Review Article

Psoriatic Arthritis
Abstract
Michael Sean Day, MD, MPhil Denis Nam, MD Susan Goodman, MD Edwin P. Su, MD Mark Figgie, MD

Psoriatic arthritis is a chronic inammatory arthropathy that affects approximately 6% to 48% of patients with psoriasis. Arthritis is not correlated with the extent of skin disease. Classic radiographic ndings of the involved joint include erosion, ankylosis, and uffy periostitis. Site-specic characteristic deformities such as pencil-incup deformity of the phalanges also may be present. The disease typically follows a moderate course, but up to 47% of cases develop into destructive arthritis in which the inammatory process leads to bony erosion and loss of joint architecture. The mainstay of treatment is biologic therapy (eg, tumor necrosis factor- inhibitors) in conjunction with disease-modifying antirheumatic drugs. Patients with end-stage joint destruction may require surgery to alleviate pain and restore function. Orthopaedic surgeons should be cognizant of the risk factors (eg, increased risk of cardiovascular disease) and potential complications (eg, poor wound healing and increased risk of infection) associated with psoriatic arthritis.

From the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY (Dr. Day), the Department of Orthopedic Surgery (Dr. Nam, Dr. Su, and Dr. Figgie), and the Department of Rheumatology (Dr. Goodman), Hospital for Special Surgery, New York. Dr. Su or an immediate family member serves as a paid consultant to Smith & Nephew and has received research or institutional support from Smith & Nephew and Cool Systems. Dr. Figgie or an immediate family member has received research or institutional support from Ethicon. None of the following authors or any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Day, Dr. Nam, and Dr. Goodman. J Am Acad Orthop Surg 2012;20: 28-37 Copyright 2012 by the American Academy of Orthopaedic Surgeons.

soriatic arthritis (PsA) is a chronic inflammatory arthropathy of peripheral and axial joints that affects a subset of patients with psoriasis. Although the mainstay of treatment is medical, surgery may be necessary for pain relief and restoration of function in some patients. The treating orthopaedic surgeon must be aware of the unique considerations involved in the treatment of PsA patients.

Epidemiology and Etiopathogenesis

The prevalence of psoriasis in the general population ranges from 0.6% to 4.8%,1 whereas prevalence estimates of PsA range from 0.02% to 0.25%.2 Typically, onset of PsA occurs in the fourth decade of life, with an equal distribution between the sexes. PsA affects 6% to 48% of

patients with psoriasis, and rigorous screening has resulted in increased prevalence.3 Typically, arthritis follows the appearance of a skin lesion, but this presentation occurs only in two thirds of patients.2 Familial and twin studies strongly suggest a genetic component associated with precipitating environmental factors such as trauma and infection, particularly HIV infection.4 An exuberant proinflammatory process occurs in both the skin and synovium. The common thread between these seemingly disparate tissues may lie in tissue biomechanics. Both the dermal-epidermal and the tendonbone interfaces have vascular tissue meeting avascular tissue at an irregular interface designed to resist shear because these interfaces are naturally high-stress areas.5 In affected individuals, these areas are host to an inflammatory infiltrate that contains clonally expanded CD4+ and CD8+

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T cells.6 In addition, human leukocyte antigens have been associated with progressive joint damage such as that associated with the presence of human leukocyte antigen (HLA)B27 plus HLA-B39.7 Psoriatic skin is marked by angioproliferation and abnormally increased microvascular permeability as a result of an upregulation of adhesion molecules.8 Similar to rheumatoid synovium, PsA synovium has been shown to have an increased expression of proinflammatory factors such as matrix metalloproteinases, adhesion molecules, and vascular markers.8 A host of inflammatory cytokines and chemokines are involved, most notably tumor necrosis factor (TNF)-, interleukin (IL)-1, IL-6, and IL-13. Upregulation of receptor activator of nuclear factor- ligand results in enhanced osteoclastogenesis, ultimately leading to osteoclast-driven destruction of the joint.9 Several lines of investigation have characterized the immunologic nature of this pathogenesis, including the efficacy of cytokine and T cell directed therapies such as the TNF- class of biologics and the exacerbation of psoriasis by antiinflammatory cytokines such as interferon-.10

Figure 1

AP radiographs of the hands (A) and the right foot (B) demonstrating marked erosion, bone loss, ankylosis, and deformity, particularly at the proximal interphalangeal joints, in two patients with psoriatic arthritis.

