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Stoltzfus MT, Nguyen K, Freedman Z, Hallan DR, Hong J, Rizk E. Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study. Cureus 2024; 16:e57197. [PMID: 38681464 PMCID: PMC11056191 DOI: 10.7759/cureus.57197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes among patients undergoing spinal fusions are inadequately described. This study compares the odds of developing complications among patients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60). The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.
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Affiliation(s)
- Mason T Stoltzfus
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Kenny Nguyen
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Zachary Freedman
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - David R Hallan
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Jinpyo Hong
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Department of Neurosurgery, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
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McCormick BP, Sequeira SB, Hasenauer MD, McKinstry RP, Boucher HR. Cushing's Syndrome Is Associated With Early Medical- and Surgical-Related Complications Following Total Joint Arthroplasty: A National Database Study. J Arthroplasty 2023; 38:2568-2572. [PMID: 37315630 DOI: 10.1016/j.arth.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Cushing's syndrome (CS) is a disorder characterized by exposure to supraphysiologic levels of glucocorticoids. The purpose of this study was to evaluate the association between CS and postoperative complication rates following total joint arthroplasty (TJA). METHODS Patients diagnosed with CS undergoing TJA for degenerative etiologies were identified from a large national database and matched 1:5 to a control cohort using propensity scoring. Propensity score matching resulted in 1,059 total hip arthroplasty (THA) patients with CS matched to 5,295 control THA patients and 1,561 total knee arthroplasty (TKA) patients with CS matched to 7,805 control TKA patients. Rates of medical complications occurring within 90 days of TJA and surgical-related complications occurring within 1 year of TJA were compared using odds ratios (ORs). RESULTS The THA patients with CS had higher incidences of pulmonary embolism (OR 2.21, P = .0026), urinary tract infection (UTI) (OR 1.29, P = .0417), pneumonia (OR 1.58, P = .0071), sepsis (OR 1.89, P = .0134), periprosthetic joint infection (OR 1.45, P = .0109), and all-cause revision surgery (OR 1.54, P = .0036). The TKA patients with CS had significantly higher incidences of UTI (OR 1.34, P = .0044), pneumonia (OR 1.62, P = .0042), and dislocation (OR 2.43, P = .0049) and a lower incidence of manipulation under anesthesia (MUA) (OR 0.63, P = .0027). CONCLUSION CS is associated with early medical- and surgical-related complications following TJA and a reduced incidence of MUA following TKA.
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Affiliation(s)
- Brian P McCormick
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Sean B Sequeira
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Mark D Hasenauer
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Robert P McKinstry
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Henry R Boucher
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
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3
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Wilkinson BG, Bangura A, Burke CE, O'Connor K, Gupta J, Demyanovich HK, Healey K, O'Hara NN, Schneiderman BA, Nascone JW, O'Toole RV. A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail. Injury 2023; 54:110965. [PMID: 37572509 DOI: 10.1016/j.injury.2023.110965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 06/09/2023] [Accepted: 07/26/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES To identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population. METHODS A retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract. RESULTS Deep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%-6% with <10 points to high risk (58%-69%) with >40 points. CONCLUSIONS This risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.
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Affiliation(s)
- Brandon G Wilkinson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Abdulai Bangura
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Cynthia E Burke
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Katherine O'Connor
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Jayesh Gupta
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Haley K Demyanovich
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Kathleen Healey
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Nathan N O'Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Brian A Schneiderman
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Jason W Nascone
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD, United States.
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Piple AS, Wang JC, Kebaish KJ, Mills ES, Oakes DA, Lieberman JR, Christ AB, Heckmann ND. Does Prednisone Dose Affect Rates of Periprosthetic Joint Infection Following Primary Total Hip and Total Knee Arthroplasty? J Arthroplasty 2023; 38:1024-1031. [PMID: 36566997 DOI: 10.1016/j.arth.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/14/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Prednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA. METHODS A national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage as follows: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not. RESULTS After controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, P < .001), PJI (aOR 2.67, P < .001), and surgical site infection (aOR: 2.56, P = .035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, P < .001) and PJI (aOR: 1.73, P = .001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate. CONCLUSION Patients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.
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Affiliation(s)
- Amit S Piple
- Keck School of Medicine of USC, Los Angeles, California
| | | | | | - Emily S Mills
- Keck School of Medicine of USC, Los Angeles, California
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5
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Khader SG, Hussain WHZ, Moorthy A. Rheumatology patients on immunosuppressive treatment and their perioperative management: Review of recommendations. Musculoskeletal Care 2023; 21:571-575. [PMID: 36461920 DOI: 10.1002/msc.1721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 06/16/2023]
Affiliation(s)
| | | | - Arumugam Moorthy
- University Hospitals of Leicester NHS Trust, Leicester, UK
- College of Life Sciences, University of Leicester, Leicester, UK
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6
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Perioperative management of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society for Rheumatology. Z Rheumatol 2023; 82:1-11. [PMID: 35235025 DOI: 10.1007/s00393-021-01150-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
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7
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Russell LA, Craig C, Flores EK, Wainaina JN, Keshock M, Kasten MJ, Hepner DL, Edwards AF, Urman RD, Mauck KF, Oprea AD. Preoperative Management of Medications for Rheumatologic and HIV Diseases: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2022; 97:1551-1571. [PMID: 35933139 DOI: 10.1016/j.mayocp.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/21/2022] [Accepted: 05/04/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Linda A Russell
- Department of Rheumatology, Hospital for Special Surgery, New York, NY.
| | - Chad Craig
- Department of Medicine, Medical College of Wisconsin, Madison, NY
| | - Eva K Flores
- Section of Hospital Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - J Njeri Wainaina
- Department of Medicine, Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI
| | - Maureen Keshock
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mary J Kasten
- Department of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Angela F Edwards
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen F Mauck
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Adriana D Oprea
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
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Hong M, Zhang ZY, Sun XW, Wang WG, Zhang QD, Guo WS. Pneumocystis jiroveci pneumonia after total hip arthroplasty in a dermatomyositis patient: A case report. World J Clin Cases 2022; 10:3313-3320. [PMID: 35603336 PMCID: PMC9082693 DOI: 10.12998/wjcc.v10.i10.3313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/26/2022] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pneumocystis jiroveci pneumonia (PJP) is a serious opportunistic infection that occurs mostly in patients with immunodeficiency and long-term immunosuppressive therapy. In non-human immunodeficiency virus-infected patients, the most important risk factor for PJP is the use of glucocorticoids in combination with other immunosuppressive treatments. The management of glucocorticoids during the perioperative period in patients with dermatomyositis requires special care.
CASE SUMMARY We report a case of PJP in the perioperative period. A 61-year-old woman with a history of anti-melanoma differentiation-associated gene 5 (MDA5)-positive dermatomyositis and interstitial pneumonia was administered with long-term oral methylprednisolone and cyclosporine. The patient underwent right total hip arthroplasty in the orthopaedic department for bilateral osteonecrosis of the femoral head. She was given intravenous drip hydrocortisone before anesthesia and on the first day after surgery and resumed oral methylprednisolone on the second postoperative day. On the fifth day after surgery, the patient suddenly developed dyspnea. The computed tomography scan showed diffuse grid shadows and ground glass shadows in both lungs. Polymerase chain reaction testing of bronchoalveolar lavage fluid was positive for Pneumocystis jiroveci. The patient was eventually diagnosed with PJP and was administered with oral trimethoprim-sulfamethoxazole. At the 6-mo review, there was no recurrence or progression.
CONCLUSION Continued perioperative glucocorticoid use in patients with anti-MDA5-positive dermatomyositis may increase the risk of PJP.
