Disparities in Outcomes for African Americans and Whites Undergoing Total Knee Arthroplasty: A Systematic Literature Review.

OBJECTIVE: African Americans in the United States undergo total knee arthroplasty (TKA) less often than whites, in part because of lower expectations among African Americans for successful surgery. Whether this lower expectation is justified is unknown. Our objective is to compare health-related quality of life (HRQOL) and satisfaction after TKA between African Americans and whites. METHODS: A systematic review of English language articles using Medline, the Cochrane register, Embase (April 21, 2015), and a hand search of unlisted disparities journals was performed. Search terms included total knee replacement, quality of life, outcomes, and satisfaction. High-quality cohort studies that examined HRQOL in African Americans and white adults 6 months or more after TKA were included. RESULTS: Of the 4781 studies screened by title, and 346 by abstract, 7 studies included race in their analysis. Results included 5570 TKA patients, 4077 whites (89%), and 482 (11%) blacks. Because studies used different outcome measures and were inconsistent in their adjustment for confounders, we could not perform a quantitative synthesis of results. In 5 studies, US blacks had worse pain, in 5 worse function, and in 1 less satisfaction 6 months to 2 years after TKA. CONCLUSION: US blacks may derive less benefit from TKA than whites as measured by HRQOL, pain, function, and satisfaction. Many studies assessing predictors of patient-related TKA outcomes fail to analyze race as a variable, which limited our study. More studies assessing the effect of race and socioeconomic factors on TKA outcome are needed.

Management of perioperative tumour necrosis factor α inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis.

OBJECTIVE: Tumour necrosis factor α inhibitors (TNFis) are widely used in RA patients who undergo surgery, and optimal perioperative management must balance the risk of infection with the risk of post-operative flare. The purpose of this study is to examine the impact of TNFi exposure on surgical site infections (SSIs) in RA patients undergoing elective orthopaedic surgery by systematic review and meta-analysis. METHODS: A systematic review of the literature and meta-analysis were performed using PUBMED, EMBASE and the Cochrane Central Register of Controlled Trials, through May 2014. Two independent reviewers screened titles and abstracts, and analysed selected papers in detail. Included studies assessed RA patients with or without TNFi exposure prior to orthopaedic surgery, and described post-operative infections. Study quality was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Meta-analyses of the individual study odds ratios (ORs) were conducted, and each pooled OR was calculated using a random effects model. RESULTS: Eight observational studies and three case control studies met inclusion criteria; risk of bias was low in eight studies and moderate in three. Publication bias was not apparent. These studies represent 3681 patients with recent exposure to TNFis (TNFi+) and 4310 with no recent exposure to TNFis (TNFi-) at the time of surgery. The TNFi+ group had higher risk of developing SSI compared with patients in the TNFi- group (random effects model: OR 2.47 (95% CI 1.66, 3.68); P < 0.0001). CONCLUSION: Data from the available literature suggest that there is an increased risk of SSIs in RA patients who use or have recently used TNFis at the time of elective orthopaedic surgery. Prospective studies to confirm these findings and establish the optimal withhold and restart time of TNFis, in the context of other risk factors for infection in RA patients such as higher disease activity, corticosteroid use, smoking and diabetes, are needed.