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Objective: Total hip replacement (THR) outcomes have been worse for patients with rheumatoid arthritis (RA) compared with those who have osteoarthritis (OA). Whether this remains true in contemporary patients with RA with a high use of disease-modifying and biologic therapy is unknown. The purpose of our study is to assess pain, function, and quality of life 2 years after primary THR, comparing patients with RA and patients with OA., Methods: Baseline and 2-year data were compared between validated patients with RA and patients with OA who were enrolled in a single-center THR registry between May 1, 2007, and February 25, 2011., Results: There were 5666 eligible primary THR identified, of which 193 were for RA. RA THR had worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (44.8 vs 53.2, p < 0.001) and function (38.7 vs 49.9, p < 0.001) compared with OA. These differences remained after surgery: pain (88.4 vs 94.0, p < 0.001) and function (82.9 vs 91.8, p < 0.001). Patients with RA were as likely to have a significant improvement as patients with OA (Δ WOMAC > 10) in pain (94% vs 96%, p = 0.35) and function (95% vs 94%, p = 0.69), but were 4 times as likely to have worse function (WOMAC ≤ 60; 19% vs 4%, p < 0.001) and pain (12% vs 3%, p < 0.001). In multivariate logistic regression controlling for multiple potential confounders, RA increased the odds of poor postoperative function (OR 4.32, 95% CI 1.57-11.9), and in patients without a previous primary THR, worse postoperative pain (OR 3.17, 95% CI 1.06-9.53)., Conclusion: Contemporary patients with RA have significant improvements in pain and function after THR, but higher proportions have worse 2-year pain and function. In addition, RA is an independent predictor of 2-year pain and poor function after THR, despite high use of disease-modifying therapy.

Objective: The patterns and risks of perioperative use of anti-tumor necrosis factor (anti-TNF) medication in patients with rheumatoid arthritis (RA) are not well studied. We examined the patterns of perioperative anti-TNF use and risk of postoperative adverse events (AE) in patients undergoing total knee replacement (TKR)., Method: Retrospective cohort study with followup. RA cases within a TKR registry were identified by ICD-9 code (714.0) or self-report. Mailed questionnaires queried anti-TNF use and duration of RA. AE were determined by chart review and patient self-report, and included surgical site infection, pulmonary embolus, deep venous thrombosis, pneumonia, and any infection or re-operation within 6 months., Results: There were 268 TKR cases with RA. The stop time for anti-TNF preoperatively correlated with dosing schedule; restart time was after wound healing. There were 7 surgical site infections (3%), one (0.4%) of which was a deep joint infection in bilateral TKA requiring explant. The anti-TNF group had 3.26% (3/92) local site infection versus 2.10% (3/143) in the group without anti-TNF and this difference was not statistically significant (Fisher exact test, p = 0.68). The one deep joint infection was in the anti-TNF group. Six-month AE rate was 7.61% in the anti-TNF group versus 6.99% in the group without anti-TNF (Fisher exact test, p = 1.0)., Conclusion: There was a low risk of infection and perioperative adverse events in patients with RA receiving anti-TNF therapy who were undergoing TKR. This raises the question whether it is necessary to stop anti-TNF for a long period prior to surgery. Given the possible risks associated with stopping anti-TNF, including worsening of disease, further study is needed to determine optimal perioperative use of anti-TNF among patients with RA undergoing TKR.

Rheumatoid arthritis often affects multiple joints simultaneously with pain, deformity and loss of function. The indications for surgical treatment are presented along with guidelines for determining the surgical priorities along with guidelines for determining the surgical priorities when multiple joints require surgery.

Consideration of the individual, his or her needs, and what he or she hopes to gain through surgery is of primary importance in determining a surgical plan for the rheumatoid patient. Nevertheless, procedures undertaken to save life or prevent neurologic demise must, of course, take precedence. Alleviation of pain and correction of disabling deformity take next priority. Many other considerations go into the formulation of the list of surgical priorities. A full understanding of these considerations and a well-integrated team approach to the rheumatoid patient provide the best chance for optimal outcome following surgery.

Sixty-seven feet in forty-five patients who had rheumatoid arthritis were followed for an average of six years (range, four to ten years) after an operation on the forefoot that included resection of the metatarsophalangeal heads or joints and the insertion of a double-stemmed silicone-rubber implant in the first metatarsophalangeal joint. There were forty-two women and three men, and the average age at the time of the operation was fifty-six years (range, thirty-six to seventy-nine years). The mean duration of known rheumatoid arthritis was fifteen years (range, three to thirty-seven years). Resection of the metatarsophalangeal heads or joints was performed through a plantar approach in forty-one feet and a dorsal approach in twenty-six feet. A double-stemmed silicone-rubber implant was placed in the first metatarsophalangeal joint in all feet. Each patient was evaluated clinically and radiographically with use of a foot-scoring system that was developed for this study. The results were assessed for relief of pain, ability to walk (including the use of shoes), presence of calluses or deformity, and radiographic findings. The average preoperative foot score was 47 points; the score had improved to an average of 81 points at the latest follow-up examination. A good or excellent result was obtained in fifty-eight feet (87 per cent). Complications were infrequent. In three feet, there was delayed healing of the wound; three implants were removed because of dislocation and infection; and four feet had revision to correct deformities of the lesser toes.