“A Joint Operation”: Rheumatologists, Orthopedists Collaborate to Improve Patient Outcomes

NOVEMBER 15, 2016
Ryan Black
Dr. Susan Goodman, the Associate Director of the Inflammatory Arthritis Center at Hospital for Special Surgery in New York, couldn’t resist the pun:

“Clearly, this was going to be a joint operation, and it really turned out to be an enormous amount of fun.”

She, alongside Dr. Bryan Springer, an Orthopedic Surgeon at the OrthoCarolina Hip and Knee Center in North Carolina, spoke together at the 2016 American College of Rheumatology Annual Meeting about a collaboration between rheumatologists and orthopedists. With extensive literature review and expert input, the ACR and the American Association of Hip and Knee Surgeons (AAHKS) have come together to propose a set of guidelines for medication during the perioperative period for patients undergoing knee or hip arthroplasty.

Despite the increasingly widespread use of potent biologic or disease-modifying antirheumatic drugs (DMARDs), the prevalence of such large joint arthroplasty operations remains constant, according to Goodman. The majority of patients seeking such surgeries are also undergoing those treatments, creating a need for the surgeons and prescribing rheumatologists to jointly address any possible complications they may cause.

“The rheumatic disease patients, both those with inflammatory arthritis and lupus, are at high risk for complications related to surgery or arthroplasty. We know the incidence of infection is increased in these patients, and these are really devastating complications,” she explained in the press conference.

Because disease severity and general debility are not modifiable factors, it becomes even more necessary for clinicians to monitor the things they can control, like medication.

The group’s first recommendation was that synthetic DMARDs should continue to be taken throughout the time of surgery, citing data that showed risk of infection actually was decreased in their use. Biologics, based on previous randomized control trial data outside of the surgical setting, did however show an increased risk.

Lupus patients presented a particular set of a considerations. Observational studies had shown those with severe manifestations of the disease had high perioperative risk, they still recommended the continuation of synthetic DMARD treatment. Biologics, however, were recommended to be withheld.

For lupus that was not deemed severe, they recommended all medications be discontinued for time of surgery, as the team considered a flare of the disease to present a lower chance of morbidity than an operative infection.

They did not recommend cessation of glucocorticoids, but suggested that those on high doses be tapered down before clearing them for surgery.

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