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Preoperative evaluation and perioperative management of patients with rheumatic diseases

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

INTRODUCTION

Clinicians caring for patients with rheumatic diseases must be aware that there are specific issues involved in their pre- and postoperative management [1,2].

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".)

PREOPERATIVE EVALUATION

History and physical examination — All patients require a careful preoperative history and physical examination, with further evaluation indicated in some individuals. Some particular concerns among patients with rheumatic diseases include the following:

Many rheumatic diseases are associated with increased risks of coronary artery disease, arrhythmias, heart failure, or cardiac death. (See "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis", section on 'Cardiac disease'.)

Determining cardiovascular risk may be more difficult because many patients with rheumatic diseases are not physically active. An exercise or pharmacologic stress test may be necessary in some circumstances to adequately assess the risk of perioperative myocardial infarction. (See "Evaluation of cardiac risk prior to noncardiac surgery".)

                      
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Literature review current through: Nov 2017. | This topic last updated: Sep 27, 2017.
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References
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  1. Kelley JT, Conn DL. Perioperative management of the rheumatic disease patient. Bull Rheum Dis 2002; 51.
  2. Figgie MP. Introduction to the surgical treatment of rheumatic diseases. In: Rheumatology, Klippel JH, Dieppe PA (Eds), Mosby, St. Louis 1994.
  3. Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care Res (Hoboken) 2017; 69:1111.
  4. Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. J Arthroplasty 2017; 32:2628.
  5. Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Rheumatol 2017; 69:1538.
  6. Somayaji R, Barnabe C, Martin L. Risk factors for infection following total joint arthroplasty in rheumatoid arthritis. Open Rheumatol J 2013; 7:119.
  7. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002; 287:236.
  8. Hoes JN, Jacobs JW, Boers M, et al. EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis 2007; 66:1560.
  9. 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.
  10. Salt E, Wiggins AT, Rayens MK, et al. Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis. Semin Arthritis Rheum 2017; 46:423.
  11. 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.
  12. 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.
  13. 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.
  14. Tanaka N, Sakahashi H, Sato E, et al. Examination of the risk of continuous leflunomide treatment on the incidence of infectious complications after joint arthroplasty in patients with rheumatoid arthritis. J Clin Rheumatol 2003; 9:115.
  15. Fuerst M, Möhl H, Baumgärtel K, Rüther W. Leflunomide increases the risk of early healing complications in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Rheumatol Int 2006; 26:1138.
  16. Escalante A, Beardmore TD. Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis. J Rheumatol 1995; 22:1844.
  17. Mushtaq S, Goodman SM, Scanzello CR. Perioperative management of biologic agents used in treatment of rheumatoid arthritis. Am J Ther 2011; 18:426.
  18. Bongartz T. Elective orthopedic surgery and perioperative DMARD management: many questions, fewer answers, and some opinions... J Rheumatol 2007; 34:653.
  19. Goodman SM. Rheumatoid arthritis: Perioperative management of biologics and DMARDs. Semin Arthritis Rheum 2015; 44:627.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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.
  26. 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.
  27. Pham T, Bachelez H, Berthelot JM, et al. Abatacept therapy and safety management. Joint Bone Spine 2012; 79 Suppl 1:3.
  28. Nishida K, Nasu Y, Hashizume K, et al. Abatacept management during the perioperative period in patients with rheumatoid arthritis: report on eight orthopaedic procedures. Mod Rheumatol 2014; 24:544.
  29. 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.
  30. Strand V, Ahadieh S, French J, et al. Systematic review and meta-analysis of serious infections with tofacitinib and biologic disease-modifying antirheumatic drug treatment in rheumatoid arthritis clinical trials. Arthritis Res Ther 2015; 17:362.
  31. Palmisano AC, Kuhn AW, Urquhart AG, Pour AE. Post-operative medical and surgical complications after primary total joint arthroplasty in solid organ transplant recipients: a case series. Int Orthop 2017; 41:13.
  32. Klement MR, Penrose CT, Bala A, et al. How Do Previous Solid Organ Transplant Recipients Fare After Primary Total Knee Arthroplasty? J Arthroplasty 2016; 31:609.
  33. 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.
  34. 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.
  35. 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.
  36. Schnaser EA, Browne JA, Padgett DE, et al. Perioperative Complications in Patients With Inflammatory Arthropathy Undergoing Total Hip Arthroplasty. J Arthroplasty 2016; 31:2286.
  37. Sundaram NA, Murphy JC. Heterotopic bone formation following total hip arthroplasty in ankylosing spondylitis. Clin Orthop Relat Res 1986; :223.
  38. 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.
  39. Roberts JE, Mandl LA, Su EP, et al. Patients with Systemic Lupus Erythematosus Have Increased Risk of Short-term Adverse Events after Total Hip Arthroplasty. J Rheumatol 2016; 43:1498.
  40. Merayo-Chalico J, Gónzalez-Contreras M, Ortíz-Hernández R, et al. Total Hip Arthroplasty Outcomes: An 18-Year Experience in a Single Center: Is Systemic Lupus Erythematosus a Potential Risk Factor for Adverse Outcomes? J Arthroplasty 2017; 32:3462.
  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.