Orthopedics

A 50-year-old man sustained a rope-burn injury to his left hand during a fishing trip in early August 2004. He subsequently presented to an orthopedic facility with complaints of a hand infection and was eventually referred to orthopedic surgeon Dr. W.

One week later, Dr. W administered a steroid injection, which caused the infection to worsen. The patient claimed that the steroid injection was contraindicated by the underlying infection. Dr. W referred the patient to Dr. C for infectious disease management.

In November 2004, Dr. W performed an incision and drainage procedure, and specimens were sent for pathology study and cultures. The pathology results were sent to both Dr. W and Dr. C, but the culture results were sent only to Dr. W. Other specimens were sent for culture in November 2004 and January 2005.

The results from the first culture, received by Dr. W in three reports, indicated “Mycobacterium,” “rare presumptive Mycobacterium mar­inum,” and “Myocbacterium marinum.” Dr. W did not forward these results to Dr. C and allegedly did not review the last report. Dr. C treated the plaintiff for a fungal infection based on the results of the second culture. After the third specimen in January 2005 grew acid-fast bacilli, Dr. C was informed that the patient likely had an infection caused by M. marinum.

The patient alleged that the 44-day delay in diagnosis and treatment of the M. marinum infection allowed the infection to worsen. The patient was hospitalized for one week at a major clinic and underwent three debridement surgeries to his left hand. He subsequently underwent five months of physical therapy and received long-term intravenous antibiotics for the infection.

The patient lacks full range of motion in his hand and is unable to fully open the fingers or make a tight fist. He has a trigger finger, surgical scars, and painful nodules. The hand is also extremely intolerant to temperature. The plaintiff claimed that the debridement surgeries would have been unnecessary if the initial culture reports had been acted upon in a timely manner.

The defendants claimed Dr. W saw no evidence of infection at the first office visit and that there was no sign of infection when the steroid injection was administered. The defendants claimed that the hand’s condition did not worsen after the injection and that the plaintiff was referred to Dr. C when a second fishing trip led to a flare-up that eluded diagnosis. Dr. W maintained that, during the procedure that produced the first cultures, he instructed the circulating nurse to have all lab results sent to both himself and Dr. C. Dr. W believed that Dr. C had been sent the results when he saw both their names on the pathology reports.

Continue reading to see the outcome... 

OUTCOME

A $215,000 verdict was returned. The surgical center at which the procedure was performed that produced the first culture settled prior to trial for $200,000.

Continue reading for David M. Lang's commentary... 

COMMENT

This case raises three issues: 

First, hand infections can be problematic and are often trivialized by the initially consulted clinician. The presentation of certain hand infections, such as paronychiae and felons, generally will be straightforward. Paronychiae are usually managed by the clinician who first sees the patient. Felon management is more difficult, but it still may be drained in ambulatory settings by experienced clinicians. Deeper and more troublesome infections of the hand should raise immediate concern; these include tendon sheath infection, septic arthritis, and deep space hand infections. Hand cases can become complicated, and prompt referral to a specialist is usually warranted for all but the most basic infections.

Second, clinicians must always be on the lookout for important clues pointing to an oddball cause. Here, the overlooked clue was the significance of the patient’s fishing trip. While M. marinum seems obscure, the specific bacteria is known to cause tendon sheath infections when a patient’s hand is punctured by fish spines or when a simple wound is contaminated with stagnant water in nature or from an aquarium.¹ Many of us are familiar with the fungal infection sporotrichosis, which can occur after a gardener is stuck by a rose thorn. Asking about a patient’s hobbies and activities may provide a context for an injury.

Third, communication breakdown is something clinicians often just don’t “get.” After receiving the culture report, the orthopedist should have called the infectious diseases physician to discuss the unusual case. This is particularly true in light of the fact that the orthopedic surgeon injected the hand with steroids, which may have worsened the patient’s condition. Jurors would have the expectation that the case would be followed closely. Everyone is busy, but unusual cases such as this one require a quick call to help the patient and avert liability. Pick up the phone.

Furthermore, the defense strategy here seems misplaced.  The defense argued that the orthopedic surgeon saw no evidence of infection but administered a steroid injection for inflammation. But how can you tell the difference from external observation alone? We’ve all been trained in the classic signs and symptoms of calor (heat), dolor (pain), rubor (redness), and tumor (swelling). But both infectious and noninfectious inflammation will produce these, so the cause would not be readily distinguishable without further investigation.

In sum, take hand infections seriously. Thanks to television shows such as House, lay jurors expect clinicians to puzzle together facts to arrive at an obscure diagnosis. So, before we discharge a patient with a common condition, it is useful to ask about the patient’s job and hobbies. We might also ask the generic question “Were you doing anything unusual?” You may just save a patient and solve a puzzle at the same time.

Finally, communication with other clinicians in complicated cases is required and expected by jurors. —DML

Reference

1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.

A 50-year-old man sustained a rope-burn injury to his left hand during a fishing trip in early August 2004. He subsequently presented to an orthopedic facility with complaints of a hand infection and was eventually referred to orthopedic surgeon Dr. W.

One week later, Dr. W administered a steroid injection, which caused the infection to worsen. The patient claimed that the steroid injection was contraindicated by the underlying infection. Dr. W referred the patient to Dr. C for infectious disease management.

In November 2004, Dr. W performed an incision and drainage procedure, and specimens were sent for pathology study and cultures. The pathology results were sent to both Dr. W and Dr. C, but the culture results were sent only to Dr. W. Other specimens were sent for culture in November 2004 and January 2005.

