Increased Risk of Complications Following Total Joint Arthroplasty in Patients With Rheumatoid Arthritis

Authors

  • Bheeshma Ravi,

    Corresponding author
    1. University of Toronto, Toronto, Ontario, Canada
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  • Ruth Croxford,

    1. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Simon Hollands,

    1. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • J. Michael Paterson,

    1. University of Toronto and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Earl Bogoch,

    1. University of Toronto and St. Michael's Hospital, Toronto, Ontario, Canada
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    • Dr. Bogoch has received consulting fees, speaking fees, and/or honoraria from Merck Frosst Canada and Merck Sharpe & Dohme (more than $10,000 each) and has received research support as a principal investigator from Amgen Canada, Novartis Canada, and Warner Chilcott.

  • Hans Kreder,

    1. University of Toronto and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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  • Gillian A. Hawker

    1. University of Toronto, Institute for Clinical Evaluative Sciences, and Women's College Hospital, Toronto, Ontario, Canada
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    • Dr. Hawker holds the F. M. Hill Chair in Academic Women's Medicine at the University of Toronto.


  • The opinions, results, and conclusions reported herein are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the Ontario Ministry of Health and Long-Term Care is intended or should be inferred.

Abstract

Objective

Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are based on patients with osteoarthritis (OA); less is known about outcomes in rheumatoid arthritis (RA). Using a validated algorithm for identifying patients with RA, we undertook this study to compare the rates of complications among THA and TKA recipients between those with RA and those without RA.

Methods

In patients who underwent a first primary elective THA or TKA between 2002 and 2009, those with RA were identified using a validated algorithm: a hospitalization with a diagnosis code for RA or 3 physician billing claims with a diagnosis code for RA, with at least 1 claim by a specialist (rheumatologist, orthopedic surgeon, or internist) in a 2-year period. Recipients with diagnostic codes suggesting an inflammatory arthritis, but not meeting RA criteria, were classified as having inflammatory arthritis. All remaining patients were deemed to have OA. Cox proportional hazards models, censored on death, were used to determine the relationship between the type of arthritis and the occurrence of specific complications, adjusting for potential confounders (age, sex, comorbidity, and provider volume).

Results

We identified 43,997 eligible THA recipients (3% with RA) and 71,793 eligible TKA recipients (4% with RA). Total joint arthroplasty recipients with RA had higher age and sex–standardized rates of dislocation following THA (2.45%, compared with 1.21% for recipients with OA) and higher age and sex–standardized rates of infection following TKA (1.26%, compared with 0.84% for recipients with OA). Controlling for potential confounders, recipients with RA remained at increased risk of dislocation within 2 years of THA (adjusted hazard ratio [HR] 1.91, P = 0.001) and remained at increased risk of infection within 2 years of TKA (adjusted HR 1.47, P = 0.03) relative to recipients with OA.

Conclusion

Patients with RA are at higher risk of dislocation following THA and are at higher risk of infection following TKA relative to those with OA. Further research is warranted to elucidate explanations for these findings, including the roles of medication profile, implant choice, postoperative antibiotic protocol, and method of rehabilitation following joint replacement.

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