Anti-rheumatic treatment and prosthetic joint infection: An observational study in 494 elective hip and knee arthroplasties.

Borgas, Ylva; Gülfe, Anders; Kindt, Mikael; Stefánsdóttir, Anna

doi:10.21203/rs.2.18845/v1

Cited by 4 publications

(3 citation statements)

References 26 publications

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“…This conditional recommendation now includes apremilast, but it is otherwise unchanged from the 2017 guideline. Four observational studies provided additional indirect evidence to the previous systematic literature review and found no relationship between the included drugs and the risk of postoperative infections, although the number of included cases and events were low (11,(27)(28)(29). Patients with a history of severe or recurrent infections or prior prosthetic joint infection may elect to withhold these medications before surgery.…”

Section: Recommendationsmentioning

confidence: 97%

2022 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

Goodman

Springer

Chen

et al. 2022

Arthritis & Rheumatology

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Objective To develop updated guidelines for the perioperative management of disease‐modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). Methods We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. Results This guideline updates the 2017 recommendations for perioperative use of disease‐modifying antirheumatic therapy, including traditional disease‐modifying antirheumatic drugs, biologic agents, targeted synthetic small‐molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. Conclusion This updated guideline includes recently introduced immunosuppressive medications to help decision‐making by clinicians and patients regarding perioperative disease‐modifying medication management for patients with IA and SLE at the time of elective THA or TKA.

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Section: Recommendationsmentioning

confidence: 97%

2022 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

Goodman

Springer

Chen

et al. 2022

Arthritis & Rheumatology

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“…The role of anti-RA drugs in infection susceptibility has been studied and did not show a significant increase in the rate of infection. 26 Active cortisone treatment is the only medication that substantially poses the patient at risk of a devastating infection. 3,17…”

Section: Figurementioning

confidence: 99%

Total Ankle Replacement Outcome in Patients With Inflammatory Versus Noninflammatory Arthritis: A Systematic Review and Meta-analysis

Mousavian

Baradaran

Schon

et al. 2022

Foot & Ankle Specialist

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Background The decision regarding total ankle replacement (TAR) is challenging in patients with inflammatory arthritis (IA) regarding more inferior bone quality, large bone cysts, and increased risk of infections. This systematic review and meta-analysis aimed to compare the functional outcome, revision rate, complication rate, and survival rate of TAR between IA (including rheumatoid arthritis [RA]) and noninflammatory arthritis (NIA) (primary and posttraumatic). Methods After reviewing the full texts, 30 articles fulfilled all inclusion criteria from 1985 until 2021, comparing TAR results. The eligible studies included 5508 patients, of whom 1565 patients had IA and 3943 patients had NIA. At the time of surgery, the average age was 58 years in the IA group and 63 in the NIA group. The average follow-up was 67.2 months in the IA group and 67 months in the NIA group. The outcome measures were the American Orthopaedic Foot and Ankle Society (AOFAS) score and the rate of complications, revisions, and survival. Results The mean final AOFAS score was 82 (95% confidence interval [CI]: 78-86) in the IA group and 83 (95% CI: 78-88) in the NIA group, with no significant difference. There was no significant difference in the mean preoperative to postoperative AOFAS score change between the IA and the NIA. The complication rate was 16% (95% CI: 9%-27%) in the IA group and 15% (95% CI: 8%-27%) in the NIA group with no significant difference. The revision rate was 12% (95% CI: 10%-15%) in the IA group and 13% (95% CI: 10%-18%) in the NIA group, which was significant (P = .04). There was no significant difference in the survival rate between IA and NIA. Conclusion Total ankle replacement is a safe procedure in inflammatory ankle arthritis, specifically in RA patients with relatively minor and major complications close to other reasons for ankle replacement. Levels of Evidence: Level IV: prognostic

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“…To date, there is no clear evidence of whether or when to stop (and restart) bDMARDs during the perioperative period, with some studies concluding that bDMARDs could be safely continued [18][19][20] and others reporting an increased risk of infection with continued use 21,22 . A systematic review 23 comparing patients who continued with those who withheld bDMARDs perioperatively found a reduced risk of infection among those who withheld; however, this analysis was limited to data obtained from 3 studies, and additional studies have since been published 20,[24][25][26][27][28][29] .…”

mentioning

confidence: 99%

The Effect of Perioperative Biologic Disease-Modifying Anti-Rheumatic Drugs on the Risk of Postoperative Complications

Duren

Wignall

Goodman

et al. 2022

Journal of Bone and Joint Surgery

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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.

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Anti-rheumatic treatment and prosthetic joint infection: An observational study in 494 elective hip and knee arthroplasties.

Cited by 4 publications

References 26 publications

2022 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

2022 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

Total Ankle Replacement Outcome in Patients With Inflammatory Versus Noninflammatory Arthritis: A Systematic Review and Meta-analysis

The Effect of Perioperative Biologic Disease-Modifying Anti-Rheumatic Drugs on the Risk of Postoperative Complications

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