Living with Arthritis

Surgery and Arthritis

It is important for all patients with inflammatory arthritis such as Rheumatoid Arthritis to understand the risks surrounding surgery.

Patients with Rheumatoid Arthritis are at an increased risk for complications when undergoing joint surgery. There is a lot that can be done to improve the chance of having the best outcome.

Attend a Pre-Operative Risk Clinic

With most surgical procedures, the patient is asked to attend a pre-operative risk clinic. This is especially important for patients with Rheumatoid Arthritis to address a number of issues including:

  1. Cardiovascular Risk: Patients with Rheumatoid Arthritis are an an increased risk of having a heart problem around surgery. A proper assessment before surgery can help to minimize this risk.
  2. Infection Risk: Patients with Rheumatoid Arthritis are at an increased risk for infection after surgery. This is because the immune system is suppressed in people with Rheumatoid Arthritis both from the disease itself and from the medications used to treat it.
  3. Arthritis Risk: Unless surgery is mandatory, it is not recommended to have surgery when the arthritis is very active. This will delay healing and recovery.
  4. Cervical Spine: All patients with Rheumatoid Arthritis should have an evaluation of the cervical spine before surgery. This is important as the neck is manipulated during intubation which could result in permanent damage if the spine is unstable. If there is concern x-rays of the cervical spine should be done before surgery to look for instability.

Medications

It is important to decide whether or not to stop medications before surgery.

The American College of Rheumatology and the American Association of Hip and Knee Surgeons to developed the following guidelines for patients undergoing total joint replacement:

  1. Continue the current dose of methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine (nonbiologic DMARDs) for patients undergoing elective total hip or knee replacement.
  2. Stop all current biologic agents prior to surgery and plan the surgery at the end of the dosing cycle for that specific medication.
  3. Biologic therapy that was withheld prior to surgery can be restarted as long as the wound is healing well and there is no sign of infection or drainage (approximately 14 days).
  4. Withhold Xeljanz (tofacitinib), Olumiant (baricitinib), and Rinvoq (upadacitinib) for at least 7 days prior to surgery in patients with Rheumatoid Arthritis. They can be restarted as long as the wound is healing well and there is no sign of infection or drainage (~14 days).
  5. Continue the current daily dose of prednisone in patients who are receiving prednisone. It is not necessary to administer a “stress dose” of prednisone for elective surgeries.