title: Patterns and associated risk of perioperative use of anti-tumor necrosis factor in patients with rheumatoid arthritis undergoing total knee replacement.
abstract: OBJECTIVE
  The patterns and risks of perioperative use of anti-tumor necrosis factor (anti-TNF) medication in patients with rheumatoid arthritis (RA) are not well studied. We examined the patterns of perioperative anti-TNF use and risk of postoperative adverse events (AE) in patients undergoing total knee replacement (TKR).
  
  
  METHODS
  Retrospective cohort study with followup. RA cases within a TKR registry were identified by ICD-9 code (714.0) or self-report. Mailed questionnaires queried anti-TNF use and duration of RA. AE were determined by chart review and patient self-report, and included surgical site infection, pulmonary embolus, deep venous thrombosis, pneumonia, and any infection or re-operation within 6 months.
  
  
  RESULTS
  There were 268 TKR cases with RA. The stop time for anti-TNF preoperatively correlated with dosing schedule; restart time was after wound healing. There were 7 surgical site infections (3%), one (0.4%) of which was a deep joint infection in bilateral TKA requiring explant. The anti-TNF group had 3.26% (3/92) local site infection versus 2.10% (3/143) in the group without anti-TNF and this difference was not statistically significant (Fisher exact test, p = 0.68). The one deep joint infection was in the anti-TNF group. Six-month AE rate was 7.61% in the anti-TNF group versus 6.99% in the group without anti-TNF (Fisher exact test, p = 1.0).
  
  
  CONCLUSIONS
  There was a low risk of infection and perioperative adverse events in patients with RA receiving anti-TNF therapy who were undergoing TKR. This raises the question whether it is necessary to stop anti-TNF for a long period prior to surgery. Given the possible risks associated with stopping anti-TNF, including worsening of disease, further study is needed to determine optimal perioperative use of anti-TNF among patients with RA undergoing TKR.
authors.affiliation: Rheumatology Department, Hospital for Special Surgery and the Columbia University Mailman School of Public Health, New York, New York 10021, USA. beverly.johnson06@gmail.com
authors.forename: Beverly K
authors.initials: BK
authors.lastname: Johnson
authors.forename: Susan M
authors.initials: SM
authors.lastname: Goodman
authors.forename: Michael M
authors.initials: MM
authors.lastname: Alexiades
authors.forename: Mark P
authors.initials: MP
authors.lastname: Figgie
authors.forename: Ryan T
authors.initials: RT
authors.lastname: Demmer
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Mandl
mesh_terms: D018501:Antirheumatic Agents / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000503:physiopathology; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D019990:Perioperative Care; D011788:Quality of Life; D020127:Recovery of Function; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013530:Surgical Wound Infection / Q000209:etiology*; D011795:Surveys and Questionnaires; D063189:Symptom Assessment / Q000379:methods; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha
keywords: ARTHROPLASTY; INFECTION; RHEUMATOID ARTHRITIS; SURGERY; TUMOR NECROSIS FACTOR INHIBITORS
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