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.