Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis

Full Guidelines-From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis

BACKGROUND

Systemic immunomodulatory agents are indicated in the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis. Perioperative use of these medications may increase the risk of surgical site infection (SSI) and complication.

OBJECTIVE

To evaluate the risk of SSI and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alfa [TNF-α] inhibitors, interleukin [IL] 12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte-associated antigen-4 costimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine (CsA), and methotrexate [MTX]) undergoing surgery.

METHODS

We performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery.

RESULTS

We examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease.

CONCLUSION

For low-risk procedures, TNF-α inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, MTX, CsA, and apremilast can safely be continued. For intermediate- and high-risk surgery, MTX, CsA, apremilast, abatacept, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab are likely safe to continue; however, a case-by-case approach is advised. Acitretin can be continued for any surgery. There is insufficient evidence to make firm recommendations on tofacitinib, upadacitinib, and deucravacitinib.

Effect of tumour necrosis factor-a inhibitors exposure on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery: A meta-analysis

A meta-analysis investigation was executed to evaluate the effect of tumour necrosis factor-a inhibitor exposure on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery. A comprehensive literature investigation till October 2023 was applied, and 82 470 individuals with orthopaedic surgery were in the chosen investigations' starting point. Odds ratio (OR) in addition to 95% confidence intervals (CIs) was utilized to compute the value of the effect of tumour necrosis factor-a inhibitors exposure on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery by the dichotomous approaches and a fixed or random model. Tumour necrosis factor uses had significantly higher surgical site infections (OR, 1.65; 95% CI, 1.21-2.25, p = 0.001) compared with tumour necrosis factor non-use in rheumatoid arthritis patients undergoing elective orthopaedic surgery. However, no significant difference was found between discontinued and continued tumour necrosis factor on surgical site infections (OR, 0.61; 95% CI, 0.35-1.05, p = 0.07) in rheumatoid arthritis patients undergoing elective orthopaedic surgery.Significantly higher surgical site infections was found comparing tumour necrosis factor uses to non-use; however, no significant difference was found between discontinued and continued tumour necrosis factor on surgical site infections in rheumatoid arthritis patients undergoing elective orthopaedic surgery. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

Rheumatoid arthritis patients are at increased risk for adverse events following lumbar discectomy

BACKGROUND CONTEXT

Lumbar discectomy is a common procedure for which patients with rheumatoid arthritis (RA) may be considered. RA is an autoinflammatory disease that may predispose patients to postoperative adverse outcomes.

PURPOSE

To assess the relative odds of adverse events after lumbar discectomy for those with versus without RA in a large, national, administrative dataset.

STUDY DESIGN/SETTING

Retrospective cohort study using the 2010 to 2020 MSpine PearlDiver dataset.

PATIENT SAMPLE

After exclusion of patients under 18 years old, those with any trauma, neoplasm, or infection diagnosis within the month before lumbar discectomy, and any patients who had any alternative lumbar spinal surgery performed on the same day as lumbar discectomy, we identified 36,479 lumbar discectomy patients. 2,937 (8.1%) of these patients had a prior diagnosis of RA. After matching 4:1 by patient age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated via ICD-9 and 10 diagnosis codes), 8,485 lumbar discectomy patients without RA and 2,149 with RA were included.

OUTCOME MEASURES

Incidence of severe and minor adverse events in the 90-days following lumbar discectomy, predictive factors for adverse events within 90-days of lumbar discectomy, risk of adverse events within 90-days of lumbar discectomy stratified by patient medication regimen, 5-year survival to reoperation following lumbar discectomy.

METHODS

Patients undergoing lumbar discectomy were identified from the PearlDiver MSpine dataset. The subset of those with versus without RA were identified and matched 1:4 based on patient age, sex, and ECI scores. The incidence of 90-day adverse events in the two groups was determined and compared by univariate and multivariate analyses. Subgroup analysis was performed based on RA medications being taken.

RESULTS

Matched lumbar discectomy patients with RA (n=2,149) and without RA (n=8,485) were identified. Controlling for patient age, sex, and ECI, those with RA were at significantly higher odds of any (odds ratio [OR] 3.30), severe (OR 2.78), and minor (OR 3.30) adverse events (p<.0001 for all). Stratifying by medications being taken (and relative to those without RA), there was increasing odds of all adverse events (AAE) based on potency of medications (no biologic or disease modifying antirheumatic drugs [DMARDs] OR 2.33, DMARDs only OR 3.86, biologic±DMARDs OR 5.69 (p<.0001 for all). Despite this, no statistically significant difference in 5-year survival from subsequent lumbar surgery was found between those with versus without RA (p=.1000).

CONCLUSIONS

Lumbar discectomy patients with RA were found to be at significantly higher risk for 90-day adverse events following lumbar discectomy, and this was incrementally greater for those on increasingly suppressive medications. Lumbar discectomy patients with RA bear specific consideration and perioperative monitoring when considered for lumbar discectomy.

Perioperative treatment with TNF inhibitors does not affect survival of total hip arthroplasty in inflammatory arthritis: a registry-based cohort study

OBJECTIVES

Aim of this study was to investigate the effect of perioperative exposure to TNF inhibitors (TNFi) on the long-term survival of total hip arthroplasty (THA) in inflammatory arthritis patients from a large regional register of arthroplasty procedures (RIPO).

METHODS

This study is a retrospective analysis of data from RIPO for THAs performed between 2008 and 2019. After extraction of the procedures of interest from the RIPO dataset, cross-matching with administrative databases were used to identify patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), primary osteoarthritis (OA), and treatments of interest. Three different cohorts of patients were identified: perioperative TNFi-treated patients (6 months before or after the surgery), perioperative non-bDMARD/tsDMARD (biologic or targeted-synthetic disease modifying antirheumatic drugs), and OA.

RESULTS

At an average follow-up of 5 years, survival rates (using any revision surgery as an endpoint) were not significantly different when perioperative TNFi users and non-bDMARD/tsDMARD patients were compared (p = 0.713), and between TNFi-treated and OA controls (p = 0.123). At the latest available follow-up, 2.5% patients in the TNFi cohort, 3% in the non-bDMARD/tsDMARD cohort, and 0.8% in the OA cohort underwent revision surgery. No significant differences were found comparing the risk of postoperative infection or aseptic loosening among groups.

CONCLUSION

Risk of revision surgery is not increased in patients with inflammatory arthritis perioperatively exposed to TNFi. Our results support the long-term safety of this class of molecules on survival of prosthetic implants.

