What are the considerations for Total Knee Replacement (TKR) in a young patient with Rheumatoid Arthritis (RA)?

Total Knee Replacement in Young Rheumatoid Arthritis Patients

Young RA patients are appropriate candidates for TKR when conservative management fails, and they can expect significant improvement in pain and function, though they face higher risks of infection, dislocation, and readmission compared to osteoarthritis patients. 1

Key Surgical Candidacy Considerations

Disease Activity and Timing

• Optimize RA disease control before proceeding to surgery, as uncontrolled disease activity increases perioperative complications 1
• Ensure the patient has failed adequate conservative management including DMARDs and biologic therapy 2, 3
• Young age alone is not a contraindication—the decision hinges on functional impairment and quality of life impact 1

Infection Risk Assessment

• RA patients have inherently higher infection rates (including prosthetic joint infection) than osteoarthritis patients undergoing TKR 1
• Evaluate for modifiable risk factors: overall disability level, disease severity, history of recurrent infections, and prior prosthetic joint infections 1
• Patients with severe or recurrent infections may require additional preoperative optimization 1

Perioperative Medication Management

Non-Biologic DMARDs

• Continue methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast through surgery without interruption 1
• These medications do not increase postoperative infection risk and continuing them prevents disease flares 1
• Exception: patients with history of severe/recurrent infections may elect to withhold these medications 1

Biologic Agents

• Withhold all biologics (TNF inhibitors, rituximab, abatacept, etc.) prior to surgery and schedule the procedure when the next dose would be due 1
• This timing allows one full dosing cycle to elapse before surgery, minimizing infection risk while limiting time off medication 1
• Anti-TNF biologics clearly increase infection risk and must be withheld 4

JAK Inhibitors

• Withhold tofacitinib, baricitinib, and upadacitinib for at least 3 days prior to surgery 1

Glucocorticoids

• Continue the patient's current daily glucocorticoid dose through surgery rather than administering supraphysiologic "stress doses" 1
• Most RA patients on chronic steroids receive 25% or less of their usual dose as glucocorticoids 1
• Avoid doses >30 mg/day prednisone equivalent perioperatively unless evaluating alternative diagnoses 5

Restarting Medications Postoperatively

• Resume all antirheumatic therapy once the wound shows evidence of healing, sutures/staples are removed, there is no significant swelling/erythema/drainage, and no ongoing infection—typically around 14 days postoperatively 1

Special Considerations for Young Patients

Implant Longevity

• Younger patients have longer life expectancy, raising concerns about implant survival and potential need for revision surgery
• Modern implants have improved durability, but this remains a consideration in shared decision-making 1

Activity Expectations

• Discuss realistic activity levels post-TKR with young patients who may have higher functional demands
• Balance desire for activity with implant preservation 1

Disease Progression

• RA is a systemic disease that may affect other joints over time
• Consider the patient's overall disease burden and likelihood of requiring additional joint replacements 6, 3

Critical Pitfalls to Avoid

• Do not continue biologics through surgery—this significantly increases prosthetic joint infection risk 1, 4
• Do not abruptly stop non-biologic DMARDs perioperatively—this increases flare risk without reducing infection risk 1
• Do not administer supraphysiologic glucocorticoid doses—current evidence does not support stress-dose steroids for patients on chronic glucocorticoids 1
• Do not restart medications before adequate wound healing—premature resumption increases infection risk 1
• Do not delay surgery indefinitely due to young age—prolonged disability and pain significantly impact quality of life 1

Multidisciplinary Coordination

• Ensure close communication between the orthopedic surgeon and rheumatologist regarding medication timing and disease optimization 1
• Document the medication plan clearly, including specific dates for withholding and restarting therapy 1
• Schedule follow-up with rheumatology within 2-4 weeks postoperatively to resume disease management 1