Clinical Manifestations
Moll and Wright11 described five distinct clinical patterns of PsA: (1) asymmetric oligoarticular or monoarticular arthritis primarily affecting the distal interphalangeal (DIP), proximal interphalangeal (PIP), and metatarsophalangeal joints; (2) DIPpredominant arthritis; (3) arthritis mutilans; (4) symmetric, rheumatoid factor (RF)-negative polyarthritis; and (5) psoriatic spondyloarthropathy. This classification is based on the patients presenting features, which have significant overlap over
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time. This system defined PsA as a clinical entity separate from rheumatoid arthritis (RA). PsA was originally believed to be a milder disease. Arthritis mutilans refers to destructive disease that typically affects the fingers and toes. This pattern is present in 5% of patients with PsA.11 The disease follows a moderate course in some, but 47% of cases evolve to destructive arthritis in which the inflammatory process leads to bony erosion and loss of joint architecture.12 Osteolysis of the affected joints can lead to resorption of the distal tufts, causing shortening of the digit and flail digit11 (Figure 1). In a study of 588 patients with PsA, symmetric polyarthritis was seen in 63%, whereas asymmetric oligoarticular disease was seen in approximately 13%.13 Axial involvement with spinal and sacroiliac disease occurred in approximately 14%, and these patients may carry the HLA-B27 genetic marker. Features of axial disease are typical of inflammatory low back pain: morning stiffness, poor localization of pain, and improvement with exer-

cise. DIP-predominant involvement was only present in 4% of patients. Variability in the reported prevalence of these presenting features may reflect variability across populations as well as difficulties in diagnosis.

Diagnosis
PsA remains a clinical diagnosis due to the lack of definitive laboratory tests for the condition. Patients may have anemia of chronic disease, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, hypergammaglobulinemia, hypercomplementemia, or an elevated uric acid level. In a study of 625 patients with PsA, the average ESR was 22.5 mm/h (range, 0 to 105).14 In a study of 144 patients with PsA who were treated with adalimumab, the mean CRP level was 1.4 mg/L 2.1, and 62.8% of patients had a normal level (ie, <1.0 mg/L).15 Radiographic findings are more specific than laboratory tests; a study of 129 patients with PsA reported that 47% demonstrated radiographic evidence of joint damage at a 1- to

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Figure 2

Table 1 CASPAR Criteria for the Diagnosis of Psoriatic Arthritis18 Criteria Current evidence of psoriasis Past or family history of psoriasis Current nail lesions, including pits or onycholysis Negative rheumatoid factor Dactylitis (current or documented by a rheumatologist) Fluffy periostitis detected on radiographs Points 2 1 1 1 1 1

Diagnosis of psoriatic arthritis can be made based on accrual of three points. CASPAR = Classication of Psoriatic Arthritis study group

Postoperative AP radiograph of the right hand demonstrating marked deformity following proximal interphalangeal (PIP) arthroplasty in a patient with psoriatic arthritis. Note the ankylosis of the interphalangeal joints of the middle nger as well as the pencil-in-cup deformity of the PIP joint of the ring nger.

2-year follow-up.12 Radiographic examination should include AP and lateral views of hands and feet to permit differentiation of DIP involvement associated with PsA from that associated with osteoarthritis. Radiographs of the lower thoracic and lumbar spine also should be obtained to evaluate for atypical syndesmophytes, which may occur in the absence of sacroiliitis. The distinctive radiographic features of PsA are the result of a combination of erosive and proliferative bone changes. Characteristic findings include opera-glass deformity, which consists of telescoping erosive joint destruction; fluffy periostitis caused by periosteal ossification; pencil-incup deformity in which simultaneous destruction of the head of the middle phalanx and expansion of the base of the distal phalanx produces the

characteristic finding; and acroosteolysis, consisting of resorption of the tuft of the distal phalanx (Figure 2). Patients with axial disease may exhibit sacroiliitis, syndesmophytes, paravertebral ossification, and destructive discovertebral lesions. For detection of early disease or enthesitis, MRI is more sensitive than plain radiographs.16 In an MRI case-control study, findings characteristic of enthesitis were reported in 5 of 6 patients with psoriasis on topical treatment only, suggesting the need for more aggressive evaluation of patients with skin psoriasis and further research to evaluate the effectiveness of MRI for diagnosis of PsA.16 Ultrasonography also may be used to assess enthesopathy; enthesopathic tendons demonstrate relative thickening on ultrasonography, and this modality can easily be applied in the clinical setting.17 Cutaneous lesions associated with reactive arthritis can mimic psoriasis, which is an important consideration when diagnosing PsA. Although both gout and PsA may present with hyperuricemia, gout can be confirmed by the presence of monosodium urate crystals in synovial fluid. PsA is distinguished from RA by the presence of dactylitis (ie, inflammation of an entire digit), asymmetric joint involvement, DIP involvement,

