Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy

May 29, 2004

Infectious and healing complications after elective orthopaedic foot and

ankle surgery during tumor necrosis factor-alpha inhibition therapy.

1: Foot Ankle Int. 2004 May;25(5):331-5.

Bibbo C, Goldberg JW.

Department of Orthopaedic Surgery, Marshfield Clinic, WI 54449, USA.

bibbo.christopher@...

BACKGROUND: Biologic response modifiers are assuming a larger role in the

management of patients with rheumatoid arthritis. The tumor necrosis

factor-alpha (TNF-alpha) inhibitors etanercept and infliximab improve

patient symptoms and function. However, these agents have been associated

with a risk for healing and infectious complications due to systemic

blockade of TNF-alpha, a ubiquitous mediator required in the normal

inflammatory response in tissue healing and infection surveillance. This

study analyzed the risk of healing/infectious complications in patients

undergoing elective foot and ankle surgery while being treated with

TNF-alpha inhibitors etanercept and infliximab. METHODS: Patients with

rheumatoid arthritis undergoing elective foot and ankle surgery over a

12-month period were prospectively followed for the development of

complications in the postoperative period. All patients continued their

antirheumatic medication schedule unaltered in the perioperative period.

Data collected included sex, age, all medications used to treat rheumatoid

arthritis, smoking history, and number of orthopaedic foot and ankle

procedures performed. Patients were then stratified into two groups based on

the use of immunomodulation via TNF-alpha inhibition (group 1) versus

patients who did not receive TNF-alpha inhibition therapy (group 2). Groups

1 and 2 were followed and compared for the development of infectious/healing

complications. RESULTS: Thirty-one patients were enrolled in the study.

Group 1 (n = 16) and group 2 (n = 15) patients were comparable for sex

distribution, number of orthopaedic procedures performed, and use of

steroids, methotrexate, leflunamide, and nonsteroidal anti-inflammatory

drugs. Group 1 contained six times the number of smokers in group 2. At mean

follow-up of 10.6 months (group 1) and 9.7 months (group 2), healing or

infectious complications were similar in both groups. However, when total

complications (healing + infection) were analyzed, group 1 (TNF-alpha

inhibition, " higher risk " ) patients demonstrated a lower complication rate

(p =.033). CONCLUSIONS: The data suggest that in patients with rheumatoid

arthritis undergoing elective foot and ankle surgery, the use of TNF-alpha

inhibition agents may be safely undertaken in the perioperative period

without increasing the risk of healing or infectious complications.

PMID: 15134615

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