Prevalence of wound infections and postoperative complications after total elbow arthroplasty for rheumatoid arthritis: A meta‐analysis

Abstract

This study aimed to systematically evaluate the prevalence of surgical site wound infections and postoperative complications after total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA) for clinical research and application. Embase, PubMed, Cochrane Library, CNKI, VIP, CBM, and Wanfang databases were electronically searched to collect clinical studies on the application of TEA in the treatment of RA from inception to August 2023. Two independent researchers performed literature screening, data extraction, and quality assessment. A meta‐analysis was performed using the R 4.3.1 software. Overall, 26 studies with a total of 2374 patients were included. The results of the meta‐analysis revealed that after TEA in patients with RA, the prevalence of surgical site wound infections and postoperative complications was 3.37% (95% confidence interval [CI]: 2.68%–4.13%), and 31.63% (95% CI: 24.97%–38.28%), respectively. The prevalence of surgical site wound infections is low, whereas that of postoperative complications is high; thus, the safety of TEA remains debatable. Owing to limitations on the quality and number of included studies, the findings need to be verified in higher‐quality studies.

1. INTRODUCTION

Rheumatoid arthritis (RA) is an autoimmune disease with an unclear pathogenesis, which can cause joint swelling, stiffness, and pain, leading to joint deformity, loss of function, and ultimately varying degrees of disability. ¹ Currently, the worldwide prevalence of RA is approximately 0.5%–1%, ² whereas its prevalence in China is approximately 0.42%. Moreover, the prevalence of RA is significantly higher in women than in men. ³ Owing to the high prevalence of RA, pain and deformity of joint destruction seriously affect the quality of life and working ability of patients, while the huge costs incurred by the treatment of the disease impose a heavy economic burden on patients and their families, and ultimately have a huge impact on the social economy. ⁴ , ⁵

Currently, the main treatment for RA is pharmacological therapy, including non‐steroidal anti‐inflammatory drugs, glucocorticoids, disease‐modifying anti‐rheumatic drugs, and biologics, whose application can improve the clinical symptoms of arthritis swelling and pain and delay the disease process in patients with RA. ⁶ General anti‐rheumatic drugs are less effective and more difficult to treat, especially for patients with advanced RA. ⁷ For early to mid‐stage RA with elbow pain and stiffness, arthroplasty or adhesion release is an option. For patients with end‐stage RA, total elbow arthroplasty (TEA) is one of the most effective surgical procedures because such patients are unable to perform daily functions, including eating and toileting. ⁸ , ⁹ TEA is a newer joint replacement technique than total hip or knee arthroplasty, and it has been demonstrated as a clinically feasible treatment for elbow disease, providing greater pain relief, correcting deformity, and improving elbow mobility. ¹⁰

However, studies have reported that TEA has a higher complication rate and a lower prosthesis survival rate than other joint replacements. ¹¹ , ¹² , ¹³ The main complications of TEA include periprosthetic infection, fracture, loosening of the prosthesis, instability, and triceps rupture, ¹¹ resulting in widespread clinical concerns regarding its safety. Therefore, we conducted this meta‐analysis to explore the prevalence of surgical site wound infections and postoperative complications after TEA for RA to provide a more reliable basis for clinical application and research.

2. MATERIALS AND METHODS

2.1. Literature search

The Embase, PubMed, Cochrane Library, CNKI, VIP, CBM, and Wanfang databases were electronically searched for clinical studies on the application of TEA in the treatment of RA. The search period was from the establishment of each database to September 2023, and the language type was not limited. A combination of medical subject terms and free words was used in the search. The search terms included RA, TEA, and total elbow replacement.

2.2. Inclusion and exclusion criteria

2.2.1. Inclusion criteria

Studies were included if the patients had an RA diagnosis meeting the 1987 classification criteria of the American College of Rheumatology ¹⁴ and/or the 2010 classification criteria developed jointly by the American College of Rheumatology and the European Union of Rheumatology ¹⁵ ; the patients had a definite diagnosis of RA and underwent TEA; the outcome indicators included at least one postoperative wound infection and postoperative complication; and the study design was an observational study, prospective study, or case series report.

2.2.2. Exclusion criteria

The following studies were excluded from the analysis: animal studies; reviews, letters, conference abstracts, or duplicate publications; and studies that did not include the research metrics required for a meta‐analysis.