The results from the first culture, received by Dr. W in three reports, indicated “Mycobacterium,” “rare presumptive Mycobacterium mar­inum,” and “Myocbacterium marinum.” Dr. W did not forward these results to Dr. C and allegedly did not review the last report. Dr. C treated the plaintiff for a fungal infection based on the results of the second culture. After the third specimen in January 2005 grew acid-fast bacilli, Dr. C was informed that the patient likely had an infection caused by M. marinum.

The patient alleged that the 44-day delay in diagnosis and treatment of the M. marinum infection allowed the infection to worsen. The patient was hospitalized for one week at a major clinic and underwent three debridement surgeries to his left hand. He subsequently underwent five months of physical therapy and received long-term intravenous antibiotics for the infection.

The patient lacks full range of motion in his hand and is unable to fully open the fingers or make a tight fist. He has a trigger finger, surgical scars, and painful nodules. The hand is also extremely intolerant to temperature. The plaintiff claimed that the debridement surgeries would have been unnecessary if the initial culture reports had been acted upon in a timely manner.

The defendants claimed Dr. W saw no evidence of infection at the first office visit and that there was no sign of infection when the steroid injection was administered. The defendants claimed that the hand’s condition did not worsen after the injection and that the plaintiff was referred to Dr. C when a second fishing trip led to a flare-up that eluded diagnosis. Dr. W maintained that, during the procedure that produced the first cultures, he instructed the circulating nurse to have all lab results sent to both himself and Dr. C. Dr. W believed that Dr. C had been sent the results when he saw both their names on the pathology reports.

Continue reading to see the outcome... 

OUTCOME

A $215,000 verdict was returned. The surgical center at which the procedure was performed that produced the first culture settled prior to trial for $200,000.

Continue reading for David M. Lang's commentary... 

COMMENT

This case raises three issues: 

First, hand infections can be problematic and are often trivialized by the initially consulted clinician. The presentation of certain hand infections, such as paronychiae and felons, generally will be straightforward. Paronychiae are usually managed by the clinician who first sees the patient. Felon management is more difficult, but it still may be drained in ambulatory settings by experienced clinicians. Deeper and more troublesome infections of the hand should raise immediate concern; these include tendon sheath infection, septic arthritis, and deep space hand infections. Hand cases can become complicated, and prompt referral to a specialist is usually warranted for all but the most basic infections.

Second, clinicians must always be on the lookout for important clues pointing to an oddball cause. Here, the overlooked clue was the significance of the patient’s fishing trip. While M. marinum seems obscure, the specific bacteria is known to cause tendon sheath infections when a patient’s hand is punctured by fish spines or when a simple wound is contaminated with stagnant water in nature or from an aquarium.¹ Many of us are familiar with the fungal infection sporotrichosis, which can occur after a gardener is stuck by a rose thorn. Asking about a patient’s hobbies and activities may provide a context for an injury.

Third, communication breakdown is something clinicians often just don’t “get.” After receiving the culture report, the orthopedist should have called the infectious diseases physician to discuss the unusual case. This is particularly true in light of the fact that the orthopedic surgeon injected the hand with steroids, which may have worsened the patient’s condition. Jurors would have the expectation that the case would be followed closely. Everyone is busy, but unusual cases such as this one require a quick call to help the patient and avert liability. Pick up the phone.

Furthermore, the defense strategy here seems misplaced.  The defense argued that the orthopedic surgeon saw no evidence of infection but administered a steroid injection for inflammation. But how can you tell the difference from external observation alone? We’ve all been trained in the classic signs and symptoms of calor (heat), dolor (pain), rubor (redness), and tumor (swelling). But both infectious and noninfectious inflammation will produce these, so the cause would not be readily distinguishable without further investigation.

In sum, take hand infections seriously. Thanks to television shows such as House, lay jurors expect clinicians to puzzle together facts to arrive at an obscure diagnosis. So, before we discharge a patient with a common condition, it is useful to ask about the patient’s job and hobbies. We might also ask the generic question “Were you doing anything unusual?” You may just save a patient and solve a puzzle at the same time.

Finally, communication with other clinicians in complicated cases is required and expected by jurors. —DML

Reference

1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.

A 50-year-old man sustained a rope-burn injury to his left hand during a fishing trip in early August 2004. He subsequently presented to an orthopedic facility with complaints of a hand infection and was eventually referred to orthopedic surgeon Dr. W.

One week later, Dr. W administered a steroid injection, which caused the infection to worsen. The patient claimed that the steroid injection was contraindicated by the underlying infection. Dr. W referred the patient to Dr. C for infectious disease management.

In November 2004, Dr. W performed an incision and drainage procedure, and specimens were sent for pathology study and cultures. The pathology results were sent to both Dr. W and Dr. C, but the culture results were sent only to Dr. W. Other specimens were sent for culture in November 2004 and January 2005.

The results from the first culture, received by Dr. W in three reports, indicated “Mycobacterium,” “rare presumptive Mycobacterium mar­inum,” and “Myocbacterium marinum.” Dr. W did not forward these results to Dr. C and allegedly did not review the last report. Dr. C treated the plaintiff for a fungal infection based on the results of the second culture. After the third specimen in January 2005 grew acid-fast bacilli, Dr. C was informed that the patient likely had an infection caused by M. marinum.

