Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery

Influence of Janus kinase inhibitors on early postoperative complications in patients with rheumatoid arthritis undergoing orthopaedic surgeries

OBJECTIVE

We retrospectively reviewed the records of rheumatoid arthritis (RA) patients who underwent orthopaedic surgery to examine the influence of the perioperative use of Janus kinase (JAK) inhibitors on early postoperative complications.

PATIENTS AND METHODS

Thirty-two patients with RA under disease control with JAK inhibitors who underwent 49 orthopaedic procedures were included in the study. Patient records after surgery were investigated for surgical site infection (SSI), delayed wound healing (DWH), a flare-up of the disease, preoperative and postoperative absolute lymphocyte counts (ALCs), venous thromboembolism, and other postoperative complications.

RESULTS

JAK inhibitors were continued during the perioperative period in 31 procedures. In the remaining 18 procedures, JAK inhibitors were discontinued perioperatively with a mean discontinuation period of 2.4 days. No instances of SSI were identified in any patient during at least 90 days' follow-up, while DWH was seen in one patient. Disease flare-up was noted in two patients after 3 and 9 days of discontinuation of JAK inhibitors, respectively. The ALCs significantly decreased on postoperative Day 1 (P < .0001), and there was a significant correlation between pre- and post-one-day ALCs (r = 0.75, P < .0001).

CONCLUSION

JAK inhibitors seem to be safe during the perioperative period of orthopaedic surgery.

Long-Term Oral Steroid Use: A Unique Risk Factor in 4-Corner Fusion Compared With Other Wrist Salvage Operations

INTRODUCTION

Salvage procedures such as proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, and total wrist arthrodesis are commonly used at the end stages of wrist arthritis. These operations have high complication rates, and significant controversy exists regarding the selection of procedure. Long-term oral glucocorticoid therapy has previously been identified as a risk factor for complications in multiple orthopedic procedures. The purpose of this study is to investigate the effect long-term oral preoperative corticosteroid use has on complications after different salvage operations for wrist arthritis.

METHODS

The National Surgical Quality Improvement Program database was queried to identify patients who underwent proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, or total wrist fusion between 2005 and 2020. Patients were classified by steroid use. Univariate analysis and multivariate logistic regression were used to assess the risk of complications.

RESULTS

A total of 1298 patients were identified. Overall, steroid use was found to be independently associated with a higher complication rate. On multivariate analysis of patients who underwent 4-corner fusion, steroid use was found to be associated with higher complication rate and surgical site infection rate. Steroid use was not associated with increased complications in patients who underwent proximal row carpectomy, total wrist arthroplasty, or total wrist fusion when examined individually.

CONCLUSION

Long-term oral corticosteroid therapy was associated with an increased risk of postoperative infections in patients who underwent 4-corner fusion, which was not found in other wrist salvage operations.

Preoperative Management of Medications for Rheumatologic and HIV Diseases: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.

Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis

Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.

Perioperative management of disease-modifying antirheumatic drugs for patients undergoing elective spine surgery: a systematic review

BACKGROUND

In preparation for surgery, patients being treated with disease-modifying antirheumatic drugs (DMARDs) are recommended to either continue or withhold therapy perioperatively. Some of these drugs have known effects against bone healing, hence the importance of adequately managing them before and after surgery.

OBJECTIVE

We aim to assess the current evidence for managing conventional synthetic and/or biologic DMARDs in the perioperative period for elective spine surgery.

METHODS

A systematic review of four databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included manuscripts were methodically scrutinized for quality, postoperative infections, wound healing characteristics, bone fusion rates, and clinical outcomes.

RESULTS

Six studies were identified describing the management of conventional synthetic and/or biologic DMARDs. There were 294 DMARD-treated patients described undergoing various spine surgeries such as craniovertebral junction fusions. Three of the studies involved exclusive continuation of DMARDs in the perioperative window; one study involved exclusive discontinuation of DMARDs in the perioperative window; and two studies involved continuation or discontinuation of DMARDs perioperatively. Of patients that continued DMARDs in the perioperative period, 13/50 patients (26.0%) had postoperative surgical site infections or wound dehiscence, 2/19 patients (10.5%) had delayed wound healing, and 32/213 patients (15.0%) had secondary revision surgeries. A fusion rate of 14/19 (73.6%) was described in only one study for patients continuing DMARDs perioperatively.

