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Tumour necrosis factor α (TNFα) antagonists are now established as therapeutic agents for active rheumatoid arthritis (RA) resistant to conventional drug treatment.1 However, they decrease resistance to infection, including unusual infections such as tuberculosis,2,3 and in an experimental setting have been shown to impair wound healing.4 Previous studies have shown that TNFα antagonists do not increase the risk of postoperative surgical complications in patients with Crohn’s disease who undergo resective bowel surgery,5,6 but the safety of these drugs in patients with RA who undergo elective orthopaedic surgery has not yet been established.
As over 10% of patients with RA at our institution receiving antirheumatic drugs still require some form of elective orthopaedic surgical intervention we carried out a retrospective study of patients who received anti-TNF drug treatment before elective orthopaedic surgery.
Depending on the complexity, operations were divided into major surgery, including joint replacement surgery and lower limb arthrodeses; minor cases, including day case surgery; and the remaining procedures, which were in an intermediate group.
Patient records were used to identify which anti-TNFα antagonist was used. We reviewed 16 operations in 11 patients who had received an anti-TNFα drug in the perioperative period. Patients comprised six women and five men with a mean age of 57.8 years (range 33–75). Of the patients studied, 10 had RA and one patient had psoriatic arthritis. The average disease duration from diagnosis was 17.6 years (range 6–27).
Two groups of patients were identified. Group A represented patients in whom anti-TNFα drug treatment was continued in the postoperative period, whereas group B comprised patients for whom the drug was stopped before surgery and restarted after the procedure. In group A, infliximab was used in one operation, the patient receiving the injection 3 days before surgery while etanercept (Enbrel) was used in three patients. All the patients in group A underwent joint replacement surgery. Figure 1 shows when the different drugs were stopped and started with reference to surgery in group B. Infliximab, owing to its long half life and different administration schedule, was stopped nearly 4 weeks before surgery, whereas adalimumab and etanercept were stopped at 2 weeks. The timings for restarting the drug were variable and depended on the preference of individual consultants.
Three patients had complications (table1). The patient who underwent hip replacement surgery required revision surgery to correct the femoral stem and had an inpatient stay of 55 days. In the remaining patients who underwent major surgery the duration of stay was between 6 and 13 days, with an average of 10.6 days.
There was no serious wound or systemic infections in any of the patients on follow up. Postoperatively, one flare up occurred in a patient receiving etanercept in group B, who underwent a triple arthrodesis of the ankle. The flare up developed during the postoperative period and was well controlled once the drug was restarted.
In a previous similar study by the authors, the overall rate of complications and infections in the perioperative period was found to be 10% in 388 patients.7 In the present study none of the patients being treated with an anti-TNF antagonist developed infections. Although two of the three complications were in group A, these were not thought to be to be drug related. Therefore in this small study there is no evidence that anti-TNF drug treatment, whether discontinued or continued, increased either the rate of infection or the complication rate.
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