The Impact of Perioperative Use of Nonbiologic Disease-Modifying Anti-rheumatic Drugs on Perioperative Blood Loss and Complications in Patients Who Have Rheumatoid Arthritis Undergoing Total Knee Arthroplasty

BACKGROUND

The use of disease-modifying antirheumatic drugs (DMARDs) before total knee arthroplasty (TKA) was associated with increased risk of postoperative periprosthetic joint and wound infections as well as worse platelet function in patients who have knee rheumatoid arthritis (RA). This study investigated the effects of DMARDS on perioperative blood loss, complications, and blood transfusion in patients undergoing TKA for knee RA.

METHODS

We retrospectively enrolled patients undergoing TKA for knee RA at our hospital between 2017 and 2021 who received DMARDs (n = 73) or not (n = 84). Every RA patient was matched with patients who had osteoarthritis (OA) in a ratio of 1:1 or 1:2. Primary outcomes were intraoperative and perioperative blood losses, while secondary outcomes were complications and allogeneic transfusions.

RESULTS

The mean total (804 versus 728 mL (mL), P = .114), mean intraoperative (113 versus 101 mL, P = .488), or hidden blood losses (705 versus 640 mL, P = .340) did not differ statistically between RA patients who received DMARDs versus those who did not. RA patients who received DMARDs showed significantly greater mean total (804 versus 654 mL, P = .001), intraoperative (113 versus 75 mL, P = .002), and hidden blood losses (705 versus 560 mL, P = .016) than OA patients. No statistical differences were found in complications or allogeneic transfusions.

CONCLUSION

Although RA patients experienced greater perioperative blood loss than OA patients, there was no statistical difference in perioperative blood loss, complications, or allogeneic transfusions between RA patients who received DMARDs and those who did not.

Rheumatoid Arthritis in Spine Surgery: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVE

The purpose of this study is to synthesize recommendations for perioperative medical management of RA patients and quantify outcomes after spine surgery when compared to patients without RA.

METHODS

A search of available literature on patients with RA and spine surgery was performed. Studies were included if they provided a direct comparison of outcomes between patients undergoing spine surgery with or without RA diagnosis. Meta-analysis was performed on operative time, estimated blood loss, hospital length of stay, overall complications, implant-related complications, reoperation, infection, pseudarthrosis, and adjacent segment disease.

RESULTS

Included in the analysis were 9 studies with 703 patients with RA undergoing spine surgery and 2569 patients without RA. In RA patients compared to non-RA patients undergoing spine surgery, the relative risk of infection was 2.29 times higher (P = .036), overall complications 1.61 times higher (P < .0001), implant-related complications 3.93 times higher (P = .009), and risk of reoperation 2.45 times higher (P < .0001). Hospital length of stay was 4.6 days longer in RA patients (P < .0001).

CONCLUSIONS

Treatment of spinal pathology in patients with RA carries an increased risk of infection and implant-related complications. Spine-specific guidelines for perioperative management of antirheumatic medication deserve further exploration. All RA patients should be perioperatively co-managed by a rheumatologist. This review helps identify risk profiles in RA specific to spine surgery and may guide future studies seeking to medically optimize RA patients perioperatively.

Comprehensive risk analysis of postoperative complications in patients with rheumatoid arthritis for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis

OBJECTIVES

To examine the risk factors of surgical site infection (SSI), delayed wound healing, and death after orthopedic surgery in patients with rheumatoid arthritis (RA).

METHODS

We identified articles indexed in the Cochrane Library, PubMed, and Japan Centra Revuo Medicina Web published from 2013 to 2019 and other articles. Articles fulfilling the predefined inclusion criteria were reviewed systematically and their quality was appraised according to the Grading of Recommendations Assessment, Development, and Evaluation system with some modifications.

RESULTS

After inclusion and exclusion by full-text review, 29 articles were analyzed. Use of biological disease modifying antirheumatic drugs was a risk factor of SSI (risk ratio 1.66, 95% confidence interval 1.25-2.19), but not of delayed wound healing. RA itself was a risk factor of SSI, and oral glucocorticoid use was a risk factor of SSI in three of the four studies analyzed and of postoperative death. Age, male sex, comorbidities such as diabetes mellitus and chronic obstructive pulmonary disease, surgical factors such as foot/ankle and spine surgery and longer operative time were risk factors of those postoperative complications.

CONCLUSION

Patients with those factors should be dealt with appropriate cautions to strike a risk-benefit balance of orthopedic surgeries.

Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review

»

Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery.

»

For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld.

»

Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug.

»

For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing.

»

In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.

Comparison of Clinical Outcomes After Total Ankle Arthroplasty Between End-Stage Osteoarthritis and Rheumatoid Arthritis

BACKGROUND

Total ankle arthroplasty (TAA) is known to be a reliable operative option for end-stage rheumatoid arthritis. However, higher risk of postoperative complications related to chronic inflammation and immunosuppressive treatment is still a concern. With the use of a newer prosthesis and modification of anti-rheumatic medications, we compared clinical outcomes after TAA between patients with osteoarthritis and rheumatoid arthritis.

METHODS

Forty-five patients with end-stage osteoarthritis (OA group) and 19 with rheumatoid arthritis (RA group) were followed for more than 3 years after 3 component mobile-bearing TAA (Zenith^TM). Perioperative anti-rheumatic medications were modified using an established guideline used in total hip and knee arthroplasty. Clinical evaluations consisted of American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM).

RESULTS

In the preoperative and postoperative evaluation at final follow-up, there were no significant differences in AOFAS, FAOS, and FAAM scores between 2 groups. Despite statistical similarity in total scores, the OA group showed significantly better scores in FAOS sports and leisure (mean, 57.4 ± 10.1) and FAAM sports activity (mean, 62.5 ± 13.6) subscales than those in the RA group (mean, 52.2 ± 9.8, P = .004; and 56.4 ± 13.2, P < .001, respectively). There were no significant differences in perioperative complication and revision rates between 2 groups.

CONCLUSION

Patients with end-stage ankle RA had clinical outcomes comparable to the patients with OA, except for the ability related to sports activities. In addition, there were no significant differences in early postoperative complication rates, including wound problem and infection.

LEVEL OF EVIDENCE

Level III, prognostic, prospective comparative study.

Higher age, female gender, osteoarthritis and blood transfusion protect against periprosthetic joint infection in total hip or knee arthroplasties: a systematic review and meta-analysis

PURPOSE

The goal of this systematic review and meta-analysis was to identify the main risk factors for periprosthetic joint infection (PJI) in patients undergoing total hip or knee arthroplasties.

METHODS

A systematic review was conducted of the potential risk factors for PJI in total hip or total knee arthroplasty. Risk factors were compared and grouped according to demographics, comorbidities, behavior, infections, native joint diseases and other patient-related and procedure-related factors. Meta-analysis (random-effects models) was conducted using odds ratio (OR) and mean difference (MD). Risk of bias (ROBBINS-I) and strength of the evidence (GRADE) were assessed.

