found comparing tumour necrosis factor uses to non-use; however, no significant difference was found between discontinued and continued tumour necrosis factor on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.
Collapse
Affiliation(s)
- Xinglin Liu
- School of Clinical MedicineWeifang Medical UniversityWeifangChina
| | - Cuie Wei
- School of Clinical MedicineWeifang Medical UniversityWeifangChina
| | - Jianan Wang
- School of Clinical MedicineWeifang Medical UniversityWeifangChina
| | - Ming Li
- Rheumatology and Immunology DepartmentThe First Affiliated Hospital of Weifang Medical CollegeWeifangChina
| |
Collapse
|
6
|
Asai S, Takahashi N, Kishimoto K, Suzuki M, Ohashi Y, Terabe K, Kojima T, Imagama S. Increased prevalence of Staphylococcus aureus nasal carriage in rheumatoid arthritis patients with moderate/high disease activity. J Orthop Sci 2023; 28:1400-1406. [PMID: 36210264 DOI: 10.1016/j.jos.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/27/2022] [Accepted: 09/19/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Staphylococcus aureus (S. aureus) nasal carriage is a well-known risk factor for surgical site infection (SSI) after total joint arthroplasty. This study aimed to compare the prevalence of S. aureus nasal carriage between patients with osteoarthritis (OA), a degenerative joint disease, and those with rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease, who underwent total joint arthroplasty, and to investigate the influence of RA disease activity on nasal carriage rate. METHODS This retrospective study targeted 508 OA and 107 RA patients who underwent S. aureus nasal screening prior to primary total knee and/or hip arthroplasty. RA patients were divided into two groups based on disease activity: the remission/low disease activity (REM/LDA) group and the moderate/high disease activity (MDA/HDA) group. Factors associated with S. aureus nasal carriage were assessed with multivariate logistic regression models. RESULTS Of all 615 patients, 155 (25%) carried S. aureus in their nares. Compared to OA patients, RA patients had a significantly higher rate of S. aureus nasal carriage (24% vs. 33%, p = 0.049). Compared to the REM/LDA group (n = 39), the MDA/HDA group (n = 58) had a significantly higher rate of S. aureus nasal carriage (21% vs. 41%, p = 0.032). Multivariate analysis revealed that the MDA/HDA group, but not the REM/LDA group, had a significantly higher odds of S. aureus nasal carriage compared to the OA group (odds ratio: 2.76, 95% confidence interval: 1.07-7.12). CONCLUSION Preoperative nasal screening for S. aureus is beneficial, especially in RA patients with moderate/high disease activity.
Collapse
Affiliation(s)
- Shuji Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | - Nobunori Takahashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kenji Kishimoto
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Mochihito Suzuki
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshifumi Ohashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kenya Terabe
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| |
Collapse
|
7
|
Bounajem GJ, DeClercq J, Collett G, Ayers GD, Jain N. Does interaction occur between risk factors for revision total knee arthroplasty? Arch Orthop Trauma Surg 2023:10.1007/s00402-023-05107-2. [PMID: 37902892 DOI: 10.1007/s00402-023-05107-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/09/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION Several risk factors for revision TKA have previously been identified, but interactions between risk factors may occur and affect risk of revision. To our knowledge, such interactions have not been previously studied. As patients often exhibit multiple risk factors for revision, knowledge of these interactions can help improve risk stratification and patient education prior to TKA. MATERIALS AND METHODS The State Inpatient Databases (SID), part of the Healthcare Cost and Utilization Project (HCUP), were queried to identify patients who underwent TKA between January 1, 2006 and December 31, 2015. Risk factors for revision TKA were identified, and interactions between indication for TKA and other risk factors were analyzed. RESULTS Of 958,944 patients who underwent TKA, 33,550 (3.5%) underwent revision. Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA were significantly associated with revision (p < 0.05). Age was the strongest predictor (p < 0.0001), with younger patients exhibiting higher revision risk. Risks associated with age were modified by an interaction with indication for TKA (p < 0.0001). There was no significant interaction between sex and indication for TKA (p = 0.535) or race and indication for TKA (p = 0.187). CONCLUSIONS Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA are significantly associated with revision TKA. Interaction occurs between age and indication.
Collapse
Affiliation(s)
- Georges J Bounajem
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA.
- UT Southwestern Medical Center at Frisco, 12500 Dallas Parkway, 3rd Floor, Orthopaedic Surgery, Frisco, TX, 75033-9071, USA.
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Garen Collett
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Gregory D Ayers
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Nitin Jain
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
8
|
Wang Y, Li G, Ji B, Xu B, Zhang X, Maimaitiyiming A, Cao L. Diagnosis of periprosthetic joint infections in patients who have rheumatoid arthritis. Bone Joint Res 2023; 12:559-570. [PMID: 37704202 PMCID: PMC10499527 DOI: 10.1302/2046-3758.129.bjr-2022-0432.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Aims To investigate the optimal thresholds and diagnostic efficacy of commonly used serological and synovial fluid detection indexes for diagnosing periprosthetic joint infection (PJI) in patients who have rheumatoid arthritis (RA). Methods The data from 348 patients who had RA or osteoarthritis (OA) and had previously undergone a total knee (TKA) and/or a total hip arthroplasty (THA) (including RA-PJI: 60 cases, RA-non-PJI: 80 cases; OA-PJI: 104 cases, OA-non-PJI: 104 cases) were retrospectively analyzed. A receiver operating characteristic curve was used to determine the optimal thresholds of the CRP, ESR, synovial fluid white blood cell count (WBC), and polymorphonuclear neutrophil percentage (PMN%) for diagnosing RA-PJI and OA-PJI. The diagnostic efficacy was evaluated by comparing the area under the curve (AUC) of each index and applying the results of the combined index diagnostic test. Results For PJI prediction, the results of serological and synovial fluid indexes were different between the RA-PJI and OA-PJI groups. The optimal cutoff value of CRP for diagnosing RA-PJI was 12.5 mg/l, ESR was 39 mm/hour, synovial fluid WBC was 3,654/μl, and PMN% was 65.9%; and those of OA-PJI were 8.2 mg/l, 31 mm/hour, 2,673/μl, and 62.0%, respectively. In the RA-PJI group, the specificity (94.4%), positive predictive value (97.1%), and AUC (0.916) of synovial fluid WBC were higher than those of the other indexes. The optimal cutoff values of synovial fluid WBC and PMN% for diagnosing RA-PJI after THA were significantly higher than those of TKA. The specificity and positive predictive value of the combined index were 100%. Conclusion Serum inflammatory and synovial fluid indexes can be used for diagnosing RA-PJI, for which synovial fluid WBC is the best detection index. Combining multiple detection indexes can provide a reference basis for the early and accurate diagnosis of RA-PJI.
Collapse
Affiliation(s)
- Yulai Wang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Guoqing Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Boyong Xu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| |
Collapse
|
9
|
Wooster BM, Kennedy NI, Dugdale EM, Sierra RJ, Perry KI, Berry DJ, Abdel MP. Contemporary outcomes of primary total hip arthroplasty in patients with inflammatory arthritis. Bone Joint J 2023; 105-B:768-774. [PMID: 37399088 PMCID: PMC10386849 DOI: 10.1302/0301-620x.105b7.bjj-2023-0220.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
Aims Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis. Methods We identified 418 hips (350 patients) with a primary diagnosis of inflammatory arthritis who underwent primary THA with HXLPE liners from January 2000 to December 2017. Of these hips, 68% had rheumatoid arthritis (n = 286), 13% ankylosing spondylitis (n = 53), 7% juvenile rheumatoid arthritis (n = 29), 6% psoriatic arthritis (n = 24), 5% systemic lupus erythematosus (n = 23), and 1% scleroderma (n = 3). Mean age was 58 years (SD 14.8), 66.3% were female (n = 277), and mean BMI was 29 kg/m2 (SD 7). Uncemented femoral components were used in 77% of cases (n = 320). Uncemented acetabular components were used in all patients. Competing risk analysis was used accounting for death. Mean follow-up was 4.5 years (2 to 18). Results The ten-year cumulative incidence of any revision was 3%, and was highest in psoriatic arthritis patients (16%). The most common indications for the 15 revisions were dislocations (n = 8) and periprosthetic joint infections (PJI; n = 4, all on disease-modifying antirheumatic drugs (DMARDs)). The ten-year cumulative incidence of reoperation was 6.1%, with the most common indications being wound infections (six cases, four on DMARDs) and postoperative periprosthetic femur fractures (two cases, both uncemented femoral components). The ten-year cumulative incidence of complications not requiring reoperation was 13.1%, with the most common being intraoperative periprosthetic femur fracture (15 cases, 14 uncemented femoral components; p = 0.13). Radiological evidence of early femoral component subsidence was observed in six cases (all uncemented). Only one femoral component ultimately developed aseptic loosening. Harris Hip Scores substantially improved (p < 0.001). Conclusion Contemporary primary THAs with HXLPE in patients with inflammatory arthritis had excellent survivorship and good functional outcomes regardless of fixation method. Dislocation, PJI, and periprosthetic fracture were the most common complications in this cohort with inflammatory arthritis.
Collapse
Affiliation(s)
- Benjamin M. Wooster
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Nicholas I. Kennedy
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Evan M. Dugdale
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Rafael J. Sierra
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Kevin I. Perry
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| |
Collapse
|
10
|
Koyama T, Mori Y, Kamimura M, Aki T, Izumiyama T, Mori N, Chiba D, Hashimoto K, Yamamoto N, Aizawa T. Two-stage revision knee arthroplasty for metallosis in a patient with rheumatoid arthritis: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231177752. [PMID: 37325170 PMCID: PMC10265328 DOI: 10.1177/2050313x231177752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
We report a successful case of two-stage revision total knee arthroplasty performed for treating painless metallosis after total knee arthroplasty with a metal-backed patella. A 63-year-old woman diagnosed with rheumatoid arthritis underwent left total knee arthroplasty with a metal-backed patella at 32 years of age. The patient did not have knee pain; however, knee joint swelling, a strange noise, and pigmentation were reported 4 years ago. Radiographs showed cloud and metal-line signs anteriorly and posteriorly at the femoral condyle. Therefore, a two-stage surgery was performed for infection prevention and ease of performing posterior synovectomy. The patient underwent initial synovectomy via a posterior approach, followed by anterior synovectomy and revision total knee arthroplasty. Synovectomy was performed well without perioperative infection or failure of wound healing. In cases with metallosis after total knee arthroplasty, the two-stage revision total knee arthroplasty should be considered, depending on the degree of synovial proliferation and the risk of complications.
