Title : To what extent do disease modifying anti rheumatic drugs affect bone union in trauma and orthopaedic patients
Abstract:
Introduction: Rheumatoid Arthritis (RA) comes with significant morbidity for patients. They have an increased risk of post-operative complications in orthopaedic surgery because of the effect of the disease on bone as well as the immunomodulatory medications that can interfere with bone healing. Our literature review aims to synthesise current literature on disease modifying antirheumatic drugs (DMARDs) available to aid decision-making in withholding or continuing these medications in the perioperative period.
Methods: A literature search was conducted on Embase, PubMed and Medline. The initial search around foot and ankle osteotomies and DMARDs only yielded 4 original papers. After expanding our search to include trauma and elective procedures, the search yielded 80 papers. The papers were reviewed independently by two authors. By excluding duplicates, non-English language texts, conference abstracts and case reports, 9 papers were identified for inclusion.
Results: Methotrexate (MTX) appears to have a dose dependent effect on bone healing with lower doses used in RA showing no adverse effect on bone healing. However, some animal studies suggested MTX reduced biochemical markers of osteogenesis. In spinal surgery, those who continued DMARDs had greater radiographic fusion outcomes and fewer disease flares compared to those who discontinued the drug. Biologic medications, however, showed adverse effects on bone healing and carried a higher rate of revision surgery. The overall recommendation supported by the 2017 American College of Rheumatology advises continuing conventional DMARDs in the perioperative period, but biologics should be held for at least two weeks or until there are signs of wound healing.
Discussion: Our review has highlighted an important literature gap on the effects of DMARDs on bone union. We recognise withholding these medications can increase the risk of disease flares which can further increase morbidity. Patients’ risk factors and disease severity should be considered when deciding to withhold medication prior to joint surgery. A limitation of our review is the lack of level 1 evidence on this topic; therefore, our findings should be interpreted with caution.
Conclusion: We recommend a multi-disciplinary and patient centred approach in determining which anti-rheumatic medications to withhold before any orthopaedic surgery.
