Cath Lab Digest

Reportedly 64 percent of infections that occur in patients with RA occur in the foot and ankle. In order to minimize the risks of infection and other potential complications with podiatric surgery in this patient population, this author reviews the literature and offers insights on whether medications for RA should be withdrawn, continued or modified during the perioperative period.

   Increasingly, the treatment of rheumatoid arthritis includes the utilization of immunosuppressive therapeutic agents. The effectiveness of disease modifying agents in reversing the progression of rheumatoid arthritis (RA) is illustrated by the reduced frequency with which patients with RA undergo surgery for bone and joint deformities.

   Louie and Ward demonstrated that in the state of California, rates of joint surgery for the treatment of RA declined in the 1990s and have continually diminished since that time.¹ The authors concluded that the favorable long-term outcomes for the treatment of rheumatoid arthritis with newer agents have resulted in a decreased need for bone and joint surgery in patients afflicted with this disease.

   The patient with RA generally suffers with multiple joint involvement. Perioperative considerations include systemic factors as well as local factors. The patient with RA who is undergoing surgery has an associated increased rate of complications and generally has a less predictable outcome due to the effects of the disease. These patients may also have a significantly prolonged recovery in comparison to those without RA undergoing the same procedure.

   In addition to the usual medical evaluation, which would precede any surgical procedure, and careful evaluation of the entire lower extremity, physicians must assess disease activity as well as the medications utilized to treat the rheumatoid arthritis.

   Many of the complications associated with rheumatoid arthritis may be associated with the medications utilized to treat the disease rather than the disease process itself. For example, Hansen wondered if “surgeons have been much more pessimistic and therefore nihilistic about rheumatoid foot deformities than these conditions warrant.”² He goes on to note “in fact, compromised healing is due not to the intrinsic disease but to the effects of anti-arthritic drugs such as steroids or methotrexate on healing.”

   Authors have reported a significant incidence of infectious disorders in patients with RA not undergoing surgery.³ The increased rate of infections may be due to soft tissue atrophy in combination with pressure-induced ulceration secondary to rheumatoid foot deformity. Infection may also be a direct result of the increased utilization of immunosuppressive agents for the treatment of RA. Sixty-four percent of infections occurring in a patient with RA occur in the foot and ankle.³

   Nassar and Cracchiolo noted that in general, surgery for patients with RA for the correction of foot deformity was successful.⁴ They also noted the frequent occurrence of complications due to the disease process itself and medications utilized to treat the disease. Complications are also due to the fact that patients with RA frequently require multiple operations and not infrequently require complicated procedures due to advanced deformity, according to the authors.