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

Outcomes of Total Hip Arthroplasty in Seronegative Spondyloarthropathies: A Propensity-Matched Cohort Analysis

BACKGROUND

Total hip arthroplasty (THA) is a common surgical intervention for patients who have seronegative spondyloarthropathies (SpA). However, there is a paucity of literature addressing the outcomes of THA specifically in SpA patients. This study aimed to investigate both the short-term and long-term systemic and orthopaedic outcomes of THA in SpA patients as a whole, as well as within the individual subtypes of SpA.

METHODS

This retrospective cohort study used a federated health research network, identifying 3,074 SpA patients who underwent THA between 2005 and 2022. Propensity score matching was used to compare SpA and non-SpA patients, balancing baseline characteristics. Short-term (30 days, 180 days, and 1 year) and long-term (5 years) postoperative complications were analyzed. The outcomes included systemic and joint complications. Chi-square analyses were done to compare outcomes across categorical data.

RESULTS

The SpA patients had increased rates of revision THA, prosthetic dislocation, periprosthetic joint infection, and aseptic loosening at various postoperative intervals. Surgical site infections and myocardial infarctions were more frequent at 1 month, 6 months, and 1 year. Additionally, SpA patients exhibited a higher incidence of deep vein thrombosis at 6 months and 1 year. Subtype analysis revealed that ankylosing spondylitis patients were more likely to have revision surgery and prosthetic dislocation, while psoriatic arthritis patients had a lower risk of hip dislocation and femur fractures.

CONCLUSIONS

The SpA patients undergoing THA are at greater risk for systemic and orthopaedic complications compared to non-SpA patients. The increased incidence of infections, thromboembolic events, and prosthetic issues highlights the need for careful preoperative assessment and postoperative management.

Ulcerative Colitis Patients Are at Increased Risk for Adverse Events Following Total Hip Arthroplasty

BACKGROUND

Patients who have the autoinflammatory bowel disease ulcerative colitis (UC) may become candidates for total hip arthroplasty (THA). Having UC may predispose patients to postoperative adverse events, but it remains unclear if these events are related more to the disease process itself or perhaps related to the medications used to treat the condition.

METHODS

Patients undergoing THA were identified from a large administrative dataset. Those who did not have and those who had UC were matched 4:1 based on patient age, sex, and the Elixhauser Comorbidity Index. Matched THA patients who did not have UC (n = 19,482) and those who had UC (n = 4,874) were identified. The matched groups were compared regarding 90-day adverse and five-year survival. Further analyses were performed based on classes of medications.

RESULTS

Controlling for patient age, sex, and Elixhauser Comorbidity Index, UC patients were at significantly higher odds of 90-day adverse events: any (odds ratio [OR]: 1.59), severe (OR: 1.72), and minor (OR: 1.63) (all P < 0.001). Despite this, no differences in 5-year survival were identified. Relative to those who did not have UC, there were increasing odds of any adverse event based on the potency of related medications: no corticosteroids/immunomodulators/5-aminosalicylic acid (5-ASA) (OR: 1.42), corticosteroids only (OR: 1.58), 5-ASA ± corticosteroids OR (1.72), and immunomodulators ± corticosteroids (OR: 1.74, all P < 0.001).

CONCLUSIONS

Total hip arthroplasty patients who have UC were at higher odds for 90-day postoperative adverse events relative to those who did not have UC, and this risk was even greater for those on defined classes of medications. Total hip arthroplasty patients who have UC bear specific considerations, and surgeons must carefully consider and manage the patient's medication regimen in the perioperative period of the THA.

Data-Driven Approach to Development of a Risk Score for Periprosthetic Joint Infections in Total Joint Arthroplasty Using Electronic Health Records

BACKGROUND

Periprosthetic joint infection (PJI) is an uncommon, but serious complication in total joint arthroplasty. Personalized risk prediction and risk factor management may allow better preoperative assessment and improved outcomes. We evaluated different data-driven approaches to develop surgery-specific PJI prediction models using large-scale data from the electronic health records (EHRs).

METHODS

A large institutional arthroplasty registry was leveraged to collect data from 58,574 procedures of 41,844 patients who underwent at least one primary and/or revision hip and/or knee arthroplasty between 2000 and 2019. The registry dataset was augmented with additional clinical, procedural, and laboratory data from the EHRs for more than 100 potential predictor variables. The main outcome was PJI within the first year after surgery. We implemented both traditional and machine learning methods for model development (lasso regression, relaxed lasso regression, ridge regression, random forest, stepwise regression, extreme gradient boosting, neural network) and used 10-fold cross-validation to calculate measures of model performance in terms of discrimination (c-statistic) and calibration.

