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Risk Factors for Transfusions Following Total Joint Arthroplasty in Patients With Rheumatoid Arthritis.
Salt E, Wiggins AT, Rayens MK, Brown K, Eckmann K, Johannemann A, Wright RD, Crofford LJ
(2018) J Clin Rheumatol 24: 422-426
MeSH Terms: Adult, Aged, Arthritis, Rheumatoid, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, Blood Loss, Surgical, Blood Transfusion, Cohort Studies, Databases, Factual, Female, Follow-Up Studies, Humans, Logistic Models, Male, Middle Aged, Odds Ratio, Postoperative Care, Prosthesis Failure, Retrospective Studies, Risk Assessment, Severity of Illness Index, Treatment Outcome
Show Abstract · Added March 25, 2020
BACKGROUND/OBJECTIVE - Despite effective therapies, rheumatoid arthritis (RA) can result in joint destruction requiring total joint arthroplasty to maintain patient function. An estimated 16% to 70% of those undergoing total joint arthroplasty of the hip or knee will receive a blood transfusion. Few studies have described risk factors for blood transfusion following total joint arthroplasty in patients with RA. The aim of this study was to identify demographic and clinical risk factors associated with receiving a blood transfusion following total joint arthroplasty among patients with RA.
METHODS - A retrospective study (n = 3270) was conducted using deidentified patient health claims information from a commercially insured, US data set (2007-2009). Data analysis included descriptive statistics and multivariate logistic regression.
RESULTS - Females were more likely to receive a blood transfusion (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.16-1.87; p = 0.001). When compared with those in the South, patients residing the Midwest were less likely to receive a blood transfusion following total joint arthroplasty (OR, 0.56; 95% CI, 0.44-0.71). Relative to those receiving total knee arthroplasty, patients who underwent total hip arthroplasty were more likely to receive a blood transfusion (OR, 1.39; 95% CI, 1.14-1.70), and patients who underwent a total shoulder arthroplasty were less likely to receive a blood transfusion (OR, 0.14; 95% CI, 0.05-0.38; p < 0.001). Patients with a history of anemia were more likely to receive a blood transfusion compared with those who did not have this diagnosis (OR, 3.30; 95% CI, 2.62-4.14; p < 0.001).
CONCLUSIONS - Risk factors for the receipt of blood transfusions among RA patients who have undergone total joint arthroplasty were identified.
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Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis.
Salt E, Wiggins AT, Rayens MK, Morris BJ, Mannino D, Hoellein A, Donegan RP, Crofford LJ
(2017) Semin Arthritis Rheum 46: 423-429
MeSH Terms: Aged, Allopurinol, Arthritis, Rheumatoid, Arthroplasty, Replacement, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, Arthroplasty, Replacement, Shoulder, Case-Control Studies, Comorbidity, Diabetes Mellitus, Female, Glucocorticoids, Gout, Gout Suppressants, HIV Infections, Humans, Immunologic Deficiency Syndromes, Immunosuppressive Agents, Logistic Models, Lupus Erythematosus, Systemic, Male, Middle Aged, Multivariate Analysis, Neoplasms, Obesity, Osteoarthritis, Osteoarthritis, Hip, Osteoarthritis, Knee, Prednisone, Prosthesis-Related Infections, Retrospective Studies, Risk Factors, Sex Factors, Shoulder Joint, Surgical Wound Infection
Show Abstract · Added March 25, 2020
OBJECTIVE - Inconclusive findings about infection risks, importantly the use of immunosuppressive medications in patients who have undergone large-joint total joint arthroplasty, challenge efforts to provide evidence-based perioperative total joint arthroplasty recommendations to improve surgical outcomes. Thus, the aim of this study was to describe risk factors for developing a post-operative infection in patients undergoing TJA of a large joint (total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty) by identifying clinical and demographic factors, including the use of high-risk medications (i.e., prednisone and immunosuppressive medications) and diagnoses [i.e., rheumatoid arthritis (RA), osteoarthritis (OA), gout, obesity, and diabetes mellitus] that are linked to infection status, controlling for length of follow-up.
METHODS - A retrospective, case-control study (N = 2212) using de-identified patient health claims information from a commercially insured, U.S. dataset representing 15 million patients annually (from January 1, 2007 to December 31, 2009) was conducted. Descriptive statistics, t-test, chi-square test, Fisher's exact test, and multivariate logistic regression were used.