2.3. Data extraction and quality assessment

Two researchers performed data extraction and literature quality assessment for the study. The retrieved literature was first imported into the NoteExpress software, and duplicates were manually removed using the NoteExpress weight‐checking function. Titles, abstracts, and full texts were screened independently according to the inclusion and exclusion criteria, and a consensus was reached through joint discussion in case of disagreement. Data were also extracted independently from each eligible study, including the first author of the literature, year of publication, country, sample size, age, and sex. The quality of the included studies was assessed using the National Institutes of Health Quality Assessment Tool for Case Series Studies, ¹⁶ with a total score of 9; a study with a score of >4 was considered medium to high quality.

2.4. Statistical analyses

Data were analysed using the R 4.3.1 software. The heterogeneity of the included studies was tested using the I ² and χ ² tests. If I ² < 50% and p > 0.1, a fixed‐effects model was used. If significant heterogeneity was observed in I ² > 50% and p < 0.1, a random‐effects model was used. Potential publication bias was assessed using funnel plots and Egger's test. Significance was set at p < 0.05.

3. RESULTS

3.1. Study selection and quality assessment

In total, 802 articles were retrieved, 321 duplicates were excluded, and 26 studies were finally included after screening the titles and abstracts according to the inclusion and exclusion criteria. ⁸ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ The literature screening process is presented in Figure 1. Altogether, 2374 patients were included in this study. The general conditions of the included studies and quality of the literature are listed in Table 1.

FIGURE 1.

Flow chart of literature screening.

TABLE 1.

Characteristics of the included studies.

Study	Year	Country	Sample size	Age (years)	Sex (male/female)
Landor	2006	Czech Republic	49	53 (22–71)	7/42
Kondo	2019	Japan	67	64 ± 9	6/61
Kodama	2017	Japan	31	58.9 (34–74)	NR
Khatri	2005	England	47	42–87	9/38
Ikävalko	2010	Finland	403	57 (20–81)	33/370
Hanninen	2017	Finland	79	57 (29–79)	NR
Brinkman	2007	Netherlands	36	56 (23–83)	13/23
Gambhir	2023	USA	14	59.6 ± 7.7	0/14
Braig	2023	USA	12	63 (44–78)	3/9
Little	2005	England	92	62.67	25/74
Pham	2018	France	46	60 (29–83)	11/35
Ovesen	2005	Denmark	41	56 (25–78)	12/29
Nishida	2018	Japan	75	62 (35–79)	3/72
Nishida	2014	Japan	39	59.0 ± 8.7	2/37
Mukka	2015	Sweden	19	64 (29–80)	3/16
Minami	2018	Japan	405	56.6 (48–82)	68/319
Lo	2003	China	14	58 (40–77)	3/11
Willems	2004	Belgium	35	57.5 (36–74)	12/23
Van	2004	Netherlands	166	61 (24–83)	49/117
Toulemonde	2016	France	91	63 ± 14	17/74
Thillemann	2006	Denmark	17	60.3 (41–77)	3/13
Tachihara	2008	Japan	72	61.1	5/67
Strelzow	2019	USA	82	61 ± 10	18/64
Sanchez‐Sotelo	2016	USA	387	64 ± 11	82/305
Reinhard	2003	Netherlands	34	53 (23–76)	7/27
Williams	2016	UK	21	59.1 (32–78)	9/12

3.2. Prevalence of surgical site wound infections

The prevalence of surgical site wound infections was assessed in all 26 included studies, with 88 patients experiencing infections. No significant heterogeneity was observed among the studies (p = 0.083, I ² = 29.2%); therefore, a fixed‐effects model was used. The meta‐analysis revealed that the prevalence of postoperative wound infections in patients with RA who underwent TEA was 3.37% (95% confidence interval [CI]: 2.68%–4.13%) (Figure 2).

FIGURE 2.

Forest plot of meta‐analysis of the prevalence of surgical site wound infection.

3.3. Prevalence of postoperative complications

The prevalence of postoperative complications was assessed in all the 16 included studies, and 405 patients experienced postoperative complications. Significant heterogeneity was observed among the studies (p < 0.001, I ² = 86.0%); therefore, a random‐effects model was used. The meta‐analysis revealed that the prevalence of postoperative complications in patients with RA treated with TEA was 31.63% (95% CI: 24.97%–38.28%) (Figure 3).

FIGURE 3.

Forest plot of meta‐analysis of the prevalence of postoperative complications.

3.4. Publication bias

We used funnel plots to analyse the publication bias for each outcome indicator, and the scatter positions of the funnel plots for the prevalence of wound infection (Figure 4) and postoperative complications (Figure 5) in patients with RA undergoing TEA were asymmetric, with some scatters deviating from the CIs. The results of the Egger's test indicated publication bias in studies of the prevalence of wound infections (p = 0.005 < 0.05) and postoperative complications (P = 0.004 < 0.05).