negative RF, enthesopathy, and psoriatic skin plaques. Characteristic nail changes include pitting and onycholysis, that is, incomplete loosening of the nails starting at the distal free edge. A positive RF in a patient with symmetric polyarthritis and psoriasis indicates the possibility of concurrent diseases. Current authorities on PsA have agreed on new criteria to facilitate early and accurate diagnosis. The Classification of Psoriatic Arthritis (ie, CASPAR) study group has formulated criteria that can be applied to patients with an inflammatory musculoskeletal condition, such as inflammatory arthritis, enthesitis, or spondylitis (Table 1). The criteria were derived from an analysis of 588 patients with PsA and 536 control subjects and were 98.7% specific and 91.4% sensitive.18 Criteria include the presence of psoriasis or a family history of psoriasis, dactylitis, juxta-articular new bone formation, negative RF, and nail dystrophy. Points are accrued on the basis of these findings. Accrual of at least three points is indicative of PsA, and diagnosis requires review by a rheumatologist to ensure accurate identification of the characteristic features described by the criteria and to ensure that criteria are applied in the context of an inflammatory musculoskeletal illness.18 In addition to psori-

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atic skin disease, radiographic, serologic, and physical findings are included in the determination of the diagnosis, markedly increasing diagnostic sensitivity and specificity. Typical inflammatory features such as morning stiffness, joint swelling and warmth, poorly localized back pain, and symptoms that improve with exercise must be present before the diagnostic criteria can be applied. When PsA is suspected in patients with inflammatory arthritis, enthesitis, or inflammatory back pain, evaluation should begin with identification of the clinical features included in the CASPAR criteria and radiographic assessment of appropriate areas, such as the sacroiliac joints or the hands and feet. Laboratory testing should be performed before beginning medical treatment to assess ESR, CRP level, RF, liver and kidney function, and complete blood count and screen for tuberculosis and viral hepatitis. Joint aspiration should be performed in the patient who presents with monoarthritis to rule out crystal arthropathy or infection. Arthrocentesis can also be used for synovial fluid white blood cell (WBC) quantification. Degenerative joint disease, for example, yields synovial fluid with a low (ie, non-inflammatory) WBC count (<2,000/L), whereas PsA produces a more inflammatory picture (2,000 to 75,000 WBC/L). Arthrocentesis will not aid in differentiation of PsA from other inflammatory arthropathies because current analytic capabilities indicate a common end-inflammatory pathway despite disparate etiologies.8 A full diagnostic workup is performed in the patient with a history and physical examination that suggest an inflammatory clinical picture. A full workup is unnecessary in clear cases of osteoarthritis (ie, no effusion, no inflammatory features) in patients with psoriatic skin plaques.
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However, ambiguous findings that increase clinical suspicion of an inflammatory process should be pursued aggressively because confirmation of PsA diagnosis permits appropriate medical interventions to prevent progressive joint damage.

Medical Management
Initially, it was believed that PsA had a more benign course than does RA, but this belief has been disproven. Treatment recommendations for PsA developed by a task force of the European League Against Rheumatism, as well as the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, have been released.19 Appropriate therapy is determined by considering the severity and specific manifestation of PsA. Recognition of the sustained benefit of early aggressive therapy in patients with RA, using specific disease activity end points such as the Disease Activity Score, has encouraged similar expectations in management of PsA. Currently, efforts are underway to define reproducible, useful outcome measures, and treatment algorithms developed by both of these groups incorporate this concept. Initial therapy for musculoskeletal manifestations of PsA includes nonsteroidal anti-inflammatory drugs (Table 2). Traditional disease modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX), sulfasalazine, and leflunomide should be started early when there is evidence of persistent inflammation, erosive disease, multiple swollen joints, and elevation of the ESR and CRP level, all of which are known poor prognostic indicators.19 When inflammation persists in spite of treatment with a traditional DMARD such as MTX, TNF- inhibitor therapy should be considered. Patients may present with ex-

