A preoperative cervical spine assessment also can provide insights into cervical conditions inherent to rheumatoid patients, such as cervical instability, Dr. Baez says. “Anesthesiologists often use a GlideScope for intubation to protect cervical spine manipulation,” he says.
In addition to softer bones, other systemic concerns could become a factor during surgery, says Timothy Gibson, MD, orthopedic surgeon and medical director, MemorialCare Joint Replacement Center at Orange Coast Medical Center, Fountain Valley, Calif. For example, the patient may have pulmonary issues or skin issues that increase the risk for complications. “They can be much more complicated than the general osteoarthritis patient,” he says.
Surgical Outcomes
Although special surgical concerns may exist for patients under rheumatological care, outcomes can be quite good.
“Usually, rheumatologic patients are low demand, and joint replacements are a fantastic option,” Dr. Baez says.
However, that hasn’t always been the case.
“Historically, patients with rheumatoid arthritis were challenging medically and needed to be more closely followed,” Dr. Parks says. “Now, with the excellent treatment available with many medications, patients are not as likely as they were in the past to present with destructive arthritis requiring surgery.”
“I’ve found that people who have RA have dealt with pain for a long time, so they have a certain temperament that’s positive. If you can avoid the complications of surgery, they tend to do great and have good range of motion. And they tend to be the most satisfied patients,” Dr. Gibson says.
Overall, surgical treatment seems to have decreased due to better medical management. “We don’t do nearly as many surgical procedures for contracture release or synovectomy or even joint replacement as in the past,” Dr. Smith says.
The patients who do best are those with specific areas that need targeting with surgery, Dr. Levine says. “If they have systemic problems and multi-pain issues, they don’t do as well,” he says.
From Orthopedics to Rheumatology
Orthopedic surgeons share some advice to keep the constant collaboration with rheumatology humming well.
1. Meet with your potential orthopedics referral partner, Dr. Mirza recommends. “Open a line of communication, and develop collaborative treatment pathways for management of patients with osteoarthritis and end-stage arthritis from inflammatory arthropathies,” he says. If you’re new to an area, a newer physician or, perhaps, just looking for a new referral partner, get to know a local orthopedic surgeon or practice face to face.
Some orthopedic surgeons relish their organization’s direct connection with rheumatologists. Dr. Smith says the team-based approach at the Shriners Hospital for Children in Chicago means that rheumatologists are right down the hall and that patients often can be seen for a same-day initial appointment with the physician from a cross specialty.
