185340

8122019 185340

httpslidepdfcomreaderfull185340 17

8122019 185340


983090 Autoimmune Diseases

complicated population Despite the challenges midterm andlong-term outcomes have demonstrated the success o KAin improving quality o lie Ranawat et al presented his serieso midterm outcomes at 983094983089 years o 983097983091 cemented KAs (983089983095OA 983095983091 RA) Good or excellent results were seen in 983097983095983095o the knees and authors predicted a 983097983094 survivorship at

983089983088 years [983094] Gill et al demonstrated good-to-excellent long-term outcomes at 983097983097 years or patients undergoing cementedKA younger than 983093983093 years comparing 983090983097 knees with RAto 983091983095 knees with OA [983095] Authors concluded that the ldquogoodrdquooutcomes in 983089983088 o their patients were due to the multiply affected joints in rheumatoid arthritis Tis led Lee and Choito suggest that these patients should not be evaluated by the unctionality o each joint individually but rather ontheir overall physiologic status instead o numeric age whenconsidering surgical intervention [983093]

Te difficulty to control the polyarticular nature o the disease is urther challenging physicians anaka et aldemonstrated that the most commonly affected joints arethe wrist metacarpophalangeal joint and proximal inter-phalangeal joints although the majority o the pain anddisability is secondary to shoulder knee and hip pathology [983091] When combined together in the same patient the overallprognosis is exponentially worsened and ofen hip and kneesynovitis and arthritis are coexistent [983096] It is accepted that inthose patients with ipsilaterally affected hip and knee jointswith end-stage arthritis total hip arthroplasty (HA) shouldbe perormed 1047297rst prior to KA [983093] Controversy existson whether upper or lower extremity pathology should beaddressed 1047297rst Clement et al arguethat stresses placed on theupper extremity during therapy or KA may urther damagepreviously repaired joints [983092] Conversely Chmell et albelieve that upper extremity impairment such as severe wristpain due to RA may impair lower extremity rehabilitationand thus wrist usion should be considered prior to KA It isourpracticeto evaluate all afflicted jointspriorto arthroplasty to determine the in1047298uence o other joints on rehabilitationand outcome

3 Perioperative Medication Management

Rheumatoid arthritis is generally treated using a combinationo medications including nonsteroidal anti-in1047298ammatory drugs (NSAIDs) glucocorticoids and disease-modiyingantirheumatic drugs (DMARDs) NSAIDs have also played

a smaller role in symptomatic management but these COX-983089 and nonselective COX inhibitors can be associated withincreased bleeding risk and should be withheld 983089 week priorto surgery [983093] In our practice we prescribe COX-983090 inhibitors(Celecoxib) postoperatively as other studies have suggestedthat the slight increase in bleeding risk does not signi1047297cantly increase the need or transusion [983097]

Glucocorticoids on the other hand can be used to treat1047298ares o disease and as a maintenance medication and its usein the perioperative period must be speci1047297cally tailored to thepatient requirements [983093] It must be considered that patientswho have received a prolonged treatment course o steroidsmay be prone to secondary adrenal insufficiency secondary

983137983138983148983141 983089 Disease-modiying antirheumatic drugs (DMARDs) dos-ing regimen in the perioperative period Te preoperative withhold-ing period prior to surgery is speci1047297ed as well as the waiting periodpostoperatively prior to reinstituting the medication

Agent Preoperative hold Postoperative restart

Methotrexateand [983089983093 983089983094] No hold No hold

Le1047298unomide [983093] 983089-983090 days 983089-983090 weeks

Sulasalazine [983093] 983089 day 983091 days

Hydroxychloroquine [983093] No hold No hold

Etanercept [983089983088 983089983095] 983089 wk 983089983088ndash983089983092 days

In1047298iximab [983089983088 983089983095] End dose cycle 983089983088ndash983089983092 days

Adalimumab [983089983088 983089983095] End dose cycle 983089983088ndash983089983092 days

