The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy: a nationwide register-based study from 1995 through 2010.

BACKGROUND AND PURPOSE: Drug-based treatment of rheumatoid arthritis (RA) has evolved markedly over the past 2 decades. Using nationwide register data, we studied how this has affected the rates of hip, knee, shoulder, and elbow replacement from 1995 to 2010. METHODS: The number of primary joint replacements was obtained from the Finnish Arthroplasty Register. To test the hypothesis that improvements in medical treatment of RA reduce the need for joint replacements, we also collected data about purchases of different disease-modifying anti-rheumatic agents (DMARDs) and biological drugs from the nationwide drug registers. RESULTS: The annual incidence of primary joint replacements for RA declined from 19 per 10(5) in 1995 to 11 per 10(5) in 2010. The decline was greater for upper-limb operations than for lower-limb operations. At the same time, the numbers of individuals using methotrexate, hydroxychloroquine, and sulfasalazine (the most commonly used DMARDs) increased 2- to 4-fold. INTERPRETATION: Our results are in accordance with observations from other countries, and indicate that the use of joint replacements in RA has decreased dramatically. Our data suggest that effective medical therapy is the most likely explanation for this favorable development.

Incidence of rheumatoid arthritis-related ankle replacement and ankle arthrodesis: a Finnish nationwide register-based study from 1997­2010.

BACKGROUND AND PURPOSE: For 20 years, medical treatment of rheumatoid arthritis (RA) has been improving and the incidence of joint surgery has decreased. We investigated the rates of primary ankle joint arthrodesis and total ankle arthroplasty in patients with RA in Finland between 1997 and 2010 to establish whether trends have changed during that period. METHODS: The annual figures for primary ankle joint arthrodeses and total ankle replacements performed in patients with RA were obtained from nationwide population-based registries. Incidences were calculated per population of 10(5) and they are reported in 2-year periods. RESULTS: During the study period, 593 primary ankle joint arthrodeses and 318 total ankle arthroplasties were performed in patients with RA. The incidence of ankle joint arthrodesis reached its highest value (2.4/10(5)) in 1997-1998 and it was lowest in 2001-2002 (1.1/10(5)). After 2002, the incidence increased slightly but did not reach the level in 1997-1998, even though total ankle replacements almost ended in Finland during the period 2009-2010. From 1997, total ankle replacements increased until 2003-2004 (incidence 1.5/10(5)) and then gradually decreased. In 2009-2010, the incidence of total ankle replacements was only 0.4/10(5). INTERPRETATION: During the observation period 1997-2010, while total ankle replacements generally became more common in patients with RA, the incidence of primary ankle joint arthrodesis decreased and did not increase in the period 2009-2010, even though total ankle replacement surgery almost ended in Finland. No change in the incidence of these operations, when pooled together, was observed from 1997 to 2010.

Wear particles promote endotoxin tolerance in macrophages by inducing interleukin-1 receptor-associated kinase-M expression.

Toll-like receptors (TLRs) recognizing pathogen-associated molecular patterns (PAMP) play a role in local immunity and participate in implant-associated loosening. TLRs-mediated signaling is regulated by interleukin-1 receptor-associated kinase-M (IRAK-M). Our previous studies have proved that IRAK-M is induced by wear particles in macrophages from periprosthetic tissues. In this study, the IRAK-M-related mechanisms were further explored by lipopolysaccharide (LPS) and/or titanium (Ti) particles stimulations and small interfering RNAs (siRNAs). The protein level of IRAK-M was studied using western blotting and tumor necrosis factor-α (TNF-α), and interleukin-1ß (IL-1ß) levels were measured using ELISA. Results showed that in RAW264.7 cells stimulated by LPS after Ti particle pre-exposure, IRAK-M was slightly changed, compared with LPS stimulation. And levels of TNF-α and IL-1ß in cultures stimulated by LPS first after Ti particle pre-exposure were lower than in the other two groups which were stimulated by LPS with or without Ti particles (p < 0.001), whereas there were no statistic differences between the later two (p > 0.05). The cytokines were lowest in Ti particles alone stimulation. After siRNAs silenced, IRAK-M-deficient cells exhibited increased expression of the cytokines in LPS stimulation after Ti particle pre-exposure and when stimulated with Ti particles alone. Our findings suggest that debris-induced IRAK-M decreases foreign body reactions, but at the same time, the over-expression of IRAK-M may also be detrimental on local intrusion of PAMPs or bacteria, negatively regulates the LPS-induced and TLRs-mediated inflammation and results in immunosuppression in periprosthetic tissue, which may predispose to implant-associated infections.

