title: The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis.
abstract: BACKGROUND
  Rheumatoid arthritis (RA) is one of a number of inflammatory arthropathies resulting in foot pain and deformity. Patients with this disease may require surgical intervention as part of their management. Many of these patients are now taking biologic agents which pose several risks to patients in the perioperative phase. The surgical team therefore need to be aware of these associated complications and how to manage these cases.
  
  
  OBJECTIVE
  This paper aims to review the current literature about perioperative needs (foot and ankle surgery) associated with patients with rheumatoid arthritis receiving biologic therapy.
  
  
  RESULTS
  The majority of the literature discusses the perioperative complications associated with patients on anti-TNFα therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) have produced guidelines for the management of patients on anti-TNFα therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of post-operative infection need to be balanced against the risk of a post-operative disease flare. In essence, it is suggested anti-TNFα therapy is stopped 3-5 times the half-life of the drug whilst Tocilizumab is stopped 4 weeks prior to surgery.
  
  
  CONCLUSIONS
  Good communication is needed between the surgical team and the local Rheumatology department managing the patient's disease in order to optimise perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.
authors.affiliation: Podiatry Department, Turner Centre, St. James Hospital, Locksway Road, Portsmouth PO4 8LD, UK. Electronic address: Rdiaper606@googlemail.com.
authors.forename: Ross
authors.initials: R
authors.lastname: Diaper
authors.affiliation: Department of Rheumatology, Portsmouth Hospitals Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK.
authors.forename: Ernest
authors.initials: E
authors.lastname: Wong
authors.affiliation: Podiatry Department, Turner Centre, St. James Hospital, Locksway Road, Portsmouth PO4 8LD, UK.
authors.forename: Stuart A
authors.initials: SA
authors.lastname: Metcalfe
mesh_terms: D000842:Ankle / Q000601:surgery*; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000601:surgery*; D017558:Elective Surgical Procedures; D005528:Foot / Q000601:surgery*; D006801:Humans; D011300:Preoperative Care; D013530:Surgical Wound Infection / Q000517:prevention & control; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D014945:Wound Healing / Q000187:drug effects
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; C502936:tocilizumab
keywords: Ankle; Biologics; Foot; Rheumatoid arthritis; Surgery