Clin Rheumatol (2008) 27:553–556
DOI 10.1007/s10067-008-0839-7
REVIEW ARTICLE
Anaesthesiological problems in patients with rheumatoid
arthritis undergoing orthopaedic surgeries
Barbara Lisowska & Lidia Rutkowska-Sak &
Pawel Maldyk & Renata Cwiek
Received: 11 December 2007 / Revised: 22 December 2007 / Accepted: 4 January 2008 / Published online: 18 January 2008
# Clinical Rheumatology 2008
Abstract The article presents anaesthesiological problems
in patients with rheumatoid arthritis (RA) scheduled for
orthopaedic surgeries. Organ changes due to RA and related
treatment were taken into account. The anaesthetic tech-
niques used for patients with RA underwent orthopaedic
procedures were presented.
Keywords Anaesthesia . Orthopaedic surgery .
Rheumatoid arthritis
Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune disease
that causes stiffness, pain, loss of mobility, inflammation
and erosion (deterioration) in the joints. It usually affects
multiple joints symmetrically, the hand and wrists most
commonly, but also elbows, neck, shoulders, hips, knees
and feet. Virtually, every organ can be affected by the
disease and compelling evidence exists to relate active and
severe RA. Patients with RA may develop anaemia,
B. Lisowska (*) : R. Cwiek
Department of Anesthesiology, Institute of Rheumatology,
Spartańska 1,
02 637 Warsaw, Poland
e-mail: aleksander_lisowski@sggw.pl
B. Lisowska : P. Maldyk
Department of Rheumoorthopaedic Surgery,
Institute of Rheumatology,
Spartańska 1,
02 637 Warsaw, Poland
L. Rutkowska-Sak
Department of Rheumatology, Institute of Rheumatology,
Spartańska 1,
02 637 Warsaw, Poland
systemic complications and other co-existing autoimmune
disorders. The anesthesiologist must be aware of airway
pathologies, pain management techniques and available
pharmacology parameters.
Systemic diseases and side effects of therapy
in patients with RA
Rheumatoid arthritis is a systemic disorder that may affect
almost any organ system. Systemic features may dominate
articular manifestations in some individuals and may
predate joint disease.
The patients with RA have shown a decrease in vital
capacity, total lung volume and arterial hypoxemia. The
interstitial fibrosis has also been observed [1]. The rheuma-
toid nodules that appear in the lung may occur inflammation
causing shortness of breath and fluid accumulation in the
lung.
The most common rheumatoid affection of the cardio-
vascular system has been reported to induce conduction
abnormalities and regurgitant valvular defects. When in-
flamed, the condition is referred to as pericarditis. Inflam-
mation of heart muscle, called myocarditis, can also develop.
Rheumatoid vasculitis can range in severity from a
widespread, life-threatening disease refractory to treatment.
It can lead to skin ulcerations, bleeding stomach or small
bowel ulcerations and neuropathies with the nerve prob-
lems causing pain, numbness or tingling [2–5].
Renal and hepatic failure often occurs as result of
amyloidosis or drug therapy. Subclinical renal and hepatic
dysfunction is common in patients with RA.
The most intensified changes regard the osteoarticular
system, where the chronic inflammatory process leads to
significant deformations. In patients with prolonged RA,
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there are also changes in the blood supply to the synovial
membrane consisting of decreased sympathetic innervation
when compared to sensory innervation; described differ-
ences might be also a reflection of the degree of disease
progression [6].
Side effects of drug therapy for RA may produce further
difficulties. Steroid-induced reduced bone density (osteo-
porosis) is often recognised in patients with RA and is
associated with a high risk of bone fractures and spinal
deformation. The most common adverse events of Non-
steroidal anti-inflammatory drugs (NSAIDs) are gastric
irritation, ulceration and severe haemorrhage from the
upper gastrointestinal tract [7, 8]. Using of coxibs allowed
reducing the prevalence of haemorrhage in the gastrointes-
tinal tract from 50% to 60% [9, 10], but a study showed
a significant increased risk of cardiovascular events. A
negative influence of coxibs and NSAIDs on the circulatory
system is connected with a disturbed balance between
thromboxane and prostacyclin synthesis, prostaglandin syn-
thesis and disturbances of glomerular filtration [11–13]. For
example, Methotrexate is responsible for haematological
and pulmonary side-effects as pancytopaenia and irre-
versible pulmonary fibrosis [14, 15]. The treatment with
leflunomide has been associated with disturbances in the
gastrointestinal tract and with the development of peripheral
neuropathy [16, 17]. Etanercept has also been suggested to
have been the cause of acute lung injury and polyneuropathy
due to demyelinisation of nerve fibres [18, 19].
Surgical procedures
Surgical procedures are performed for severely affected
joints. Usually, the first surgical treatment is removal of the
synovium (synovectomy). The most frequently performed
procedures include hip and knee alloplasty, surgeries on
hands and feet. Surgeries can relieve joint pain, correct
deformities and modestly improve joint function. The most
successful surgeries seemed to be hip and knee joints
alloplasty due to rheumatoid arthritis or osteoarthritis.
