International Conference on Orthopedics, Musculoskeletal Research and Innovation

TBA

Inflammatory rheumatic diseases, particularly rheumatoid arthritis (RA), frequently lead to progressive joint destruction, often necessitating joint replacement surgery. These patients are commonly treated with immunosuppressive agents (csDMARDs, bDMARDs, tsDMARDs), which increase the risk of postoperative infection, and often with long-term glucocorticoids, which may impair wound healing and compromise soft tissue integrity. Appropriate perioperative management, including temporary, carefully timed discontinuation of immunosuppressive therapy, may significantly reduce these risks while minimizing the likelihood of disease flare. Beyond drug management, five areas warrant attention: cervical spine and airway integrity, cardiovascular risk, venous thromboembolism (VTE) and antiphospholipid antibodies, infection risk, and postoperative flares. The cervical spine is frequently involved in RA (atlantoaxial subluxation), usually asymptomatically. Neck extension and muscle relaxation during intubation may precipitate spinal cord compression. Cricoarytenoid and temporomandibular joint involvement may further complicate airway management. RA and systemic lupus erythematosus (SLE) carry a significant cardiovascular risk underestimated by conventional risk scores. EULAR advises multiplying the estimated risk by 1.5 in RA; in SLE, the risk may be up to 50-fold higher than in age-matched controls. NSAID use should be carefully weighed given its cardiovascular and renal toxicity. All patients undergoing major orthopedic surgery are at risk of VTE, further increased in RA or positive antiphospholipid antibodies. Mechanical and pharmacological prophylaxis combined with early mobilization may reduce this risk. JAK inhibitors may also increase thromboembolic risk. Patients with inflammatory rheumatic diseases are at significant risk of postoperative infection, which glucocorticoids and DMARDs may exacerbate. High disease activity, comorbidities, and prior or recurrent infections should be carefully evaluated before surgery. Disease flares are common after temporary discontinuation of immunosuppressive therapy. Some clinicians recommend stopping only the bDMARD while continuing the csDMARD. The paucity of direct randomized controlled trial data limits high-quality, evidence-based guidelines on this matter.