CONCLUSIONS

The available published data may suggest a higher risk of wound healing concerns and lower than average bone fusion, although this may be under-reported given the current state of the literature.

Advantages and disadvantages of corticosteroid use for acute exacerbation of interstitial pneumonia after pulmonary resection

OBJECTIVES

Acute exacerbation of interstitial pneumonia (AE-IP) is the top cause of 30-day mortality in surgery for lung cancer patients. The general treatment for AE-IP is corticosteroid; however, there are some disadvantages of corticosteroid use after surgery. This study was conducted to report the clinical course of AE-IP after surgery and evaluate the effect of corticosteroid use.

METHODS

This retrospective study was performed on 337 patients with interstitial pneumonia who underwent surgical resection for lung cancer at our institute between 2009 and 2018. AE-IP were observed in 14 patients (4.2%) and their management and clinical outcome were investigated.

RESULTS

All patients received methylprednisolone pulse therapy. Six patients (42.9%) became convalescent after pulse therapy and eight (57.1%) died within 90 days after surgery due to lack of therapeutic efficacy. Oxygenation and ground-glass opacities of the survivors improved within 3 days after starting pulse therapy. Patients who responded to the first pulse also responded to the second pulse. Four patients developed complications including two with bronchopulmonary fistulas that may be related to steroid treatment. Even if the corticosteroid was effective, all AE-IP patients died within 1 year after surgery.

CONCLUSIONS

Corticosteroid therapy is effective for AE-IP after surgery; however, it may lead to severe complications after surgery.

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.

Hand Infections Associated with Systemic Conditions

Systemic conditions are associated with higher rates of hand and upper extremity infections, leading to more severe and atypical presentations. Understanding the unique problems associated with some of the most common systemic conditions, including human immunodeficiency virus, diabetes mellitus, and rheumatoid arthritis, can assist the hand surgeon in diagnosing and treating infection in these patients. This article reviews the most common presentation of hand infections for these patients and summarizes current approaches to the management of hand infections for patients with common immunocompromising conditions.

Hand Infections: Epidemiology and Public Health Burden

Upper extremity infections are common. Most infections can be effectively treated with minor surgical procedures and/or oral antibiotics; however, inappropriate or delayed care can result in significant, long-term morbidity. The basic principles of treating hand infections were described more than a century ago and most remain relevant today. Immunosuppressant medications, chronic health conditions such as diabetes and human immunodeficiency virus, and public health problems like intravenous drug use, have changed the landscape of hand infections and provide new challenges in treatment.

Refractory healing after surgical therapy of osteonecrosis of the jaw: associated risk factors in aged patients

Purpose: Osteonecrosis of the jaw (ONJ), both medication-related and non medication-related, mainly occurs in aged patients. It needs surgical intervention. Refractory healing after an operation of ONJ can significantly lower the quality of life of elderly patients. The purpose of this study was to determine risk factors associated with refractory healing in aged patients.

Patients and methods: We performed a retrospective study of ONJ in aged patients who underwent surgical treatments in a single institute during a 12-year period. Multiple logistic regression analysis was used to determine independent risk factors associated with refractory healing.

Results: A total of 122 patients were included. Of them, 25 patients were identified as the refractory group and 97 patients as the control group. Diabetes mellitus (DM) (AOR=5.03, 95% CI: 1.74–14.52) and glucocorticoid administration (AOR=7.97, 95% CI: 2.52–25.23) were found to be significant risk factors for refractory healing of ONJ.

Conclusion: DM and medication of glucocorticoid might be risk factors for refractory healing of ONJ.

