Paper of the Week: Perioperative Continuation of Biologic Medications Increases Odds of Periprosthetic Joint Infection in Patients With Inflammatory Arthropathy

Carlson VR, Anderson LA, Lu CC, Sauer BC, Blackburn BE, Gililland JM

J Arthroplasty. 2021;36(7):2546-2550.
DOI: 10.1016/j.arth.2021.02.025

Summary by Mohammad S Abdelaal MD, MSc

Multiple studies have identified inflammatory arthropathy (IA) as an independent risk factor for prosthetic joint infection (PJI), particularly following total knee arthroplasty[1,2]. One hypothesis postulates that the continued use of pharmacologic agents around the time of surgery hinders the immune system and predisposes the patient to infection. Although non-biologic disease modifying antirheumatic drugs (DMARDs) have not been shown to increase risk of PJI when continued perioperatively, less is known about the effects of biologic medications despite nearly half of IA patients being on biologics at the time of TJA[3–5].

In this study, Carlson et al. retrospectively reviewed all reported cases of PJI that occurred within the first year of a primary TJA performed in IA patients (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis) on biologic medications from 2005 to 2018 in the US Veterans Affairs Corporate Data Warehouse. The same database was used to identify control patients who underwent TJA for IA but did not develop PJI. Those PJI cases were matched to up to 3 controls by accounting for: age ±5 years, gender, operation (hip or knee), BMI, and prevalence of diabetes mellitus, chronic kidney disease, and smoking. Provider documentation and medication reconciliations were reviewed for all cases to determine continuation or suspension of the biologic dosing cycle in the perioperative period. They found that biologic medications were continued perioperatively without suspension in 35% (9/26) of patients who developed PJI compared to 14% (8/58) of controls (P =.031), which yielded 3.46 higher odds (95% confidence interval: 1.11-10.78) of developing PJI in patients who continued biologic medications. The mean interval from the index procedure to PJI was 83 days with a standard deviation of 87 days. The most common infecting organisms were methicillin resistant and sensitive Staphylococcus aureus, followed by polymicrobial infections.

The authors concluded that despite the limited numbers available in this study, there was an association between perioperative continuation of biologic medications and PJI. The data provide support for current guidelines from the American College of Rheumatology and the  American Association of Hip and Knee Surgeons (AAHKS) to withhold biologics before TJA with surgery scheduled at the end of the dosing cycle and medication resumption only after wound healing[6].

Study limitations include its retrospective design with risk of confounding factors, small sample size (n=84), surgeries in the database performed at multiple locations with different rates of PJI, not including all subtypes of IA, and finally the comparative risk of PJI cannot be inferred for specific biologic drugs.


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  6. Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Rheumatol 2017;69:1538–51.

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