Perioperative Management of Biologic Agents Used in Treatment of Rheumatoid Arthritis

Autoimmune Disease and Breast Implants: Systematic Review of Outcomes

ABSTRACT

Given that the use of breast implants for both cosmetic and reconstructive purposes is growing in the United States, an evaluation of factors that may affect the outcome of breast implant surgery is needed. A systematic review was conducted to evaluate the question: Does a personal or family history of autoimmune disease affect outcomes in breast implant surgery? The literature search yielded 2425 records, but after removal of duplicates, abstract screening, and full-text assessment, only 2 studies met the inclusion criteria for the final review. Both studies provided level III evidence and the average Methodological Index for Non-Randomized Studies score was 16.5 (range, 15-18 of 24), indicating a fair level of evidence overall. This systematic review found no evidence to support that a diagnosis of an autoimmune disease and/or a family history of autoimmune diseases will lead to poor surgical outcomes in breast implant surgery. Further study is warranted.

Acute surgical site infection after total knee arthroplasty in patients with rheumatoid arthritis versus osteoarthritis

Osteoarthritis is the main cause for total knee arthroplasty (TKA), followed by rheumatoid arthritis. Previous studies have reported conflicting results concerning the risk of surgical site infection after TKA for rheumatoid arthritis and osteoarthritis patients. Thus, this study aimed to examine whether rheumatoid arthritis patients had a higher risk of acute surgical site infection after TKA compared to osteoarthritis patients. We conducted a retrospective cohort study using Taiwan’s National Health Insurance Research Database of the whole population from 2012 to 2015, and collected the medical records of osteoarthritis patients or rheumatoid arthritis patients who underwent TKA. To evaluate the risk of acute surgical site infection in rheumatoid arthritis patients, propensity score matching was implemented for osteoarthritis patients. Acute surgical site infection was observed in 2.58% of TKA cases in rheumatoid arthritis patients and 2.66% of TKA cases in osteoarthritis patients. Rheumatoid arthritis and osteoarthritis patients had comparable risk for 90-day (odds ratio = 0.81, 95% confidence interval: 0.371–1.768) and 1-year (odds ratio = 0.463, 95% confidence interval: 0.121–1.766) surgical site infection. In conclusion, patients with rheumatoid arthritis were not at higher risk of acute surgical site infection after TKA compared to osteoarthritis patients. The current treatment strategy for patients with RA is safe and appropriate if they require TKA.

Gel network comprising UV crosslinked PLGA-b-PEG-MA nanoparticles for ibuprofen topical delivery

Ibuprofen is a non-steroidal anti-inflammatory drug for the treatment of Rheumatoid Arthritis and osteoarthritis. In this study, we prepared topical gel network for enhancement of ibuprofen penetration, maintenance of controlled release and increased patient compliance. Nanoparticles containing ibuprofen were prepared by means of emulsion formation/solvent diffusion method using synthesized copolymer. Nanoparticles were then conjugated with aminoethylmethacrylate, resulting in ibuprofen-loaded nanoparticles in PLGA-b-PEG-MA structure. Ibuprofen-loaded gel networks were developed by crosslinking nanoparticles via UV exposure. Suitability for topical application has been assessed through characterization of particle size, zeta potential, morphology, encapsulation efficiency, in vitro release, cytotoxicity and enhancement of in vitro wound healing. The mean diameter of nanoparticles was measured as 230 ± 20 nm. Gel network formulations with higher particle size (2800 ± 350 nm) and zeta potential (39.8 ± 9.2 mV), depending on conjugation of methacrylate within copolymeric structure, and having encapsulation efficacy of 73.6 ± 2.8% were prepared. The in vitro release of ibuprofen was sustained for more than 7 hours. Gel network improved collagen synthesis, type I collagen mRNA expression and fibrosis in dose dependent manner. Based on this, we can conclude that PLGA-b-PEG gel network might be a promising systems for the local delivery of ibuprofen in RA patients.

Perioperative Management of Rheumatoid Medications in Orthopedic Surgery

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disorder known to cause progressive joint destruction. Over time, untreated RA can lead to pain and increasing disability, making orthopedic intervention necessary. The treatment of RA revolves around a variety of medications that blunt the overall immune response. However, this may increase the risk of infection and impair wound healing. Given the nature of this disease, orthopedists frequently encounter patients with RA in the operative setting. To optimize surgical outcomes, orthopedists must carefully manage and pay special attention to the adverse side effects of the complicated medication regimens of these patients perioperatively. [Orthopedics. 2017; 40(5):282-286.].

Reconstructive surgery in immunocompromised patients: evaluation and therapy

Background: An increasing number of patients undergoing reconstructive surgery are immunocompromised due to different reasons and different medical treatments. Some of the used immunosuppressive drugs may affect the process of wound healing and thereby, impair the long-term success of surgical treatment. Therefore, this retrospective analysis aimed at the evaluation of the perioperative treatment and surgical outcome of immunocompromised patients undergoing different reconstructive procedures.

Methods: A retrospective review was performed of 8 immunocompromised patients with different primary diseases who needed reconstructive surgery: 2 patients with non-Hodgkin lymphoma, 1 patient with an acute myeloid leukemia, 1 patient with colitis ulcerosa, 1 patient with liver cirrhosis, 1 patient with chronic polyarthritis, and 2 patients with malignant melanoma.

Results: In 7 of our 8 presented cases, multiple operations with wound debridements have been necessary to optimize the granulation of the wound bed before reconstructive surgery. 3 out of these 7 patients required further operations due to wound dehiscence or necrosis, with 2 of them as a result of increased immunosuppressive therapy. 5 out of 8 patients needed no further surgical treatment.

Conclusions: Both the perioperative drug therapy and the reconstructive surgery concept need to be determined carefully in each individual case of the immunocompromised patients. Thus, the appropriate point in time of operation to achieve the best possible wound healing as well as the complexity of the procedure will require the consideration of a ‘less is more’ strategy in selected cases.

Rheumatoid arthritis vs osteoarthritis in patients receiving total knee arthroplasty: perioperative outcomes

There is a paucity of data available on perioperative outcomes of patients undergoing total knee arthroplasty (TKA) for rheumatoid arthritis (RA). We determined differences in demographics and risk for perioperative adverse events between patients suffering from osteoarthritis (OA) versus RA using a population-based approach. Of 351,103 entries for patients who underwent TKA, 3.4% had a diagnosis of RA. RA patients were on average younger [RA: 64.3 years vs OA: 66.6 years; P<0.001] and more likely female [RA: 79.2% vs OA: 63.2%; P<0. 001]. The unadjusted rates of mortality and most major perioperative adverse events were similar in both groups, with the exception of infection [RA: 4.5% vs. OA: 3.8%; P<0.001]. RA was not associated with increased adjusted odds for combined adverse events.

Advances in the medical treatment of rheumatoid arthritis

Over the past 2 decades, the treatment of rheumatoid arthritis (RA) has been revolutionized by advances in the understanding of its pathologic mechanisms and the development of drugs that target them. These newer medications have shown great promise at improving disease outcomes, but they come with notable side effects that can pose long-term treatment challenges and difficulties in the perioperative arena. In this article, the major manifestations of RA and the current medical options for management are discussed. Complications from treatment are then reviewed, and special consideration is given to perioperative medication recommendations.