Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment?

Impact of smoking cessation on healing after foot and ankle surgery

INTRODUCTION

Perioperative smoking is the main risk factor for the development of postoperative cutaneous wound healing complications. We require that all patients undergoing elective foot and ankle surgery stop smoking (6 weeks before and 3 months after) and this abstinence is monitored with a preoperative cotinine test. We therefore wanted to understand how this impacted wound healing in elective foot and ankle surgery: do wounds heal differently in patients who quit smoking for surgery, former smokers and nonsmokers?

HYPOTHESIS

Our hypothesis was that patients who stopped smoking for an upcoming surgery had the same wound healing complications as nonsmokers and former smokers.

MATERIALS AND METHODS

This was a historical, single-center, single-surgeon cohort study of adult patients who underwent an elective ankle or foot surgery between June 2016 and July 2017. Patients were divided into 3 groups: group 1 smokers who stopped for surgery, group 2 former smokers, and group 3 nonsmokers. The primary endpoint was the occurrence of wound healing complications during the wound care consult scheduled 3 weeks after surgery.

RESULTS

A total of 256 patients with a mean age of 58±14.2 years (range, 18-88) were included. Group 3 had more women and a lower BMI than the other groups, but all the other demographic characteristics were similar. Smoking cessation was achieved in group 1 on average 2.5±1.3 months (range, 1-6) before surgery. There were a total of 20 wound healing complications or 7.5% of the cohort: 13% in group 1, 11.1% in group 2 and 6.4% in group 3. The univariate analysis found that the odds ratio was 2.3 when comparing Group 1 to Group 3 and 1.85 when comparing group 2 to group 3 (p=413). No significant risk factors for wound healing complications were found.

DISCUSSION/CONCLUSION

Smoking cessation for foot and ankle surgery seems to limit the risk of wound healing complications, with results close to those of former smokers and nonsmokers. Mandatory smoking cessation before surgery could be one of the solutions to prevent this frequent complication.

LEVEL OF EVIDENCE

III.

Effects and Progress of Photo-Crosslinking Hydrogels in Wound Healing Improvement

Wound healing is a dynamic physiological process, including three stages: inflammation, tissue formation, and remodeling. The quality of wound healing is affected by many topical and systemic factors, while any small factor may affect the process. Therefore, improving the quality of wound healing is a complex and arduous challenge. Photo-crosslinking reaction using visible light irradiation is a novel method for hydrogel preparation. Photo-crosslinking hydrogels can be controlled in time and space, and are not interfered by temperature conditions, which have been widely used in the fields of medicine and engineering. This review aims to summarize the application of photo-crosslinking hydrogels in improving the quality of wound healing, mainly including the material design, application mechanism, and effect of photo-crosslinking hydrogels applied in wound healing, followed by the applicable animal models for experimental research. Finally, this review analyzes the clinical application prospects of photo-crosslinking hydrogels in the field of wound healing.

Recent technological advances in the management of chronic wounds: A literature review

Background

Wound treatment comprises a substantial portion of the healthcare budgets in developed countries. Studies suggest that about 50% of patients admitted to hospitals have wounds, while 1%−2% of the general population in the developed world suffers from chronic wounds. Chronic wounds fail to repair themselves within the expected period of 30 days. Technologies have been developed to address challenges encountered during wound care with the aim of alleviating pain, promoting healing, or controlling wound infections.

Objective

The objective of this study was to explore the technological improvements that have been made in this field over time.

Methods

To gain insight into the future of wound management, a systematic review of literature on the subject was conducted in scientific databases (PubMed, Scopus, Web of Science, Medline, and Clinical Trials).

Results and Discussion

Results indicate that wound dressings have evolved from the traditional cotton gauze to composite materials embedded with appropriate ingredients such as metal‐based nanoparticles. Studies on biodegradable dressing materials are also underway to explore their applicability in dressing large and irregular wounds. On the other hand, conventional drugs and traditional formulations for the management of pain, inflammation, infections, and accelerating healing have been developed. However, more research needs to be carried out to address the issue of microbial resistance to drugs. Drugs for managing other ailments also need to be designed in such a way that they can augment wound healing. In addition, it has been demonstrated that a coordinated integration of conventional and traditional medicine can produce laudable results in chronic wound management.

Conclusion

Accordingly, collaborative efforts and ingenuity of all players in the field can accelerate technological advances in the wound care market to the benefit of the patients.

Wounds affect about 50% of patients admitted to hospitals.

Technologies have been developed including biodegradable dressing materials to address underlying challenges.

Technological advancement, rising incidences of chronic wounds, growing government support, and a rising elderly population will drive wound market growth.

A careful combination of recent research outputs can greatly change wound care technologies.

This review highlights the recent research advances and opportunities in the wound care field.

The future lies in biodegradable dressing materials, probably embedded with selected nanoparticles and which shall be combined in predetermined ratios.

Active rheumatoid arthritis in a mouse model is not an independent risk factor for periprosthetic joint infection

INTRODUCTION

Periprosthetic joint infection (PJI) represents a devastating complication of total joint arthroplasty associated with significant morbidity and mortality. Literature suggests a possible higher incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA). There is, however, no consensus on this purported risk nor a well-defined mechanism. This study investigates how collagen-induced arthritis (CIA), a validated animal model of RA, impacts infectious burden in a well-established model of PJI.

