Introduction
Rheumatoid arthritis (RA) is often characterized as an inflammatory autoimmune disease, causing cartilage and bone damage with progression to joint malformation and eventual loss of function. Joints typically involved in disease include the small joints of the hands and feet, as well as large joints of the hips, knees and ankle. Knee lesions are commonly seen in chronic RA patients, gradually impairing ambulatory capacity and subsequent quality of life [1-3]. Progressive pathophysiology of RA together with increase in global life expectancy warrants extensive attention in management and treatment of severe knee deterioration.
Fundamental approach to RA disease management attempts to accomplish inflammatory control, pain relief, and maintain function of affected joints through pharmaceutical and surgical interventions. Anti-inflammatory glucocorticoids (GC) are commonly used to reduce pain, stiffness and to slow progressive bone erosion [3-5]. Another cornerstone class of RA medication is disease-modifying anti-rheumatic drugs (DMARDs), consisting of conventional and biologic DMARDs, which slow disease progression by targeting and resolving inflammatory disease pathophysiology. Co-therapy using GC with DMARDs provides additive benefit and is reported to reduce risk for joint replacement and radiographic disease progression compared to drug monotherapy [6,7,8]. However, despite improvements in joint function and quality of life using these drugs, rates of total knee arthroplasty (TKA) in end-stage disease have remained stable, with literature reporting close to 70% of joint replacement patients to have been treated with DMARDs in the past [7,9].
Conventional practice is often to take patients off medications prior to surgery for fear of infection or surgical complication, however it has been reported that medication cessation can lead to exacerbating RA symptoms. With some suggesting that continuation of drug therapy perioperatively helps control RA flares, improves postoperative rehabilitation, and reduces disease activity, pain and fatigue; benefits that can be weighed directly against infectious risk [7]. Long term effects and outcomes of perioperative drug therapy in TKA presently remain unclear and current guidelines are based largely on theory and clinician opinion, warranting formal clinical investigation. This study will evaluate short-term effects, long-term clinical outcome and complications associated with preoperative GC and DMARD use in RA patients undergoing TKA surgery.