Interleukin-1 receptor antagonist attenuates tumor necrosis factor-induced alterations in wound breaking strength

More complications and higher transfusion rate in patients with rheumatoid arthritis than osteoarthritis undergoing total hip arthroplasty

PURPOSE

Total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA) has been associated with an increased risk of periprosthetic joint infection, periprosthetic fractures, dislocations, and post-operative blood transfusion. However, higher post-operative blood transfusion is unclear whether it reflects peri-operative blood loss or is characteristic of RA. This study aimed to compare the complications, allogenic blood transfusion, albumin use, and peri-operative blood loss between patients who underwent THA because of RA or osteoarthritis (OA).

METHODS

Patients undergoing cementless THA for hip RA (n = 220) or hip OA (n = 261) at our hospital between 2011 and 2021 were retrospectively enrolled. Deep vein thrombosis, pulmonary embolism, myocardial infarction, calf muscular venous thrombosis, wound complications, deep prosthetic infection, hip prosthesis dislocation, periprosthetic fractures, 30-day mortality, 90-day readmission, allogeneic blood transfusion, and albumin infusions were considered as primary outcomes, while secondary outcomes included the number of perioperative anaemia patients as well as total, intra-operative, and hidden blood loss.

RESULTS

Compared to the OA group, patients with hip RA showed significantly higher rates of wound aseptic complications, hip prosthesis dislocation, homologous transfusion, and albumin use. RA patients also showed a significantly higher prevalence of pre-operative anemia. However, no significant differences were observed between the two groups in total, intra-operative, or hidden blood loss.

CONCLUSIONS

Our study suggests that RA patients undergoing THA are at a higher risk of wound aseptic complications and hip prosthesis dislocation than patients with hip OA. Pre-operative anaemia and hypoalbuminaemia in patients with hip RA place them at a significantly higher risk of post-operative blood transfusion and use of albumin.

Wound healing complications and infection following surgery for rheumatoid arthritis

The goal of the foot and ankle surgeon is to achieve balanced correction of deformity in patients who have rheumatoid arthritis (RA) while minimizing the risk for complications. To achieve these goals, a large number of procedures may be required at a single or in a staged operative setting. In this article, the evaluation of the patient to assess operative risks and the management of perioperative complications in the RA foot and ankle patient are presented.

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

OBJECTIVES

To review published data on the perioperative management of antirheumatic treatment and perioperative outcome in patients with rheumatoid arthritis (RA).

METHODS

The review is based on a MEDLINE (PubMed) search of the English-language literature from 1965 to 2005, using the index keywords "rheumatoid arthritis" and "surgery". As co-indexing terms the different disease-modifying antirheumatic drugs (DMARDs) as well as nonsteroidal anti-inflammatory drugs (NSAIDs) and "glucocorticoids" were used. In addition, citations from retrieved articles were scanned for additional references. Furthermore, because the number of published articles is so limited, relevant abstracts presented at congresses were included in the analysis.

RESULTS

Continuation of methotrexate (MTX) appears to be safe in the perioperative period. Only a limited number of studies address the use of leflunomide and the results are conflicting. Because of the very long drug half-life, its discontinuation would need to be of long duration and is probably not necessary. Data on hydroxychloroquine do not show increased risks of infection. Regarding sulfasalazine, there are no studies from which definite answers could be drawn on whether it should be withheld perioperatively. Preliminary data show that the risk of infections during treatment with TNF-blocking agents may be lower than initially expected. The only available recommendation (Club Rhumatismes et Inflammation, CRI) suggests discontinuing the drugs before surgery for several weeks, depending on the risk of infection and the drug used. They should not be restarted until wound healing is complete. To avoid the antiplatelet effect during surgery, NSAIDs other than aspirin should be withheld for a duration of 4 to 5 times the drug half-life. Patients with chronic glucocorticoid therapy and suppressed hypothalamic-pituitary-adrenal (HPA) axis need perioperative supplementation.

CONCLUSIONS

While continuation of MTX likely is safe, data on other DMARDs are sparse. In particular, more data on the perioperative use of the biologic agents are needed.