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Affiliation(s)
- Mao Hong
- Beijing University of Chinese Medicine, Beijing 100029, China
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zi-Yu Zhang
- Beijing University of Chinese Medicine, Beijing 100029, China
| | - Xiao-Wei Sun
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100029, China
| | - Wei-Guo Wang
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Qi-Dong Zhang
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
| | - Wan-Shou Guo
- Department of Orthopaedic Surgery, Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, Beijing 100029, China
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9
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Ong CB, Saxena A, Krueger CA, Star AM. "Uncontrolled" Hypertension Is Not an Independent Risk Factor for Adverse Short-Term Outcomes Following Total Joint Arthroplasty. J Arthroplasty 2022; 37:449-453. [PMID: 34775005 DOI: 10.1016/j.arth.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/27/2021] [Accepted: 11/05/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Uncontrolled hypertension (HTN) is a risk factor for mortality following elective surgery and poor hemodynamic control during total joint arthroplasty (TJA). However, the relationship between uncontrolled HTN and TJA outcomes remains poorly understood. The purpose of this study is to better define HTN parameters that are predictive of adverse arthroplasty outcomes. METHODS This is a retrospective cohort analysis on patients who underwent primary TJA for osteoarthritis between 2017 and 2021 at a large orthopedic practice. Uncontrolled HTN was defined as a systolic blood pressure (SBP) > 140 mm Hg, or diastolic blood pressure (DBP) > 90 mm Hg. Spearman's rank correlations were used to evaluate relationships among uncontrolled HTN and operative duration, hemoglobin drop, allogenic transfusions, length of stay, intraoperative/postoperative complications, and readmissions. RESULTS Four thousand three hundred forty-five patients met the selection criteria, of which 55.1% (N = 2394) presented with uncontrolled HTN. In total, 17.1% (N = 745) and 3.2% (N = 138) of patients had an SBP ≥ 160 and 180 mm Hg, respectively. In addition, 1.9% of patients (N = 84) presented with SBP ≥ 200 mm Hg (N = 13) and/or DBP ≥ 100 mm Hg (N = 71). Eight-four percent (N = 626) of patients who presented with SBP > 160 mm Hg had been preoperatively prescribed HTN control medications. Receiver operator curve analysis demonstrated poor predictive value of blood pressure for all aforementioned outcome variables. CONCLUSION Our findings suggest that as defined, uncontrolled HTN is not an appropriate individual predictor of TJA outcomes and should not be used as a "hard stop" when determining eligibility for elective surgery. Further research utilizing a larger cohort is needed to define the relationship between HTN and TJA outcomes.
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Affiliation(s)
- Christian B Ong
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Arjun Saxena
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Andrew M Star
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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10
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Are deep infections that present before and after 90 days from orthopaedic trauma different? An analysis of the validity of the recent change in CDC criteria for infections. Injury 2022; 53:912-918. [PMID: 34732287 DOI: 10.1016/j.injury.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In 2016, the Centers for Disease Control and Prevention (CDC) changed the time frame for their definition of deep surgical site infection (SSI) from within 1 year to within 90 days of surgery. We hypothesized that a substantial number of infections in patients who have undergone fracture fixation present beyond 90 days and that there are patient or injury factors that can predict who is more likely to present with SSI after 90 days. METHODS A retrospective review yielded 452 deep SSI after fracture fixation. These patients were divided into two groups-those infected within 90 days of surgery and those infected beyond 90 days . Data were collected on risk factors for infection. Univariate and multiple logistic regression analyses were performed to compare the two groups. A randomly selected control group was used to build infection prediction models for both outcomes. The two outcomes were then modelled against each other to determine whether differences in predictors for early versus late infection exist. RESULTS Of the 452 infections, 144 occurred beyond 90 days (32% [95% CI, 28%-36%]). No statistically significant patient factors were found in multivariable analysis between the early and late infection groups. The need for flap coverage was the only injury characteristic that differed significantly between groups, with patients in the late infection group more likely to have needed a flap. When modelled against the control group and directly comparing the two models, predictors for early infection include male sex and fractures of the pelvis, acetabulum, or hip, whereas predictors of late infection include hepatitis C and/or human immunodeficiency virus (HIV) and admission to the intensive care unit (ICU). CONCLUSION Use of the recent CDC definition will underestimate the rate of actual postoperative infections when applied to orthopaedic trauma patients. Hepatitis C and/or HIV and ICU admission are predictors of late infection, whereas male sex and pelvis, acetabulum, or hip fractures are predictors of early infection. Patients who receive flap coverage may be more likely to present with late infection.
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11
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Albrecht K, Poddubnyy D, Leipe J, Sewerin P, Iking-Konert C, Scholz R, Krüger K. [Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]. Z Rheumatol 2021; 81:212-224. [PMID: 34928422 DOI: 10.1007/s00393-021-01140-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
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Affiliation(s)
| | - Denis Poddubnyy
- Rheumatologie am Campus Benjamin Franklin - Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Philipp Sewerin
- Uniklinik Düsseldorf Poliklinik, Funktionsbereich & Hiller Forschungszentrum für Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Christof Iking-Konert
- Sektion Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Roger Scholz
- Orthopädie und Unfallchirurgie, Collm Klinik Oschatz, Oschatz, Deutschland
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, St.-Bonifatius-Str. 5, 81541, München, Deutschland.
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12
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Almeida RP, Mokete L, Sikhauli N, Sekeitto AR, Pietrzak J. The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review. EFORT Open Rev 2021; 6:872-880. [PMID: 34760287 PMCID: PMC8559557 DOI: 10.1302/2058-5241.6.200054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive. PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics. Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI. Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described. The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available.
Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054
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Affiliation(s)
- Richard Peter Almeida
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Lipalo Mokete
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkhodiseni Sikhauli
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Allan Roy Sekeitto
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jurek Pietrzak
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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13
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Plantz MA, Sherman AE, Miller CH, Hardt KD, Lee YC. Outcomes of Total Knee Arthroplasty in Patients With Rheumatoid Arthritis. Orthopedics 2021; 44:e626-e632. [PMID: 34590960 DOI: 10.3928/01477447-20210817-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to examine current literature regarding the efficacy of total knee arthroplasty for patients with rheumatoid arthritis. Studies that assessed total knee arthroplasty outcomes in patients with rheumatoid arthritis were identified on MEDLINE from January 2009 to November 2018. All 4 studies that assessed knee pain and 9 of 11 studies that assessed knee function noted significant improvement in average knee score. However, between 10% and 47% of patients had significant knee pain at final follow-up. Total knee arthroplasty provides significant improvement in knee pain and function for patients with rheumatoid arthritis. However, the rates of postoperative pain vary widely. [Orthopedics. 2021;44(5):e626-e632.].
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14
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Carlson VR, Anderson LA, Lu CC, Sauer BC, Blackburn BE, Gililland JM. Perioperative Continuation of Biologic Medications Increases Odds of Periprosthetic Joint Infection in Patients With Inflammatory Arthropathy. J Arthroplasty 2021; 36:2546-2550. [PMID: 33653628 DOI: 10.1016/j.arth.2021.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Rates of prosthetic joint infection (PJI) are elevated among patients with inflammatory arthropathy (IA). The effect of continuing biologic drugs perioperatively with regard to PJI is unknown. The purpose of this study is to compare rates of perioperative biologic continuation in IA patients who did and did not develop PJI after primary total joint arthroplasty (TJA). METHODS All cases of PJI within 1 year of primary TJA in IA patients on biologic medications were retrospectively reviewed from 2005 to 2018 in the US Veterans Affairs Corporate Data Warehouse. Matched controls who did not develop PJI after TJA were populated from the same database. Biologic suspension, defined as medication interruption prior to TJA with surgery occurring after the end of the dosing cycle and resumption after wound healing, was compared among cases and controls. RESULTS Biologic medications were continued through surgery in 35% (9/26) of patients who developed PJI compared to 14% (8/58) of controls (P = .031; adjusted odds ratio of 3.46 [1.11-10.78]). No significant difference existed among cases (n = 26) and controls (n = 58) for age, gender, procedure, body mass index, rates of diabetes or chronic kidney disease, smoking status, or preoperative opioid use (all P > .05). CONCLUSION With the limited sample sizes available in this study, we found an association with perioperative continuation of biologic medications and PJI. This data may provide support for current guidelines from the American Association of Hip and Knee Surgeons to withhold biologics before TJA with surgery scheduled at the end of the dosing cycle and medication resumption only after wound healing.
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Affiliation(s)
- Victor R Carlson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Lucas A Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Chao-Chin Lu
- Veterans Administration Medical Center, Salt Lake City, UT
| | - Brian C Sauer
- Veterans Administration Medical Center, Salt Lake City, UT
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15
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Goodman SM, George MD. 'Should we stop or continue conventional synthetic (including glucocorticoids) and targeted DMARDs before surgery in patients with inflammatory rheumatic diseases?'. RMD Open 2021; 6:rmdopen-2020-001214. [PMID: 32719151 PMCID: PMC7722271 DOI: 10.1136/rmdopen-2020-001214] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/14/2022] Open
Abstract
Total hip and total knee arthroplasty) remain important interventions to treat symptomatic knee and hip damage in patients with rheumatoid arthritis, with little change in utilisation rates despite the increasingly widespread use of potent conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and targeted DMARDs including Janus kinase inhibitors and biologics. The majority of patients are receiving these immunosuppressing medications and glucocorticoids at the time they present for arthroplasty. There is minimal randomised controlled trial data addressing the use of DMARDs in the perioperative period, yet patients and their physicians face these decisions daily. This paper reviews what is known regarding perioperative management of targeted and csDMARDs and glucocorticoids.