Anakinra [983089983088] 983089-983090 days 983089983088 daysandIn patients with normal renal unction methotrexate should be continuedthroughout the preoperativepostoperativeperiod I renal unction is abnor-mal the medication should be held 983089 week prior to surgery and restarted 983089-983090weeks postoperatively afer the immediate stresses o surgery have subsided

to the chronic suppression o corticotrophin-releasing hor-mones rom the hypothalamus Tese patients require stressdoses perioperatively o 983093983088ndash983089983088983088 mg o hydrocortisone or 983089983088ndash983089983093 mg o methylprednisone intravenously with an immediatetaper to prevent an Addisonian crisis [983089983088] Additionallychronic glucocorticoid use is associated with poor bone qual-ity compromise o the immune system and impaired woundhealing Studies have demonstrated that rheumatoid arthritispatients undergoing joint replacement who take chronicsteroids have increased rates o joint inection reaching 983090983093ndash983091times that o the general population [983089983088ndash983089983090] Tus meticuloussterile technique careul intraoperative skin handling andtight closure are essential

Te most in1047298uential intervention to delay or prevent end-stage joint destruction has been DMARDs Included in thiscategory are methotrexate le1047298unomide sulasalazine aza-thioprine hydroxychloroquine tumor necrosis actor alpha(NF-) inhibitors (etanercept in1047298iximab adalimumab)and interleukin-983089 (IL-983089) inhibitors (anakinra) as listed inable 983089 Tese biologic agents help control the variouscytokines produced in this disease that help limit prolier-ation o 1047297broblasts destruction o bone and cartilage andprogression o disease Additionally it is well establishedthat NF- a proin1047298ammatory cytokine is produced by synovial cells and chondrocytes Tis led oki et al to

conclude that synovectomy and chondrocyte resection thatoccurs with KA help to urther improve patient outcomecomplementing the action o the DMARDs systemically [983089983091] However these medications are associated with anincreased risk o opportunistic inections Despite this itis crucial to avoid re1047298exive continuation or cease o theuse o DMARDs in the perioperative period as this may be associated with an in1047298ammatory 1047298are in the smaller

joints resulting in stiffness added pain and swelling thuscompromising the patientrsquos ability to rehabilitate [983089983088 983089983092 983089983093]Here communication between the orthopedic surgeon andrheumatologist is essential to achieve equilibrium betweenrisk reduction or inection and disease suppression

8122019 185340


Autoimmune Diseases 983091

983137983138983148983141 983090 Literature review o DMARD saety in the perioperative period

Medication Patients Inections Flares

Methotrexate

[983089983093]Continued 983096983096 983090 (983090) 983088

Held Medicationand 983095983090 983089983089 (983089983093) 983094 (983096)

Other DMARDsteroid 983090983090983096 983090983092 (983089983089) 983097 (983092)NF- Inhibitorlowast

[983089983095]Etanercept 983091983091 983088 mdash

In1047298iximab 983090983090 983089 (983093) mdash

Adalimumab 983091 983088 mdashandMethotrexate washeld twoweeksbeore until twoweeksafersurgery in thisgrouplowastEtanercept and adalimumab were held twoweeksbeore until twoweeksafer surgery while in1047298iximab was held both our weeks prior to and afer surgery

Few studies have been published that demonstrate thesaety o these medications perioperatively Grennan et alpublished their 1047297ndings rom a prospectively randomizedclinical study o 983091983096983096 cases o rheumatoid arthritis patientsundergoing joint arthroplasty (see able 983090) [983089983093] Tey oundthat at one-year ollow-up the group that continued totake methotrexate throughout the perioperative period hadsigni1047297cantly better outcome compared to those who tem-porarily held the medication or who used a differentDMARDor corticosteroid Sreekumar et al reexamined the samepopulation o patients at 983089983088 years rom surgery andound thatcontinuing methotrexate in the long term was not associatedwith any additional cases o deep bone inection [983089983094] Whilethe majority o patients should continue to take methotrexateperioperatively in patients with renal dysunction it isprudent to hold this medication 983089 week preoperatively and983089-983090 weeks postoperatively Tis is because the postoperativeperiod may cause added stress to the kidneys worseningunderlying renal insufficiency and propagating methotrexatetoxicity [983089983088] Hayashi et al investigated the NF- inhibitingDMARDs in their prospective cohort o 983092983093 cases o RAin patients requiring large total joint arthroplasty whichincluded 983091983091 KA (see able 983090) [983089983095] At one-year ollow-upthey were able to conclude that NF- inhibitors are sae andefficacious perioperatively when held or a short period o time

As there exist limited prospective studies on this topic wehave delineated our preerred regimen (see able 983089) derivedrom the available literature

