Peri-operative management of rheumatoid arthritis (RA) patients undergoing arthroplasty


Kieran Murray, Tristan Cassidy, Candice Low, Francis Young, Douglas Veale


Bone and Joint Unit, Saint Vincent's University Hospital Orthopaedics, Beaumont Hospital


Immunosuppression, surgical complexities and atlanto-axial subluxation can complicate arthroplasty in RA. Management guidelines differ significantly.


To compare peri-operative RA management between rheumatologists and orthopaedists.


An anonymous 24 question survey was distributed at the Irish Society of Rheumatology meeting and the Irish Institute of Trauma and Orthopaedic Surgery Curriculum Day, examining imaging and prescribing in these patients.


33 orthopaedists and 23 rheumatologists responded.

22 always perform cervical spine imaging prior to arthroplasty in patients undergoing a general anaesthetic (10 sometimes, 1 not sure). 31 perform X-rays, 1 MRI and 1 CT.
7 never stop steroids pre-operatively (13 sometimes, 6 always, 5 unsure). 9 never increase steroids (13 sometimes, 6 always, 5 not sure). 1 never stops synthetic DMARDs (sDMARDs). 19 never discontinue methotrexate (5 respondents unsure). For other sDMARDs (leflunomide, hydroxychloroquine, azathioprine, sulfasalazine and ciclosporin), a minority (range 3-5 for the different medications) never discontinue. Many (range 11-17) were unsure. 8 stop sDMARDs at 1 week pre-operatively, 13 at 2 weeks, 5 at 4 weeks. 6 were unsure. 19 restart sDMARDs at 2 weeks post-operatively.
2 never stop biologic DMARDs (etanercept, golimumab, adalimumab, infliximab, certolizumab, tocilizumab, rituximab and abaptacept). Depending on the medication, 14-15 stop 8 weeks. 10-12 unsure.
11 always perform cervical spine imaging (11 sometimes, 1 never). 22 perform X-rays, 1 MRI. 14 never stop steroids (8 sometimes, 1 not sure). 12 respondents sometimes increase steroid dosing (8 always, 1 never, 1 not sure, 1 no answer).
8 never stop methotrexate/leflunomide. 20 never stop hydroxychloroquine and 14 sulfasalazine. Ciclosporin and azathioprine are never stopped by 5 and 9 respectively. 8 don’t stop sDMARDs, 8 stop 2 weeks pre-operatively, 6 at 1 week, 1 no answer. 9 restart sDMARDs at 2 weeks, 5 at 1 week, 1 at 4 weeks.
2-4 never stop bDMARDs pre-operatively. Responses vary medication half-life. For example, 18 hold etanercept for 8 weeks.


There is a high degree of uncertainty and contrasting practices between rheumatologists and orthopaedists. Unified guidelines may facilitate increased agreement.

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