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Impact of psoriasis on THA and TKA outcomes: A systematic review
, Andrew K. Chowa, Charles R. Reiterb, Brady Ernstb, Matthew Smithb, Joshua Setliffb, John Cyrusc, Jibanananda Satpathyb
⁎Corresponding author: Robert S. Chin. chinr@vcu.edu
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Psoriasis is an autoimmune inflammatory condition that often intersects with orthopaedic care due to its connection to psoriatic arthritis. However, not all psoriasis patients develop psoriatic arthritis. Psoriasis patients may undergo hip or knee arthroplasties for reasons unrelated to psoriasis. This condition, marked by inflamed, scaly skin caused by an overactive immune system, may pose challenges for orthopaedic surgeries. This systematic review evaluated outcomes for psoriasis patients after total hip arthroplasty (THA) or total knee arthroplasty (TKA), focusing on postsurgical impact to inform additional considerations for patients.
Following PRISMA guidelines, a systematic search was conducted in Medline, Embase, Web of Science, and Cochrane (up to October 2024). Studies involving patients with psoriasis undergoing THA or TKA were analyzed for postoperative outcomes.
359 studies were screened, 7 met inclusion criteria. Two studies focused on THA, three on TKA, and two examined both procedures. Patients with psoriasis undergoing THA showed increased risk of infections compared to non-psoriasis patients. For TKA, results were mixed in whether psoriasis led to higher infection rates. Psoriasis did not lead to increased revisions in both THA and TKA. Additionally, two studies found no significant differences in wound complications in TKA patients.
This systematic review underscores the importance of considering post-surgical complications in psoriasis patients undergoing either a THA or TKA. However, lack of research makes it difficult to generalize findings. Psoriasis is an important factor to consider for surgical outcomes, but further research is needed to clarify risks and optimize care for patients.
Keywords
Psoriasis
Total hip arthroplasty
Total knee arthroplasty
Autoimmune disease
1 Introduction
Psoriasis (PsO) is a chronic autoimmune condition consisting of immune-mediated inflammation often presenting as scaly plaques on extensor surfaces such as elbows, knees, and hips.1,2 The persistent immune activation and cutaneous manifestations have been known to complicate outcomes of various surgical procedures.3 Autoimmune disease, such as psoriasis, has been shown to impact outcomes after total hip arthroplasty and total knee arthroplasty.4
It is crucial to distinguish PsO from psoriatic arthritis (PsA). PsA is a condition that develops in patients with PsO and is characterized by bone erosions and inflammatory lesions that lead to joint instability/pain that may require orthopaedic surgery interventions.5,6 PsA may present with soft tissue inflammation and imaging findings known as the “pencil-in-cup” formation, unlike osteoarthritis which mainly consists of cartilage loss and joint space narrowing. However, not all PsO patients develop PsA; in an analysis of about 2200 patients with psoriasis, only 12 % also had PsA.7,8 While psoriatic arthritis is an indication for arthroplasty,5 patients solely affected by psoriasis may undergo THA or TKA for other reasons, such as osteoarthritis.9 Psoriatic arthritis postoperative complications are widely documented in current literature.5 On the other hand, information on psoriasis alone in orthopaedic literature is less common. Psoriasis potentially poses problems for orthopaedic surgeries because of the inflamed scaly patches on the skin and the dysregulated immune system. Psoriasis can be exacerbated due to surgical site locations in other surgeries like breast reconstruction and Mohs surgery, suggesting relevance for arthroplasties.10,11 As a result, there is a need to consider patients' surgical outcomes for those who are only diagnosed with psoriasis prior to undergoing THA and TKA.
This systematic review was the first to synthesize information following psoriasis outcomes of THA and TKA for osteoarthritis. The goal of this study was to understand pertinent complications and impacts on postsurgical outcomes to suggest any additional considerations for THA and TKA patients suffering from psoriasis.
2 Methods and materials
2.1 Literature and database search
This systematic review was registered on PROSPERO (CRD42024599159). A systematic search of peer-reviewed studies published on and prior to October 10th, 2024 was conducted across Medline, Embase, Web of Science, and Cochrane. Search terms included: psoriasis, total hip/knee arthroplasty, hip/knee replacement, infections, complications, and outcomes (full terms in Appendix Table A.1-A.4). Identified studies were screened on Covidence, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.12 IRB approval was not required.
