Operative Management of Rheumatoid Arthritis: Perioperative and Surgical Principles

Introduction to Rheumatoid Arthritis in Orthopaedics

Rheumatoid arthritis (RA) is a systemic, autoimmune, inflammatory polyarthritis characterized by hypertrophic synovitis that relentlessly progresses to destroy joint cartilage, erode subchondral bone, and compromise periarticular soft tissues. It remains one of the most debilitating and painful chronic rheumatic diseases encountered in orthopaedic practice. The hallmark of the disease is the formation of a hyperplastic synovial pannus, driven by a complex cascade of cytokines (notably TNF-α, IL-1, and IL-6), which invades and degrades articular structures.

As the disease advances, the hypertrophic synovium not only destroys the joint cartilage but also erodes and ruptures adjacent tendons, compresses peripheral nerves, and leads to profound joint subluxation, dislocation, and erosion. Despite the preservation of gross motor function in the early stages, socialization and psychological well-being are frequently altered by disfiguring deformities, particularly the characteristic mutilating arthropathies of the hands and wrists.

Operative treatment must never be viewed in isolation; rather, it is a critical adjunct to systemic medical management. The modern orthopaedic surgeon must possess a profound understanding of the disease's pathophysiology, the systemic implications of the patient's pharmacologic regimen, and the unique biomechanical challenges presented by the rheumatoid skeleton.

The Multidisciplinary Management Paradigm

At various times throughout their disease course, the treatment of patients with rheumatoid arthritis necessitates a highly coordinated management team. This multidisciplinary consortium typically includes a rheumatologist, an internist, an orthopaedic surgeon, specialized physical and occupational therapists, and psychological counselors.

Operative treatment should be considered an integral component of general disease management, aimed at pain relief, functional restoration, and the prevention of further structural deterioration. The decision to operate must be made collaboratively, ensuring that the patient's systemic disease is optimally controlled prior to any surgical intervention.

Clinical Pearl: The "rheumatoid patient" is a systemic patient. Never evaluate a single painful joint without assessing the entire musculoskeletal system, the cervical spine, and the patient's current immunomodulatory regimen.

Perioperative Pharmacologic Management

Rheumatoid arthritis patients are typically managed with a complex polypharmacy regimen that may include nonsteroidal anti-inflammatory drugs (NSAIDs), systemic corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and biologic or targeted synthetic DMARDs (bDMARDs/tsDMARDs). These medications carry significant perioperative implications, particularly regarding hemostasis, wound healing, and infection risk. Perioperative medical management by an internist or rheumatologist is frequently warranted.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Salicylates

Because of their irreversible inhibition of cyclooxygenase and subsequent effect on platelet aggregation, salicylates (aspirin) usually are discontinued 1 to 2 weeks before surgery. Traditional non-selective NSAIDs should be discontinued 2 to 5 days before surgery, depending on the specific drug's half-life (e.g., ibuprofen requires a shorter washout than meloxicam or naproxen). Cyclooxygenase-2 (COX-2) specific inhibitors do not affect platelet function and may often be continued perioperatively to assist with multimodal analgesia, provided renal function is adequate.

Corticosteroid Therapy and Stress Dosing

Patients who have taken systemic corticosteroids for more than a 3-week period in the previous 12 months are at risk for hypothalamic-pituitary-adrenal (HPA) axis suppression. These patients may be unable to mount an appropriate endogenous cortisol response to the physiologic stress of surgery and anesthesia.

Surgical Warning: Failure to recognize HPA axis suppression can lead to acute adrenal crisis, characterized by refractory hypotension, cardiovascular collapse, and potential mortality.

Such patients should receive supplemental corticosteroid therapy (stress dosing) before, during, and after surgery. A standard protocol for major orthopaedic surgery (e.g., total joint arthroplasty) includes administering 50 to 100 mg of intravenous hydrocortisone prior to induction, followed by 25 to 50 mg every 8 hours for 24 hours, before rapidly tapering back to the patient's baseline maintenance dose.

