American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015: recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis

OBJECTIVE: To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. RESULTS: In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS. CONCLUSION: These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.(AU)

Systemic lupus erythematosus is not a risk factor for poor outcomes after total hip and total knee arthroplasty.

OBJECTIVES: Historically, arthroplasty in systemic lupus erythematosus (SLE) patients has been less successful than for patients with osteoarthritis (OA). It is not known if SLE remains an independent risk factor for poor arthroplasty outcomes or if other factors, such as avascular necrosis (AVN), continue to play a role. METHODS: A case-control study using data from a single-institution arthroplasty registry compared SLE total hip arthroplasty (THA) and total knee arthroplasty (TKA) with OA controls matched by age, gender and presence of AVN. Baseline, two-year administrative and self-report data, and diagnosis leading to arthroplasty were evaluated. RESULTS: A total of 54 primary SLE THA and 45 primary SLE TKA were identified from May 2007 through June 2011. AVN was present in 32% of SLE THA and no TKA. SLE THA had worse preoperative WOMAC pain (42.5 vs. 52.7; p = 0.01) and function (38.8 vs. 48.0; p = 0.05) compared with OA. However, at two years there was no difference in WOMAC pain (91.1 vs. 92.1; p = 0.77) or WOMAC function (86.4 vs. 90.8; p = 0.28). SLE TKA were similar to OA in both preoperative pain (42.6 vs. 48.4; p = 0.14) and function (42.1 vs. 46.8; p = 0.30) and two-year pain (85.7 vs. 88.6; p = 0.50) and function (83.7 vs. 85.1; p = 0.23). Compared to OA, SLE THA and TKA patients had more renal failure (14% vs. 1%; p = 0.007) and hypertension (52% vs. 29%; p = 0.009). In a multivariate linear regression, SLE was not predictive of either poor pain or poor function. CONCLUSIONS: While SLE patients have more comorbidities than OA, and SLE THA have worse preoperative pain and function compared with OA controls, SLE was not an independent risk factor for poor short-term pain or function after either hip or knee arthroplasty.

Reducing blood loss after total knee replacement: a fibrin solution.

Blood loss during total knee replacement (TKR) remains a significant concern. In this study, 114 patients underwent TKR, and were divided into two groups based on whether they received a new generation fibrin sealant intra-operatively, or a local infiltration containing adrenaline. Groups were then compared for mean calculated total blood volume (TBV) loss, transfusion rates, and knee range of movement. Mean TBV loss was similar between groups: fibrin sealant mean was 705 ml (281 to 1744), local adrenaline mean was 712 ml (261 to 2308) (p = 0.929). Overall, significantly fewer units of blood were transfused in the fibrin sealant group (seven units) compared with the local adrenaline group (15 units) (p = 0.0479). Per patient transfused, significantly fewer units of blood were transfused in the fibrin sealant group (1.0 units) compared with the local adrenaline group (1.67 units) (p = 0.027), suggesting that the fibrin sealant may reduce the need for multiple unit transfusions. Knee range of movement was similar between groups. From our results, it appears that application of this newer fibrin sealant results in blood loss and transfusion rates that are low and similar to previously applied fibrin sealants.

Successful hip arthroplasty in an adult male with severe factor XI deficiency using Hemoleven®, a factor XI concentrate.

Severe factor XI (sFXI) deficiency is a rare bleeding disorder (RBD). FXI replacement is most often required for surgical hemostasis. Plasma, the sole US treatment option, is often complicated by life-threatening allergic reactions. In such circumstances, the FDA offers a mechanism for institution-industry collaboration to facilitate limited use of replacement products licensed abroad. A 58 years old man with sFXI deficiency, required hip replacement. In the past, he received prophylactic plasma for thyroidectomy and experienced a severe allergic reaction. A single use institutional IND FDA application was initiated in collaboration with LFB (Les Ulis, France) to access Hemoleven®, a plasma-derived FXI concentrate. The application required an investigator-initiated IRB-approved protocol for treatment and safety/efficacy monitoring that included: preoperative thrombophilia, FXI inhibitor and pharmacokinetic (PK) evaluations; peri- postoperative administration of ≤ 4 doses of 10-15 U/kg Hemoleven® ; DIC monitoring; postoperative thromboprophylaxis; observation for product efficacy and potential complications. PK study demonstrated the expected 1.8% FXI recovery per U/kg with half-life of 62 hours. Mild D-Dimer elevation was noted 6-9 hours post-infusion. The initial dose (15 U/kg) was administered 15 hours before surgery; subsequently, 3 doses (10 U/kg) were infused every 72 hours. Hemostasis was excellent. No complications were observed. Collaboration allowed for successful patient access to Hemoleven® with excellent PK, safety, and efficacy. This case underscores the need for additional efforts to ensure safe and effective licensed replacement therapies for RBD patients.