RESULTS

The study included 37 studies (2,470,827 patients). Older age was a protective factor (MD = - 1.18). Male gender (OR 1.34), coagulopathy (3.05), congestive heart failure (2.36), diabetes mellitus (1.80), obesity (1.61), systemic neoplasia (1.57), chronic lung disease (1.52), and hypertension (1.21) increased the risk for PJI. Behavioral risk factors comprised alcohol abuse (2.95), immunosuppressive therapy (2.81), steroid therapies (1.88), and tobacco (1.82). Infectious risk factors included surgical site infections (6.14), postoperative urinary tract infections (2.85), and prior joint infections (2.15). Rheumatoid arthritis, posttraumatic native joint disease, high National Nosocomial Infections Surveillance (NNIS) system surgical patient index score, prior joint operation, American Society of Anesthesiologists score ≥ 3 and obesity were also significantly associated with higher risk of PJI. Osteoarthritis and blood transfusion were protective factors.

CONCLUSIONS

The main risk factors for PJI in each category were male gender, coagulopathy, alcohol abuse, surgical site infection (highest score) and high NNIS system surgical patient index score. Protective factors were age, female gender in TKA, osteoarthritis and blood transfusion. Optimization of modifiable risk factors for PJI should be attempted in clinical practice.

LEVEL OF EVIDENCE

II.

Effect of Immunosuppressive Therapy on Clinical Outcomes for Patients With Aortic Stenosis Following Transcatheter Aortic Valve Implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an established treatment for symptomatic patients with severe aortic stenosis (AS). Sometimes patients with severe AS taking immunosuppressants are encountered. The effect of immunosuppressive therapy on clinical outcomes in patients with AS following TAVI were investigated.Methods and Results:In total, 282 consecutive patients with severe AS who underwent transfemoral TAVI from January 2016 to December 2018 at St. Marianna University School of Medicine were reviewed. They were divided into 2 groups: the immunosuppressants group (IM group) in which patients continually used immunosuppressive drugs (n=22) and the non-immunosuppressants group (non-IM group) (n=260). The composite endpoints of a major adverse cardiovascular and cerebrovascular event (MACCE) defined as non-lethal myocardial infarction, unstable angina pectoris, heart failure requiring hospitalization, stroke, and cardiovascular death were evaluated. There were no differences in the incidence of vascular access complications (32% vs. 20%, P=0.143) and the rate of procedure success (100% vs. 93%, P=0.377) between the IM and non-IM groups. During the median follow-up period of 567 (16-1,312) days after the TAVI procedure, there were no significant differences between the IM and non-IM groups in the incidence of infectious complications (14% vs. 9%, P=0.442) or MACCE (18% vs. 20%, respectively; P=0.845).

CONCLUSIONS

The use of IM after TAVI is not associated with increased vascular access complications or mid-term MACCE in patients with severe AS treated with TAVI.

Surgical Management of the Lumbar Spine in Rheumatoid Arthritis

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited.

METHODS

Using PubMed, studies published prior to November 2018 with the keywords "RA, etiology"; "RA, spine management"; "RA, surgical management"; "RA, treatment"; "RA, DMARDs"; "RA, lumbar spine"; "RA, spine surgical outcomes"; "RA, imaging" were evaluated.

RESULTS

The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine.

CONCLUSIONS

Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.

The Management of Perioperative Immunosuppressant Medications for Rheumatoid Arthritis During Elective Hand Surgery

PURPOSE

Rheumatoid arthritis (RA) is a destructive inflammatory disease that commonly involves joints of the hand and wrist. Different recommendations exist for continuing or discontinuing immunosuppressant medications during the perioperative time period. The purpose of our study was to determine whether continuing or discontinuing medications (steroids, nonbiological, and/or biological disease-modifying antirheumatic drugs [DMARDs]) were associated with an increased or decreased risk of postoperative complications.

METHODS

We performed a single-center, retrospective review of a cohort of RA patients who had elective hand surgery by a single surgeon. Patients were included if they had a documented diagnosis of seropositive RA by a rheumatologist and had elective hand surgery and/or a disease-related surgical procedure involving the upper extremity between January 2008 and August 2018. We stratified patients into different groups for comparison by classes of immunosuppressant medications for managing RA. These classes included corticosteroids, nonbiological DMARDs, biological DMARDs, and/or no medications. Immunosuppressant medications were then compared with no medications for the incidence of postoperative overall complications.

RESULTS

Eighty-eight patients had elective hand and/or upper extremity surgeries for RA. Mean patient age at the time of surgery (± SD) was 55 ± 13 years (range, 24-74 years). Of these 88 patients, 8 (9%) overall complications occurred. Complications were wound healing failures (n = 5), tendon rupture (n = 1), hematoma (n = 1), and surgical-site infection (n = 1). Perioperative medications included steroids (n = 31), nonbiological DMARDs (n = 68), biological DMARDs (n = 5), and no medication (n = 27). There were no significant differences in overall complications between patients on immunosuppressant medications and those on no medications. Median (interquartile range) follow-up was 11.5 months (5-25.8) (range, 2-74 months).

CONCLUSIONS

We found that patients who continued or discontinued medications within 1 dosing interval of their usual dose perioperatively had similar rates of complications following elective hand surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Complications of Hand Infections

Although most hand infections can be eradicated by appropriate management with return to normal function, complications are frequently encountered. Common complications include stiffness, osteomyelitis, and large soft tissue defects that require complex wound management. Risk factors for hand infections include an immunocompromised host state, as is the case in patients with diabetes mellitus or human immunodeficiency virus/AIDS, as well as those on immunosuppressive medications for autoimmune disorders or following organ transplantation. Patients at risk for complications secondary to hand infections should be monitored closely during the treatment process so that complications may be identified and treated early.

Impact of Chronic DMARD Therapy in Patients With Rheumatoid Arthritis Undergoing Surgery of the Craniovertebral Junction: A Multi-center Retrospective Study

STUDY DESIGN

A multi-centered retrospective review from five institutions.

OBJECTIVE

The aim of this study was to determine whether continuing or withholding disease-modifying antirheumatoid drugs (DMARDs) in the perioperative period affect outcomes in rheumatoid arthritis (RA) patients undergoing arthrodesis at the craniovertebral junction SUMMARY OF BACKGROUND DATA.: RA is a chronic systemic inflammatory disease that affects the cervical spine and is treated with DMARDs. Some advocate withholding DMARDs in the perioperative period due to concern for the cytotoxic effects of these medications. However, the impact of DMARDs in the perioperative period is not well understood.