4 Intraoperative and TechnicalConsiderations

In addition to the preoperative and perioperative consid-erations o RA patients there are speci1047297c technical chal-lenges that these patients present during the KA procedurewhich are not present in primary OA as these patientsare generally younger [983089983096] Te musculoskeletal problemso RA patients include both inerior bone and sof tissuequality Te direct autoimmune nature o RA as well as thecommon use o corticosteroids in these patients results inpoor subchondral bone substrate which is needed or strong

implant 1047297xation Tis resultant osteopenia is important torecognize as this may decrease implant longevity and may also result in signi1047297cant bone cysts While small cysts canbe 1047297lled during cementation larger cysts require 1047297lling witheither autologous graf rom the bone cuts or allograf rommorselized emoral head Similarly the sof tissue structuresthat stabilize the knee o RA patients may also be poorofen resulting in ligamentous laxity and joint deormity Tispresents a special concern or the surgeon because grossligament instability may require increased constraint in theprosthesis yet this increased constraint can transmit shearand rotational orces to the bone-cement interace resultingin debonding and premature ailure Fortunately with theadvanced medical management o RA most patients with RApresent with mild coronal plane deormity though a 1047297xed

valgus deormity is sometimes present (see Figures 983089 and983090) Fixed 1047298exion contractures may also occur thus urtherpotentiating the overall complexity o the RA patient Finaloutcomes o such a case are seen in Figures 983091 and 983092

An essential component o the reconstruction involvesull joint synovectomy to lessen the in1047298ammatory processwhich may continue postoperatively i not ully addressedas an in1047298ammatory synovitis [983089983097] When perorming a syn-ovectomy it is important to preserve the atty tissue betweenthe synovium and the anterior emur to prevent scarring andadhesion ormation [983089983090]

Te use o a cruciate-retaining (CR) versus a posterior-stabilized (PS) prosthesis is still controversial Te posteriorcruciate ligament (PCL) is a structure taking origin on thelateral aspect o the medial emoral condyle and inserting

on the tibial plateau between the intercondylar notch andposterolateral tibial plateau on the posterior surace Tisintraarticular ligament has multiple unctions but is mainly used in KA or assisting with emoral rollback during knee1047298exion in order to achieve knee hyper1047298exion Althoughexcellent results have been reported with the CR prosthesisthere are some concerns that late instability due to PCLattenuation may occur with longer-term ollow-up [983090983088 983090983089]Some have recommended that the PCL should be assessedintraoperatively and perorm CR KA in patients only whenthe PCL was present and unctioning normally Hanyu et alassessed the PCL intraoperatively and perormed CR KAin patients only when the PCL was present and unctioning

8122019 185340



R

F983145983143983157983154983141 983089 Posteroanterior radiographic view o bilateral kneesdemonstrating advancedarthritisNote the valgus alignmentto bothlegs RA and OA radiographs differ in that RA radiographs will

show periarticular erosions and osteopenia whereas periarticularosteophytes subchondral sclerosis and joint space narrowing aremore common in OA

R

F983145983143983157983154983141 983090 Lateral radiograph o the right knee A small effusion ispresent as well

normally In their series 983089983088-year survivorship o the entire

KA cohort (both CR and PS) was 983097983091 No revisions wereperormed or instability in the CR group [983090983090] Miller et alound a twenty-year implant survival rate o 983097983091 when PCLinsufficiency was the endpoint [983090983091]

5 Complications

RA patients are at twice the risk o developing inectionregardless o the site than the non-RA population [983090983092] By the later stage o the degenerative process many patientshave been taking several immune suppressing medicationsincluding DMARDs glucocorticoids and NF- inhibitorsor a lengthy period o time Even though most o these

R

F983145983143983157983154983141 983091 Te same patient rom Figures 983089ndash983091 now 983090983090 monthsafer right KA was perormed Te PA radiographs are seen withimprovedjoint alignmentin therightknee Te patientis doingwell

walking without pain in the right knee and is now being consideredor a lef KA

R

F983145983143983157983154983141 983092 Lateral view o the right knee 983090983090 months afer KA

medicines are stopped beore surgery the risk o inection

remains quite high with an increased risk o opportunisticinections [983090983093 983090983094] Additionally the majority will restart theirtreatment postoperatively At 983093 years afer primary KA RApatients had 983091 times more inections than OA patients (983092983090compared to 983089983092) [983090983093] Not all drugs seem to have the sameeffect on the inection site or instance patients taking NF- inhibitors are shown to be more prone to develop super1047297cialinection o the surgical site but not deep bone inections[983090983095]

