Abstract
OBJECTIVES—To determine whether continued methotrexate treatment increases the risk of postoperative infections or of surgical complications in patients with rheumatoid arthritis (RA) within one year of elective orthopaedic surgery. DESIGN—A prospective randomised study of postoperative infection or surgical complications occurring within one year of surgery in patients with RA who underwent elective orthopaedic surgery. SUBJECTS—388 patients with RA who were to undergo elective orthopaedic surgery. Patients who were receiving methotrexate were randomly allocated to groups who either continued methotrexate (group A) or who discontinued methotrexate from two weeks before surgery until two weeks after surgery (group B). Their complication rates were compared with complications occurring in 228 patients with RA (group C) who were not receiving methotrexate and who also underwent elective orthopaedic surgery. MAIN OUTCOME MEASURES—Signs of postoperative infection were recorded, including rubor, discharge, systemic infection, and frequency of wound dehiscence as well as the incidence of any surgical complication requiring a secondary revision procedure that occurred within one year of surgery. The frequencies of flare up activity of RA at six weeks and six months after surgery were also recorded. A flare of rheumatoid disease was defined as an increase in joint pain in two or more joints notified by the patient as well as by an increase in articular index of at least 25% after surgery. RESULTS—Signs of infection or surgical complications occurred in two of 88 procedures in group A (2%), 11 of 72 procedures in group B (15%), and 24 of 228 (10.5%) procedures in group C. The surgical complication or infection frequency in group A was less than that in either group B (p<0.003) or group C (p=0.026). At six weeks after surgery there were no flares in group A, six flares in group B (8%), and six flares in group C (2.6%). Logistic regression analysis of the overall surgical complication rate in all the patients with RA studied showed that methotrexate, whether continued or discontinued before surgery, did not increase the early complication rate in the patients with RA who underwent elective orthopaedic surgery. Other drugs—penicillamine, indometacin, cyclosporin, hydroxychloroquine, chloroquine, and prednisolone—all did significantly increase the risk of infection or surgical complication after elective orthopaedic surgery. The risk of surgery was also increased in the presence of intercurrent chronic diseases—diabetes, hypertension, bronchiectasis, psoriasis, asthma, and ischaemic heart disease. CONCLUSION—Continuation of methotrexate treatment does not increase the risk of either infections or of surgical complications occurring in patients with RA within one year of elective orthopaedic surgery. Thus methotrexate treatment should not be stopped in patients whose disease is controlled by the drug before elective orthopaedic surgery.
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Selected References
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- Bridges S. L., Jr, López-Méndez A., Han K. H., Tracy I. C., Alarcón G. S. Should methotrexate be discontinued before elective orthopedic surgery in patients with rheumatoid arthritis? J Rheumatol. 1991 Jul;18(7):984–988. [PubMed] [Google Scholar]
- Carpenter M. T., West S. G., Vogelgesang S. A., Casey Jones D. E. Postoperative joint infections in rheumatoid arthritis patients on methotrexate therapy. Orthopedics. 1996 Mar;19(3):207–210. doi: 10.3928/0147-7447-19960301-09. [DOI] [PubMed] [Google Scholar]
- Garvin K. L., Hanssen A. D. Infection after total hip arthroplasty. Past, present, and future. J Bone Joint Surg Am. 1995 Oct;77(10):1576–1588. doi: 10.2106/00004623-199510000-00015. [DOI] [PubMed] [Google Scholar]
- Kasdan M. L., June L. Postoperative results of rheumatoid arthritis patients on methotrexate at the time of reconstructive surgery of the hand. Orthopedics. 1993 Nov;16(11):1233–1235. doi: 10.3928/0147-7447-19931101-10. [DOI] [PubMed] [Google Scholar]
- Kremer J. M. The changing face of therapy for rheumatoid arthritis. Rheum Dis Clin North Am. 1995 Aug;21(3):845–852. [PubMed] [Google Scholar]
- O'Callaghan J. W., Forrest M. J., Brooks P. M. Inhibition of neutrophil chemotaxis in methotrexate-treated rheumatoid arthritis patients. Rheumatol Int. 1988;8(1):41–45. doi: 10.1007/BF00541349. [DOI] [PubMed] [Google Scholar]
- Perhala R. S., Wilke W. S., Clough J. D., Segal A. M. Local infectious complications following large joint replacement in rheumatoid arthritis patients treated with methotrexate versus those not treated with methotrexate. Arthritis Rheum. 1991 Feb;34(2):146–152. doi: 10.1002/art.1780340204. [DOI] [PubMed] [Google Scholar]
- Ritchie D. M., Boyle J. A., McInnes J. M., Jasani M. K., Dalakos T. G., Grieveson P., Buchanan W. W. Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Q J Med. 1968 Jul;37(147):393–406. [PubMed] [Google Scholar]
- Sany J., Anaya J. M., Canovas F., Combe B., Jorgensen C., Saker S., Thaury M. N., Gavroy J. P. Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis. J Rheumatol. 1993 Jul;20(7):1129–1132. [PubMed] [Google Scholar]