METHODS

A multicenter retrospective study from five affiliated institutions was performed. Adult patients with RA on chronic DMARDs undergoing posterior arthrodesis of the craniovertebral junction (occipital-cervical or atlanto-axial arthrodesis) were identified. Patients were stratified based on whether DMARD therapy was continued (C group) or discontinued (DC group) in the perioperative period. The primary outcome was the need for reoperation and reason for reoperation.

RESULTS

Thirty-nine patients met inclusion criteria, 19 in C group and 20 in DC group. Average follow-up time was 42 months. Four patients (three in DC group and one in C group) required reoperation. Two patients from the DC group required readmission secondary to RA flare-up.

CONCLUSION

Our cohort of RA patients who underwent occipital-cervical and C1/C2 posterior arthrodesis showed no significant differences in surgical complications when DMARD therapy was continued or discontinued in the perioperative period. The decision to continue or discontinue DMARD therapy in the perioperative period is at the discretion of the treating physician, but we encourage physicians to counsel patients regarding this theoretical risk and their tolerance of the medications as well as the risk of RA flare-up. Factors such as overall health, disease burden, nutrition, bone quality, smoking status, and other comorbid conditions are likely to have a larger influence on perioperative complications.

LEVEL OF EVIDENCE

3.

Anti-rheumatic treatment and prosthetic joint infection: an observational study in 494 elective hip and knee arthroplasties

Background

Surgical site infections are more frequent among patients with rheumatic disease. To what extent this is related to immunosuppressive antirheumatic drugs is unclear, as is the value of discontinuing medication perioperatively. The aim of study was to assess the rate of surgical site infections after knee and hip replacement in patients with inflammatory joint disease, with an emphasis on periprosthetic joint infection, and to investigate the influence of treatment with disease-modifying antirheumatic drugs (DMARDs) in this regard.

Methods

Data were collected from 494 primary elective hip (51.4%) and knee arthroplasties, along with demographic and medication data. The primary outcome was surgical site infection during the first year after surgery.

Results

In 78% (n = 385) of the cases the patient used 1 to 3 disease-modifying antirheumatic drugs perioperatively. Thirty-two percent (n = 157) of patients used a TNF-alpha inhibitor. The rate of surgical site infection was 3.8% (n = 19). The rate of periprosthetic joint infection was 1.4% (n = 7), all of which occurred after knee arthroplasty. Periprosthetic joint infection occurred in only 1 patient medicating perioperatively with a TNF-alpha inhibitor.

Conclusion

Surgical site infections were not associated with ongoing medication with disease-modifying antirheumatic drugs. Due to the low event rate this should be interpreted with caution, but our center will maintain its routine of continuing treatment with TNF-alpha inhibitors perioperatively.

Assessing the incidence of skin and soft tissue infection in patients on biologics

BACKGROUND

Biologic agents may predispose patients to skin and soft tissue infections (SSTIs). Guidelines recommend discontinuing the agent preoperatively; the true risk of infection is unclear.

OBJECTIVES

To assess the incidence of SSTIs in patients receiving biologic agents for all clinical indications. A secondary aim was to assess those undergoing surgery to determine postoperative SSTI risk.

METHODS

A retrospective medical record review was conducted at 2 urban tertiary care hospitals. Biologic agent use ranged from June 2013 to June 2018. Data were extracted on biologic agent injections, surgical procedures, and patient characteristics.

RESULTS

Hypertension, former smoking, and corticosteroid use were significantly associated with SSTI risk (P < .05). There was no increased SSTI risk among biologic agents (P = .49). Biologic therapy with concomitant corticosteroid use increased risk of SSTI (P = .0049). There was no difference in postoperative SSTI risk in patients who stopped biologic therapy before surgery and those who did not.

LIMITATIONS

This study is limited by its retrospective design.

CONCLUSIONS

There was no increased risk of either postoperative or nonperioperative SSTI risk among biologic agents. Concomitant corticosteroid use increased SSTI risk. Current guidelines regarding stopping biologic agents before surgery warrant re-evaluation, because there was no difference in SSTI risk in patients who did so.

Perioperative management of patients with rheumatoid arthritis undergoing orthopaedic surgery

Rheumatoid arthritis is an autoimmune disease which is characterised by systemic inflammation. In the recent decades, the advent of disease modifying anti-rheumatic drugs have reduced the need for orthopaedic procedures. However, there are numerous patients in which pharmacological treatment fails and these patients require surgical intervention. Complications can arise due to the underlying pathology and multitude of medications these patients can be on, specifically increased infection rates due to use of immunosuppressive agents. An understanding into the disease itself, as well as perioperative management, may improve overall patient outcomes and prevent future complications.

Osteonecrosis and osteomyelitis of the jaw associated with tumour necrosis factor-alpha (TNF-α) inhibitors: a systematic review

Tumour necrosis factor-α (TNF-α) inhibitors are increasingly being used as immunomodulators to manage inflammatory conditions such as rheumatoid arthritis and Crohn's disease. Reported serious side effects include an increased incidence of lymphoma and greater susceptibility to infections such as tuberculosis. The aim of this systematic review was to find out whether there is an associated risk of medication-related osteonecrosis of the jaw (MRONJ). Three authors independently searched PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials for published reports of oral osteonecrosis (ONJ) or osteomyelitis (OM) in patients who took anti TNF-α drugs and had no history of antiangiogenic agents or antiresorptive treatment. All types of studies on humans treated with TNF-α inhibitors were considered. Only six were eligible for analysis, and all were independently assessed for risk of bias. They included six patients with ONJ or OM that was attributed solely to TNF-α inhibitors. The most common site of ONJ was the posterior mandible (n=5). The mean (SD) duration of anti-TNF-α treatment before the development of bony lesions was 62.5 (47.4) months. Invasive surgery was reported as a precipitating factor in five cases, and the ONJ/OM resolved with conservative management in five. Although all the studies were judged to be at high risk of bias, the limited data suggest that some patients will potentially develop ONJ/OM as a result of treatment with TNF-α inhibitors. Studies of higher quality are now needed to establish the relative risk of MRONJ in patients who take them.

Does Abatacept Increase Postoperative Adverse Events in Rheumatoid Arthritis Compared with Conventional Synthetic Disease-modifying Drugs?

Objective.

To investigate whether abatacept (ABA) causes more adverse events (AE) than conventional synthetic disease-modifying antirheumatic drugs (csDMARD) after orthopedic surgery in patients with rheumatoid arthritis (RA).

Methods.

A retrospective multicenter nested case–control study was performed in 18 institutions. Patients receiving ABA (ABA group) were matched individually with patients receiving csDMARD and/or steroids (control group). Postoperative AE included surgical site infection, delayed wound healing, deep vein thrombosis or pulmonary embolism, flare, and death. The incidence rates of the AE in both groups were compared with the Mantel-Haenszel test. Risk factors for AE were analyzed by logistic regression model.

Results.