Surgical wound healing is also a major concern or thisgroup o patients Many have a history o corticosteroid usewhich is known to blunt the in1047298ammatory phase o woundhealing and to alter the remodeling o the wound however

8122019 185340



the dose o corticosteroids received by RA patients is nothigh enough to generate these issues [983090983096 983090983097] Methotrexatehas also been shown to reduce wound tensile strength butsimilar to corticosteroid dosages the amount usually givento an RA patient is relatively small and usually does notin1047298uence the healing [983089983093] Some studies have shown more

wound dehiscence in the NF-

inhibitor group [983090983097] Tis isanother reason why we temporarily withhold these agents inthe perioperative period andas detailed in able 983089 Te BritishSociety or Rheumatology has taken this one step urtherand declared ldquoreatment may be restarted post-operatively i there is no evidence o inection and once wound healing issatisactoryrdquo [983091983088]

One area where RA patients are at lower risk or com-plication is deep venous thromboembolism (DV) It iswell established that lower extremity orthopedic surgery isassociated with a risk o DV in up to 983093983088 patients under-going large joint replacement Deadly pulmonary embolismoccurs in one to six percent o patients not taking DV

prophylaxis medications Previous studies have reported thatthe incidence o DV in patients with RA undergoing hip orknee surgery is three to ten times less than that in patientswith OA [983091983089 983091983090] In both studies the decreased occurrenceo DV in patients with RA was attributable to a younger ageo patients and the requent use o NSAIDs with the resultantantiplatelet activity Matta et al in their study show that DVrisk in hospitalized RA patients is higher than the non-RApopulation however one exception occurs when patientsundergo joint surgery where RA patients hada decreased risk o developing DV in comparison to OA patients [983091983091]

In a recent meta-analysis Ravi et al looked at the compli-cations ollowing total joint replacement in RA patients [983091983092]

Tey conclude that RA patients were at higher risk o inec-tion ollowing KA compared to OA patients nonethelessthey ound no difference regarding risk o revision 983097983088-day mortality or venous thromboembolic events within 983097983088 dayso KA

6 Conclusions

Rheumatoid arthritis is predominantly ound in small jointssuch as 1047297ngers and wrists however it is well understood thatthe majority o the impairment o activities o daily livingstems rom the impairment to the large joints (knee hip

and shoulder) Early diagnosis by primary care physiciansand reerral to rheumatologists or aggressive treatment o rheumatoid arthritis remain paramount For these patientswith end-stage degenerative changes in the knee total kneearthroplasty has proven in long-term ollow-up studies tobe a highly successul solution or patients suffering romadvanced joint destruction secondary to rheumatoid arthri-tis Complications afer KA are more requent comparedto the general population and represent signi1047297cant adverseevents requiring revision surgery Tus as DMARDs con-tinue to be widely used to decrease rates o disease progress-ing to end stages a common understanding by orthopedicsurgeonsand rheumatologists alikeo the proper balance and

timing o medications to control the systemic illness whileminimizing adverse events perioperatively is paramount

Conflict of Interests

Jeffrey Geller serves as a paid consultant serves as a paid

consultant or Smith amp Nephew and serves on the editorialboard or Clinical Orthopaedics and Related Research andthe Journal o Arthroplasty He also serves as a board memberor holds committee appointments or the American Associa-tion o Hipand Knee Surgeonsand the American Academy o Orthopaedic Surgeons Forthe remainingauthorsno con1047298icto interests is declared

References

[983089] G H Louie and M M Ward ldquoChanges in the rates o jointsurgery among patients with rheumatoid arthritis in Caliornia983089983097983096983091ndash983090983088983088983095rdquo Annals of the Rheumatic Diseases vol 983094983097 no 983093 pp

983096983094983096ndash983096983095983089 983090983088983089983088[983090] E da Silva M F Doran C S Crowson W M OrsquoFallon and E