tremely active polyarticular disease and structural damage at onset, which indicates a poor outcome; initial therapy with a TNF- inhibitor should be considered. Intra-articular and entheseal injections also can be employed.19 Although MTX is a commonly prescribed therapeutic mainstay for PsA, little evidence exists to support its role as a DMARD. Early studies showed little benefit in terms of radiologic progression, and these findings have been recently been confirmed.21 Nonetheless, MTX continues to have a role in PsA therapy given its beneficial effect on psoriatic skin lesions and its role in reducing pain and inflammation. Currently, the mainstay of medical treatment involves TNF-blocking agents, including infliximab, etanercept, and adalimumab, all of which may have dramatic therapeutic effects. Other drugs, such as alefacept, efalizumab, and abatacept, target various T-cell interactions involved in the inflammatory disease state. These new biologic treatments are expensive, but they are the only agents that have demonstrated a decrease in radiologic progression of peripheral arthritis and can be used to manage dactylitis, enthesitis, and spondylitis as well as skin and nail disease.20,22,23 In terms of quality-adjusted lifeyears (QALYs) alone, TNF antagonists may be cost-effective.24 A model was used to assess the QALYs gained from the use of etanercept compared with those gained with a combination therapy of MTX and cyclosporine; the authors noted that over 10 years, the modeled etanercept treatment gave 0.82 more QALY compared with the combination therapy.24 Thus, the potential cost-effectiveness of etanercept for adults with PsA appears encouraging.

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Table 2 Drugs Used to Treat Psoriatic Arthritis Drug NSAIDs Corticosteroids Sulfasalazine Methotrexate Cyclosporine Leunomide Etanercept Mechanism Inhibits cyclooxygenase Inhibits multiple inammatory cytokines Exact mechanism unknown Inhibits dihydrofolate reductase and lymphocyte proliferation Exact mechanism unknown; inhibits T lymphocytes Inhibits pyrimidine synthesis via dihydroorotate dehydrogenase inhibition TNF- receptor recombinant fusion protein that competitively inhibits cytokines action and binds soluble TNF Chimeric mAb that binds membrane-bound and soluble TNF- Fully human anti-TNF- mAb Human LFA-3/IgG1 fusion protein that binds to the CD2 receptor on T cells, selectively depleting CD45RO+ memory effector T cells Humanized mAb directed against CD11a disrupts T-cell costimulatory LFA-1/ICAM-1 interaction Recombinant human fusion protein, binds CD80/86 and blocks CD28 receptor on T cells Comments First-line agent for symptomatic treatment No RCTs in PsA patients; 15% of patients in biologics trials on steroids20 One third of patients have gastrointestinal distress, dizziness, or liver toxicity Liver toxicity more frequent than in RA patients More often used for skin psoriasis than PsA Effective for symptoms of arthritis, disability, and skin psoriasis in patients with PsA Administered as subcutaneous injection

Iniximab Adalimumab Alefacept

First TNF- blocker studied for treatment of psoriasis; administered as intravenous infusion Administered as subcutaneous injection Alefacept and methotrexate superior to placebo and methotrexate Withdrawn from European and US markets in 2009 due to three reports of progressive multifocal leukoencephalopathy Approved for RA, under study for PsA

Efalizumab

Abatacept

ICAM = intercellular adhesion molecule, IgG1 = immunoglobulin G1, LFA = leukocyte function antigen, mAb = monoclonal antibody, NSAIDs = nonsteroidal anti-inammatory drugs, PsA = psoriatic arthritis, RA = rheumatoid arthritis, RCTs = randomized controlled trials, TNF = tumor necrosis factor

Surgical Considerations
Literature on the surgical management of PsA is limited by studies with a small number of patients and variable inclusion criteria; some studies include patients with psoriasis and arthritis, without necessarily confirmed PsA. In addition, surgical series often include multiple procedures, making it difficult to draw conclusions about specific procedures (Table 3). In a study of 444 patients with confirmed PsA, <10% required surgical management of their arthropathy for pain relief and restoration of function.25 Thirty-one patients (7%) with PsA were treated with various

surgical procedures at an average of 13.9 years after diagnosis (range, 1 to 46 years).25 Radiographic severity, number of involved joints, and duration of disease were the only predictors of the need for future surgery in that cohort. The authors assessed radiographic severity using the Steinbrocker functional capacity activity grading system (grades I-IV); grades I and II were grouped together and described as mildly damaged joints, and grades III and IV were described as severely damaged joints.25,26 Baseline radiographic assessment of patients who required surgery, compared with those who did not, showed that patients in the surgery cohort had more actively inflamed and severely damaged joints than did

the nonsurgical cohort (14.1 versus 8.5 joints and 16.7 versus 4.5 joints, respectively). Other characteristics, such as ESR, RF, functional class, clinical pattern, nail changes, and symmetry, were not predictors of the need for future surgery. Other reports indicate that 23.8%27 of PsA patients required hand surgery, 1.8%28 required hip arthroplasty, 1.4%25 underwent total knee replacement, and 1.2%29 needed foot or ankle surgery.

