**5.2 Results**

24 Recent Advances in Arthroplasty

Standard monitoring including continuous electrocardiogram, nonivasive automated blood pressure and pulse oxymetry. Cardiovascular and respiratory monitoring was continued at the time following surgery. All patients were transferred in the postoperative care unit after

Crystalloids, colloids were used perioperatively. Homologous blood was used for

Patients with long-term steroids therapy received additional steroid doses during

All patients received antibiotic prophylaxis with Cephazolin 1g on induction and 1 g eight-

For postoperative pain relief, they were given standard analgesic drug consisting of opioid

Exclusion criteria included an ASA≥3, BMI>30 (obesities), Hb≤9g/dl, treatment with

The duration of RA was evaluated and the Disease Activity Score-28 (DAS28) was calculate for all patients before operation. The set of questionnaires was used, the Disease Activity Score-28 was assessed by the number of swollen and tender joints, erythrocyte sedimentation rate (ESR, mm/h) and general health assessment on a visual analog scale

During observation the normally physical examination of respiratory system was performed in all patients. No patient had significant tachycardia, tachypnea or other symptoms of atelectasis. Moreover, none of patient complained of sharp pain burning sensation in urine tract that might be a sign of infection and no patient had documented wound complication

Patients were divided into two groups depending on the activity of the disease being evaluated DAS28. The patients with DAS-28 score lower than 5.0 were classified into the group 1 (G1) and the patient with DAS28 score≥5 were classified into the group 2 (G2).

Samples of venous blood were taken before induction of anesthesia (a baseline sample-0 h) and at 6, 12, 24, 36 hours (6h, 12h, 24h, 36h) after the end of surgery. Blood was collected in 5 ml pyrogen –free tube, the samples were centrifuged at 3000 rpm for 10 min then serum was

The serum concentration of interleukins IL-6, TGF-β and C-reactive protein (CRP) were

The serum concentration of IL-6 was determined with a commercially available using ELISA

TGF-β was determined with using DuoSet ELISA kits (R&D System). All determinations

CRP was determined using routine diagnostic test (dry chemistry) in analizator Vitros 250. Statistical analysis of results was performed using a standard computer application Statistica version 9. Continuous parametric data were assessed using one-way analysis of

The study was approved by the medical Ethics Committee of the Institute of Rheumatology

determined in all patients. Serum CRP was determined rapidly after obtaining.

transfusion depending on the patient's requirements.

Thromboprophylaxis with low-molecular weight heparin was given.

The tourniquet was used in all patients. Tourniquet pressure was 350 mmHg.

biologic agents, allergy to local anesthetics, contraindications to spinal anesthesia.

postoperative period in a predefined regiment.

separated and stored at -70oC for future analysis.

were performed according to the manufacturer's instructions.

variance (ANOVA). Statistical significance was considered at the p ≤0,05

and informed written consent was obtained from each patient all the patients.

the operation.

hourly within 3-5 days.

and paracetamol.

during observations.

Blood samples:

kits (R&D System).

(VAS).

The study population consisted of 37 patients (35 women, 2 men) with a primary diagnosis of rheumatoid arthritis underwent total knee arthoplasty under spinal anesthesia. ASA physical status II.

Patients were divided into two groups depending on the activity of the disease being evaluated DAS-28. Group 1 (G1) DAS-28 <5, group 2 (G2) DAS-28≥5


Data are mean ±SD or n

Table 1. Characteristics and surgical data of patients divided into DAS-28 groups (G1, G2)

Details of 37 patients studied are shown in Table 1. The significant difference was observed in relation to age between groups. By contrast, there were no significant differences between groups in terms of volume given fluids and tourniquet duration.

With regard to the DAS, the difference between groups is not statistically significant but this difference is particularly shown in the clinical observation.

No significant differences were observed with cardiovasculary parameters between groups during observation: MAP (p=0.61) and SaO2 (p=0.98). MAP: G1: 89.6±11, G2: 86.7±10.2 and SaO2: G1 97.2±1.3 G2 96.5±1.3, the values are mean ±SD.

Analysis of concentration level of IL-6 shown statistically significant difference between groups (Fv1=1, v2=171 =41.23, p<0.0001). The was no found significant differences in concentration level of IL-6 in time segments (Fv1=4, v2=171 =0.13, p=0.9721). No interaction time and groups for IL-6 (Fv1=4, v2=171 =0.15, p=0.9650).

The concentration of IL-6 before operation was particularly higher in patients in G2. Moreover, a comparison of value of IL-6 concentration thirty-six hours after surgery with baseline value indicated small increase of IL-6 in patients in this group.

Taking into consideration the range of IL-6 value it can be concluded that the concentration of IL-6 was kept on the similar levels after operation.

There were none changes in concentration of IL-6 during observation in patients in G1 (Fig. 1).

In terms of TGF-β concentration, the analysis of results shown no statistically significant variation of mean value across time (Fv1=4, v2=168 =0.29, p=0.8867). There was no found the significant difference between groups (Fv1=2, v2=168 =2.79, p=0.0966). However, in opposition to IL-6, in both group the values of TGF-β measured at 36 hour were lower in comparison with preoperative values (Fig.2).

The Stress Response and Its Functional Implications in the Immune

p<0.005 across time (Fv1=4, v2=160 =26.56, p<0.0001) in both groups.

increased during observation with the peak level at 36 hour (Fig. 3).

and progression of joint damage.

mean

**5.3 Discussion** 

CRP, mg/l

Response After Surgery in Patients with Chronic Inflammation Undergoing Arthroplasty 27

The analysis of results of serum CRP concentration shown statistically significant variation

No significant difference was observed in CRP serum concentration between groups across time (Fv1=2, v2=160 =4.10, p=0.0446). In all patients the concentration of CRP systematically

> 0 6 12 24 36 time, h

No significant difference (p>0.05) in DAS 28 was shown between groups. However, these differences were strongly marked in a clinical picture. The patients with higher DAS 28 demonstrated significantly more swollen and painful joint counts that related to disability

High, as well as the very high, the cytokines concentration such as IL-6 and TGF-β was observed in all patients before the surgery. The disease severity common with degenerative joint changes were directly influence on the high cytokines concentrations. This also consistent with previous publications demonstrated the high serum IL-6 level in patients with chronic inflammatory disease (Kaneko et al., 2000; Desgeorges et al., 1997). The preoperative stress has also been proposed as one of factor could affect the IL-6 level (Hirano et al. 1988; Tanno et al., 2004). However, taking into consideration the very high baseline level of IL-6 the stress factor did not seem play significant role in this study. Besides that, the preoperative stress response was reduced with midanium premedication in all patients before the surgery. The autoimmune disease severity, as well as joint cartilage

Fig. 3. Changes in serum CRP concentration against time in group G1 and G2. Data are

G1 G2

Fig. 1. Changes in serum IL-6 level against time in group G1 and G2. Presented values are mean.

Fig. 2. Mean serum levels of TGF-β at predefined time in group G1 and G2.

The analysis of results of serum CRP concentration shown statistically significant variation p<0.005 across time (Fv1=4, v2=160 =26.56, p<0.0001) in both groups.

No significant difference was observed in CRP serum concentration between groups across time (Fv1=2, v2=160 =4.10, p=0.0446). In all patients the concentration of CRP systematically increased during observation with the peak level at 36 hour (Fig. 3).

Fig. 3. Changes in serum CRP concentration against time in group G1 and G2. Data are mean