Epidermal growth factor intralesional infiltrations can prevent amputation in patients with advanced diabetic foot wounds

This study examined if a series of epidermal growth factor (EGF) local infiltrations can enhance the healing process of complicated diabetic wounds. Twenty-nine in-hospital patients with diabetic neuropathic or ischaemic lesions with high risk of amputation were treated in a non controlled pilot study conducted at the National Institute of Angiology, Havana. Lesions, classified as Wagner's grade 3 or 4, included ulcers > or = 20 cm2 for > or = 25 days or amputation residual bases > or = 30 cm2 for > or = 15 days, healing refractory despite comprehensive wound care. EGF (25 microg) intralesional infiltrations (approximately 250 microl of a 25 microg/ml solution/injection point) were performed thrice weekly up to the eighth week. Wound closure was monitored during the treatment and recurrence examined for a year following discharge from hospital. Eighty-six per cent of the patients treated showed a productive granulation at infiltration session 8. Histological examination at this point indicated a substantial wound matrix transformation, granulation tissue cell repopulation and angiogenesis. Of the 29 patients treated, amputation was prevented in 17 (58.6%) of them who completed 24 infiltration sessions. They averaged 71.1 +/- 18.3% of reepithelisation during a mean in-hospital period of 66.5 +/- 4.9 days. Wound recurrence after 1 year of follow-up appeared in only one patient. Preliminary evidences suggest that EGF intralesional infiltrations may be effective in reducing diabetic lower limb amputation.

Methylglyoxal administration induces diabetes-like microvascular changes and perturbs the healing process of cutaneous wounds

Increased formation of MG (methylglyoxal) and related protein glycation in diabetes has been linked to the development of diabetic vascular complications. Diabetes is also associated with impaired wound healing. In the present study, we investigated if prolonged exposure of rats to MG (50-75 mg/kg of body weight) induced impairment of wound healing and diabetes-like vascular damage. MG treatment arrested growth, increased serum creatinine, induced hypercholesterolaemia (all P < 0.05) and impaired vasodilation (P < 0.01) compared with saline controls. Degenerative changes in cutaneous microvessels with loss of endothelial cells, basement membrane thickening and luminal occlusion were also detected. Acute granulation appeared immature (P < 0.01) and was associated with an impaired infiltration of regenerative cells with reduced proliferative rates (P < 0.01). Immunohistochemical staining indicated the presence of AGEs (advanced glycation end-products) in vascular structures, cutaneous tissue and peripheral nerve fibres. Expression of RAGE (receptor for AGEs) appeared to be increased in the cutaneous vasculature. There were also pro-inflammatory and profibrotic responses, including increased IL-1beta (interleukin-1beta) expression in intact epidermis, TNF-alpha (tumour necrosis factor-alpha) in regions of angiogenesis, CTGF (connective tissue growth factor) in medial layers of arteries, and TGF-beta (transforming growth factor-beta) in glomerular tufts, tubular epithelial cells and interstitial endothelial cells. We conclude that exposure to increased MG in vivo is associated with the onset of microvascular damage and other diabetes-like complications within a normoglycaemic context.

Perioperative management of patients with rheumatoid arthritis in the era of biologic response modifiers

PURPOSE OF REVIEW

This article provides guidelines for the perioperative management of the most commonly used antirheumatic drugs being used to treat patients with rheumatoid arthritis, with an emphasis on the relatively new addition of biologic response modifiers.

RECENT FINDINGS

Few clinical data exist examining the perioperative management of the biologic drugs, which include the inhibitors of tumor necrosis factor-alpha (etanercept, infliximab, and adalimumab), the interleukin-1 receptor antagonist anakinra, and to a much lesser extent the CD20 inhibitor rituximab. The only human data available in that regard is based on the use of the tumor necrosis factor-alpha inhibitor infliximab in surgical patients with Crohn disease. Although quite limited, that data appeared favorable in finding that infliximab did not result in an increased risk of postoperative complications in that setting.