L Matteson ldquoDeclining use o orthopedic surgery in patientswith rheumatoid arthritis Results o a long-term population-based assessmentrdquo ArthritisCare and Research vol983092983097no983090 pp983090983089983094ndash983090983090983088 983090983088983088983091

[983091] E anaka A Saito S Kamitsuji et al ldquoImpact o shoulderelbowand knee joint involvement on assessment o rheumatoidarthritis using the American College o Rheumatology CoreData Setrdquo Arthritis Care and Research vol 983093983091 no 983094 pp 983096983094983092ndash983096983095983089 983090983088983088983093

[983092] N D Clement S J Breusch and L C Biant ldquoLower limb jointreplacement in rheumatoid arthritisrdquo Journal of OrthopaedicSurgery and Research vol 983095 p 983090983095 983090983088983089983090

[983093] J K Lee andC H Choi ldquootal knee arthroplastyin rheumatoidarthritisrdquo Knee Surgery amp Related Research vol983090983092 no 983089 pp 983089ndash983094983090983088983089983090

[983094] C S Ranawat D E Padgett and Y Ohashi ldquootal knee arthro-plasty or patients younger than 983093983093 yearsrdquo Clinical Orthopaedicsand Related Research no 983090983092983096 pp 983090983095ndash983091983091 983089983097983096983097

[983095] G S Gill KCasey Chan and D M Mills ldquo983093- o 983089983096-year ollow-up study o cemented total knee arthroplasty or patients 983093983093years old or youngerrdquo Journal of Arthroplasty vol 983089983090 no 983089 pp983092983097ndash983093983092 983089983097983097983095

[983096] R K Jacoby M I Jayson and J A Cosh ldquoOnset early stagesand prognosis o rheumatoid arthritis a clinical study o 983089983088983088patients with 983089983089-year ollow-uprdquo British medical journal vol 983090

no 983093983096983093983096 pp 983097983094ndash983089983088983088 983089983097983095983091[983097] C M Samama O Bastien F Forestier et al ldquoAntiplatelet agents

in the perioperative period expert recommendations o theFrench Society o Anesthesiology and Intensive Care (SFAR)983090983088983088983089-Summary Statementrdquo Canadian Journal of Anesthesia vol983092983097 supplement 983094 pp S983090983094ndash983090983091983093 983090983088983088983090

[983089983088] C R Howe G C Gardner andN J Kadel ldquoPerioperative med-ication management or the patient with rheumatoid arthritisrdquo Journal of the American Academy of Orthopaedic Surgeons vol983089983092 no 983097 pp 983093983092983092ndash983093983093983089 983090983088983088983094

[983089983089] C P Luessenhop L D Higgins B DBrauseand C S RanawatldquoMultiple prosthetic inections afer total joint arthroplasty risk actor analysisrdquo Journal of Arthroplasty vol 983089983089 no 983095 pp 983096983094983090ndash983096983094983096 983089983097983097983094

8122019 185340



[983089983090] M JChmelland R D Scottldquootal knee arthroplastyin patientswith rheumatoid arthritis an overviewrdquo Clinical Orthopaedicsand Related Research no 983091983094983094 pp 983093983092ndash983094983088 983089983097983097983097

[983089983091] H oki S Momohara K Ikari et al ldquoReturn o in1047298iximabefficacy afer total knee arthroplasty in a patient with rheuma-toid arthritisrdquo Clinical Rheumatology vol 983090983095 no 983092 pp 983093983092983097ndash983093983093983088983090983088983088983096

[983089983092] S Momohara K Kawakami Iwamoto et al ldquoProsthetic jointinection afer total hip or knee arthroplasty in rheumatoidarthritis patients treated with nonbiologic and biologic disease-modiying antirheumaticdrugsrdquo Modern Rheumatology vol983090983089no 983093 pp 983092983094983097ndash983092983095983093 983090983088983089983089

[983089983093] D M Grennan J Gray J Loudon and S Fear ldquoMethotrexateand early postoperative complications in patients with rheuma-toid arthritis undergoing elective orthopaedic surgeryrdquo Annalsof the Rheumatic Diseases vol 983094983088 no 983091 pp 983090983089983092ndash983090983089983095 983090983088983088983089

[983089983094] R SreekumarJ Gray P Kay and D M Grennan ldquoMethotrexateand post operative complications in patients with rheumatoidarthritis undergoing elective orthopaedic surgery-a ten yearollow-uprdquo Acta Orthopaedica Belgica vol 983095983095 no 983094 pp 983096983090983091ndash983096983090983094 983090983088983089983089