Hand Infections in the Immunocompromised Patient: An Update

Physicians are increasingly caring for immunocompromised individuals owing, in part, to the improved treatments and the increased life expectancy in these patients. Presentation of a patient with hand infection can vary greatly depending on the patient's underlying immune status. It is important to recognize and treat the infections quickly and effectively owing to the higher morbidity and mortality that may result from ineffective or delayed treatment in this patient population. The purpose of this article is to provide an outline of the most common and some of the more exotic organisms causing hand infections in patients with human immunodeficiency virus/acquired immunodeficiency syndrome, diabetes, and patients on immunosuppressive treatment. We discuss presentation, clinical picture, evidence-based approaches in treatment, and possible complications. It is important to inform surgeons of the atypical presentation of hand infections and systemic infections with hand manifestation in immunocompromised patients in order to shorten time to accurate diagnosis and effective treatment.

Acute Deep Infections of the Upper Extremity: The Utility of Obtaining Atypical Cultures in the Presence of Purulence

PURPOSE

In the setting of acute deep upper extremity infections, evidence is lacking to guide the decision whether to send atypical cultures (fungal and acid-fast-bacillus [AFB]) during surgical debridement, especially in the presence of purulent fluid that is commonly observed with typical bacterial infections. Our purpose was to determine the frequency of positive atypical cultures and the frequency with which they alter treatment, and identify factors associated with positive atypical cultures.

METHODS

We retrospectively identified 100 adult patients undergoing surgical debridement of acute deep infections of the upper extremity in which fungal and/or AFB cultures were sent. Necrotizing and superficial infections were excluded. Descriptive statistics were used to describe patient characteristics, infection diagnoses, number of cultures sent with corresponding rates of positivity, and treatments. Cohorts with positive and negative atypical cultures were compared with bivariate analysis for all collected variables.

RESULTS

One or more immunocompromising comorbidities were present in 46% of patients. Diagnoses included soft tissue abscess (46%), suppurative flexor tenosynovitis (22%), septic arthritis (21%), osteomyelitis (9%), and septic bursitis (2%). Aerobic bacterial, anaerobic bacterial, fungal, and AFB cultures were sent in 100%, 99%, 94%, and 82% of patients, respectively. Corresponding rates of positivity were 74%, 34.3%, 5.3%, and 2.4%, respectively. Atypical cultures were positive for 7% of patients and 2.9% of all atypical tests sent. Antibiotic treatment was influenced by atypical culture data for 4% of patients. For patients with positive atypical cultures, purulence was observed during surgery in 86% of cases. Bivariate analysis demonstrated symptom duration greater than 7 days as potentially associated with atypical culture positivity.

CONCLUSIONS

Intraoperative purulence at the time of surgical intervention should not deter the surgeon from obtaining atypical cultures. As expected, atypical cultures are infrequently positive given the rarity of associated diseases. Symptoms greater than 7 days may predict a higher incidence of atypical culture positivity for patients being treated surgically within 30 days of initial symptom onset.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Effect of methotrexate on bone and wound healing

INTRODUCTION

Methotrexate (MTX) is one of the most commonly used disease modifying drugs administered for wide spectrum of conditions. Through the expansion of the indications of MTX use, an increasing number of patients nowadays attend orthopaedic departments receiving this pharmacological agent. The aim of this manuscript is to present our current understanding on the effect of MTX on bone and wound healing. Areas covered: The authors offer a comprehensive review of the existing literature on the experimental and clinical studies analysing the effect of MTX on bone and wound healing. The authors also analyse the available literature and describe the incidence of complications after elective orthopaedic surgery in patients receiving MTX. Expert opinion: The available experimental data and clinical evidence are rather inadequate to allow any safe scientific conclusions on the effect of MTX on bone healing. Regarding wound healing, in vitro and experimental animal studies suggest that MTX can adversely affect wound healing, whilst the clinical studies show that lose-dose MTX is safe and does not affect the incidence of postoperative wound complications.

Adverse outcomes following hand surgery in patients with rheumatoid arthritis

Background

Up to 70% of patients with long-standing rheumatoid arthritis (RA) may present with rheumatic hand disease and benefit from hand surgical procedures (HSPs).

Objective

Through retrospective review, the present study aimed to report HSPs in RA patients at a tertiary care centre to identify patient adverse outcomes (AOs) and their predictors.