Infection and Wound Healing

Psoriatic plaques have been shown to harbor increased concentrations of bacteria compared with unaffected

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Table 3 Outcomes of Surgical Treatment in Psoriatic Arthritis Patients Study Lambert and Wright35 Belsky et al27 Procedure Multiple Multiple (hand/wrist) No. of Procedures 41 190 55 No. of Patients 21 25 38 Comments 1 infection; satisfactory results Stiffness a major clinical problem; 2 deep infections 9.1% supercial infection, 5.5% deep infection; no perioperative antibiotics used, 11 patients on steroids at operation 16.6% deep infection, 21% revision 1 deep infection; diagnosis of psoriasis, not psoriatic arthritis 89% successful; 1 supercial infection Prospective; 72.8% chance of denite improvement at 36 months; signicant decrease in all measured clinical parameters at 6, 12, 24, and 36 months; no complications reported 1 infection; results similar to those associated with other forms of arthritis Mean age at rst arthroplasty: 41 yr (range, 2563 yr); outcomes not reported

Menon and Wroblewski32 Total hip arthroplasty

Stern et al33 Beyer et al34 Hicken et al29 Fiocco et al45

Total knee arthroplasty Total knee arthroplasty Multiple (foot/ankle) Knee synovectomy

24 50 27 35

16 34 17 32

Zangger et al36 Michet et al28

Multiple Total hip arthroplasty

71 14

43 9

skin, causing concern for an increased risk of infection and/or defect in wound healing in patients with these plaques.30 However, in a study of 10 hospitalized men with psoriasis, 7 underwent standard perioperative sterilization of psoriatic plaques with an iodine and alcohol preparation, which successfully sterilized the plaques in all 7 patients.31 Skin sampling was taken from trunk and extremity sites but not from intertriginous areas. Wound healing may be complicated by the Koebner phenomenon, that is, psoriatic outbreak following trauma. However, affected skin showed the same rate of healing as normal skin; after healing, normal dermatologic treatment can resume.31 Infection rates in surgical series vary; thus, no consensus exists regarding the degree of caution required for surgical treatment of patients with PsA. Some authors have
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reported alarming infection rates associated with orthopaedic surgery in this patient population. One series reported five superficial infections (9.1%) and three deep infections (5.5%) in 55 total hip arthroplasties in patients with long-standing psoriasis.32 However, perioperative antibiotics were not used, and 11 patients were on steroids at the time of surgery. In 24 total knee replacements in 16 patients with long-standing psoriasis, four (16.6%) deep infections and two (8.3%) episodes of mild skin necrosis were reported.33 Lower infection rates, ranging from 1.4% to 3.7%, have been reported in multiple orthopaedic procedures, including implant arthroplasty.27,29,34-36 In one series, 3 of 34 patients had skin incisions through or very close to a psoriatic plaque.34 These studies were limited by small sample sizes (range, 17 to 43 patients), the retrospective nature of

the study, and the inability to control for patient factors or, in some series, the type of surgery. Even the lower infection rates reported in these series may be considered high by modern standards. It should be noted that American Academy of Orthopaedic Surgeons clinical practice guidelines cite immunosuppression (including psoriatic arthropathy) as a risk factor for periprosthetic infection of the knee (but not the hip), as supported by a systematic review of available evidence, whereas skin psoriasis has been posited as a risk factor by consensus of the American Academy of Orthopaedic Surgeons work group.37

Perioperative Considerations
Clinicians should be mindful of the systemic inflammatory nature of PsA and increased all-cause mortality in

