Flares in Patients with Rheumatoid Arthritis after Total Hip and Total Knee Arthroplasty: Rates, Characteristics, and Risk Factors

Goodman, Susan M.; Bykerk, Vivian P.; DiCarlo, Edward F.; Cummings, Ryan; Donlin, Laura T.; Orange, Dana E.; Hoang, Annie; Mirza, Serene; McNamara, Michael; Andersen, Kayte; Bartlett, Susan J.; Szymonifka, Jackie; Figgie, Mark P.

doi:10.3899/jrheum.170366

Cited by 49 publications

(39 citation statements)

References 33 publications

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“…In addition, where microbiologic diagnosis for septic arthritis including PJI was available, S. aureus was the most frequently reported organism in RA patients whether they were treated with TNFi (57%) or a traditional DMARDs (43%) (20). DMARDs and biologics are known to increase infection risk and are often in use by RA patients at the time of arthroplasty (21,22), but the association of DMARDs and biologics with surgical arthroplasty infections has not been directly established through randomized controlled trials performed in patients undergoing surgery (23,24). However, in a registry database study, the risk of septic arthritis including PJI was doubled for RA patients treated with TNFi, and a meta-analysis of surgical site infection in patients exposed to TNFi also showed an elevated infection risk (OR 2.47, 95% CI 1.66, 3.68) (20,25).…”

Section: Discussionmentioning

confidence: 99%

“…However, a pharmaco-epidemiologic study using a large insurance database did not find an association between infliximab use and infection after arthroplasty (23). Altered immune function in active RA increases the risk of infection, and active RA at the time of arthroplasty may contribute to increased risk of PJI infection in these patients (26,27).…”

Section: Discussionmentioning

confidence: 99%

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Increased Staphylococcus aureus Nasal Carriage Rates in Rheumatoid Arthritis Patients on Biologic Therapy

Goodman

Nocon

Selemon

et al. 2019

The Journal of Arthroplasty

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Background: Rheumatoid arthritis patients are at increased risk for periprosthetic joint infection after arthroplasty. The reason is multifactorial. Nasal colonization with Staphylococcus aureus is a modifiable risk factor; carriage rates in RA patients is unknown. The goal of this study was to determine the S. aureus nasal carriage rates of RA patients on biologics, RA patients on traditional DMARDs, and osteoarthritis. Methods: Consecutive patients with RA on biologics (+/− DMARDs), RA on non-biologic DMARDs, or OA were prospectively enrolled from April 2017 to May 2018 123 patients were determined necessary per group to show a difference in carriage rates. Patients underwent a nasal swab and answered questions to identify additional risk factors. S. aureus positive swabs were further categorized using Spa typing. Logistic regression evaluated the association with S. aureus colonization between the groups after controlling for known risk factors. Results: RA patients on biologics, 70% of whom were on DMARDs, had statistically significant increase in S. aureus colonization (37%) compared to RA on DMARDs alone (24%), or OA (20%) p = 0.01 overall. After controlling for glucocorticoids, antibiotic use, recent hospitalization, and diabetes, RA on biologics had a significant increased risk of S. aureus nasal colonization (OR=1.80, 95% CI 1.00-3.22); p=0.047). Conclusion: S. aureus colonization risk was increased for RA on biologics compared to RA not on biologics and OA. Nasal S. aureus carriage increases the risk of surgical site infection; this

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Increased Staphylococcus aureus Nasal Carriage Rates in Rheumatoid Arthritis Patients on Biologic Therapy

Goodman

Nocon

Selemon

et al. 2019

The Journal of Arthroplasty

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“…Patients included in this analysis were at least 18 years old and undergoing total hip arthroplasty or total knee arthroplasty as previously described . All patients met either the ACR/European League Against Rheumatism 2010 classification criteria for RA or the ACR 1987 classification criteria for RA , and had both preoperative Disease Activity Score in 28 joints using the ESR (DAS28‐ESR) scores and complete histologic scores available.…”

Section: Methodsmentioning

confidence: 99%

Histologic and Transcriptional Evidence of Subclinical Synovial Inflammation in Patients With Rheumatoid Arthritis in Clinical Remission

