1 Introduction

The aim of this chapter is to present a simple approach to the assessment of patients with different rheumatologic diseases, especially rheumatoid arthritis (RA), before undergoing orthopedic surgery. Perioperative assessment confirms an early diagnosis of the patient’s medical condition and comorbidities, overall health, and the assessment of the risk factors associated with the proposed interventions. Perioperative assessment allows for proper postoperative management of complications. It can also aid in the management of high-risk drugs used by rheumatologic patients such as disease-modifying antirheumatic drugs (DMARD), antiplatelets, and corticosteroids. The assessment also supports postoperative plans and patient education [1,2,3].

1.1 Objectives

  1. 1.

    To present a comprehensive preoperative medical evaluation for patients with rheumatologic disorders before undergoing orthopedic surgery.

  2. 2.

    To clarify the assessment of specific clinical issues in patients with RA and systemic lupus erythematosus (SLE).

  3. 3.

    To present the perioperative management of medications for patients with rheumatologic disorders before undergoing orthopedic surgery.

  4. 4.

    To clarify how to follow-up and educate the patient postoperatively.

2 The Preoperative Medical Evaluation

2.1 History Taking

Detailed information should be obtained. There are several components of the history that should be outlined. These include the patient’s age, duration of rheumatologic disorder, current functional level, specific joint involvement with arthritis, any extra-articular manifestations of the disease, current medications including DMARDs and previous use of steroids, previous complications associated with surgery, and any comorbidities like hypertension and/or diabetes mellitus.

2.2 Physical Examination

Obviously, for any rheumatic disease patients, there should be specific focus on the musculoskeletal system during the physical examination. This should include posture, location and pattern of joint involvement, gait, and range of motion (ROM) of the examined joints. Furthermore, underlying disorder must be identified. The skin should also be assessed for any manifestations suggestive of an underlying rheumatologic diseases that may impact skin integrity.

2.3 Investigations

The following tests may be considered along with routine tests:

  • A complete blood count for an examination of possible drug related hematologic side effects. This may include anemia due to gastric or duodenal irritation, leukopenia, and/or pancytopenia from massive bone marrow suppression. This is essential in situations where significant blood loss is expected, such as total hip replacements.

  • A complete renal profile, liver enzymes, and liver function tests to screen for DMARDs side effects.

  • A urinalysis and urine culture should be obtained. It is important to rule out urinary tract infections in patients undergoing total joint arthroplasty [4, 5].

  • A 12-lead electrocardiogram (ECG) is necessary as a baseline cardiovascular evaluation for patients undergoing surgeries. ECG is recommended in men over the age 40 and women over 50 having major surgery. This is essential even in the absence of history or physical exam findings.

  • Chest x-ray is necessary as a baseline for pulmonary evaluation. It is indicated for patients over the age 50 undergoing major joint or spine surgery. This is even in the absence of symptoms and/or signs suggestive of active pulmonary disease [6, 27].

2.4 Assessment of Specific Clinical Problems in Patients with RA

2.4.1 Cardiovascular

Special focus should be made to risk stratify RA patients for coronary artery disease. Many contributing factors including accelerated atherosclerosis put RA patients at high risk for cardiac morbidity and mortality. RA patients presenting for orthopedic surgery for any kind of procedure and/or intervention should receive careful preoperative cardiac risk stratification. There are several measures to be taken. Dipyridamole thallium scintigraphy (DTS) conducted preoperatively is found to be most useful to stratify selected nonvascular surgery patients at intermediate or high risk by clinical assessment [6,7,8,9, 28,7,8,].

2.4.2 Pulmonary

Multiple pulmonary complications including fibrosis, bronchiolitis, and pleuritis can have significant impact on RA patients. Serial pulmonary function test (PFT) among patients with RA is recommended. This can help in early detection of defected ventilation. [10]

2.4.3 Cricoarytenoid Arthritis

This is a common involvement in RA patients. It places concerns of complicated intubation or obstructed airway after surgery. Most patients are asymptomatic, but despite that they may present with symptoms such as hoarseness, sore throat, and/or difficult inspiration. Therefore, it is extremely essential to avoid intraoperative musculoskeletal trauma in patients with RA by applying generous padding during joint positioning and by avoiding sudden movements of the neck and torso [11, 23,24,25,26].

3 Perioperative Drug Management

3.1 Perioperative Management if Antirheumatic Drugs [12,13,14,15,16]

(See Table 18.1)

Table 18.1 Perioperative management of antirheumatic drugs
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3.2 Perioperative Management of Other Systemic Medications [12,13,14, 16, 17]

(See Table 18.2)

Table 18.2 Perioperative management of medications
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3.3 DVT Prophylaxis

  • Meta-analysis showed that extended-duration prophylaxis against deep vein thrombosis (DVT) with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) in patients with major hip or knee replacement surgery can reduce the risk of symptomatic venous thromboembolism significantly [18].

  • There are many options for the prevention of venous thromboembolism in patients undergoing elective hip or knee arthroplasty and who are not at increased risk beyond that of the surgery itself for venous thromboembolism or bleeding. Prophylaxis should be started after surgery (specific timing given separately for each drug) and continued for 28–35 days for hip patients and 10–14 days for knee patients: dabigatran, fondaparinux, LMWH, rivaroxaban, and UFH (for patients with renal failure) are all options [18, 19, 35].