Comorbid diseases as predictors of survival of primary total hip and knee replacements: a nationwide register-based study of 96 754 operations on patients with primary osteoarthritis.

OBJECTIVES: To examine how comorbid diseases (cardiovascular diseases, hypertension, diabetes, cancer, pulmonary diseases, depression, psychotic disorders and neurodegenerative diseases) affect survival of hip and knee replacements. METHODS: Data for this register-based study were collected by combining data from five nationwide health registers. 43 747 primary total hip and 53 007 primary total knee replacements performed for osteoarthritis were included. The independent effects of comorbid diseases on prosthesis survival were analysed using multivariate Cox regression analysis. RESULTS: Occurrence of one or more of the diseases analysed was associated with poorer survival of hip (HR for revision 1.16, 95% CI 1.08 to 1.23) and knee replacements (1.23, 1.16 to 1.30). Cardiovascular diseases and psychotic disorders were associated with increased risk of revision after both hip (1.19, 1.06 to 1.34 and 1.41, 1.04 to 1.91, respectively) and knee replacement (1.29, 1.14 to 1.45 and 1.41, 1.07 to 1.86, respectively). Hypertension and diabetes were associated with early revision (0-5 years after primary operation) after knee replacements (1.14, 1.01 to 1.29 and 1.27, 1.08 to 1.50, respectively). Cancer was associated with poorer survival of hip replacements (1.27, 1.05 to 1.54) and late revision (>5 years) of knee replacements (2.21, 1.31 to 3.74). Depression affected the risk of early revision after hip replacement (1.50, 1.02 to 2.21). Neurodegenerative and pulmonary diseases did not affect prosthesis survival. CONCLUSIONS: Comorbid diseases may play an important role in predicting survival of primary hip and knee replacements. The mechanisms underlying these findings and their effect on cost-effectiveness of joint replacements, merit further research.

IRAK-M in macrophages around septically and aseptically loosened hip implants.

The most common long-term complication of joint arthroplasty is loosening, which is mediated by chronic inflammatory cytokines produced by macrophages stimulated by implant-derived debris and eventually bacterial components adherent to such debris. In this study, antiinflammatory interleukin-1 receptor-associated kinase-M (IRAK-M) was studied in macrophages in interface membranes in vivo using immunohistochemical staining and in titanium particle-stimulated macrophages in vitro using reverse transcriptase-polymerase chain reaction. Results show that the interface membranes of septically and aseptically loosened prosthesis express more IRAK-M protein than control membranes from osteoarthritic patient and that IRAK-M mRNA-levels increase upon particle stimulation. These findings suggest that, the upregulation of IRAK-M in macrophages is involved in the local immunosuppression around implants, and may contribute to septic and aseptic implant loosening.

Incidence of prosthetic joint infections after primary knee arthroplasty.

We report the 1-year incidence of postoperative infections in an unselected series of 2647 consecutive primary knee arthroplasties (3137 knees) performed in a modern specialized hospital dedicated solely to joint arthroplasty surgery in 2002 to 2006. The rates of superficial and prosthetic joint infections were 2.9% and 0.80%, respectively. Prospective surveillance by hospital infection register failed to detect 6 of the 24 prosthetic joint infections. Increased rate of prosthetic joint infections was associated with complex surgery and with several patient-related factors, for example, comorbidity, obesity, and poor preoperative clinical state. The rate of prosthetic joint infections in contemporary knee arthroplasty is low and mainly related to patient-related factors, of which patient comorbidity has the most profound effect on the infection rate.

Total hip replacement in patients eighty years of age and older.