Orange

Agius

DiCarlo

et al. 2019

Arthritis & Rheumatology

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Objective. Patients with rheumatoid arthritis (RA) in clinical remission may have subclinical synovial inflammation. This study was undertaken to determine the proportion of patients with RA in remission or with low disease activity at the time of arthroplasty who had histologic or transcriptional evidence of synovitis, and to identify clinical features that distinguished patients as having subclinical synovitis.Methods. We compared Disease Activity Score in 28 joints (DAS28) to synovial histologic features in 135 patients with RA undergoing arthroplasty. We also compared DAS28 scores to RNA-Seq data in a subset of 35 patients.Results. Fourteen percent of patients met DAS28 criteria for clinical remission (DAS28 <2.6), and another 15% met criteria for low disease activity (DAS28 <3.2). Histologic analysis of synovium revealed synovitis in 27% and 31% of samples from patients in remission and patients with low disease activity, respectively. Patients with low disease activity and synovitis also exhibited increased C-reactive protein (CRP) (P = 0.0006) and increased anti-cyclic citrullinated peptide (anti-CCP) antibody levels (P = 0.03) compared to patients without synovitis. Compared to patients with a "low inflammatory synovium" subtype, 183 genes were differentially expressed in the synovium of patients with subclinical synovitis. The majority of these genes (86%) were also differentially expressed in the synovium of patients with clinically active disease (DAS28 ≥3.2).Conclusion. Thirty-one percent of patients with low clinical disease activity exhibited histologic evidence of subclinical synovitis, which was associated with increased CRP and anti-CCP levels. Our findings suggest that synovial gene expression signatures of clinical synovitis are present in patients with subclinical synovitis.

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“…Most relapses or flare of symptoms has been attributed to tapering off or stopping biologics [40] or poorly controlled states. While nothing has been addressed in the literature specific to physical therapy treatment causing worsening of flares while tapering off biologics, Goodman et al [41] found an increased frequency of symptomatic flares in patients with rheumatoid arthritis following total hip and total knee arthroplasty. While inflammatory autoimmune disorders should not preclude dry needling, proper screening of the stability of the disease and medication status is merited to avoid overly aggressive dry-needling dosage and technique in unstable or active flares to prevent exacerbating symptoms.…”

Section: Inflammatory Autoimmune Disordersmentioning

confidence: 99%

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

Kearns

Fernández‐de‐las‐Peñas

Brismée

et al. 2019

Journal of Manual & Manipulative Therapy

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Myofascial trigger points are not an isolated neuromusculoskeletal phenomenon and have been implicated in systemic, visceral, and metabolic pathology, as a side effect of some medications and in the presence of psychological risk factors. This complexity can complicate adequate screening of patients prior to choosing dry needling as a treatment intervention. Regardless of whether clinicians practice in a direct access setting, they should be cognizant of medical conditions, comorbidities, and risk factors that will influence clinical decisions for dry-needling appropriateness, technique chosen, and potential adverse responses to treatment. Of primary concern are conditions that can either manifest with myalgia and/or myopathy or masquerade as a more common musculoskeletal condition. This clinical commentary reviews system-specific considerations and other common disorders that should be screened for and discusses not only whether dry needling is appropriate but comments on technique and dosage considerations when initiating dry needling.

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Flares in Patients with Rheumatoid Arthritis after Total Hip and Total Knee Arthroplasty: Rates, Characteristics, and Risk Factors

Abstract: Flares are frequent in patients with RA undergoing arthroplasty. Higher baseline disease activity significantly increases the risk. Although more patients stopping biologics flared, this did not independently predict flaring. The effect of early postsurgery flares requires further study.

Cited by 49 publications

References 33 publications

Increased Staphylococcus aureus Nasal Carriage Rates in Rheumatoid Arthritis Patients on Biologic Therapy

Increased Staphylococcus aureus Nasal Carriage Rates in Rheumatoid Arthritis Patients on Biologic Therapy

Histologic and Transcriptional Evidence of Subclinical Synovial Inflammation in Patients With Rheumatoid Arthritis in Clinical Remission

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

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