What is the first arthroplasty procedure recommended for a patient with rheumatoid arthritis (RA)?

Knee Arthroplasty Should Be Prioritized First in Rheumatoid Arthritis Patients Requiring Joint Replacement

For patients with rheumatoid arthritis requiring arthroplasty, knee replacement should be prioritized first over hip, ankle, or foot procedures when multiple joints are affected.

Rationale for Knee-First Approach

Disease Impact and Functional Outcomes

• Knee involvement in rheumatoid arthritis (RA) typically causes more significant functional limitation and pain than other joints
• Total knee arthroplasty (TKA) has been shown to be a well-proven modality that provides substantial pain relief and restoration of mobility for those with debilitating knee arthritis 1
• Knee arthroplasty addresses weight-bearing function, which is critical for subsequent rehabilitation of other joints

Rehabilitation Considerations

• Successful knee arthroplasty provides a stable foundation for:
  • Better weight-bearing during rehabilitation
  • Improved gait mechanics for subsequent hip or ankle procedures
  • Enhanced ability to participate in physical therapy

Perioperative Management

• According to the 2022 ACR/AAHKS guideline, specific perioperative medication management is recommended for RA patients undergoing TKA 2:
  • Continue conventional DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, apremilast)
  • Withhold biologics prior to surgery and plan surgery after the next dose is due
  • Withhold JAK inhibitors (tofacitinib, baricitinib, upadacitinib) for at least 3 days prior to surgery
  • Restart medications once wound healing is evident, typically around 14 days post-surgery

Special Considerations for RA Patients

Medication Management

• The 2022 ACR/AAHKS guideline specifically addresses perioperative management for RA patients undergoing TKA 2
• Continuing current daily dose of glucocorticoids rather than administering supraphysiologic doses on the day of surgery is conditionally recommended

Surgical Timing

• For patients with RA who have been indicated for elective TKA through shared decision-making and have completed trials of nonoperative therapy without improvement, proceeding to TKA without delay is conditionally recommended 2
• The 2023 ACR/AAHKS guideline notes that "there should be no mandate that patients wait 3 months prior to TJA as an arbitrary cool-down period" 2

Non-Surgical Management Prior to Surgery

• Before considering arthroplasty, patients should have attempted appropriate nonoperative treatments:
  • Physical therapy
  • NSAIDs
  • Intraarticular injections (glucocorticoids or viscosupplementation) 2

Sequence of Multiple Joint Replacements

When multiple joints are affected and require replacement, the recommended sequence is:

1. Knee - Prioritize for improved weight-bearing and mobility
2. Hip - After knee function is restored
3. Ankle - After lower limb alignment is optimized
4. Foot - After more proximal joints are addressed

Caveats and Pitfalls

• Individual Assessment: While knee-first is generally recommended, severe hip disease causing greater pain or disability might warrant prioritizing hip replacement in specific cases
• Medication Timing: Failure to properly manage immunosuppressive medications perioperatively increases infection risk
• Rehabilitation Planning: Inadequate post-operative rehabilitation can compromise outcomes in RA patients
• Component Selection: RA patients may require special implant considerations due to bone quality and deformity

Conclusion

Knee arthroplasty should be prioritized first in rheumatoid arthritis patients requiring joint replacement due to its significant impact on weight-bearing function, mobility, and subsequent rehabilitation potential. Following evidence-based perioperative medication management protocols is essential to minimize complications while optimizing outcomes.