A total of 3358 cases were collected. After inclusion and exclusion, 2651 patients were selected for matching, and 194 patients in 97 pairs were chosen for subsequent comparative analyses between the ABA and control groups. No between-group differences were detected in the incidence rates of each AE or in the incidence rates of total AE (control vs ABA: 15.5% vs 20.7% in total, 5.2% vs 3.1% in death).

Conclusion.

Compared with csDMARD and/or steroids without ABA, adding ABA to the treatment does not appear to increase the incidence rates of postoperative AE in patients with RA undergoing orthopedic surgery. Large cohort studies should be performed to add evidence for the perioperative safety profile of ABA.

Osseous and Soft Tissue Complications Associated With Foot and Ankle Surgery in Patients With Rheumatoid Arthritis Taking a Variety of Antirheumatic Medications

There are multiple antirheumatic drug modalities available to patients with symptomatic rheumatoid arthritis (RA) that function to suppress the overactive immune system, but the inflammatory and immune suppression may contribute to postoperative complications. The purpose of this study was to determine if antirheumatic medications increased the risk of both soft tissue and osseous postoperative complications in patients with RA who underwent foot and ankle surgery. We reviewed patients with RA, aged 18years and older, who underwent either an elective or a nonelective foot or ankle surgery involving an osseous procedure between 2009 and 2014. Chart review was conducted to document procedure type, active medications, and postoperative complications. Of the final 110 subjects meeting inclusion criteria, 31 (28%) patients had a postoperative complication (13 soft tissue, 9 osseous, and 9 both soft tissue and osseous). There was no statistically significant association between taking antirheumatic medications in the perioperative period and postoperative complications. Increased surgery duration and peripheral neuropathy were associated with a statistically significant increase in postoperative complications. Every 15 minutes of increased surgery time led to a 1.2-fold increase in complication risk. Nonelective procedures had a higher risk of soft tissue complications than did elective procedures (odds ratio 4.2, 95% confidence interval 1.1 to 16.0). Although there was no statistically significant association between the specific medication and complications, some medications trended toward statistical significance. When working with patients with RA, our findings suggest the importance of considering the risk of surgery duration and the potential risk of antirheumatic medications in the perioperative period.

Arthroscopic Treatment of a Low-Velocity Gunshot Injury to a Primary Total Hip Arthroplasty: A Case Report

CASE

An immunosuppressed 51-year-old man sustained a ballistic injury about the site of a primary total hip arthroplasty, which had been performed for osteonecrosis of the femoral head 2 years earlier. He was treated with arthroscopic debridement and irrigation, inspection of the implants, and removal of foreign bodies.

CONCLUSION

Ballistic injury to a hip arthroplasty site with retained foreign bodies is an unusual injury. Hip arthroscopy may represent a minimally invasive treatment option for implant inspection, joint debridement, and removal of intra-articular fragments while minimizing the risk of soft-tissue complications.

Physcion 8‑O‑β‑glucopyranoside extracted from Polygonum cuspidatum exhibits anti‑proliferative and anti‑inflammatory effects on MH7A rheumatoid arthritis‑derived fibroblast‑like synoviocytes through the TGF‑β/MAPK pathway

The present study aimed to investigate the anti-arthritic effect of physcion 8-O-β-glucopyranoside (POGD) and its possible mechanisms. The anti-proliferative effects of POGD on MH7A cells were detected using a CCK-8 assay, and the release of pro-inflammatory cytokines, interleukin (IL)-1β, IL-6, IL-8, IL-12 and IL-17A, were determined by ELISA. A type II collagen-induced arthritis (CIA) rat model was established to evaluate the anti-arthritic effect of POGD in vivo. The paw volumes, arthritis indices and serum levels of tumor necrosis factor (TNF)-α, IL-1β, IL-6, IL-8, IL-17A were determined by ELISA. The mRNA expression levels of matrix metalloproteinase (MMP)-2, MMP-3, MMP-9, vascular endothelial growth factor and cyclooxygenase-2 were determined by reverse transcription-quantitative polymerase chain reaction analysis, and the expression levels of transforming growth factor (TGF)-β1, small mothers against decapentaplegic (Smad)4, Smad7, c-Jun N-terminal kinase (JNK), phosphorylated (p-)JNK, p-P38, P38, p-extracellular signal-regulated kinase (ERK)1/2, ERK1/2, nuclear factor (NF)-κB p65 in the nucleus (N), cytosolic NF-κB p65 (C), and inhibitor of NF-κB (IκB) were determined by western blot analysis. The results indicated that POGD significantly inhibited MH7A cell growth. POGD markedly inhibited paw swelling and the arthritis indices of the CIA rats, and POGD may also inhibit the release of pro-inflammatory cytokines. Furthermore, POGD downregulated the expression levels of TGF-β1, Smad4, NF-κB p65 (N), p38, p-p38, p-ERK1/2, JNK, p-JNK, TGF-β1, Smad4, p-JNK, JNK, p-P38, P38, p-ERK1/2, ERK1/2 and NF-κB p65 (N), and upregulated the Smad7, NF-κB p65 (C) and IκB in TNF-α induced MH7A cells. In conclusion, the results suggested that POGD is a promising potential anti-inflammatory drug, and that POGD may decrease the expression of pro-inflammatory cytokines and mediators via inhibiting the TGF-β/NF-κB/mitogen-activated protein kinase pathways.

Rheumatoid Arthritis, Disease Modifying Agents, and Periprosthetic Joint Infection: What Does a Joint Surgeon Need to Know?

The incidence of periprosthetic joint infection (PJI) among patients with rheumatoid arthritis (RA) is 1.6× greater than in patients undergoing the same procedure for osteoarthritis. This higher risk "may" be due to the immunosuppressive therapies for RA patients including corticosteroids, such as prednisone, and disease-modifying antirheumatic drugs (DMARDs), such as methotrexate. There is a debate about the role of DMARDs in increasing the incidence of subsequent PJI. Studies show conflicting results, with some demonstrating no significant increase in the rates of PJI and some finding otherwise. The International Consensus Meeting on PJI recommended that DMARDs should be halted prior to an elective total joint arthroplasty based on their half-life. Moreover, the International Consensus Meeting stated that cessation of immunosuppressant medications should be performed in consultation with and under the direction of the treating physician. In this review, we aimed to provide an introduction to the available treatment options and cover the recommendations on the treatment protocols for RA patients who undergo elective total joint arthroplasty.

Ankylosing Spondylitis Increases Perioperative and Postoperative Complications After Total Hip Arthroplasty

BACKGROUND

Ankylosing spondylitis (AS) is a chronic autoimmune spondyloarthropathy that primarily affects the axial spine and hips. Progressive disease leads to pronounced spinal kyphosis, positive sagittal balance, and altered biomechanics. The purpose of this study is to determine the complication profile of patients with AS undergoing total hip arthroplasty (THA).

