Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.
Weill Cornell Medicine, New York, NY.
J Bone Joint Surg Am. 2022 Jun 15;104(12):1116-1126. doi: 10.2106/JBJS.21.00811. Epub 2022 Feb 17.
Biologic disease-modifying anti-rheumatic drugs (bDMARDs) are effective in treating inflammatory diseases and have been increasingly utilized over the past decade. Patients who receive bDMARDs have been shown to be at an increased risk for surgical site infection following surgical procedures. The severe consequences of infection following orthopaedic surgery have led to the practice of withholding bDMARDs perioperatively; however, there has been no definitive evidence showing a clear benefit of withholding the use of bDMARDs, and in doing so, patients may be at an increased risk for higher disease activity. As such, the purpose of the present study was to compare the risk of infection, delayed wound healing, and disease flares associated with the use of bDMARDs in patients undergoing orthopaedic surgical procedures.
We performed a systematic literature search of MEDLINE, Embase, and PubMed CENTRAL databases for studies comparing continuing and withholding the use of bDMARDs in patients undergoing orthopaedic procedures. Inclusion criteria were established following the PICO (Population, Intervention, Comparison, and Outcomes) approach: Population = patients who underwent orthopaedic surgical procedures and who were taking bDMARDs. Intervention = withholding the use of bDMARDs. Comparator = continuing the use of bDMARDs. Outcomes = surgical site infection, delayed wound healing, and disease flares. Article titles and abstracts were screened prior to review of the full text. Overall odds ratios (ORs) and associated 95% confidence intervals (CIs) for pooled effects were calculated.
Eleven studies met the inclusion criteria, providing data for 7,344 patients, including 2,385 patients who continued and 4,959 who withheld their bDMARDs perioperatively. Continuing bDMARDs was associated with a significantly lower risk of disease flares (OR, 0.22; 95% CI, 0.05 to 0.95; p = 0.04) and nonsignificant increases in surgical site infections (OR, 1.11; 95% CI, 0.82 to 1.49; p = 0.49) and wound complications (OR, 2.16; 95% CI, 0.48 to 9.85; p = 0.32).
The present systematic review highlights the limited evidence supporting the current practice of stopping bDMARDs perioperatively. These findings suggest that patients may not be at an increased risk for developing infection or wound complications if bDMARDs are continued but are at an increased risk for disease flare if bDMARDs are withheld. However, our conclusions are limited by the retrospective and heterogenous nature of the data, and possibly by a lack of study power.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
生物制剂改善病情的抗风湿药物（bDMARDs）在治疗炎症性疾病方面非常有效，在过去十年中越来越多地被使用。接受 bDMARDs 治疗的患者在接受手术治疗后，手术部位感染的风险增加。骨科手术后感染的严重后果导致了围手术期停止使用 bDMARDs 的做法；然而，目前还没有明确的证据表明停止使用 bDMARDs 有明显的益处，而且这样做，患者可能会面临更高的疾病活动度的风险。因此，本研究的目的是比较接受骨科手术的患者继续使用和停止使用 bDMARDs 与感染、伤口愈合延迟和疾病发作相关的风险。
我们对 MEDLINE、Embase 和 PubMed CENTRAL 数据库进行了系统的文献检索，以比较继续和停止使用 bDMARDs 的患者在接受骨科手术的患者中的比较。纳入标准是按照 PICO（人群、干预、比较和结局）方法建立的：人群=接受骨科手术并正在服用 bDMARDs 的患者。干预=停止使用 bDMARDs。比较=继续使用 bDMARDs。结局=手术部位感染、伤口愈合延迟和疾病发作。在审查全文之前，先筛选文章的标题和摘要。总体优势比（OR）和相关的 95%置信区间（CI）进行了汇总分析。
11 项研究符合纳入标准，共纳入 7344 例患者的数据，其中 2385 例患者继续使用 bDMARDs，4959 例患者围手术期停止使用 bDMARDs。继续使用 bDMARDs 与疾病发作风险显著降低相关（OR，0.22；95%CI，0.05 至 0.95；p = 0.04），而手术部位感染（OR，1.11；95%CI，0.82 至 1.49；p = 0.49）和伤口并发症（OR，2.16；95%CI，0.48 至 9.85；p = 0.32）的风险增加无统计学意义。
本系统评价强调了支持目前围手术期停止使用 bDMARDs 的现有证据有限。这些发现表明，如果继续使用 bDMARDs，患者可能不会增加感染或伤口并发症的风险，但如果停止使用 bDMARDs，患者可能会增加疾病发作的风险。然而，我们的结论受到数据的回顾性和异质性的限制，也可能受到研究能力的限制。
治疗学 III 级。请参阅作者指南，以获取完整的证据水平描述。