Collapse
Affiliation(s)
- Tomoki Koyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masayuki Kamimura
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Aki
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuya Izumiyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoko Mori
- Department of Radiology, Akita University Graduate School of Medicine, Akita, Japan
| | - Daisuke Chiba
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
11
|
Viswanathan VK, Sakthivelnathan V, Menedal A, Purudappa PP, Mounasamy V, Sambandam S. How does systemic lupus erythematosus impact the peri-operative complication rates in primary hip arthroplasty? A national inpatient sample-based study. Arch Orthop Trauma Surg 2023; 143:2209-2216. [PMID: 35643817 DOI: 10.1007/s00402-022-04475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/05/2022] [Indexed: 02/09/2023]
Abstract
INTRODUCTION With prolonged life expectancy, the number of patients with systemic lupus erythematosus (SLE) undergoing total hip arthroplasty (THA) has substantially increased over the past years. The post-operative outcome and complications in SLE are less clearly understood than other inflammatory diseases, due to limited availability of evidence within the literature. METHODS Using the National Inpatient Sample (NIS) database, patients who underwent THA between 2016 and 2019 were identified (ICD-10 CMP code). Patients were then classified into one of the two groups, namely those with SLE (ICD-10-CM; code710.0) or those without SLE (NSLE). Data regarding demographic details, co-morbidities, details regarding hospital stay, expenditure incurred, and complications encountered were analyzed, and compared between the groups. RESULTS Overall, among 367,894 patients undergoing THA, 1684 (0.5%) had SLE. Mean age of SLE (57.3 ± 14.5 years) patients undergoing THA was significantly lower than NSLE (65.9 ± 11.4 years) population (p = 0.001). There was a greater proportion of female patients in SLE group [89.6% (SLE) vs 55.8% (NSLE); p = 0.001]. SLE patients had a greater incidence of emergent hospital admissions (p = 0.04), longer hospital stay (p = 0.001), and higher hospital-related expenditure (p = 0.001). Among the peri-operative complications, SLE patients had significantly greater risk of developing post-operative anemia (p = 0.001), need for blood transfusion (p = 0.001), peri-prosthetic mechanical complications (p = 0.04), and prosthetic dislocations (p = 0.001). There was also a greater incidence of peri-prosthetic infections in the SLE group (p = 0.001). CONCLUSION The presence of SLE significantly lengthens hospital stay and augments healthcare-related costs in patients undergoing THA. The three main complications which may significantly affect the post-operative course of these patients include higher rates of post-operative anemia, peri-prosthetic infections, and early prosthetic dislocations.
Collapse
Affiliation(s)
| | | | | | | | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, TX, USA
| | | |
Collapse
|
12
|
Di Martino A, Ursini F, Bordini B, Ancarani C, Ciaffi J, Brunello M, D'Agostino C, Faldini C. Perioperative treatment with TNF inhibitors does not affect survival of total hip arthroplasty in inflammatory arthritis: a registry-based cohort study. Semin Arthritis Rheum 2023; 60:152201. [PMID: 37028127 DOI: 10.1016/j.semarthrit.2023.152201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/04/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES Aim of this study was to investigate the effect of perioperative exposure to TNF inhibitors (TNFi) on the long-term survival of total hip arthroplasty (THA) in inflammatory arthritis patients from a large regional register of arthroplasty procedures (RIPO). METHODS This study is a retrospective analysis of data from RIPO for THAs performed between 2008 and 2019. After extraction of the procedures of interest from the RIPO dataset, cross-matching with administrative databases were used to identify patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), primary osteoarthritis (OA), and treatments of interest. Three different cohorts of patients were identified: perioperative TNFi-treated patients (6 months before or after the surgery), perioperative non-bDMARD/tsDMARD (biologic or targeted-synthetic disease modifying antirheumatic drugs), and OA. RESULTS At an average follow-up of 5 years, survival rates (using any revision surgery as an endpoint) were not significantly different when perioperative TNFi users and non-bDMARD/tsDMARD patients were compared (p = 0.713), and between TNFi-treated and OA controls (p = 0.123). At the latest available follow-up, 2.5% patients in the TNFi cohort, 3% in the non-bDMARD/tsDMARD cohort, and 0.8% in the OA cohort underwent revision surgery. No significant differences were found comparing the risk of postoperative infection or aseptic loosening among groups. CONCLUSION Risk of revision surgery is not increased in patients with inflammatory arthritis perioperatively exposed to TNFi. Our results support the long-term safety of this class of molecules on survival of prosthetic implants.
Collapse
Affiliation(s)
- Alberto Di Martino
- 1st Orthopedic and Traumatology Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Francesco Ursini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy; Medicine & Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Barbara Bordini
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristina Ancarani
- Medical Technology Laboratory, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Jacopo Ciaffi
- Medicine & Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Matteo Brunello
- 1st Orthopedic and Traumatology Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Claudio D'Agostino
- 1st Orthopedic and Traumatology Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Cesare Faldini
- 1st Orthopedic and Traumatology Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| |
Collapse
|
13
|
Chen Y, Xue Y, Yuan DJ, Chen KJ. Hydrogel combined with antimicrobial protease dressing accompanied with emotional support to treat wounds of patients taking immunosuppressive agents: A longitudinal study. J Tissue Viability 2023; 32:63-68. [PMID: 36658004 DOI: 10.1016/j.jtv.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/12/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to evaluate the healing process of chronic wounds treated with hydrogel combined with antimicrobial protease dressing and emotional support intervention in patients taking immunosuppressive agents. CASES The case series involved 8 patients treated at a tertiary public hospital for 12 weeks. Data were analysed by SPSS version 27.0. The intention-to-treat principle was carried out, without the loss or exclusion of the participants. The subjects had wounds for 70 (98) days, and they consisted of 50% (4/8) males with a mean age of 42.63 years (±16.94). All (100%) subjects had taken immunosuppressive agents, and 62.5% (5/8) had systolic hypertension. The mean initial area of all wounds was 19.54 (5.89) cm2, and the mean final area was 3.0 cm2, with a reduction rate of 89% over the 12 weeks of treatment. In addition, we found that tissue types of these wounds changed by using hydrogel combined with antibacterial protease dressings, especially devitalised tissue (P = 0.011). The amount of exudate did not statistically change (P = 0.083). No participant had severe or local adverse events during the study period. Hence, giving emotional support along with wound care for 12 weeks could significantly reduce anxiety scores (P = 0.012). These results suggested that hydrogel combined with antimicrobial protease dressing and emotional support intervention is a promising method for the healing of wounds in patients who suffer from immunosuppressive diseases or are receiving current immunosuppressive treatment.
Collapse
Affiliation(s)
- Yi Chen
- Wound care clinic, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, China.
| | - Yuan Xue
- Cardiology Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, China
| | - De-Jing Yuan
- Cardiology Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, China.
| | - Ke-Jian Chen
- Outpatient Department of Internal Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, China.
| |
Collapse
|
14
|
Ito H, Nishida K, Kojima T, Matsushita I, Kojima M, Hirata S, Kaneko Y, Kishimoto M, Kohno M, Mori M, Morinobu A, Murashima A, Seto Y, Sugihara T, Tanaka E, Nakayama T, Yamanaka H, Kawahito Y, Harigai M. Non-drug and surgical treatment algorithm and recommendations for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis-secondary publication. Mod Rheumatol 2023; 33:36-45. [PMID: 35294030 DOI: 10.1093/mr/roac019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The aim of this study was to update the Japan College of Rheumatology (JCR) clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) and prepare an algorithm for non-drug and surgical treatments. This article is a digest version of the guidelines. METHODS The Japanese Ministry of Health, Labour and Welfare's research group, in collaboration with the JCR, used the Grading of Recommendations, Assessment, Development, and Evaluation method to update the 2014 JCR CPG for RA. The consensus was formed by CPG panel members. RESULTS We raised 19 clinical questions regarding non-drug and surgical treatments for RA and developed recommendations. The treatments included exercise therapy; occupational therapy; joint injection of corticosteroids; and orthopaedic surgeries including cervical spine surgery, wrist and foot arthroplasty, ankle arthrodesis, and replacement arthroplasty of the shoulder, elbow, finger, hip, knee, and ankle. Recommendations regarding the risks of surgery and perioperative discontinuation of medications have also been developed. Based on these recommendations, we created an original algorithm for the non-drug and surgical treatment of RA. CONCLUSIONS These recommendations are expected to serve rheumatologists, health care professionals, and patients with RA as tools for shared decision-making to treat residual limb joint symptoms and functional impairment.
Collapse
Affiliation(s)
- Hiromu Ito
- Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Orthopedic Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Keiichiro Nishida
- Department of Orthopedic Surgery, Okayama University Academic Field of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Isao Matsushita
- Department of Rehabilitation Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Masayo Kojima
- Department of Frailty Research, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuko Kaneko
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Masataka Kohno
- Inflammation and Immunology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Mori
- Division of Rheumatology and Allergology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsuko Murashima
- Center for Maternal-Fetal, Neonatal, and Reproductive Medicine/Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development, Tokyo, Japan
| | - Yohei Seto
- Department of Rheumatology, Yachiyo Medical Center, Tokyo Women's Medical University School of Medicine, Yachiyo, Japan
| | - Takahiko Sugihara
- Division of Rheumatology and Allergology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Eiichi Tanaka
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | | | - Yutaka Kawahito
- Inflammation and Immunology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masayoshi Harigai
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| |
Collapse
|
15
|
Zala K, Mathur H, Chokshi J. Causes of revision after total hip arthroplasty in patients undergoing revision total hip arthroplasty younger than 50 years of age. JOURNAL OF ORTHOPAEDIC DISEASES AND TRAUMATOLOGY 2023. [DOI: 10.4103/jodp.jodp_100_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
|
16
|
Perioperative management of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society for Rheumatology. Z Rheumatol 2023; 82:1-11. [PMID: 35235025 DOI: 10.1007/s00393-021-01150-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
Collapse
|
17
|
Rodriguez-Merchan EC, Delgado-Martinez AD. Risk Factors for Periprosthetic Joint Infection after Primary Total Knee Arthroplasty. J Clin Med 2022; 11:6128. [PMID: 36294449 PMCID: PMC9605414 DOI: 10.3390/jcm11206128] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 08/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a major adverse event of primary total knee arthroplasty (TKA) from the patient's perspective, and it is also costly for health care systems. In 2010, the reported incidence of PJI in the first 2 years after TKA was 1.55%, with an incidence of 0.46% between the second and tenth year. In 2022, it has been published that 1.41% of individuals require revision TKA for PJI. The following risk factors have been related to an increased risk of PJI: male sex, younger age, type II diabetes, obesity class II, hypertension, hypoalbuminemia, preoperative nutritional status as indicated by prognostic nutritional index (PNI) and body mass index, rheumatoid arthritis, post-traumatic osteoarthritis, intra-articular injections prior to TKA, previous multi-ligament knee surgery, previous steroid therapy, current tobacco use, procedure type (bilateral), length of stay over 35 days, patellar resurfacing, prolonged operative time, use of blood transfusions, higher glucose variability in the postoperative phase, and discharge to convalescent care. Other reported independent risk factors for PJI (in diminishing order of importance) are congestive heart failure, chronic pulmonary illness, preoperative anemia, depression, renal illness, pulmonary circulation disorders, psychoses, metastatic tumor, peripheral vascular illness, and valvular illness. Preoperative intravenous tranexamic acid has been reported to diminish the risk of delayed PJI. Knowing the risk factors for PJI after TKA, especially those that are avoidable or controllable, is critical to minimizing (ideally preventing) this complication. These risk factors are outlined in this article.
