Postoperative complications in patients with rheumatoid arthritis using a biological agent – A systematic review and meta-analysis

Complications after orthopaedic surgeries in patients with rheumatoid arthritis treated with Janus kinase inhibitors: A retrospective observational study

OBJECTIVES

The current study compared the outcome after orthopaedic surgeries in patients with rheumatoid arthritis receiving Janus kinase inhibitors (JAKis) versus biologic disease-modifying anti-rheumatic drugs (bDMARDs).

METHODS

This was a retrospective observational study of Japanese patients with rheumatoid arthritis. Sixty-two patients with rheumatoid arthritis using JAKi preoperatively underwent orthopaedic surgeries. Using propensity score matching, these 62 patients were matched with 62 patients using bDMARDs preoperatively. The number of adverse events was counted. We also examined whether the drug-withholding period in the JAKi-treated group was associated with the occurrence of major postoperative adverse events, namely inflammatory flares and delayed wound healing.

RESULTS

JAKi-treated patients had a higher incidence of postoperative flares than bDMARD-treated patients (29% versus 12.1%, P = .01). The incidences of postoperative complications other than flares were not significantly different between the two groups. Among the JAKi-treated group, a longer perioperative drug-withholding period (≥11 days) was associated with a higher incidence of postoperative flares (P = .04). The incidences of delayed wound healing and surgical site infection were not associated with the duration of the JAKi-withholding period.

CONCLUSIONS

JAKi-treated patients had a higher incidence of postoperative flares than bDMARD-treated patients. A total of ≥11 days of drug withdrawal was associated with postoperative flares.

Development of biomedical hydrogels for rheumatoid arthritis treatment

Rheumatoid Arthritis (RA) is an autoimmune disorder that hinders the normal functioning of bones and joints and reduces the quality of human life. Every year, millions of people are diagnosed with RA worldwide, particularly among elderly individuals and women. Therefore, there is a global need to develop new biomaterials, medicines and therapeutic methods for treating RA. This will improve the Healthcare Access and Quality Index and also relieve administrative and financial burdens on healthcare service providers at a global scale. Hydrogels are soft and cross-linked polymeric materials that can store a chunk of fluids, drugs and biomolecules for hydration and therapeutic applications. Hydrogels are biocompatible and exhibit excellent mechanical properties, such as providing elastic cushions to articulating joints by mimicking the natural synovial fluid. Hence, hydrogels create a natural biological environment within the synovial cavity to reduce autoimmune reactions and friction. Hydrogels also lubricate the articulating joint surfaces to prevent degradation of synovial surfaces of bones and cartilage, thus exhibiting high potential for treating RA. This work reviews the progress in injectable and implantable hydrogels, synthesis methods, types of drugs, advantages and challenges. Additionally, it discusses the role of hydrogels in targeted drug delivery, mechanistic behaviour and tribological performance for RA treatment.

Early Resection of the Tibialis Anterior Tendon for Tendon Exposure After Total Ankle Arthroplasty to Prevent Deep Infection: A Report of Three Cases in Patients With Rheumatoid Arthritis

Exposure of the tibialis anterior (TA) tendon with wound dehiscence after total ankle arthroplasty (TAA) with the anterior approach is a problematic complication, especially in rheumatoid arthritis (RA) patients. Once the TA tendon is exposed, the duration of wound healing is prolonged, and it could be a risk factor for deep infection. Thus, early resection of the TA tendon was evaluated for tendon exposure with wound dehiscence after TAA in RA patients. In this case report, three rheumatoid ankles that showed wound dehiscence with exposure of the TA tendon after TAA with the anterior approach are presented. Early resection of the TA tendon and debridement under local anesthesia were performed within two days after wound dehiscence. In all cases, wound healing was completed within two weeks after the treatment. Drop foot was not seen in any patients, and there was no difference between the pre and postoperative (1 year after TAA) range of dorsiflexion. Muscle strength for ankle dorsiflexion was also maintained. In conclusion, early resection of the TA tendon appears to be a useful option for undesirable tendon exposure with wound dehiscence to prevent deep infection and prolonged wound healing after total ankle arthroplasty in RA patients.