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PsA patients when considering surgical management. Psoriasis is strongly associated with obesity, which increases the risk of surgical site infection and deep vein thrombosis. Psoriasis also has been associated with one or more risk factors for metabolic syndrome: abdominal obesity, high levels of triglycerides, low levels of high density lipoprotein cholesterol, elevated blood pressure, and elevated fasting glucose.38 Psoriasis has also been identified as an independent risk factor for myocardial infarction.39 Preoperative assessment should include careful evaluation of cardiac status in these at-risk patients, according to the recommendations of the American College of Cardiology and the American Heart Association. When patients are unable to exercise vigorously, stress testing may be indicated to stratify risk. Additionally, beta blockade should be considered to decrease pulse and oxygen demand, thus diminishing cardiac risk.40 Biologic therapy, although revolutionary for medical treatment of PsA, poses a new concern in the perioperative setting. TNF- plays an important role in response to infection and may play a role in wound healing.41 Although most of the large-scale, randomized trials of anti-TNF drugs had only mild infectious complications (eg, upper respiratory infection), rare but serious infections have been reported in perioperative and postoperative settings, such as mycobacterial hand infections after routine hand surgery.42 Most available literature on the use of perioperative biologics focuses on patients with inflammatory bowel disease and RA in whom no statistically significant risk of infection has been reported with perioperative use of biologics, although a trend toward increased infection in RA patients is cause for concern.41 The lack of consensus on

surgical infection risk in patients with PsA relative to patients without PsA at baseline (ie, not on biologic therapy) makes definitive recommendations on perioperative biologic treatment difficult.

Preoperative Optimization
Although no definitive studies exist to guide drug management in the perioperative period, prudence suggests holding biologic agents preoperatively based on half-life; etanercept should be held for 2 weeks, adalimumab for 3 to 4 weeks, and infliximab for 6 to 8 weeks. Biologic agents are typically restarted following surgery, after the stitches have been removed and the wound is healing well without drainage or erythema, usually by 2 weeks postoperatively. MTX can be continued, based on studies of RA patients who demonstrated a reduction in disease flares without an increase in wound complications.43,44 Patients with active skin disease should see their dermatologist preoperatively, and every attempt should be made to manage skin plaques before surgery to decrease bacterial burden. Treatment ranges from topical corticosteroids to systemic treatments, such as ultraviolet therapy for severe disease. Contamination of the surgical site can be avoided by not operating directly through active skin lesions; surgery should be postponed or incision sites should be modified to avoid incising through a psoriatic plaque. We operate through a psoriatic plaque only when absolutely necessary. Antibiotic-impregnated cement should be considered for large joint arthroplasty.43 Careful preoperative cardiac evaluation can prompt interventions such as perioperative beta blockade, which may decrease cardiac complications in appropriate patients when postoperative blood pressure permits

its use. Because patients with PsA are also at increased risk of diabetes, preoperative evaluation should include measurement of hemoglobin A1c level and control of blood glucose, if needed, because uncontrolled diabetes may contribute to perioperative infection.

Technical Considerations
When arthroplasty is considered, orthopaedic surgeons should be aware of several technical considerations unique to PsA patients. Soft-tissue contractures may affect reconstruction or outcome, and polyarticular disease may necessitate staging of surgical procedures. Although these patients have characteristically less osteopenia than do RA patients, PsA patients may present technical challenges as a result of periarticular bone loss.36 In contrast to patients with juvenile idiopathic arthritis, those with PsA do not necessarily tend to be small in stature; therefore, custom implants may not be necessary for arthroplasty unless the patient presents with a particularly severe deformity.

Surgical Management
Surgical management of PsA is tailored to the pattern and severity of joint involvement as well as the patients needs. Total joint arthroplasty is an option for patients with endstage joint destruction that results in significant disability from pain and loss of function. Arthrodesis may be useful in select joints (eg, hand, ankle, hindfoot, foot). Arthroscopic synovectomy is another option for knee joint synovitis in RA or PsA knees and may limit progression of joint destruction.35, 45 A variety of surgical procedures specific to each joint can be used to treat PsA patients. Indications for

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such procedures have developed from experience in patients with RA who have similar degrees of joint destruction. For example, in the shoulder, total joint arthroplasty may be used for restoration of joint function, and synovectomy has been used to treat patients with elbow arthropathy.25 A variety of procedures in the wrist and hand, ranging from arthroplasty to manipulation under anesthesia, has been used primarily to restore function in hands significantly deformed by PsA. In the lower extremity, total hip arthroplasty is the treatment of choice for patients with PsA who have severe hip arthropathy. Patients with knee joint destruction may be treated with total joint arthroplasty or synovectomy in an attempt to prevent or slow such destruction. Surgical management of ankle arthropathy relies primarily on arthrodesis, whereas arthroplasty may be considered for forefoot or toe joints.