RESULTS

All models discriminated similarly in predicting PJI risk, with negligible differences of less than 0.08 between the best- and worst-performing models. The relaxed and fully relaxed lasso models using the Cox model structure outperformed the other models with concordances of 0.787 in primary hip arthroplasty and 0.722 in revision hip arthroplasty, with the number of predictors ranging from nine to 41. The concordances with the relaxed lasso models were 0.681 in primary and 0.699 in revision knee arthroplasty, with a higher number of predictors in the models. Predictors included in the models varied substantially across the four surgical groups.

CONCLUSIONS

The incorporation of additional data from the EHRs offers limited improvement in PJI risk stratification. Furthermore, improvement in PJI risk prediction was modest with the machine learning approaches and may not justify the added complexity.

Is synovectomy still of benefit today in total knee arthroplasty with rheumatoid arthritis?

PURPOSE

There is a lack of long-term data evaluating the impact of synovectomy versus no synovectomy during total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA). This study aimed to assess and compare bilateral TKA outcomes with and without synovectomy in the same patients over a similar follow-up period.

METHODS

A retrospective review was conducted on 65 bilateral staged posterior-stabilized (PS) fixed-bearing TKAs (28 men, 37 women) performed by a single surgeon on RA-affected knees, with an average follow-up of 17 years (range: 15-24 years). In the first knee, synovectomy was performed during TKA, while no synovectomy for the contralateral TKA. Outcomes assessed included Knee Society scores for knee and function, radiographic findings, complications, and patellar position using the Insall-Salvati ratio.

RESULTS

The synovectomy group had a higher rate of blood transfusion (23.3% vs. 16.6%; P < 0.01) and longer hospital stays (mean 9.60 days [95% CI: 6.56-13.63] vs. 6.51 days [95% CI: 5.50-9.52]; P < 0.001). The group without synovectomy demonstrated significantly better Knee Society Scores (89.1 vs. 80.2 points; P = 0.02) and greater range of motion (ROM) for flexion (130° vs. 102°; P = 0.01). Both groups had similar knee alignment, stability, and femoral and tibial component alignment. Patella baja was observed in six patients in the synovectomy group. Severe haematoma (n = 6) and deep infections (n = 4) were noted exclusively in the synovectomy group. Kaplan-Meier survivorship at 15 years was 81% (95% CI: 78-95) for TKA with synovectomy and 95% (95% CI: 90-100) for TKA without synovectomy.

CONCLUSION

Knees undergoing synovectomy during primary TKA exhibited reduced knee flexion, inferior Knee Society pain scores, and higher complication rates compared to contralateral knees without synovectomy. Omitting synovectomy in RA patients did not increase the risk of implant loosening.

Advances in the Medical Treatment of Rheumatoid Arthritis

Rheumatoid arthritis is a common, chronic autoimmune disease. Its clinical presentation includes both articular and extra-articular manifestations. The past few decades have seen significant developments in our understanding of RA pathogenesis, leading to the development of effective novel targeted treatment options. This article reviews the clinical presentation, pathogenesis, and treatment of RA, along with specific treatment considerations related to reproductive health, vaccination, and the perioperative period.

Perioperative Nursing Management of Patients With Rheumatoid Arthritis Undergoing Total Joint Arthroplasty

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes joint inflammation, pain, and potential disability. Patients with RA have unique needs when undergoing total joint arthroplasty (TJA). Careful and comprehensive evaluation and management includes physical assessment, patient history, and knowledge about the medication regimen in the setting of elective TJA. Nursing care is critical to patients with RA in the perioperative period. Nursing interventions can improve patient outcomes and reduce potential risks related to the RA and the surgical procedure. Registered nurses must be knowledgeable about the pathophysiology and pharmacological management of patients with RA to provide appropriate nursing care.

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

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

Update on Perioperative Medication Management for the Hand Surgeon: A Focus on Diabetes, Weight Loss, Rheumatologic, and Antithrombotic Medications

Diabetes mellitus and obesity are growing health concerns. New pharmacologic interventions have recently begun to play a more notable role in the treatment pathway of these separate but related conditions. In particular, glucagon-like peptide-1 receptor agonists, such as semaglutides (Ozempic, Wegovy) and tirzepatide (Mounjaro), and sodium glucose co-transporter 2 inhibitors, such as dapagliflozin (Farxiga) and empagliflozin (Jardiance), have emerged as treatment options. Multiple clinical trials have demonstrated their efficacy in regulating metabolism, improving glycemic control, and managing long-term weight reduction. However, glucagon-like peptide-1 receptor agonists have also been associated with gastrointestinal side effects, including delayed gastric emptying as well as regurgitation and aspiration during general anesthesia or deep sedation, and sodium glucose co-transporter 2 inhibitors have been associated with severe diabetic ketoacidosis. Therefore, discontinuation of these medications before surgery is imperative. Given the popularity of these medications among the general public, it is essential for hand surgeons, to understand how to appropriately manage them perioperatively. The objective of this article was to review these new diabetes mellitus and weight loss medications, including their mechanisms of action, indications for use, and perioperative management guidelines. Additionally, we will take this opportunity to review perioperative guidelines for other common medications relevant to patients undergoing procedures involving the hand and upper extremity such as antithrombotic medications and rheumatoid arthritis-related immunosuppressive medications. Finally, we will describe how the electronic medical record system can be used to optimize perioperative medication management in this population.