The Relationship Between Autoimmune Disease and Disease-Modifying Antirheumatic Drugs on Wound Healing

Objective: To evaluate the role of disease-modifying antirheumatic drugs (DMARDs) on wound healing outcomes of patients with autoimmune disease at our tertiary wound care center. Approach: Retrospective review of patients presenting to our wound care center between 2014 and 2018 with both chronic wounds and a history of inflammatory disease. Patient demographics, comorbid conditions, and progression to complete wound healing were compared between those taking DMARDs or not at the time of wound onset. The study adheres to the STROBE statement. Results: Fifty-eight patients with a total of 296 wounds were retrospectively reviewed. Patients were taking at least one DMARD at wound onset in 217 (73.3%) of these wounds. The average number of DMARDs at wound onset was 1.5 (standard deviation 1.2). Two hundred ten wounds progressed to heal (70.9%), with a median time to healing of 229.5 days (interquartile range 71.0-490.0). Of the 210 wounds that healed, patients taking at least one DMARD had a significantly shorter time to healing relative to patients who were not on any DMARDs (median 190.5 days vs. 340.0 days, p = 0.0156). Innovation: Characterizing wound healing outcomes at a tertiary hospital with a dedicated wound care center and analyzing the role of DMARDs in wound healing progression. Conclusions: The median time to healing in the studied cohort was 229.5 days, which is much longer than the healing time for noninfected diabetic foot ulcers at our institution. These findings highlight the wound healing challenges posed by underlying autoimmune disease.¹⁰.

Rheumatoid Arthritis in Spine Surgery: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVE

The purpose of this study is to synthesize recommendations for perioperative medical management of RA patients and quantify outcomes after spine surgery when compared to patients without RA.

METHODS

A search of available literature on patients with RA and spine surgery was performed. Studies were included if they provided a direct comparison of outcomes between patients undergoing spine surgery with or without RA diagnosis. Meta-analysis was performed on operative time, estimated blood loss, hospital length of stay, overall complications, implant-related complications, reoperation, infection, pseudarthrosis, and adjacent segment disease.

RESULTS

Included in the analysis were 9 studies with 703 patients with RA undergoing spine surgery and 2569 patients without RA. In RA patients compared to non-RA patients undergoing spine surgery, the relative risk of infection was 2.29 times higher (P = .036), overall complications 1.61 times higher (P < .0001), implant-related complications 3.93 times higher (P = .009), and risk of reoperation 2.45 times higher (P < .0001). Hospital length of stay was 4.6 days longer in RA patients (P < .0001).

CONCLUSIONS

Treatment of spinal pathology in patients with RA carries an increased risk of infection and implant-related complications. Spine-specific guidelines for perioperative management of antirheumatic medication deserve further exploration. All RA patients should be perioperatively co-managed by a rheumatologist. This review helps identify risk profiles in RA specific to spine surgery and may guide future studies seeking to medically optimize RA patients perioperatively.

The Effect of Perioperative Biologic Disease-Modifying Anti-Rheumatic Drugs on the Risk of Postoperative Complications: Surgical Site Infection, Delayed Wound Healing, and Disease Flares Following Orthopaedic Surgical Procedures

BACKGROUND

Biologic disease-modifying anti-rheumatic drugs (bDMARDs) are effective in treating inflammatory diseases and have been increasingly utilized over the past decade. Patients who receive bDMARDs have been shown to be at an increased risk for surgical site infection following surgical procedures. The severe consequences of infection following orthopaedic surgery have led to the practice of withholding bDMARDs perioperatively; however, there has been no definitive evidence showing a clear benefit of withholding the use of bDMARDs, and in doing so, patients may be at an increased risk for higher disease activity. As such, the purpose of the present study was to compare the risk of infection, delayed wound healing, and disease flares associated with the use of bDMARDs in patients undergoing orthopaedic surgical procedures.

METHODS

We performed a systematic literature search of MEDLINE, Embase, and PubMed CENTRAL databases for studies comparing continuing and withholding the use of bDMARDs in patients undergoing orthopaedic procedures. Inclusion criteria were established following the PICO (Population, Intervention, Comparison, and Outcomes) approach: Population = patients who underwent orthopaedic surgical procedures and who were taking bDMARDs. Intervention = withholding the use of bDMARDs. Comparator = continuing the use of bDMARDs. Outcomes = surgical site infection, delayed wound healing, and disease flares. Article titles and abstracts were screened prior to review of the full text. Overall odds ratios (ORs) and associated 95% confidence intervals (CIs) for pooled effects were calculated.