Two independent reviewers conducted all screenings on Covidence, with a third reviewer resolving conflicts. Initial abstract screening identified studies that involved psoriasis, total knee arthroplasty, or total hip arthroplasty, and outcomes of surgery. Cadaveric or biomechanical studies, non-English studies, in-vitro research, case reports, systematic reviews, technical papers, abstracts, and editorial commentary were screened out. Only studies that analyzed psoriasis patients were included. Studies considering psoriatic arthritis as the primary diagnosis were removed.
2.2 Quality assessment
Quality assessment was conducted by two authors, with conflicts resolved by a third reviewer, using the JBI Clinical Appraisal tool13 to evaluate risk of bias for included studies, resulting in inclusion of all 7 studies. The 2 prospective studies analyzed had a mean score of 9/11.14,15 The 3 retrospective studies analyzed had a mean score of 7.33/11.16–18 Lastly, the 2 case series analyzed had a mean score of 8/10.19,20
2.3 Data extraction
Two independent reviewers performed data extraction, including only data available at final follow-up. Data points of interest included: level of evidence, study type, number of patients, number of patients with psoriasis, sex, mean age, surgery type, follow-up time, infection rate, revision rate, post-operative pain, healing outcomes, and other salient outcomes. Information on biological agent use for psoriasis was not consistently reported.
2.4 Data analyses
Due to heterogeneity, no meta-analysis was performed. Categorical variables were summated as raw values or percentages while continuous variables were calculated as averages.
3 Results
3.1 Literature screening and data extraction
Initial database searches included 359 studies. The initial screen yielded 13 studies eligible for full-text evaluation based on inclusion and exclusion criteria. 7 studies met final criteria for inclusion. Data extraction was performed on 7 studies, consisting of 2 Level II evidence prospective cohort studies, 3 Level III evidence retrospective cohort studies, and 2 Level IV evidence case series (Fig. 1).
3.2 Patient demographics
A total of 63,132 patients were analyzed as patients with psoriasis (n = 45,321) or controls without psoriasis (n = 17,811), who underwent either a THA or TKA and were considered in follow-up evaluations. Out of all the patients, 49.49 % (n = 31,242) underwent a TKA and 50.51 % (n = 31,890) underwent a THA. The patients had a mean age of 64.5 years (26–81). Follow-up ranged from 1 year to 14 years, with averages varying. Three studies analyzed TKA, two studies analyzed THA, and two studies analyzed outcomes of both procedures. Six studies provided data for infection rate, while four studies analyzed revisions. Two studies reported on healing complications. One study also considered risk of transfusion for TKA (See Tables 1 and 2).
| Study | LoE | Study Type | N (total) | N (psoriasis) | M/F (before f/u) | Mean Age (yrs; ±SD, Range) | Surgery |
| Beyer et al. (1991) | IV | Case Series | 34 | 34 | 18:17 (psoriasis) | 62 (29–81) | TKA |
| Drancourt et al. (1997) | III | Retrospective Cohort | 288 | 17 | 138:154 (total) | 61 ± 15 | Both |
| TKA: 187 | |||||||
| THA: 101 | |||||||
| Gold et al. (2022) | II | Prospective Cohort | 10,727 | 133 | Unclear | 65 ± 9 | TKA |
| Mandl et al. (2016) | II | Prospective Cohort | 1131 | 153 | 86:67 (psoriasis) | 61 ± 10.8 | THA |
| Menon & Wroblewski (1983) | IV | Case Series | 38 | 38 | 16:26 (total) | 58.4 (26–76) | THA |
| Sleiman et al. (2023) | III | Retrospective Cohort | 50,848 | 44,935 | Unclear | Unclear | Both |