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Affiliation(s)
- Susan M Goodman
- Department of Medicine, Hospital for Special Surgery, Weill Cornell Medicine, New York, USA
| | - Michael D George
- Department of Biostatistics, Epidemiology and Informatics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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16
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Cho BK, An MY, Ahn BH. Comparison of Clinical Outcomes After Total Ankle Arthroplasty Between End-Stage Osteoarthritis and Rheumatoid Arthritis. Foot Ankle Int 2021; 42:589-597. [PMID: 33557617 DOI: 10.1177/1071100720979923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total ankle arthroplasty (TAA) is known to be a reliable operative option for end-stage rheumatoid arthritis. However, higher risk of postoperative complications related to chronic inflammation and immunosuppressive treatment is still a concern. With the use of a newer prosthesis and modification of anti-rheumatic medications, we compared clinical outcomes after TAA between patients with osteoarthritis and rheumatoid arthritis. METHODS Forty-five patients with end-stage osteoarthritis (OA group) and 19 with rheumatoid arthritis (RA group) were followed for more than 3 years after 3 component mobile-bearing TAA (ZenithTM). Perioperative anti-rheumatic medications were modified using an established guideline used in total hip and knee arthroplasty. Clinical evaluations consisted of American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM). RESULTS In the preoperative and postoperative evaluation at final follow-up, there were no significant differences in AOFAS, FAOS, and FAAM scores between 2 groups. Despite statistical similarity in total scores, the OA group showed significantly better scores in FAOS sports and leisure (mean, 57.4 ± 10.1) and FAAM sports activity (mean, 62.5 ± 13.6) subscales than those in the RA group (mean, 52.2 ± 9.8, P = .004; and 56.4 ± 13.2, P < .001, respectively). There were no significant differences in perioperative complication and revision rates between 2 groups. CONCLUSION Patients with end-stage ankle RA had clinical outcomes comparable to the patients with OA, except for the ability related to sports activities. In addition, there were no significant differences in early postoperative complication rates, including wound problem and infection. LEVEL OF EVIDENCE Level III, prognostic, prospective comparative study.
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Affiliation(s)
- Byung-Ki Cho
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea.,Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Min-Yong An
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Byung-Hyun Ahn
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Korea
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17
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Chan VW, Chan PK, Fu H, Cheung MH, Cheung A, Yan CH, Chiu KY. Preoperative optimization to prevent periprosthetic joint infection in at-risk patients. J Orthop Surg (Hong Kong) 2021; 28:2309499020947207. [PMID: 32851909 DOI: 10.1177/2309499020947207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.
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Affiliation(s)
- Vincent Wk Chan
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China
| | - P K Chan
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China
| | - H Fu
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China
| | - M H Cheung
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China
| | - A Cheung
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China
| | - C H Yan
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China
| | - K Y Chiu
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, 26473Queen Mary Hospital, Hong Kong, SAR, China
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18
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Gold PA, Garbarino LJ, Sodhi N, Anis HK, Ehiorobo JO, Kurtz SM, Danoff JR, Rasquinha VJ, Higuera CA, Mont MA. Annual Nationwide Infection Trends for Revision Total Knee Arthroplasty. J Knee Surg 2021; 34:378-382. [PMID: 31491795 DOI: 10.1055/s-0039-1696690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Several recent intraoperative and wound management techniques have been developed and implemented in the United States over the past decade; however, it is unclear what the effects of these newer modalities have on reducing surgical site infection (SSI) rates. Therefore, the purpose of this study was to track the annual rate and trends of (1) overall, (2) deep, and (3) superficial SSIs following revision total knee arthroplasty (TKA). The National Surgical Quality Improvement Program database was queried for all revision TKA cases performed between 2011 and 2016, which yielded 9,887 cases. Cases with superficial and/or deep SSIs were analyzed separately and then combined to evaluate overall SSI rates. After an overall 6-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 5 years. Correlation coefficients and chi-square tests were used to determine correlation and statistical significance. No significant correlations between combined, deep, and/or superficial SSI rates and year were noted (p > 0.05). The lowest overall SSI incidence was in 2012 (1.16%), while the greatest incidence was in 2014 (1.76%). The deep SSI incidence over the 6 years was 0.67% (66 out of 9,887 cases). Deep SSI rate decreased by 10% in 2016 compared with 2011 (0.50 vs. 0.56%, p > 0.05). In this 6-year period, 94 cases out of 9,887 were complicated by a superficial SSI, an incidence of 0.95%. The lowest superficial SSI incidence occurred in 2015 (n = 17, 0.77%). Overall, the incidence of SSIs in revision TKA has remained fairly low with some annual variance, indicating room for improvement. These variations likely as revision surgeries can be more complex and have several associated confounding factors influencing outcomes, when compared with primary cases. Further research is needed to identify revision-specific strategies to reduce the risk of surgical site infections.
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Affiliation(s)
- Peter A Gold
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Luke J Garbarino
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
| | - Steven M Kurtz
- Department of Biomedical Engineering, Drexel University, Philadelphia, Pennsylvania
| | - Jonathan R Danoff
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Vijay J Rasquinha
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
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19
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Resende VAC, Neto AC, Nunes C, Andrade R, Espregueira-Mendes J, Lopes S. Higher age, female gender, osteoarthritis and blood transfusion protect against periprosthetic joint infection in total hip or knee arthroplasties: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2021; 29:8-43. [PMID: 30413860 DOI: 10.1007/s00167-018-5231-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/17/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE The goal of this systematic review and meta-analysis was to identify the main risk factors for periprosthetic joint infection (PJI) in patients undergoing total hip or knee arthroplasties. METHODS A systematic review was conducted of the potential risk factors for PJI in total hip or total knee arthroplasty. Risk factors were compared and grouped according to demographics, comorbidities, behavior, infections, native joint diseases and other patient-related and procedure-related factors. Meta-analysis (random-effects models) was conducted using odds ratio (OR) and mean difference (MD). Risk of bias (ROBBINS-I) and strength of the evidence (GRADE) were assessed. RESULTS The study included 37 studies (2,470,827 patients). Older age was a protective factor (MD = - 1.18). Male gender (OR 1.34), coagulopathy (3.05), congestive heart failure (2.36), diabetes mellitus (1.80), obesity (1.61), systemic neoplasia (1.57), chronic lung disease (1.52), and hypertension (1.21) increased the risk for PJI. Behavioral risk factors comprised alcohol abuse (2.95), immunosuppressive therapy (2.81), steroid therapies (1.88), and tobacco (1.82). Infectious risk factors included surgical site infections (6.14), postoperative urinary tract infections (2.85), and prior joint infections (2.15). Rheumatoid arthritis, posttraumatic native joint disease, high National Nosocomial Infections Surveillance (NNIS) system surgical patient index score, prior joint operation, American Society of Anesthesiologists score ≥ 3 and obesity were also significantly associated with higher risk of PJI. Osteoarthritis and blood transfusion were protective factors. CONCLUSIONS The main risk factors for PJI in each category were male gender, coagulopathy, alcohol abuse, surgical site infection (highest score) and high NNIS system surgical patient index score. Protective factors were age, female gender in TKA, osteoarthritis and blood transfusion. Optimization of modifiable risk factors for PJI should be attempted in clinical practice. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Vera Alice Correia Resende
- Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal.
- Centro Hospitalar de Entre o Douro e Vouga, Rua Dr. Cândido de Pinho, 4520-211, Santa Maria da Feira, Portugal.
| | - Artur Costa Neto
- Centro Hospitalar de Entre o Douro e Vouga, Rua Dr. Cândido de Pinho, 4520-211, Santa Maria da Feira, Portugal
| | - Carla Nunes
- Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal
- Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Renato Andrade
- Clínica do Dragão, Espregueira-Mendes Sports Centre-FIFA Medical Centre of Excellence, Porto, Portugal
- Faculty of Sports, University of Porto, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
| | - João Espregueira-Mendes
- Clínica do Dragão, Espregueira-Mendes Sports Centre-FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- 3B's Research Group-Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, 4805-017, Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Orthopaedics Department of Minho University, Braga, Portugal
| | - Sílvia Lopes
- Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal
- Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal
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20
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Taylor-Williams O, Nossent J, Inderjeeth CA. Incidence and Complication Rates for Total Hip Arthroplasty in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis Across Four Decades. Rheumatol Ther 2020; 7:685-702. [PMID: 33000421 PMCID: PMC7695804 DOI: 10.1007/s40744-020-00238-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/19/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Over the past several decades, management of rheumatoid arthritis (RA) has evolved significantly, but few studies have examined the real-world impact of these changes on orthopaedic surgery in patients with RA. This systematic review assessed total hip arthroplasty (THA) incidence and postoperative complication rates across the past four decades. METHODS This is a systematic literature review sourcing data on THA in patients with RA from the electronic databases MEDLINE, EMBASE, Scopus, and Cochrane between January 1, 1980 and December 31, 2019. RESULTS The search retrieved 1715 articles of which 44 were included for quantitative synthesis. The rate for THA decreased by almost 40% from 11/1000 patient years (PY) in the 2000s to 7/1000 PY in the 2010s, while the overall complication rate decreased from 9.9% in the 1990s to 5.3% in the 2010s. Throughout the duration of the study, THA incidence and overall complication rate decreased. However, not all individual complication rates decreased. For example, revision and periprosthetic fracture decreased, infection and aseptic loosening remained constant, and dislocation increased. CONCLUSION Medical management of patients with RA has reduced the need for THA, while postoperative medical and surgical management has improved some postoperative outcomes. Nevertheless, there remains room for further improvement to postoperative outcomes through RA-specific management.