Collapse
Affiliation(s)
- Emerito Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research—IdiPAZ (La Paz University Hospital—Autonomous University of Madrid), 28046 Madrid, Spain
| | - Alberto D. Delgado-Martinez
- Department of Orthopedic Surgery, Hospital Universitario de Jaen, 23007 Jaen, Spain
- Department of Surgery, University of Jaen, 23071 Jaen, Spain
| |
Collapse
|
18
|
Ling K, Kim M, Nazemi A, Smolev E, Komatsu DE, Wang ED. Chronic steroid use and readmission following total shoulder arthroplasty. JSES Int 2022; 6:775-780. [PMID: 36081686 PMCID: PMC9446210 DOI: 10.1016/j.jseint.2022.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Degenerative arthritis is a major indication for both anatomic and reverse total shoulder arthroplasty (TSA). Degenerative arthritis is an age-related process that can be secondary to mechanical wear or inflammatory or autoimmune diseases, such as rheumatoid arthritis or systemic lupus erythematosus. Management of these diseases can include chronic corticosteroid for their anti-inflammatory and immunosuppressive effects. Given the well-known complications of chronic steroid use on other surgical procedures, investigation into postoperative complications specific to TSA will assist physicians in risk stratification and preoperative planning. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TSA. Methods The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Multivariate logistic regression was used to identify postoperative complications associated with chronic preoperative steroid use. Reasons and risk factors for readmission among chronic steroid users were subsequently identified, as well. Results A total of 26,669 patients were included in this study: 25,376 (95.2%) were included in the nonsteroid cohort and 1293 (4.8%) were included in the chronic steroid cohort. The postoperative complications that were significantly associated with chronic preoperative steroid use were septic shock (P = .007), urinary tract infection (P = .016), myocardial infarction (P = .022), ventilator >48 hours (P = .028), readmission (P < .001), nonhome discharge (P < .001), and mortality (P = .007). The only postoperative complication independently associated with chronic preoperative steroid use was readmission (odds ratio, 1.36; 95% confidence interval, 1.04-1.79; P = .027). Conclusion Preoperative chronic steroid use is an independent predictor for readmission following TSA. As procedural improvement increases surgical volume for TSA, a better understanding of preoperative risk factors can improve perioperative risk stratification and help to minimize adverse outcomes.
Collapse
|
19
|
Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, Finlayson H, George MD, Giles JT, Gilliland J, Klatt B, MacKenzie R, Michaud K, Miller A, Russell L, Sah A, Abdel MP, Johnson B, Mandl LA, Sculco P, Turgunbaev M, Turner AS, Yates A, Singh JA. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. J Arthroplasty 2022; 37:1676-1683. [PMID: 35732511 DOI: 10.1016/j.arth.2022.05.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To develop updated American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
Collapse
Affiliation(s)
- Susan M Goodman
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York.
| | | | | | | | - David R Fernandez
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Mark Figgie
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Heather Finlayson
- Multispecialty Physician Partners, LLC, Colorado Arthritis Associates, Lakewood, Colorado
| | | | | | - Jeremy Gilliland
- University of Utah and Veterans Affairs Medical Center, Salt Lake City
| | - Brian Klatt
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ronald MacKenzie
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, Nebraska, and Forward Databank, Wichita, Kansas
| | - Andy Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Linda Russell
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Alexander Sah
- Sah Orthopaedic Associates, Institute for Joint Restoration, Freemont, California
| | | | | | - Lisa A Mandl
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Peter Sculco
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
| |
Collapse
|
20
|
Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, Finlayson H, George MD, Giles JT, Gilliland J, Klatt B, MacKenzie R, Michaud K, Miller A, Russell L, Sah A, Abdel MP, Johnson B, Mandl LA, Sculco P, Turgunbaev M, Turner AS, Yates A, Singh JA. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Rheumatol 2022; 74:1464-1473. [PMID: 35722708 DOI: 10.1002/art.42140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/18/2022] [Accepted: 04/07/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To develop updated guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
Collapse
Affiliation(s)
- Susan M Goodman
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | | | | | | | - David R Fernandez
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Mark Figgie
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Heather Finlayson
- Multispecialty Physician Partners, LLC, Colorado Arthritis Associates, Lakewood, Colorado
| | | | | | - Jeremy Gilliland
- University of Utah and Veterans Affairs Medical Center, Salt Lake City
| | - Brian Klatt
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ronald MacKenzie
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, Nebraska, and Forward Databank, Wichita, Kansas
| | - Andy Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Linda Russell
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Alexander Sah
- Sah Orthopaedic Associates, Institute for Joint Restoration, Freemont, California
| | | | | | - Lisa A Mandl
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Peter Sculco
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
| |
Collapse
|
21
|
Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, Finlayson H, George MD, Giles JT, Gilliland J, Klatt B, MacKenzie R, Michaud K, Miller A, Russell L, Sah A, Abdel MP, Johnson B, Mandl LA, Sculco P, Turgunbaev M, Turner AS, Yates A, Singh JA. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care Res (Hoboken) 2022; 74:1399-1408. [PMID: 35718887 DOI: 10.1002/acr.24893] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/18/2022] [Accepted: 04/07/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To develop updated guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
Collapse
Affiliation(s)
- Susan M Goodman
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | | | | | | | - David R Fernandez
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Mark Figgie
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Heather Finlayson
- Multispecialty Physician Partners, LLC, Colorado Arthritis Associates, Lakewood, Colorado
| | | | | | - Jeremy Gilliland
- University of Utah and Veterans Affairs Medical Center, Salt Lake City
| | - Brian Klatt
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ronald MacKenzie
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, Nebraska, and Forward Databank, Wichita, Kansas
| | - Andy Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Linda Russell
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Alexander Sah
- Sah Orthopaedic Associates, Institute for Joint Restoration, Freemont, California
| | | | | | - Lisa A Mandl
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Peter Sculco
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
| |
Collapse
|
22
|
Barretto JM, Campos ALS, Ooka NHM. Periprosthetic Knee Infection - Part 1: Risk Factors, Classification and Diagnosis. Rev Bras Ortop 2022; 57:185-192. [PMID: 35652026 PMCID: PMC9142234 DOI: 10.1055/s-0041-1729935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 11/19/2022] Open
Abstract
Infection is one of the most feared complications in the postoperative period of knee arthroplasties. With the progressive aging of the population and the increased incidence of degenerative joint diseases, there is an exponential increase in the number of arthroplasties performed and, consequently, in the number of postoperative infections. The diagnosis of these should follow a hierarchical protocol, with well-defined criteria, which lead to diagnostic conclusion, thus guiding the most appropriate treatment. The aim of the present update article is to present the main risk factors, classifications and, mainly, to guide diagnostic investigation in an organized manner.
Collapse
Affiliation(s)
| | - André Luiz Siqueira Campos
- Departamento de Ortopedia e Traumatologista, Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brasil
| | - Nelson Hiroyuki Miyabe Ooka
- Departamento de Ortopedia e Traumatologista, Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brasil.,Departamento de Ortopedia e Traumatologista, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brasil
| |
Collapse
|
23
|
Dieperink SS, Glintborg B, Oestergaard LB, Nørgaard M, Benfield T, Mehnert F, Petersen A, Torp-Pedersen C, Hetland ML. Risk of Staphylococcus aureus bacteraemia in patients with rheumatoid arthritis and the effect of orthopaedic implants on the risk: a nationwide observational cohort study. Scand J Rheumatol 2022; 52:250-258. [PMID: 35442139 DOI: 10.1080/03009742.2022.2049057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE It remains disputed how much the risk of Staphylococcus aureus bacteraemia (SAB) is increased in patients with rheumatoid arthritis (RA), and the extent to which orthopaedic implants explain the risk. We assessed SAB incidence rates (IRs) and incidence rate ratios (IRRs), comparing RA patients with a general population cohort (GPC) and individuals with versus without orthopaedic implants. METHOD Danish residents aged ≥ 18 years without prior RA or SAB (=GPC) were followed up for RA and microbiologically verified SAB events (1996-2017). IRRs were calculated by age- and sex-stratified Poisson regression adjusted for age, comorbidities, calendar year, and socioeconomic status. RESULTS The GPC comprised 5 398 690 individuals. We identified 33 567 incident RA patients (=RA cohort) (median follow-up 7.3 years, IQR 3.6-12.3). We observed 25 023 SAB events (n = 224 in the RA cohort). IRs per 100 000 person-years were 81.0 (RA cohort) and 29.9 (GPC). IRs increased with age. Adjusted IRRs in 18-59-year-old RA patients were 2.6 (95% confidence interval 1.8-3.7) for women and 1.8 (1.1-3.1) for men, compared with same sex and age group GPC. IRRs declined with age. Compared with the GPC without implants, IRRs for RA patients with implants ranged from 1.9 (1.3-2.8) (women ≥ 70 years) to 5.3 (2.2-12.8) (18-59-year-old men). CONCLUSION In this nationwide registry-based cohort study RA was a risk factor for SAB, and orthopaedic implants further increased the risk. Clinicians should be aware of potential SAB in patients with RA and orthopaedic implants.
Collapse
Affiliation(s)
- S S Dieperink
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B Glintborg
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - L B Oestergaard
- Cardiovascular Research Center, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - M Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - T Benfield
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - F Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - A Petersen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - C Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - M L Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO Registry, Centre for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| |
Collapse
|
24
|
Ito H, Murata K, Sobue Y, Kojima T, Nishida K, Matsushita I, Kawahito Y, Kojima M, Hirata S, Kaneko Y, Kishimoto M, Kohno M, Mori M, Morinobu A, Murashima A, Seto Y, Sugihara T, Tanaka E, Nakayama T, Harigai M. Comprehensive risk analysis of postoperative complications in patients with rheumatoid arthritis for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis. Mod Rheumatol 2022; 32:296-306. [PMID: 33855932 DOI: 10.1080/14397595.2021.1913824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/01/2019] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To examine the risk factors of surgical site infection (SSI), delayed wound healing, and death after orthopedic surgery in patients with rheumatoid arthritis (RA). METHODS We identified articles indexed in the Cochrane Library, PubMed, and Japan Centra Revuo Medicina Web published from 2013 to 2019 and other articles. Articles fulfilling the predefined inclusion criteria were reviewed systematically and their quality was appraised according to the Grading of Recommendations Assessment, Development, and Evaluation system with some modifications. RESULTS After inclusion and exclusion by full-text review, 29 articles were analyzed. Use of biological disease modifying antirheumatic drugs was a risk factor of SSI (risk ratio 1.66, 95% confidence interval 1.25-2.19), but not of delayed wound healing. RA itself was a risk factor of SSI, and oral glucocorticoid use was a risk factor of SSI in three of the four studies analyzed and of postoperative death. Age, male sex, comorbidities such as diabetes mellitus and chronic obstructive pulmonary disease, surgical factors such as foot/ankle and spine surgery and longer operative time were risk factors of those postoperative complications. CONCLUSION Patients with those factors should be dealt with appropriate cautions to strike a risk-benefit balance of orthopedic surgeries.