METHODS

Control mice were compared against CIA mice. Whole blood samples were collected to quantify systemic IgG levels via ELISA. Ex vivo respiratory burst function was measured via dihydrorhodamine assay. Ex vivo Staphylococcus aureus Xen36 burden was measured directly via colony forming unit (CFU) counts and crystal violet assay to assess biofilm formation. In vivo, surgical placement of a titanium implant through the knee joint and inoculation with S. aureus Xen36 was performed. Bacterial burden was then quantified by longitudinal bioluminescent imaging.

RESULTS

Mice with CIA demonstrated significantly higher levels of systemic IgG compared with control mice (p = 0.003). Ex vivo, there was no significant difference in respiratory burst function (p = 0.89) or S. aureus bacterial burden as measured by CFU counts (p = 0.91) and crystal violet assay (p = 0.96). In vivo, no significant difference in bacterial bioluminescence between groups was found at all postoperative time points. CFU counts of both the implant and the peri-implant tissue were not significantly different between groups (p = 0.82 and 0.80, respectively).

CONCLUSION

This study demonstrated no significant difference in S. aureus infectious burden between mice with CIA and control mice. These results suggest that untreated, active RA may not represent a significant intrinsic risk factor for PJI, however further mechanistic translational and clinical studies are warranted.

Saudi consensus statement on biologic treatment of chronic plaque psoriasis (2020)

Psoriasis is a common chronic and complex inflammatory skin disease that affects over 125 million people worldwide. Management of psoriasis in daily clinical practice in Saudi Arabia is variable. Local preferences for management differ, which may have a bearing on the treatment selection. Biologic therapy is now a well-established strategy for managing moderate-to-severe plaque psoriasis. There is a clear need for national consensus statements due to the extended role and high availability of literature on these agents. As a result of an initiative of the Ministry of Health, a multidisciplinary expert panel of dermatologists and pharmacists with practical experience in the clinical management of psoriasis were invited to be part of a work group to update the previous practical guidelines on the biologic treatment of psoriasis published in the Journal of Dermatological Treatment, 2014. The overall aim of this consensus document is to deliver evidence-based recommendations on the use, screening, and monitoring of biologic therapy in patients with moderate-to-severe plaque psoriasis. These recommendations also address the use of biologic therapy in special patient populations. They were developed after rigorous evaluation of existing international guidelines as well as the latest emerging evidence. Updates of the present consensus document will be provided as needed to incorporate new data or agents.

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

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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.

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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.

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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.

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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.

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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.

Does Rheumatoid Arthritis Affect the Infection and Complications Rates of Spinal Surgery? A Systematic Review and Meta-Analysis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune disease that produces synovial membrane inflammation and causes progressive articular damage with function loss. Some controversy exists regarding whether RA is associated with infection and complications after spinal surgery. The present study aimed to determine the effect of RA on spinal surgery infection and complications.

METHODS

A systematic literature search was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. All studies that had compared patients who had undergone spinal surgery with and without RA were included in the analysis.

RESULTS

We found significantly greater rates statistically of complications (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.20-1.70; P < 0.05) and infections (OR, 1.69; 95% CI, 1.46-1.95, P < 0.05) in those with RA than in those without RA after spinal surgery. When registry data were excluded, the results suggested that the incidence of complications (OR, 2.24; 95% CI, 0.92-5.44; P = 0.08) and infections (OR, 1.76; 95% CI, 1.50-2.07; P < 0.05) was still greater for the RA group than for the non-RA group.

CONCLUSION

When undergoing spinal surgery, patients with RA have a greater risk of operative complications and infection. Surgeons should be aware of these risks and appropriately plan spinal operation for patients with RA to reduce the risk of complications.

Surgical Management of Monoarticular Rheumatoid Arthritis of the Fifth Metatarsophalangeal Joint

OBJECTIVE

To investigate the clinical and radiological outcomes in patients with monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint after Weil osteotomy.

METHODS

From July 2011 to September 2015, 18 feet of 16 rheumatoid arthritis patients who underwent Weil osteotomy of the fifth metatarsal toe with a mean age at the time of surgery of 48.8 ± 7.4 years were reviewed retrospectively. The mean disease duration was 44.6 ± 6.8 months, and the follow-up period was 36 months. Clinical outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), 10-item SF-36 physical functioning and 2-item SF-36 bodily pain, Visual Analogue Scale (VAS), and satisfaction scores. In the radiologic evaluation, fifth metatarsophalangeal angle (MTP-5), lateral deviation angle (LDA), and longitudinal axes of the fifth metatarsal were measured on anterior-posterior (AP) weight-bearing radiographs preoperative and at the last follow-up.

RESULTS

Clinical assessment showed that the total average of AOFAS was significantly increased from preoperative 53.6 ± 9.0 to 98.7 ± 2.0 points, and the VAS score was significantly decreased from preoperative 4.1 ± 1.5 to 1.1 ± 0.8 points at the last follow-up (P < 0.001). The total averages of SF-36 physical functioning and SF-36 bodily pain were significantly increased from preoperative 48.9 ± 9.0 to 99. ± 2.1 and from 61.4 ± 12.1 to 99.4 ± 2.4 points, respectively, at the last follow-up (P < 0.001). Subjectively, the excellent outcome of the surgery results were rated by 13 patients (81.3%) that underwent surgery and three patients (18.7%) were rated as good. Regarding radiographic parameters, the mean MTP-5 significantly decreased from 21.5° ± 1.2° preoperatively to 10.2° ± 1.2°, the mean LDA significantly decreased from 7.1° ± 1.2° preoperatively to -2.4° ± 1.0°, and the mean length of the fifth metatarsal was significantly shortened from 71.5 ± 1.4 preoperatively to 67.8 ± 1.5 mm at the final follow-up visit (P < 0.001). No malunion, nonunion, necrosis, pseudoarthrosis, or fracture of the fifth metatarsal was found. No exuberant bone growth, perforation of the screw, subluxation, or dislocation was observed. No indications of modification, revision or repeat surgery, or delayed wound healing were observed during follow-up period.

