Orthopedic surgery and its complication in systemic lupus erythematosus

Abstract

Systemic lupus erythematosus (SLE) is a multi-systemic immune-complex mediated autoimmune condition which chiefly affects women during their prime year. While the management of the condition falls into the specialty of internal medicine, patients with SLE often present with signs and symptoms pertaining to the territory of orthopedic surgery such as tendon rupture, carpal tunnel syndrome, osteonecrosis, osteoporotic fracture and infection including septic arthritis, osteomyelitis and spondylodiscitis. While these orthopedicrelated conditions are often debilitating in patients with SLE which necessitate management by orthopedic specialists, a high index of suspicion is necessary in diagnosing these conditions early because lupus patients with potentially severe orthopedic conditions such as osteomyelitis frequently present with mild symptoms and subtle signs such as low grade fever, mild hip pain and back tenderness. Additionally, even if these orthopedic conditions can be recognized, complications as a result of surgical procedures are indeed not uncommon. SLE per se and its various associated pharmacological treatments may pose lupus patients to certain surgical risks if they are not properly attended to and managed prior to, during and after surgery. Concerted effort of management and effective communication among orthopedic specialists and rheumatologists play an integral part in enhancing favorable outcome and reduction in postoperative complications for patients with SLE through thorough pre-operative evaluation, careful peri-operative monitoring and treatment, as well as judicious postoperative care.© 2014 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: orthopedics; Complications; Surgery; Systemic lupus erythematosus; operation Core tip: Systemic lupus erythematosus (SLE) is a complex autoimmune condition. orthopedic specialists often encounter patients with SLE presenting with various orthopedic conditions which require surgical intervention but due to the complexity of SLE and its associated treatment, pre-operative preparation and post-operative care for these patients are often challenging. Concerted effort of management and effective communication between orthopedic specialists and rheumatologists play an integral part in enhancing favorable outcome and reduction in postoperative complications for patients with SLE through thorough preoperative evaluation, careful peri-operative monitoring and treatment, as well as judicious postoperative care.Mak A. Orthopedic surgery and its complication in systemic lupus erythematosus.

Pediatric systemic lupus erythematosus

“…Systemic lupus erythematosus (SLE) is an autoimmune disease which predominantly affects females. 1 Approximately, children signify 15% to 20% of all SLE patients. They tend to have a more severe disease than adults at the onset.…”

Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview

“…NSAIDs have variable half-lives ranging from 2 to 6 h (ibuprofen, ketoprofen, indomethacin), to 7–15 h (celecoxib, naproxen, diflunisal), to > 20 h (meloxicam, nabumetone, piroxicam) [ 52 ]. It is advisable to withhold NSAIDs preoperatively for a period equivalent to five half-lives of the drugs [ 52 ] and to re-start them 2–3 days postoperatively [ 53 ].…”

Risk factors for development of early infectious and noninfectious complications in systemic lupus erythematosus patients undergoing major surgery

“…All data were abstracted from the medical records and included: demographic variables; SLE clinical characteristics at diagnosis and at the time of the surgery; disease duration and presence of secondary APS; comorbidities (obesity, smoking, arterial hypertension, diabetes mellitus, dyslipidemia, heart failure, end-stage renal disease, cancer and cerebrovascular disease); use of oral anticoagulants or aspirin; SLE treatment at the time of surgery, including dose of immunosuppressants; disease activity and damage accrued at the time of surgery using the Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K) and Systemic Lupus International Collaborating Clinics/ACR Damage Index SLICC/ACR-DI, respectively. 10,11 The presence of a severe SLE manifestation three months before surgery was considered, defined as SLEDAI-2K score > 12, a new clinical manifestation or worsening of vasculitis, lupus nephritis, thrombocytopenia < 60,000/ mm 3 or autoimmune hemolytic anemia that required doubling the prednisone dose, or a dose >0.5 mg/kg/day, and/or an increase of prednisone > 0.5 mg/kg/day or new onset of immunosuppresants. 12 Preoperative variables included laboratory parameters and SLE serologic disease activity markers such as anti-double-stranded DNA (anti-dsDNA), complement C3 and C4; preoperative cardiovascular risk assessment 13 and Charlson Comorbidity Index.…”

“…1,2 Pathophysiology is multifactorial and comprises environmental, neuroendocrine, genetic, hormonal and infectious mechanisms. 3 Mortality in SLE patients displays a bimodal pattern: Early death is associated with disease activity and severe infections, while late mortality is due to cardiovascular complications related to atherosclerosis. 1 SLE patients present traditional cardiovascular risk factors (i.e.…”