SUMMARY

Perioperative guidelines have never been well established for a majority of the traditional antirheumatic drugs in use today. Recommendations for the perioperative use of nonsteroidal antiinflammatory drugs and glucocorticoids have the most evidence-based support. Data for the use of methotrexate are also available from which to generate reasonable guidelines; however, for the remaining antirheumatic drugs in current use, the available data cannot support any clear evidence-based recommendations. To provide reasonable guidelines for the use of the biologics, perhaps the best we can do is to extrapolate from the very limited data coming from the concurrent use of infliximab in patients with Crohn disease who have undergone surgery. Beyond that, we are left with animal and tissue culture data from which any recommendations would be rather tenuous.

Cytokines and wound healing: the role of cytokine and anticytokine therapy in the repair response

Wound healing is an integrated and complex process involving a large number of regulatory molecules, including proinflammatory cytokines and growth factors, and an orchestrated tissue response. Dysregulation in cytokine or growth factor expression dramatically alters the normal wound healing process, and blocking the inappropriate production of specific proinflammatory cytokines or supplementing the milieu with increased quantities of growth factors has demonstrated the central role played by these mediators. Both protein-based and DNA-based (gene transfer) therapies are currently under clinical development as tools to improve the healing process. Although there has been some success with these approaches in both experimental models and in patients, only through a better understanding of the complexity and diversity of the wound healing process, as well as an improved comprehension of the time-dependent and concentration-dependent responses to individual proinflammatory cytokines or growth factors, will further development in the therapeutic treatment of healing wounds be attained.

IL-1 plays a critical role in oral, but not dermal, wound healing

Wound healing is a well-orchestrated complex process leading to the repair of injured tissues. After injury, proinflammatory cytokines act as important modulators of the inflammatory process. IL-1 expression has been regarded as necessary for healing; however, its effects have also been implicated in delayed wound repair. Currently, there is no consensus or direct evidence that IL-1 activity plays a central role in the healing process. The present investigation was undertaken to define the role of IL-1R signaling in the healing outcome of an excisional wound in the palate or scalp of mice that had targeted deletions of the IL-1R type 1 (IL-1R1(-/-)) compared with matched wild-type mice. Histomorphometric analysis was undertaken to assess the degree of healing and the recruitment of polymorphonuclear and mononuclear phagocytes. After 14 days, wild-type mice exhibited complete closure of intraoral wounds, while IL-1R1(-/-) animals had only partial closure (50%). In the IL-1R1(-/-) mice, healing tissues exhibited a persistent inflammatory cell infiltrate, which did not occur in wild-type animals. Treatment with antibiotics significantly diminished the persistent inflammatory infiltrate and improved healing in the experimental animals. In contrast to oral wounds, the rate of healing and recruitment of polymorphonuclear cells in scalp wounds was similar in IL-1R1(-/-) and wild-type mice. The present data underscore the importance of IL-1 in wound healing in a challenging environment and identify its principal role in facilitating the healing process by protecting an open wound from bacterial insult. In a less challenging environment, the production of new connective tissue and its coverage by migrating epithelium are minimally affected by the absence of IL-1 activity.

THE PIG AS A MODEL FOR HUMAN WOUND HEALING

The medical literature describes numerous in vitro and in vivo wound-healing models. The selection of an animal model depends on a number of factors including availability, cost, ease of handling, investigator familiarity, and anatomical/functional similarity to humans. Small mammals are frequently used for wound healing studies, however, these mammals differ from humans in a number of anatomical and physiological ways. Anatomically and physiologically, pig skin is more similar to human skin. The many similarities between man and pig would lead one to believe that the pig should make an excellent animal model for human wound healing. The purpose of this paper is to review the existing literature for evidence of this supposition and determine how well the various models correlate to human wound healing. Studies of wound dressings, topical antimicrobials, and growth factors are examined. Over 180 articles were utilized for this comparative review. Our conclusion is that the porcine model is an excellent tool for the evaluation of therapeutic agents destined for use in human wounds.