Disease-Modifying Antirheumatic Drugs (DMARDs)

The management of DMARDs requires balancing the risk of postoperative infection against the risk of a systemic RA flare.
* csDMARDs: Current American College of Rheumatology (ACR) and American Association of Hip and Knee Surgeons (AAHKS) guidelines recommend continuing current doses of methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide throughout the perioperative period for elective total joint arthroplasty, as the risk of flare outweighs the negligible increase in infection risk.
* bDMARDs and tsDMARDs: Biologic agents (e.g., infliximab, etanercept, adalimumab) and targeted synthetic agents (e.g., JAK inhibitors like tofacitinib) significantly impair the host immune response. These should be withheld prior to surgery. The timing of surgery should be scheduled at the end of the dosing cycle for that specific medication (e.g., if a biologic is taken every 4 weeks, surgery is scheduled for week 5). The medication is typically restarted 14 days postoperatively, provided the wound is healing well with no signs of surgical site infection.

Preoperative Anesthetic Considerations: The Cervical Spine and Airway

If a general anesthetic is to be used during an operation on a patient with rheumatoid arthritis, the alignment and stability of the cervical spine must be rigorously evaluated. Cervical spine involvement occurs in up to 80% of RA patients, often remaining asymptomatic until catastrophic neurologic injury occurs during endotracheal intubation or patient positioning.

Cervical Spine Instability

The destructive pannus frequently targets the synovial joints of the craniovertebral junction, leading to three distinct patterns of instability:
1. Atlantoaxial Subluxation (AAS): The most common deformity, caused by destruction of the transverse ligament and the facet joints between C1 and C2.
2. Basilar Invagination (Cranial Settling): Destruction of the occipitoatlantal and atlantoaxial joints allows the odontoid process to migrate proximally through the foramen magnum, compressing the brainstem and upper cervical cord.
3. Subaxial Subluxation: "Stair-stepping" instability occurring below C2, driven by facet and disc destruction.

Surgical Pitfall: Never proceed with elective orthopaedic surgery in an RA patient without recent flexion-extension lateral cervical spine radiographs. An Anterior Atlantodens Interval (ADI) > 3.5 mm indicates instability, but a Posterior Atlantodens Interval (PADI) < 14 mm is the critical threshold indicating impending neurologic compromise and necessitates preoperative MRI and potential neurosurgical intervention.

Airway and Temporomandibular Joint Involvement

In addition to cervical instability, the anesthesiologist must navigate potential cricoarytenoid arthritis, which can cause vocal cord fixation, narrowing of the glottic opening, and post-extubation airway obstruction. Furthermore, temporomandibular joint (TMJ) synovitis may severely restrict mouth opening, making direct laryngoscopy impossible and necessitating awake fiberoptic intubation.

Principles of Surgical Intervention and Staging

Surgical intervention in the rheumatoid patient is fundamentally different from that in the osteoarthritic patient. The bone is frequently osteopenic, the soft tissues are attenuated, and multiple joints are simultaneously involved.

Staging of Multiple Joint Procedures

When a patient presents with severe, multi-joint disease, the sequence of surgical reconstruction must be carefully planned to optimize rehabilitation and minimize complications:
1. Cervical Spine: Any neurologically significant cervical instability must be addressed (e.g., occipitocervical fusion) before any other elective procedure to prevent catastrophic spinal cord injury during subsequent anesthetics.
2. Lower Extremities: Lower extremity joints (hips, knees, feet) are generally reconstructed before upper extremity joints. A stable, pain-free lower extremity is required to bear weight and participate in rehabilitation.
3. Hips vs. Knees: If both the hip and knee on the same side are symptomatic, the hip is typically replaced first. A painful, stiff hip will compromise knee rehabilitation, and correcting hip contractures often alters the mechanical axis, influencing the subsequent knee arthroplasty.
4. Upper Extremities: The shoulder, elbow, wrist, and hand are addressed subsequently. Upper extremity function is vital for utilizing assistive devices (crutches, walkers) during lower extremity rehabilitation; however, severe upper extremity deformities may require early intervention if tendon rupture is imminent.