Risks Following Total Knee Arthroplasty in Patients Who Have Antiphospholipid Syndrome

BACKGROUND

Antiphospholipid syndrome (APS) is recognized as a thrombophilic autoimmune condition characterized by a tendency to develop venous thromboembolism. Total knee arthroplasty (TKA) is a prevalent procedure in patients who have advanced knee arthritis. Notably, TKA is unequivocally considered a thrombotic risk factor. However, outcomes of APS patients after TKA are still poorly documented in literature. The purpose of this study was to evaluate APS as a potential risk factor for complications after TKA.

METHODS

Using the PearlDiver Mariner database from 2010 to 2022, APS patients undergoing primary TKA were identified and compared to 10:1 matched control based on age, sex, and relevant comorbidities. A total of 7,478 patients undergoing primary TKA were analyzed, of which 683 had APS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications including revision up to 2 years. Ninety-day emergency department visit and inpatient readmission were also documented.

RESULTS

Within 90 days after TKA, patients who have APS exhibited higher rates of cerebrovascular accident (adjusted odds ratio 2.04, 95% confidence interval 1.12 to 3.57; P = .014) and deep vein thrombosis (adjusted odds ratio 2.87, 95% confidence interval 1.99 to 4.06; P < .001) as compared to matched controls. No difference in surgical or nonthrombotic medical complications was observed between 2 cohorts.

CONCLUSIONS

There were significantly higher rates of stroke and deep vein thrombosis in APS patients. Our study did not find statistical differences in other surgical complications or readmissions between the 2 groups. Orthopaedic surgeons should consider appropriate prophylaxis of thrombosis in this patient population undergoing TKA perioperatively.

The Risk of Early Postoperative Complications Associated With Preoperative Immunosuppression in Patients Undergoing Total Elbow Arthroplasty

PURPOSE

Patients considering total elbow arthroplasty (TEA) may be receiving immunosuppressive therapy; however, the relationship between immunosuppressive medications and postoperative complications is not well defined. Our purpose was to assess the relationship between preoperative immunosuppression and short-term complications following TEA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2005 to 2020 to identify patients undergoing TEA. Procedures indicated for malignancy or infection were excluded. Patients were grouped according to preoperative chronic immunosuppressive status. Demographic and operative characteristics were compared between groups. The 30-day incidence of complications and reoperations were compared between groups. Multiple logistic regression models, inverse-weighted by propensity scores, were used to calculate odds ratio (OR) of experiencing any complication or return to the operating room based on immunosuppression status and other demographic characteristics.

RESULTS

A total of 769 patients undergoing TEA were included, of whom 142 (18.5%) received chronic immunosuppression. Distribution of age, sex, race, body mass index, diabetes, and American Society of Anesthesiologists classification differed significantly between groups. Most procedures were performed on an inpatient basis, and the median operative duration was 148 minutes. Most procedures were indicated for fracture in the nonimmunosuppressed group and rheumatoid arthritis in the immunosuppressed group. Overall complication rates were 7.0% for immunosuppressed patients and 10.2% for nonimmunosuppressed patients. The incidence of complications and reoperations did not significantly differ between groups. After controlling for confounding and adjusting for patient characteristics, immunosuppressed patients were 0.52 times less likely to experience a complication. Additionally, there was no association between immunosuppression status and odds of return to the operating room.

CONCLUSION

Similar rates of complications were observed following TEA, regardless of preoperative immunosuppression status. Chronic immunosuppression does not appear to increase the rates of postoperative complications for patients undergoing TEA.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Naru-3 inhibits inflammation, synovial hyperplasia, and neovascularization in collagen-induced arthritis in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Naru-3 is a prescribed formulation based on the theory of Mongolian medicine for the treatment of rheumatoid arthritis (RA). Naru-3 consists of three medicinal agents: Aconitum kusnezoffii Reichb (caowu), Terminalia chebula Retz (hezi), and Piper longum L (biba). These medicinal agents are widely distributed in the Mongolian area of China and have been used to treat rheumatism for centuries.

BACKGROUND

Mongolian medicine Naru-3 is commonly prescribed to treat RA, but its mechanism of action is unknown.