Indications, technique, and results of total shoulder arthroplasty in rheumatoid arthritis.

Unconstrained total shoulder arthroplasty is a highly effective and successful operation in the patient with rheumatoid arthritis. Reliable pain relief can be obtained, often with an improvement in range-of-motion and function of the entire extremity. Rheumatoid patients may present with difficult soft-tissue and bony deficiencies, but careful planning and intraoperative procedures help to maximize the outcome and minimize the possible complications.

Failed total wrist arthroplasty. Analysis of failures and results of operative management.

Nine metal on polyethylene total wrist arthroplasties were revised for failure, including eight trispherical devices and one Volz implant. Causes of failure include sepsis in one patient, progressive wrist flexion contracture in two patients, and mechanical failure in six patients. The most common mode of mechanical failure was metacarpal loosening with dorsal perforation of the stem. This was associated with an intact articulation between the third metacarpal and the capitate, with a proximal position of the metacarpal component in the shaft, and with poor cement fill of the metacarpal shaft. The one infected wrist was managed with resection arthroplasty. Five patients had conversion to a wrist arthrodesis and three patients underwent revision total wrist arthroplasty with custom trispherical components. Followup averaged 3.3 years. All patients undergoing arthrodesis attained a solid painless fusion after a single operation at an average of 4.8 months. The three patients treated with revision arthroplasty had wrists that were pain free, functional, and had no evidence of loosening at latest followup. Failed total wrist arthroplasties can be salvaged successfully to either a fusion or a revision arthroplasty in most patients.

Wrist arthroplasty with the trispherical total wrist prosthesis.

The clinical results and long-term implant survival of wrist arthroplasty with the Trispherical total wrist prosthesis was evaluated in patients with inflammatory arthritis. Using the Hospital for Special Surgery wrist scoring system, the clinical evaluation of 35 Trispherical total wrist arthroplasties showed an excellent result in 20, good result in 8, fair result in 3, poor result in 2, and failed result requiring revision in 2 wrists at an average follow-up of 9 years. Cumulative implant survival in 67 consecutive Trispherical total wrist arthroplasties was 97% at 5 years and 93% at 10 and 12 years postoperatively. Patient satisfaction with wrist arthroplasty using the Trispherical prosthesis was excellent. We attribute the favorable long-term results obtained with the use of this prosthesis to its inherent design that allows for accurate restoration of the center of rotation of the wrist.

Sagittal measurements of the cervical spine in subaxial fractures and dislocations. An analysis of two hundred and eighty-eight patients with and without neurological deficits.

We analyzed three factors involved in fractures and dislocations of the cervical spine and their relation to the degree of injury of the spinal cord. The three factors were the space available for the spinal cord at the level of the injury, the sagittal diameter of the spinal canal at the uninjured levels, and the Pavlov ratio at the uninjured levels. Of the 288 patients analyzed, eighty-three had a complete injury of the spinal cord, ninety-two had an incomplete injury of the spinal cord, thirty had an isolated nerve-root injury, and eighty-three had no neurological deficit. The mean space available for the spinal cord at the level of the injury was 10.5 millimeters for the patients who had a complete injury of the spinal cord, 13.1 millimeters for those who had an incomplete injury of the spinal cord, 15.9 millimeters for those who had an isolated nerve-root injury, and 16.7 millimeters for those who had no neurological deficit. The difference between the groups was significant (p < 0.001) except for the difference between the patients who had an isolated nerve-root injury and those who had no neurological deficit. The mean sagittal diameter of the canal at the uninjured levels was 16.1 millimeters for the patients who had a complete injury of the spinal cord, 16.1 millimeters for those who had an incomplete injury of the spinal cord, 17.9 millimeters for those who had an isolated nerve-root injury, and 18.1 millimeters for those who had no neurological deficit. The difference between the patients who had a complete injury of the spinal cord and those who had an incomplete injury of the spinal cord and that between the patients who had an isolated nerve-root injury and those who had no neurological deficit were not significant (p > 0.05). However, the patients who had a complete injury of the spinal cord and those who had an incomplete injury of the spinal cord were significantly different from the patients who had an isolated nerve-root injury and those who had no neurological deficit (p < 0.001). The mean Pavlov ratio at the uninjured levels was 0.82 for the patients who had a complete injury of the spinal cord, 0.84 for those who had an incomplete injury of the spinal cord, 0.96 for those who had an isolated nerve-root injury, and 0.96 for those who had no neurological deficit.(ABSTRACT TRUNCATED AT 400 WORDS)

Revision total elbow replacement.