RESULTS - Male gender (OR = 1.42, p < 0.001), diagnosis of RA (OR = 1.47, p = 0.031), diabetes mellitus (OR = 1.38, p = 0.001), obesity (OR = 1.66, p < 0.001) or gout (OR = 1.95, p = 0.001), and a prescription for prednisone (OR = 1.59, p < 0.001) predicted a post-operative infection following total joint arthroplasty. Persons with post-operative joint infections were significantly more likely to be prescribed allopurinol (p = 0.002) and colchicine (p = 0.006); no significant difference was found for the use of specific disease-modifying anti-rheumatic drugs and TNF-α inhibitors.
CONCLUSION - High-risk, post-operative joint infection groups were identified allowing for precautionary clinical measures to be taken.
Copyright © 2017 Elsevier Inc. All rights reserved.
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Factor XI antisense oligonucleotide for prevention of venous thrombosis.
Büller HR, Bethune C, Bhanot S, Gailani D, Monia BP, Raskob GE, Segers A, Verhamme P, Weitz JI, FXI-ASO TKA Investigators
(2015) N Engl J Med 372: 232-40
MeSH Terms: Adult, Aged, Anticoagulants, Arthroplasty, Replacement, Knee, Blood Coagulation, Clinical Protocols, Enoxaparin, Factor XI, Female, Hemorrhage, Humans, Length of Stay, Male, Middle Aged, Oligonucleotides, Oligonucleotides, Antisense, Partial Thromboplastin Time, Postoperative Complications, Venous Thrombosis
Show Abstract · Added January 20, 2015
BACKGROUND - Experimental data indicate that reducing factor XI levels attenuates thrombosis without causing bleeding, but the role of factor XI in the prevention of postoperative venous thrombosis in humans is unknown. FXI-ASO (ISIS 416858) is a second-generation antisense oligonucleotide that specifically reduces factor XI levels. We compared the efficacy and safety of FXI-ASO with those of enoxaparin in patients undergoing total knee arthroplasty.
METHODS - In this open-label, parallel-group study, we randomly assigned 300 patients who were undergoing elective primary unilateral total knee arthroplasty to receive one of two doses of FXI-ASO (200 mg or 300 mg) or 40 mg of enoxaparin once daily. The primary efficacy outcome was the incidence of venous thromboembolism (assessed by mandatory bilateral venography or report of symptomatic events). The principal safety outcome was major or clinically relevant nonmajor bleeding.
RESULTS - Around the time of surgery, the mean (±SE) factor XI levels were 0.38±0.01 units per milliliter in the 200-mg FXI-ASO group, 0.20±0.01 units per milliliter in the 300-mg FXI-ASO group, and 0.93±0.02 units per milliliter in the enoxaparin group. The primary efficacy outcome occurred in 36 of 134 patients (27%) who received the 200-mg dose of FXI-ASO and in 3 of 71 patients (4%) who received the 300-mg dose of FXI-ASO, as compared with 21 of 69 patients (30%) who received enoxaparin. The 200-mg regimen was noninferior, and the 300-mg regimen was superior, to enoxaparin (P<0.001). Bleeding occurred in 3%, 3%, and 8% of the patients in the three study groups, respectively.
CONCLUSIONS - This study showed that factor XI contributes to postoperative venous thromboembolism; reducing factor XI levels in patients undergoing elective primary unilateral total knee arthroplasty was an effective method for its prevention and appeared to be safe with respect to the risk of bleeding. (Funded by Isis Pharmaceuticals; FXI-ASO TKA ClinicalTrials.gov number, NCT01713361.).
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Detectable serum tobramycin levels in patients with renal dysfunction and recent placement of antibiotic-impregnated cement knee or hip spacers.
Noto MJ, Koethe JR, Miller G, Wright PW
(2014) Clin Infect Dis 58: 1783-4
MeSH Terms: Acute Kidney Injury, Aged, Aged, 80 and over, Anti-Bacterial Agents, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, Bone Cements, Female, Humans, Male, Middle Aged, Prosthesis-Related Infections, Reoperation, Tobramycin
Added May 27, 2014
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Immediate complications following hip and knee arthroplasty: does race matter?
Adelani MA, Archer KR, Song Y, Holt GE
(2013) J Arthroplasty 28: 732-5
MeSH Terms: African Continental Ancestry Group, Aged, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, European Continental Ancestry Group, Female, Humans, Male, Middle Aged, Postoperative Complications, Regression Analysis, United States
Show Abstract · Added March 10, 2014
Black race has been associated with a higher rate of complications following total joint arthroplasty, such as infection, deep vein thrombosis, pulmonary embolism, and death. We hypothesized that there would be no significant association between black race and adverse outcome when medical conditions were adjusted for. Data on 585,269 patients from the Nationwide Inpatient Samples were assessed by multivariable logistic regression analysis. Black race was significantly associated with postoperative complication and death. Comorbidities do not account for racial differences in adverse events. Black race was an independent predictive factor for increased complications and death following hip and knee arthroplasty.