The patient alleged that the 44-day delay in diagnosis and treatment of the M. marinum infection allowed the infection to worsen. The patient was hospitalized for one week at a major clinic and underwent three debridement surgeries to his left hand. He subsequently underwent five months of physical therapy and received long-term intravenous antibiotics for the infection.

The patient lacks full range of motion in his hand and is unable to fully open the fingers or make a tight fist. He has a trigger finger, surgical scars, and painful nodules. The hand is also extremely intolerant to temperature. The plaintiff claimed that the debridement surgeries would have been unnecessary if the initial culture reports had been acted upon in a timely manner.

The defendants claimed Dr. W saw no evidence of infection at the first office visit and that there was no sign of infection when the steroid injection was administered. The defendants claimed that the hand’s condition did not worsen after the injection and that the plaintiff was referred to Dr. C when a second fishing trip led to a flare-up that eluded diagnosis. Dr. W maintained that, during the procedure that produced the first cultures, he instructed the circulating nurse to have all lab results sent to both himself and Dr. C. Dr. W believed that Dr. C had been sent the results when he saw both their names on the pathology reports.

Continue reading to see the outcome... 

OUTCOME

A $215,000 verdict was returned. The surgical center at which the procedure was performed that produced the first culture settled prior to trial for $200,000.

Continue reading for David M. Lang's commentary... 

COMMENT

This case raises three issues: 

First, hand infections can be problematic and are often trivialized by the initially consulted clinician. The presentation of certain hand infections, such as paronychiae and felons, generally will be straightforward. Paronychiae are usually managed by the clinician who first sees the patient. Felon management is more difficult, but it still may be drained in ambulatory settings by experienced clinicians. Deeper and more troublesome infections of the hand should raise immediate concern; these include tendon sheath infection, septic arthritis, and deep space hand infections. Hand cases can become complicated, and prompt referral to a specialist is usually warranted for all but the most basic infections.

Second, clinicians must always be on the lookout for important clues pointing to an oddball cause. Here, the overlooked clue was the significance of the patient’s fishing trip. While M. marinum seems obscure, the specific bacteria is known to cause tendon sheath infections when a patient’s hand is punctured by fish spines or when a simple wound is contaminated with stagnant water in nature or from an aquarium.¹ Many of us are familiar with the fungal infection sporotrichosis, which can occur after a gardener is stuck by a rose thorn. Asking about a patient’s hobbies and activities may provide a context for an injury.

Third, communication breakdown is something clinicians often just don’t “get.” After receiving the culture report, the orthopedist should have called the infectious diseases physician to discuss the unusual case. This is particularly true in light of the fact that the orthopedic surgeon injected the hand with steroids, which may have worsened the patient’s condition. Jurors would have the expectation that the case would be followed closely. Everyone is busy, but unusual cases such as this one require a quick call to help the patient and avert liability. Pick up the phone.

Furthermore, the defense strategy here seems misplaced.  The defense argued that the orthopedic surgeon saw no evidence of infection but administered a steroid injection for inflammation. But how can you tell the difference from external observation alone? We’ve all been trained in the classic signs and symptoms of calor (heat), dolor (pain), rubor (redness), and tumor (swelling). But both infectious and noninfectious inflammation will produce these, so the cause would not be readily distinguishable without further investigation.

In sum, take hand infections seriously. Thanks to television shows such as House, lay jurors expect clinicians to puzzle together facts to arrive at an obscure diagnosis. So, before we discharge a patient with a common condition, it is useful to ask about the patient’s job and hobbies. We might also ask the generic question “Were you doing anything unusual?” You may just save a patient and solve a puzzle at the same time.

Finally, communication with other clinicians in complicated cases is required and expected by jurors. —DML

Reference

1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.

SNOWMASS, COLO. – Total knee replacement surgery rates in patients with systemic lupus erythematosus jumped sixfold nationally during a recent 15-year span – and buried within this statistic is some very good news.

The sharp rise in total knee replacement (TKR) among systemic lupus erythematosus (SLE) patients has been driven by a hefty increase in operations performed for osteoarthritis, while TKR for active SLE in the knee has declined. These trends reflect the increased longevity of patients with SLE resulting from improved medical management. For the first time, large numbers of SLE patients are surviving to an age when they, like other Americans, are more vulnerable to osteoarthritis, Dr. Susan M. Goodman explained at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.

"Lupus is no longer the highly mortal disease that it was," she observed. "Clearly, patients are surviving and – I don’t know how else to put it – they’ve become middle-aged women who are having knee replacements, which is kind of a success."

She presented highlights of a soon-to-be-published study involving analysis of 10 state databases including nearly 2.8 million arthroplasties performed during 1991-2005. The rate of TKR in SLE patients climbed sixfold from 0.03 per 100,000 population in 1991 to 0.18 per 100,000 in 2005. Meanwhile, total hip replacement (THR) in SLE patients showed a modest but statistically significant increase from 0.11 to 0.18 cases per 100,000.

The proportion of lupus patients undergoing arthroplasty for avascular necrosis fell from 53% in 1991 to 24% in 2005, while the proportion undergoing arthroplasty because they developed osteoarthritis went from 23% to 61%.