CONCLUSION

Surgical management of the monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint can achieve good clinical and radiological outcomes, with pain relief and dislocation reduction, as well as high satisfaction and improvement without recurrence or progression during the follow-up period.

Systematic review of perioperative use of immunosuppressive agents in patients undergoing bariatric surgery

BACKGROUND

Patients who qualify for bariatric surgery are increasingly experiencing co-morbid conditions, which often require management through the use of immunosuppressive agents, such as corticosteroids, tumor necrosis factor-alpha inhibitors, or other immunomodulators, which may increase the risk of infection or wound healing complications. Perioperative management of these agents in bariatric surgery is challenging because of the lack of research in this patient population. With the use of immunosuppressive agents on the rise, the effects of these medications must be understood, both the risks posed in the perioperative period, and the benefit their sustained use may have for co-morbidity management.

OBJECTIVES

To describe the safety of immunosuppressive agents prior to bariatric surgery.

SETTING

United States of America.

METHODS

A systematic review was conducted to answer these questions about commonly encountered immunosuppressive agents. This review includes information from 37 studies to present recommendations and reasoning for the discontinuation and postoperative reinitiation of immunosuppressive agents including, tumor necrosis alpha factor-a inhibitors, methotrexate, and more.

RESULTS

Research addressing complications of these medications in patients undergoing bariatric surgery is sparse. Information from abdominal or general surgical complications may serve as a basis for conservative recommendations. Data specific to each agent or class are presented below.

CONCLUSIONS

The use of these agents may be critical for patients' chronic disease management, and the consequences of their impact should be considered by bariatric surgeons. While their immune system effects ultimately lead to disease management, each agent must be handled individually due to the varying effects and the potential for perioperative untoward effects.

Practical Guidelines for Managing Patients With Psoriasis on Biologics: An Update

The paradigm for treating inflammatory diseases has shifted dramatically in the past 10 to 20 years with the discovery of targeted therapeutics or "biologic" agents. Patients with rheumatoid arthritis, inflammatory bowel disease, psoriatic arthritis, and psoriasis, among others, are reaping the benefits of decades of bench to bedside research, allowing them to live more productive lives with less side effects than traditional systemic therapies. Despite these advances, many physicians unfamiliar with biologics are left to care for the basic needs of these patients and may be unaware of the multisystem comorbidities associated with psoriasis and the screening, monitoring, and other special considerations required of biologics patients. This can be overwhelming to primary care physicians and inadvertently expose patients to undue risks. The aim of this review is to provide a practical approach for all health care providers caring for patients with psoriasis being treated with biologics to facilitate communication with their treating dermatologist and ultimately provide patients with more comprehensive care.

Perioperative Management of the Rheumatoid Patient

Rheumatoid arthritis is a complex disease state with multiple associated comorbidities. Perioperative evaluation of the rheumatoid patient from a multidisciplinary approach is necessary to achieve favorable outcomes. A complete history and physical, laboratory, cervical, cardiovascular, pulmonary, and medication assessment before surgery should be performed. Educating the patient on potential complications, such as wound dehiscence, infection, and venous thromboembolism, as well as general postoperative expectations, is essential when evaluating the rheumatoid patient for surgery.

Should a patient with rheumatoid arthritis be a kidney donor?

We cared for a woman with sero-positive rheumatoid arthritis (RA), in clinical remission on oral methotrexate (MTX) and hydroxychloroquine, who wished to donate a kidney to a brother with end-stage renal disease (ESRD). We could find scant literature about this unusual clinical circumstance, and therefore review pertinent aspects of renal disease in RA, perioperative medical management, maintenance of disease remission, outcomes for RA patients who have donated kidneys, and relevant ethical issues. Renal complications in RA are not uncommon, with as many as 50% of patients at risk of reduced eGFR. This reflects anti-rheumatic and analgetic medication use (non-steroidal anti-inflammatory drugs, acetaminophen, DMARDs [cyclosporine and, historically, D-penicillamine and gold compounds], and others), glomerulitis, interstitial nephritis, complicating Sjogren's syndrome, vasculitis, or amyloidosis, and/or emergence of an "overlap" syndrome or other rheumatic disorder. The literature suggests that MTX need not be interrupted for surgery. The risk of perioperative infection to our patient would be low and remission should be sustained. We are aware of one study of six patients with RA who donated kidneys; they experienced no complications, ESRD, or deaths after a median follow-up of 8.2 years. Our ethical responsibilities are to balance patient autonomy of decision-making while assuring clinical beneficence and minimizing potential maleficence. Our perspective was that it would not be unreasonable to support this patient donating a kidney if, when fully informed, that remained her wish.

Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview

Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.

