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The Impact of TNF-alpha Inhibition on Survival of Pyrocarbon Metacarpophalangeal Arthroplasty in Patients with Rheumatoid Arthritis
Adam Schluttenhofer, BS
1, Andy Tom, BS
1, Alex Yonkman, BS
1; Marco Rizzo, MD
2(1)Mayo Clinic, Rochester, MN, (2)Division of Hand Surgery, Mayo Clinic, Rochester, MN
Introduction: Pyrocarbon metacarpophalangeal (MCP) arthroplasty in rheumatoid arthritis patients exhibits high rates of complications and revision, often attributed to lack of soft tissue stability able to support a non-constrained implant. Modern tumor necrosis factor alpha inhibiting medications (TNFi) offer superior clinical control of RA by inhibiting a key inflammatory cytokine, though their impact on MCP arthroplasty outcomes is unknown. We investigated the impact of TNFi use on implant survival following pyrocarbon MCP arthroplasty for RA.
Methods: We retrospectively reviewed all primary pyrocarbon MCP arthroplasties for RA at our institution from 2000-2022. We classified patients according to their postoperative TNFi (i.e., adalimumab) use. We excluded patients taking other biologic DMARDs. We used Kaplan-Meier estimates with log-rank tests to initially compare survival free from revision (implant removal/replacement) and all-cause reoperation. We analyzed the influence of TNFi use on these endpoints using cluster-robust Cox proportional hazards models to account for multiple joints per patient, controlling potential confounders.
Results: We included 43 joints (16 patients) with TNFi use and 101 joints (35 patients) that were not on TNFi. There was no difference in preoperative deformity, anti-CCP/rheumatoid factor seropositivity, conventional DMARD (i.e., methotrexate) use, or steroid use between groups. There were 27 total revisions (18.8%), most commonly for recurrent ulnar deviation/deformity (n = 17). There were 23 joints with non-revision reoperations (16.0%), most commonly for soft tissue repair (n = 17). Patients on TNFi had higher 10-year survival free from revision (97.7% vs 72.2%, p = 0.04, Figure 1) and all-cause reoperation (86.0% vs 53.6%, p = 0.003, Figure 2). In multivariate analysis, controlling for age and BMI, TNFi use was a significant protective factor against revision (HR 0.26, 95% CI 0.07-0.98, p = 0.05) and all-cause reoperation (HR 0.27, 95% CI 0.10-0.77, p = 0.01).
Conclusions: Joints in RA patients on TNFi experienced a nearly four-fold decrease in hazard for revision and all-cause reoperation after pyrocarbon MCP arthroplasty. This effect may be related to TNFs role in soft tissue weakening, bone resorption, and RA disease progression, though more work is needed to elucidate the mechanism underlying these findings.
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