Revision total elbow surgery is technically demanding with high complication rates. It requires precise preoperative planning and a surgeon prepared to use any of several surgical options during surgery. Satisfactory results can be achieved in complex cases.

Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases.

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis.

Intramedullary deposits of hydroxyapatite crystals in a patient with rheumatoid arthritis.

A 63-year-old women with a 12-year history of rheumatoid arthritis (RA) had calcific deposits in the periarticular soft tissues with subsequent involvement of the medullary canals of adjacent bones. Except for the RA, there was no evidence of other abnormalities of the bones or mineral homeostasis. Chemical analyses of the deposits identified the crystalline material as apatite. Although the deposition of apatite in the soft tissues of RA is known to occur rarely, this is the first known case of intraosseous apatite deposition.

Triple arthrodesis in rheumatoid arthritis.

Fifty-five patients with rheumatoid arthritis were treated with 65 triple arthrodeses of the hindfoot from March 1975 through July 1985. Twelve patients (12 procedures) have died, and follow-up evaluation could not be completed on three patients (four procedures), leaving 40 patients (49 procedures) available for clinical and roentgenographic evaluation. There were 32 women and eight men, with an average age at the time of surgery of 50 years. The follow-up period averaged five years. Standard operative technique involved medial and lateral incisions with staple fixation and local bone grafting. Correction of deformity was performed with closing wedge osteotomies. All patients had moderate to severe pain preoperatively and difficulty with ambulation. Postoperatively, 94% of the patients had significant pain relief and 83% had complete pain relief. Ambulatory status was improved in 80% of the patients. Ninety percent were at least community ambulators at the time of review, whereas more than half the patients were limited to household ambulation preoperatively. Complications included four superficial wound infections, all of which responded to local care. One patient required revision surgery for pseudarthrosis, and three patients had progression of ankle disease and required pantalar arthrodeses. There was no significant progression of fore-foot or knee symptoms, however, and there was no progression of ankle symptoms in patients whose hindfeet were corrected to 0 degrees-10 degrees valgus. Triple arthrodesis in the rheumatoid population has a high union rate. Pain relief and ambulation improvement can be expected.

Custom total shoulder arthroplasty in inflammatory arthritis. Preliminary results.

Twenty-three patients with inflammatory arthritis and rotator cuff deficiency have undergone 27 custom-fit total shoulder arthroplasties. The design used included a short-stem humeral component and a metal-backed glenoid component with an offset keel. The glenoid component was custom-fit to provide maximum coverage of the glenoid surface. The average age of the patients at the time of surgery was 55 years (range, 20-75 years). All patients had inflammatory arthritis, 16 were on steroids, and all had some degree of rotator cuff involvement ranging from small to complete tears. The average length of follow-up study was 5 years (range, 3-7 years). The average preoperative shoulder score was 36 points (range, 15-50 points) with an average pain score of 7 (of 30) points. Postoperatively, the shoulder score improved to 85 points with a pain score of 28 points. Twenty-one shoulders scored a good to excellent result. Two patients required reoperation, both for recurrent rotator cuff tears, one of which occurred after a fall. Radiographic analysis revealed no incidence of humeral radiolucency and six cases of glenoid radiolucency. Only two of these were progressive and both were associated with irreparable rotator cuff tears. Thus, in the early follow-up, this design of glenoid has decreased the incidence of glenoid radiolucency in this difficult patient population.

Distal femoral replacement with allograft/prosthetic reconstruction for treatment of supracondylar fractures in patients with total knee arthroplasty.

