Disease-Modifying Antirheumatic Drugs May Reduce the Risk of Manipulation Under Anesthesia or Lysis of Adhesions Following Primary Total Knee Arthroplasty.

Abstract

Stiffness is a debilitating complication following total knee arthroplasty (TKA), often necessitating manipulation under anesthesia (MUA) or arthroscopic lysis of adhesions (LOA). While nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids have been shown to reduce the risk of stiffness, the effect of disease-modifying antirheumatic drugs (DMARDs) remains unknown. This study aimed to evaluate whether DMARD use was associated with reduced rates of MUA or LOA after TKA. A national health network was queried for patients who had rheumatoid arthritis and underwent primary TKA between 2013 and 2023. Patients were stratified into traditional, biologic, and dual DMARD groups based on prescriptions within one year before surgery. Each DMARD group was matched with non-DMARD controls using propensity score matching (1:1), controlling for demographics, comorbidities, and perioperative NSAID and corticosteroid use. The primary outcome was MUA or LOA at 90 days, six months, one year, and two years. Other surgical complications and inflammatory markers were also recorded. A total of 16,596 patients were included (traditional: 5,507; biologic: 929; dual: 1,862). Traditional DMARD use was associated with significantly reduced MUA or LOA risk at 90 days (OR [odds ratio] 0.73), six months (OR 0.66), one year (OR 0.69), and two years (OR 0.71). Dual DMARD therapy demonstrated even greater risk reductions (OR range 0.48 to 0.55), but significantly increased early revision and periprosthetic joint infection rates. Biologic DMARD use was not associated with MUA or LOA. All DMARD groups demonstrated lower inflammatory markers compared to controls. Traditional and dual DMARDs were independently associated with reduced rates of stiffness-related reoperations after TKA, supporting their role in attenuating the postoperative fibrotic response. However, dual therapy carries a higher risk of PJI and revision. DMARDs are a potential pharmacologic strategy to prevent postoperative stiffness, although prospective studies are needed to confirm causality and optimize perioperative management.