Predictors of revision, prosthetic joint infection and mortality following total hip or total knee arthroplasty in patients with rheumatoid arthritis: a nationwide cohort study using Danish healthcare registers

OBJECTIVES

To investigate predictors of 10-year risk of revision and 1-year risk of prosthetic joint infection (PJI) and death following total hip/total knee arthroplasty (THA/TKA) in (1) patients with rheumatoid arthritis (RA) compared with patients with osteoarthritis (OA); and (2) patients with RA treated with biological disease-modifying antirheumatic drugs (bDMARD) within 90 days preceding surgery compared with non-treated.

METHODS

Register-based cohort study using the Danish National Patient Register, the DANBIO rheumatology register (RA-specific confounders and treatment episodes) and the Danish Hip and Knee Arthroplasty Registers. Survival analyses were used to calculate confounder-adjusted sub-HRs (SHR) and HRs.

RESULTS

In total, 3913 patients with RA with THA/TKA were compared with 120 499 patients with OA. Patients with RA had decreased risk of revision (SHR 0.71 (0.57-0.89)), but increased risk of PJI (SHR=1.46 (1.13-1.88)) and death (HR=1.25 (1.01-1.55)). In DANBIO, 345 of 1946 patients with RA with THA/TKA had received bDMARD treatment within 90 days preceding surgery. bDMARD-treated patients did not have a statistically significant increased risk of revision (SHR=1.49 (0.65-3.40)), PJI (SHR=1.61 (0.70-3.69)) nor death (HR=0.75 (0.24-2.33)) compared with non-treated. Glucocorticoid exposure (HR=2.87 (1.12-7.34)) and increasing DAS28 (HR=1.49 (1.01-2.20)) were risk factors for mortality.

CONCLUSION

Patients with RA had a decreased 10-year risk of revision while the risk of death and PJI was increased compared with patients with OA following THA/TKA. bDMARD exposure was not associated with statistically significant increased risk of neither PJI nor death in this study. Glucocorticoid exposure and increased disease activity were associated with an increased risk of death.

Medications affecting healing: an evidence-based analysis

The purpose of this arm of the study was to investigate the impact of medication on healing times of the various wound types, including acute wounds and leg ulcers. A prospective longitudinal study design was used, with de-identified data collected using an electronic mobile wound care database system. Three main categories of data were collected, including patients' demographics, wounds types and treatment characteristics. For acute wounds, there was a total of 1732 patients with 2089 acute wounds. The average healing time was about 35 days. The only significant association was with chemotherapy, which increased healing time by 21 days (P = 0·048). There were non-significant trends towards reduced healing times with antibiotics (0·5 days; P = 0·853), anticoagulants (1·7 days, P = 0·673) and corticosteroids (4·98 days, P = 0·303). Non-steroidal anti-inflammatory drugs (NSAIDs) were associated with a non-significant increase in healing time (2·17 days, P = 0·707). For leg ulcers, there was a total of 264 patients with 370 leg ulcers. We only examined the impact of antibiotics, anticoagulants, corticosteroids and NSAIDs on healing times as they had an adequate number of wounds to analyse. The average healing times of leg ulcers were found to be 73 days. None of the classes of medications had any significant impact on healing time. Both anticoagulants and NSAIDs increased healing time by (22·5 days, P = 0·08) and (12·5 days, P = 0·03), respectively. On the other hand, antibiotics and corticosteroids decreased healing times non-significantly by (9·1 days, P = 0·33) and (21·6 days, P = 0·84), respectively.

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.

Surgical Outcome of Cerebral Aneurysm Clipping Treated with Immunosuppressants: Report of 11 Cases and Review of the Literature

There are no reports on the outcomes of clippings in patients who receive immunosuppressants, for example, due to connective tissue diseases or following organ transplantation. We thoroughly reviewed these cases focusing on the perioperative management phase. The study included 11 patients with intracranial aneurysms who were taking immunosuppressants; between 2007 and 2014. We performed 12 clipping surgeries. Their clinical records were reviewed for age and gender, aneurysms' location and size, perioperative management of the immunosuppressive drugs, and surgical complications. The study included nine females and two males, aged between 52 and 71 years (mean 60.1 ± 8.5 years). The clinical presentation in five cases was subarachnoid hemorrhage (SAH); the aneurysm was incidentally diagnosed in six patients (7 aneurysms). The reasons for taking immunosuppressants were autoimmune disorder in nine patients and liver transplantation in two patients. Daily intake of oral immunosuppressants for the patients with liver transplantation was discontinued for 2-4 days, and no infectious complications were evidenced. The weekly course of immunosuppressive drugs for the patients with autoimmune disorder was continued in eight of nine patients. Caution must be exercised when considering the suitability of clipping for patients taking immunosuppressants, but surgery outcomes are generally favorable; when operative treatment is required, we believe it to be comparatively safe, if the perioperative management is conducted in close collaboration with the relevant departments.

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.

Update on the surgical treatment for rheumatoid arthritis of the wrist and hand

Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.

[Recommendations of the German Society for Rheumatology on the perioperative approach under therapy with DMARDs and biologicals in inflammatory rheumatic diseases]

BACKGROUND

The perioperative administration of antirheumatic medication can lead to an increased risk of infection and to a malfunction in wound healing up to a manifest infection; however, the termination of antirheumatic therapy can result in a flare up of the disease. Both situations can endanger the success of the operation, particularly in arthroplasty.

METHOD

The recommendations have been developed and approved by the Pharmacotherapy Commission of the German Society for Rheumatology following a systematic literature search (as of 30 April 2013) and a consensus process.

