Perioperative Management of Non-Biological and Biological Therapies in Rheumatic Patients Undergoing Orthopedic Surgery

Abstract

Patients with rheumatoid arthritis (RA) or other inflammatory arthropathies often require orthopedic surgery, and the management of their medical treatments during the perioperative period is an important issue. The two main concerns during this period are the risk of infection and wound healing complications. These patients receive multidisciplinary care from orthopedic surgeons, rehabilitators and rheumatologists (1). Before orthopedic surgery, the activity of the arthropathy and the nonbiological and biological therapies of patients must be taken into consideration for an optimal outcome with no infectious or wound-healing complications. Good clinical and biological control of the disease must be obtained before the surgery, and effective coordination between surgeon and rheumatologist is essential (2). The management of non-biological (immunosuppressive or immunomodulatory) and biological therapies in orthopedic surgery patients remains controversial. This chapter focuses on disease-modifying anti-rheumatic drugs (DMARDs) and biological therapies (see table 1). Although corticosteroids are immunosuppressants, protocols for their replacement or supplementation are well established in the literature and are not addressed here (3). DMARDs and especially biological therapies are the subject of multiple consultations between rheumatologists and orthopedists or anesthetists before surgery. The objective of this chapter is to discuss current protocols for the application of these treatments before and after orthopedic surgery, based on the best available scientific evidence or, in its absence, on accepted recommendations.