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Affiliation(s)
| | - Johannes Nossent
- School of Medicine, The University of Western Australia, Perth, Australia.
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
| | - Charles A Inderjeeth
- School of Medicine, The University of Western Australia, Perth, Australia.
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
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21
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Tihista M, Gu A, Wei C, Weinreb JH, Rao RD. The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery. J Clin Orthop Trauma 2020; 11:921-927. [PMID: 32904286 PMCID: PMC7452358 DOI: 10.1016/j.jcot.2020.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/07/2020] [Accepted: 04/04/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Corticosteroids have a negative impact on the human immune system's ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine. METHODS A retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment. RESULTS 26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024). CONCLUSION Long-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.
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Key Words
- ACS NSQIP, American College of Surgery National Surgical Quality Improvement Program
- ANOVA, Analysis of Variance
- ASA, American Society of Anesthesiologists
- BMI, Body Mass Index
- CPT, Current Procedure Terminology
- Complications
- Corticosteroid use
- DM, diabetes mellitus
- ICD, International Classification of Disease
- IDDM, Insulin Dependent Diabetes Mellitus
- IL, Interleukin
- LOS, Length of Stay
- Lumbar decompression
- MAC/IV, Monitored Anesthesia Care, Intravenous: NIDDM
- NIDDM, Non-Insulin dependent diabetes mellitus
- National surgical quality improvement program
- OR, Odds Ratio
- UTI, Urinary Tract Infection
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Affiliation(s)
- Mikel Tihista
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Alex Gu
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Chapman Wei
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Jeffrey H. Weinreb
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
| | - Raj D. Rao
- Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA
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Zakaryan A, Ginosyan K. Perioperative Management of Patients With Ankylosing Spondylitis Undergoing Spine Surgery. Front Pharmacol 2020; 11:1017. [PMID: 32742263 PMCID: PMC7364138 DOI: 10.3389/fphar.2020.01017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/23/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Arman Zakaryan
- Department of Neurosurgery, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
| | - Knarik Ginosyan
- Department of Rheumatology, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
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Fassihi SC, Gu A, Perim DA, Wei C, Stake S, Thakkar S, Unger AS, Ast MP, Sculco PK. Chronic preoperative corticosteroid use is not associated with surgical site infection following revision total knee arthroplasty. J Orthop 2020; 20:173-176. [PMID: 32025143 PMCID: PMC6997114 DOI: 10.1016/j.jor.2020.01.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION The objective of this study was to determine whether chronic preoperative corticosteroid use is associated with increased infectious complications following revision total knee arthroplasty (rTKA). METHODS A retrospective cohort analysis was conducted using patients from a large national database. Patients were divided into two cohorts based upon chronic steroid usage preoperatively. Infectious complications in the 30-day postoperative period were recorded, and univariate and multivariate analyses were performed. RESULTS A total of 10,973 patients were included in this study. No significant difference was observed in surgical site infection rates between patients with and without preoperative steroid use. In multivariate analysis, preoperative steroid use was independently associated with an increased likelihood of septic shock (OR 6.17; p = 0.015) and prolonged length-of-stay (OR 1.57; p = 0.038). CONCLUSION Chronic preoperative steroid is not a significant risk factor for surgical site infection following rTKA, but it is independently associated with increased risk of septic shock and prolonged hospital length of stay.
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Affiliation(s)
- Safa C. Fassihi
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Alex Gu
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
- Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York City, NY, 10021, USA
| | - Dana A. Perim
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Chapman Wei
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Seth Stake
- Department of Orthopedic Surgery, George Washington School of Medicine and Health Sciences, 2300 Eye St NW, Washington DC, 20037, USA
| | - Savyasachi Thakkar
- Department of Orthopaedic Surgery, MedStar Georgetown Orthopaedic Institute at Washington Hospital Center, 110 Irving St NW, Washington DC, 20010, USA
| | - Anthony S. Unger
- Gildenhorn Institute of Bone and Joint Health, Sibley Memorial Hospital, 5255 Loughboro Road NW, Washington, DC, 20016, USA
| | - Michael P. Ast
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, 535 E 70th St, New York City, NY, 10021, USA
| | - Peter K. Sculco
- Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 E 70th St, New York City, NY, 10021, USA
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Kittle H, Ormseth A, Patetta MJ, Sood A, Gonzalez MH. Chronic Corticosteroid Use as a Risk Factor for Perioperative Complications in Patients Undergoing Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e2000001. [PMID: 32672719 PMCID: PMC7366416 DOI: 10.5435/jaaosglobal-d-20-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/22/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Osteoarthritis may be caused by or concurrent with diseases such as rheumatoid arthritis or systemic lupus erythematosus, which rely on chronic corticosteroids regimens for treatment. If a total knee or hip arthroplasty is needed, this chronic treatment method has been associated with poorer surgical outcomes. METHODS A retrospective analysis of data collected by the American College of Surgeons National Surgical Quality Improvement Program was conducted. The Current Procedural Terminology codes were used to identify 403,566 total knee arthroplasty and total hip arthroplasty patients who were then stratified by the use of chronic corticosteroids for univariate analysis. RESULTS Forteen thousand seven hundred seventy-four of the patients identified were prescribed chronic corticosteroid regimens. A statistically significant difference was observed in perioperative complications for patients prescribed with corticosteroids, including higher rates of surgical site infection (P = 0.0001), occurrence of deep incisional surgical site infection (P < 0.0001), occurrences of organ space surgical site infection (P < 0.0001), wound dehiscence (P < 0.0001), general would infection (P < 0.0001), pneumonia (P < 0.0001), occurrences of unplanned intubation (P = 0.0002), urinary tract infection (P < 0.0001), and readmission (P < 0.0001). No statistically significant difference was observed in the 30-day mortality between the 2 groups (0.63), venous thromboembolic event (0.42), cerebrovascular accident (0.12), myocardial infarction (0.49), cardiac arrest (0.098), deep vein thrombosis (0.17), or sepsis (0.52). CONCLUSION Many of the notable differences in complications may be directly attributed to the immunosuppressive nature of corticosteroids. With increased knowledge of which perioperative complications to monitor, surgeons can tailor treatment strategies to this population that reduce morbidity and improve outcomes.
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Affiliation(s)
- Haley Kittle
- From the Department of Orthopaedics, University of Illinois College of Medicine (Ms. Kittle and Dr. Ormseth), and the Department of Orthopaedics, University of Illinois College of Medicine (Dr. Patetta, Dr. Sood, and Dr. Gonzalez), Chicago, IL
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Risk of medical complications following total hip or knee arthroplasty in patients with rheumatoid arthritis: A register-based cohort study from Denmark. Semin Arthritis Rheum 2020; 50:30-35. [DOI: 10.1016/j.semarthrit.2019.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/03/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
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Lespasio M, Mont M, Guarino A. Identifying Risk Factors Associated With Postoperative Infection Following Elective Lower-Extremity Total Joint Arthroplasty. Perm J 2020; 24:1-3. [PMID: 33482967 DOI: 10.7812/tpp/20.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This article addresses the importance of identifying risk factors associated with postoperative infection following elective lower-extremity total joint arthroplasty. Specifically, this review discusses risk factors recognized by the American Academy of Orthopaedic Surgeons that should be carefully considered and assessed by the orthopaedic team in collaboration with the primary care provider before proceeding with surgery.
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Affiliation(s)
- Michelle Lespasio
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - Michael Mont
- Northwell Health Physician Partners Orthopaedic Institute at Lenox Hill, Lenox Hill Hospital, New York, NY
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Wang JH, Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. Outcomes following total elbow arthroplasty for rheumatoid arthritis versus post-traumatic conditions: a systematic review and meta-analysis. Bone Joint J 2019; 101-B:1489-1497. [PMID: 31786989 PMCID: PMC6896228 DOI: 10.1302/0301-620x.101b12.bjj-2019-0799.r1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. MATERIALS AND METHODS We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). RESULTS This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. CONCLUSION The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489-1497.