  • It has to be considered that the benefit here is associated with increased risk of minor bleeding but with no excess major bleeding [18].

  • In patients undergoing hip fracture surgery (HFS), it is recommended to use one of the following rather than no antithrombotic prophylaxis for a minimum of 10 to 14 days: LMWH, fondaparinux, LDUH, adjusted-dose VKA, or aspirin.

  • There are specific considerations for patients undergoing major orthopedic surgery, total hip arthroplasty (THA), total knee arthroplasty (TKA), hip fracture surgery (HFS), and receiving LMWH as thromboprophylaxis; it is recommended to start either 12 h or more preoperatively or 12 h or more postoperatively, rather than within 4 h or less preoperatively or 4 h or less postoperatively [19, 36].

  • It has to be noted that in patients undergoing THA or TKA, irrespective of the concomitant use of an intermittent pneumatic compression device (IPCD) or length of treatment, it is suggested to use LMWH in preference to the other agents recommended as alternatives: fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose UFH, adjusted-dose vitamin K antagonist (VKA), or aspirin.

3.4 Prophylactic Antibiotics [20, 29]

  • Prophylactic antibiotics are needed for RA patients who will be undergoing long procedures especially patients with TKA, joint replacement, and prosthetic joints. This is to prevent surgical site infections.

  • Obviously, antibiotics must be administered to patients undergoing surgery in an infected area with a high bacteremia risk.

  • Cefazolin or cefuroxime antibiotics are the antibiotic of choice and should be given 30 to 60 min before skin incision.

  • In case of a confirmed ß-lactam allergy, vancomycin may be used. It should be started within 2 h prior to incision.

  • The dose of antibiotic varies according to patient’s weight; for patients >80 kg, the doses of cefazolin should be doubled.

  • It has to be noted that additional intraoperative doses of antibiotic might be needed. It should be given for prolonged procedures and if there is significant blood loss during the procedure.

  • Prevention of wound infection is essential. This can be prevented after surgical repair of closed fractures by a single dose of cephalosporin.

  • Prophylactic antibiotics should be stopped within 24 h of the end of surgery.

4 Assessment of Specific Clinical Problems in Patients with SLE

Specific perioperative concerns must be considered for patients with SLE undergoing orthopedic surgery. This should include assessing risk factors for worse outcomes including smoking or use of oral contraceptive pills (OCP), adequate blood pressure (BP), and lipid control. It has to be noted that SLE patients undergoing both nonelective and elective hip and knee surgery have a high mortality and morbidity rate compared to RA patients [21].

It is also necessary to assess medication management around the operation time. SLE patients have multiple organ involvement. This should be assessed as well including hematologic abnormalities, renal disease, and immune dysfunction, and thromboembolic disease. Moreover, a careful balance should be addressed in the risk assessment in patients with antiphospholipid antibody syndrome (APS). The aim is to evaluate these patients preoperatively to decrease the risk of major bleeding and the risk of a thromboembolic event.

5 Postoperative Follow-Up

There has to be a thorough postoperative risk assessment for the following patients:

  • Carful follow-up for patients with RA and SLE assessing the risk of prosthetic joint infections, DVT, and pulmonary embolism. These patients have greater risk for the development of these complications postoperatively.

  • Hospitalized patients with autoimmune disease have a high risk of postoperative venous thrombosis. These patients can be offered a regional anesthesia, as it reduces the postoperative DVT significantly.

  • Patients with gout should be assessed for the risk of flare of gout postoperatively.

  • There are special precautions for patients with Raynaud’s phenomenon. Hypothermia must be avoided postoperatively and pressure ulcers must also be prevented [22].

6 Patient Education

To assure patients’ safety, it is recommended to inform the patient of the following:

  • Patients should be aware about the expected duration of movement limitations and options for pain control. This is immediately after the surgery and in the following weeks to months.

  • They should also be aware about the importance of a comprehensive physical activity program following surgery.

  • Each patient should be aware of the pain control plan. The associated fluctuation of pain with different medication withdrawal or institution must be explained.

  • More details should be delivered to patients according to their needs, issues like possible drug-drug and/or drug-food interactions of new medication regimens. The classical and common examples are the potential risk of anticoagulant drugs and foods affecting potency of warfarin. Patients should be aware about any follow-up instructions including monitoring of laboratory investigations.

  • Obviously, patients should be aware about the importance of early immobilization [22].

7 Physical Activity and Rehabilitation

Patients should undertake physical therapy since physical activities are essential for patients with rheumatologic disease. The major benefits are to prevent disabilities, restore function, and relieve pain. These activities should be evaluated preoperatively to verify consistency with treatment goals. These are greatly augmented by prescribed therapeutic exercises and functional activities. Special precautions should be given for patients with active inflammatory joint or soft tissue diseases. The therapeutic exercises should be balanced with essential rest periods for a successful treatment. The aim is usually dedicated at preserving or increasing functional level, decreasing pain and joint inflammation, and increasing range of motion and strength [22].

Figure 18.1 illustrates a summary of perioperative management of patients with rheumatic diseases.

Fig. 18.1
figure 1

Summary of the Perioprative Mangment of Patients with Rheumatic Diseases

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