A Systematic Review and Meta-Analysis Comparing Complications Following Total Joint Arthroplasty for Rheumatoid Arthritis Versus for Osteoarthritis

University of Toronto, Toronto, Ontario, Canada. .
Arthritis & Rheumatology (Impact Factor: 7.76). 12/2012; 64(12):3839-49. DOI: 10.1002/art.37690
Source: PubMed


Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is based on studies of patients with osteoarthritis (OA), with little being known about outcomes in patients with rheumatoid arthritis (RA). The objective of the present study was to review the current evidence regarding rates of THA/TKA complications in RA versus OA.
Data sources used were Medline, EMBase, Cinahl, Web of Science, and reference lists of articles. We included reports published between 1990 and 2011 that described studies of primary total joint arthroplasty of the hip or knee and contained information on outcomes in ≥200 RA and OA joints. Outcomes of interest included revision, hip dislocation, infection, 90-day mortality, and venous thromboembolic events. Two reviewers independently assessed each study for quality and extracted data. Where appropriate, meta-analysis was performed; if this was not possible, the level of evidence was assessed qualitatively.
Forty studies were included in this review. The results indicated that patients with RA are at increased risk of dislocation following THA (adjusted odds ratio 2.16 [95% confidence interval 1.52-3.07]). There was fair evidence to support the notion that risk of infection and risk of early revision following TKA are increased in RA versus OA. There was no evidence of any differences in rates of revision at later time points, 90-day mortality, or rates of venous thromboembolic events following THA or TKA in patients with RA versus OA. RA was explicitly defined in only 3 studies (7.5%), and only 11 studies (27.5%) included adjustment for covariates (e.g., age, sex, and comorbidity).
The findings of this literature review and meta-analysis indicate that, compared to patients with OA, patients with RA are at higher risk of dislocation following THA and higher risk of infection following TKA.

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Available from: Bheeshma Ravi, Nov 08, 2015
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    • "A recent systematic review and meta-analysis indicate that, compared with osteoarthritis (OA) patients, patients with rheumatoid arthritis have a higher risk of infection following TKA7). "
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    ABSTRACT: Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). The demand for TKA is rapidly increasing, resulting in a subsequent increase in infections involving knee prosthesis. Despite the existence of common management practices, the best approach for several aspects in the management of periprosthetic knee infection remains controversial. This review examines the current understanding in the management of the following aspects of PJI: preoperative risk stratification, preoperative antibiotics, preoperative skin preparation, outpatient diagnosis, assessing for infection in revision cases, improving culture utility, irrigation and debridement, one and two-stage revision, and patient prognostic information. Moreover, ten strategies for the management of periprosthetic knee infection based on available literature, and experience of the authors were reviewed.
    Full-text · Article · Dec 2013
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    • "Modifiable risk factors should be identified in order to optimize surgical outcomes. A recent systematic review highlights that knowledge of TJA infection risk in RA is actually quite limited [6]. As well, the literature focuses on surgical site and prosthetic joint infections, and neglects the risk for infections of other sites which may complicate the hospital course. "
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    ABSTRACT: Determine risk factors for infection following hip or knee total joint arthroplasty in patients with rheumatoid arthritis. All rheumatoid arthritis patients with a hip or knee arthroplasty between years 2000 and 2010 were identified from population-based administrative data from the Calgary Zone of Alberta Health Services. Clinical data from patient charts during the hospital admission and during a one year follow-up period were extracted to identify incident infections. We identified 381 eligible procedures performed in 259 patients (72.2% female, mean age 63.3 years, mean body mass index 27.6 kg/m2). Patient comorbidities were hypertension (43.2%), diabetes (10.4%), coronary artery disease (13.9%), smoking (10.8%) and obesity (32%). Few infectious complications occurred: surgical site infections occurred within the first year after 5 procedures (2 joint space infections, 3 deep incisional infections). Infections of non-surgical sites (urinary tract, skin or respiratory, n=4) complicated the hospital admission. The odds ratio for any post-arthroplasty infection was increased in patients using prednisone doses exceeding 15 mg/day (OR 21.0, 95%CI 3.5-127.2, p=<0.001), underweight patients (OR 6.0, 95%CI 1.2-30.9, p=0.033) and those with known coronary artery disease (OR 5.1, 95%CI 1.3-19.8, p=0.017). Types of disease-modifying therapy, age, sex, and other comorbidities were not associated with an increased risk for infection. Steroid doses over 15 mg/day, being underweight and having coronary artery disease were associated with significant increases in the risk of post-arthroplasty infection in rheumatoid arthritis. Maximal tapering of prednisone and comorbidity risk reduction must be addressed in the peri-operative management strategy.
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    • "We suspect that all 20 of their reported 30-day mortality events (of 7,174 RA patients) came from one surgical site’s records during 1969 through 1997 [13,15], all before the dates of the current study. Similar power issues are found with the Ravi et al. [18] systematic review that showed no difference in mortality. "
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    ABSTRACT: Serious infection, cardiovascular disease, and mortality are increased in rheumatoid arthritis (RA). Whether RA impacts the risk for these complications following total joint arthroplasty (TJA) is unknown, we hypothesize it does. We compared the occurrence of 30-day postoperative complications and mortality in a large cohort of RA and osteoarthritis (OA) patients undergoing hip or knee TJA. Analyses included seven-year data from the Veterans Affairs Surgical Quality Improvement Program. 30-day complications were compared by diagnosis using logistic regression, and long-term mortality was examined using Cox proportional hazards regression. All analyses were adjusted for age, sex, and clustering by surgical site. Additional covariates included sociodemographics, comorbidities, health behaviors, and operative risk factors. There were 34,524 patients (839 RA, 33,685 OA) undergoing knee (65.9%) or hip TJA. Patients were 95.7% men with a mean (SD) age of 64.4 (10.7) years and had 3,764 deaths over a mean follow-up of 3.7 (2.3) years. Compared to OA patients, those with RA were significantly more likely to require a return to the operating room, odds ratio (OR) 1.45 (95% CI 1.08 to 1.94), but had similar rates of 30-day postoperative infection, OR 1.02 (0.72, 1.47), cardiovascular events, OR 0.69 (0.37, 1.28), and mortality, OR 0.94 (0.38, 2.33). RA was associated with a significantly higher long-term mortality, hazard ratio (HR) 1.22 (1.00, 1.49). In this study of U.S. veterans, RA patients were not at an increased risk for short-term mortality or other major complications following TJA, although they returned to the operating room more often and had increased long-term mortality.
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