Methods

From 1989 to 2013, 96 patients who underwent ≥1 HSP(s) were identified from two local registries; their clinical records were independently reviewed by two trained physicians (surgeon and clinical) who used a standardized format. AOs were defined by consensus; data abstracter agreement was found in 90% of cases. Descriptive statistics were used in addition to Kaplan-Meier curves to determine the time to each AO, while logistic regression models were used to determine predictors of AOs.

Results

At first HSP, 89.6% of patients were female, had a mean (± SD) age of 49.1±12 years, a disease duration of 12.2±7.2 years, 93.6% were positive for rheumatoid factor and 24% were receiving intensive treatment. A total of 130 HSPs were performed: the most frequent interventions were arthrodesis (25.4%), resection of the ulnar head (15.4%) and tenorrhaphy (14.6%). During follow-up, 33 AOs were reported in 27 (28.1%) patients, 87% of which occurred after the first HSP. The most frequent AO subsets were impaired wound healing (18.2%) and exposed pin (15.2%). Longer disease duration at first HSP (OR 3.07 [95% CI 1.04 to 9.08]; P=0.04) and intensive treatment (OR 1.08 [95% CI 1.002 to 1.156]; P=0.045) were predictors of AOs. The optimal disease duration cut-off to predict AOs was 20.1 years.

Conclusion

Early referral of long-standing RA patients for hand surgery, along with less aggressive treatment, favoured improved surgical outcomes.

The incidence of upper and lower extremity surgery for rheumatoid arthritis among Medicare beneficiaries

BACKGROUND

For elderly patients with rheumatoid arthritis, aggressive immunosuppression can be difficult to tolerate, and surgery remains an important treatment option for joint pain and deformity. We sought to examine the epidemiology of surgical reconstruction for rheumatoid arthritis among older individuals who were newly diagnosed with the disorder.

METHODS

We identified a 5% random sample of Medicare beneficiaries (sixty-six years of age and older) newly diagnosed with rheumatoid arthritis from 2000 to 2005, and followed these patients longitudinally for a mean of 4.6 years. We used univariate analysis to compare the time from the diagnosis of rheumatoid arthritis to the first operation among the 360 patients who underwent surgery during the study period.

RESULTS

In our study cohort, 589 procedures were performed among 360 patients, and 132 patients (37%) underwent multiple procedures. The rate of upper extremity reconstruction was 0.9%, the rate of lower extremity reconstruction was 1.2%, and knee arthroplasty was the most common procedure performed initially (31%) and overall (29%). Upper extremity procedures were performed sooner than lower extremity procedures (fourteen versus twenty-five months; p = 0.02). In multivariable analysis, surgery rates declined with age for upper and lower extremity procedures (p < 0.001).

CONCLUSIONS

Knee replacement remains the most common initial procedure among patients with rheumatoid arthritis. However, upper extremity procedures are performed earlier than lower extremity procedures. Understanding the patient and provider factors that underlie variation in procedure rates can inform future strategies to improve the delivery of care to patients with 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.

Does use of a biologic agent increase the incidence of postoperative infection in surgery for rheumatoid arthritis after total joint arthroplasty?

OBJECTIVES

The goal of the study was to examine the influence of biological agents on postoperative infections such as surgical site infection (SSI) and late infection in patients with rheumatoid arthritis after total joint arthroplasty at our hospital between January 2006 and December 2011.

METHODS

The patients were divided into groups with (Bio group, 267 joints) and without (Non-Bio group, 300 joints) treatment with biological agents. We examined the incidence of postoperative infection in Bio group and Non-Bio group. Multivariate logistic regression analysis was performed to identify the risk factor of postoperative infection.

RESULTS

The incidences of superficial and deep SSI were 0.37% and 1.0%, respectively, in the Bio group, and 0.67% and 0%, respectively, in the Non-Bio group, with no significant difference between the two groups. The incidences of late infection were 1.0% and 0% in the Bio and Non-Bio groups, respectively, again with no significant difference between the groups. Multivariate logistic regression analysis revealed the following values for the surgery of the foot and ankle region [P = 0.001, odds ratio (OR) = 19.27; 95% confidence interval (CI) 4.67-79.45]. The use of biological agents was not a risk factor for postoperative infection.

CONCLUSIONS

These results suggest that the use of biological agents does not significantly increase the incidences of SSI and late infection after orthopedic surgery in patients with rheumatoid arthritis after total joint arthroplasty.