Collapse
Affiliation(s)
- Hiromu Ito
- Department of Advanced Medicine for Rheumatic Diseases and Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichi Murata
- Department of Advanced Medicine for Rheumatic Diseases and Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiichiro Nishida
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Matsushita
- Department of Rehabilitation Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masayo Kojima
- Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Masataka Kohno
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsuko Murashima
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine/Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development, Tokyo, Japan
| | - Yohei Seto
- Department of Rheumatology, Yachiyo Medical Center, Tokyo Women's Medical University, Chiba, Japan
| | - Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Eiichi Tanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| |
Collapse
|
25
|
Yapp LZ, Clement ND, Moran M, Clarke JV, Simpson AHRW, Scott CEH. Long-term mortality rates and associated risk factors following primary and revision knee arthroplasty : 107,121 patients from the Scottish Arthroplasty Project. Bone Joint J 2022; 104-B:45-52. [PMID: 34969267 DOI: 10.1302/0301-620x.104b1.bjj-2021-0753.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to determine the long-term mortality rate, and to identify factors associated with this, following primary and revision knee arthroplasty (KA). METHODS Data from the Scottish Arthroplasty Project (1998 to 2019) were retrospectively analyzed. Patient mortality data were linked from the National Records of Scotland. Analyses were performed separately for the primary and revised KA cohorts. The standardized mortality ratio (SMR) with 95% confidence intervals (CIs) was calculated for the population at risk. Multivariable Cox proportional hazards were used to identify predictors and estimate relative mortality risks. RESULTS At a median 7.4 years (interquartile range (IQR) 4.0 to 11.6) follow-up, 27.8% of primary (n = 27,474/98,778) and 31.3% of revision (n = 2,611/8,343) KA patients had died. Both primary and revision cohorts had lower mortality rates than the general population (SMR 0.74 (95% CI 0.73 to 0.74); p < 0.001; SMR 0.83 (95% CI 0.80 to 0.86); p < 0.001, respectively), which persisted for 12 and eighteight years after surgery, respectively. Factors associated with increased risk of mortality after primary KA included male sex (hazard ratio (HR) 1.40 (95% CI 1.36 to 1.45)), increasing socioeconomic deprivation (HR 1.43 (95% CI 1.36 to 1.50)), inflammatory polyarthropathy (HR 1.79 (95% CI 1.68 to 1.90)), greater number of comorbidities (HR 1.59 (95% CI 1.51 to 1.68)), and periprosthetic joint infection (PJI) requiring revision (HR 1.92 (95% CI 1.57 to 2.36)) when adjusting for age. Similarly, male sex (HR 1.36 (95% CI 1.24 to 1.49)), increasing socioeconomic deprivation (HR 1.31 (95% CI 1.12 to 1.52)), inflammatory polyarthropathy (HR 1.24 (95% CI 1.12 to 1.37)), greater number of comorbidities (HR 1.64 (95% CI 1.33 to 2.01)), and revision for PJI (HR 1.35 (95% 1.18 to 1.55)) were independently associated with an increased risk of mortality following revision KA when adjusting for age. CONCLUSION The SMR of patients undergoing primary and revision KA was lower than that of the general population and remained so for several years post-surgery. However, approximately one in four patients undergoing primary and one in three patients undergoing revision KA died within tenten years of surgery. Several patient and surgical factors, including PJI, were associated with the risk of mortality within ten years of primary and revision surgery. Cite this article: Bone Joint J 2022;104-B(1):45-52.
Collapse
Affiliation(s)
- Liam Zen Yapp
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK.,Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK
| | - Nick D Clement
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Matthew Moran
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK
| | - Jon V Clarke
- Scottish Arthroplasty Project, Public Health Scotland, Edinburgh, UK.,Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK
| | - A Hamish R W Simpson
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Chloe E H Scott
- Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK.,Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| |
Collapse
|
26
|
Albrecht K, Poddubnyy D, Leipe J, Sewerin P, Iking-Konert C, Scholz R, Krüger K. [Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]. Z Rheumatol 2021; 81:212-224. [PMID: 34928422 DOI: 10.1007/s00393-021-01140-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
Collapse
Affiliation(s)
| | - Denis Poddubnyy
- Rheumatologie am Campus Benjamin Franklin - Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Philipp Sewerin
- Uniklinik Düsseldorf Poliklinik, Funktionsbereich & Hiller Forschungszentrum für Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Christof Iking-Konert
- Sektion Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Roger Scholz
- Orthopädie und Unfallchirurgie, Collm Klinik Oschatz, Oschatz, Deutschland
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, St.-Bonifatius-Str. 5, 81541, München, Deutschland.
| |
Collapse
|
27
|
Vasavada K, Jazrawi LM, Samuels J. Perioperative Management of Immunosuppressive Medications in Rheumatic Disease Patients Undergoing Arthroscopy. Curr Rev Musculoskelet Med 2021; 14:421-428. [PMID: 34755277 PMCID: PMC8733073 DOI: 10.1007/s12178-021-09720-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This manuscript reviews relevant prior literature regarding management of immunosuppressants in patients with rheumatic diseases around the time of orthopedic surgery, highlighting important considerations specifically regarding arthroscopy. RECENT FINDINGS Utilization rates of arthroscopic surgery in patients with rheumatic diseases are on the rise, as immunosuppressive treatment options enable them to lead more active lives and hence experience more injuries. Physicians regularly manage patients' glucocorticoids and conventional synthetic and biologic disease modifying antirheumatic drugs around the time of orthopedic surgery, aiming to minimize infection risk while optimizing disease control. However, there is a paucity of randomized controlled trial data for orthopedic surgery-and specifically nothing in the literature pertaining to arthroscopic surgery. Recent guidelines for rheumatic disease patients undergoing elective total hip and knee arthroplasty recommend that most immunosuppressive medications should be held perioperatively, citing the high-risk profile of arthroplasty cases and arthroplasty patients. While 2017 societal guidelines for perioperative immunosuppression during arthroplasty currently serve as a guide for physicians, they may not be applicable to arthroscopy. The less aggressive arthroscopic surgeries span a broader range of patient ages and risk profiles, indications for surgery, and procedural complexity and associated risks. Given these considerations, the majority of routine arthroscopic patients may not require holding of their immunosuppressive medications in the perioperative period.
Collapse
Affiliation(s)
- Kinjal Vasavada
- Division of Sports Medicine, Department of Orthopaedic Surgery, New York University Langone Orthopedic Center, New York, NY USA
| | - Laith M. Jazrawi
- Department of Orthopaedic Surgery, New York University Langone Orthopedic Center, New York, NY USA
| | | |
Collapse
|
28
|
Chung HK, Wen SH, Chang WC, Liu KL. Acute surgical site infection after total knee arthroplasty in patients with rheumatoid arthritis versus osteoarthritis. Sci Rep 2021; 11:22704. [PMID: 34811453 PMCID: PMC8609034 DOI: 10.1038/s41598-021-02153-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/10/2021] [Indexed: 12/23/2022] Open
Abstract
Osteoarthritis is the main cause for total knee arthroplasty (TKA), followed by rheumatoid arthritis. Previous studies have reported conflicting results concerning the risk of surgical site infection after TKA for rheumatoid arthritis and osteoarthritis patients. Thus, this study aimed to examine whether rheumatoid arthritis patients had a higher risk of acute surgical site infection after TKA compared to osteoarthritis patients. We conducted a retrospective cohort study using Taiwan’s National Health Insurance Research Database of the whole population from 2012 to 2015, and collected the medical records of osteoarthritis patients or rheumatoid arthritis patients who underwent TKA. To evaluate the risk of acute surgical site infection in rheumatoid arthritis patients, propensity score matching was implemented for osteoarthritis patients. Acute surgical site infection was observed in 2.58% of TKA cases in rheumatoid arthritis patients and 2.66% of TKA cases in osteoarthritis patients. Rheumatoid arthritis and osteoarthritis patients had comparable risk for 90-day (odds ratio = 0.81, 95% confidence interval: 0.371–1.768) and 1-year (odds ratio = 0.463, 95% confidence interval: 0.121–1.766) surgical site infection. In conclusion, patients with rheumatoid arthritis were not at higher risk of acute surgical site infection after TKA compared to osteoarthritis patients. The current treatment strategy for patients with RA is safe and appropriate if they require TKA.
Collapse
Affiliation(s)
- Ho-Ken Chung
- Department of Orthopedics, Buddhist Tzu Chi General Hospital, Hualien, 970473, Taiwan
| | - Shu-Hui Wen
- Department of Public Health, College of Medicine, Tzu Chi University, Hualien, 970374, Taiwan
| | - Wei-Chuan Chang
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, 970473, Taiwan
| | - Kuan-Lin Liu
- Department of Orthopedics, Buddhist Tzu Chi General Hospital, Hualien, 970473, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, 970374, Taiwan.
| |
Collapse
|
29
|
Gausden EB, Pagnano MW, Perry KI, Suh GA, Berry DJ, Abdel MP. Synchronous Periprosthetic Joint Infections: High Mortality, Reinfection, and Reoperation. J Arthroplasty 2021; 36:3556-3561. [PMID: 34088568 DOI: 10.1016/j.arth.2021.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/05/2021] [Accepted: 05/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Synchronous periprosthetic joint infections (PJIs) are a catastrophic complication with potentially high mortality. We aimed to report mortality, risk of reinfection, revision, reoperation, and implant survivorship after synchronous PJIs. METHODS We identified 34 patients treated for PJI in more than one joint within a single 90-day period from 1990 to 2018. PJIs involved bilateral knee arthroplasty (27), bilateral hip arthroplasty (4), 1 knee arthroplasty and 1 elbow arthroplasty (1), 1 knee arthroplasty and 1 shoulder arthroplasty (1), and bilateral hip and knee arthroplasty (1). Irrigation and debridement with component retention was performed in 23 patients, implant resection in 10 patients, and a combination of irrigation and debridement with component retention and implant resection in 1 patient. A competing risk model was used to analyze implant survivorship, and Kaplan-Meier survival was used for patient mortality. Mean follow-up was 6 years. RESULTS Mortality was high at 18% at 30 days and 27% at 1 year. The 1-year cumulative incidence of any reinfection was 13% and 27% at 5 years. The 1-year cumulative incidence of any revision or implant removal was 6% and 20% at 5 years. The 1-year cumulative incidence of unplanned reoperation was 25% and 35% at 5 years. Rheumatoid arthritis was associated with increased risk of mortality (HR 7, P < .01), as was liver disease (HR 4, P = .02). CONCLUSION In the largest series to date, patients with synchronous PJIs had a high 30-day mortality rate of 18%, and one-fourth underwent unplanned reoperation within the first year.
Collapse
Affiliation(s)
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Gina A Suh
- Division of Infectious Diseases, Department of Medicine Mayo Clinic, Rochester, MN
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
30
|
Active rheumatoid arthritis in a mouse model is not an independent risk factor for periprosthetic joint infection. PLoS One 2021; 16:e0250910. [PMID: 34398899 PMCID: PMC8366981 DOI: 10.1371/journal.pone.0250910] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/29/2021] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) represents a devastating complication of total joint arthroplasty associated with significant morbidity and mortality. Literature suggests a possible higher incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA). There is, however, no consensus on this purported risk nor a well-defined mechanism. This study investigates how collagen-induced arthritis (CIA), a validated animal model of RA, impacts infectious burden in a well-established model of PJI. METHODS Control mice were compared against CIA mice. Whole blood samples were collected to quantify systemic IgG levels via ELISA. Ex vivo respiratory burst function was measured via dihydrorhodamine assay. Ex vivo Staphylococcus aureus Xen36 burden was measured directly via colony forming unit (CFU) counts and crystal violet assay to assess biofilm formation. In vivo, surgical placement of a titanium implant through the knee joint and inoculation with S. aureus Xen36 was performed. Bacterial burden was then quantified by longitudinal bioluminescent imaging. RESULTS Mice with CIA demonstrated significantly higher levels of systemic IgG compared with control mice (p = 0.003). Ex vivo, there was no significant difference in respiratory burst function (p = 0.89) or S. aureus bacterial burden as measured by CFU counts (p = 0.91) and crystal violet assay (p = 0.96). In vivo, no significant difference in bacterial bioluminescence between groups was found at all postoperative time points. CFU counts of both the implant and the peri-implant tissue were not significantly different between groups (p = 0.82 and 0.80, respectively). CONCLUSION This study demonstrated no significant difference in S. aureus infectious burden between mice with CIA and control mice. These results suggest that untreated, active RA may not represent a significant intrinsic risk factor for PJI, however further mechanistic translational and clinical studies are warranted.