Virtually all of the increase in total arthroplasties among SLE patients occurred in women aged 45 years and older. Their rate more than tripled during the study years, going from 0.076 to 0.271 cases per 100,000. Rates in female SLE patients aged 44 years and younger actually took a significant drop from 0.073 to 0.067 per 100,000. Rates in males aged 44 and younger remained flat over time, while men aged 45 and up showed a modest increase from a low baseline rate of 0.009 cases per 100,000 in 1991 to 0.034 per 100,000 in 2005, according to Dr. Goodman, a rheumatologist at the Hospital for Special Surgery and Cornell University, New York.

The proportion of TKRs among all arthroplasties performed in SLE patients increased from 16% in 1991 to 48% in 2005. Meanwhile, THRs decreased from 66% of all arthroplasties to 40%. Other joint replacements didn’t change much over time.

A particularly striking finding in the study was that the mean age at the time of arthroplasty in SLE patients increased by nearly a decade – 47.3 years in 1991 to 56.8 years in 2005. In contrast, the mean age at arthroplasty for osteoarthritis patients without SLE decreased from 71.5 to 69.0 years.

Dr. Goodman turned to additional studies by her research group and other investigators to provide a picture of arthroplasty outcomes in SLE patients.

In-hospital postoperative mortality was found to be increased in SLE patients, compared with rheumatoid arthritis patients or controls undergoing TKR or THR in a study of more than 1.5 million TKRs and THRs included in the Nationwide Inpatient Sample for 1993-2006. The Nationwide Inpatient Sample is the largest all-payer inpatient health care database in the United States.

In a multivariate logistic regression analysis adjusted for comorbidities, hospital type, and other potential confounders, investigators at Stanford (Calif.) University found that SLE patients undergoing THR had a 3.5-fold increased risk of death, compared with controls. This was driven by a 4.9-fold increased death risk in SLE patients undergoing nonelective THR or TKR, typically because of a fracture. In contrast, the rate of in-hospital death following TKR or THR in rheumatoid arthritis patients wasn’t significantly different from controls. The one comorbidity present on admission that was associated with markedly increased postoperative mortality was renal disease in SLE patients (J. Rheumatol. 2010;37:1467-72).

"Baseline renal dysfunction really seems to be a marker in lupus patients for bad perioperative outcome," Dr. Goodman observed, adding that there is a need for "increased vigilance" regarding this comorbidity.

A study of 57 SLE patients and 107 age-matched osteoarthritis patients who underwent THR at the Hospital for Special Surgery demonstrated that the lupus patients had more baseline comorbidities as reflected in their mean Charlson Comorbidity Index of 1.9, compared with 0.3 in the osteoarthritis group. Seventy-nine percent of the SLE patients, but none of the osteoarthritis patients, were on immunosuppressant therapy. The lupus patients had a 19% incidence of postoperative major adverse events, including deep vein thrombosis, arrhythmia, acute renal insufficiency, or additional surgery, compared with a 6% rate in the osteoarthritis group. The 6-day mean length of stay in the SLE group was a full day longer than that of the osteoarthritis patients, according to Dr. Goodman.

Another Hospital for Special Surgery study included 56 SLE patients undergoing THR and 45 with TKR, as well as 108 age-matched controls undergoing THR and 89 with TKR. The SLE patients had significantly worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores than did the osteoarthritis patients. At 2 years of follow-up, however, all four groups ended up with very good pain and function outcomes, with WOMAC scores in the 80-92 range.

Yet despite these excellent outcomes, the SLE patients still felt more limited by their chronic disease. This was reflected in their lower health-related quality of life on the SF-36 physical component summary score at 2 years of follow-up: 39 in the SLE THR patients, compared with 50.1 in the osteoarthritis THR group, and 38 in the SLE TKR patients, compared with 48.4 in the osteoarthritis controls.

This and other studies paint a picture of contemporary SLE patients undergoing TKR as more closely resembling osteoarthritis patients with TKR than SLE patients undergoing THR. The average age of the SLE TKR patients, at 62.4 years, was 8 years older than the SLE THR group. The SLE TKR group’s mean body mass index of 31.5 kg/m² was 5 kg/m² greater than in the SLE THR group. And none of the SLE TKR patients had avascular necrosis, compared with one-third of those undergoing THR.

Dr. Goodman reported having no relevant financial relationships.

[email protected]

SNOWMASS, COLO. – Total knee replacement surgery rates in patients with systemic lupus erythematosus jumped sixfold nationally during a recent 15-year span – and buried within this statistic is some very good news.

The sharp rise in total knee replacement (TKR) among systemic lupus erythematosus (SLE) patients has been driven by a hefty increase in operations performed for osteoarthritis, while TKR for active SLE in the knee has declined. These trends reflect the increased longevity of patients with SLE resulting from improved medical management. For the first time, large numbers of SLE patients are surviving to an age when they, like other Americans, are more vulnerable to osteoarthritis, Dr. Susan M. Goodman explained at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.

"Lupus is no longer the highly mortal disease that it was," she observed. "Clearly, patients are surviving and – I don’t know how else to put it – they’ve become middle-aged women who are having knee replacements, which is kind of a success."

She presented highlights of a soon-to-be-published study involving analysis of 10 state databases including nearly 2.8 million arthroplasties performed during 1991-2005. The rate of TKR in SLE patients climbed sixfold from 0.03 per 100,000 population in 1991 to 0.18 per 100,000 in 2005. Meanwhile, total hip replacement (THR) in SLE patients showed a modest but statistically significant increase from 0.11 to 0.18 cases per 100,000.

The proportion of lupus patients undergoing arthroplasty for avascular necrosis fell from 53% in 1991 to 24% in 2005, while the proportion undergoing arthroplasty because they developed osteoarthritis went from 23% to 61%.

