From the Guidelines
Patients with Crohn's disease undergoing orthopedic surgery face a moderate risk of disease flare-up, with the most recent evidence suggesting that the risk is influenced by several factors including disease activity at the time of surgery, medication regimens, and surgical stress. The risk of flare-up can be minimized by continuing maintenance medications through the perioperative period whenever possible, including biologics and immunomodulators 1.
Factors Influencing Flare Risk
- Disease activity at the time of surgery: Patients with well-controlled Crohn's disease have lower flare risk compared to those with active disease 1
- Medication regimens: Continuing maintenance medications, including biologics (infliximab, adalimumab) and immunomodulators (azathioprine, 6-mercaptopurine), can help minimize flare risk 1
- Surgical stress: Surgical stress triggers inflammatory cascades that can exacerbate Crohn's disease, and close coordination between the orthopedic surgeon and gastroenterologist is essential to optimize disease control before elective procedures and manage medications appropriately during the perioperative period 1
Preoperative Optimization
- Exclusive enteral nutrition may be an effective therapy in malnourished patients before undergoing elective surgery for Crohn’s disease to optimize nutritional status and reduce postoperative complications 1
- Patients with penetrating or stricturing Crohn’s disease, or those who are malnourished, may benefit from exclusive or partial enteral nutrition for at least 6 weeks preoperatively 1
Medication Management
- Corticosteroids should be stopped or dose minimized wherever possible to reduce risk of postoperative complications 1
- Biologics and immunomodulators should be continued through the perioperative period whenever possible 1
- Pain medications, particularly NSAIDs, can trigger flares and should be avoided when possible, with acetaminophen and opioids being safer alternatives 1
From the Research
Risk of Crohn's Disease Flare-Up in Orthopedic Surgery
- The risk of Crohn's disease flare-up in a patient undergoing orthopedic surgery is a significant concern, as Crohn's disease is a chronic inflammatory disorder with a high risk of recurrence 2.
- Studies have shown that the risk of postoperative recurrence in Crohn's disease can be reduced with the use of certain medications, such as biologics, immunomodulators, and 5-aminosalicylates 3.
- However, the risk of flare-up is also influenced by other factors, such as stress and the external locus of control, which can have a significant impact on the development of flare-ups in Crohn's disease patients 4.
- In terms of orthopedic surgery specifically, there is limited direct evidence on the risk of Crohn's disease flare-up, but studies have shown that perioperative anti-tumor necrosis factor therapy does not increase the rate of early postoperative complications in Crohn's disease patients 5.
- A decision-tree based approach has been proposed to predict the risk of disabling, surgery, and reoperation in Crohn's disease patients, which may be useful in identifying patients at high risk of flare-up 6.
Factors Influencing Flare-Up Risk
- Stress and external locus of control: High stress levels and a high external locus of control have been shown to increase the risk of flare-ups in Crohn's disease patients 4.
- Medications: Biologics, immunomodulators, and 5-aminosalicylates have been shown to reduce the risk of postoperative recurrence in Crohn's disease 3.
- Disease severity: Patients with more severe disease, such as those with B2 or B3 phenotype, may be at higher risk of flare-up 6.
- Timing of pharmacological therapy: Patients with later introduction of pharmacological therapy may be at higher risk of reoperation 6.