Background/Purpose: Biologic agents have been associated with an increased risk of infection, thrombosis and delayed wound healing. However, there is no definitive consensus on suspension or continuity in the perioperative period, with few data assessing the risk of complications in rheumatic patients in use of these medications. The aim of this study is to evaluate the rate of complications after orthopedic procedures in rheumatic patients, assessing the effect of the disruption of biological therapy and trying to identify other potential predictors of complications.

Methods: We retrospectively assessed a monocentric cohort of patients with autoimmune rheumatic diseases who underwent orthopedic surgery from January 2007 to December 2014. 

Results: A total of 87 patients underwent orthopedic surgery in the period, accounting for 178 procedures. Baseline diagnosis were rheumatoid arthritis (54%), juvenile idiopathic arthritis (17.2%), psoriatic arthritis (5.7%), ankylosing spondylitis (18.4%), systemic lupus erythematosus (1.1%), enteropathic spondyloarthropathy (1.1%), adult onset Still’s disease (1.1%) and reactive arthritis (1.1%). The main cause of surgery was osteoarthritis secondary to the underlying disease (57.4%). The main surgeries were total hip arthroplasty (40.4%) and total knee arthroplasty (14%). A hundred twenty six patients were on nonbiologic disease-modifying antirheumatic drugs (DMARDs) and 53 were on biological therapy. Infliximab accounted for the majority of cases (33.9%), followed by etanercept (26.4%), adalimumab (18.9%), abatacept (11.3%), rituximab (5.7%), and tocilizumab (3.8%). In almost all cases the biological therapy was suspended in the preoperative period (98%), from an average of 20 days. Seven patients had postoperative infectious complications (3.9%), including superficial wound infection to necrosis and amputation of the affected limb. Five patients (2.8%) had severe complications requiring hospitalization or intravenous antibiotics. From these 7 patients, 2 (28.6%) were on abatacept, 2 (28.6%) on infliximab, 1 (14.3%) on tocilizumab, 1 (14.3%) on adalimumab and 1 on DMARD only. DMARDs associated with infections were leflunomide (3 patients, 42.9%), methotrexate (1 patient, 14.3%) and azathioprine (1 patient, 14.3%); 2 patients were on biologic agents only. Primary hypertension, dyslipidemia, diabetes mellitus and chronic kidney disease were present in 85.7, 57.1, 42.8 and 14.3% of patients with complications, respectively. 

Conclusion: In our cohort, the rate of postoperative complications in orthopedic surgery performed in rheumatic patients treated with biological therapy was low compared to the literature (3.9% vs. 6.5%). Patients with complications had a high prevalence of comorbidities, which may have contributed to this outcome. Biological therapy discontinuation occurred in the majority of cases and seems to be a safe strategy for this population, however the ideal period of the suspension should be subject of further studies.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/postoperative-complications-rate-in-orthopaedic-surgery-performed-in-rheumatic-patients-in-use-of-biologic-agents/