Collapse
|
31
|
Zhou VY, Lacaille D, Lu N, Kopec J, Garbuz D, Qian Y, Aviña-Zubieta JA, Esdaile J, Xie H. Has the incidence of total joint arthroplasty in rheumatoid arthritis decreased in the era of biologics use? A population-based cohort study. Rheumatology (Oxford) 2021; 61:1819-1830. [PMID: 34373899 DOI: 10.1093/rheumatology/keab643] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine whether the introduction of biological disease-modifying anti-rheumatic drugs (bDMARDs) was associated with reduced incidences of total hip and knee arthroplasty (THA/TKA) among patients with rheumatoid arthritis (RA) compared with osteoarthritis (OA). METHODS Using a population-based cohort in British Columbia, Canada, RA and OA patients diagnosed between 1995-2007 were divided into semi-annual cohorts according to diagnosis date. For each cohort, we calculated 8-year incidence rates of THA and TKA. We compared levels and trends of THA/TKA incidence in RA/OA patients diagnosed during pre-bDMARDs (1995-2001) and post-bDMARDs (2003-2007) periods using interrupted time-series analysis, adjusting for baseline characteristics. Adjusted 8-year TJA incidence estimated for RA/OA cohorts diagnosed five years after bDMARDs introduction were compared with expected rates assuming no bDMARDs introduction, based on extrapolation of pre-bDMARDs trends. RESULTS We identified 60,227 RA and 288,260 OA incident cases. For cohorts diagnosed pre-bDMARDs, 8-year THA/TKA incidence rates increased over time in both RA and OA. For cohorts diagnosed post-bDMARDs, these rates decreased over time in RA but continued to increase for OA. For RA, differences between the post- and pre-bDMARDs secular trends in incidence rates were -0.49 (p = 0.002) for THA and -0.36 (p = 0.003) for TKA, compared to + 0.40 (p = 0.006) and +0.54 (p < 0.001), respectively, for OA. For RA cohorts diagnosed five years after bDMARDs introduction, 8-year incidence were 26.9% and 12.6% lower for THA and TKA, respectively, than expected rates. In contrast, corresponding rates in OA were higher by 11.7% and 16.6%, respectively. CONCLUSION Arthritis onset after bDMARDs introduction is associated with a significant reduction in THA/TKA incidence in RA, but not in OA. The reduction reflects a significant improvement in RA treatment during the biological era.
Collapse
Affiliation(s)
- Vivienne Y Zhou
- Arthritis Research Canada, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Diane Lacaille
- Arthritis Research Canada, Vancouver, British Columbia, Canada.,Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Na Lu
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Jacek Kopec
- Arthritis Research Canada, Vancouver, British Columbia, Canada.,Division of Epidemiology, Biostatistics and Public Health Practice, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Don Garbuz
- Arthritis Research Canada, Vancouver, British Columbia, Canada.,Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Yi Qian
- Sauder School of Business, University of British Columbia, Vancouver, Canada
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, Vancouver, British Columbia, Canada.,Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - John Esdaile
- Arthritis Research Canada, Vancouver, British Columbia, Canada.,Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Hui Xie
- Arthritis Research Canada, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| |
Collapse
|
32
|
Chukir T, Goodman SM, Tornberg H, Do H, Thomas C, Sigmund A, Sculco P, Figgie M, Mehta B, Russell L, Stein E. Perioperative Glucocorticoids in Patients With Rheumatoid Arthritis Having Total Joint Replacements: Help or Harm? ACR Open Rheumatol 2021; 3:654-659. [PMID: 34288590 PMCID: PMC8449040 DOI: 10.1002/acr2.11306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 06/22/2021] [Indexed: 11/22/2022] Open
Abstract
Objective The optimal strategy for perioperative glucocorticoid (GC) management in patients with rheumatoid arthritis (RA) on chronic GCs is unknown. Although there is a concern for hypotension if inadequate doses are used, higher GC exposure may increase perioperative complications. We aimed to investigate the relationships between perioperative GCs with hemodynamic instability and short‐term postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients with RA. Methods This retrospective study included patients with RA who underwent THA and TKA. GC exposure was assessed by the total cumulative dose (in prednisone equivalents) during hospitalization. Perioperative complications and hypotension were assessed. Results Of 432 patients, 387 (90%) received supraphysiologic perioperative GC. Thirty percent of patients were using chronic GCs (mean daily dose, 7 ± 4 mg). Half (54%) underwent TKA. The median age was 65 years, and 79% were women. The median cumulative GC dose during hospitalization was 37 mg (interquartile range, 27‐53.3). A lower cumulative dose of GC did not increase odds of hypotension during hospitalization (unadjusted odds ratio, 1.00 [95% confidence interval, 0.99‐1.01]; P = 0.66)]. However, postoperative complications were higher among patients who received higher cumulative doses after adjustment for age, body mass index, home GC use, smoking, and Charlson Comorbidity Index. Risk of short‐term complications increased by 8.4% (P = 0.017) for every 10‐mg increase in GC dose. Conclusion A lower GC dose was not associated with increased hypotension. However, patients with higher GC exposure were more likely to have hyperglycemia and other complications. These findings suggest that harms may be associated with high perioperative GC doses. Further research is needed to determine the optimal perioperative regimen for patients with RA.
Collapse
Affiliation(s)
- Tariq Chukir
- Weill Cornell Medicine and New York Presbyterian Hospital, New York, and Weill Cornell Medicine-Qatar, Education City, Doha, Qatar
| | | | | | - Huong Do
- Hospital for Special Surgery, New York, New York
| | - Charlene Thomas
- Weill Cornell Medicine and New York Presbyterian Hospital, New York
| | | | - Peter Sculco
- Hospital for Special Surgery, New York, New York
| | - Mark Figgie
- Hospital for Special Surgery, New York, New York
| | - Bella Mehta
- Hospital for Special Surgery, New York, New York
| | | | - Emily Stein
- Weill Cornell Medicine and New York Presbyterian Hospital and Hospital for Special Surgery, New York
| |
Collapse
|
33
|
Mathias K, Amarnani A, Pal N, Karri J, Arkfeld D, Hagedorn JM, Abd-Elsayed A. Chronic Pain in Patients with Rheumatoid Arthritis. Curr Pain Headache Rep 2021; 25:59. [PMID: 34269913 DOI: 10.1007/s11916-021-00973-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Chronic pain is highly prevalent in patients with rheumatoid arthritis (RA) and can cause various physical and psychological impairments. Unfortunately, the appropriate diagnosis of chronic pain syndromes in this population can be challenging because pain may be primary to RA-specific inflammation and/or secondary to other conditions, typically osteoarthritis (OA) and fibromyalgia (FM). This disparity further poses a clinical challenge, given that chronic pain can often be discordant or undetected with standard RA-specific surveillance strategies, including serological markers and imaging studies. In this review, we provide a robust exploration of chronic pain in the RA population with emphasis on epidemiology, mechanisms, and management strategies. RECENT FINDINGS Chronic pain associated with RA typically occurs in patients with anxiety, female sex, and elevated inflammatory status. Up to 50% of these patients are thought to have chronic pain despite appropriate inflammatory suppression, typically due to peripheral and central sensitization as well as secondary OA and FM. In addition to the standard-of-care management for OA and FM, patients with RA and chronic pain benefit from behavioral and psychological treatment options. Moreover, early and multimodal therapies, including non-pharmacological, pharmacological, interventional, and surgical strategies, exist, albeit with varying efficacy, to help suppress inflammation, provide necessary analgesia, and optimize functional outcomes. Overall, chronic pain in RA is a difficult entity for both patients and providers. Early diagnosis, improved understanding of its mechanisms, and initiation of early, targeted approaches to pain control may help to improve outcomes in this population.
Collapse
Affiliation(s)
- Kristen Mathias
- Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Abhimanyu Amarnani
- Department of Internal Medicine, Division of Rheumatology, Los Angeles County + University of Southern California (LAC + USC) and Keck Medicine of USC, Los Angeles, CA, USA
| | - Neha Pal
- Texas A&M School of Medicine, Bryan, TX, USA
| | - Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Arkfeld
- Department of Internal Medicine, Division of Rheumatology, Los Angeles County + University of Southern California (LAC + USC) and Keck Medicine of USC, Los Angeles, CA, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| |
Collapse
|
34
|
Goodman SM, George MD. 'Should we stop or continue conventional synthetic (including glucocorticoids) and targeted DMARDs before surgery in patients with inflammatory rheumatic diseases?'. RMD Open 2021; 6:rmdopen-2020-001214. [PMID: 32719151 PMCID: PMC7722271 DOI: 10.1136/rmdopen-2020-001214] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022] Open
Abstract
Total hip and total knee arthroplasty) remain important interventions to treat symptomatic knee and hip damage in patients with rheumatoid arthritis, with little change in utilisation rates despite the increasingly widespread use of potent conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and targeted DMARDs including Janus kinase inhibitors and biologics. The majority of patients are receiving these immunosuppressing medications and glucocorticoids at the time they present for arthroplasty. There is minimal randomised controlled trial data addressing the use of DMARDs in the perioperative period, yet patients and their physicians face these decisions daily. This paper reviews what is known regarding perioperative management of targeted and csDMARDs and glucocorticoids.
Collapse
Affiliation(s)
- Susan M Goodman
- Department of Medicine, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Michael D George
- Department of Biostatistics, Epidemiology and Informatics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
35
|
Portney DA, Baker HP, Boyle MM, Barbosa VH, Luu HH. Drug Reaction with Eosinophilia and Systemic Syndrome in Revision Arthroplasty for a Prosthetic Knee Infection: A Case Report. JBJS Case Connect 2021; 11:e20.00805. [PMID: 34038391 DOI: 10.2106/jbjs.cc.20.00805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 51-year-old woman underwent stage I of a 2-stage revision for a prosthetic knee infection with a vancomycin-impregnated articulating cement spacer followed by IV vancomycin and ceftriaxone. Four weeks later, she developed fevers, a diffuse cutaneous eruption, lymphadenopathy, transaminitis, and acute renal tubular necrosis before being diagnosed with drug reaction with eosinophilia and systemic syndrome (DRESS). CONCLUSION DRESS is a rare, potentially life-threatening adverse drug reaction with cutaneous manifestations and multiorgan involvement. Although rare, its incidence in orthopaedic patients is likely to increase with the aging population. It must be recognized early to minimize end-stage organ dysfunction and mortality.
