Disease activity and flares after total knee arthroplasty in rheumatoid arthritis - Systematic review

Despite the continuous therapeutic development of biological DMARDs which has delayed disease progression in Rheumatoid arthritis, joint destruction is inevitable and end-stage arthritis remains the ultimate outcome, following which surgical intervention becomes a necessity. Controversy still exists about the systemic effects following Total Knee Arthroplasty (TKA) on patients in terms of disease activity and flares during the peri-operative period since most patients present with varying levels of disease activity at the time of surgery. The objective of this review is to determine the influence of TKA on longitudinal disease activity and flares in patients with rheumatoid arthritis and to determine its influence on quality of life, laboratory parameters, and medication requirement during the peri-operative period and subsequent long-term follow-ups. A complete search was conducted according to the PRISMA guidelines in Pubmed/MEDLINE, Scopus, Google Scholar, Web of Science electronic databases and trial registries on disease activity or flares in patients suffering from rheumatoid arthritis after total knee replacement in September 2022. A total of 16 studies were identified for final review. Flares (RA-FQ), DAS-28, CDAI, mHAQ, ESR, CRP and medication requirement were evaluated in serial follow-ups before and after TKA. Majority of the studies show confirm that a combination of TKA and pharmacological therapy can achieve better therapeutic effects and maintain disease activity at low/ remission levels in patients with end stage rheumatoid arthritis. Patients with high disease activity during the perioperative period are less compliant to rehabilitation and physiotherapy, thereby affecting their overall function scores and satisfaction with the procedure and are found to be more prone to flares. TKA is found to reduce overall disease activity in RA and reduce the need for medication requirement. However, patients with a high disease activity pre-operatively remain at risk for flares and are unable to reach remission levels of activity after TKA and require supplemental long term pharmacological therapy thereby highlighting the need for adequate pre-operative optimization.