RESULTS

Eleven studies met the inclusion criteria, providing data for 7,344 patients, including 2,385 patients who continued and 4,959 who withheld their bDMARDs perioperatively. Continuing bDMARDs was associated with a significantly lower risk of disease flares (OR, 0.22; 95% CI, 0.05 to 0.95; p = 0.04) and nonsignificant increases in surgical site infections (OR, 1.11; 95% CI, 0.82 to 1.49; p = 0.49) and wound complications (OR, 2.16; 95% CI, 0.48 to 9.85; p = 0.32).

CONCLUSIONS

The present systematic review highlights the limited evidence supporting the current practice of stopping bDMARDs perioperatively. These findings suggest that patients may not be at an increased risk for developing infection or wound complications if bDMARDs are continued but are at an increased risk for disease flare if bDMARDs are withheld. However, our conclusions are limited by the retrospective and heterogenous nature of the data, and possibly by a lack of study power.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Replacement in Patients with Rheumatoid Arthritis: Trends in Incidence and Complication Rates Over 35 Years

INTRODUCTION

Advances in rheumatoid arthritis (RA) management have made disease remission achievable. We evaluated trends in total hip replacement (THR) and postoperative outcomes in patients with RA in Western Australia (WA) over more than three decades.

METHODS

This was a retrospective analysis of routinely collected prospective data from a state-wide registry containing longitudinally linked administrative health data based on International Classification of Diseases (ICD) diagnostic and procedural codes. We included patients with two or more diagnostic codes for RA (between 1980 and 2015) and studied THR incidence rates (THR IR) and complication rates (revision, peri-prosthetic fracture, infection, venous thrombosis, and mechanical loosening). Survival rates were estimated by Kaplan-Meier method and predictors analyzed by Cox regression.

RESULTS

We followed 9201 RA patients over 111,625 person-years, during which 1560 patients (16.9%) underwent THR. From 1985 to 2015, THR IR (per 1000 RA patient-years) decreased from 20.8 (95% CI 20.1-21.5) to 7.3 (95% CI 7.2-7.5), and 5-year THR-free survival increased from 84.3 to 95.3% (1980-2015). Ten-year prosthetic survival was 91.2%. Complication rates in the first 5 years post-THR decreased significantly from 13.1 to 3.7% (p < 0.001). Mechanical complications such as loosening and periprosthetic fracture rates decreased significantly (> 35%, P < 0.05), while infection and revision did not change over the observation period (p > 0.05).

CONCLUSIONS

Over the last 30 years in RA patients, THR IR and mechanical complication rates decreased significantly, but the medical complication of infection has not changed significantly.

Long-term outcomes and duration of outdoor ambulation following primary total knee arthroplasty in patients with rheumatoid arthritis

BACKGROUND

The medical treatment of rheumatoid arthritis (RA) has made remarkable progress with the introduction of methotrexate and biological agents. However, there have been few reports of long-term results of total knee arthroplasty (TKA) for RA since the introduction of these drugs. Ambulation is an important form of exercise for maintaining health. We investigated the long-term outcomes and the ability to walk outdoors following TKA in patients with RA.

METHODS

We retrospectively reviewed 142 patients with RA (201 knees) who had undergone primary TKA. The mean follow-up was 10.6 years.

RESULTS

Markers of RA disease activity all improved significantly postoperatively. Mean Japanese Orthopedic Association scores improved from 49.3 points before surgery to 81.8 at follow-up. The mean maximum flexion angle improved from 107.8° to 112.9°. The causes of TKA revision comprised 2 mechanical loosening, 1 late infection, and 1 fracture of the femoral condyle. The survival rate of TKA was 96.6% at 15 years. Fifty-five patients were not able to walk outdoors. The rate of inability to ambulate outdoors was 38.3 per 1000 person-years. The survival rate of ability to ambulate outdoors were 48.8% at 15 years. Preoperative advanced age, low body weight, steroid use and non-use of biologics were identified as risk factors for inability to ambulate outdoors.

CONCLUSIONS

Although the cumulative survival rate of TKA implants was as good as 96.6% in 15 years, the cumulative rate of ability to ambulate outdoors was only 48.8%. The reason for the inability to walk outdoors was thought to be mainly due to deterioration of RA, comorbidity or muscular weakness associated with aging, rather than knee dysfunction.

Comprehensive risk analysis of postoperative complications in patients with rheumatoid arthritis for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis

OBJECTIVES

To examine the risk factors of surgical site infection (SSI), delayed wound healing, and death after orthopedic surgery in patients with rheumatoid arthritis (RA).