RESULTS

As very little data with sufficiently high evidence are available, the present recommendations should be considered as having an advisory quality and an individual risk assessment should always be carried out. Classical disease-modifying antirheumatic drugs (DMARD), such as methotrexate can be continued in normal cases but whether this is also true for leflunomide is still undecided. For biologicals a break of two half-life periods before the operation is recommended. The therapy can be continued after wound healing has been completed and when there are no signs of infection.

Perioperative management of the patient with rheumatoid arthritis

A multidisciplinary approach is required to care for patients with rheumatoid arthritis (RA) in the perioperative period. In preparation for surgery, patients must have a cardiovascular risk assessment performed due to the high risk of heart disease in patients with RA. Treatment of RA is with immunomodulatory medications, which present unique challenges for the perioperative period. Currently, there is no consensus on how to manage disease modifying antirheumatic drug (DMARD) therapy in the perioperative setting. Much of the data to guide therapy is based on retrospective cohort data. Choices regarding DMARDs require an individualized approach with collaboration between surgeons and rheumatologists. Consensus regarding biologic therapy is to hold the therapy in the perioperative period with the length of time dictated by the half-life of the medication. Special attention is required at the time of surgery for potential need for stress dose steroids. Further, there must be close communication with anesthesiologists in terms of airway management particularly in light of the risk for cervical spine disease. There are no consensus guidelines regarding the requirement for cervical spine radiographs prior to surgery. However, history and exam alone cannot be relied upon to identify cervical spine disease. Patients with RA who undergo joint replacement arthroplasty are at higher risk for infection and dislocation compared to patients with osteoarthritis, necessitating particular vigilance in postoperative follow up. This review summarizes available evidence regarding perioperative management of patients with RA.

Systemic effects and safety of triamcinolone-impregnated nasal packing after endoscopic sinus surgery: a randomized, double-blinded, placebo-controlled study

BACKGROUND

Steroid-infused absorbable nasal dressings after endoscopic sinus surgery (ESS) have been used to improve wound healing and to reduce the recurrence of polyps. However, their systemic effects are not well known. The purpose of this study was to evaluate the systemic effects and safety of steroid-impregnated absorbable nasal packing after ESS.

METHODS

Patients who underwent bilateral ESS for chronic rhinosinusitis were recruited and randomized into two groups. Ten patients in the triamcinolone (TA) group received a TA (20 mg)-soaked bioabsorbable dressing in both nasal cavities while 10 patients in the control group took saline-impregnated dressing in both nasal cavities. Nasal dressings were not removed until postoperative day 10. Serum cortisol, 12-hour urine cortisol, serum adrenal-corticotropic hormone (ACTH), and serum osteocalcin were measured preoperatively and on postoperative days 2 and 10. Serum cortisol levels were checked 1 day after surgery additionally, while urine cortisol levels were not checked at postoperative day 10.

RESULTS

All 20 patients completed this study. The serum cortisol levels were significantly suppressed at postoperative days 1 and 2 in the TA group. Serum ACTH and 12-hour urine cortisol levels were lower 2 days after surgery in the TA group, although these changes were not statistically significant. There were no differences in all other parameters between the TA and control groups on postoperative day 10.

CONCLUSIONS

TA-impregnated nasal dressings suppress serum cortisol levels during the early postoperative period. This systemic effect was recovered gradually and normalized 10 days after the operation.

Infection risk after orthopedic surgery in patients with inflammatory rheumatic diseases treated with immunosuppressive drugs

OBJECTIVE

The influence of specific medications on the risk of postoperative infection in patients with rheumatoid arthritis and other inflammatory rheumatic diseases (IRDs) remains unclear. This retrospective study examined the risk of postoperative infection at the site of surgery in patients treated with immunosuppressive drugs (including biologic agents) undergoing different types of orthopedic surgery.

METHODS

The study included 50,359 cases of orthopedic surgery performed in our hospital between 2000 and 2008. The primary outcome was operation-related infection. IRD patients were compared with those with degenerative or posttraumatic disorders, and in IRD patients, the effect of immunosuppressive medication, specifically tumor necrosis factor α (TNFα) inhibitors and their preoperative management, was examined.

RESULTS

There were 373 operation-related infections (0.8%) of 47,887 cases in the degenerative/posttraumatic group and 49 (2.0%) of 2,472 in the IRD group (higher infection rate in the IRD group; odds ratio [OR] 2.58 [95% confidence interval (95% CI) 1.91-3.48], P < 0.001). In the IRD group, elbow and foot surgery had the highest infection rates. The risk of infection was significantly increased in patients taking multiple conventional disease-modifying antirheumatic drugs (DMARDs; OR 2.49 [95% CI 1.06-5.84], P = 0.036) or TNFα inhibitors (OR 2.54 [95% CI 1.08-5.97], P = 0.032). The risk was especially high (6 [12%] of 49) if the last dose of TNFα inhibitor was given <1 administration interval before surgery.

CONCLUSION

The risk of postoperative infection was elevated in patients with IRDs, especially those taking >1 conventional DMARD or TNFα inhibitors. It may be advisable to consider stopping TNFα inhibitors ≥1 administration interval before surgery, since the risk of postoperative infection appears to be higher if the operation occurs within this period.