| TKA: 17,655 | |||||||
| THA: 27,280 | |||||||
| Stern et al. (1989) | III | Retrospective Cohort | 24 | 11 | 5:11 (psoriasis) | 61 (37–81) | TKA |
| Study | Avg F/U Time (yrs) | Infection Rate (Deep infections) | Revision Rate | Post-op Pain (WOMAC) | Delayed Healing | Other Reported Outcomes |
| Beyer et al. (1991) | 4 (1–14) | 2.8 % | 14.7 % | – | 0 % | No increased risk for infection with use of peri-operative antibiotics (no p value given) |
| Drancourt et al. (1997) | 2.5 (2–3) | THA:91.67 % (PsO); 28 % (C)TKA:80 % (PsO); 38.5 % (C) | – | – | – | Suggests presence of psoriasis statistically significantly higher in THA infections (p-value <10−6) |
| Gold et al. (2022) | – | 3.8 % (PsO); 1.2 % (C)(p = 0.023) | – | – | 2.3 % (PsO)0.6 % (C)(p = 0.056) | – |
| Mandl et al. (2016) | 2 | – | 5 % | 16.1 ± 20 (p = 0.78)13 % poor (p = 0.6) | – | No difference in satisfaction (p = 0.54), WOMAC pain (p = 0.6), or revision rates with control patients (p = 0.63) |
| Menon & Wroblewski (1983) | 3.25 (1–12) | 13.1 % (D)7.8 % (S) | – | – | – | – |
| Sleiman et al. (2023) | – | THA: 1.93 %Odds ratio: 2.44 [1.892–3.15]TKA: 1.36 %Odds ratio: 1.262 (0.989–1.61) | THA Odds ratio: 1.444 [0.595–3.505]TKA Odds ratio: 1.861 (0.689–5.026) | – | – | Associated with increased risk of transfusion following TKA (Odds ratio = 1.33 [1.076–1.64]) |
| Stern et al. (1989) | 4 | 12.5 % | 12.5 % | – | – | – |
3.3 Comparison with controls
Five of seven studies compared outcomes against non-psoriasis controls, including patients with no psoriasis diagnosis and similar conditions like rheumatoid arthritis. The two studies that focused only on psoriasis patients were case series studies, analyzing THA20 and TKA19 outcomes respectively.
3.4 Post-operative outcomes - infection rates, revision rates
Six of the seven studies reported on postoperative deep infection rates with psoriasis infection rates for TKA ranging from 1.36 % to 80 %. Psoriasis infection rates for THA ranged from 1.93 % to 91.67 %. In the three studies that compared patients with psoriasis against control, there was an increase in infection rate for patients with psoriasis undergoing THA surgeries.14,16,18 On the other hand, only one of those three studies suggested an increase in infection rate for TKA surgeries.15
Four studies considered revision rates, though the reasons for revision varied. Beyer et al. reported revision in 14.7 % (n = 5) of psoriatic TKA patients, but all revisions were due to either aseptic loosening or instability.19 Mandl et al. reported psoriasis revision rates of 5 % (p = 0.63) for THA.15 Sleiman et al. found that for both THA and TKA surgeries, there was no difference in revision rate compared to psoriasis and non-psoriasis patients with odds ratios of 1.444 [0.595–3.505] and 1.861 (0.689–5.026), respectively.16 Lastly, Stern et al. reported a revision rate of 12.5 % for TKA in patients with psoriasis.
3.5 THA versus TKA
Two studies compared psoriasis between THA and TKA surgeries. They found that patients with joint infections were found to have statistically higher rates of psoriasis diagnosis for THA surgeries, but this was not found to be significant for TKA surgeries.18 The other study also found psoriasis infection rates were statistically higher for THA (odds ratio: 2.44 [1.982–3.15]). On the other hand, no difference in infection rates was found for TKA procedures, (odds ratio: 1.262 [0.989–1.61]). This study also found no difference in revision rates between patients with and without psoriasis for both THA (THA odds ratio = 1.444 [0.595–3.505] and TKA (odds ratio = 1.861 [0.689–5.026]).