METHODS

We identified articles indexed in the Cochrane Library, PubMed, and Japan Centra Revuo Medicina Web published from 2013 to 2019 and other articles. Articles fulfilling the predefined inclusion criteria were reviewed systematically and their quality was appraised according to the Grading of Recommendations Assessment, Development, and Evaluation system with some modifications.

RESULTS

After inclusion and exclusion by full-text review, 29 articles were analyzed. Use of biological disease modifying antirheumatic drugs was a risk factor of SSI (risk ratio 1.66, 95% confidence interval 1.25-2.19), but not of delayed wound healing. RA itself was a risk factor of SSI, and oral glucocorticoid use was a risk factor of SSI in three of the four studies analyzed and of postoperative death. Age, male sex, comorbidities such as diabetes mellitus and chronic obstructive pulmonary disease, surgical factors such as foot/ankle and spine surgery and longer operative time were risk factors of those postoperative complications.

CONCLUSION

Patients with those factors should be dealt with appropriate cautions to strike a risk-benefit balance of orthopedic surgeries.

Does exercise therapy improve patient-reported outcomes in rheumatoid arthritis? A systematic review and meta-analysis for the update of the 2020 JCR guidelines for the management of rheumatoid arthritis

OBJECTIVES

This study aimed to evaluate the impact of exercise therapy on patient-reported outcomes (PROs) in rheumatoid arthritis (RA) as part of the process of updating the 2020 Japanese guidelines for the management of RA according to the Grading of Recommendations, Assessment, Development, and Evaluation system.

METHODS

We searched PubMed, Japana Centra Revuo Medicina Web, and the Cochrane Library (from 2009 to 2018) to identify articles that evaluated PROs of exercise therapy and RA disease activity.

RESULTS

A total of 662 articles were identified, including nine RCTs, and meta-analyses were performed on six RCTs on systemic exercise therapy and three RCTs on upper extremity exercise therapy. Analyzed exercise therapies were diverse, differing in target population, intervention method, and duration. Significant improvements were observed in the Health Assessment Questionnaire Disability Index (mean difference -0.35, 95% confidence interval (CI): -0.60 to -0.10), pain (standardized mean difference -2.04, 95% CI: -3.77 to -0.32), and SF-36. For upper extremity exercise therapy, significant improvements in PROs (Disabilities of the Arm, Shoulder, and Hand Questionnaire, Michigan Hand Outcome Questionnaire) were observed.

CONCLUSION

Exercise therapy in RA treatment improves patient subjective assessment of pain, physical function, and quality of life.

Patient satisfaction with total joint replacement surgery for rheumatoid arthritis: a questionnaire survey for the 2020 update of the Japan college of rheumatology clinical practice guidelines

OBJECTIVE

This study aimed to evaluate satisfaction with total joint replacement (TJR) surgery among patients with rheumatoid arthritis (RA).

METHODS

We mailed questionnaires to randomly selected members of the Japan Rheumatism Friendship Association, stratified by age and prefecture, throughout Japan. The questionnaire collected demographic and clinical characteristics as well as patients' satisfaction with TJR and their current therapy.

RESULTS

Of the 1156 patients who returned the questionnaire, 339 (29.3%) responded that they had had TJR of any type. The mean age was 66.6 years, and 94.4% were women. The mean time period from the hip and knee TJR was 14-15 years. Over half of the patients who had had TJR were satisfied with the results, especially those who had had hip (89.6%) and knee TJR (87.3%), who reported a high level of satisfaction. Multivariable linear regression analysis revealed that, in patients with knee TJR, satisfaction with current therapy was significantly related to whether they were satisfied with the results of the surgery.

CONCLUSION

Most patients with RA who had undergone TJR were satisfied with the results even after a long period of time, and their level of satisfaction was associated with their satisfaction with current therapy.

Immunomodulatory treatment and surgical management of idiopathic uveitis and juvenile idiopathic arthritis-associated uveitis in children: a French survey practice

BACKGROUND

Surgeries for idiopathic uveitis and juvenile idiopathic arthritis-associated uveitis in children are complex because of the high risk of inflammatory postoperative complications. There is no consensus about treatment adaptation during the perioperative period. The objectives of this study are to report the therapeutic changes made in France and to determine whether maintaining or stopping immunosuppressive therapies is associated with an increased risk of surgical site infection or an increased risk of uveitis or arthritis flare-up.

