1 Principles of Orthopaedic Rheumatology

Rheumatoid arthritis is a chronic systemic inflammatory autoimmune disorder that can progress to involve all of the synovial tissues and even the internal organs. The inflammatory reaction begins in the joints and can lead to irreversible damage. Depending on the acuteness of the situation, either a rheumatologist or an orthopaedic surgeon assumes responsibility for management of disease progression when patients require treatment. A combination of physical therapy, occupational therapy, medical social services, orthopaedic technology, and psychological care is utilized in a multidisciplinary approach. Patient support associations (for example, the European League Against Rheumatism [EULAR]) and other specialties also provide assistance.

Joint swelling with effusions and synovitis are characteristic of rheumatoid disease. If left untreated for more than 6 weeks, the inflammation can cause joint damage with deformities and dislocations. A similar process leads to tenosynovitis and can also affect the visceral organs. Early confirmation of the diagnosis (EULAR classification criteria) is based on clinical signs and laboratory results.

Medical drug therapy is imperative. A rheumatologist typically makes the initial and differential diagnoses and initiates appropriate antirheumatic drug therapy. Oral administration of glucocorticoid medication often leads to a rapid relief of symptoms. However, long-term control or even remission requires administration of DMARDs (disease-modifying antirheumatic drugs). Methotrexate is the gold standard and modern biologicals are frequently added as immunomodulators, either in combination or as an alternative treatment.

Preoperatively, particular attention should be given to the risks of impaired wound healing, infection, and thrombosis. These risks are already elevated due to the underlying illness and may be potentiated by medication therapy. Perioperative management of antirheumatic medications is based on the extent of the surgical procedure, the age of the patient, the amount of disease activity, and other comorbidities. The perioperative medication management plan should be discussed with the patient and coordinated with the treating rheumatologist. Recommendations for management of biologic agents have been developed by the German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie [DGRh]).

We discontinue biologicals perioperatively. The increased risk of a drug-related postoperative infection is weighed against the possibility that an interruption of immunosuppressive therapy could trigger another serious flare in the underlying illness. There is no standardized approach and definitive studies are not yet available. Care must be taken to discontinue biologic immunosuppressive medication at least 2 half-lives prior to surgery. A washout procedure with cholestyramine is usually advisable when discontinuing leflunomide because of its high degree of tissue binding.

For patients taking glucocorticoids at doses high enough to cause Cushing’s syndrome, a perioperative cortisone regimen (based on the extent of the surgical intervention) is recommended for prophylaxis against an Addisonian crisis.

Immunosuppressive medications can be resumed once the wound has completely healed.

The type of surgical intervention is typically dictated by the stage of the disease. In the early stages with joint swelling that persists despite optimization of oral medication therapy and intra-articular cortisone injections, the initial surgical treatment is arthroscopy and synovectomy. To help prevent recurrence, synovectomies are usually combined with radiosynoviorthesis 6 weeks postoperatively.

More advanced findings such as bone and cartilage destruction (Larsen >III) may require prosthetic implants, arthroplasties, and arthrodesis.

We find it important not to miss appropriate timing for surgical interventions. Reconstructive procedures may slow disease progression, particularly in the hands and feet. Thus, for example, radiolunate arthrodesis is recommended for an unstable wrist (Schulthess classification) in order to counteract subluxation. The same applies to the foot: osteotomies are a good option if the joints have not yet been destroyed and the soft tissues can still be reconstructed.

Because “rheumatic” patients require a large number of surgical interventions and hospital stays, a patient-oriented treatment approach should be considered. It is preferable to begin with the “best surgical procedure,” that is, one that will provide the patient with a rapid and sustained improvement in symptoms. In addition, patients should be given an expected timeframe for recovery: for example, when they can resume walking or when they can return to work.

To preserve mobility in patients with severe and simultaneous involvement of both upper and lower extremities, surgical treatment of the lower extremity is crucial. It is also reasonable to perform combined complex hand and foot operations; alternatively, several procedures can be performed simultaneously on multiple small joints/tendons located on a single extremity. In individual cases simultaneous bilateral operations can be performed on the lower extremities. These include total hip arthroplasty, total knee arthroplasty, and complex forefoot procedures.

Furthermore, the rule “proximal before distal” applies.

Preoperative evaluation of “rheumatic patients” includes a general physical examination, blood sampling, a detailed discussion with the surgeon, and an anesthesiology assessment with particular focus on temporomandibular joint function and cervical spine mobility. Radiographic imaging of the specific joint to be operated on and functional imaging of the cervical spine (lateral view of cervical spine with head in flexion, centered on C1, and hard palate) to exclude C1–C2 subluxation should also be performed.

Postoperatively, early physiotherapeutic mobilization is particularly important in patients with chronic inflammatory joint diseases. This often requires special aids adapted to the individual patient (e.g., underarm crutches with ergonomic handles, forearm supports, or armpit supports). Optimal postoperative care should include early occupational therapy and use of orthopaedic aids.