Copyright © 2013 Elsevier Inc. All rights reserved.
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Acute kidney injury after placement of an antibiotic-impregnated cement spacer during revision total knee arthroplasty.
Menge TJ, Koethe JR, Jenkins CA, Wright PW, Shinar AA, Miller GG, Holt GE
(2012) J Arthroplasty 27: 1221-7.e1-2
MeSH Terms: Acute Kidney Injury, Aged, Aminoglycosides, Anti-Bacterial Agents, Arthroplasty, Replacement, Knee, Bone Cements, Cohort Studies, Creatinine, Female, Humans, Incidence, Kidney, Knee Prosthesis, Male, Middle Aged, Prosthesis-Related Infections, Reoperation, Retrospective Studies, Tobramycin
Show Abstract · Added May 27, 2014
We performed a retrospective cohort study of 84 patients to determine the incidence and predictors of acute kidney injury after antibiotic-impregnated cement spacer (ACS) placement for infected total knee arthroplasties. Acute kidney injury was defined as a more than 50% rise in serum creatinine from a preoperative baseline to a level greater than 1.4 mg/dL within 90 days postoperatively. Total incidence was 17% (n = 14; 95% confidence interval [CI], 10%-26%), and acute kidney injury was significantly associated with ACS tobramycin dose as both a dichotomous variable (>4.8 g; odds ratio, 5.87; 95% CI, 1.43-24.19; P = .01) and linear variable (odds ratio, 1.24 for every 1-g increase; 95% CI, 1.00-1.52; P = .049). Routine monitoring of serum creatinine and measurement of serum aminoglycoside levels in response to a threshold creatinine rise may be warranted after the placement of an aminoglycoside-containing ACS.
Copyright © 2012 Elsevier Inc. All rights reserved.
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Metal-backed versus all-polyethylene tibias in megaprostheses of the distal femur.
Crosby SN, Polkowski GG, Schwartz HS, Shinar AA, Holt GE
(2011) J Arthroplasty 26: 451-7
MeSH Terms: Adolescent, Adult, Aged, Aged, 80 and over, Arthroplasty, Replacement, Knee, Bone Marrow Neoplasms, Child, Female, Femur, Humans, Kaplan-Meier Estimate, Knee Prosthesis, Male, Metals, Middle Aged, Osteosarcoma, Polyethylene, Prosthesis Design, Prosthesis Failure, Reoperation, Retrospective Studies, Tibia, Treatment Outcome, Young Adult
Show Abstract · Added March 5, 2014
In megaprostheses, the tibial component is rarely a source of failure. The evolution of these implants has followed standard arthroplasty trends moving from majority use of all-polyethylene tibias (APT) to high volume use of metal-backed tibial (MBT) components. We report the results of 72 endoprostheses using either MBT (n = 42) or APT (n = 30) implanted between 1994 and 2006. Failures of the implant related to the tibial component were isolated, and 5-year survival of the tibial implant of the MBT cohort was 94%, and for the APT cohort, 87% (P = .39). The difference in tibial component failures between the 2 groups was not statistically significant (Pearson χ(2) = 0.1535, P = .6952). Revision rates for the entire implant and infection rates were not significantly different between the 2 groups.
Copyright © 2011 Elsevier Inc. All rights reserved.
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24 MeSH Terms
Early failure of a mobile-bearing unicompartmental knee replacement.
Arastu MH, Vijayaraghavan J, Chissell H, Hull JB, Newman JH, Robinson JR
(2009) Knee Surg Sports Traumatol Arthrosc 17: 1178-83
MeSH Terms: Aged, Aged, 80 and over, Arthroplasty, Replacement, Knee, Female, Humans, Knee Joint, Male, Middle Aged, Pain, Prosthesis Design, Prosthesis Failure, Radiography, Reoperation, Retrospective Studies
Show Abstract · Added March 5, 2014
Concerned by a perceived high revision rate, we retrospectively reviewed the survivorship of a series of 43 cemented, medial, mobile-bearing Preservation unicompartmental knee replacements implanted during a 2-year period at a single institution. The initial post-operative AP and lateral radiographs were independently assessed to test the hypothesis that suboptimal implantation of the prosthesis was responsible for early failure. An X-ray scoring system based on the criteria for assessing the Oxford mobile-bearing unicompartmental knee replacement was devised. The components of this score included assessment of prosthesis alignment, sizing and cementation. Nine (21%) LCS Preservation mobile-bearings prostheses had required revision at a mean of 22 months post-implantation. The commonest causes for failure were pain (44%) and tibial component loosening (33%). Analysis of post-operative radiographs showed no difference (n.s.) between the compound error scores for the revised and the surviving prostheses. No particular surgical error was identifiable leading to subsequent need for revision. The high failure rates shown in this study have led us to cease using this implant. The clinical relevance of this study is that the captive running track of the LCS mobile-bearing prosthesis may over constrain the meniscal component leading to early failure.