Virtually all of the increase in total arthroplasties among SLE patients occurred in women aged 45 years and older. Their rate more than tripled during the study years, going from 0.076 to 0.271 cases per 100,000. Rates in female SLE patients aged 44 years and younger actually took a significant drop from 0.073 to 0.067 per 100,000. Rates in males aged 44 and younger remained flat over time, while men aged 45 and up showed a modest increase from a low baseline rate of 0.009 cases per 100,000 in 1991 to 0.034 per 100,000 in 2005, according to Dr. Goodman, a rheumatologist at the Hospital for Special Surgery and Cornell University, New York.

The proportion of TKRs among all arthroplasties performed in SLE patients increased from 16% in 1991 to 48% in 2005. Meanwhile, THRs decreased from 66% of all arthroplasties to 40%. Other joint replacements didn’t change much over time.

A particularly striking finding in the study was that the mean age at the time of arthroplasty in SLE patients increased by nearly a decade – 47.3 years in 1991 to 56.8 years in 2005. In contrast, the mean age at arthroplasty for osteoarthritis patients without SLE decreased from 71.5 to 69.0 years.

Dr. Goodman turned to additional studies by her research group and other investigators to provide a picture of arthroplasty outcomes in SLE patients.

In-hospital postoperative mortality was found to be increased in SLE patients, compared with rheumatoid arthritis patients or controls undergoing TKR or THR in a study of more than 1.5 million TKRs and THRs included in the Nationwide Inpatient Sample for 1993-2006. The Nationwide Inpatient Sample is the largest all-payer inpatient health care database in the United States.

In a multivariate logistic regression analysis adjusted for comorbidities, hospital type, and other potential confounders, investigators at Stanford (Calif.) University found that SLE patients undergoing THR had a 3.5-fold increased risk of death, compared with controls. This was driven by a 4.9-fold increased death risk in SLE patients undergoing nonelective THR or TKR, typically because of a fracture. In contrast, the rate of in-hospital death following TKR or THR in rheumatoid arthritis patients wasn’t significantly different from controls. The one comorbidity present on admission that was associated with markedly increased postoperative mortality was renal disease in SLE patients (J. Rheumatol. 2010;37:1467-72).

"Baseline renal dysfunction really seems to be a marker in lupus patients for bad perioperative outcome," Dr. Goodman observed, adding that there is a need for "increased vigilance" regarding this comorbidity.

A study of 57 SLE patients and 107 age-matched osteoarthritis patients who underwent THR at the Hospital for Special Surgery demonstrated that the lupus patients had more baseline comorbidities as reflected in their mean Charlson Comorbidity Index of 1.9, compared with 0.3 in the osteoarthritis group. Seventy-nine percent of the SLE patients, but none of the osteoarthritis patients, were on immunosuppressant therapy. The lupus patients had a 19% incidence of postoperative major adverse events, including deep vein thrombosis, arrhythmia, acute renal insufficiency, or additional surgery, compared with a 6% rate in the osteoarthritis group. The 6-day mean length of stay in the SLE group was a full day longer than that of the osteoarthritis patients, according to Dr. Goodman.

Another Hospital for Special Surgery study included 56 SLE patients undergoing THR and 45 with TKR, as well as 108 age-matched controls undergoing THR and 89 with TKR. The SLE patients had significantly worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores than did the osteoarthritis patients. At 2 years of follow-up, however, all four groups ended up with very good pain and function outcomes, with WOMAC scores in the 80-92 range.

Yet despite these excellent outcomes, the SLE patients still felt more limited by their chronic disease. This was reflected in their lower health-related quality of life on the SF-36 physical component summary score at 2 years of follow-up: 39 in the SLE THR patients, compared with 50.1 in the osteoarthritis THR group, and 38 in the SLE TKR patients, compared with 48.4 in the osteoarthritis controls.

This and other studies paint a picture of contemporary SLE patients undergoing TKR as more closely resembling osteoarthritis patients with TKR than SLE patients undergoing THR. The average age of the SLE TKR patients, at 62.4 years, was 8 years older than the SLE THR group. The SLE TKR group’s mean body mass index of 31.5 kg/m² was 5 kg/m² greater than in the SLE THR group. And none of the SLE TKR patients had avascular necrosis, compared with one-third of those undergoing THR.

Dr. Goodman reported having no relevant financial relationships.

[email protected]

SNOWMASS, COLO. – Total knee replacement surgery rates in patients with systemic lupus erythematosus jumped sixfold nationally during a recent 15-year span – and buried within this statistic is some very good news.

The sharp rise in total knee replacement (TKR) among systemic lupus erythematosus (SLE) patients has been driven by a hefty increase in operations performed for osteoarthritis, while TKR for active SLE in the knee has declined. These trends reflect the increased longevity of patients with SLE resulting from improved medical management. For the first time, large numbers of SLE patients are surviving to an age when they, like other Americans, are more vulnerable to osteoarthritis, Dr. Susan M. Goodman explained at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.

"Lupus is no longer the highly mortal disease that it was," she observed. "Clearly, patients are surviving and – I don’t know how else to put it – they’ve become middle-aged women who are having knee replacements, which is kind of a success."