[983089983095] M Hayashi Kojima K Funahashi et al ldquoEffect o totalarthroplasty combined with anti-tumor necrosis actor agentsin attenuatingsystemic disease activity in patientswith rheuma-toid arthritisrdquo Modern Rheumatology vol 983090983090no 983091 pp 983091983094983091ndash983091983094983097983090983088983089983090

[983089983096] R Poss F C Ewald W H Tomas and C B Sledge ldquoCom-plications o total hip replacement arthroplasty in patients withrheumatoid arthritisrdquo Journal of Bone and Joint Surgery A vol983093983096 no 983096 pp 983089983089983091983088ndash983089983089983091983091 983089983097983095983094

[983089983097] D Cooke V Cooke and S Richer ldquoLocalization o anti-gen antibody complexes in intraarticular collagenous tissuesrdquo Annals of the New York Academy of Sciences vol 983090983093983094 pp 983089983088ndash983090983092983089983097983095983093

[983090983088] R S Laskin and H M OrsquoFlynn ldquootal knee replacement withposterior cruciate ligament retention in rheumatoid arthritisproblems and complicationsrdquo Clinical Orthopaedics and Related Research no 983091983092983093 pp 983090983092ndash983090983096 983089983097983097983095

[983090983089] M J Archibeck R A Berger R M Barden et al ldquoPosteriorcruciate ligament-retaining total knee arthroplasty in patientswith rheumatoid arthritisrdquo Journal of Bone and Joint Surgery A vol 983096983091 no 983096 pp 983089983090983091983089ndash983089983090983091983094 983090983088983088983089

[983090983090] Hanyu A Murasawa and ojo ldquoSurvivorship analysis o total knee arthroplasty with the kinematic prosthesis in patientswho have rheumatoid arthritisrdquo Journal of Arthroplasty vol 983089983090no 983096 pp 983097983089983091ndash983097983089983097 983089983097983097983095

[983090983091] M D Miller N M Brown C J Della Valle A G Rosenbergand J O Galante ldquoPosterior cruciate ligament-retaining total

knee arthroplasty in patients with rheumatoid arthritis aconcise ollow-up o a previousreportrdquo Journalof Bone and Joint Surgery A vol 983097983091 no 983090983090 pp 983089ndash983094 983090983088983089983089

[983090983092] M F Doran C S Crowson G R Pond W M OrsquoFallon and SE Gabriel ldquoFrequency o inection in patients with rheumatoidarthritis compared with controls a population-based studyrdquo Arthritis and Rheumatism vol 983092983094 no 983097 pp 983090983090983096983095ndash983090983090983097983091 983090983088983088983090

[983090983093] Bongartz C S Halligan D R Osmon et al ldquoIncidence andrisk actors o prosthetic joint inection afer total hip or kneereplacement in patients with rheumatoid arthritisrdquo ArthritisCare and Research vol 983093983097 no 983089983090 pp 983089983095983089983091ndash983089983095983090983088 983090983088983088983096

[983090983094] S Bernatsky M Hudson and S Suissa ldquoAnti-rheumatic druguse and risk o serious inections in rheumatoid arthritisrdquoRheumatology vol 983092983094 no 983095 pp 983089983089983093983095ndash983089983089983094983088 983090983088983088983095

[983090983095] S Momohara E InoueK Ikari et al ldquoRiskactors or totalkneearthroplasty in rheumatoid arthritisrdquo Modern Rheumatology vol 983089983095 no 983094 pp 983092983095983094ndash983092983096983088 983090983088983088983095

[983090983096] S R Karukonda C Flynn E E Boh E I McBurney GG Russo and L E Millikan ldquoTe effects o drugs on woundhealing-part II Speci1047297c classes o drugs and their effect onhealing woundsrdquo International Journal of Dermatology vol 983091983097no 983093 pp 983091983090983089ndash983091983091983091 983090983088983088983088

[983090983097] A R Barnard M Regan F D Burke K C Chung and E FS Wilgis ldquoWound healing with medications or rheumatoidarthritis in hand surgeryrdquo ISRN Rheumatol vol 983090983088983089983090 Article ID983090983093983089983097983094983090 983093 pages 983090983088983089983090