Collapse
Affiliation(s)
- Daniel A Portney
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | - Hayden P Baker
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | - Margaret M Boyle
- Department of Dermatology, University of Chicago, Chicago, Illinois
| | | | - Hue H Luu
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| |
Collapse
|
36
|
Tung KK, Lee YH, Lin CC, Lee CH, Lin MC, Wei JCC. Opposing Trends in Total Knee and Hip Arthroplasties for Patients With Rheumatoid Arthritis vs. the General Population-A 14-Year Retrospective Study in Taiwan. Front Med (Lausanne) 2021; 8:640275. [PMID: 33959623 PMCID: PMC8095393 DOI: 10.3389/fmed.2021.640275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/24/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: To determine the trend of incidence rate of total knee arthroplasty (TKA), total hip arthroplasty (THA), and TKA or THA (major joint arthroplasty, MJA) among rheumatoid arthritis (RA) population and compared them with general population (GP) in Taiwan. Methods: Incidence rates and trends of TKA, THA, and MJA were determined over a 14-year period (2000–2013) among RA patients and compared them with GP. RA of patients was diagnosed based on the ACR 1987 criteria and extracted from GP. Subanalyses of incidences of TKA, THA, and MJA by year, 10-year age group, and gender were further conducted for demographic analysis. Patient profiles were extracted from the National Health Insurance Research Database (NHIRD) for interrupted time-series analysis and cohort studies. Results: Patients enrolled were 168,457 receiving TKA, 64,543 receiving THA, and 228,191 receiving MJA surgery. Incidences of TKA, THA, and MJA in RA patients were significantly lower by 49.0, 41.5, and 41.0% compared with concomitantly rises in GP by 131.0, 25.1, and 90.0% among the GP during the study period. The dominant age population for TKA, THA, and MJA were those aged 70–79 years in both GP and RA groups. Conclusions: We found an opposing trend in incidence of TKA, THA, and MJA between RA patients and the GP. The possible influence of pharmacological treatment is implicated for the lower incidence rates of TKA, THA, and MJA surgeries among RA patients.
Collapse
Affiliation(s)
- Kuan-Kai Tung
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yung-Heng Lee
- Department of Senior Services Industry Management, Minghsin University of Science and Technology, Hsinchu, Taiwan.,Department of Recreation and Sport Management, Shu-Te University, Kaohsiung, Taiwan.,Department of Orthopedics, Cishan Hospital, Ministry of Health and Welfare, Kaohsiung, Taiwan
| | - Chuan-Chao Lin
- Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Cheng-Hung Lee
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Food Science and Technology, Hung Kuang University, Taichung, Taiwan
| | - Mei-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Department of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| |
Collapse
|
37
|
Hald JT, Hesselvig AB, Jensen AK, Odgaard A. Revision for periprosthetic joint infection rate stratified by seasonality of operation in a national population of total and unicompartmental knee arthroplasty patients: a register-based analysis. J Bone Jt Infect 2021; 6:111-117. [PMID: 34084699 PMCID: PMC8129906 DOI: 10.5194/jbji-6-111-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/22/2021] [Indexed: 11/30/2022] Open
Abstract
Aim: The aim of this study was to investigate whether the revision rate for
periprosthetic joint infection (PJI) depends on the season of the primary
procedure using a national population of knee arthroplasty (KA) patients.
Seasonal variation of some surgical procedures has been observed to impact
subsequent infection risks, with a higher risk of revision for surgeries performed during summer, but an analysis of PJI rates based on a national arthroplasty register has yet to be completed. We hypothesized that an
increased risk of revision due to PJI could be demonstrated in a national
population when primary surgery was performed during the summer.
Methods: The Danish Knee Arthroplasty Registry (DKR) was used to determine the risk
of revision due to PJI within 2 years after primary surgery. All primary KA
procedures between 1 January 1997 and 31 December 2014 and revisions until 31 December 2016 were identified. Smoothing spline
regression was used to identify possible seasonal pattern effects of the primary procedure on revision risk, and logistic regression was used to calculate risk of infection differences between seasons.
Results: A total number of 124 809 primary procedures was registered in the study period. After excluding duplicates and matching primary procedures with the first revisions within 2 years after the primary procedure, 3391 were
identified. Of these, 348 cases were recorded with an indication of deep
infection requiring revision. Spline regression analyses did not demonstrate
any clear seasonal pattern of the primary procedure regarding the risk of
revision for infection or any other cause. Logistic regression found a
decreased risk of revision for infection when the primary procedure was
performed during the summer in the years 1997 to 2005, no influence on the risk of revision for infection in 2005 to 2012, and an increased risk of
revision for infection following summer procedures during the years 2013 to
2014.
Conclusion: It was not possible to demonstrate a consistent seasonal variation of the
risk of revision for PJI following primary KA. This is most likely because
the underlying etiologies for PJI are not subject to seasonal variation.
Collapse
Affiliation(s)
- Julius Tetens Hald
- Department of Orthopedic Surgery, Copenhagen University Hospital Herlev-Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - Anne Brun Hesselvig
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Henrik Harpestrengsvej 4A, 2100 Copenhagen Ø, Denmark
| | - Andreas Kryger Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen K, Denmark
| | - Anders Odgaard
- Department of Orthopaedic Surgery, Rigshospitalet Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
38
|
Ardeljan AD, Polisetty TS, Palmer JR, Toma JJ, Grewal G, Roche MW. Pigmented Villonodular Synovitis of the Hip in Patients Undergoing Total Hip Arthroplasty: A Retrospective Case-Controlled Analysis. J Arthroplasty 2021; 36:1018-1022. [PMID: 32978024 DOI: 10.1016/j.arth.2020.08.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Pigmented villonodular synovitis (PVNS) is a condition affecting larger joints such as the hip and knee. Little is known regarding the impact of PVNS on total hip arthroplasty (THA). Therefore, the aim of this study is to determine if patients with PVNS of the hip undergoing primary THA experience greater (1) in-hospital lengths of stay (LOS); (2) complications; (3) readmission rates; and (4) costs. METHODS Patients undergoing primary THA for PVNS of the hip from the years 2005 to 2014 were identified using a nationwide claims registry. PVNS patients were matched to a control cohort in a 1:5 ratio by age, gender, and various comorbidities. The query yielded 7440 patients with (n = 1240) and without (n = 6200) PVNS of the hip undergoing primary THA. Endpoints analyzed included LOS, complications, readmission rates, and costs. Multivariate logistic regression was used to determine odds ratios (OR) of developing complications. Welch's t-tests were used to test for significance in LOS and cost between the cohorts. A P-value less than .001 was considered statistically significant. RESULTS PVNS patients had approximately 8% longer in-hospital LOS (3.8 vs 3.5 days, P = .0006). PVNS patients had greater odds of (OR 1.60, P < .0001) medical and (OR 1.81, P < .0001) implant-related complications. Furthermore, PVNS patients were found to have higher odds (OR 1.84, P < .0001) of 90-day readmissions. PVNS patients also incurred higher day of surgery ($13,119 vs $11,983, P < .0001) and 90-day costs ($17,169 vs $15,097, P < .0001). CONCLUSION Without controlling for global trends in LOS, complications, readmissions, or costs between 2005 and 2014, the findings of the study suggest that PVNS of the hip is associated with worse outcomes and higher costs following primary THA. The study is useful as orthopedic surgeons can use the study to educate patients of the complications which may occur following their hip surgery.
Collapse
Affiliation(s)
- Andrew D Ardeljan
- Nova Southeastern College of Osteopathic Medicine, Fort Lauderdale, FL; Department of Orthopaedic Research, Orthopaedic Research Institute, Fort Lauderdale, FL
| | - Teja S Polisetty
- Department of Orthopaedic Research, Orthopaedic Research Institute, Fort Lauderdale, FL; Harvard Medical School, Harvard University, Boston, MA
| | - Joseph R Palmer
- Department of Orthopaedic Surgery, Broward Health Medical Center, Fort Lauderdale, FL
| | - Justin J Toma
- Department of Orthopaedic Research, Orthopaedic Research Institute, Fort Lauderdale, FL
| | - Gagan Grewal
- Department of Orthopaedic Research, Orthopaedic Research Institute, Fort Lauderdale, FL
| | - Martin W Roche
- Department of Orthopaedic Research, Orthopaedic Research Institute, Fort Lauderdale, FL
| |
Collapse
|
39
|
Zhai K, Ma W, Huang T. Hot spots and trends in knee revision research since the 21st century: a bibliometric analysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:388. [PMID: 33842609 PMCID: PMC8033385 DOI: 10.21037/atm-20-3969] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background With the popularization of knee replacement surgery in the treatment of the advanced lesions of knee joint, the amount of knee revision surgery is increasing unceasingly. Meanwhile, the continuous introduction of new clinical concepts and new technology poses a challenge to researchers and surgeons. Our study aims to inform the future scientific research and clinical treatment, by investigating the hot spots and trends of the knee revision research field with the method of bibliometric analysis. Methods Publications on knee revision included in the database of Web of Science Core Collection (WoSCC) between 2000 and 2018 were reviewed and MeSH terms of them were extracted from PubMed. Online bibliometric analysis website (http://bibliometric.com/), two pieces of software called “CiteSpace” and “Bibliographic Item Co-Occurrence Matrix Builder” (BICOMB) were used to analyze the publications reviewed at quantitative level. Another piece of software called “gCLUTO”, was used to investigate the hot spots with visualization techniques at qualitative level. Results A total of 906 publications were retrieved between 2000 and 2018. There is an increasing number of publications, from 15 in 2000 to 86 in 2018. Journal of Arthroplasty is the leading journal which has the most publications on knee revision. The United States has been the biggest contributor. Mayo Clinic became the leader among the institutions which have conducted correlational researches. David G. Lewallen, Robert L. Barrack and Michael A. Mont should be regarded as the scholars who have made outstanding contribution. Hot spots were summed up in six clusters, respectively, the solutions for infection, prostheses, the adverse effects, the surgical techniques, epidemiological characters, and the pathophysiology of the revision knee. Conclusions We found a growing trend in knee revision research and extracted the most contributive researchers, institutions, countries, journals, and most-cited articles worldwide. The solutions for complications, surgical applications and analysis for epidemiological characters have been the hot spots. Multi-disciplinary integration is becoming the time-trend of hot spots. Minimally invasive and navigation are directions of revision surgery. They together constitute a solid foundation and set up a fingerpost for the future scientific research and clinical treatment.