She presented highlights of a soon-to-be-published study involving analysis of 10 state databases including nearly 2.8 million arthroplasties performed during 1991-2005. The rate of TKR in SLE patients climbed sixfold from 0.03 per 100,000 population in 1991 to 0.18 per 100,000 in 2005. Meanwhile, total hip replacement (THR) in SLE patients showed a modest but statistically significant increase from 0.11 to 0.18 cases per 100,000.

The proportion of lupus patients undergoing arthroplasty for avascular necrosis fell from 53% in 1991 to 24% in 2005, while the proportion undergoing arthroplasty because they developed osteoarthritis went from 23% to 61%.

Virtually all of the increase in total arthroplasties among SLE patients occurred in women aged 45 years and older. Their rate more than tripled during the study years, going from 0.076 to 0.271 cases per 100,000. Rates in female SLE patients aged 44 years and younger actually took a significant drop from 0.073 to 0.067 per 100,000. Rates in males aged 44 and younger remained flat over time, while men aged 45 and up showed a modest increase from a low baseline rate of 0.009 cases per 100,000 in 1991 to 0.034 per 100,000 in 2005, according to Dr. Goodman, a rheumatologist at the Hospital for Special Surgery and Cornell University, New York.

The proportion of TKRs among all arthroplasties performed in SLE patients increased from 16% in 1991 to 48% in 2005. Meanwhile, THRs decreased from 66% of all arthroplasties to 40%. Other joint replacements didn’t change much over time.

A particularly striking finding in the study was that the mean age at the time of arthroplasty in SLE patients increased by nearly a decade – 47.3 years in 1991 to 56.8 years in 2005. In contrast, the mean age at arthroplasty for osteoarthritis patients without SLE decreased from 71.5 to 69.0 years.

Dr. Goodman turned to additional studies by her research group and other investigators to provide a picture of arthroplasty outcomes in SLE patients.

In-hospital postoperative mortality was found to be increased in SLE patients, compared with rheumatoid arthritis patients or controls undergoing TKR or THR in a study of more than 1.5 million TKRs and THRs included in the Nationwide Inpatient Sample for 1993-2006. The Nationwide Inpatient Sample is the largest all-payer inpatient health care database in the United States.

In a multivariate logistic regression analysis adjusted for comorbidities, hospital type, and other potential confounders, investigators at Stanford (Calif.) University found that SLE patients undergoing THR had a 3.5-fold increased risk of death, compared with controls. This was driven by a 4.9-fold increased death risk in SLE patients undergoing nonelective THR or TKR, typically because of a fracture. In contrast, the rate of in-hospital death following TKR or THR in rheumatoid arthritis patients wasn’t significantly different from controls. The one comorbidity present on admission that was associated with markedly increased postoperative mortality was renal disease in SLE patients (J. Rheumatol. 2010;37:1467-72).

"Baseline renal dysfunction really seems to be a marker in lupus patients for bad perioperative outcome," Dr. Goodman observed, adding that there is a need for "increased vigilance" regarding this comorbidity.

A study of 57 SLE patients and 107 age-matched osteoarthritis patients who underwent THR at the Hospital for Special Surgery demonstrated that the lupus patients had more baseline comorbidities as reflected in their mean Charlson Comorbidity Index of 1.9, compared with 0.3 in the osteoarthritis group. Seventy-nine percent of the SLE patients, but none of the osteoarthritis patients, were on immunosuppressant therapy. The lupus patients had a 19% incidence of postoperative major adverse events, including deep vein thrombosis, arrhythmia, acute renal insufficiency, or additional surgery, compared with a 6% rate in the osteoarthritis group. The 6-day mean length of stay in the SLE group was a full day longer than that of the osteoarthritis patients, according to Dr. Goodman.

Another Hospital for Special Surgery study included 56 SLE patients undergoing THR and 45 with TKR, as well as 108 age-matched controls undergoing THR and 89 with TKR. The SLE patients had significantly worse baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores than did the osteoarthritis patients. At 2 years of follow-up, however, all four groups ended up with very good pain and function outcomes, with WOMAC scores in the 80-92 range.

Yet despite these excellent outcomes, the SLE patients still felt more limited by their chronic disease. This was reflected in their lower health-related quality of life on the SF-36 physical component summary score at 2 years of follow-up: 39 in the SLE THR patients, compared with 50.1 in the osteoarthritis THR group, and 38 in the SLE TKR patients, compared with 48.4 in the osteoarthritis controls.

This and other studies paint a picture of contemporary SLE patients undergoing TKR as more closely resembling osteoarthritis patients with TKR than SLE patients undergoing THR. The average age of the SLE TKR patients, at 62.4 years, was 8 years older than the SLE THR group. The SLE TKR group’s mean body mass index of 31.5 kg/m² was 5 kg/m² greater than in the SLE THR group. And none of the SLE TKR patients had avascular necrosis, compared with one-third of those undergoing THR.

Dr. Goodman reported having no relevant financial relationships.

[email protected]

NEW ORLEANS – In routine practice, rivaroxaban was superior to low-molecular-weight heparin for venous thromboembolism prevention in older adults undergoing hip or knee arthroplasty, without an increase in bleeding risk.

Among 24,321 patients, aged 66 years or older, the 30-day VTE event rate was 0.47% for rivaroxaban (Xarelto) (61 events) and 0.81% for low-molecular-weight heparin (LMWH) (93 events).

These findings resulted in an unadjusted relative risk of 0.58, which was statistically significant (P = .001) and did not change after adjustment for significant covariates, Dr. Alejandro Lazo-Langner said during an antithrombotic therapy session at the annual meeting of the American Society of Hematology.