Corticosteroids and wound healing: clinical considerations in the perioperative period

BACKGROUND

Determining whether systemic corticosteroids impair wound healing is a clinically relevant topic that has important management implications.

METHODS

We reviewed literature on the effects of corticosteroids on wound healing from animal and human studies searching MEDLINE from 1949 to 2011.

RESULTS

Some animal studies show a 30% reduction in wound tensile strength with perioperative corticosteroids at 15 to 40 mg/kg/day. The preponderance of human literature found that high-dose corticosteroid administration for <10 days has no clinically important effect on wound healing. In patients taking chronic corticosteroids for at least 30 days before surgery, their rates of wound complications may be increased 2 to 5 times compared with those not taking corticosteroids. Complication rates may vary depending on dose and duration of steroid use, comorbidities, and types of surgery.

CONCLUSIONS

Acute, high-dose systemic corticosteroid use likely has no clinically significant effect on wound healing, whereas chronic systemic steroids may impair wound healing in susceptible individuals.

Total ankle replacement for rheumatoid arthritis of the ankle

Rheumatoid arthritis is an autoimmune disease that may affect multiple joints, both small and large, and leads to numerous complications. The standard surgical treatment for a rheumatoid arthritic ankle has been an arthrodesis. The ideal candidate for an ankle replacement in a rheumatoid patient is one who is moderately active, has a well-aligned ankle and heel, and a fair range of motion in the ankle joint. Good surgical technique and correction of any hindfoot deformity will result in satisfactory alignment of the ankle with regard to the mechanical axis, and this will lead to increased prosthetic longevity.

[Orthopedic rheumatology]

The most common joint destructive chronic inflammatory diseases in orthopedic rheumatology are rheumatoid arthritis, psoriatic arthritis and spondyloarthropathy. They usually have a multilocular, characteristic progressive joint destructive course, which must be taken into account when planning surgical treatment. The establishment of a sequence of surgical procedures with equivalent indications follows special rheumatologic orthopedic principles. The choice of surgical procedure depends on the joint, the surrounding soft tissues and stage of destruction but the increased surgical risk and complications caused by the disease, specific medications and frequent comorbidities also have to be considered. Due to numerous perioperative characteristics close interdisciplinary cooperation especially with internist rheumatologists, anesthetists and physiotherapists is essential for a successful rheumatologic orthopedic therapy.

[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).

Perioperative care for patients with rheumatic diseases

The perioperative care of patients with rheumatic diseases is hampered by a lack of evidence-based recommendations. Rheumatologists are called upon to 'clear' their patients for surgery, yet the evidence upon which to base decisions is fractionated and inconsistent. We have systematically reviewed the current literature and developed suggestions for three key areas that require particular deliberations in patients with rheumatic diseases scheduled for surgery: the management of cardiovascular risk, use of immunosuppressive drugs, and states of altered coagulation. For patients with rheumatic diseases associated with increased cardiovascular risk, such as rheumatoid arthritis and systemic lupus erythematosus, we suggest following the American College of Cardiology-American Heart Association guidelines using the underlying disease as a risk modifier. Most evidence suggests a neutral effect of conventional DMARDs in the perioperative period, with no need to discontinue them prior to surgery. Conversely, we suggest minimizing perioperative steroid use and unnecessary 'steroid preps'. The potential benefits of discontinuing biologic drugs in the perioperative setting needs to be carefully balanced with the risks associated with a disease flare. We discuss the American College of Chest Physicians guidelines, which classify individuals with antiphospholipid antibody syndrome as high-risk patients for perioperative thrombosis who are likely to require bridging therapy in most perioperative settings.

Risk of postoperative complications in rheumatoid arthritis relevant to treatment with biologic agents: a report from the Committee on Arthritis of the Japanese Orthopaedic Association

PURPOSE

Since biologic agents were introduced to treat rheumatoid arthritis (RA) in 2003, the number of orthopedic surgical procedures under treatment with biologic agents has been increasing in Japan. However, whether biologic agents cause an increase in the prevalence of postoperative complications is as yet unknown. The Committee on Arthritis of the Japanese Orthopedic Association investigated the prevalence of postoperative complications in patients with RA in teaching hospitals in Japan.