METHODS

A rat collagen-induced arthritis (CIA) model was established to investigate the mechanism of Naru-3. Rats were treated with Naru-3, Etanercept (ETN), and sodium carboxymethylcellulose (CMC) for four weeks. After treatment was terminated, paw thickness, ankle diameter, and arthritis index (AI) were scored. Synovial hyperplasia was evaluated using hematoxylin and eosin (H&E) staining and two-dimensional ultrasonography. Synovitis and neovascularization were assayed using power Doppler imaging (PDI) and contrast-enhanced ultrasonography (CEUS). Levels of vascular endothelial growth factor (VEGF), interleukin (IL)-1, and CD31 in the serum or synovium were detected using ELISA and immunohistochemistry analyses.

RESULTS

Naru-3 and ETN alleviated the symptoms of CIA as evidenced by diminished paw thickness, ankle diameter, and AI scores. Mechanistically, Naru-3 inhibited synovial hyperplasia, synovitis, and neovascularization by diminishing systemic and local inflammation, as indicated by the relative expression of CD31, VEGF and IL-1 in the serumor synovium. After four weeks of treatment, no significant neovascularization was observed in the Naru-3 group, but neovascularization and synovitis occurred in the ETN group, as demonstrated by H&E staining, PDI, and CEUS examination.

CONCLUSION

Naru-3 inhibited inflammation, synovial hyperplasia, and neovascularization and alleviates RA in our CIA rat model. No symptom recurrence was observed four weeks after drug treatment.

A systematic review and meta-analysis comparing outcomes following total knee arthroplasty for rheumatoid arthritis versus for osteoarthritis

PURPOSE

Total knee arthroplasty (TKA) in patients with osteoarthritis (OA) are considered to be a successful procedure, but with little being known about outcomes in patients with rheumatoid arthritis (RA). The aim of this study was to compare the outcomes of TKA in patients with RA versus OA.

METHODS

Data were obtained from PubMed, Cochrane Library, EBSCO and Scopus for all available studies comparing the outcomes of THA in RA and OA patients (From January 1, 2000 to October 15, 2022). Outcomes of interest included infection, revision, venous thromboembolism (VTE), mortality, periprosthetic fractures, prosthetic loosening, length of stay, and satisfaction. Two reviewers independently assessed each study for quality and extracted data. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS).

RESULTS

Twenty-four articles with a total 8,033,554 patients were included in this review. The results found strong evidence for increased risk of overall infection (OR = 1.61, 95% CI, 1.24-2.07; P = 0.0003), deep infection (OR = 2.06, 95% CI, 1.37-3.09; P = 0.0005), VTE (OR = 0.76, 95% CI, 0.61-0.93; P = 0.008), pulmonary embolism (PE) (OR = 0.84, 95% CI, 0.78-0.90; P<0.00001), periprosthetic fractures (OR = 1.87, 95% CI, 1.60-2.17; P<0.00001); and reasonable evidence for increased risk of deep venous thrombosis (DVT) (OR = 0.74, 95% CI, 0.54-0.99; P = 0.05), and length of stay (OR = 0.07, 95% CI, 0.01-0.14; P = 0.03) after TKA in patients with RA versus OA. There were no significant differences in superficial site infection (OR = 0.84,95% CI, 0.47-1.52; P = 0.57), revision (OR = 1.33,95% CI, 0.79-2.23; P = 0.28), mortality (OR = 1.16,95% CI, 0.87-1.55; P = 0.32), and prosthetic loosening (OR = 1.75, 95% CI, 0.56-5.48; P = 0.34) between the groups.

CONCLUSION

Our study demonstrated that patients with RA have a higher risk of postoperative infection, VTE, periprosthetic fracture, and lengths of stay, but did not increase revision rate, prosthetic loosening and mortality compared to patients with OA following TKA. In conclusion, despite RA increased incidence of postoperative complications, TKA should continue to be presented as an effective surgical procedure for patients whose conditions are intractable to conservative and medical management of RA.

Consensus on targeted drug therapy for spondyloarthritis

Spondyloarthritis (SpA) is a group of chronic inflammatory diseases that predominantly involve the spine and/or peripheral joints. The clinical manifestations of SpA are highly heterogenous and complicated with various comorbidities. SpA is a disabling disease and adversely affects the quality of life of patients. Many new medications that target cytokines or pathways specific for the pathogenesis of SpA have been developed and they are becoming increasingly important in the treatment of SpA. However, identifying the target patient population and standardizing the usage of these drugs are critical issues in the clinical application of these "targeted therapeutic drugs". Under the leadership of National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), managed by Peking Union Medical College Hospital, the "Consensus on targeted drug therapy for spondyloarthritis" has been developed in collaboration with the Rheumatology and Immunology Physicians Committee, Chinese Medical Doctors Association, Rheumatology and Immunology Professional Committee, Chinese Association of Rehabilitation Medicine, and Chinese Research Hospital Association Rheumatology and Immunology Professional Committee. This consensus has been developed with evidence-based methodology and has followed the international standard for consensus development.