Large-segment distal femoral allografts were used in conjunction with non-linked total knee prostheses to reconstruct bone deficits following supracondylar fracture of the femur in seven patients with previous total knee arthroplasties. Three patients with multiple medical problems died of unrelated causes prior to a minimum 2 year follow-up. Indications for surgery were previously failed attempts at osteosynthesis and significant fracture comminution, osteopenia, and intercondylar extension or femoral component loosening. Specifics of the surgical technique included subperiosteal excision of the involved distal femur with retention of a soft tissue sleeve containing the collateral ligaments and reconstruction with a large-segment allograft and a stemmed, semiconstrained total knee prosthesis. Cement fixation using pressurized technique with intramedullary plugging of the tibial and femoral canal was routinely used to secure the prosthesis/allograft construct to the host bone. Postoperative complications included one dislocation, which was successfully treated closed, and one popliteal artery injury, which was successfully repaired. There were no postoperative infections. Two patients, however, had some degree of persistent instability, warranting bracing at the time of last follow-up. Using the Knee Society rating system, the average knee score for these patients was 71, and the average pain score and function score were 33 and 49, respectively. Range of motion averaged 96 degrees. All of the femoral components were well fixed at last follow-up. Results of this study indicate that large-segment distal femoral allografts used in conjunction with nonlinked knee prostheses can be an acceptable method of treatment of these difficult reconstructive problems.

The results of treatment of supracondylar fracture above total knee arthroplasty.

This study analyzes the results of treatment of 22 patients with 24 supracondylar femur fractures above a total knee arthroplasty. Ten knees were treated by closed methods utilizing traction and then a cast, 10 knees with immediate open reduction and internal fixation, 2 knees with a custom total knee integrated with a distal femoral allograft, 1 knee with external fixation, and 1 knee with primary arthrodesis. Nine fractures treated by closed means and 5 fractures treated by open reduction and internal fixation healed primarily. Two of the 5 surgical failures healed after replating and bone graft. The 3 failures of surgical therapy were salvaged utilizing custom total knee arthroplasty, 2 of which required integration with a distal femoral allograft. One knee treated with external fixation developed a deep infection necessitating implant removal and arthrodesis. Twelve of the 14 femoral fractures that united primarily healed with the femoral component in varus with respect to the long axis of the anatomic femur. Nine of these 12 implants developed progressive radiolucent lines at the tibial component. Three of these knees have required implant revision due to progressive loosening of the tibial and/or femoral components. The results of this evaluation indicate that fractures above a well-fixed total knee arthroplasty are difficult to manage. If anatomical alignment cannot be achieved by simple closed techniques, then primary open reduction and internal fixation should be considered. However, because of the complexity of the problem, the surgeon should be prepared to perform a primary arthrodesis or revision using custom components with or without a distal femoral allograft.

Results of reconstruction for failed total elbow arthroplasty.

Failure of total elbow arthroplasty leads to difficult and complicated surgical reconstruction. This study evaluates the results of reconstruction after implant removal with respect to pain, motion, and functional ability. Between 1978 and 1985, 11 patients required implant removal. Indications for removal were infection for seven, implant fracture for three, and recurrent dislocation for one. The original diagnosis was rheumatoid arthritis in six elbows and traumatic arthritis in five. The average length of the follow-up period was 5.5 years after implant removal (minimum, two years). Treatment consisted of implant removal and soft-tissue arthroplasty combined with external fixation in ten patients, and attempted arthrodesis with external fixation in one. There were four good, one fair, two poor, and four failed results. Satisfactory results were obtained in seven of the eight elbows in which an anatomic arthroplasty was achieved. This consisted of containment of the ulna by the humeral epicondylar remnants. All eight elbows were pain-free with an average arc of motion of 85 degrees (range, 55 degrees to 120 degrees). They had excellent elbow flexion power; however, triceps strength was often compromised. In the three elbows in which anatomic arthroplasty could not be achieved, one was flail, one was later converted to an arthrodesis with a customized plate, and the third required an immediate arthrodesis. All three were rated as failures. Fractures occurred in five of the 11 elbows. One occurred preoperatively, three occurred intraoperatively, and one occurred postoperatively. All healed satisfactorily during the course of immobilization. The importance of an anatomic arthroplasty when removing a total arthroplasty cannot be overemphasized. Retaining the epicondylar segments is important because satisfactory results were obtained in patients in whom entrapment of the olecranon within the epicondylar ridges was obtained. Such patients can achieve a satisfactory soft-tissue arthroplasty without the use of an interpositional material. When the epicondylar ridges were not retained and there was marked instability, the patients did not achieve satisfactory results.

