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

Abstract

Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.

Менеджмент Пацієнтів З Ревматоїдним Артритом У Періопераційному Періоді

“…Very often the RA patients are subjected to the urgent surgical interventions, even at the peak of inflammatory autoimmune process. Taking into account the fact that the RA patients are considered a high risk group, the regulating societies in charge of rheumatologic condition treatment consider perioperative management of such patients to be an interdisciplinary issue, requiring involvement of a rheumatologist, anesthesiologist, cardiologist, hematologist and operating surgeon/orthopedist [2].…”

“…Megakaryocyte function is recovered due to the auto-production via the totipotent stem cells regulated by thrombopoietin (THPO) from the liver and kidneys. Based on this fact, some researchers, concerned about the perioperative hemorrhage, recommend the aspirin's cessation 10 days before surgery in order to ensure the appropriate platelet formation [2]. However, a major retrospective study by N. R. Smilowitz et al (2016) reports no connection of aspirin use with an elevated risk of hemorrhage in the perioperative period [38].…”

Total Joint Arthroplasty in Patients with Inflammatory Rheumatic Diseases

“…A higher disease activity has been associated with a higher probability of developing infections. Despite the elevated risk of infection, there is currently no evidence supporting the use of perioperative protocols different from the general population, but specific attention is recommended in postoperative follow-up and wound healing [ 4 – 6 ]. An interesting aspect is the fear of infection related to previous corticosteroid injections.…”

“…In the future, these antibodies may be used as routine biomarkers in perioperative risk stratification. Practical management strategies to prevent potential perioperative complications in patients already treated with anticoagulants should include ensuring correct hydration of the patient, reducing to a minimum the periods without anticoagulant drugs, and encouraging postoperative mobilization as early and as much as tolerated, together with the use of antithrombotic stockings, if not contraindicated [ 6 , 24 ].…”

Influence of Medication on Flare Up and Infection After Elective Orthopedic Surgery in Rheumatoid Arthritis Patient - A Narrative Review

“…5 However, these guidelines may vary and are sometimes contradictory. 6,7 Whether DMARDs increasing the incidence of postoperative infections has been debated. 4 Immunosuppressive effects of DMARDs and immunosuppressants in RA patients treated with this drug may lead to perioperative side effects postoperative infections.…”