METHODS

Between January 2004 and November 2008, surveillance forms about medications and surgical procedures in patients with RA were sent to 2,019 teaching hospitals. Data were analyzed by the Rheumatoid Arthritis Committee.

RESULTS

Biologic agents were administered to RA patients in 632 of 1,245 hospitals (50.8%); 430 of the 1,245 hospitals (34.5%) used surgical intervention under treatment with biologic agents. The number of surgical procedures under treatment with biologic agents was 3,468, and the prevalence of infection was 1.3% (46 cases). The prevalence of infection was 1.0% (567 procedures) in 56,339 procedures under treatment with nonbiologic disease-modifying anti-rheumatic drugs. There were no significant differences between biological and nonbiological treatment groups with respect to the prevalence of infection. In the joint arthroplasty group, the number of procedures under biological and nonbiological treatment was 1,626 and 29,903, and the prevalence of infection was 2.1% (34 procedures) and 1.0% (298 procedures), respectively. There was a significant difference between groups. The odds ratio was 2.12 (95% confidence interval 1.48-3.03, P < 0.0001).

CONCLUSION

The chance of having biological treatment with joint arthroplasty was more than twofold greater in patients with surgical-site infections compared with those treated with nonbiologic agents. Caution is required for surgical procedure, perioperative course, and obtaining consent for joint arthroplasty for patients with RA undergoing surgery under biological agents.

The association between systemic glucocorticoid therapy and the risk of infection in patients with rheumatoid arthritis: systematic review and meta-analyses

INTRODUCTION

Infection is a major cause of morbidity and mortality in patients with rheumatoid arthritis (RA). The objective of this study was to perform a systematic review and meta-analysis of the effect of glucocorticoid (GC) therapy on the risk of infection in patients with RA.

METHODS

A systematic review was conducted by using MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials database to January 2010 to identify studies among populations of patients with RA that reported a comparison of infection incidence between patients treated with GC therapy and patients not exposed to GC therapy.

RESULTS

In total, 21 randomised controlled trials (RCTs) and 42 observational studies were included. In the RCTs, GC therapy was not associated with a risk of infection (relative risk (RR), 0.97 (95% CI, 0.69, 1.36)). Small numbers of events in the RCTs meant that a clinically important increased or decreased risk could not be ruled out. The observational studies generated a RR of 1.67 (1.49, 1.87), although significant heterogeneity was present. The increased risk (and heterogeneity) persisted when analyses were stratified by varying definitions of exposure, outcome, and adjustment for confounders. A positive dose-response effect was seen.

CONCLUSIONS

Whereas observational studies suggested an increased risk of infection with GC therapy, RCTs suggested no increased risk. Inconsistent reporting of safety outcomes in the RCTs, as well as marked heterogeneity, probable residual confounding, and publication bias in the observational studies, limits the opportunity for a definitive conclusion. Clinicians should remain vigilant for infection in patients with RA treated with GC therapy.

Oral bisphosphonate-related osteonecrosis of the jaws in rheumatoid arthritis patients: a critical discussion and two case reports

BACKGROUND

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a clinical condition characterized by the presence of exposed bone in the maxillofacial region. Its pathogenesis is still undetermined, but may be associated with risk factors such as rheumatoid arthritis (RA). The aim of this paper is to report two unpublished cases of BRONJ in patients with RA and to conduct a literature review of similar clinical cases with a view to describe the main issues concerning these patients, including demographic characteristics and therapeutic approaches applied.

METHODS

Two case reports of BRONJ involving RA patients were discussed

RESULTS

Both patients were aging female taking alendronate for more than 3 years. Lesions were detected in stage II in posterior mandible with no clear trigger agent. The treatment applied consisted of antibiotics, oral rinses with chlorhexidine, drug discontinuation and surgical procedures. Complete healing of the lesions was achieved.

CONCLUSIONS

This paper brings to light the necessity for rheumatologists to be aware of the potential risk to their patients of developing BRONJ and to work together with dentists for the prevention and early detection of the lesions. Although some features seem to link RA with oral BRONJ and act as synergistic effects, more studies should be developed to support the scientific bases for this hypothesis.