3.6 Other reported outcomes and conclusions
In addition to infection and revision rates, some studies also analyzed other outcomes. One study calculated WOMAC pain scores (p = 0.78) and percentage of patients who reported a poor pain outcome (p = 0.6) for THA.15 Two studies analyzed healing outcomes, with one reporting no delayed healing in patients with psoriasis who underwent a TKA.19 The other study found no difference in wound healing (p = 0.056) for TKA with 2.3 % delayed healing in patients with psoriasis and 0.6 % in non-psoriasis patients.14 In regard to conclusions, Beyer et al. also suggested no increased risk for infection with psoriasis when using perioperative antibiotics, however, no statistical analysis was done to support this claim.19 Drancourt et al. found that psoriasis was statistically higher in patients with THA infections (p-value <10−6), but did not find the same for TKA. Mandl et al. found that there was no difference in satisfaction for patient-reported outcomes in psoriasis vs. non-psoriasis patients who underwent a THA.15 Lastly, Sleiman et al. found that for patients with psoriasis who underwent a TKA, there was an increased risk of transfusion (Odds ratio = 1.33 [1.075–1.64]).16
4 Discussion
The purpose of this systematic review was to assess the influence of psoriasis on postoperative outcomes in TKA and THA. Collectively, the data suggested patients with psoriasis undergoing THA had increased risk for deep postoperative infections compared to those without psoriasis. This trend was not conclusive for TKA as findings were mixed. One study reported elevated infection rates and others observing no difference. The data also suggested no difference in revision rates for both procedures. One study did suggest an increased risk of transfusion for patients with psoriasis undergoing a TKA. Furthermore, additional salient outcomes from individual studies suggested no differences for pain levels, pain satisfaction, and wound healing in patients with psoriasis.
Prior studies found similar outcomes in psoriatic patients on post-surgical infection rates in other orthopaedic surgeries. In an analysis of total shoulder arthroplasties for patients with psoriasis, there was an increased risk of periprosthetic joint infection and deep surgical infection.21 An additional study by Day et al. analyzed lumbar discectomy and found an increase in surgical site infections for the patients with psoriasis group compared to the control group.3 The impact of psoriasis also seems to expand beyond just surgery as Dobry et al. found increased non-surgical infection rates, such as sepsis and pneumonia, in patients with psoriasis.22 Given the mechanism behind psoriasis is immune system dysregulation, these findings match with the proposed theory in the lower extremity arthroplasties. The overarching effect of psoriasis could be explained as psoriasis may worsen due to the trauma of surgery.23 The pathophysiology behind psoriasis potentially causes increased complications with THA and TKA given PsO commonly present on the extensor surfaces, thus increasing the likelihood of involving psoriasis during surgery.24 These studies provide an important point to acknowledge as it suggests that patients with psoriasis have higher risk of infection in general across various surgeries.
The difference between hip and knee findings is a bit more difficult to explain. In current literature, generally TKA exhibits higher infection rates compared to THA.25 However, our study could not definitively detect a difference as THA had increased infection rates, while TKA did not have a consensus conclusion. THA in particular is associated with greater soft tissue involvement and dissection given the anatomical positioning of the hip joint vs the knee joint,26 which may explain why psoriasis may have a greater impact on THA than normal. The lack of data found regarding TKA for patients with psoriasis may also be a reason for the discrepancy, as some studies suggested an increased risk of infection, while others did not. There may be more conclusive results that align with overall trends of TKA and THA general infection rates if more research was available on the topic. The variance of these findings between patients with psoriasis and general patients suggests a need for additional research to understand why psoriasis may be more impactful in THA.
A potential theory behind why psoriasis may increase risk of infection in joint arthroplasties is due to immune system overactivity characteristic in psoriasis.2 Psoriasis involves Type I interferons and Th17 and Th1 pathways, which release cytokines to promote chronic inflammation.27,28 This chronic inflammation leads to dysregulation and overactivation of the immune system, especially in moments of external triggers such as trauma.29 As a result, surgeries like THA and TKA may be the trigger leading to dysregulation of an immune system that is already compromised, thus limiting a patient's potential to ward off post-operative infections. Another potential basis behind this increased risk of infection involves the use of immuno-suppressants commonly used in inflammatory conditions like psoriasis. In lumbar laminotomy/discectomy, patients with psoriasis taking topic treatment with biologics were 3.102 more likely to develop postoperative infections compared to other treatments.3 Due to the known impact of biologic agents on infection risk, the lack of data on their usage across the studies presents a significant limitation. This acknowledgement highlights the need for further research to investigate a potential relationship between biologic agents and THA and TKA outcomes.