METHODS

The Medicare sample was searched from 2005 to 2012 yielding 1006 patients with AS who subsequently underwent THA. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for 90-day, 2-year, and the final postoperative follow-up for complications including hip dislocation, periprosthetic fracture, wound complication, revision THA, and postoperative infection.

RESULTS

Compared to controls, AS patients had an RR of 2.50 (CI, 1.04-5.99) of THA component breakage at 90-days post-operatively and 1.99 (CI, 1.10-3.59) at 2-years. The RR of periprosthetic hip dislocation was elevated at 90 days (1.44; CI, 0.93-2.22) and significantly increased at 2-years (1.67; CI, 1.25-2.23) and overall follow-up (1.49; CI, 1.14-1.93). Similarly, the RR for THA revision was elevated at 90-days (1.46; CI, 0.97-2.18) and significantly increased at 2-years (1.69; CI, 1.33-2.14) and overall follow-up (1.51; CI, 1.23-1.85).

CONCLUSION

Patients with AS are at increased risk for complications after THA. Altered biomechanics from a rigid, kyphotic spine place increased demand on the hip joints. The elevated perioperative and postoperative risks should be discussed preoperatively, and these patients may require increased preoperative medical optimization as well as possible changes in component selection and position to compensate for altered spinopelvic biomechanics.

Characteristics of rheumatoid arthritis patients undergoing reverse shoulder arthroplasty

The risks and complication profile of reverse total shoulder arthroplasty (RSA) in rheumatoid arthritis (RA) patients has yet to be clearly defined as most studies have small cohorts. Using a large inpatient database, the purpose on our study was to determine the overall demographics, hospitalization characteristics, and early complication rates in rheumatoid patients and compared these to rotator-cuff arthropathy patients without RA undergoing RSA. Utilizing United States Nationwide Inpatient Sample from 2010 to 2013, we evaluated a total of 919 RA RSA and compared them to 8097 patients without RA undergoing RSA. The outcomes included demographic characteristics like age, race, sex, Deyo comorbidity score, perioperative complications, and mean length-of-stay. The RA cohort had 81% females versus 60% in the comparison cohort. This cohort was younger (p = 0.006) and had longer hospitalization time (p = 0.001), but the total inpatient costs were not significantly different (p = 0.15). In regards to Deyo index, rheumatoid patients had significantly higher scores (p < 0.001). The inpatient complication rates for infection (p = 0.9), nerve injury (p = 0.9), and instability (p = 0.19) were similar, but the RA cohort had more prosthetic-related (p = 0.001) and greater tuberosity-related (p = 0.008) complications. The mortality rates were also similar (p = 0.625). In RSA for RA patients, surgeons should be mindful of preoperative risk factors and demographic characteristics that may influence their outcomes. Caution should specifically be paid to the possibility of longer hospitalization time and increased incidence of certain complications, including intraoperative fracture, when compared to non-rheumatoid patients. Close collaboration between rheumatologists, surgeons, and primary care physicians is a must for optimizing and managing these patients.

[Periprosthetic infections in patients with rheumatism : A challenge]

The increasing number of implantations will lead to more periprosthetic infections. Periprosthetic infections in patients with rheumatism, who are often undergoing immunosuppressive treatment, represent a challenge for the treating physicians. The optimal care and treatment therefore necessitate an interdisciplinary agreement between orthopedic surgeons, specialists for infections and rheumatologists.

Should Preoperative Antibiotics Be Tailored According to Patient's Comorbidities and Susceptibility to Organisms?

BACKGROUND

Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint arthroplasty patients regardless of their medical conditions or immune status; however, no studies have evaluated the individualizing of antibiotics. The aims of this study were (1) to determine if comorbidities influence the organism profile of PJIs, and (2) to investigate if the efficacy of two different perioperative antibiotics (cefazolin or vancomycin) for preventing PJI is affected by patient's comorbidities.

METHODS

Using an institutional database of 1022 PJIs, the influence of different patient's comorbidities on the organism profile was evaluated. To investigate the influence of perioperative antibiotics (cefazolin or vancomycin monotherapy) on PJI rate, 8575 primary total joint arthroplasties were identified, crossmatched for PJI, and analyzed based on the comorbidities of the cohort. The PJI rate of each antibiotic within each comorbidity was compared.

RESULTS

Although no comorbidities were associated with an increased rate of Gram-positive infections or Gram-negative infections, metastatic disease (odds ratio [OR] 5.71, P = .018), congestive heart failure (OR 2.2, P = .010), chronic pulmonary disease (OR 1.76, P = .015), and diabetes mellitus (OR 1.66, P = .019) were associated with antibiotic resistant organisms. However, there was no difference in the PJI rate between cefazolin and vancomycin monotherapy when stratifying for diabetes mellitus, rheumatoid arthritis, liver disease, and hypothyroidism.

CONCLUSION

The results of the present study support the current recommendations of a universal antibiotic prophylaxis protocol rather than an antibiotic regimen individualized to a patient's comorbidities.

The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) is one of a number of inflammatory arthropathies resulting in foot pain and deformity. Patients with this disease may require surgical intervention as part of their management. Many of these patients are now taking biologic agents which pose several risks to patients in the perioperative phase. The surgical team therefore need to be aware of these associated complications and how to manage these cases.

AIM

This paper aims to review the current literature about perioperative needs (foot and ankle surgery) associated with patients with rheumatoid arthritis receiving biologic therapy.

MAIN FINDINGS

The majority of the literature discusses the perioperative complications associated with patients on anti-TNFα therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) have produced guidelines for the management of patients on anti-TNFα therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of post-operative infection need to be balanced against the risk of a post-operative disease flare. In essence, it is suggested anti-TNFα therapy is stopped 3-5 times the half-life of the drug whilst Tocilizumab is stopped 4 weeks prior to surgery.

CONCLUSION

Good communication is needed between the surgical team and the local Rheumatology department managing the patient's disease in order to optimise perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.

Antibiotic prophylaxis in orthopaedic surgery: difficult decisions in an era of evolving antibiotic resistance

Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics. Cite this article: Bone Joint J 2016;98-B:1014-19.

Parapharyngeal Abscess in a Patient Receiving Etanercept

Objective:

To report a case of parapharyngeal abscess associated with Streptococcus viridans in a patient with rheumatoid arthritis receiving treatment with etanercept.

