Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Preoperative evaluation and perioperative management of patients with rheumatic diseases

John S Axford, DSc, MD, FRCP, FRCPCH
Section Editors
Robert H Shmerling, MD
Stephanie B Jones, MD
Deputy Editor
Monica Ramirez Curtis, MD, MPH


There is a spectrum of rheumatic diseases that affect patients of all ages [1]. Thus, clinicians working with patients with musculoskeletal disorders must be aware that there are general and specific issues involved in their pre- and postoperative management [2,3].

Areas of special concern for patients with rheumatic diseases who are having surgery will be discussed here. General issues in preoperative medical consultation and perioperative management are presented separately. (See "Preoperative medical evaluation of the adult healthy patient" and "Evaluation of cardiac risk prior to noncardiac surgery" and "Prevention of venous thromboembolic disease in surgical patients" and "Perioperative medication management".)


A thorough history, physical examination, targeted laboratory studies, and specific imaging procedures are recommended.

History and physical examination — All patients require a careful history and physical examination, with further evaluation indicated in some individuals. As examples:

Rheumatoid arthritis (RA) is associated with a 60 percent increase in risk of cardiovascular death compared with the general population [4].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2017. | This topic last updated: Oct 11, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Axford JS, O'Callaghan C. Medicine, Second Edition, Blackwell Science, Cambridge 2004.
  2. Kelley JT, Conn DL. Perioperative management of the rheumatic disease patient. Bull Rheum Dis 2002; 51.
  3. Figgie MP. Introduction to the surgical treatment of rheumatic diseases. In: Rheumatology, Klippel JH, Dieppe PA (Eds), Mosby, St. Louis 1994.
  4. Meune C, Touzé E, Trinquart L, Allanore Y. Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 2009; 48:1309.
  5. Vieira EM, Goodman S, Tanaka PP. [Anesthesia and rheumatoid arthritis]. Rev Bras Anestesiol 2011; 61:367.
  6. Kwek TK, Lew TW, Thoo FL. The role of preoperative cervical spine X-rays in rheumatoid arthritis. Anaesth Intensive Care 1998; 26:636.
  7. Mulroy WF, Estok DM, Harris WH. Total hip arthroplasty with use of so-called second-generation cementing techniques. A fifteen-year-average follow-up study. J Bone Joint Surg Am 1995; 77:1845.
  8. Nawabi DH, Chin KF, Keen RW, Haddad FS. Vitamin D deficiency in patients with osteoarthritis undergoing total hip replacement: a cause for concern? J Bone Joint Surg Br 2010; 92:496.
  9. Holstege MS, Lindeboom R, Lucas C. Preoperative quadriceps strength as a predictor for short-term functional outcome after total hip replacement. Arch Phys Med Rehabil 2011; 92:236.
  10. Wymenga AB, van Horn JR, Theeuwes A, et al. Perioperative factors associated with septic arthritis after arthroplasty. Prospective multicenter study of 362 knee and 2,651 hip operations. Acta Orthop Scand 1992; 63:665.
  11. Lehman DE, Capello WN, Feinberg JR. Total hip arthroplasty without cement in obese patients. A minimum two-year clinical and radiographic follow-up study. J Bone Joint Surg Am 1994; 76:854.
  12. Pedersen AB, Sorensen HT, Mehnert F, et al. Risk factors for venous thromboembolism in patients undergoing total hip replacement and receiving routine thromboprophylaxis. J Bone Joint Surg Am 2010; 92:2156.
  13. Eijsbouts A, van den Hoogen F, Laan R, et al. Similar response of adrenocorticotrophic hormone, cortisol and prolactin to surgery in rheumatoid arthritis and osteoarthritis. Br J Rheumatol 1998; 37:1138.
  14. Friedman RJ, Schiff CF, Bromberg JS. Use of supplemental steroids in patients having orthopaedic operations. J Bone Joint Surg Am 1995; 77:1801.
  15. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002; 287:236.
  16. Liu SS, Bae JJ, Bieltz M, et al. Association of perioperative use of nonsteroidal anti-inflammatory drugs with postoperative myocardial infarction after total joint replacement. Reg Anesth Pain Med 2012; 37:45.
  17. Jain A, Maini R, Nanchahal J. Disease modifying treatment and elective surgery in rheumatoid arthritis: the need for more data. Ann Rheum Dis 2004; 63:602.