Current view of glucocorticoid co-therapy with DMARDs in rheumatoid arthritis

Glucocorticoids are widely used anti-inflammatory and immunosuppressive drugs for rheumatoid arthritis (RA). The disease-modifying potential of low to medium doses of glucocorticoids has been reconfirmed in the past decade, and co-administration of DMARDs and glucocorticoids has become standard in many treatment protocols, especially those for early disease stages but also for long-standing RA. The glucocorticoid regimens used range from continuous low doses to intermittent high doses. Studies of the rationale for and clinical use of glucocorticoids as co-therapy with DMARDs in RA have shown that this approach has a place in modern (tight control) treatment strategies, and that glucocorticoid co-therapy has disease-modifying effects during the first 2 years of treatment in patients with early RA. Furthermore, medium and high doses of glucocorticoids are useful for bridging the interval between initiation of DMARDs and onset of their therapeutic effect. Intra-articular glucocorticoids give good local control and have been used in tight control strategies. New glucocorticoid compounds are becoming available for clinical use that might have an enhanced risk:benefit ratio. Better monitoring of glucocorticoid use will also improve this ratio, and help to allay both patient and rheumatologist concerns about treatment-related adverse effects.

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.

Metacarpophalangeal joint arthritis

Arthritis of the metacarpophalangeal joint can result in considerable disability and pain. Inflammatory, posttraumatic, crystalline, and osteoarthritis are common etiologies of joint disease. A variety of nonsurgical treatment options have been shown to be effective, including activity modification, anti-inflammatory medications, splinting, and cortisone injections. In addition, newer generation disease-modifying antirheumatic drugs geared toward the treatment of rheumatoid arthritis have shown promise in retarding the inflammatory process. Another, relatively newer, conservative treatment option includes topical anti-inflammatories such as diclofenac sodium that are now approved by the Federal Drug Administration. Surgical treatment options most commonly include arthroplasty and arthrodesis. In the treatment of thumb metacarpophalangeal arthritis, arthrodesis is a popular and generally reliable surgical solution. In the fingers, arthroplasty remains the most common treatment option. Traditional constrained silicone joint replacements remain the most commonly used. Newer generation, unconstrained, surface replacement arthroplasties have shown promise in the treatment of osteoarthritis and select cases of inflammatory arthritis in which there is good bone stock, no or minimal deformity, adequate supporting soft tissues, and good disease control.

Current concepts and treatment for the rheumatoid wrist

Wrist involvement in rheumatoid arthritis (RA) is common. Within 2 years of diagnosis, more than half of patients will have wrist pain, and more than 90% will have wrist disease by 10 years. Although wrist involvement is generally thought to be less disabling than RA of the fingers and hand, it can be a significant cause of pain and disability. Severe disease with bony destruction and synovitis in the wrist can also result in soft-tissue problems including tendon ruptures. In addition to musculoskeletal involvement, systemic manifestations of RA can occur. Felty syndrome can result in a low white blood count and splenomegaly in association with RA. New generation, disease-modifying pharmacologic agents offer promise in controlling the disease progression. Surgical treatments for the diseased wrist are aimed at relieving pain and restoring function. Common procedures include: synovectomy and tenosynovectomy, tendon reconstruction, distal ulnar resection and/or distal radioulnar joint reconstruction, partial and full wrist arthrodesis, and total wrist arthroplasty.

Postoperative infections: prevention and management

Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.

[Management of problematic clinical situations in rheumatoid arthritis patients. Surgery]

Even though clinical management and treatment of rheumatoid arthritis patients has improved, orthopedic surgery is now a common situation in daily clinical practice. Usually, the rheumatologist is who manages the anti-rheumatic treatment in the perioperative period and decisions are not always supported by scientific information of suitable quality.

Wound complications

This article discusses postoperative wound complications in detail, including host factors that predispose the patient to nonhealing, technical factors in surgery that can reduce the likelihood of infection and dehiscence, and recommendations for postoperative management that can prevent wound healing problems. This discussion includes the treatment of wound complications, ranging from local wound care to various wound coverage options.