It is suggested that for both THA and TKA, psoriasis does not increase risk of requiring a prosthesis revision. This conclusion is based on two studies that found no significant difference in revision rates for THA and TKA in patients with and without psoriasis. One of these studies considered both THA and TKA, while the other only analyzed THA, suggesting that the conclusion on THA revision rates offers a better point of relevance given the consensus. It is reasonable to believe that increased infection rates should have resulted in increased revision rates. However, due to the heterogeneity of studies and varying follow-up times, not all studies included revisions in their timeframe. Furthermore, older studies may have had different protocols in which management of infections did not necessitate revisions. Overall, literature suggests that both THA and TKA revision rates have decreased over the past couple decades,30,31 likely due to improved surgical approach and perioperative care, making these findings difficult to fully equate with a current relevant conclusion. As a result, the lack of data on revision rates following TKA suggests a potential for additional information and research to fully understand the impact of psoriasis on this surgical outcome.
5 Limitations
Limitations must be considered when analyzing the conclusions drawn from our study. The wide variation in study designs and time frames introduced risks such as selection bias, reporting bias, lack of controls in some studies, sample size limitations, and inconsistencies in time frames. The evolution of psoriasis treatment is also crucial as treatments have evolved significantly with the introduction of biologics in the early 2000s and advancements in genetic and molecular understanding.32 As such, many included studies, some dating back to the late 20th century, may not have completely reflected current psoriasis treatment. When comparing the more current studies compared to the ones from the 20th century, there is a trend of older studies reporting higher infection rates. For this reason, the changes in technique, surgical optimization, and psoriasis treatment should be an acknowledged bias in these results. Additionally, the absence of further statistical analysis and scarcity of data for certain outcomes makes it challenging to confidently advance clinical recommendations. Many of the other outcomes such as wound healing, pain scoring, transfusion risk, and patient satisfaction were only analyzed in a singular study, making these claims difficult to generalize. While these studies offer valuable insight, they emphasize the need for updated and additional research regarding psoriasis and joint arthroplasties. Another limitation is the potential influence of confounding factors and comorbidities, which were often undocumented due to the lack of individual patient data across studies. Variability in pre-surgical psoriasis treatments may have also contributed to differences in reported outcomes. Moreover, many studies were conducted within specific hospital systems or geographical regions, potentially affecting the generalizability of treatment approaches, as well as pre-and post-operative care. Differences in surgical techniques and considerations across the analyzed patients present another source of variability. Lastly, publication bias and the exclusion of non-English studies further limit the comprehensiveness of this review.
6 Conclusion
Psoriasis is an autoimmune condition that impacts postoperative outcomes after THA or TKA. Our findings suggest an increased risk of postoperative infections in total hip arthroplasties, while the risk for total knee arthroplasties remains inconclusive. Data on revision rates indicate no significant difference between patients with psoriasis and those without in the likelihood of prosthesis revision for both total hip and total knee arthroplasties. Additionally, the review found no differences in pain levels or patient satisfaction following total hip arthroplasty, no significant differences in wound healing following total knee arthroplasty, and a potential increased risk of transfusion for patients with psoriasis undergoing total knee arthroplasty. However, these findings should be interpreted considering the varied heterogeneity and age of included studies that may have impacted treatment variation. Regardless, these findings highlight important clinical considerations in guiding surgical management and recovery of patients with psoriasis who undergo a total hip or knee arthroplasty.
Credit author statement
Robert Chin: Conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, supervision, validation, visualization, Writing -original draft, writing-review and editing.
Andrew Chow: Data curation, formal analysis, investigation, methodology, project administration, Writing -original draft, writing-review and editing.
Charles Reiter: Conceptualization, data curation, methodology, project administration, supervision, writing-review and editing.
Brady Ernst: Conceptualization, supervision, validation, writing-review and editing.
Matthew Smith: Conceptualization, supervision, validation, writing-review and editing.
Joshua Setliff: Conceptualization, supervision, validation, writing-review and editing.
John Cyrus: Data curation, resources.
Jibanananda Satpathy: Validation, Supervision, writing-review and editing.
Ethical statement
Not applicable.
Funding sources
None.
Patient Consent
Not applicable.
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