Case Summary:

A 40-year-old man diagnosed with rheumatoid arthritis had received treatment with nonsteroidal antiinflammatory drugs, methotrexate, and deflazacort. Six months prior to admission, the patient had a Disease Activity Score of 3.4; clinicians decided to start treatment with etanercept. Chest X-rays were normal and the tuberculin skin test was negative. Treatment with etanercept plus methotrexate was started. Three months later, methotrexate was discontinued. Six months after etanercept therapy was started, the patient presented to our emergency department with a swelling of his neck, odynophagia, otalgia, and trismus. The clinical course was consistent with parapharyngeal abscess. Etanercept treatment was suspended. The parapharyngeal abscess was drained and intravenous methylprednisolone, amoxicillin/clavulanic acid, and clindamycin were administered. The parapharyngeal abscess secretion culture was positive for S. viridans and Bacteroides spp. The patient's condition improved with antibiotic therapy; he was discharged 5 days after admission.

Discussion:

Tumor necrosis factor-α plays an essential role in the immune-mediated response to infection. In our patient, the most possible cause of parapharyngeal abscess was considered to be etanercept because of the temporal relationship between exposure to the drug and onset of symptoms. Etanercept was the only drug administered before the abscess developed. Based on the Naranjo probability scale, an association between etanercept and the adverse reaction could be considered possible.

Conclusions:

Patients initiated on etanercept therapy should be closely monitored for the development of tuberculosis and other infections. During treatment, all febrile or novel illnesses should be evaluated promptly. If clinical evaluation leads to the suspicion of tuberculosis and other infections associated with etanercept, it should be discontinued immediately.

Management of Biologic Therapy in Moderate to Severe Psoriasis in Surgical Patients: Data From the Spanish Biobadaderm Registry

BACKGROUND AND OBJECTIVE

We now have considerable experience in the use of biologic agents to treat psoriasis, but doubts about management arise in certain clinical settings. Surgery is one of them. Although treatment guidelines advise that biologics be suspended before major surgery, data about actual clinical practices and associated complications are lacking. We aimed to analyze current practice in the clinical management of these cases.

METHODS

Retrospective study of cases in the Biobadaderm database. We analyzed the management of biologic therapy in patients with psoriasis who underwent surgical procedures.

RESULTS

Forty-eight of the 2113 patients registered in Biobadaderm underwent surgery. The largest percentage of procedures (31%) involved skin lesions. Biologic treatment was interrupted in 42% of the cases. No postsurgical complications were significantly related to treatment interruption. Likewise we detected no associations between treatment interruption and other variables, such as sex, age, or duration or severity of psoriasis.

CONCLUSION

Continuity of biologic treatment and the risk of postsurgical complications were not associated in this study, although conclusions are limited by the small sample size.

Co‑culture of fibroblast‑like synoviocytes with umbilical cord‑mesenchymal stem cells inhibits expression of pro‑inflammatory proteins, induces apoptosis and promotes chondrogenesis

The present study aimed to investigate the effect of co‑culture of fibroblast‑like synoviocytes (FLS) with human umbilical cord‑mesenchymal stem cells (UC‑MSCs) on rheumatoid arthritis (RA) and to understand the mechanisms that mediate the induced changes. FLS and UC‑MSCs were isolated and cultured individually, FLS were then cultured with or without UC‑MSCs. The phenotype of UC‑MSCs was analyzed prior to co‑culture. The UC‑MSCs were successfully isolated and expanded, and exhibited a fibroblast‑like morphology. Enzyme‑linked immunosorbent assay (ELISA) and reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR) were performed to determine the expression levels of interleukin (IL)‑1β, IL‑6, and chemokine (C‑C motif) ligand (CCL)‑2. The cell apoptosis rate was determined by flow cytometry. Furthermore, the RNAs of aggrecan and collagen type II were isolated and assessed in a chondrogenesis assay following co‑culture for 7, 14, 21 and 28 days. Protein expression levels of apoptosis‑related proteins, including B‑cell lymphoma (Bcl‑2), Bcl‑2‑associated X protein, p53 and phospho (p)‑AKT, and growth differentiation factor‑5 were analyzed by western blotting. ELISA and qRT‑PCR demonstrated that compared with FLS cultured alone, co‑culture with UC‑MSCs significantly downregulates the expression levels of IL‑1β, IL‑6 and CCL‑2. Additionally, the percentage of apoptotic cells was significantly increased in the co‑cultured cells (P<0.05), and the relative RNAs levels of aggrecan and collagen type II were increased compared with FLS alone. Furthermore, the expression levels of Bcl‑2 (P<0.05) and p‑AKT (P<0.05) were significantly decreased, whereas, p53 (P=0.001), Bax (P<0.01) and GDF‑5 (P<0.01) were increased by co‑culture of FLS with UC‑MSCs compared with FLS alone. In conclusion, co‑culture of FLS with UC‑MSCs may be important and clinically useful for the treatment of RA by inhibiting the expression of pro‑inflammatory mediators, inducing apoptosis and promoting chondrogenesis.

Rheumatoid Arthritis Exacerbates the Severity of Osteonecrosis of the Jaws (ONJ) in Mice. A Randomized, Prospective, Controlled Animal Study

Rheumatoid arthritis (RA), an autoimmune inflammatory disorder, results in persistent synovitis with severe bone and cartilage destruction. Bisphosphonates (BPs) are often utilized in RA patients to reduce bone destruction and manage osteoporosis. However, BPs, especially at high doses, are associated with osteonecrosis of the jaw (ONJ). Here, utilizing previously published ONJ animal models, we are exploring interactions between RA and ONJ incidence and severity. DBA1/J mice were divided into four groups: control, zoledronic acid (ZA), collagen-induced arthritis (CIA), and CIA-ZA. Animals were pretreated with vehicle or ZA. Bovine collagen II emulsified in Freund's adjuvant was injected to induce arthritis (CIA) and the mandibular molar crowns were drilled to induce periapical disease. Vehicle or ZA treatment continued for 8 weeks. ONJ indices were measured by micro-CT (µCT) and histological examination of maxillae and mandibles. Arthritis development was assessed by visual scoring of paw swelling, and by µCT and histology of interphalangeal and knee joints. Maxillae and mandibles of control and CIA mice showed bone loss, periodontal ligament (PDL) space widening, lamina dura loss, and cortex thinning. ZA prevented these changes in both ZA and CIA-ZA groups. Epithelial to alveolar crest distance was increased in the control and CIA mice. This distance was preserved in ZA and CIA-ZA animals. Empty osteocytic lacunae and areas of osteonecrosis were present in ZA and CIA-ZA but more extensively in CIA-ZA animals, indicating more severe ONJ. CIA and CIA-ZA groups developed severe arthritis in the paws and knees. Interphalangeal and knee joints of CIA mice showed advanced bone destruction with cortical erosions and trabecular bone loss, and ZA treatment reduced these effects. Importantly, no osteonecrosis was noted adjacent to areas of articular inflammation in CIA-ZA mice. Our data suggest that ONJ burden was more pronounced in ZA treated CIA mice and that RA could be a risk factor for ONJ development. © 2016 American Society for Bone and Mineral Research.

Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis

To identify risk factors for periprosthetic joint infection following primary total joint arthroplasty, a systematic search was performed in Pubmed, Embase and Cochrane library databases. Pooled odds ratios (ORs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs) were calculated. Patient characteristics, surgical-related factors and comorbidities, as potential risk factors, were investigated. The main factors associated with infection after total joint arthroplasty (TJA) were male gender (OR, 1·48; 95% CI, 1.19-1.85), age (SMD, -0·10; 95% CI, -0.17--0.03), obesity (OR, 1·54; 95% CI, 1·25-1·90), alcohol abuse (OR, 1·88; 95% CI, 1·32-2·68), American Society of Anesthesiologists (ASA) scale > 2 (OR, 2·06; 95% CI, 1·77-2·39), operative time (SMD, 0·49; 95% CI, 0·19-0·78), drain usage (OR, 0·36; 95% CI, 0·18-0·74), diabetes mellitus (OR, 1·58; 95% CI, 1·37-1·81), urinary tract infection (OR, 1·53; 95% CI, 1.09-2.16) and rheumatoid arthritis (OR, 1·57; 95% CI, 1·30-1·88). Among these risk factors, ASA score > 2 was a high risk factor, and drain usage was a protective factor. There was positive evidence for some factors that could be used to prevent the onset of infection after TJA.

Practical Considerations for the Initiation and Maintenance of Etanercept in the Treatment of Psoriasis

Etanercept is a new treatment for moderate to severe psoriasis. In contrast to traditional systemic agents, which can be given orally, etanercept is given by subcutaneous injection. Patient selection, transitioning, dosing, safety, monitoring, duration of therapy, and patient support programs are reviewed.

The safety of tumor necrosis factor-alpha inhibitors in the treatment of rheumatoid arthritis

INTRODUCTION

Tumor necrosis factor inhibitors (TNFi) were the first biologic therapy authorized for rheumatoid arthritis (RA) treatment and are currently the most used biological drugs in these patients. Although clinical efficacy is proven, adverse events associated with these agents have been described, and further knowledge is essential to facilitate detection at very early stages.

AREAS COVERED

We reviewed the safety profile of TNFi, including both articles and congress communications published on this topic, such as clinical trials, meta-analyses, observational studies, data from registries, and spontaneous clinical reports. We classified studies according to the most common and relevant adverse events associated with TNFi.

EXPERT OPINION

There is a broad spectrum of possible adverse events associated with TNFi treatment, ranging from mild to serious, and with diverse clinical manifestations. However, most adverse events may be minimized by appropriate screening before starting treatment and with ongoing surveillance to ensure an early diagnosis. In conclusion, TNFi have a reasonable safety profile, and, globally, the benefits far outweigh the possible risk of adverse events, especially compared with the risk of the untreated underlying inflammatory condition.

Prevention of Surgical Site Infections in Joint Replacement Surgery

Prosthetic joint infections (PJI), although rare, represent a serious complication of total joint arthroplasty as they pose not only a direct financial burden to the patient but also an indirect burden related to psychosocial impact that PJI incur on the patient. Treatment of PJI is complex and requires a combined surgical and medical approach. Patients are often subjected to multiple surgical procedures and prolonged courses of antimicrobial therapy. Therefore, all efforts should be directed toward maximizing the prophylactic measures in the peri-operative and post-operative phases in order to prevent the occurrence of surgical site infections. This article explores primarily the prophylactic measures that target the host and the operative theater environment. Implementation of such preventive measures requires a multi-disciplinary approach and is crucial for a successful outcome of the total joint arthroplasty.

Patient-related medical risk factors for periprosthetic joint infection of the hip and knee

Despite advancements and improvements in methods for preventing infection, periprosthetic joint infection (PJI) is a significant complication following total joint arthroplasty (TJA). Prevention is the most important strategy to deal with this disabling complication, and prevention should begin with identifying patient-related risk factors. Medical risk factors, such as morbid obesity, malnutrition, hyperglycemia, uncontrolled diabetes mellitus, rheumatoid arthritis (RA), preoperative anemia, cardiovascular disorders, chronic renal failure, smoking, alcohol abuse and depression, should be evaluated and optimized prior to surgery. Treating patients to get laboratory values under a specified threshold or cessation of certain modifiable risk factors can decrease the risk of PJI. Although significant advances have been made in past decades to identify these risk factors, there remains some uncertainty regarding the risk factors predisposing TJA patients to PJI. Through a review of the current literature, this paper aims to comprehensively evaluate and provide a better understanding of known medical risk factors for PJI after TJA.

Management of perioperative tumour necrosis factor α inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis

OBJECTIVE

Tumour necrosis factor α inhibitors (TNFis) are widely used in RA patients who undergo surgery, and optimal perioperative management must balance the risk of infection with the risk of post-operative flare. The purpose of this study is to examine the impact of TNFi exposure on surgical site infections (SSIs) in RA patients undergoing elective orthopaedic surgery by systematic review and meta-analysis.

METHODS

A systematic review of the literature and meta-analysis were performed using PUBMED, EMBASE and the Cochrane Central Register of Controlled Trials, through May 2014. Two independent reviewers screened titles and abstracts, and analysed selected papers in detail. Included studies assessed RA patients with or without TNFi exposure prior to orthopaedic surgery, and described post-operative infections. Study quality was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Meta-analyses of the individual study odds ratios (ORs) were conducted, and each pooled OR was calculated using a random effects model.

RESULTS

Eight observational studies and three case control studies met inclusion criteria; risk of bias was low in eight studies and moderate in three. Publication bias was not apparent. These studies represent 3681 patients with recent exposure to TNFis (TNFi+) and 4310 with no recent exposure to TNFis (TNFi-) at the time of surgery. The TNFi+ group had higher risk of developing SSI compared with patients in the TNFi- group (random effects model: OR 2.47 (95% CI 1.66, 3.68); P < 0.0001).

CONCLUSION

Data from the available literature suggest that there is an increased risk of SSIs in RA patients who use or have recently used TNFis at the time of elective orthopaedic surgery. Prospective studies to confirm these findings and establish the optimal withhold and restart time of TNFis, in the context of other risk factors for infection in RA patients such as higher disease activity, corticosteroid use, smoking and diabetes, are needed.

Perioperative Treatment of Patients with Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decrease in the need for orthopaedic intervention in this population. However, a substantial percentage of patients with the disease fail optimal pharmacologic treatment and still require surgical intervention. A thorough understanding of medical considerations in these patients and improved knowledge of the medical complications caused by the disease process and the pharmacologic therapy used to treat it may lead to improved preoperative planning and medical clearance, which may ultimately improve the overall postoperative outcome.