State-of-the-Art Approaches to Rheumatic Disease Diagnosis, Management & Treatment

Perioperative Management

Susan M. Goodman, MD, director of the Integrative Rheumatology and Ortho­pedics Center of Excellence at the Hospital for Special Surgery, New York, addressed the perioperative management of patients with rheumatic disease. She began by noting that although the rate of arthroplasty in this patient population remains high, these patients differ from osteoarthritis (OA) patients who seek arthroplasty. The population of rheumatoid arthritis (RA) patients who undergo arthroplasty has become older, while the population of OA patients who seek arthroplasty has become younger. Moreover, when compared with RA patients who do not seek arthroplasty, the RA patients who are at risk for arthroplasty have more erosions, are more likely to have a body mass index of 30 or more, are seropositive, with large joint swelling and may have experienced a delay in metho­trexate use.

These trends in arthroplasty extend beyond RA. Dr. Goodman explained that, in 1998, 7% of patients with psoriatic arthritis underwent orthopedic surgery.³ By 2016, that number increased to 48%.⁴ This increase partially reflects the fact that the longer a patient has psoriatic arthritis, the more likely they are to require surgery. Additional risk factors for surgery include inflamed joints and damage visible on X-ray. Patients with systemic lupus erythematosus (SLE) are also increasingly undergoing arthroplasty. Knee replacement rates in SLE patients increased sixfold from 1991–2005.⁵ Again, this dramatic increase likely reflects the increased health and survivorship of this patient population.

Dr. Goodman also discussed outcomes and adverse events associated with surgery in patients with rheumatic disease. She noted that adverse event information is required by the Centers for Medicare and Medicaid Services to determine hospital reimbursement rates. Generally, RA patients tend to have total knee replacement outcomes similar to OA patients despite having worse pain and function pre-operatively. In contrast, RA patients who receive total hip replacement are four times more likely than OA patients to have a poor functional outcome.⁶ This poor outcome can be modified with contralateral total hip replacement. Although SLE patients tend to have worse baseline pain and function than OA patients, their post-total hip replacement outcomes appear to be the same as OA patients. Likewise, patients with psoriatic arthritis (PsA), OA and OA plus cutaneous psoriasis do well after total knee replacement.

Patients with inflammatory arthritis are at a 40–80% increase risk of infections relative to those with non-inflammatory arthritis.⁷ “It is a little hard to figure out what is causing this increase,” added Dr. Goodman. One possibility is patients with inflammatory arthritis who are treated with biologics are more likely to be colonized with S. aureus, which is a risk factor for surgical site infections.

Finally, Dr. Goodman discussed perioperative, disease-modifying anti-rheumatic drugs (DMARDs), biologics and glucocorticoid management. She emphasized that optimal perioperative management requires close collaboration between orthopedists and rheumatologists because the medications used to treat rheumatological disease may contribute to the risk of infection. Although DMARDs, such as methotrexate, hydroxychloroquine and leflunomide, appear to be safe during the perioperative period, biologics should be withheld prior to surgery.