Collapse
Affiliation(s)
- Kelei Zhai
- Department of Orthopedics, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Weifeng Ma
- Department of Orthopedics, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Tao Huang
- Department of Orthopedics, the First Affiliated Hospital of China Medical University, Shenyang, China
| |
Collapse
|
40
|
Ren Y, Yang Q, Luo T, Lin J, Jin J, Qian W, Weng X, Feng B. 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. J Orthop Surg Res 2021; 16:84. [PMID: 33504345 PMCID: PMC7839203 DOI: 10.1186/s13018-021-02232-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/14/2021] [Indexed: 12/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Yi Ren
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, 100730, China
| | - Qi Yang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, 100730, China.,Department of Orthopedics, First Hospital of Harbin, Harbin, China
| | - Tim Luo
- Doctor of Medicine Program, University of Alberta, Edmonton, AB, Canada
| | - Jin Lin
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, 100730, China
| | - Jin Jin
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, 100730, China
| | - Wenwei Qian
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, 100730, China
| | - Xisheng Weng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, 100730, China
| | - Bin Feng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
41
|
Wang Y, Zhu LY, Deng HB, Yang X, Wang L, Xu Y, Wang XJ, Pang D, Sun JH, Cao J, Liu G, Liu Y, Ma YF, Wu XJ. Quality appraisal of clinical guidelines for venous thromboembolism prophylaxis in patients undergoing hip and knee arthroplasty: a systematic review. BMJ Open 2020; 10:e040686. [PMID: 33303451 PMCID: PMC7733196 DOI: 10.1136/bmjopen-2020-040686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/25/2020] [Accepted: 11/05/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) occurs in up to 40%-80% of patients after hip and knee arthroplasty. Clinical decision-making aided by guidelines is the most effective strategy to reduce the burden of VTE. However, the quality of guidelines is dependent on the strength of their evidence base. The objective of this article is to critically evaluate the quality of VTE prevention guidelines and the strength of their recommendations in VTE prophylaxis in patients undergoing hip and knee arthroplasty. METHODS Relevant literature up to 16 March 2020 was systematically searched. We searched databases such as Web of Science, PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, China National Knowledge Infrastructure and WanFang and nine guidelines repositories. The identified guidelines were appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation II and appraised the strength of their recommendations independently. Following quality assessment, a predesigned data collection form was used to extract the characteristics of the included guideline. RESULTS We finally included 15 guidelines. Ten of the included guidelines were rated as 'recommended' or 'recommended with modifications'. The standardised scores were relatively high in the domains of Clarity of Presentation, and Scope and Purpose. The lowest average standardised scores were observed in the domains of Applicability and Stakeholder Involvement. In reference to the domains of Rigour of Development and Editorial Independence, the standardised scores varied greatly between the guidelines. The agreement between the two appraisers is almost perfect (intraclass correlation coefficients higher than 0.80). A considerable proportion of the recommendations is based on low-quality or very-low-quality evidence or is even based on working group expert opinion. CONCLUSIONS In summary, the majority of the recommendations are based on low-quality evidence, and further confirmation is needed. Furthermore, guideline developers should pay more attention to methodological quality, especially in the Stakeholder Involvement domain and the Applicability domain.
Collapse
Affiliation(s)
- Yu Wang
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Li-Yun Zhu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Hai-Bo Deng
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xu Yang
- Department of Orthopedic Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lei Wang
- Department of Vascular Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yuan Xu
- Department of Orthopedic Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiao-Jie Wang
- Department of Breast Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Dong Pang
- School of Nursing, Peking University, Beijing, China
- Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, Peking University Health Science Centre, Beijing, China
| | - Jian-Hua Sun
- Intensive Care Unit, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Cao
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ge Liu
- Department of Neurological Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ying Liu
- Department of General Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yu-Fen Ma
- Outpatient Department, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xin-Juan Wu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| |
Collapse
|
42
|
Chen CH, Chen TH, Lin YS, Chen DW, Sun CC, Kuo LT, Shao SC. The impact of systemic lupus erythematosus on the risk of infection after total hip arthroplasty: a nationwide population-based matched cohort study. Arthritis Res Ther 2020; 22:214. [PMID: 32928288 PMCID: PMC7488693 DOI: 10.1186/s13075-020-02300-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/24/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND We aimed to assess the impact of systemic lupus erythematosus (SLE) on the risk of infection after total hip arthroplasty (THA). METHODS We identified patients undergoing primary THA (1996-2013) in Taiwan National Health Insurance Research Database (NHIRD). Patients were then divided into the SLE and control groups according to the diagnosis of SLE. We used 1:1 propensity score to match the control to the SLE group by age, sex, and comorbidities. The primary outcome was infection, including early and late superficial wound infection and periprosthetic joint infection (PJI). The secondary outcome was in-hospital complications. RESULTS We enrolled 325 patients in each group. In the primary outcome, the incidence of early superficial wound infection and PJI was comparable between the SLE and matched-control group. However, the incidence of late superficial wound infection and PJI in the SLE group was higher than that in matched-control group (11.4% vs. 5.5%, P = 0.01; 5.2% vs 2.2%, P = 0.04, respectively). Furthermore, the SLE group had a higher risk for late superficial wound infection and PJI (hazard ratio = 2.37, 95% confidence interval (CI) 1.35-4.16; HR = 2.74, 95% CI 1.14-6.64, respectively) than the matched-control. Complications other than infection and in-hospital mortality cannot be compared because of very low incidence. CONCLUSIONS SLE is a risk factor for developing late superficial wound infection and PJI, but not for early postoperative complications following THA. Clinical presentations should be monitored to avoid misdiagnosis of PJI in SLE patients after THA.
Collapse
Affiliation(s)
- Chien-Hao Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Keelung, Taiwan.,Biostatistical Consultation Center of Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Dave W Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chi-Chin Sun
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan.,Department of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Medical Research and Development, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Liang-Tseng Kuo
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan. No. 6 West Sec, Chia-Pu Road, Putz City, Chiayi, Taiwan. .,Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Shih-Chieh Shao
- Biostatistical Consultation Center of Chang Gung Memorial Hospital, Keelung, Taiwan.,Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
43
|
Morse KW, Heinz NK, Abolade JM, Wright-Chisem JI, Russell LA, Zhang M, Mirza SZ, Orange DE, Figgie MP, Sculco PK, Goodman SM. Tranexamic Acid Does Not Reduce the Risk of Transfusion in Rheumatoid Arthritis Patients Undergoing Total Joint Arthroplasty. J Arthroplasty 2020; 35:2367-2374. [PMID: 32423756 PMCID: PMC11334526 DOI: 10.1016/j.arth.2020.04.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) receive transfusions more often than patients with osteoarthritis following lower extremity total joint arthroplasty (TJA), but mitigating factors are not described. Tranexamic acid (TXA) is widely used to reduce blood loss in patients undergoing TJA, but its effect on transfusion rates in patients with RA has not been studied. METHODS We retrospectively reviewed data from a prospectively collected cohort of patients with RA undergoing TJA. Disease activity measured by Clinical Disease Activity Index, patient-reported outcome measures, and serologies was obtained. Baseline characteristics were summarized and compared. Transfusion requirements and TXA usage were obtained from chart review. Logistic regression was used to determine factors associated with transfusion in RA patients undergoing TJA. RESULTS The cohort included 252 patients, mostly women with longstanding RA and end-stage arthritis requiring TJA. In multivariate analysis, 1 g/dL decrease in baseline hemoglobin (odds ratio [OR] = 0.394, 95% confidence interval [CI] [0.232, 0.669], P = .001), 1-minute increase in surgical duration (OR = 1.022, 95% CI [1.008, 1.037], P = .003), and 1-point increase in Clinical Disease Activity Index (OR = 1.079, 95% CI [1.001, 1.162]) were associated with increased risk of transfusion. TXA use was not associated with decreased risk of postoperative transfusion. CONCLUSIONS Preoperative health optimization should include assessment and treatment of anemia in RA patients before TJA, as preoperative hemoglobin level is the main risk factor for postoperative transfusion. Increased disease activity and increased surgical time were independent risk factors for postoperative transfusion but are less modifiable. While TXA did not decrease transfusion risk in this population, a prospective trial is needed to confirm this. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Kyle W Morse
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Nicole K Heinz
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Jeremy M Abolade
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Linda A Russell
- Department of Rheumatology, Hospital for Special Surgery, New York, NY
| | - Meng Zhang
- Feinstein Institute, Northwell Health, Manhasset, NY
| | - Serene Z Mirza
- Department of Rheumatology, Hospital for Special Surgery, New York, NY
| | - Dana E Orange
- Department of Rheumatology, Hospital for Special Surgery, New York, NY; Laboratory of Molecular Neurooncology, Rockefeller University, New York, NY
| | - Mark P Figgie
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Susan M Goodman
- Department of Rheumatology, Hospital for Special Surgery, New York, NY
| |
Collapse
|
44
|
Goodman SM, Mirza SZ, DiCarlo EF, Pearce-Fisher D, Zhang M, Mehta B, Donlin LT, Bykerk VP, Figgie MP, Orange DE. Rheumatoid Arthritis Flares After Total Hip and Total Knee Arthroplasty: Outcomes at One Year. Arthritis Care Res (Hoboken) 2020; 72:925-932. [PMID: 31609524 PMCID: PMC7153968 DOI: 10.1002/acr.24091] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/08/2019] [Indexed: 12/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Susan M. Goodman
- Hospital for Special Surgery, New York, New York
- Weill Cornell Medical College, New York, New York
| | | | | | | | - Meng Zhang
- The Feinstein Institute for Medical Research, Northwell Health
| | - Bella Mehta
- Hospital for Special Surgery, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Laura T. Donlin
- Hospital for Special Surgery, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Vivian P. Bykerk
- Hospital for Special Surgery, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Mark P. Figgie
- Hospital for Special Surgery, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Dana E. Orange
- Hospital for Special Surgery, New York, New York
- Rockefeller University, New York, New York
| |
Collapse
|
45
|
Komnos GA, Manrique J, Goswami K, Tan TL, Restrepo C, Sherman MB, Parvizi J. Periprosthetic Joint Infection in Patients Who Have Multiple Prostheses in Place: What Should Be Done with the Silent Prosthetic Joints. J Bone Joint Surg Am 2020; 102:1160-1168. [PMID: 32618923 DOI: 10.2106/jbjs.18.01500] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although periprosthetic joint infection (PJI) can affect multiple joints concurrently, the majority of patients with multiple prosthetic joints present with PJI of a single joint. Data regarding the optimal management of these patients are limited. We aimed to identify the prevalence, risk factors for a subsequent PJI, and clinical circumstances of PJI in patients with multiple prosthetic joints. METHODS We retrospectively reviewed the clinical records of 197 patients with ≥2 total joint prostheses in place who presented with PJI from 2000 to 2017. The average follow-up was 3.6 years (range, 0.5 to 17 years). Demographic data and risk factors for synchronous or metachronous PJI were identified. The time from the initial to the second PJI and organism profile data were collected as well. The workup for other joints with a prosthesis in place at the time of the initial PJI was noted. RESULTS Among the 197 patients with PJI and multiple joint prostheses in situ, 37 (19%) developed PJI in another joint; 11 had a synchronous PJI and 26 had a metachronous PJI. The average time between the first and the second infection in the metachronous cases was 848 days (range, 20 to 3,656 days). Females and patients with an initial PJI with methicillin-resistant Staphylococcus aureus (MRSA) were more likely to have a metachronous PJI, and patients with rheumatoid arthritis had an increased risk of a second (metachronous or synchronous) PJI. Three of 11 patients in the synchronous group and 19% (5) of the 26 in the metachronous group had bacteremia at the time of the initial PJI compared with 12% (19) of the 160 with a single PJI. The percentage of negative cultures increased from 10% for the initial PJIs to 38% for the metachronous PJIs. CONCLUSIONS Patients who have multiple prosthetic joints in place and present with PJI of a single joint are at risk of developing PJI in another joint. Female sex, rheumatoid arthritis, bacteremia at presentation, and infection with MRSA appear to be risk factors for PJI of another joint. Clinical evaluation of the other prosthetic joint(s) should be carried out in all patients and aspiration of those joint(s) should be considered for patients with any of the above risk factors. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- George A Komnos
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jorge Manrique
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Timothy L Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew B Sherman
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| |
Collapse
|
46
|
Kittle H, Ormseth A, Patetta MJ, Sood A, Gonzalez MH. Chronic Corticosteroid Use as a Risk Factor for Perioperative Complications in Patients Undergoing Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e2000001. [PMID: 32672719 PMCID: PMC7366416 DOI: 10.5435/jaaosglobal-d-20-00001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/22/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Osteoarthritis may be caused by or concurrent with diseases such as rheumatoid arthritis or systemic lupus erythematosus, which rely on chronic corticosteroids regimens for treatment. If a total knee or hip arthroplasty is needed, this chronic treatment method has been associated with poorer surgical outcomes. METHODS A retrospective analysis of data collected by the American College of Surgeons National Surgical Quality Improvement Program was conducted. The Current Procedural Terminology codes were used to identify 403,566 total knee arthroplasty and total hip arthroplasty patients who were then stratified by the use of chronic corticosteroids for univariate analysis. RESULTS Forteen thousand seven hundred seventy-four of the patients identified were prescribed chronic corticosteroid regimens. A statistically significant difference was observed in perioperative complications for patients prescribed with corticosteroids, including higher rates of surgical site infection (P = 0.0001), occurrence of deep incisional surgical site infection (P < 0.0001), occurrences of organ space surgical site infection (P < 0.0001), wound dehiscence (P < 0.0001), general would infection (P < 0.0001), pneumonia (P < 0.0001), occurrences of unplanned intubation (P = 0.0002), urinary tract infection (P < 0.0001), and readmission (P < 0.0001). No statistically significant difference was observed in the 30-day mortality between the 2 groups (0.63), venous thromboembolic event (0.42), cerebrovascular accident (0.12), myocardial infarction (0.49), cardiac arrest (0.098), deep vein thrombosis (0.17), or sepsis (0.52). CONCLUSION Many of the notable differences in complications may be directly attributed to the immunosuppressive nature of corticosteroids. With increased knowledge of which perioperative complications to monitor, surgeons can tailor treatment strategies to this population that reduce morbidity and improve outcomes.