Surgical Options: Synovectomy, Arthrodesis, and Arthroplasty

• Synovectomy: Indicated in the early stages of the disease (Larsen stages I-II) when hypertrophic synovitis is refractory to medical management for 6 months, but articular cartilage remains intact. While it does not halt the systemic disease, it provides significant local pain relief and delays tendon rupture, particularly in the dorsal compartments of the wrist.
• Arthrodesis: Remains the gold standard for specific joints where stability is paramount and arthroplasty implants have high failure rates. This includes the atlantoaxial joint, the radiocarpal joint, the first metatarsophalangeal (MTP) joint, and the hindfoot/midfoot joints.
• Arthroplasty: Total joint arthroplasty (TJA) is the definitive treatment for end-stage joint destruction. In RA, surgeons must be prepared for complex primary arthroplasties. Osteopenia necessitates careful reaming and often the use of cemented components, particularly in the femoral stem of a total hip arthroplasty or the tibial baseplate of a total knee arthroplasty.

Regional Surgical Considerations in the Rheumatoid Patient

The Rheumatoid Hand and Wrist

The hand and wrist are the epicenters of rheumatoid deformity. The disease typically presents with volar subluxation and ulnar drift of the metacarpophalangeal (MCP) joints, swan-neck deformities (PIP hyperextension, DIP flexion), and boutonnière deformities (PIP flexion, DIP hyperextension).

Clinical Pearl: Caput Ulnae Syndrome is a classic rheumatoid presentation characterized by dorsal subluxation of the distal ulna, supination of the carpus, and volar subluxation of the extensor carpi ulnaris (ECU). This creates a saw-like effect that leads to sequential rupture of the extensor tendons, beginning with the extensor digiti minimi (Vaughan-Jackson syndrome).

Early dorsal tenosynovectomy and resection of the distal ulna (Darrach procedure or Suave-Kapandji procedure) are critical to preventing extensor tendon ruptures. If ruptures have occurred, tendon transfers (e.g., EIP to EDC) are required.

The Lower Extremity: Hip, Knee, and Foot

• The Hip: RA frequently causes concentric loss of joint space and protrusio acetabuli (medial migration of the femoral head past the ilioischial line). During total hip arthroplasty, the surgeon must be prepared to use morselized bone graft (often from the resected femoral head) to restore the medial wall of the acetabulum and lateralize the center of rotation.
• The Knee: Rheumatoid knees classically present with a valgus deformity, lateral compartment destruction, and attenuation of the medial collateral ligament (MCL). Total knee arthroplasty may require highly constrained implants (e.g., varus-valgus constrained or rotating hinge) if the collateral ligaments are incompetent.
• The Foot: Forefoot involvement is nearly universal, characterized by severe hallux valgus, dorsal subluxation of the lesser MTP joints, and painful plantar callosities. The classic rheumatoid forefoot reconstruction involves arthrodesis of the first MTP joint combined with resection arthroplasty of the lesser metatarsal heads (Hoffman procedure) to restore a plantigrade, braceable foot.

Postoperative Protocols and Complication Avoidance

The postoperative management of the rheumatoid patient requires heightened vigilance. These patients are at a significantly elevated risk for complications compared to the general orthopaedic population.

Wound Healing and Infection Prevention

Compromised skin integrity, chronic corticosteroid use, and systemic immunosuppression dramatically increase the risk of delayed wound healing and surgical site infections (SSIs). Meticulous soft tissue handling is paramount. Sutures or staples should be left in place longer than usual (often 2-3 weeks). Prophylactic antibiotics must be dosed appropriately, and any postoperative erythema or drainage must be evaluated aggressively to rule out deep periprosthetic joint infection (PJI).

Bone Quality and Periprosthetic Fractures

Severe osteopenia secondary to both the disease process and chronic steroid use increases the risk of intraoperative and postoperative periprosthetic fractures. Surgeons should have a low threshold for utilizing prophylactic cerclage wiring during femoral preparation in hip arthroplasty and must employ gentle, controlled impaction techniques.

Rehabilitation and Functional Recovery

Rehabilitation must be tailored to the patient's systemic reserve and the status of their other joints. Weight-bearing restrictions may need to be modified if the upper extremities cannot support the use of standard crutches or walkers. Platform walkers are frequently utilized to offload the wrists and hands. Close collaboration with physical and occupational therapy is essential to ensure that the patient regains maximal functional independence while protecting both the newly reconstructed joint and the adjacent rheumatoid articulations.

Ultimately, the operative management of rheumatoid arthritis is a complex, highly rewarding endeavor that requires the orthopaedic surgeon to act not merely as a technician, but as a comprehensive physician, seamlessly integrating surgical biomechanics with advanced systemic medical management.