title: Increased surgeon experience with rheumatoid arthritis reduces the risk of complications following total joint arthroplasty.
abstract: OBJECTIVE
  To determine the relationship between surgeon experience with, and complications following, total joint arthroplasty (TJA) in patients with rheumatoid arthritis (RA).
  
  
  METHODS
  Using administrative data, we assembled a cohort of patients with RA who had undergone at least 1 elective primary hip or knee replacement procedure between 2002 and 2009. Cox proportional hazards, censored on death and accounting for clustering of patients within surgeons, were used to determine the relationship between overall and "RA-specific" surgeon TJA volume and the occurrence of a composite "complication" outcome (revision, infection, dislocation, or periprosthetic fracture within 2 years of the initial TJA), controlling for potential confounders (patient age, sex, comorbidity, and disease severity).
  
  
  RESULTS
  We identified 4,762 patients with RA who were eligible for TJAs (1,515 total hip arthroplasties and 3,247 total knee arthroplasties). Among these patients, 152 (3.2%) experienced a surgical complication within 2 years of the procedure. After controlling for patient and hospital factors, greater surgeon TJA volume in patients with RA (RA TJA), but not overall TJA volume (all TJA), was associated with a reduced risk of complications (for surgeon RA TJA volume per 10 cases, adjusted hazard ratio [HR] 0.81, 95% confidence interval [95% CI] 0.71-0.93, P = 0.002; for surgeon all TJA volume, adjusted HR 0.98, 95% CI 0.97-1.00, P = 0.09).
  
  
  CONCLUSIONS
  In a cohort of patients with RA who underwent hip or knee TJA, increased surgeon experience performing TJA in patients with RA, irrespective of their overall TJA experience and hospital factors, was associated with a decreased risk of surgical complications. These findings have potential implications for surgeon training and the referral practices of rheumatologists.
authors.affiliation: University of Toronto and Women's College Hospital, Toronto, Ontario, Canada.
authors.forename: Bheeshma
authors.initials: B
authors.lastname: Ravi
authors.forename: Ruth
authors.initials: R
authors.lastname: Croxford
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.forename: Simon
authors.initials: S
authors.lastname: Hollands
authors.forename: J Michael
authors.initials: JM
authors.lastname: Paterson
authors.forename: Earl
authors.initials: E
authors.lastname: Bogoch
authors.forename: Hans
authors.initials: H
authors.lastname: Kreder
authors.forename: Gillian A
authors.initials: GA
authors.lastname: Hawker
mesh_terms: D000368:Aged; D001172:Arthritis, Rheumatoid / Q000601:surgery*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D002983:Clinical Competence; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology*; D012306:Risk; D016896:Treatment Outcome