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Affiliation(s)
- Jou-Hua Wang
- Department of Orthopaedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Hsuan-Hsiao Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Te-Feng A Chou
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Reliability of stemless shoulder arthroplasty in rheumatoid arthritis: observation of early lysis around the humeral component. Musculoskelet Surg 2019; 105:139-148. [PMID: 31696419 DOI: 10.1007/s12306-019-00629-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate whether stemless shoulder implants in rheumatoid arthritis (RA) patients provide comparable functional outcomes to patients with osteoarthritis or post-traumatic arthritis. In addition, the study assessed for differences in incidence of radiolucent lines or proximal humeral bone loss during radiographic follow-up. METHODS Consecutive stemless shoulder arthroplasties performed in RA patients and a matched control group were retrospectively identified between February 2012 and 2018. Thirty-five patients were included in each group: 24 total shoulder arthroplasty (TSA) and 11 hemiarthroplasty (HA). Patients were evaluated annually using the Oxford Shoulder Score (OSS) and radiographically. RESULTS The mean OSS significantly improved in all groups until 24 months. The mean improvement for RA TSA and HA patients at 24 months was 19.86 (95% CI 10.66-29.05, p = 0.0004) and 19.71 (95% CI 7.33-32.31, p = 0.0084), respectively. The mean improvement in the control TSA and HA patients at 24 months was 20.86 (95% CI 17-24.71, p = 0.0001) and 17.86 (95% CI 1.36-34.35, p = 0.0381), respectively. During the study period, two patients in the RA TSA group (8%), one patient in the control TSA group (4%) and one patient in the control HA group (9%) required revision. The proportion of progressive proximal humeral bone loss after TSA was 33% in the RA group and 13% in the control group. CONCLUSION Stemless shoulder implants can provide significant improvement in functional scores in RA patients in the short term. However, early bone loss around the humeral implant is a concern and the authors recommend long-term clinical and radiological follow-up.
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Abstract
OBJECTIVES To determine factors predictive of postoperative surgical site infection (SSI) after fracture fixation and create a prediction score for risk of infection at time of initial treatment. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Study group, 311 patients with deep SSI; control group, 608 patients. INTERVENTION We evaluated 27 factors theorized to be associated with postoperative infection. Bivariate and multiple logistic regression analyses were used to build a prediction model. A composite score reflecting risk of SSI was then created. MAIN OUTCOME MEASURES Risk of postoperative infection. RESULTS The final model consisted of 8 independent predictors: (1) male sex, (2) obesity (body mass index ≥ 30) (3) diabetes, (4) alcohol abuse, (5) fracture region, (6) Gustilo-Anderson type III open fracture, (7) methicillin-resistant Staphylococcus aureus nasal swab testing (not tested or positive result), and (8) American Society of Anesthesiologists classification. Risk strata were well correlated with observed proportion of SSI and resulted in a percent risk of infection of 1% for ≤3 points, 6% for 4-5 points, 11% for 6 to 8-9 points, and 41% for ≥10 points. CONCLUSION The proposed postoperative infection prediction model might be able to determine which patients have fractures at higher risk of infection and provides an estimate of the percent risk of infection before fixation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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George MD, Baker JF, Winthrop K, Alemao E, Chen L, Connolly S, Hsu JY, Simon TA, Wu Q, Xie F, Yang S, Curtis JR. Timing of Abatacept Before Elective Arthroplasty and Risk of Postoperative Outcomes. Arthritis Care Res (Hoboken) 2019; 71:1224-1233. [PMID: 30740938 DOI: 10.1002/acr.23843] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 02/05/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Guidelines recommend withholding biologic therapies before hip and knee arthroplasty, yet evidence to inform optimal timing is limited. The aim of this study was to determine whether withholding abatacept infusions is associated with lower risk of adverse postoperative outcomes. METHODS This retrospective cohort study, which used US Medicare and Truven MarketScan administrative data from January 2006 to September 2015, evaluated adults with rheumatoid arthritis who received intravenous abatacept (precisely dated in claims data) within 6 months of elective primary or revision hip or knee arthroplasty. Propensity weighted analyses using inverse probability weights compared the risk of 30-day hospitalized infection and 1-year prosthetic joint infection (PJI) between patients with different abatacept stop timing (time between last infusion and surgery). Secondary analyses evaluated nonurinary hospitalized infections and 30-day readmissions. RESULTS After 1,939 surgeries among 1,780 patients, there were 175 hospitalized infections (9.0%), 115 nonurinary hospitalized infections (5.9%), 39 PJIs (2.4/100 person-years), and 114/1,815 30-day readmissions (6.3%). There were no significant differences in outcomes with abatacept stop timing <4 weeks (1 dosing interval) versus 4-8 weeks (hospitalized infection odds ratio [OR] 0.93 [95% confidence interval (95% CI) 0.65-1.34]; nonurinary hospitalized infection OR 0.93 [95% CI 0.60-1.44]; PJI hazard ratio 1.29 [95% CI 0.62-2.69]; 30-day readmission OR 1.00 [95% CI 0.65-1.54]). Similarly, there were no significant differences in outcomes with abatacept stop timing <4 weeks versus ≥8 weeks. Glucocorticoid use >7.5 mg/day was associated with greater risk of hospitalized infection (OR 2.19 [95% CI 1.28-3.77]) and nonurinary hospitalized infection (OR 2.38 [95% CI 1.22-4.64]). CONCLUSION Compared to continuing intravenous abatacept, withholding abatacept for ≥4 weeks (one dosing interval) before surgery was not associated with a lower risk of hospitalized infection, nonurinary hospitalized infection, PJI, or 30-day readmission.
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Affiliation(s)
- Michael D George
- University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Joshua F Baker
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennyslvania
| | | | - Evo Alemao
- Bristol-Myers Squibb, Princeton, New Jersey
| | | | | | - Jesse Y Hsu
- University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | - Qufei Wu
- University of Pennsylvania Perelman School of Medicine, Philadelphia
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George MD, Baker JF, Winthrop K, Alemao E, Chen L, Connolly S, Hsu JY, Simon TA, Wu Q, Xie F, Yang S, Curtis JR. Risk of Biologics and Glucocorticoids in Patients With Rheumatoid Arthritis Undergoing Arthroplasty: A Cohort Study. Ann Intern Med 2019; 170:825-836. [PMID: 31108503 PMCID: PMC7197029 DOI: 10.7326/m18-2217] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) are at increased risk for infection after arthroplasty, yet risks of specific biologic medications are unknown. OBJECTIVE To compare risk for postoperative infection among biologics and to evaluate the risk associated with glucocorticoids. DESIGN Retrospective cohort study. SETTING Medicare and Truven MarketScan administrative data from January 2006 through September 2015. PATIENTS Adults with RA who were having elective inpatient total knee or hip arthroplasty, either primary or revision, and had a recent infusion of or prescription for abatacept, adalimumab, etanercept, infliximab, rituximab, or tocilizumab before surgery. MEASUREMENTS Propensity-adjusted analyses using inverse probability weights evaluated comparative risks for hospitalized infection within 30 days and prosthetic joint infection (PJI) within 1 year after surgery between biologics or with different dosages of glucocorticoids. Secondary analyses evaluated non-urinary tract hospitalized infections and 30-day readmissions. RESULTS Among 9911 patients treated with biologics, 10 923 surgical procedures were identified. Outcomes were similar in patients who received different biologics. Compared with an 8.16% risk for hospitalized infection with abatacept, predicted risk from propensity-weighted models ranged from 6.87% (95% CI, 5.30% to 8.90%) with adalimumab to 8.90% (CI, 5.70% to 13.52%) with rituximab. Compared with a 2.14% 1-year cumulative incidence of PJI with abatacept, predicted incidence ranged from 0.35% (CI, 0.11% to 1.12%) with rituximab to 3.67% (CI, 1.69% to 7.88%) with tocilizumab. Glucocorticoids were associated with a dose-dependent increase in postoperative risk for all outcomes. Propensity-weighted models showed that use of more than 10 mg of glucocorticoids per day (vs. no glucocorticoid use) resulted in a predicted risk for hospitalized infection of 13.25% (CI, 9.72% to 17.81%) (vs. 6.78%) and a predicted 1-year cumulative incidence of PJI of 3.83% (CI, 2.13% to 6.87%) (vs. 2.09%). LIMITATION Residual confounding is possible, and sample sizes for rituximab and tocilizumab were small. CONCLUSION Risks for hospitalized infection, PJI, and readmission after arthroplasty were similar across biologics. In contrast, glucocorticoid use, especially with dosages above 10 mg/d, was associated with greater risk for adverse outcomes. PRIMARY FUNDING SOURCE Rheumatology Research Foundation, National Institutes of Health, and Bristol-Myers Squibb.
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Affiliation(s)
- Michael D George
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Joshua F Baker
- University of Pennsylvania Perelman School of Medicine and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania (J.F.B.)
| | - Kevin Winthrop
- Oregon Health & Science University, Portland, Oregon (K.W.)
| | - Evo Alemao
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Sean Connolly
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Jesse Y Hsu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Teresa A Simon
- Bristol-Myers Squibb, New York, New York (E.A., S.C., T.A.S.)
| | - Qufei Wu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.)
| | - Fenglong Xie
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Shuo Yang
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, Birmingham, Alabama (L.C., F.X., S.Y., J.R.C.)
