Approach to Inflammatory Arthritis – Preoperative Planning
– includes rheumatoids, SLE, ank spond, psoriatic arthritis
– beware the increased risk of infection: psoriatic arthritis patients have a higher risk of deep infection – probably from skin lesions colonized with bacteria. Rheumatoids also have higher risk of infection
– beware skin ulceration: rheumatoids may have skin vasculitis that makes them prone to ulceration
– beware atlanto-axial and atlanto-occipital instability in rheumatoids – may be asymptomatic in over 50% May also see instability in ank sponds. Does not require fusion – requires careful intubation (awake, fluoroscopic)
– beware limited chest wall expansion in ank sponds or other seronegative arthritides – need preop pulmonary function studies and careful positioning so as to not impede their diaphragmatic breathing
– beware pulmonary disease in rheumatoids – restrictive +/- nodules – need preop pulmonary function
– beware ileitis and colitis when associated with arthritis – increased risk of infection
– beware anemia of chronic disease – almost universal
– beware immune suppression, with and without steroid use
– beware variations in bone quality – rheumatoids have increased bone turnover in periarticular bone – may attribute to high loosening rates; be wary of using cementless fixation in this population
– beware soft tissue contractures and joint DEFORMITY in inflammatory arthritis – be prepared for difficult ligament balancing and soft tissue releases around the knee and hip
– beware the medications that they may be on – NSAIDs, steroids, methotrexate – all should be noted, and arguably stopped in lieu of their surgery
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