[983091983088] J Ledingham and C Deighton ldquoUpdate on the British Society or Rheumatology guidelines or prescribing NF blockers inadults with rheumatoid arthritis (update o previous guidelineso April 983090983088983088983089)rdquo Rheumatology vol 983092983092 no 983090 pp 983089983093983095ndash983089983094983091 983090983088983088983093

[983091983089] H A E M van Heereveld R F J M Laan F H J Van denHoogen M C De Waal Male1047297jt I R O Novakova and LB A Van de Putte ldquoPrevention o symptomatic thrombosiswith short term (low molecularweight) heparin in patients with

rheumatoid arthritis afer hip or knee replacementrdquo Annals of the Rheumatic Diseases vol 983094983088 no 983089983088 pp 983097983095983092ndash983097983095983094 983090983088983088983089

[983091983090] Y Niki H Matsumoto A Hakozaki Mochizuki and SMomohara ldquoRheumatoid arthritis a risk actor or deep venousthrombosis afer total knee arthroplasty Comparative study with osteoarthritisrdquo Journal of Orthopaedic Science vol 983089983093 no983089 pp 983093983095ndash983094983091 983090983088983089983088

[983091983091] F Matta R Singala A Y Yaekoub R Najjar and P D SteinldquoRisk o venous thromboembolism with rheumatoid arthritisrdquoTrombosis and Haemostasis vol 983089983088983089 no 983089 pp 983089983091983092ndash983089983091983096 983090983088983088983097

[983091983092] B Ravi B Escott P S Shah et al ldquoA systematic review andmeta-analysis comparing complications ollowing total jointarthroplasty or rheumatoid arthritis versus or osteoarthritisrdquo Arthritis and Rheumatism vol 983094983092 no 983089983090 pp 983091983096983091983097ndash983091983096983092983097 983090983088983089983090

8122019 185340


Submit your manuscripts at

httpwwwhindawicom

8122019 185340



complicated population Despite the challenges midterm andlong-term outcomes have demonstrated the success o KAin improving quality o lie Ranawat et al presented his serieso midterm outcomes at 983094983089 years o 983097983091 cemented KAs (983089983095OA 983095983091 RA) Good or excellent results were seen in 983097983095983095o the knees and authors predicted a 983097983094 survivorship at

983089983088 years [983094] Gill et al demonstrated good-to-excellent long-term outcomes at 983097983097 years or patients undergoing cementedKA younger than 983093983093 years comparing 983090983097 knees with RAto 983091983095 knees with OA [983095] Authors concluded that the ldquogoodrdquooutcomes in 983089983088 o their patients were due to the multiply affected joints in rheumatoid arthritis Tis led Lee and Choito suggest that these patients should not be evaluated by the unctionality o each joint individually but rather ontheir overall physiologic status instead o numeric age whenconsidering surgical intervention [983093]

Te difficulty to control the polyarticular nature o the disease is urther challenging physicians anaka et aldemonstrated that the most commonly affected joints arethe wrist metacarpophalangeal joint and proximal inter-phalangeal joints although the majority o the pain anddisability is secondary to shoulder knee and hip pathology [983091] When combined together in the same patient the overallprognosis is exponentially worsened and ofen hip and kneesynovitis and arthritis are coexistent [983096] It is accepted that inthose patients with ipsilaterally affected hip and knee jointswith end-stage arthritis total hip arthroplasty (HA) shouldbe perormed 1047297rst prior to KA [983093] Controversy existson whether upper or lower extremity pathology should beaddressed 1047297rst Clement et al arguethat stresses placed on theupper extremity during therapy or KA may urther damagepreviously repaired joints [983092] Conversely Chmell et albelieve that upper extremity impairment such as severe wristpain due to RA may impair lower extremity rehabilitationand thus wrist usion should be considered prior to KA It isourpracticeto evaluate all afflicted jointspriorto arthroplasty to determine the in1047298uence o other joints on rehabilitationand outcome

