“These medications are effective for controlling symptoms and preventing disease progression. Unfortunately, they also can interfere [with] and slow down surgical incision healing after surgery and can be associated with increased infection risk for joint replacement surgery,” says orthopedic surgeon Amer Mirza, MD, co-founder, Go To Ortho, Lake Oswego, Ore. The orthopedic surgeons interviewed for this article rely heavily on their rheumatologist colleagues to provide guidance on when to stop medications before surgery.
Explore this issueAugust 2018
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Guidance may vary for each individual patient, but generally speaking, Dr. Rapoport stops biologic medications for two half-lives before surgery and sometimes two half-lives after. Methotrexate is not always stopped before surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are typically stopped five half-lives preoperatively, he added.
Most patients will not have a bad disease flare during the brief time they are off their medications, Dr. Rapoport says. In fact, it’s important the patient have their disease under control even as surgery is in the planning stages, Dr. Sayeed says. “If there is active disease, especially in someone with RA, we discourage them from having surgery because [surgery has been] shown to cause more infection and inflammation. We tend to recommend holding off on surgery until the disease is more controlled or in remission prior to surgery,” she says.
At the Center for Advanced Orthopaedics/Mid-Maryland Musculoskeletal Institute, Frederick, Md., rheumatologists and orthopedic physicians are both on staff and work together to plan when to stop medication use, says orthopedic surgeon Matthew J. Levine, MD. “Once we get surgical recovery done, we continue disease management with the rheumatologist,” he says.
It’s also important to let the surgeon know what medications the patient was using prior to surgery and when they were stopped. For example, sometimes a patient who has used steroids in the six months before surgery may need stress-steroid dosing in the operating room to avoid adrenal issues, Dr. Reznik says.
Surgical timing can also be a concern if a patient receives extra-articular corticosteroid injections, Dr. Reznik says. Mounting evidence shows these injections could increase the risk for infection during surgery if they were done three to six months prior to knee or hip surgery. During the waiting time between injections and surgery, Dr. Reznik may recommend other treatments, such as NSAID use, icing, bracing, strengthening and decreased use of impact load activities, such as jumping and running.
Some patients with joint disease require special care during surgery itself. “Bone quality is often poor and osteopenic, requiring gentle manipulation and hammering,” Dr. Baez says. “It is more likely in these cases to consider cementing components because of poor quality bone.”