[Multimodal oncological therapy concepts, chemotherapy and immunosuppressive drugs: effects on surgical morbidity and mortality]

Systemic chemotherapy, targeted therapies and radiotherapy for patients with malignant tumors lead to unfavorable surgical conditions with increased risks of postoperative complications. For gastric cancer and cancer of the esophagogastric junction, surgery after neoadjuvant treatment is associated with a mortality of approximately 5 %. Given the increase in metastatic surgery for colorectal carcinoma, surgeons should be aware of the specific side effects of therapeutic drugs to ensure an optimal course of treatment. The impact of chemotherapy-induced hepatic lesions on postoperative development is unclear. Bevacizumab treatment should be stopped at least 5 weeks before surgery to reduce the risk of thromboembolic events, bleeding and wound healing complications. Immunosuppressive and immunomodulating agents alter wound healing and preoperative alterations should be carefully evaluated. For patients with chronic corticosteroid therapy, perioperative supplementation should be considered when planning surgery as well as routine dosages.

Patients with arthritis undergoing surgery: how should we manage tumour necrosis factor blocking agents perioperatively?-A systematic literature review

We systematically reviewed the literature on the infectious risk in patients treated with tumour necrosis factor blocking agents (TNF-BA) undergoing surgery: we searched the Medline (PubMed) and the online archive from the Annual European Congress of Rheumatology and the Annual Scientific Meeting of the American College of Rheumatology. Of total 1259 reports, 14 were finally analysed. With one exception all were retrospective. Four of 6 studies compared patients on TNF-BA with those not receiving TNF-BA, and found an increased risk of infection with the use of TNF-BA. None of the other studies which compared continued with discontinued treatment at surgery found an increased risk of infection, when the medication was continued perioperatively. In conclusion, while in theory there is an increased risk of infections when TNF-BA are administered perioperatively, the available literature does not necessarily support this. It rather appears that patients receiving TNF-BA are a priori at a higher risk of postoperative infections. Scheduling surgery at the end of the drug interval and adding one "safety" week prior to surgery should be an acceptable plan in daily clinical practice.

Wound healing with medications for rheumatoid arthritis in hand surgery

Introduction. Medications used to treat rheumatoid arthritis, such as corticosteroids, disease-modifying agents (DMARDs), and injectable biological agents (anti-TNFα), may have widespread effects on wound healing. In hand surgery, it is important to balance the risks of poor wound healing from continuing a medication against the risks of a flare of rheumatoid arthritis if a drug is temporarily discontinued. Materials and Methods. A United Kingdom (UK) group of 28 patients had metacarpophalangeal joint replacement surgery in 35 hands (140 wounds). All medication for rheumatoid arthritis was continued perioperatively, except for the injectable biological agents. Results. There were no instances of wound dehiscence or deep infection and only one episode of minor superficial infection. Conclusions. We conclude that provided care is taken to identify and treat any problems promptly, it is appropriate to continue most antirheumatoid medications in the perioperative period during hand surgery to reduce the risk of destabilising the patients' overall rheumatoid disease control.

Suppressed wound healing in a patient with rheumatoid arthritis taking leflunomide (arava)

Although patients with rheumatoid arthritis taking disease-modifying antirheumatic drugs (DMARDs) are monitored for various medication adverse events, DMARDs, and leflunomide in particular, have effects that are not observed clinically, specifically adverse effects on wound healing.

[Peri-operative management of disease modifying anti-rheumatic drugs: recommendations based on a meta-analysis]

The objective of this paper is make recommendations for the perioperative management of antirheumatic treatment based on the best available evidence. A systematic review was performed including studies in which patients with rheumatic diseases treated with biological and non-biological disease-modifying antirheumatic drugs (DMARDs) had undergone surgery. A total of 5,285 studies were recorded, of which 27 were finally included. These contained information on 5,268 patients and 7,933 surgeries. The majority were women (mean age 55 years) were diagnosed with rheumatoid arthritis, and the most studied drug was methotrexate (MTX). The final recommendations include: maintaining treatment with MTX or leflunomide in the perioperative period in the absence of other risk factors for postoperative complications (Level of Evidence 1c, Grade D recommendation). Biological DMARDs should be temporarily suspended, or the surgery scheduled as far as possible from the last dose, and, if there were other risk factors a space at least two doses (Level of Evidence 2c; Grade D recommendation).

Canadian Rheumatology Association recommendations for the pharmacological management of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs: part II safety

OBJECTIVE

The Canadian Rheumatology Association (CRA) has developed recommendations for the pharmacological management of rheumatoid arthritis (RA) with traditional and biologic disease-modifying antirheumatic drugs (DMARD) in 2 parts. Part II, focusing on specific safety aspects of treatment with traditional and biologic DMARD in patients with RA, is reported here.

METHODS

Key questions were identified a priori based on results of a national needs-assessment survey. A systematic review of all clinical practice guidelines and consensus statements regarding treatment with traditional and biologic DMARD in patients with RA published between January 2000 and June 2010 was performed in Medline, Embase, and CINAHL databases, and was supplemented with a "grey literature" search including relevant public health guidelines. Systematic reviews of postmarketing surveillance and RA registry studies were performed to update included guideline literature reviews as appropriate. Guideline quality was independently assessed by 2 reviewers. Guideline characteristics, recommendations, and supporting evidence from observational studies and randomized trials were synthesized into evidence tables. The working group voted on recommendations using a modified Delphi technique.