There were 23 major bleeding events in both the rivaroxaban (0.18%) and LMWH (0.20%) groups. The unadjusted relative risk was 0.89 (P = .700) and did not change after adjustment in the population-based, retrospective cohort analysis.

Rivaroxaban has been the subject of numerous randomized controlled trials, but "We don’t have much real-life data in these patients," said Dr. Lazo-Langner, a hematologist specializing in thromboembolic diseases at Western University, London, Ontario, Canada.

In a meta-analysis of eight randomized rivaroxaban trials, the factor Xa inhibitor was associated with a significant 52% reduction in thrombosis after total hip or knee replacement, compared with enoxaparin (Lovenox) in roughly 14,000 patients (BMJ 2012;344:e3675 [doi:10.1136/bmj.e3675]). This came at a cost, however, of a slightly increased risk of clinically significant bleeding (relative risk, 1.25), he noted.

For the current analysis,the investigators used linked health care databases in Ontario to identify 24,321 patients who received an outpatient prescription for rivaroxaban or subcutaneous LMWH including dalteparin (Fragmin), tinzaparin (Innohep), or enoxaparin on discharge after total hip or knee arthroplasty between 2002 and 2012 across 121 hospitals.

Their average age was 74 years, 59% were women, and 12,850 received rivaroxaban. The anticoagulants were prescribed for a median of 14 days. Patients were excluded if they had other indications for anticoagulation, prosthetic mechanical heart valves, required dialysis, or lived in a long-term-care facility.

At 90 days, the VTE event rate was significantly lower in the rivaroxaban group than in the LMWH group (0.71% vs. 1.20%; adjusted RR, 0.59; P = .001). Once again, major bleeding events were similar (0.24% vs. 0.27%; adjusted RR, 0.63; P = .138), Dr. Lazo-Langner reported.

No differences were observed between the two groups at 30 or 90 days for hospitalization with endoscopy or hospitalization with major bleeding or endoscopy.

All-cause mortality was not estimable at 30 days but was lower with rivaroxaban at 90 days (16 deaths vs. 25 deaths; adjusted RR, 0.52; P = .058).

Additional analyses were conducted to test the robustness of the findings and no differences in rates of thrombosis were found when the analysis was restricted to 2009 to 2012, by type of joint replacement, or different low-molecular-weight heparins, he said.

Finally, a cost analysis was performed that showed a modest, but significant increase in direct drug costs to patients prescribed LMWH rather than rivaroxaban (Canadian $242 vs. $228; P less than .001) and home-care costs, likely from increased nursing ($1,082 vs. $959; P less than .001), Dr. Lazo-Langner said.

During a discussion of the results, he said there was no difference in novel anticoagulant use across surgeons or hospital settings, which was academic for 21% of LMWH patients and 15% of rivaroxaban patients.

Session comoderator Dr. Elaine Hylek, professor of medicine at Boston University, called this reassuring, but also urged caution in extrapolating conclusions on treatment effect outside a randomized trial.

Dr. Lazo-Langner reported research funding from Alexion, serving as a speaker for Pfizer, and honoraria from Pfizer, Leo Pharma, and Boehringer Ingelheim.

[email protected]

NEW ORLEANS – In routine practice, rivaroxaban was superior to low-molecular-weight heparin for venous thromboembolism prevention in older adults undergoing hip or knee arthroplasty, without an increase in bleeding risk.

Among 24,321 patients, aged 66 years or older, the 30-day VTE event rate was 0.47% for rivaroxaban (Xarelto) (61 events) and 0.81% for low-molecular-weight heparin (LMWH) (93 events).

These findings resulted in an unadjusted relative risk of 0.58, which was statistically significant (P = .001) and did not change after adjustment for significant covariates, Dr. Alejandro Lazo-Langner said during an antithrombotic therapy session at the annual meeting of the American Society of Hematology.

There were 23 major bleeding events in both the rivaroxaban (0.18%) and LMWH (0.20%) groups. The unadjusted relative risk was 0.89 (P = .700) and did not change after adjustment in the population-based, retrospective cohort analysis.

Rivaroxaban has been the subject of numerous randomized controlled trials, but "We don’t have much real-life data in these patients," said Dr. Lazo-Langner, a hematologist specializing in thromboembolic diseases at Western University, London, Ontario, Canada.

In a meta-analysis of eight randomized rivaroxaban trials, the factor Xa inhibitor was associated with a significant 52% reduction in thrombosis after total hip or knee replacement, compared with enoxaparin (Lovenox) in roughly 14,000 patients (BMJ 2012;344:e3675 [doi:10.1136/bmj.e3675]). This came at a cost, however, of a slightly increased risk of clinically significant bleeding (relative risk, 1.25), he noted.

For the current analysis,the investigators used linked health care databases in Ontario to identify 24,321 patients who received an outpatient prescription for rivaroxaban or subcutaneous LMWH including dalteparin (Fragmin), tinzaparin (Innohep), or enoxaparin on discharge after total hip or knee arthroplasty between 2002 and 2012 across 121 hospitals.

Their average age was 74 years, 59% were women, and 12,850 received rivaroxaban. The anticoagulants were prescribed for a median of 14 days. Patients were excluded if they had other indications for anticoagulation, prosthetic mechanical heart valves, required dialysis, or lived in a long-term-care facility.