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14 MeSH Terms
Trabecular metal endoprosthetic limb salvage reconstruction of the lower limb.
Holt GE, Christie MJ, Schwartz HS
(2009) J Arthroplasty 24: 1079-85
MeSH Terms: Adolescent, Adult, Aged, Arthroplasty, Replacement, Hip, Arthroplasty, Replacement, Knee, Artificial Limbs, Bone Neoplasms, Child, Disability Evaluation, Female, Fibula, Follow-Up Studies, Humans, Leg, Limb Salvage, Male, Metals, Middle Aged, Radiography, Retrospective Studies, Sarcoma, Tibia, Treatment Outcome, Young Adult
Show Abstract · Added March 5, 2014
Currently, porous tantalum (trabecular metal) implants are widely accepted and frequently used for primary and revision hip and knee replacement surgery. This study examines the results of porous tantalum endoprostheses used to reconstruct large skeletal defects following resection of bone tumors. Seven custom tantalum implants were used to reconstruct 7 patients following resection for skeletal sarcomas in the femur and proximal tibia. Patient ages ranged from 13 to 71, with a mean of 34 years. Minimum patient follow-up was 6 years. The average Musculoskeletal Tumor Society functional evaluation score was 95 % of normal. There were no infections, hardware failures, or adverse events. One implant was revised 98 months post insertion because of fibrosis, loss of motion and loosening. In this small clinical series, the use of porous tantalum for limb salvage reconstruction is shown to be safe, to successfully provide osteointegration and soft tissue ingrowth, and to facilitate return of limb girdle muscle function.
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24 MeSH Terms
Prospective examination of pain-related and psychological predictors of CRPS-like phenomena following total knee arthroplasty: a preliminary study.
Harden NR, Bruehl S, Stanos S, Brander V, Chung OY, Saltz S, Adams A, Stulberg DS
(2003) Pain 106: 393-400
MeSH Terms: Aged, Arthroplasty, Replacement, Knee, Complex Regional Pain Syndromes, Cross-Sectional Studies, Female, Follow-Up Studies, Humans, Male, Middle Aged, Multivariate Analysis, Pain, Predictive Value of Tests, Prospective Studies
Show Abstract · Added March 5, 2014
We hypothesized that preoperative emotional distress and pain intensity would predict the occurrence of signs and symptoms of complex regional pain syndrome (CRPS) following total knee arthroplasty (TKA). Depression (Beck Depression Inventory, BDI), anxiety (State Trait Anxiety Inventory, STAI), pain (McGill Pain Questionnaire-Short Form, MPQ), and signs/symptoms meeting IASP criteria for CRPS were assessed preoperatively, and at 1-, 3-, and 6-months postoperatively in 77 patients undergoing TKA. The prevalence of subjects fulfilling CRPS criteria was 21.0% at 1 month, 13.0% at 3 months, and 12.7% at 6 months postoperative. Higher preoperative scores on the STAI predicted positive CRPS status at 1-month follow-up (P<0.05), with a similar non-significant trend for preoperative BDI scores (P<0.10). Diagnostic sensitivity for the STAI was good (0.73), with moderate specificity (0.56). Neither measure predicted CRPS at later follow-up (P>0.10). Greater preoperative pain intensity predicted positive CRPS status at 3-month (MPQ-Sensory and MPQ-Affective; P<0.01) and 6-month (MPQ-Sensory) follow-up (P<0.01), but not at 1-month (P>0.10). Diagnostic sensitivity was high (0.83-1.00), with moderate specificity (0.53-0.60). Post-TKA patients with CRPS were more depressed at 1-month follow-up (P<0.05) and more anxious at 6-month follow-up (P<0.05) than patients with ongoing non-CRPS pain (all other comparisons non-significant, P>0.10). Overall, results indicate that CRPS-like phenomena occur in a significant number of patients early post-TKA; however, it is not associated with significantly greater complaints of postoperative pain. There appears to be a modest utility for preoperative distress and pain in predicting CRPS signs and symptoms following TKA, although false positive rates are relatively high.
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13 MeSH Terms