FIGURE 4.

Funnel plot of meta‐analysis of the prevalence of surgical site wound infection.

FIGURE 5.

Funnel plot of meta‐analysis of the prevalence of postoperative complications.

4. DISCUSSION

RA is a common chronic systemic, connective tissue autoimmune disease involving multiple joints throughout the body, with 20%–65% of patients with RA having elbow joint involvement, ⁴² thus severely affecting the function of the upper limb. ⁴³ , ⁴⁴ Elbow joint injury, especially RA and other causes of the combined elbow joint swelling and flexion, extension and forearm rotation function is limited, and the late formation of elbow joint stiffness or even ankylosis can seriously affect the quality of life of patients. ⁴⁵ Currently, traditional treatments for RA, such as arthroplasty, synovectomy, arthrodesis, and joint fusion, have improved the clinical symptoms of patients to a certain extent. However, complete restoration of the joint function of patients is not possible with such treatments, ⁴⁶ , ⁴⁷ and their clinical application has limitations. ⁴⁸

In recent years, with the improvement of artificial joint materials and medical technology, artificial joints have become increasingly widely used in the treatment of serious diseases of large joints of the whole body, such as hip joints and knee joints. However, because the development and application of artificial elbow joints started late in China, the development and application of artificial joints lagged behind those of hip and knee replacements. ⁴⁹ As an effective treatment for various elbow joint diseases, TEA can help patients significantly reduce pain and restore function and daily life activities. ²⁵ With the advancement of surgical technology, the birth of new prostheses, and the continuous improvement of clinical efficacy, the application of TEA has become increasingly extensive. ⁵⁰ The main goal for TEA is relieving the patient's pain, followed by restoring the stability and mobility of the elbow joint. Previously, no effective surgical method has been identified for end‐stage elbow joint diseases causing elbow pain, dysfunction, or inability to complete daily life activities, and TEA was a good treatment option. However, complications such as postoperative wound infections, prosthesis instability, ulnar nerve injury, and loss of muscle strength are difficult problems in orthopaedic treatment, and TEA for treating RA remains controversial. Therefore, by systematically evaluating the safety of TEA in RA treatment, evidence‐based medicine can be developed for clinical applications.

Adverse events and surgical complications are crucial in assessing the efficacy and safety of surgery. Wound infection is one of the more aggressive complications of TEA, with a higher incidence than that in hip or knee replacement. Recent studies have demonstrated that although the infection rate has decreased, it remains high at 3.3%. ⁵⁰ , ⁵¹ This is mainly because patients with RA have been taking hormonal drugs and immunosuppressants for a long time and have thin soft tissues, which, together with the inflammatory response, increase the risk of infection. ⁵² Pham et al. ⁵³ summarised follow‐up reports from various clinical centres and reported that the incidence of postoperative complications after TEA with RA as an indication ranged from 14% to 33%. Sun et al. ⁵⁴ conducted a retrospective analysis of the clinical data of 121 patients with RA who underwent TEA therapy and reported that 21 patients developed postoperative complications, with a relatively high incidence rate of 17.35%. According to the results of this meta‐analysis, the prevalence of wound infections and postoperative complications was 4.03% and 31.63%, respectively, in patients with RA who underwent TEA. However, owing to the high rate of postoperative complications, the safety of the procedure still needs to be verified.

In conclusion, data extraction and meta‐analysis of 26 studies on the application of TEA in the treatment of RA, which all had inclusion and exclusion criteria, were conducted to elucidate the safety of TEA, and the results of this study were highly credible. However, this study inevitably has limitations. Owing to the characteristics of wound infection and postoperative complication rates and the inclusion of studies reporting only positive results and those published in journals, the study inclusion may have a publication bias. Moreover, heterogeneity was observed between the groups in this study, and although a random‐effects model was used, the potential of heterogeneity affecting the conclusions could not be completely ruled out. Future studies should expand the sample size based on this study or include additional original literature from different countries to increase the representativeness of the sample and improve the credibility of the results.

5. CONCLUSION

TEA can effectively treat elbow joint destruction caused by RA, resulting in significant improvement in elbow pain, function, and quality of life. However, our results indicate that the prevalence of postoperative complications of TEA is still high, and the improvement of surgical techniques remains the direction of future efforts.

CONFLICT OF INTEREST STATEMENT

The authors declare that there is no conflict of interest.

Chen Q‐Y, Liu L, Gu F‐Z. Prevalence of wound infections and postoperative complications after total elbow arthroplasty for rheumatoid arthritis: A meta‐analysis. Int Wound J. 2024;21(2):e14451. doi: 10.1111/iwj.14451

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.