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George MD, Baker JF. Perioperative management of immunosuppression in patients with rheumatoid arthritis. Curr Opin Rheumatol 2019; 31:300-306. [PMID: 30920454 PMCID: PMC6446585 DOI: 10.1097/bor.0000000000000589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Patients with rheumatoid arthritis are at increased risk of infection after surgery. Recent literature has provided more data and updated guidelines to guide the management of immunosuppression in the perioperative period. RECENT FINDINGS Studies over the past few years have confirmed that patients with rheumatoid arthritis are at increased risk of infection after surgery. Patients treated with biologics are at greater risk of postoperative infection, but this risk might be explained by the comorbidities and greater disease severity often seen in these patients. Recent observational studies have suggested that interruption of biologic therapies before surgery may not be associated with better outcomes. Glucocorticoids, however, have consistently been found to be risk factors for infection. Recent guidelines from the American College of Rheumatology/American Association of Hip and Knee Surgeons recommend continuing conventional disease-modifying drugs and holding biologics for one dosing interval before surgery. SUMMARY Prolonged interruption of conventional and biologic therapies before surgery does not appear to substantially reduce infection risk. Guidelines now recommend continuing conventional DMARDs and holding biologics for just one dosing interval before surgery. Glucocorticoids are strongly associated with the risk of postoperative infection and should be minimized before surgery.
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Affiliation(s)
| | - Joshua F. Baker
- University of Pennsylvania, Division of Rheumatology
- Philadelphia Veterans Affairs Medical Center, Division of Rheumatology
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Dougherty CD, Hung YY, Weintraub MLR, Patel S, King CM. Osseous and Soft Tissue Complications Associated With Foot and Ankle Surgery in Patients With Rheumatoid Arthritis Taking a Variety of Antirheumatic Medications. J Foot Ankle Surg 2019; 58:508-513. [PMID: 30885450 DOI: 10.1053/j.jfas.2018.09.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Indexed: 02/03/2023]
Abstract
There are multiple antirheumatic drug modalities available to patients with symptomatic rheumatoid arthritis (RA) that function to suppress the overactive immune system, but the inflammatory and immune suppression may contribute to postoperative complications. The purpose of this study was to determine if antirheumatic medications increased the risk of both soft tissue and osseous postoperative complications in patients with RA who underwent foot and ankle surgery. We reviewed patients with RA, aged 18years and older, who underwent either an elective or a nonelective foot or ankle surgery involving an osseous procedure between 2009 and 2014. Chart review was conducted to document procedure type, active medications, and postoperative complications. Of the final 110 subjects meeting inclusion criteria, 31 (28%) patients had a postoperative complication (13 soft tissue, 9 osseous, and 9 both soft tissue and osseous). There was no statistically significant association between taking antirheumatic medications in the perioperative period and postoperative complications. Increased surgery duration and peripheral neuropathy were associated with a statistically significant increase in postoperative complications. Every 15 minutes of increased surgery time led to a 1.2-fold increase in complication risk. Nonelective procedures had a higher risk of soft tissue complications than did elective procedures (odds ratio 4.2, 95% confidence interval 1.1 to 16.0). Although there was no statistically significant association between the specific medication and complications, some medications trended toward statistical significance. When working with patients with RA, our findings suggest the importance of considering the risk of surgery duration and the potential risk of antirheumatic medications in the perioperative period.
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Affiliation(s)
- Colten D Dougherty
- Third-Year Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser San Francisco Bay Area Foot and Ankle Residency, San Francisco, CA
| | - Yun-Yi Hung
- Third-Year Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser San Francisco Bay Area Foot and Ankle Residency, San Francisco, CA
| | - Miranda L Ritterman Weintraub
- Senior Research Project Manager, Graduate Medical Education, Kaiser Permanente Oakland Medical Hospital, Oakland, CA
| | - Sandeep Patel
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, Walnut Creek, CA
| | - Christy M King
- Residency Director, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Oakland, CA.
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Vivino FB, Bunya VY, Massaro-Giordano G, Johr CR, Giattino SL, Schorpion A, Shafer B, Peck A, Sivils K, Rasmussen A, Chiorini JA, He J, Ambrus JL. Sjogren's syndrome: An update on disease pathogenesis, clinical manifestations and treatment. Clin Immunol 2019; 203:81-121. [PMID: 31022578 DOI: 10.1016/j.clim.2019.04.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/19/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Frederick B Vivino
- Penn Sjögren's Center, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, 3737 Market Street, Philadelphia, PA 19104, USA.
| | - Vatinee Y Bunya
- Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, 51 N. 39(th) Street, Philadelphia, PA 19104, USA.
| | - Giacomina Massaro-Giordano
- Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, 51 N. 39(th) Street, Philadelphia, PA 19104, USA.
| | - Chadwick R Johr
- Penn Sjögren's Center, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, 3737 Market Street, Philadelphia, PA 19104, USA.
| | - Stephanie L Giattino
- Penn Sjögren's Center, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, 3737 Market Street, Philadelphia, PA 19104, USA.
| | - Annemarie Schorpion
- Penn Sjögren's Center, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, 3737 Market Street, Philadelphia, PA 19104, USA.
| | - Brian Shafer
- Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, 51 N. 39(th) Street, Philadelphia, PA 19104, USA.
| | - Ammon Peck
- Department of Infectious Diseases and Immunology, University of Florida College of Veterinary Medicine, PO Box 100125, Gainesville, FL 32610, USA.
| | - Kathy Sivils
- Oklahoma Medical Research Foundation, Arthritis and Clinical Immunology Program, 825 NE 13th Street, OK 73104, USA.
| | - Astrid Rasmussen
- Oklahoma Medical Research Foundation, Arthritis and Clinical Immunology Program, 825 NE 13th Street, OK 73104, USA.
| | - John A Chiorini
- NIH, Adeno-Associated Virus Biology Section, National Institute of Dental and Craniofacial Research, Building 10, Room 1n113, 10 Center DR Msc 1190, Bethesda, MD 20892-1190, USA.
| | - Jing He
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - Julian L Ambrus
- Division of Allergy, Immunology and Rheumatology, SUNY at Buffalo School of Medicine, 100 High Street, Buffalo, NY 14203, USA.
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Baker JF, George MD. Prevention of Infection in the Perioperative Setting in Patients with Rheumatic Disease Treated with Immunosuppression. Curr Rheumatol Rep 2019; 21:17. [PMID: 30847768 DOI: 10.1007/s11926-019-0812-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Patients with autoimmune rheumatic disease are at increased risk of infection after surgery. The goal of this manuscript is to review current evidence on important contributors to infection risk in these patients and the optimal management of immunosuppression in the perioperative setting. RECENT FINDINGS Recent studies have confirmed that patients with autoimmune rheumatic disease, including rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), are at increased risk of infection after surgery, with most evidence coming from studies of joint replacement surgery. Immunosuppression, disease activity, comorbidities, demographics, and surgeon and hospital volume are all important contributors to post-operative infection risk. Recently published guidelines regarding immunosuppression management before joint replacement recommend continuing the conventional disease-modifying drugs used to treat RA (e.g., methotrexate) without interruption, holding more potent conventional therapies for 1 week unless the underlying disease is severe, and holding biologic therapies for one dosing interval before surgery. Recent observational data suggests that holding biologics may not have a substantial impact on infection risk. These data also implicate glucocorticoids as a major contributor to post-operative infection risk. Observational data supports recent recommendations to continue many therapies in the perioperative period with only short interruptions of biologics and other potent immunosuppression. Even brief interruptions may not significantly lower risk, although the field continues to evolve. Clinicians should also consider other risk factors and should focus on minimizing glucocorticoids before surgery when possible to limit the risk of post-operative infection.
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Affiliation(s)
- Joshua F Baker
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia VA Medical Center, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA.
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Zainul-Abidin S, Amanatullah DF, Anderson MB, Austin M, Barretto JM, Battenberg A, Bedard NA, Bell K, Blevins K, Callaghan JJ, Cao L, Certain L, Chang Y, Chen JP, Cizmic Z, Coward J, DeMik DE, Diaz-Borjon E, Enayatollahi MA, Feng JE, Fernando N, Gililland JM, Goodman S, Goodman S, Greenky M, Hwang K, Iorio R, Karas V, Khan R, Kheir M, Klement MR, Kunutsor SK, Limas R, Morales Maldonado RA, Manrique J, Matar WY, Mokete L, Nung N, Pelt CE, Pietrzak JRT, Premkumar A, Rondon A, Sanchez M, Novaes de Santana C, Sheth N, Singh J, Springer BD, Tay KS, Varin D, Wellman S, Wu L, Xu C, Yates AJ. General Assembly, Prevention, Host Related General: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S13-S35. [PMID: 30360983 DOI: 10.1016/j.arth.2018.09.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
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.
