Perioperative Management of the Rheumatoid Patient

"Detect Anemia Preoperatively": A Scoping Review of Recommendations

Background

Preoperative anemia significantly impacts patient outcomes, prompting increasing global implementation of patient blood management (PBM) measures. Timely diagnosis and differentiation of preoperative anemia are crucial components of PBM to maximize its effectiveness. Despite this, comprehensive implementation remains inconsistent. This scoping review aims to give an overview of recommendations regarding preoperative anemia management to detect gaps in knowledge and emerging ideas.

Methods

A scoping review, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, investigated preoperative anemia detection, focusing on patient population, timing, extent, and process of investigations. PubMed and ScienceDirect were searched for English and German articles published in the last 5 years, supplemented by manual selection. Pediatric and obstetric recommendations were excluded. Results were synthesized based on key questions.

Results

Four hundred sixty-five articles were screened, and 80 met the inclusion criteria, including 25 clinical practice guidelines. Most (n = 62) suggested "detect and correct" anemia without further specification. The rest advised conducting investigations early, ideally up to 30 days before major procedures with expected blood loss >500 mL. Recommended tests include blood counts, various iron parameters, folic acid/vitamin B12, inflammation markers, and renal, hepatic, and thyroid function tests. Ten articles described detailed algorithms. Other key recommendations included using reticulocyte hemoglobin, point-of-care Hb measurements, and automated laboratory algorithms. The underlying quality of scientific evidence is heterogeneous.

Conclusions

International recommendations on the detection of preoperative anemia are heterogeneous and often generic. Automated algorithms could make a significant contribution to practicability. While practice-oriented guidelines, especially by surgical societies, could promote standardized and efficient implementation, further research is needed to improve the quality of underlying scientific evidence.

Rheumatoid Deformities of the Lesser Toes

Rheumatoid arthritis is a chronic heterogeneous autoimmune disease characterized by painful joint inflammation and causes destructive bone erosions. Most common deformities in the rheumatoid forefoot are hallux valgus and claw toes. Radiographs are helpful to show the deformity and the associated pathologies. Nonsurgical treatment is focused on pain reduction, function preservation, and prevention of further deformity, by relieving pressure and pain with shoe modification and use of insoles. Surgical procedures can address either soft tissue and bone deformities that can be performed by a percutaneous or open approach.

Perioperative Considerations for Hip Arthroplasty in Patients with Rheumatoid Arthritis

Due to its distinct features, rheumatoid arthritis (RA), an inflammatory autoimmune disorder, poses challenges in planning for surgical interventions. This review includes available evidence regarding perioperative considerations in management of RA patients, with a focus on hip surgery. RA can affect multiple joints, with development of extra-articular manifestations; therefore, preoperatively, comprehensive medical assessments, including cardiovascular or pulmonary evaluation must be considered in addition to surgical considerations. Modification of medications capable of controlling RA-related disease activity is critical, and requires collaboration with rheumatologists. Surgical considerations include the choice of surgical approach, implant selection, and problems related to weakened soft tissues, fragile bone density, and bony deformity such as protrusio acetabuli. Careful monitoring and more active rehabilitation are recommended for RA patients due to higher risk of postoperative complications. For achievement of optimal outcomes, use of a multidisciplinary perioperative approach is required for patients with RA.

Total Joint Arthroplasty in the Patient with Inflammatory Arthritis: A Review

Inflammatory arthritis is a family of conditions including rheumatoid arthritis, juvenile inflammatory arthritis, and spondyloarthropathies affecting both the large and small joints. Total joint arthroplasty is commonly used for surgical management of end-stage disease. Preoperative and postoperative considerations as well as perioperative medical management and intraoperative treatment of patients with inflammatory arthritis undergoing total joint arthroplasty are reviewed. Although individualized, multidisciplinary approaches to treatment are necessary due to the complex nature of the disease and the varying levels of severity, patients generally have favorable outcomes with respect to pain scores and functional outcomes.

Preoperative Optimization and Tips to Avoiding Surgical Complications Before the Incision

In preparation for surgery, it is important for surgeons to have a detailed discussion with patients about the risks, benefits, and alternatives to surgery. Patient optimization, ensuring the patient is in the best medical condition before surgery, is also an important aspect of patient care that the surgeon must consider. Although complications cannot be eliminated, there are often opportunities to optimize patients, so these risks can be minimized based on current evidence-based medicine. To minimize the risk of complications, the surgeon should take an active role in each step of the patient's care beginning with the history and physical examination, obtaining the correct preoperative labs, and continuing through positioning, draping, and prepping before making an incision.

'Should we stop or continue conventional synthetic (including glucocorticoids) and targeted DMARDs before surgery in patients with inflammatory rheumatic diseases?'

Total hip and total knee arthroplasty) remain important interventions to treat symptomatic knee and hip damage in patients with rheumatoid arthritis, with little change in utilisation rates despite the increasingly widespread use of potent conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and targeted DMARDs including Janus kinase inhibitors and biologics. The majority of patients are receiving these immunosuppressing medications and glucocorticoids at the time they present for arthroplasty. There is minimal randomised controlled trial data addressing the use of DMARDs in the perioperative period, yet patients and their physicians face these decisions daily. This paper reviews what is known regarding perioperative management of targeted and csDMARDs and glucocorticoids.

Perioperative management of patients with rheumatoid arthritis undergoing orthopaedic surgery

Rheumatoid arthritis is an autoimmune disease which is characterised by systemic inflammation. In the recent decades, the advent of disease modifying anti-rheumatic drugs have reduced the need for orthopaedic procedures. However, there are numerous patients in which pharmacological treatment fails and these patients require surgical intervention. Complications can arise due to the underlying pathology and multitude of medications these patients can be on, specifically increased infection rates due to use of immunosuppressive agents. An understanding into the disease itself, as well as perioperative management, may improve overall patient outcomes and prevent future complications.