METHODS

We conducted a retrospective cohort study between January 1, 2006 and December 31, 2018 in six large University Hospitals in France. Inclusion criteria were chronic idiopathic uveitis or chronic uveitis associated with juvenile idiopathic arthritis under immunosuppressive therapies at the time of the surgical procedure, operated before the age of 16. Data on perioperative treatments, inflammatory relapses and post-operative infections were collected.

RESULTS

A total of 76 surgeries (42% cataract surgeries, 30% glaucoma surgeries and 16% posterior capsule opacification surgeries) were performed on 37 children. Adaptation protocols were different in the six hospitals. Immunosuppressive therapies were discontinued in five cases (7%) before surgery. All the children in the discontinuation group had an inflammatory relapse within 3 months after surgery compared to only 25% in the other group. There were no postoperative infections.

CONCLUSIONS

The results of this study show varying practices between centres. The benefit-risk balance seems to favour maintaining immunosuppressive therapies during surgery. Further studies are needed to determine the optimal perioperative treatments required to limit post-operative inflammatory relapses.

Incidence and Complication Rates for Total Hip Arthroplasty in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis Across Four Decades

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.

Expression of miR-495 and miR-326 in peripheral blood of rheumatoid arthritis patients and its significance

The aim of the present study was to investigate the expression of microRNA (miR)-495 and miR-326 in the peripheral blood of patients with rheumatoid arthritis (RA). A total of 107 RA patients, admitted to the Yidu Central Hospital of Weifang (Weifang, China) from February 2016 to February 2019, and 112 healthy subjects, who underwent physical examination during the same period, were selected as the research subjects for prospective analysis. The RA patients served as the study group and the healthy subjects as the control group. The expression levels of miR-495 and miR-326 in the peripheral blood of the two groups of subjects were compared. The association between miR-495 and miR-326 with RA clinical pathology and the diagnostic value of miR-495 and miR-326 for RA were analyzed. In the study group, miR-495 expression was significantly higher than that in the control group, and miR-326 expression was significantly lower than that in the control group (P<0.001). miR-495 and miR-326 combined diagnosis showed good predictive value for the occurrence of RA (P<0.001) and was closely related to RA clinical pathology (P<0.001). After treatment, miR-495 expression was significantly decreased in the study group, whereas miR-326 expression was significantly increased (P<0.001). Pearson's correlation coefficient analysis showed that rheumatoid factor (RF) was positively correlated with miR-495 expression and negatively correlated with miR-326 expression (P<0.001). In conclusion, miR-495 was highly expressed in patients with RA, whereas miR-326 was poorly expressed in RA patients, and the combined detection of miR-495 and miR-326 has good diagnostic value for RA.

The Management of Perioperative Immunosuppressant Medications for Rheumatoid Arthritis During Elective Hand Surgery

PURPOSE

Rheumatoid arthritis (RA) is a destructive inflammatory disease that commonly involves joints of the hand and wrist. Different recommendations exist for continuing or discontinuing immunosuppressant medications during the perioperative time period. The purpose of our study was to determine whether continuing or discontinuing medications (steroids, nonbiological, and/or biological disease-modifying antirheumatic drugs [DMARDs]) were associated with an increased or decreased risk of postoperative complications.

METHODS

We performed a single-center, retrospective review of a cohort of RA patients who had elective hand surgery by a single surgeon. Patients were included if they had a documented diagnosis of seropositive RA by a rheumatologist and had elective hand surgery and/or a disease-related surgical procedure involving the upper extremity between January 2008 and August 2018. We stratified patients into different groups for comparison by classes of immunosuppressant medications for managing RA. These classes included corticosteroids, nonbiological DMARDs, biological DMARDs, and/or no medications. Immunosuppressant medications were then compared with no medications for the incidence of postoperative overall complications.

RESULTS

Eighty-eight patients had elective hand and/or upper extremity surgeries for RA. Mean patient age at the time of surgery (± SD) was 55 ± 13 years (range, 24-74 years). Of these 88 patients, 8 (9%) overall complications occurred. Complications were wound healing failures (n = 5), tendon rupture (n = 1), hematoma (n = 1), and surgical-site infection (n = 1). Perioperative medications included steroids (n = 31), nonbiological DMARDs (n = 68), biological DMARDs (n = 5), and no medication (n = 27). There were no significant differences in overall complications between patients on immunosuppressant medications and those on no medications. Median (interquartile range) follow-up was 11.5 months (5-25.8) (range, 2-74 months).