Outcomes
Several authors have reported outcomes of orthopaedic procedures performed in patients with psoriasis or PsA; most of these studies are small and retrospective and feature a mix of procedures (Table 3). Many of the patients included in the studies had multiple orthopaedic procedures that were analyzed as independent events; however, these events cannot be considered truly separate. Four studies specifically examined lower extremity large-joint arthroplasty. Menon and Wroblewski32 retrospectively reviewed 55 Charnley low-friction hip arthroplasties performed in 38 patients with psoriasis. They observed a high rate of infection (9.1% superficial, 5.5% deep) and concluded that perioperative antibiotics, which were not used in their study, are warranted when
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treating patients with psoriasis. Stern et al33 reviewed 27 total knee arthroplasties performed in 18 patients with psoriasis. Eight patients had psoriasis with osteoarthritis, seven had PsA, and three had RA with psoriasis. Sixteen patients (24 knees) were available for follow-up. Hospital for Special Surgery (HSS) knee scores improved from a mean of 52 preoperatively to 68 at an average of 4 years postoperatively. Based on HSS knee scores, excellent, good, and poor results were reported in 16 (67%), 1 (4%), and 7 (29%) knees, respectively, with no fair outcomes reported. Deep infections occurred in 16.6% of knees and revision in 21%. Notably, perioperative intravenous antibiotics were used in this study, but the authors did not indicate whether antibiotic-impregnated cement was used. In contrast, Beyer et al34 reported complications, including deep infection (1), deep vein thrombosis (1), pulmonary embolism (1), ileus (1), and exacerbation of psoriasis (2) in a study of 50 primary total knee replacements performed in 34 patients with psoriasis. The authors concluded that there was no increased risk of infection in the psoriasis population. In a study of hip disease in patients with PsA, Michet et al28 reported that 32 of 504 patients (6.3%) developed hip disease; only 17 were available for follow-up. Of the 32 patients, 9 underwent total hip arthroplasty, and 16 were treated within 5 years of onset of hip symptoms. The authors concluded that hip disease is uncommon and that the therapeutic window for intervention may be small once symptoms develop. Other authors have studied cohorts of patients treated with a variety of surgical procedures, presumably to increase the number of patients available for study. Lambert and

Wright35 tracked complications in 41 orthopaedic procedures in 21 patients with psoriasis, and all but one patient had PsA. They reported one infection and three Koebner phenomena (ie, psoriatic outbreak after trauma). Their report did not include any differential statistics and noted only that healing was satisfactory. Belsky et al27 performed a variety of hand or wrist procedures in 25 patients with confirmed PsA. Wrist involvement was treated with arthroplasty, fusion, or distal ulnar resection, and limited range of motion was achieved compared with range of motion in RA patients. Spontaneous fusion in a functional position was common. Fifty-eight metacarpophalangeal (MP) joint arthroplasties, 12 MP joint manipulations, and 3 soft-tissue releases were performed and resulted in MP joint motion that was improved but limited. Twenty-two of 25 patients had PIP involvement, and 50 PIP fusions, 10 manipulations, and 11 implant arthroplasties were performed, resulting in motion in the range of 20. Eight fusions and seven manipulations were performed in patients with suboptimal DIP joint position. In patients with thumb involvement, two MP joint and six carpometacarpal arthroplasties, as well as seven interphalangeal joint and five MP joint fusions, were performed and resulted in definite but limited functional improvement. The authors concluded that stiffness, which is both an indication for surgery and a factor that adversely affects outcome, was the major clinical problem in the hand and wrist. Hicken et al29 retrospectively reviewed 27 foot and ankle procedures in 17 patients with PsA over 15 years. Procedures included forefoot and toe arthroplasty; metatarsophalangeal, ankle, hindfoot, and PIP arthrodesis; toe dbridement; and matrixectomy. Twenty-four of 27