At 90 days, the VTE event rate was significantly lower in the rivaroxaban group than in the LMWH group (0.71% vs. 1.20%; adjusted RR, 0.59; P = .001). Once again, major bleeding events were similar (0.24% vs. 0.27%; adjusted RR, 0.63; P = .138), Dr. Lazo-Langner reported.

No differences were observed between the two groups at 30 or 90 days for hospitalization with endoscopy or hospitalization with major bleeding or endoscopy.

All-cause mortality was not estimable at 30 days but was lower with rivaroxaban at 90 days (16 deaths vs. 25 deaths; adjusted RR, 0.52; P = .058).

Additional analyses were conducted to test the robustness of the findings and no differences in rates of thrombosis were found when the analysis was restricted to 2009 to 2012, by type of joint replacement, or different low-molecular-weight heparins, he said.

Finally, a cost analysis was performed that showed a modest, but significant increase in direct drug costs to patients prescribed LMWH rather than rivaroxaban (Canadian $242 vs. $228; P less than .001) and home-care costs, likely from increased nursing ($1,082 vs. $959; P less than .001), Dr. Lazo-Langner said.

During a discussion of the results, he said there was no difference in novel anticoagulant use across surgeons or hospital settings, which was academic for 21% of LMWH patients and 15% of rivaroxaban patients.

Session comoderator Dr. Elaine Hylek, professor of medicine at Boston University, called this reassuring, but also urged caution in extrapolating conclusions on treatment effect outside a randomized trial.

Dr. Lazo-Langner reported research funding from Alexion, serving as a speaker for Pfizer, and honoraria from Pfizer, Leo Pharma, and Boehringer Ingelheim.

[email protected]

NEW ORLEANS – In routine practice, rivaroxaban was superior to low-molecular-weight heparin for venous thromboembolism prevention in older adults undergoing hip or knee arthroplasty, without an increase in bleeding risk.

Among 24,321 patients, aged 66 years or older, the 30-day VTE event rate was 0.47% for rivaroxaban (Xarelto) (61 events) and 0.81% for low-molecular-weight heparin (LMWH) (93 events).

These findings resulted in an unadjusted relative risk of 0.58, which was statistically significant (P = .001) and did not change after adjustment for significant covariates, Dr. Alejandro Lazo-Langner said during an antithrombotic therapy session at the annual meeting of the American Society of Hematology.

There were 23 major bleeding events in both the rivaroxaban (0.18%) and LMWH (0.20%) groups. The unadjusted relative risk was 0.89 (P = .700) and did not change after adjustment in the population-based, retrospective cohort analysis.

Rivaroxaban has been the subject of numerous randomized controlled trials, but "We don’t have much real-life data in these patients," said Dr. Lazo-Langner, a hematologist specializing in thromboembolic diseases at Western University, London, Ontario, Canada.

In a meta-analysis of eight randomized rivaroxaban trials, the factor Xa inhibitor was associated with a significant 52% reduction in thrombosis after total hip or knee replacement, compared with enoxaparin (Lovenox) in roughly 14,000 patients (BMJ 2012;344:e3675 [doi:10.1136/bmj.e3675]). This came at a cost, however, of a slightly increased risk of clinically significant bleeding (relative risk, 1.25), he noted.

For the current analysis,the investigators used linked health care databases in Ontario to identify 24,321 patients who received an outpatient prescription for rivaroxaban or subcutaneous LMWH including dalteparin (Fragmin), tinzaparin (Innohep), or enoxaparin on discharge after total hip or knee arthroplasty between 2002 and 2012 across 121 hospitals.

Their average age was 74 years, 59% were women, and 12,850 received rivaroxaban. The anticoagulants were prescribed for a median of 14 days. Patients were excluded if they had other indications for anticoagulation, prosthetic mechanical heart valves, required dialysis, or lived in a long-term-care facility.

At 90 days, the VTE event rate was significantly lower in the rivaroxaban group than in the LMWH group (0.71% vs. 1.20%; adjusted RR, 0.59; P = .001). Once again, major bleeding events were similar (0.24% vs. 0.27%; adjusted RR, 0.63; P = .138), Dr. Lazo-Langner reported.

No differences were observed between the two groups at 30 or 90 days for hospitalization with endoscopy or hospitalization with major bleeding or endoscopy.

All-cause mortality was not estimable at 30 days but was lower with rivaroxaban at 90 days (16 deaths vs. 25 deaths; adjusted RR, 0.52; P = .058).

Additional analyses were conducted to test the robustness of the findings and no differences in rates of thrombosis were found when the analysis was restricted to 2009 to 2012, by type of joint replacement, or different low-molecular-weight heparins, he said.

Finally, a cost analysis was performed that showed a modest, but significant increase in direct drug costs to patients prescribed LMWH rather than rivaroxaban (Canadian $242 vs. $228; P less than .001) and home-care costs, likely from increased nursing ($1,082 vs. $959; P less than .001), Dr. Lazo-Langner said.

During a discussion of the results, he said there was no difference in novel anticoagulant use across surgeons or hospital settings, which was academic for 21% of LMWH patients and 15% of rivaroxaban patients.

Session comoderator Dr. Elaine Hylek, professor of medicine at Boston University, called this reassuring, but also urged caution in extrapolating conclusions on treatment effect outside a randomized trial.

Dr. Lazo-Langner reported research funding from Alexion, serving as a speaker for Pfizer, and honoraria from Pfizer, Leo Pharma, and Boehringer Ingelheim.

[email protected]