Metacarpal-phalangeal joint arthroplasty of the rheumatoid thumb.

Fifty patients with rheumatoid arthritis had 59 Swanson implants of the metacarpal-phalangeal joint of the thumb. Eleven patients (15 implants) have since died and only 1 patient (1 implant) has been lost to follow-up leaving 43 implants available for study. The most common preoperative deformity was a boutonniere deformity with a flexible interphalangeal joint. All thumbs had less pain after operation. The average range of active motion is 25 degrees, with a flexion arc from 15 to 40 degrees. There is an average key pinch strength of 4 pounds (range, 0.5 to 10). Improvement in activities of daily living were noted in 40 hands. One thumb required reoperation for instability; the implant was removed and a metacarpal-phalangeal arthrodesis was done. Radiographic progression of disease was noted in only one thumb at the interphalangeal joint and in two other thumbs at the carpometacarpal joint. None of these have required further operations. The maintenance of motion appears to help in activities of daily living as stability and pinch strength are often adequate.

Trispherical total wrist arthroplasty in rheumatoid arthritis.

Thirty-four patients, with 35 trispherical total wrist arthroplasties for treatment of rheumatoid arthritis, were evaluated at an average follow-up of 9 years (range, 5 to 11 years). The average preoperative score was 25 points inasmuch as all patients had severe pain and loss of function. The average postoperative score improved to 87 points since 30 wrists were free of pain. Twenty-eight wrists rated as a good-to-excellent result. The average arc of flexion and extension improved from 35 to 50 degrees. There were no deep infections or dislocations. Two wrists required revision, one for loosening and one for persistent pain, both requiring removal of the implant and arthrodesis. Postoperative tendon attrition occurred in six wrists, all of which had preoperative tendon ruptures necessitating tendon transfer. Radiographs showed radiolucencies in seven wrists, including seven around the metacarpal stem and one around the radial stem. The optimum results were achieved in those patients with intact extensor tendons before operation.

Management of infection about total elbow prostheses.

Deep infection was a complication after twelve (7.3 per cent) of 164 primary total elbow replacements. Two additional patients who had an infection about an elbow prosthesis were referred for treatment after total elbow replacement elsewhere. A statistical analysis of all of these primary total elbow arthroplasties, including the two in patients who were referred from outside institutions, identified preoperative factors that placed a patient at significant risk for subsequent infection. The risk factors included a previous operation on the elbow, a previous infection in the region of the elbow, psychiatric illness, class-IV rheumatoid arthritis, drainage from the wound after operation, spontaneous drainage after ten days, and reoperation for any reason. Three modes of treatment were used for patients who had an established infection: débridement and salvage of the implant, resection arthroplasty, and arthrodesis. After early operative débridement and suppression of the infection with long-term antibiotic therapy, three patients were able to retain the prosthesis, with restoration of range of motion and function of the upper extremity. One prosthesis was reimplanted after a six-week course of intravenous administration of antibiotics.

Total knee arthroplasty for the treatment of chronic hemophilic arthropathy.

Total knee arthroplasty (TKA) for hemophilic (factor VIII deficiency) arthropathy is a complex and demanding procedure with a high complication rate. However, the long-term benefits have not previously been reported. This study reviews 19 TKAs performed for hemophilic arthropathy that were followed for a minimum of 5.5 years and an average of 9.5 years. At present, 13 knees have good or excellent results, and six knees rate as poor or failures. Those patients with excellent results have maintained good pain relief and function. Four of the six failures were among the first seven arthroplasties performed, when only 80% factor VIII coverage was used during the perioperative period. Since the use of 100% factor VIII coverage was instituted, the failure rate has declined. Ten of the 19 knees suffered complications, including one deep infection, six superficial skin necroses, three nerve palsies, seven postoperative bleedings, and one transfusion reaction. Six of the seven knees operated on under 80% factor VIII coverage had complications. Once 100% factor VIII coverage was instituted, the only complications included one skin necrosis and three postoperative bleedings. The roentgenographic failure rate has remained high with progressive roentgenographic lucencies in 13 of 19 tibial components, associated with component shift in three knees. While these roentgenographic findings have not necessarily correlated with clinical results, they are disturbing and may portend future failures. However, pain relief and improved function are maintained at longer follow-up times. The best results were obtained under 100% factor VIII coverage using a posterior stabilized prosthesis and patellar resurfacing.