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Affiliation(s)
- Jesse Wolfe
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA
| | - Joshua Wolfe
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA
| | - H John Visser
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA.
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Ronald MacKenzie C, Goodman SM, Miller AO. The management of surgery and therapy for rheumatic disease. Best Pract Res Clin Rheumatol 2018; 32:735-749. [DOI: 10.1016/j.berh.2019.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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[Perioperative management of immunosuppressive treatment in patients undergoing joint surgery]. Z Rheumatol 2018; 76:767-775. [PMID: 28913596 DOI: 10.1007/s00393-017-0379-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The perioperative management of patients on immunosuppressive drugs is uncertain due to a lack of controlled studies. Continuation of medication without a pause may increase the risk of postoperative infections and wound healing disorders and when the pause is too long this can induce a flare of the underlying rheumatic disease. Additional factors, such as rheumatic disease activity, comorbidities, previous infections and the type of surgical procedure also modulate the risk. The highest risk of infection is associated with corticosteroids depending on the dose, so that a dosage as low as possible but stable in the perioperative period is recommended. Among the conventional disease-modifying antirheumatic drugs (DMARDs) only methotrexate has been sufficiently investigated and in this case a pause in treatment induces higher risks than continuation. Antimalarial agents and sulphasalazine should be continued due to the low risks, whereas leflunomide should be washed out before major surgical interventions. The perioperative risk of treatment with biologics is still far from clear; therefore, as a rule of thumb, withholding treatment for two serum half-lives before an intervention and restarting after completed wound healing are recommended.
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Ward IM, Knott A. Practical Pearls About Current Rheumatic Medications. Prim Care 2018; 45:193-212. [PMID: 29759120 DOI: 10.1016/j.pop.2018.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
New and existing rheumatic disease is frequently encountered in the primary care setting. The number of medications used to treat various rheumatic conditions continues to increase. Some medications have very specific indications, whereas others have increasing off-label uses. Regardless of the indication, the medications used in rheumatology have variable dosing recommendations, significant side effects, recommended monitoring parameters, and potential medication interactions. Clinicians need to be aware of the potential uses as well as possible pitfalls associated with medications used in rheumatology.
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Affiliation(s)
- Ian M Ward
- Rheumatology Service, Department of Medicine, Landstuhl Regional Medical Center, Landstuhl, Germany.
| | - Amanda Knott
- Department of Pharmacy, Landstuhl Regional Medical Center, Landstuhl, Germany
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Premkumar A, Morse K, Levack AE, Bostrom MP, Carli AV. Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: Prevention and Diagnosis. Curr Rheumatol Rep 2018; 20:68. [PMID: 30203376 DOI: 10.1007/s11926-018-0777-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Periprosthetic joint infection (PJI) is a devastating complication that can occur following total joint arthroplasty (TJA), causing significant morbidity and often requiring revision surgery. This goal of this manuscript is to review the current evidence for the prevention and diagnosis of PJI in patients with inflammatory arthritis. RECENT FINDINGS Patients with inflammatory arthritis have a higher risk of PJI after TJA; however, there are several preventive, diagnostic, and therapeutic measures that can be optimized to lower the burden of PJI in this population. This manuscript will review the current evidence and clinical practice recommendations that support specific features of preoperative evaluation, perioperative medication management, and surgical planning in inflammatory arthritis patients undergoing TJA. Evidence and recommendations for the diagnosis of PJI in this patient population will also be reviewed. Despite increased research efforts directed towards PJI, specific approaches directed at the inflammatory arthritis patient population remain surprisingly limited. Optimization strategies such as adequately managing disease-modifying medications, treating preoperative anemia, encouraging smoking cessation, and improving weight management are strongly encouraged before entering the perioperative period. If PJI does occur in the inflammatory arthritis patient, establishing the diagnosis is challenging, since guidelines were created from investigations of PJI in primarily patients without inflammatory arthritis. Future prospective research is required to better guide clinicians in preventing and diagnosing PJI in inflammatory arthritis patients undergoing TJA.
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Affiliation(s)
- Ajay Premkumar
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Kyle Morse
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ashley E Levack
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Mathias P Bostrom
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Alberto V Carli
- Department of Academic Training, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Holroyd CR, Seth R, Bukhari M, Malaviya A, Holmes C, Curtis E, Chan C, Yusuf MA, Litwic A, Smolen S, Topliffe J, Bennett S, Humphreys J, Green M, Ledingham J. The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis. Rheumatology (Oxford) 2018; 58:e3-e42. [DOI: 10.1093/rheumatology/key208] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Christopher R Holroyd
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rakhi Seth
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Marwan Bukhari
- Rheumatology Department, University Hospitals of Morecombe Bay NHS Foundation Trust, Lancaster, UK
| | - Anshuman Malaviya
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Claire Holmes
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elizabeth Curtis
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Christopher Chan
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mohammed A Yusuf
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Anna Litwic
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- Rheumatology Department, Salisbury District Hospital, Salisbury, UK
| | - Susan Smolen
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Joanne Topliffe
- Rheumatology Department, Mid Essex hospitals NHS Trust, Chelmsford, UK
| | - Sarah Bennett
- Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jennifer Humphreys
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Muriel Green
- National Rheumatoid Arthritis Society, Queen Alexandra Hospital, Portsmouth, UK
| | - Jo Ledingham
- Rheumatology Department, Queen Alexandra Hospital, Portsmouth, UK
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Economic Evaluation of Antibacterial Coatings on Healthcare Costs in First Year Following Total Joint Arthroplasty. J Arthroplasty 2018. [PMID: 29530518 DOI: 10.1016/j.arth.2018.01.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Antibacterial coatings (ABCs) of implants have proven safe and effective to reduce postsurgical infection, but little is known about their possible economic impact on large-scale use. This study evaluated the point of economic balance, during the first year after surgery, and the potential overall annual healthcare cost savings of 3 different antibacterial technologies applied to joint arthroplasty: a dual-antibiotic-loaded bone cement (COPAL G + C), an antibacterial hydrogel coating (DAC), and a silver coating (Agluna). METHODS The variables included in the algorithm were average cost and number of primary joint arthroplasties; average cost per patient of the ABC; incidence of periprosthetic joint infections and expected reduction using the ABCs; average cost of infection treatment and expected number of cases. RESULTS The point of economic balance for COPAL G + C, DAC, and Agluna in the first year after surgery was reached in patient populations with an expected postsurgical infection rate of 1.5%, 2.6%, and 19.2%, respectively. If applied on a national scale, in a moderately high-risk population of patients with a 5% expected postsurgical infection rate, COPAL G + C and DAC hydrogel would provide annual direct cost savings of approximately €48,800,000 and €43,200,000 (€1220 and €1080 per patient), respectively, while the silver coating would be associated with an economic loss of approximately €136,000,000. CONCLUSION This economic evaluation shows that ABC technologies have the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections, provided that the technology is used in the appropriate risk class of patients.
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Gualtierotti R, Parisi M, Ingegnoli F. Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview. Adv Ther 2018; 35:439-456. [PMID: 29556907 PMCID: PMC5910481 DOI: 10.1007/s12325-018-0686-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 02/06/2023]
Abstract
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.
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Goodman SM, Bass AR. Perioperative medical management for patients with RA, SPA, and SLE undergoing total hip and total knee replacement: a narrative review. BMC Rheumatol 2018; 2:2. [PMID: 30886953 PMCID: PMC6390575 DOI: 10.1186/s41927-018-0008-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022] Open
Abstract
Total hip (THA) and total knee arthroplasty (TKA) are widely used, successful procedures for symptomatic end stage arthritis of the hips or knees, but patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and spondyloarthritis (SPA) including ankylosing spondylitis (AS) and psoriatic arthritis (PSA) are at higher risk for adverse events after surgery. Utilization rates of THA and TKA remain high for patients with RA, and rates of arthroplasty have increased for patients with SLE and SPA. However, complications such as infection are increased for patients with SLE, RA, and SPA, most of whom are receiving potent immunosuppressant medications and glucocorticoids at the time of surgery. Patients with SLE and AS are also at increased risk for perioperative cardiac and venous thromboembolism (VTE), while RA patients do not have an increase in perioperative cardiac or VTE risk, despite an overall increase in VTE and cardiac disease. This narrative review will discuss the areas of heightened risk for patients with RA, SLE, and SPA, and the perioperative management strategies currently used to minimize the risks.