RESULTS

Thirteen recommendations addressing perioperative care, screening for latent tuberculosis infection prior to the initiation of biologic DMARD, optimal vaccination practices, and treatment of RA patients with active or a history of malignancy were developed for rheumatologists, other primary prescribers of RA drug therapies, and RA patients.

CONCLUSION

These recommendations were developed based on a synthesis of international RA and public health guidelines, supporting evidence, and expert consensus in the context of the Canadian health system. They are intended to help promote best practices and improve healthcare delivery for persons with RA.

Biologic Therapy in Psoriasis: Perspectives on Associated Risks and Patient Management

Background:

Previous publications have described practical considerations for initiating biologic therapy in psoriasis patients. However, most publications have focused on anti–tumor necrosis factor (TNF) therapy.

Objective:

To create an evidence-based, practical tool that provides guidance on patient management for all biologics currently approved in Canada and the United States.

Methods:

Psoriasis publications regarding safety issues in the initiation or monitoring of adalimumab, alefacept, etanercept, infliximab, or ustekinumab therapy were identified through a PubMed search. Phase III trials and open-label extensions (regardless of indication) and relevant guidelines from Health Canada were used to compile this review.

Results:

Although these biologic agents have demonstrated efficacy in patients with psoriasis and are generally considered safe and well tolerated, rare but serious safety issues (ie, demyelination, infection, tuberculosis, malignancy, lymphoma, cardiovascular outcomes, hepatitis, pregnancy, surgery, and vaccination) have been observed. Attention to specific aspects of patient management (ie, prescreening requirements, symptoms to watch for, appropriate treatment, and referrals) is required to mitigate risk.

Conclusion:

Much of the evidence regarding the long-term safety of these agents has been based on experience in other patient populations. However, it does serve to guide us in understanding the risks that may impact the management of psoriasis patients.

Suppressed wound healing in a patient with rheumatoid arthritis taking leflunomide (arava)

Although patients with rheumatoid arthritis taking disease-modifying antirheumatic drugs (DMARDs) are monitored for various medication adverse events, DMARDs, and leflunomide in particular, have effects that are not observed clinically, specifically adverse effects on wound healing.

Harnessing and modulating inflammation in strategies for bone regeneration

Inflammation is an immediate response that plays a critical role in healing after fracture or injury to bone. However, in certain clinical contexts, such as in inflammatory diseases or in response to the implantation of a biomedical device, the inflammatory response may become chronic and result in destructive catabolic effects on the bone tissue. Since our previous review 3 years ago, which identified inflammatory signals critical for bone regeneration and described the inhibitory effects of anti-inflammatory agents on bone healing, a multitude of studies have been published exploring various aspects of this emerging field. In this review, we distinguish between regenerative and damaging inflammatory processes in bone, update our discussion of the effects of anti-inflammatory agents on bone healing, summarize recent in vitro and in vivo studies demonstrating how inflammation can be modulated to stimulate bone regeneration, and identify key future directions in the field.

Comparative efficacy of a secretory phospholipase A2 inhibitor with conventional anti-inflammatory agents in a rat model of antigen-induced arthritis

Introduction

Previously, secretory phospholipase A₂ (sPLA₂) inhibition has been used as an adjunct to conventional rheumatoid arthritis therapy in human clinical trials without significant improvement of arthritic pathology. In this study, we compared the efficacy of a potent and orally active group IIa secretory phospholipase A₂ inhibitor (sPLA₂I) to conventional anti-arthritic agents; infliximab, leflunomide and prednisolone, in a rat model of antigen-induced arthritis.

Methods

Initially, to establish efficacy and dose-response, rats were orally dosed with the sPLA₂I (1 and 5 mg/kg) two days prior to arthritis induction, and then daily throughout the 14-day study period. In the second trial, rats were orally dosed with the sPLA₂I (5 and 10 mg/kg/day) beginning two days after the induction of arthritis, at the peak of joint swelling. Separate groups of rats were also dosed with the tumour necrosis factor-alpha (TNF-α) inhibitor infliximab (single 3 mg/kg i.v. injection), leflunomide (10 mg/kg/day, oral) or prednisolone (1 mg/kg/day, oral) at this same time point and used as comparative treatments.

Results

In the pathology prevention trial, both 1 and 5 mg/kg dose groups of sPLA₂I demonstrated a significant reduction in joint swelling and gait disturbances; however, only the higher 5 mg/kg dose resulted in significantly reduced histopathology scores. In the post-induction trial, rats dosed with sPLA₂I showed a significant improvement in joint swelling and gait scoring, whereas none of the conventional therapeutics achieved a significant decrease in both of these two disease markers. Histopathological scoring at the end-point of the study demonstrated significantly reduced median scores in rats treated with 10 mg/kg sPLA₂I and leflunomide.

Conclusions

The results from this study suggest a pathogenic role for sPLA₂ enzymes in this model of arthritis in rats, and the potential clinical utility of sPLA₂ inhibition as a safer, and more effective, alternative to conventional anti-arthritic therapeutics.

Open posterior approach for tibiotalar arthrodesis

Traumatic injury to the ankle and hindfoot often results in tibiotalar or subtalar arthritis. The associated joint pain, stiffness, and deformity may be difficult to treat with conservative measures. For such problems, arthrodesis of the ankle or hindfoot joints is the mainstay of treatment. This article discusses the application of the posterior approach to complete a tibiotalar and tibiotalocalcaneal arthrodesis as well as its use for converting a failed total ankle arthroplasty to an arthrodesis.

Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs

The aim of this study was to identify risk factors for acute surgical-site infection (SSI) after total joint arthroplasty in rheumatoid arthritis (RA) patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs). We performed a retrospective study of all consecutive total hip (THA) and total knee (TKA) arthroplasties performed during a 5-year period (THA 81; TKA 339). Multivariate logistic regression analysis was performed to identify SSI risk factors. Of the patients undergoing THA or TKA, 24 cases (5.7%) developed a superficial incisional SSI requiring the use of antibiotics and three cases (0.7%) developed an organ/space SSI necessitating surgical treatment to remove the artificial joint prosthesis. Multivariate logistic regression analysis revealed that the use of biologic DMARDs [P = 0.0007, odds ratio (OR) = 5.69; 95% confidence interval (CI) 2.07-15.61] and longer RA duration (P = 0.0003, OR = 1.09; 95% CI 1.04-1.14) were the only significant risk factors for acute SSI. Furthermore, an analysis that individually evaluated major agents (n > 10) adjusted for disease duration indicated that tumor necrosis factor alpha blockers increased the risk of SSI (infliximab P = 0.001, OR = 9.80, 95% CI 2.41-39.82; etanercept P = 0.0003, OR = 9.16, 95% CI 2.77-30.25). We found that the use of infliximab or etanercept and longer disease duration were associated with an increased risk of acute SSI in RA patients. Prospective studies are thus needed to determine the safety of biologic DMARDs in the perioperative period.

[Perioperative use of biologicals in rheumatoid arthritis]

The high prevalence of patients with rheumatoid arthritis (RA) treated with biologics and the high proportion of RA patients requiring elective orthopaedic surgery indicates that the question of whether to continue or to interrupt biologic therapy in the context of a surgical procedure is a clinically relevant problem. Few data are available and the quality of the studies performed is somewhat limited. Thus, a straightforward recommendation on how this problem should be handled cannot be given on this basis. Therefore, individualized management based on risk stratification for postoperative complications seems currently to be the best solution.

Reappraisal of the clinical use of leflunomide in rheumatoid arthritis and psoriatic arthritis

Leflunomide is a disease-modifying antirheumatic drug (DMARD) that has been in routine clinical use for the treatment of rheumatoid arthritis (RA) and psoriatic arthritis for a decade. In RA, clinical trials of up to two years' duration showed that leflunomide monotherapy was equivalent to methotrexate in clinical and radiographic disease outcomes (tender and swollen joint counts, physician and patient global assessments, American College of Rheumatology and Disease Activity Score responses, slowing or halting of radiographic progression). In a number of studies, quality of life measurements indicated that leflunomide is superior to methotrexate. Leflunomide has been studied in combination with methotrexate and shows efficacy in patients only partly responsive to this agent. Recent trials have shown that leflunomide can be used safely with biologic DMARDs, including antitumor necrosis factor agents and rituximab as part of the treatment algorithm in place of methotrexate as a cotherapy. Leflunomide has demonstrated efficacy as a monotherapy in psoriatic arthritis, and it also has a beneficial effect in psoriasis. Postmarketing studies have shown that retention on treatment with leflunomide is equal to methotrexate and superior to other DMARDs. In general, its side effect profile is acceptable compared with other DMARDS, with nausea, diarrhea, and hair fall occurring commonly, but only rarely leading to discontinuation. Liver toxicity is the most significant problem in clinical use although it is uncommon. Peripheral neuropathy, hypertension, pneumonitis, and cytopenia occur more rarely. Leflunomide is contraindicated in pregnancy and should be used with caution in women during child-bearing years. In this review, the place of leflunomide in therapy is discussed and practical advice informed by evidence is given regarding dosing regimens, safety monitoring, and managing side effects. Leflunomide remains one of the most useful of the nonbiologic DMARDs.

Risk factors for incision-healing complications following total ankle arthroplasty

BACKGROUND

The anterior incision used for the insertion of total ankle arthroplasty systems is at high risk for wound complications, and little has been documented regarding who is at risk for the development of these complications.

METHODS

We conducted a retrospective chart review of 106 total ankle arthroplasties. Independent risk variables, including age, sex, body-mass index, diabetes, smoking, medications, preoperative diagnosis, implant size, tourniquet time, closure method, and anticoagulation status, were recorded. Postoperative office notes were reviewed for wound-related complications. Outcomes were divided into three categories: no complications (uncomplicated wound-healing), minor complications (wounds requiring only local care/oral antibiotics), and major complications (requiring a return to the operating room for treatment). Simultaneously, categorical variables were compared with use of chi-square analysis. Multivariate logistic regression and odds ratio assessment were performed as well.

RESULTS

When patients who had no complications were compared with those who had minor complications, a history of diabetes was the only variable that was identified as resulting in a significant risk increase (p = 0.04). When patients who had no wound complications or minor wound complications were compared with those who had major wound complications, female sex, a history of corticosteroid use, and underlying inflammatory arthritis were all associated with increased risk. Multivariate logistic regression demonstrated underlying inflammatory arthritis (p = 0.004) to be the only significant risk factor for major wound complications, with an odds ratio demonstrating a 14.03 times increased risk of requiring reoperation.

CONCLUSIONS

We recommend that caution be used when selecting and educating patients with inflammatory arthritic conditions who are potential candidates for total ankle arthroplasty.