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Spondyloarthritis is associated with higher healthcare utilization and complication rates after primary total knee or total hip arthroplasty


Our objective was to assess healthcare utilization and complication rates after primary total knee/hip arthroplasty (TKA/THA) in people with spondyloarthritis (SpA) compared with people without SpA. We performed multivariable-adjusted logistic regression using the 1998–2014 US National Inpatient Sample (NIS), adjusted for age, race/ethnicity, gender, income, Deyo-Charlson comorbidity index, insurance payer, and the underlying diagnosis. The primary THA cohort consisted of 4,116,484 THAs (1.7% with SpA) and primary TKA cohort of 8,127,282 TKAs (1% with SpA). Compared with people without SpA, people with SpA had higher odds ratio (OR (95% confidence interval (CI)) of the following post-THA and post-TKA, respectively: (1) discharge to care facility, 1.16 (1.12, 1.21) and 1.14 (1.11, 1.18); (2) hospital stay > 3 days, 1.15 (1.11, 1.20) and 1.05 (1.01, 1.10); and (3) transfusion, 1.16 (1.12, 1.21) and 1.10 (1.05, 1.14); but lower odds of (1) mortality, 0.78 (0.64, 0.96) and 0.40 (0.19, 0.84); and (2) hospital charges above the median, 0.49 (0.46, 0.53) and 0.48 (0.45, 0.51). SpA was associated with higher odds of implant infection, 3.02 (2.27, 4.03) post-TKA, not post-THA. In-hospital revision rate did not differ. People with SpA utilize more healthcare services and have more complications post-THA/TKA. Interventions to reduce complications and associated utilization are needed.

Key Points
People with spondyloarthritis utilized more healthcare services and had a higher risk of transfusion post-THA/TKA, compared with people without spondyloarthritis.
Spondyloarthritis was associated with lower in-hospital mortality rates after THA/TKA.
Spondyloarthritis was associated with a higher risk of implant infection after TKA, but not THA.
A pre-operative discussion with people with spondyloarthritis of possibly higher implant infection after TKA could lead to a more informed consent.

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This material is the result of work supported by research funds from the Division of Rheumatology at the University of Alabama at Birmingham and the resources and use of facilities at the Birmingham VA Medical Center, Birmingham, Alabama, USA.

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Authors and Affiliations



Mr. Cleveland had full access to all of the data in the study and takes the responsibility for the integrity of the data and accuracy of the data analysis. He was supervised by Dr. Singh, who reviewed all results. Study Concept and Design: Singh. Data acquisition, analysis, and interpretation of results: Singh, Cleveland. Drafting of the manuscript: Singh. Critical revision of the manuscript for important intellectual content: Singh, Cleveland. Statistical analysis: Cleveland. Obtained funding: Singh. Administrative, technical, or material support: Singh. Study supervision: Singh.

Corresponding author

Correspondence to Jasvinder A. Singh.

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Conflict of interest

There are no financial conflicts related directly to this study. JAS has received consultant fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Medscape, WebMD, Clinical Care options, Clearview Healthcare Partners, Putnam Associates, Spherix, and the National Institutes of Health and the American College of Rheumatology. JAS owns stock options in Amarin pharmaceuticals and Viking therapeutics. JAS is on the speaker’s bureau of Simply Speaking. JAS is a member of the executive of OMERACT, an organization that develops outcome measures in rheumatology and receives arms-length funding from 36 companies. JAS serves on the FDA Arthritis Advisory Committee. JAS is a member of the Veterans Affairs Rheumatology Field Advisory Committee. JAS is the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis. JAS previously served as a member of the following committees: member, the American College of Rheumatology’s (ACR) Annual Meeting Planning Committee (AMPC) and Quality of Care Committees, the Chair of the ACR Meet-the-Professor, Workshop and Study Group Subcommittee and the co-chair of the ACR Criteria and Response Criteria subcommittee. JDC has no conflicts.

Role of the funder/supporter

The funding body did not play any role in design, in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

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Ethics/IRB approval and consent to participate

The University of Alabama at Birmingham’s Institutional Review Board approved this study and waived the need for informed consent for this database study (X120207004). All investigations were conducted in conformity with ethical principles of research.

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Appendix 1

Table 4 Sensitivity analyses additionally adjusting the main analyses for hospital variablesa for outcomes post-THA and post-TKA

Appendix 2

Table 5 Sensitivity analysesa for the main analyses by including SpA as primary or secondary (non-primary) diagnosis for outcomes post-THA and post-TKA

Appendix 3

Table 6 Full main model: Multivariable-adjusted association of SpA with healthcare utilization outcomes and in-hospital implant infection, transfusion, revision surgery, and mortality post-THA

Appendix 4

Table 7 Full main model: multivariable-adjusted association of SpA with healthcare utilization outcomes and in-hospital implant infection, transfusion, revision surgery, and mortality post-TKA

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Singh, J.A., Cleveland, J.D. Spondyloarthritis is associated with higher healthcare utilization and complication rates after primary total knee or total hip arthroplasty. Clin Rheumatol 39, 2345–2353 (2020).

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  • Complications
  • Health services utilization
  • Healthcare utilization
  • Hip arthroplasty
  • Knee arthroplasty
  • Outcomes
  • Resource utilization
  • Spondyloarthritis