“A Joint Operation”

Total hip and knee replacement are among some of the most successful operations in all of medicine at reducing pain and restoring mobility. However, infection is a major complication associated with the procedure. Although rare, (risk approx 0.5-2%), the consequences can be devastating. Patients with inflammatory arthritis (rheumatoid arthritis, lupus, etc.) are at particularly high risk for development of an infection following joint replacement. Much of this risk is due to anti-rheumatic medications patients take to control their disease. Because these medications can suppress the immune system, they place patients at high risk for infection.

To date, there have been limited recommendations on how to manage these medications in the time around joint replacement surgery. For example, should the medications be stopped? If so when and for how long before surgery? If they are stopped, when should they be restarted after surgery? All of these questions can have an effect on the patient’s disease control, but can also affect the risk of infection.

The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have collaborated to propose guidelines for the management of anti-rheumatic medications in patients undergoing elective hip or knee arthroplasty. Dr. Bryan Springer, Orthopedic Surgeon at The OrthoCarolina Hip and Knee Center, and Dr. Susan Goodman, the Associate Director of the Inflammatory Arthritis Center at Hospital for Special Surgery in New York, served as co-investigators of the study and presented the new guidelines together at the 2016 American College of Rheumatology Annual Meeting.

Unique to these guidelines was the inclusion of a patient panel. Patients, all who suffer from inflammatory arthritis, were asked about their preferences and values as it relates to infection risk, disease flare risk, and total joint arthroplasty. This is one of the first guidelines to incorporate patients and offers a unique perspective on guideline development.

Dr. Springer also highlighted the value of the unique collaboration between the ACR and the AAHKS, calling the effort a win both for patients, and for “collaborative efforts, collaborative research, which we just really don’t do enough of,” adding, “I hope this is a huge step towards that direction.”

Here is what you should know about the new perioperative treatment guidelines:

• Current doses of nonbiological DMARDS such as methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine should be continued in patients with rheumatic diseases undergoing elective hip and knee replacement. This recommendation is based on an extensive literature review that showed the infection rate is decreased in patients who continue these medications.
• All biologics should be withheld prior to surgery in patients with inflammatory arthritis, and surgery should be planned for the end of the dosing cycle. This matter wasn’t specifically addressed in the literature, however, numerous randomized controlled trials outside of the surgical setting demonstrate an increased risk of infection associated with their use.
• In lupus patients, rituximab and belimumab should be withheld prior to surgery, and surgery should be planned for the end of the dosing period.
• Biologics should be restarted once surgical wounds show evidence of healing and there is no clinical evidence of infection. The literature does not directly address this, though the recommendation is based on the rationale for use of these medications in patients with either active infection or risk for infection.
• Current daily doses of glucocorticoids, rather than supraphysiologic doses, should be continued in adults with RA, lupus, or inflammatory arthritis. A meta-analysis and systematic review of randomized controlled trial data and observational data showed no hemodynamic difference between daily doses and stress doses

The ACR and AAHKS’s collaborative guidelines, called Recommendations for Perioperative Management of Disease Medications, will be peer-reviewed and published.

Dr. Bryan Springer is a hip and knee surgeon with the OrthoCarolina Hip and Knee Center.

For more information about the American Academy of Hip and Knee Surgeons visit: https://www.aahks.org/.
For more information about the American College of Rheumatology visit: https://www.rheumatology.org/.