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procedures (89%) were considered successful; these patients did not require additional intervention, did not display clinical progression of disease, and were satisfied with the result of the procedure. Zangger et al36 reviewed the results of 71 operations performed in 43 patients. A wide range of orthopaedic procedures was performed. Patients were categorized as having either distal PsA, oligoarticular PsA, or polyarticular disease. Those with distal disease underwent PIP and DIP fusions. Patients with oligoarticular disease were treated with hip replacement, knee replacement, or knee synovectomy. Those with polyarticular disease underwent a variety of upper and lower extremity surgeries. Commonly used outcome scores were available in only 19 patients. The authors reported that four patients had an average Harris Hip score of 84.3 out of 100 and three had an average HSS knee score of 89.7 out of 100. The average Test dEvaluation des Membres Suprieurs de Personnes Ages hand function test score was 5.6 (best = 0), and Kitakoa foot scale scores averaged 72.9 out of 100. Late deep infection was reported in one patient with end-stage renal disease. The authors concluded that these outcomes were similar to those of surgical management of other forms of arthritis. In the only prospective study of surgical intervention in patients with PsA, Fiocco et al45 performed arthroscopic knee synovectomy in 32 patients (17 with PsA, 15 with RA). The patients were followed for 36 months, and local signs of inflammation and range of motion were scored; the sum served as a global outcome measure of recurrent or remitted knee joint synovitis based on physical examination criteria. All patients were treated with nonsteroidal anti-inflammatory drugs, and all but

three received additional second-line medical treatment, consisting of hydroxychloroquine, azathioprine, gold or D-penicillamine. Survival analysis showed a 72.8% chance of definite improvement at 36 months and 61.2% chance of clinical remission, which was more marked in PsA than RA knees (86.3% versus 45.7%, respectively).

3(2):121-128. 2. Setty AR, Choi HK: Psoriatic arthritis epidemiology. Curr Rheumatol Rep 2007;9(6):449-454. Gladman DD: Psoriatic arthritis from Wrights era until today. J Rheumatol Suppl 2009;83:4-8. Zell D, Hu S, Kirsner R: Genetic alterations in psoriasis. J Invest Dermatol 2008;128(7):1614. McGonagle D, Tan AL, Benjamin M: The biomechanical link between skin and joint disease in psoriasis and psoriatic arthritis: What every dermatologist needs to know. Ann Rheum Dis 2008;67(1):1-4. Loffredo S, Ayala F, Marone G, Delfino G, Stranges S, Marone G: Immunopathogenesis of psoriasis and pharmacological perspectives. J Rheumatol Suppl 2009;83:9-11. Gladman DD, Farewell VT, Kopciuk KA, Cook RJ: HLA markers and progression in psoriatic arthritis. J Rheumatol 1998;25(4):730-733. van Kuijk AW, Reinders-Blankert P, Smeets TJ, Dijkmans BA, Tak PP: Detailed analysis of the cell infiltrate and the expression of mediators of synovial inflammation and joint destruction in the synovium of patients with psoriatic arthritis: Implications for treatment. Ann Rheum Dis 2006;65(12):1551-1557. Robinson H, Kelly S, Pitzalis C: Basic synovial biology and immunopathology in psoriatic arthritis. J Rheumatol Suppl 2009;83:14-16. Gaspari AA: Innate and adaptive immunity and the pathophysiology of psoriasis. J Am Acad Dermatol 2006; 54(3 suppl 2):S67-S80. Moll JM, Wright V: Psoriatic arthritis. Semin Arthritis Rheum 1973;3(1):55-78. Kane D, Stafford L, Bresnihan B, FitzGerald O: A prospective, clinical and radiological study of early psoriatic arthritis: An early synovitis clinic experience. Rheumatology (Oxford) 2003;42(12):1460-1468. Helliwell PS, Porter G, Taylor WJ, CASPAR Study Group: Polyarticular psoriatic arthritis is more like oligoarticular psoriatic arthritis, than rheumatoid arthritis. Ann Rheum Dis 2007;66(1):113-117. Bond SJ, Farewell VT, Schentag CT, Gladman DD: Predictors for radiological damage in psoriatic arthritis: Results from a single centre. Ann Rheum Dis 2007;66(3):370-376. Gladman DD, Mease PJ, Choy EH, Ritchlin CT, Perdok RJ, Sasso EH: Risk factors for radiographic progression in

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Summary
PsA is a chronic inflammatory arthropathy. Approximately 15% of patients with PsA present with arthritis before skin lesions; however, arthritis is not correlated with the extent of skin disease.45 Classic radiographic signs include DIP erosion or ankylosis, pencil-in-cup deformity, and fluffy periostitis. DMARDs and biologics are the mainstay of treatment. Arthropathy in these patients may be treated successfully with surgery, but few large-scale, highquality trials have been conducted. Postoperative infection remains a prominent concern, although debate regarding the true risk of infection is ongoing. Collaboration with dermatologists, rheumatologists, and medical doctors is essential to the successful surgical treatment of PsA.
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References
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