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Affiliation(s)
- Susan M. Goodman
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
| | - Anne R. Bass
- Department of Medicine, Weill Cornell Medical School, Division of Rheumatology Hospital for Special Surgery, 535 E 70th St, New York City, NY 10021 USA
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Vittecoq O, Richard L, Banse C, Lequerré T. The impact of smoking on rheumatoid arthritis outcomes. Joint Bone Spine 2017; 85:135-138. [PMID: 29246527 DOI: 10.1016/j.jbspin.2017.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Olivier Vittecoq
- Service de rhumatologie, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France; Université de Rouen, 76000 Rouen, France.
| | - Laetitia Richard
- Service de rhumatologie, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France; Université de Rouen, 76000 Rouen, France
| | - Christopher Banse
- Service de rhumatologie, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France; Université de Rouen, 76000 Rouen, France
| | - Thierry Lequerré
- Service de rhumatologie, CHU de Rouen, 1, rue de Germont, 76031 Rouen cedex, France; Université de Rouen, 76000 Rouen, France
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George MD, Baker JF, Hsu JY, Wu Q, Xie F, Chen L, Yun H, Curtis JR. Perioperative Timing of Infliximab and the Risk of Serious Infection After Elective Hip and Knee Arthroplasty. Arthritis Care Res (Hoboken) 2017; 69:1845-1854. [PMID: 28129484 DOI: 10.1002/acr.23209] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/24/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The optimal timing of tumor necrosis factor antagonists before elective surgery is unknown. This study evaluated the association between infliximab timing and serious infection after elective hip or knee arthroplasty. METHODS A retrospective cohort study evaluated US Medicare patients with rheumatoid arthritis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or ankylosing spondylitis who received infliximab within 6 months of elective knee or hip arthroplasty from 2007 to 2013. Propensity-adjusted analyses examined whether infliximab stop timing (time between the most recent infusion and surgery) was associated with hospitalized infection within 30 days or prosthetic joint infection (PJI) within 1 year. RESULTS Hospitalized infection within 30 days occurred after 270 of 4,288 surgeries (6.3%). Infliximab stop timing <4 weeks versus 8-12 weeks was not associated with an increase in infection within 30 days (propensity-adjusted odds ratio [OR] 0.90 [95% confidence interval (95% CI) 0.60-1.34]). The rate of PJI was 2.9 per 100 person-years and was not increased in patients with stop timing <4 weeks versus 8-12 weeks (hazard ratio [HR] 0.98 [95% CI 0.52-1.87]). Glucocorticoid dosage >10 mg/day was associated with increased risk of 30-day infection (OR 2.11 [95% CI 1.30-3.40]) and PJI (HR 2.70 [95% CI 1.30-5.60]). Other risk factors for infection included elderly age, comorbidities, revision surgery, and previous hospitalized infection. CONCLUSION Administering infliximab within 4 weeks of elective knee or hip arthroplasty was not associated with a higher risk of short- or long-term serious infection compared to withholding infliximab for longer time periods. Glucocorticoid use, especially >10 mg/day, was associated with an increased infection risk.
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Affiliation(s)
| | - Joshua F Baker
- University of Pennsylvania and Philadelphia Veterans Affairs Medical Center, Philadelphia
| | | | - Qufei Wu
- University of Pennsylvania, Philadelphia
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Abstract
Perioperative medication management for patients with systemic autoimmune inflammatory diseases has focused on strategies to improve outcomes and mitigate risks. The emphasis has been to minimize the risk of infection associated with most antirheumatic medications, while attempting to avoid flares of disease precipitated by medication withdrawal. Management of glucocorticoids in the perioperative period has been based on an assumption that supraphysiologic increases in dose were always necessary to avoid hypotension and shock in glucocorticoid treated patients, and alternative strategies were rarely considered despite the known infectious, metabolic, and wound healing risks associated with glucocorticoid administration. This paper will review current recommendations for perioperative glucocorticoid administration for glucocorticoid treated patients with systemic inflammatory autoimmune diseases and discuss glucocorticoid physiology to analyze the basis for these recommendations and consider alternative perioperative management strategies.
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Affiliation(s)
- C Ronald MacKenzie
- Department of Rheumatology, Weill Cornell Medicine, Hospital for Special Surgery, New York, NY, USA.
| | - Susan M Goodman
- Department of Rheumatology, Weill Cornell Medicine, Hospital for Special Surgery, New York, NY, USA
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Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, Gewurz-Singer O, Giles JT, Johnson B, Lee S, Mandl LA, Mont MA, Sculco P, Sporer S, Stryker L, Turgunbaev M, Brause B, Chen AF, Gililland J, Goodman M, Hurley-Rosenblatt A, Kirou K, Losina E, MacKenzie R, Michaud K, Mikuls T, Russell L, Sah A, Miller AS, Singh JA, Yates A. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. J Arthroplasty 2017. [PMID: 28629905 DOI: 10.1016/j.arth.2017.05.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). METHODS A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. RESULTS The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. CONCLUSION This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.
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Affiliation(s)
- Susan M Goodman
- Susan M. Goodman, MD, Lisa A. Mandl, MD, MPH, Peter Sculco, MD, Barry Brause, MD, Kyriakos Kirou, MD, Ronald MacKenzie, MD, Linda Russell, MD: Hospital for Special Surgery/Weill Cornell Medicine, New York, New York.
| | - Bryan Springer
- Bryan Springer, MD: OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Gordon Guyatt
- Gordon Guyatt, MD: McMaster University, Hamilton, Ontario, Canada
| | | | - Vinod Dasa
- Vinod Dasa, MD: Louisiana State University, New Orleans
| | - Michael George
- Michael George, MD: University of Pennsylvania, Philadelphia
| | | | - Jon T Giles
- Jon T. Giles, MD, MPH: Columbia University, New York, New York
| | - Beverly Johnson
- Beverly Johnson, MD: Albert Einstein College of Medicine, Bronx, New York
| | - Steve Lee
- Steve Lee, DO: Kaiser Permanente, Fontana, California
| | - Lisa A Mandl
- Susan M. Goodman, MD, Lisa A. Mandl, MD, MPH, Peter Sculco, MD, Barry Brause, MD, Kyriakos Kirou, MD, Ronald MacKenzie, MD, Linda Russell, MD: Hospital for Special Surgery/Weill Cornell Medicine, New York, New York
| | | | - Peter Sculco
- Susan M. Goodman, MD, Lisa A. Mandl, MD, MPH, Peter Sculco, MD, Barry Brause, MD, Kyriakos Kirou, MD, Ronald MacKenzie, MD, Linda Russell, MD: Hospital for Special Surgery/Weill Cornell Medicine, New York, New York
| | - Scott Sporer
- Scott Sporer, MD: Midwest Orthopaedics at Rush, Chicago, Illinois
| | - Louis Stryker
- Louis Stryker, MD: University of Texas Medical Branch, Galveston
| | - Marat Turgunbaev
- Marat Turgunbaev, MD, MPH, Amy S. Miller: American College of Rheumatology, Atlanta, Georgia
| | - Barry Brause
- Susan M. Goodman, MD, Lisa A. Mandl, MD, MPH, Peter Sculco, MD, Barry Brause, MD, Kyriakos Kirou, MD, Ronald MacKenzie, MD, Linda Russell, MD: Hospital for Special Surgery/Weill Cornell Medicine, New York, New York
| | - Antonia F Chen
- Antonia F. Chen, MD, MBA: Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Mark Goodman
- Mark Goodman, MD, Adolph Yates, MD: University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Kyriakos Kirou
- Susan M. Goodman, MD, Lisa A. Mandl, MD, MPH, Peter Sculco, MD, Barry Brause, MD, Kyriakos Kirou, MD, Ronald MacKenzie, MD, Linda Russell, MD: Hospital for Special Surgery/Weill Cornell Medicine, New York, New York
| | - Elena Losina
- Elena Losina, PhD: Brigham and Women's Hospital, Boston, Massachusetts
| | - Ronald MacKenzie
- Susan M. Goodman, MD, Lisa A. Mandl, MD, MPH, Peter Sculco, MD, Barry Brause, MD, Kyriakos Kirou, MD, Ronald MacKenzie, MD, Linda Russell, MD: Hospital for Special Surgery/Weill Cornell Medicine, New York, New York
| | - Kaleb Michaud
- Kaleb Michaud, PhD: National Data Bank for Rheumatic Diseases, Wichita, Kansas and University of Nebraska Medical Center, Omaha
| | - Ted Mikuls
- Ted Mikuls, MD, MSPH: University of Nebraska Medical Center, Omaha
| | - Linda Russell
- Susan M. Goodman, MD, Lisa A. Mandl, MD, MPH, Peter Sculco, MD, Barry Brause, MD, Kyriakos Kirou, MD, Ronald MacKenzie, MD, Linda Russell, MD: Hospital for Special Surgery/Weill Cornell Medicine, New York, New York
| | - Alexander Sah
- Alexander Sah, MD: Dearborn-Sah Institute for Joint Restoration, Fremont, California
| | - Amy S Miller
- Marat Turgunbaev, MD, MPH, Amy S. Miller: American College of Rheumatology, Atlanta, Georgia
| | | | - Adolph Yates
- Mark Goodman, MD, Adolph Yates, MD: University of Pittsburgh, Pittsburgh, Pennsylvania
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