CONCLUSIONS

We found that patients who continued or discontinued medications within 1 dosing interval of their usual dose perioperatively had similar rates of complications following elective hand surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Risk factors of postoperative delayed wound healing in patients with rheumatoid arthritis treated with a biological agent

OBJECTIVES

This retrospective study aimed to investigate the risk factors associated with delayed wound healing (DWH) after orthopedic surgery in rheumatoid arthritis (RA) patients treated with biological disease-modifying antirheumatic drugs (bDMARDs).

METHODS

We reviewed medical records of 276 orthopedic procedures for 187 RA patients treated with bDMARDs. As a preoperative nutritional status assessment, we evaluated body mass index, prognostic nutritional index (PNI), and controlling nutritional status (CONUT). We evaluated DAS28-CRP, DAS28-ESR, face scale, global health, and HAQ-DI to assess the disease activity. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors for DWH.

RESULTS

In 276 procedures, DWH was identified in 24 patients (8.7%). Disease duration, foot and ankle surgery, and preoperative use of tocilizumab were significant in the univariate analyses. These variables were entered into a multivariate model, and it was revealed that preoperative use of tocilizumab and procedures in the foot and ankle were associated with an increased risk of DWH.

CONCLUSION

The current retrospective study suggested that preoperative use of tocilizumab and procedures in the foot and ankle were risk factors for DWH.

Preoperative Japanese Society for the Surgery of the Foot Lesser toe score and erythrocyte sedimentation rate influence wound healing following rheumatoid forefoot surgery

OBJECTIVES

Delayed wound healing is one of the most common complications following forefoot surgery in patients with rheumatoid arthritis. We aimed to identify the risk factors for delayed wound healing following rheumatoid forefoot surgery.

METHODS

Consecutive patients who underwent primary rheumatoid forefoot surgery (86 feet; 53 patients) between April 2008 and February 2019 were retrospectively evaluated. Clinical data, including smoking history, duration of the disease, presence of diabetes mellitus, medication, white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein, the surgical procedure performed, and the Japanese Society for Surgery of the Foot (JSSF) scores, were collected.

RESULTS

Delayed wound healing was identified in 20 of 86 (23.3%) feet. In univariate analysis, participants showing delayed healing were older at the time of surgery (p = .04), their ESR was higher (p = .0006), and their total (p = .019) and pain (p = .016) scores on the JSSF Lesser toe scale were lower than those showing normal healing. In multivariable analysis, both the total preoperative JSSF Lesser toe scale score (p = .0239) and ESR (p = .0126) remained significant risk factors for delayed wound healing.

CONCLUSIONS

After rheumatoid forefoot surgery, surgeons should pay more attention to wound care in patients with lower preoperative JSSF Lesser toe score and high ESR.

Does Abatacept Increase Postoperative Adverse Events in Rheumatoid Arthritis Compared with Conventional Synthetic Disease-modifying Drugs?

Objective.

To investigate whether abatacept (ABA) causes more adverse events (AE) than conventional synthetic disease-modifying antirheumatic drugs (csDMARD) after orthopedic surgery in patients with rheumatoid arthritis (RA).

Methods.

A retrospective multicenter nested case–control study was performed in 18 institutions. Patients receiving ABA (ABA group) were matched individually with patients receiving csDMARD and/or steroids (control group). Postoperative AE included surgical site infection, delayed wound healing, deep vein thrombosis or pulmonary embolism, flare, and death. The incidence rates of the AE in both groups were compared with the Mantel-Haenszel test. Risk factors for AE were analyzed by logistic regression model.

Results.

A total of 3358 cases were collected. After inclusion and exclusion, 2651 patients were selected for matching, and 194 patients in 97 pairs were chosen for subsequent comparative analyses between the ABA and control groups. No between-group differences were detected in the incidence rates of each AE or in the incidence rates of total AE (control vs ABA: 15.5% vs 20.7% in total, 5.2% vs 3.1% in death).

Conclusion.

Compared with csDMARD and/or steroids without ABA, adding ABA to the treatment does not appear to increase the incidence rates of postoperative AE in patients with RA undergoing orthopedic surgery. Large cohort studies should be performed to add evidence for the perioperative safety profile of ABA.

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

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.

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

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.