Anaesthesia
The most frequent surgical procedures, in patients with RA,
are orthopaedic surgeries and choice of anaesthetic method
usually depends on patient’s general condition and the type
of surgery proposed. There is no single standard anaesthe-
tic, but all regional anaesthetic methods might be used in
orthopaedic surgeries. Using general anaesthesia techniques
also have advantages. There may provide better control of
cardiovascular and respiratory system and there is no limit
Clin Rheumatol (2008) 27:553–556
of the duration of surgery. Occasionally, using general
anaesthesia procedures is helpful in keeping patient in
unusual position.
The aims of pre-operative assessment of the patient with
RA are to evaluate the extent of the diseases process,
systemic consequences and side effects of drugs therapy for
RA so that the risk of surgery and anaesthesia may be
minimised [20].
The majority of patients have the articular changes that
may have an impact on the conduct of anaesthesia and on
the choice of anaesthetic method. The present of deformi-
ties may compromise positioning during surgery and affect
access for regional anaesthetic techniques causing signifi-
cant problems related to blockades of the nervous plexuses.
Moreover, difficulties with attending catheters placed for
continuous blockades in patients with immunosuppressive
treatment should be expected.
A number of studies have demonstrated that involvement
of the cervical spine is common among patients with early
or late disease and is associated with poor outcomes.
Approximately 40–85% of patients with RA develop neck
pain and radiographic evidence of instability (atlanto-axial
subluxation, and superior migration of the odontoid process)
and 50% of these patients are asymptomatic. In a prospective
observational study of 100 patients with early RA (less than
1 year duration), 12% developed atlanto-axial subluxation
within the first 5 years of disease [21].
Occasionally, the symptoms suggestive of atlanto-axial
instability (hemiplegia, vertigo, dysphagia, transient exten-
sor reflex) may occur in patients with RA.
Identification of instability will alter airway management
and minimise the risk of spinal cord impingement and/or
superior migration of the odontoid. In case of advanced
lesions in the atlanto-axial joint, even slight motions of the
head may cause compression of the spinal cord, medulla or
vertebral arteries, causing pyramidal symptoms, quadriple-
gia or occasionally sudden death [22]. Therefore, careful
radiological assessment of the neck prior to elective sur-
gical or endoscopic procedures is important in all patients
with established RA. Evaluation of the rheumatoid cervical
spine is optimised using MR images in the neutral, flexed
and extended positions. Measurements and relationships
between structures should be compared in all positions.
Conventional radiographs with flexion–extension views are
recommended as the first imaging method [23].
The development of fiber-optic laryngoscopes has
altered the management of rheumatoid patients when
general anaesthesia with intubation is considered necessary
[24]. However, patients with confirmed subluxation in the
cervical segment should be intubated under sedation which
allows for the assessment of neurological symptoms in case
of spinal cord trauma.
Clin Rheumatol (2008) 27:553–556
The most frequent form of anaesthesia for surgical
procedures on the lower limbs is spinal anaesthesia with
local anaesthetic agents administered alone or together with
opioids for the provision of effective postoperative analge-
sia. The addition of intrathecal midazolam and ketamine to
bupivacaine significantly improves the duration and quality
of spinal anaesthesia and provides prolonged perioperative
analgesia without significant side effects [25, 26].
The continuous blockades of the peripheral nerves or the
lumbosacral plexus are also performed for lower limbs
surgeries and they constitute an alternative to continuous
extradural analgesia. It was indicated that unilateral periph-
eral blockade provides the quality of analgesia comparable to
the continuous extradural analgesia. The peripheral block-
ades may be an optimum method for management of post-
operative analgesia after the knee surgery [27].
Surgical procedures on the upper limbs are usually
performed in blockades of the brachial plexus and the
axillary approach and Winnie’s approach are the most
popular.
Segmental intravenous anaesthesia is an alternative to
regional anaesthesia and its unquestionable benefit is that it
is easy to be performed. However, similar to the general
anaesthesia, postoperative analgesia should be provided
most rapidly by opioid after surgery. Moreover, it was
shown that the period of healing of the postoperative wound
is prolonged in case of this anaesthesia and equals –11%
when compared to –5% in general anaesthesia and –6% in
regional anaesthesia [28].
The economical factor influencing the assessment of
advantages related to anaesthesia is also extremely impor-
tant. The costs of hip and knee joint replacement performing
under general or spinal anaesthesia were compared. Calcu-
lations included only prices of medicines and equipment.
The research showed that the cost of spinal anaesthesia is
nearly half lower than the one of general anaesthesia. In
addition, after general anaesthesia, patients are required
more analgesic during the postoperative period. There was
also important while calculating the total cost of anaesthesia
[29]. From the historical point of view general anaesthesia
was recognised as the gold standard. Our experience allows
attributing the same phrase to regional anaesthesia for
rheumoorthopaedic surgeries.
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