BACKGROUND: The number of people eighty years of age and older in developed countries is increasing, with a concomitant increased demand for total hip replacement. We analyzed the outcomes of total hip arthroplasty for patients in this age group using data from the Finnish National Arthroplasty Registry. METHODS: Data from the Finnish Arthroplasty Registry on 6540 patients (6989 hips) who were eighty years of age or older at the time of a total hip arthroplasty, performed between 1980 and 2004, were evaluated with use of survival analyses. Factors affecting survivorship rates were sought, and the reasons for revision were identified. RESULTS: The mean age of the patients undergoing a primary total hip arthroplasty was 82.7 years. The mean longevity of 3065 patients who died following total hip arthroplasty was 5.1 years. With revision total hip arthroplasty for any reason as the end point, Kaplan Meier survivorship was 97% (95% confidence interval, 96% to 97%) at five years (2617 hips) and 94% (95% confidence interval, 93% to 95%) at ten years (532 hips). Of the 195 hip replacements that required revision, 183 had information on the reason for revision. Eighty-four (46%) were revised for aseptic loosening; thirty-six (20%), for recurrent dislocation; twenty-four (13%), for a periprosthetic fracture; and twenty-three (13%), for infection. Seven hundred and twenty-nine patients had undergone hybrid fixation (a cemented stem and a cementless cup). The survivorship of these replacements was significantly better than that for replacements with cementless fixation in 399 patients (p < 0.05). CONCLUSIONS: In patients who had a total hip arthroplasty when they were more than eighty years old, the prevalence of aseptic loosening was less than that encountered in younger patients, but recurrent dislocation, periprosthetic fracture, and infection were more common in this age group. Cementation of the femoral stem demonstrated better long-term results than cementless fixation, indicating that it may provide better initial fixation and, therefore, longer life-in-service.

Is longer waiting time associated with health and social services utilization before treatment? A randomized study.

OBJECTIVE: To determine whether longer waiting time for major joint replacement is associated with health and social services utilization before treatment. METHODS: When placed on the waiting list, patients were randomized to short (

Revision total knee arthroplasty: 1990 through 2002. A review of the Finnish arthroplasty registry.

BACKGROUND: National and regional arthroplasty registries have been used to study the results of primary total knee arthroplasties. The purpose of this paper was to present the results of revision total knee replacements and describe predictors of survival of those replacements, with repeat revision as the end point. METHODS: The nationwide Finnish Arthroplasty Registry included 2637 revision total knee arthroplasties from 1990 through 2002. Survivorship of the revision total knee arthroplasties was analyzed, with repeat revision as the end point. The survivorship analyses comprised evaluations of the proportional hazards assumption followed by calculations of univariate and multivariate statistics and model diagnostics as appropriate. RESULTS: The survival rate following the revision total knee arthroplasties was 95% (95% confidence interval, 94% to 96%) at two years (1874 knees), 89% (95% confidence interval, 88% to 90%) at five years (944 knees), and 79% (95% confidence interval, 78% to 81%) at ten years (141 knees). Multivariate regression analysis showed the most significant predictors of prosthetic survival to be the age of the patient and the life in service of the primary total knee replacement (that is, the time between the primary total knee replacement and the revision). Survivorship was also significantly predicted by the year of the first revision total knee arthroplasty and the reason for the revision. CONCLUSIONS: An age greater than seventy years, revision five years or more after the primary arthroplasty, and absence of patellar subluxation are positive indicators of survival of a revision total knee replacement. We believe that normal aging as well as the deconditioning effect of disease (osteoarthritis and rheumatoid arthritis) and its treatment (primary total knee replacement) may lead to a reduced activity level, which, together with a presumed reluctance to operate on elderly patients, protects against repeat revisions. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Revision total knee arthroplasty with the total condylar III system: a comparative analysis of 71 consecutive cases of osteoarthritis or inflammatory arthritis.

BACKGROUND: As revision total knee arthroplasty surgery is becoming more common, it is necessary to evaluate how individual revision prosthesis systems perform in degenerative and inflammatory arthritides. In this study, results of the use of the Total Condylar III (TC III) system in osteoarthritis (55 knees) were compared to results of its use in inflammatory arthritis (16). METHODS: Patients were followed radiographically for 5.9 (3.0-10.2) years and clinically for 3.0 (0.2-6.8) years, using re-revision as the endpoint. RESULTS: At 1 year after revision and at final follow-up, the total Knee Society knee score, function score and range of motion had improved (p < 0.001) with no differences between osteoarthritis and inflammatory arthritis. No knee had definite component loosening, although 23 knees had asymptomatic radiolucent lines. Complications comprised 4 infections, 1 patellar pain syndrome and 1 rupture of the patellar tendon. Using any re-revision of the prosthesis as the endpoint, 5-year survival was 95% and 8-year survival was 94%. INTERPRETATION: Concentration of demanding revision knee arthroplasties to a few hands led to good or excellent knee joint knee score results in four-fifths of the patients, and showed good outcome with the TCIII system. In spite of ligamentous laxity, propensity to develop infections, bone destruction and poor general health, patients with inflammatory arthritis had results similar to those with osteoarthritis.

Health-related quality of life in patients waiting for major joint replacement. A comparison between patients and population controls.

