Original Research

Shoulder Arthroplasty: Disposition and Perioperative Outcomes in Patients With and Without Rheumatoid Arthritis

Am J Orthop. 2016 May;45(4):E204-E210

References

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Results

Of the 34,970 patients who underwent SA between 2006 and 2011, 1674 (4.8%) had a diagnosis of RA and 33,296 (95.2%) did not. On average, patients with RA tended to be younger than patients without RA (66.4 vs 69.1 years; P < .001), and a larger percentage of RA patients were female (75.5% vs 54.4%; P < .001). Compared with non-RA patients, RA patients comprised a different ethnic group and had a different expected primary payer (P < .001). SA patients with and without RA did not differ in income quartile based on ZIP code, total number of hospital beds, hospital region, or hospital teaching status (P = .34, .78, .59, and .82, respectively) (Table 1).

LOS was significantly (P < .001) statistically longer for RA patients (2.196 days) than for non-RA patients (2.085 days). RA patients were significantly less likely to be discharged home (63.0% vs 67.6%; P < .001). (Routine discharge was defined as discharge home, whereas nonroutine discharge was defined as discharge to a short-term hospital, skilled nursing facility, intermediate care, another type of facility, home health care, against medical advice, or death.) In addition, inflation-adjusted charges associated with SA were significantly higher (P = .018) for RA patients ($54,284) than for non-RA patients ($52,663) (Table 1).

Regarding the rates of complications that occurred during the perioperative index, there were no significant differences between RA and non-RA cohorts. These complications included respiratory, gastrointestinal, genitourinary, accidental puncture/laceration, central nervous system, wound dehiscence, device-related, cardiac, hematoma/seroma, acute respiratory distress syndrome, postoperative shock, VTE, and postoperative infection (Table 2). In addition, there was no significant difference in mortality between the groups (P = .48).

In TSA, blood transfusions were more likely (P < .001) to be given to RA patients (9.00%) than to non-RA patients (6.16%). Multivariate regression analyses were performed with age, race, sex, hospital region, hospital type, number of hospital beds, primary payer, and hospital ownership as covariates. These analyses revealed that transfusion (P < .001), discharge type (P = .002), total inflation-adjusted charges (P < .001), and LOS (P = .047) remained significant (Table 3).

Discussion

Large national databases like NIS allow study of uncommon medical occurrences and help delineate risks and trends that otherwise might be indeterminable. Although it has been suggested that patients with RA may have poorer long-term outcomes after SA, the perioperative risk profile indicates that TSA is well tolerated in RA patients during the operative index.^3,23-25

The data on this study’s 34,970 patients, drawn from the period 2006–2011, demonstrated no significant differences in safety profile with respect to the 14 perioperative complications and outcomes examined, except blood transfusion rate. Rates of postoperative infection (RA, 0.24%; non-RA, 0.14%; P = .303), VTE (RA, 0.30%; non-RA, 0.25%; P = .905), and transfusion (RA, 9.00%; non-RA, 6.16%; P < .001) are of particular interest because of the severity of these situations.

Postoperative infection is a potentially serious complication and often occurs secondary to diabetes, RA, lupus erythematosus, prior surgery, or a nosocomial or remote source.¹ The often costly treatment options include antibiotic suppression, irrigation and debridement with implant retention, 1-stage exchange with antibiotic-impregnated cement fixation, staged reimplantation, resection arthroplasty, arthrodesis, and amputation.¹ The overall 0.14% infection rate determined in this study is lower than the 0.7% reported for SA patients in the literature.¹ Given the nature of the NIS database, this rate underestimates the true postoperative infection rate, as any infection that occurred after the perioperative period is not captured.²⁶ The present study’s perioperative infection rates (RA, 0.24%; non-RA, 0.14%) for the period 2006–2011 are comparable to the rates (RA, 0.17%; non-RA, 0.24%) reported by Hambright and colleagues3 for the same patient population over the preceding, 18-year period (1988–2005) and similarly do not significantly differ between groups. Although infection is uncommon in the immediate perioperative period, the ICD-9 codes used refer specifically to infection resulting from surgery and do not represent concomitant infection.

VTEs, which include PEs and DVTs, are rare but potentially life-threatening surgical complications.^27,28 Mechanical prophylaxis and chemical prophylaxis have been recommended for major orthopedic surgery, particularly lower extremity surgery, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA).^28,29 In the present study, VTE rates were low, 0.30% (RA) and 0.25% (non-RA), and not significantly different in bivariate or multivariate analyses. These rates are comparable to those found in other national-database SA studies.²⁸ VTEs that occur outside the index hospital admission are not captured in this database. Therefore, the rates in the present study may be lower than the true incidence after SA. Mortality secondary to VTE usually occurs within 24 hours but may occur up to 90 days after surgery. DVT rates, on the other hand, are difficult to evaluate because of differences in screening practices.^27,28,30,31