  18. Pieringer H, Stuby U, Biesenbach G. The place of methotrexate perioperatively in elective orthopedic surgeries in patients with rheumatoid arthritis. Clin Rheumatol 2008; 27:1217.
  19. Grennan DM, Gray J, Loudon J, Fear S. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis 2001; 60:214.
  20. Loza E, Martinez-Lopez JA, Carmona L. A systematic review on the optimum management of the use of methotrexate in rheumatoid arthritis patients in the perioperative period to minimize perioperative morbidity and maintain disease control. Clin Exp Rheumatol 2009; 27:856.
  21. Visser K, Katchamart W, Loza E, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis 2009; 68:1086.
  22. Mushtaq S, Goodman SM, Scanzello CR. Perioperative management of biologic agents used in treatment of rheumatoid arthritis. Am J Ther 2011; 18:426.
  23. Alvarez B, Arcos J, Fernández-Guerrero ML. Pulmonary infectious diseases in patients with primary immunodeficiency and those treated with biologic immunomodulating agents. Curr Opin Pulm Med 2011; 17:172.
  24. Schreiber S, Campieri M, Colombel JF, et al. Use of anti-tumour necrosis factor agents in inflammatory bowel disease. European guidelines for 2001-2003. Int J Colorectal Dis 2001; 16:1.
  25. Bibbo C, Goldberg JW. Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int 2004; 25:331.
  26. Talwalkar SC, Grennan DM, Gray J, et al. Tumour necrosis factor alpha antagonists and early postoperative complications in patients with inflammatory joint disease undergoing elective orthopaedic surgery. Ann Rheum Dis 2005; 64:650.
  27. Wendling D, Balblanc JC, Brousse A, et al. Surgery in patients receiving anti-tumour necrosis factor alpha treatment in rheumatoid arthritis: an observational study on 50 surgical procedures. Ann Rheum Dis 2005; 64:1378.
  28. den Broeder AA, Creemers MC, Fransen J, et al. Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study. J Rheumatol 2007; 34:689.
  29. Giles JT, Gelber AC, Nanda S, et al. TNF inhibitor therapy increases the risk of post operative orthopedic infection in patients with rheumatoid arthritis (abstract). Arthritis Rheum 2004; 50:S660.
  30. Momohara S, Kawakami K, Iwamoto T, et al. Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs. Mod Rheumatol 2011; 21:469.
  31. Pham T, Bachelez H, Berthelot JM, et al. Abatacept therapy and safety management. Joint Bone Spine 2012; 79 Suppl 1:3.
  32. Nuki G, Bresnihan B, Bear MB, et al. Long-term safety and maintenance of clinical improvement following treatment with anakinra (recombinant human interleukin-1 receptor antagonist) in patients with rheumatoid arthritis: extension phase of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2002; 46:2838.
  33. Bongartz T. Elective orthopedic surgery and perioperative DMARD management: many questions, fewer answers, and some opinions... J Rheumatol 2007; 34:653.
  34. Bongartz T, Halligan CS, Osmon DR, et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 2008; 59:1713.
  35. Neva MH, Häkkinen A, Mäkinen H, et al. High prevalence of asymptomatic cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery. Ann Rheum Dis 2006; 65:884.
  36. Lopez-Olivo MA, Andrabi TR, Palla SL, Suarez-Almazor ME. Cervical spine radiographs in patients with rheumatoid arthritis undergoing anesthesia. J Clin Rheumatol 2012; 18:61.
  37. Malviya A, Walker LC, Avery P, et al. The long-term outcome of hip replacement in adults with juvenile idiopathic arthritis: the influence of steroids and methotrexate. J Bone Joint Surg Br 2011; 93:443.
  38. Sundaram NA, Murphy JC. Heterotopic bone formation following total hip arthroplasty in ankylosing spondylitis. Clin Orthop Relat Res 1986; :223.
  39. Menon TJ, Wroblewski BM. Charnley low-friction arthroplasty in patients with psoriasis. Clin Orthop Relat Res 1983; :127.
  40. Domsic RT, Lingala B, Krishnan E. Systemic lupus erythematosus, rheumatoid arthritis, and postarthroplasty mortality: a cross-sectional analysis from the nationwide inpatient sample. J Rheumatol 2010; 37:1467.
  41. Dempsey ZS, Rowell S, McRobert R. The role of regional and neuroaxial anesthesia in patients with systemic sclerosis. Local Reg Anesth 2011; 4:47.