BACKGROUND: Several quality-of-life studies in patients awaiting major joint replacement have focused on the outcomes of surgery. Interest in examining patients on the elective waiting list has increased since the beginning of 2000. We assessed health-related quality of life (HRQoL) in patients waiting for total hip (THR) or knee (TKR) replacement in three Finnish hospitals, and compared patients' HRQoL with that of population controls. METHODS: A total of 133 patients awaiting major joint replacement due to osteoarthritis (OA) of the hip or knee joint were prospectively followed from the time the patient was placed on the waiting list to hospital admission. A sample of controls matched by age, gender, housing and home municipality was drawn from the computerised population register. HRQoL was measured by the generic 15D instrument. Differences between patients and the population controls were tested by the independent samples t-test and between the measurement points by the paired samples t-test. A linear regression model was used to explain the variance in the 15D score at admission. RESULTS: At baseline, 15D scores were significantly different between patients and the population controls. Compared with the population controls, patients were worse off on the dimensions of moving (P < 0.001), sleeping (P < 0.001), sexual activity (P < 0.001), vitality (P < 0.001), usual activities (P < 0.001) and discomfort and symptoms (P < 0.001). Further, psychological factors--depression (P < 0.001) and distress (P = 0.004)--were worse among patients than population controls. The patients showed statistically significantly improved average scores at admission on the dimensions of moving (P = 0.026), sleeping (P = 0.004) and discomfort and symptoms (P = 0.041), but not in the overall 15D score compared with the baseline. In patients, 15D score at baseline (P < 0.001) and body mass index (BMI) (P = 0.020) had an independent effect on patients' 15D score at hospital admission. CONCLUSION: Although patients' HRQoL did not deteriorate while waiting, a consistently worse HRQoL was observed in patients waiting for major joint replacement compared with population controls.

Patient outcome following revision total knee arthroplasty: a meta-analysis.

The purpose of this study was to summarize the literature describing patient outcome following revision total knee arthroplasty. Original studies were included if they were published between 1990 and 2002, enrolled ten or more patients, and measured patient outcome using a global knee rating scale. We found 33 studies with a total number of 1,356 patients. There were 429 men and 611 women with a mean age of 67 (45-90) years. The weighted mean follow-up time was 57 (6-108) months. The main indication of revision was loosening. The weighted mean preoperative and postoperative knee scores were 49 (15-82) and 84 (58-109) respectively. There were significant differences between preoperative and postoperative knee and function scores and motion (knee: t=12.507 p<0.001, function: t=4.704 p<0.001, motion: t=5.346 p<0.001). Loosening was also the main complication after revision surgery. In this analysis, revision total knee arthroplasty was a safe and effective procedure.

Souter arthroplasty for elbows with severe destruction.

One hundred fifty-eight primary Souter elbow arthroplasties were done on 134 patients (121 women) with severe joint destruction (Larsen Grade 5) or large bone defects or both. Joint replacement operations were done at our institution from 1985-1997. The study group comprised 156 joints in 132 patients with rheumatoid arthritis or other variants of chronic inflammatory joint disease, one in a patient with osteoarthritis, and one patient with posttraumatic arthrosis. The mean age of the patients at the time of surgery was 57 years (range, 26-81 years) and the mean disease duration was 27 years (tinge, 2-70 years). Radiographically, severe bone defects were detected in 100 humeri and 134 ulnas. Retentive (snap-fit) ulnar components were implanted in 110 joints, and bone grafts were used on 26 humeri and 14 ulnas. Major complications led to five early and 16 late reoperations in 19 patients. Four reoperations were done because of dislocation and eight because of aseptic loosening. One reoperation was done because of early infection and five were done because of late infection. One patient had reoperation because of superficial infection in the bursa olecrani and one triceps tendon rupture also was repaired. One patient had wound repair because of marginal necrosis. In the survival analysis, the cumulative success rate without revision for aseptic loosening at 5 years followup was 97%. Despite the demanding nature of these arthroplasties, the primary results are encouraging. Technically, it is possible to do elbow replacement, even on elbows where the humeral condyles or olecranon or both are missing, if there is sufficient bone left on the diaphyseal areas for primary stem fixation. However, in these extreme cases, the poor general condition of the patient or the difficult soft tissue problems in the elbow region may prove to be a contraindication for joint replacement.

Stress fractures of the ankle and forefoot in patients with inflammatory arthritides.

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.