3 Perioperative Medication Management

Rheumatoid arthritis is generally treated using a combinationo medications including nonsteroidal anti-in1047298ammatory drugs (NSAIDs) glucocorticoids and disease-modiyingantirheumatic drugs (DMARDs) NSAIDs have also played

a smaller role in symptomatic management but these COX-983089 and nonselective COX inhibitors can be associated withincreased bleeding risk and should be withheld 983089 week priorto surgery [983093] In our practice we prescribe COX-983090 inhibitors(Celecoxib) postoperatively as other studies have suggestedthat the slight increase in bleeding risk does not signi1047297cantly increase the need or transusion [983097]

Glucocorticoids on the other hand can be used to treat1047298ares o disease and as a maintenance medication and its usein the perioperative period must be speci1047297cally tailored to thepatient requirements [983093] It must be considered that patientswho have received a prolonged treatment course o steroidsmay be prone to secondary adrenal insufficiency secondary

983137983138983148983141 983089 Disease-modiying antirheumatic drugs (DMARDs) dos-ing regimen in the perioperative period Te preoperative withhold-ing period prior to surgery is speci1047297ed as well as the waiting periodpostoperatively prior to reinstituting the medication

Agent Preoperative hold Postoperative restart

Methotrexateand [983089983093 983089983094] No hold No hold

Le1047298unomide [983093] 983089-983090 days 983089-983090 weeks

Sulasalazine [983093] 983089 day 983091 days

Hydroxychloroquine [983093] No hold No hold

Etanercept [983089983088 983089983095] 983089 wk 983089983088ndash983089983092 days

In1047298iximab [983089983088 983089983095] End dose cycle 983089983088ndash983089983092 days

Adalimumab [983089983088 983089983095] End dose cycle 983089983088ndash983089983092 days

Anakinra [983089983088] 983089-983090 days 983089983088 daysandIn patients with normal renal unction methotrexate should be continuedthroughout the preoperativepostoperativeperiod I renal unction is abnor-mal the medication should be held 983089 week prior to surgery and restarted 983089-983090weeks postoperatively afer the immediate stresses o surgery have subsided

to the chronic suppression o corticotrophin-releasing hor-mones rom the hypothalamus Tese patients require stressdoses perioperatively o 983093983088ndash983089983088983088 mg o hydrocortisone or 983089983088ndash983089983093 mg o methylprednisone intravenously with an immediatetaper to prevent an Addisonian crisis [983089983088] Additionallychronic glucocorticoid use is associated with poor bone qual-ity compromise o the immune system and impaired woundhealing Studies have demonstrated that rheumatoid arthritispatients undergoing joint replacement who take chronicsteroids have increased rates o joint inection reaching 983090983093ndash983091times that o the general population [983089983088ndash983089983090] Tus meticuloussterile technique careul intraoperative skin handling andtight closure are essential

Te most in1047298uential intervention to delay or prevent end-stage joint destruction has been DMARDs Included in thiscategory are methotrexate le1047298unomide sulasalazine aza-thioprine hydroxychloroquine tumor necrosis actor alpha(NF-) inhibitors (etanercept in1047298iximab adalimumab)and interleukin-983089 (IL-983089) inhibitors (anakinra) as listed inable 983089 Tese biologic agents help control the variouscytokines produced in this disease that help limit prolier-ation o 1047297broblasts destruction o bone and cartilage andprogression o disease Additionally it is well establishedthat NF- a proin1047298ammatory cytokine is produced by synovial cells and chondrocytes Tis led oki et al to

conclude that synovectomy and chondrocyte resection thatoccurs with KA help to urther improve patient outcomecomplementing the action o the DMARDs systemically [983089983091] However these medications are associated with anincreased risk o opportunistic inections Despite this itis crucial to avoid re1047298exive continuation or cease o theuse o DMARDs in the perioperative period as this may be associated with an in1047298ammatory 1047298are in the smaller

joints resulting in stiffness added pain and swelling thuscompromising the patientrsquos ability to rehabilitate [983089983088 983089983092 983089983093]Here communication between the orthopedic surgeon andrheumatologist is essential to achieve equilibrium betweenrisk reduction or inection and disease suppression

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Methotrexate

[983089983093]Continued 983096983096 983090 (983090) 983088




In1047298iximab 983090983090 983089 (983093) mdash











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R



R




5 Complications


R



R





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Methotrexate

[983089983093]Continued 983096983096 983090 (983090) 983088




In1047298iximab 983090983090 983089 (983093) mdash











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R



R




5 Complications


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R





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6 Conclusions







References














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R




5 Complications


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6 Conclusions







References














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