Perioperative outcomes in patients with rheumatoid versus osteoarthritis for total hip arthroplasty: a population-based study.

OBJECTIVES: Little is known about perioperative outcomes among the subset of patients undergoing total hip arthroplasty (THA) for a diagnosis of rheumatoid arthritis (RA) rather than osteoarthritis (OA). We sought to 1) identify the prevalence of RA in patients undergoing THA, 2) compare their demographics to those being operated on for OA, 3) determine differences in perioperative outcomes and 4) analyse if RA represents an independent risk factor for complications, mortality, utilisation of resources, increased length of stay and cost. METHODS: Entries of patients who underwent elective THA between 2006 and 2010 were identified in a national database and subgrouped according to presence of a concurrent diagnosis of RA. Differences in demographics and perioperative outcomes were analysed. RESULTS: We identified 157,775 entries for patients who underwent THA between 2006 and 2010. RA was present in 3.42% (n=5,400). Patients in the group RA were on average younger [RA: 63.94 years vs. OA: 65.64 years; p<0.0001] and more likely female [RA: 75.47% vs. OA: 56.09%; p<0.0001]. While mortality was not statistically different, perioperative pulmonary and infectious complications occurred more frequently in RA patients. Compared with OA, multivariate logistic regression revealed higher overall odds for complications [OR=1.15 (CI 1.05;1.25), p=0.0037], need for mechanical ventilation [OR=1.42 (CI 1.01;2.00), p=0.0414], transfusion [OR=1.35 (CI 1.26;1.44), p<0.0001], prolonged hospitalisation [OR=1.16 (CI 1.08;1.23), p<0.0001] and increased hospital charges [OR=1.17 (CI 1.09;1.26), p<0.0001]. CONCLUSIONS: In THA patients suffering from RA, perioperative risk for complications and utilization of health care resources continues to be increased compared to OA patients.

Hemodynamic effects of angiotensin inhibitors in elderly hypertensives undergoing total knee arthroplasty under regional anesthesia.

The aim was to investigate the association between continuing angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB) with postinduction hypotension and vasoactive drug use in elderly orthopedic surgery patients under regional anesthesia. Retrospective design consisted of 114 patients (mean age 66) undergoing elective total knee arthroplasty, including 84 patients with chronic hypertension, and they were divided as group I (n = 37), ACEI/ARB continued; group II (n = 23), ACEI/ARB withdrawn; group III (n = 24), ß-blocker/calcium channel blocker continued; and group IV (n = 30), without hypertension (control). Primary end points are systolic blood pressures (SBPs) and mean arterial blood pressures (MAPs) at 0, 30, 60, and 90 minutes postinduction, incidence of hypotension (SBP <85 mm Hg), and ephedrine requirements. Repeated measurements were analyzed using generalized estimating equations controlling for baseline characteristics and accounting for correlations. Logistic regression was used for remaining variables. Hypotension occurred more frequently (P = .02) in group I (30%) versus groups II-IV (9%, 13%, 3%). Ephedrine use was increased (P < .001) in group I (51%) compared with groups II-IV (26%, 17%, 7%). Group I had lower mean SBPs compared with group II (110 vs. 120; P = .0045) and group IV (110 vs. 119; P = .0013). Lower mean MAPs were found in group I versus group II (74 vs. 81, P = .001) and group IV (74 vs. 80; P = .001). Group I had an increased odds of receiving ephedrine versus group IV (odds ratio, 16.27; 95% confidence interval, 3.10-85.41; P = .001). No adverse clinical events were recorded. Day of surgery ACEI/ARB use is associated with a high incidence and severity of postinduction hypotension with associated high vasopressor requirements. Associated clinical outcomes merit further study.

First time myocardial infarction in a rheumatic patient after elective arthroplasty.

The management of perioperative cardiovascular risk in patients with rheumatoid arthritis (RA) is challenging due to the independent contribution to risk by high grade inflammatory mechanisms and the underestimation of risk by traditional cardiac risk factors alone. RA is associated with accelerated rates of subclinical atherosclerosis and markedly higher rates of both myocardial infarction and sudden cardiac death over non-RA controls. There is an absence of prospectively validated perioperative coronary heart disease (CHD) risk assessment tools for this unique patient population and available guidelines may fail to identify those patients most at risk. We examine a singular case of first time myocardial infarction after uncomplicated elective surgery in an adult RA patient with an unrevealing preoperative cardiac assessment. We also review the current literature for shared pathogenic mechanisms between systemic inflammation and atherosclerosis, discuss clinical and biologic markers such as C-reactive protein (CRP) in RA patients associated with heightened cardiac risk and discuss recommendations based on available evidence for cardiovascular risk management in this at risk cohort.