Revisions for aseptic loosening in Souter-Strathclyde elbow arthroplasty: incidence of revisions of different components used in 522 consecutive cases.

We present the prosthesis survival of the 7 most commonly used component types of 522 primary Souter elbow replacements performed in the Rheumatism Foundation Hospital during the years 1982-1997. The cohort comprised 370 female and 33 male patients with a mean age of 57 (20-81) years. 119 patients had a bilateral procedure. The indications for operation in all cases were rheumatoid arthritis and other chronic inflammatory joint disease. The mean duration of the disease at the time of operation was 25 (2-70) years. Elbows were often severely destroyed and, in one thiird of the joints, essential bone structures were missing. Therefore, in 178 cases, the ulnar components were retentive and in the remaining 344 elbows with better bone stock non-retentive. 47 patients had 51 operations for aseptic loosening up to the end of year 2000. In the survival analysis, the general cumulative success rates for the whole study cohort, without revision because of aseptic loosening 5 and10 years after surgery, were 96% and 84%, respectively. Revision was used as an end point. Cumulative success rates of the 7 most commonly used components are presented separately. The highest 5-year-survival rate was 100%, the lowest 93%. The corresponding 10-year-survival rates were 91% and 76%, respectively.

Bone destruction patterns of the rheumatoid elbow: a radiographic assessment of 148 elbows at 15 years.

A cohort of 74 patients with rheumatoid arthritis (RA) was followed prospectively for 15 years. At the end of the study, 148 elbows were radiographed with standard methods. The bone destruction of the humerus was measured from the anteroposterior (AP) radiograph as the bone attrition of the trochlea (TM) and the capitellum (CM). The bone destruction of the ulna was measured from the AP radiograph as the width (WO) and from the lateral radiograph as the thickness (TO) of the olecranon. Moreover, elbow joint destruction was graded by the Larsen system on a scale of 0 to 5. The relation of bone destruction to Larsen grade of the elbows was examined. The mean TM of the nonaffected (Larsen grades 0 to 1, n = 73) joints was 17.5 mm (SD, 2.1 mm; range, 10-22 mm), whereas the mean of Larsen grade 3 to 5 joints (n = 26) was 11.5 mm (SD, 5.2 mm). The mean CM of the nonaffected joints was 19.6 mm (SD, 2.6 mm; range, 15-25 mm), and the corresponding mean of Larsen grade 3 to 5 joints 15.5 mm (SD, 4.5 mm). The mean TO of the nonaffected joints was 18.9 mm (SD, 1.5 mm; range, 17-23 mm), and the mean of Larsen grade 3 to 5 joints was 13.9 mm (SD, 4.1 mm). The mean WO of the nonaffected joints was 23.3 (SD, 2.4 mm; range, 18-28 mm), and the mean of Larsen grade 3 to 5 joints was 22.4 mm (SD, 6.2 mm). Spearman correlation coefficients between TM, CM, and TO and Larsen grade of the joint were -0.45 (95% CI, -0.31 to -0.57), -0.38 (95% CI, -0.23 to -0.51), and -0.46 (95% CI, -0.31 to -0.57), respectively. Bone destruction in both the humerus and the olecranon appears to be a late consequence of rheumatoid elbow involvement. Bone loss is always present in the situation of rheumatoid elbow replacement, and it is most remarkable in Larsen grade 5 joints; the risk of preoperative and intraoperative complications due to bone destruction is significantly increased in this group.

A comparison of postoperative C-reactive protein changes in primary and revision hip arthroplasty in patients with rheumatoid arthritis.

C-reactive protein (CRP) response was studied in 40 consecutive patients with rheumatoid arthritis undergoing primary (n = 20) or revision (n = 20) total hip arthroplasty (THA). In patients with primary THA, the median preoperative CRP concentration was 10 mg/L (interquartile range [IQR], 6-17 mg/L), and the median change in CRP was 69 mg/L (IQR, 43-69 mg/L) at the 1st or 2nd postoperative day (P< .001). In the patients with revision THA, the results were 8 mg/L (IQR, 0-32 mg/L) and 48 mg/L (IQR, 21-78 mg/L) (P< .001). Median change in CRP from preoperative to postoperative values did not differ significantly among the patients with primary and revision THA. No correlation was found between the preoperative and perioperative background variables and the change in CRP compared with patients with primary and revision THA. It seems that the revision operation has no significant additional influence on the postoperative CRP response. More detailed analyses are needed to evaluate the significance of endocrine, metabolic, and inflammatory responses in these patients.