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Surgery in patients receiving anti-tumour necrosis factor α treatment in rheumatoid arthritis: an observational study on 50 surgical procedures
  1. D Wendling,
  2. J-C Balblanc,
  3. A Brousse,
  4. A Lohse,
  5. G Lehuede,
  6. P Garbuio,
  7. E Toussirot,
  8. B Auge,
  9. D Jacques
  1. Regional Rheumatologic Network for Biotherapies, Department of Rheumatology, University Teaching Hospital, F-25030 Besançon, France
  1. Correspondence to:
    Professor D Wendling

Statistics from

Currently, little information is available about the interaction between anti-tumour necrosis factor (TNF) treatment and surgery.1

In an attempt to evaluate the relative safety of anti-TNF and its impact on the course of disease in patients with rheumatoid arthritis (RA) undergoing surgery, we included in a retrospective study all such patients followed up in a regional network. The network allows close follow up as the patients regularly renew their prescription at the hospital. Surgical outcomes focused on infection and other complications together with the postoperative impact on RA disease activity. A flare of RA was defined as an increase in the joint count and global assessment of >20%.

Fifty surgical procedures were recorded in 30 patients with RA (25 women), with a mean age of 54.6 years, a mean disease duration of 12.3 years, and a mean of 3.7 previous disease modifying antirheumatic drugs. In 38 cases, anti-TNF was associated with a disease modifying antirheumatic drug (methotrexate 33 cases) and with general steroid treatment in 41/50 patients receiving a mean of 8.2 mg/day of prednisone. The TNF blocker at the time of surgery was infliximab (n = 26), etanercept (n = 13), adalimumab (n = 11), with a mean exposure to an anti-TNF agent of 12.1 months (range 1–42). Discontinuation of the anti-TNF agent occurred before surgery in 18/50 patients, and for the rest, surgery was performed between two anti-TNF injections.

Table 1 summarises the type of surgery; the mean follow up after surgery was 14 months (range 1–42). No major complications, especially infections, occurred in either group whether the anti-TNF agent was disontinued or not. Three cases (6%) of minor postoperative side effects were recorded (delay of wound healing of 1–2 weeks). Six cases (12%) of moderate short lasting RA flares were reported occurring with each TNF blocker, in orthopaedic surgery, and significantly associated with anti-TNF interruption before surgery (5 interruptions/6 cases of flare versus 13 interruptions/44 surgical procedures without flare; Fisher’s exact p value  = 0.02).

Table 1

 Type of surgery in patients with RA receiving an anti-TNF agent

In this group of patients with classic RA receiving an anti-TNF agent, the main result was the absence of a major complication after surgery, particularly pyogenic infection.2,3 Methotrexate does not seem to have deleterious impact upon surgical outcome in RA.4

In Crohn’s disease, Marchal et al found no significant differences in postoperative early minor or major complications or in duration of hospitalisation between infliximab exposed and infliximab naïve patients.5 In RA, Bibbo and Goldberg found similar rates of complications in both groups (16 patients receiving an anti-TNF agent compared with 15 matched anti-TNF naïve patients) in foot and ankle surgery.6

In our study the overall rate of complication is lower than reported in large studies of anti-TNFα treatment, irrespective of surgery. For example the percentage of patients developing severe infection is 2% in the ATTRACT study7 (infliximab in RA), 4% in the ACCENT study in Crohn’s disease,8 and up to 18% in some RA cohort studies.9 The retrospective design, the size of our population, the absence of comorbidities and of a control group may represent bias in the present study. Recently, Giles et al reported an increased risk of infection (odds ratio = 5.3) during orthopaedic surgery for patients receiving an anti-TNF agent.10

Our observational study did not find an increased frequency of adverse events related to uninterrupted use of anti-TNF treatment in patients with RA undergoing surgery.


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