Collapse
Affiliation(s)
- Haley Kittle
- From the Department of Orthopaedics, University of Illinois College of Medicine (Ms. Kittle and Dr. Ormseth), and the Department of Orthopaedics, University of Illinois College of Medicine (Dr. Patetta, Dr. Sood, and Dr. Gonzalez), Chicago, IL
| | | | | | | | | |
Collapse
|
47
|
Anti-rheumatic treatment and prosthetic joint infection: an observational study in 494 elective hip and knee arthroplasties. BMC Musculoskelet Disord 2020; 21:410. [PMID: 32600315 PMCID: PMC7325063 DOI: 10.1186/s12891-020-03459-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 06/24/2020] [Indexed: 11/27/2022] Open
Abstract
Background Surgical site infections are more frequent among patients with rheumatic disease. To what extent this is related to immunosuppressive antirheumatic drugs is unclear, as is the value of discontinuing medication perioperatively. The aim of study was to assess the rate of surgical site infections after knee and hip replacement in patients with inflammatory joint disease, with an emphasis on periprosthetic joint infection, and to investigate the influence of treatment with disease-modifying antirheumatic drugs (DMARDs) in this regard. Methods Data were collected from 494 primary elective hip (51.4%) and knee arthroplasties, along with demographic and medication data. The primary outcome was surgical site infection during the first year after surgery. Results In 78% (n = 385) of the cases the patient used 1 to 3 disease-modifying antirheumatic drugs perioperatively. Thirty-two percent (n = 157) of patients used a TNF-alpha inhibitor. The rate of surgical site infection was 3.8% (n = 19). The rate of periprosthetic joint infection was 1.4% (n = 7), all of which occurred after knee arthroplasty. Periprosthetic joint infection occurred in only 1 patient medicating perioperatively with a TNF-alpha inhibitor. Conclusion Surgical site infections were not associated with ongoing medication with disease-modifying antirheumatic drugs. Due to the low event rate this should be interpreted with caution, but our center will maintain its routine of continuing treatment with TNF-alpha inhibitors perioperatively.
Collapse
|
48
|
Thomas K, Vassilopoulos D. Infections in Patients with Rheumatoid Arthritis in the Era of Targeted Synthetic Therapies. Mediterr J Rheumatol 2020; 31:129-136. [PMID: 32676571 PMCID: PMC7361184 DOI: 10.31138/mjr.31.1.129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/15/2022] Open
Abstract
The third decade of the 21st century marks the beginning of a new era in the treatment of rheumatoid arthritis (RA). Recently, after the introduction in clinical practice of different biologics in the first decade, three different oral synthetic targeted agents (JAK inhibitors) have been licensed for the treatment of RA, in patients who had failed or are intolerant to disease modifying anti-rheumatic drugs (DMARDs). Despite the significant progress that these agents bring to the care of RA patients, the risk of infections is still present and clear, given that their risk for serious infections is at least comparable with that of biologic DMARDs, whereas the incidence of herpes zoster is higher than that of bDMARDs. Here, we review the most recent data regarding the risk for serious and opportunistic infections in RA patients treated with biologics or JAK inhibitors, as well the up-to-date approach for managing and preventing such infections in RA patients.
Collapse
Affiliation(s)
- Konstantinos Thomas
- 4 Department of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Vassilopoulos
- Clinical Immunology-Rheumatology Unit, 2 Department of Medicine and Laboratory, Hippokration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| |
Collapse
|
49
|
George MD, Baker JF, Winthrop KL, Goldstein SD, Alemao E, Chen L, Wu Q, Xie F, Curtis JR. Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery. Ann Rheum Dis 2020; 79:573-580. [PMID: 32209540 PMCID: PMC7171699 DOI: 10.1136/annrheumdis-2019-216802] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The impact of immunosuppression on postoperative outcomes has primarily been studied in patients undergoing joint replacement surgery. We aimed to evaluate the impact of biologics and glucocorticoids on outcomes after other major surgeries. METHODS This retrospective cohort study used Medicare data 2006-2015 to identified adults with rheumatoid arthritis undergoing hip fracture repair, abdominopelvic surgery (cholecystectomy, hysterectomy, hernia, appendectomy, colectomy) or cardiac surgery (coronary artery bypass graft, mitral/aortic valve). Logistic regression with propensity-score-based inverse probability weighting compared 90-day mortality and 30-day readmission in patients receiving methotrexate (without a biologic or targeted synthetic disease-modifying antirheumatic drug (tsDMARD)), a tumour necrosis factor inhibitor (TNFi) or a non-TNFi biologic/tsDMARD <8 weeks before surgery. Similar analyses evaluated associations between glucocorticoids and outcomes. RESULTS We identified 10 777 eligible surgeries: 3585 hip fracture, 5025 abdominopelvic and 2167 cardiac surgeries. Compared with patients receiving methotrexate, there was no increase in the risk of 90-day mortality or 30-day readmission among patients receiving a TNFi (mortality adjusted OR (aOR) 0.83 (0.67 to 1.02), readmission aOR 0.86 (0.75 to 0.993)) or non-TNFi biologic/tsDMARD (mortality aOR 0.78 (0.49 to 1.22), readmission aOR 1.02 (0.78 to 1.33)). Analyses stratified by surgery category were similar. Risk of mortality and readmission was higher with 5-10 mg/day of glucocorticoids (mortality aOR 1.41 (1.08 to 1.82), readmission aOR 1.26 (1.05 to 1.52)) or >10 mg/day (mortality aOR 1.64 (1.02 to 2.64), readmission aOR 1.60 (1.15 to 2.24)) versus no glucocorticoids, although results varied when stratifying by surgery category. CONCLUSIONS Recent biologic or tsDMARD use was not associated with a greater risk of mortality or readmission after hip fracture, abdominopelvic or cardiac surgery compared with methotrexate. Higher dose glucocorticoids were associated with greater risk.
Collapse
Affiliation(s)
- Michael D George
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua F Baker
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Rheumatology, Philadelphia VAMC, Philadelphia, Pennsylvania, USA
| | - Kevin L Winthrop
- Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Seth D Goldstein
- Surgery, Northwestern University, Evanston, Illinois, USA
- Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - E Alemao
- Bristol-Myers Squibb, Princeton, New Jersey, USA
| | - Lang Chen
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Qufei Wu
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fenglong Xie
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
50
|
Moon JK, Jung JW, Kim Y, Yang JH, Park YS, Kim YH. Acetabular cup migration after primary cementless total hip arthroplasty in rheumatoid arthritis and its influencing factors: a comparative study with osteoarthritic hip. INTERNATIONAL ORTHOPAEDICS 2020; 44:1047-1053. [PMID: 32076792 DOI: 10.1007/s00264-020-04502-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/04/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the radiographic migration profiles of primary cementless total hip arthroplasty (THA) between patients with rheumatoid arthritis (RA) and those with osteoarthritis (OA). METHODS A total of 197 patients (215 hips) who underwent cementless THA for RA or OA between January 2001 and January 2013 and followed up for a minimum of 5.5 years were included. Ninety-four RA patients (109 hips) were compared with 103 OA patients (106 hips). Radiological evaluation was performed for acetabular cup loosening, and cup migration was measured using Einzel-Bild-Röntgen-Analyse (EBRA) software. Multiple variables were assessed to identify influencing factors for cup migration. RESULTS Early cup migration was observed in 13 hips (11.9%) in the RA group and four hips (3.8%) in the OA group, showing a significant difference (p = 0.041). Acetabular cup loosening occurred in three cups (2.8%) in the RA group and in one cup (0.9%) in the OA group, showing no significant difference (p = 0.321). Total cup migration was higher in the RA group (2.62 mm) than in the OA group (1.44 mm, p = 0.005). Total cup migration was significantly higher in patients aged < 50 years than in those aged > 50 years (p = 0.005). Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody influenced total cup migration. Patients with seropositive RA showed significantly higher total cup migration and early cup migration incidence than those with seronegative RA (p = 0.005, p = 0.038, respectively). CONCLUSIONS Acetabular cups in primary cementless THAs of RA patients were less stable in terms of cup migration compared with that of OA patients.
Collapse
Affiliation(s)
- Jun-Ki Moon
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Gyomoon-dong 249-1, Guri, Gyunggi-do, 471-701, South Korea
| | - Ji-Won Jung
- Department of Orthopedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Yeesuk Kim
- Department of Orthopedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Jae-Hyuk Yang
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Gyomoon-dong 249-1, Guri, Gyunggi-do, 471-701, South Korea
| | - Ye-Soo Park
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Gyomoon-dong 249-1, Guri, Gyunggi-do, 471-701, South Korea
| | - Young-Ho Kim
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Gyomoon-dong 249-1, Guri, Gyunggi-do, 471-701, South Korea.
| |
Collapse
|