Berenice Adams, LCSW, an HSS orthopedic social worker, and Friedrich Boettner, MD, Assistant Attending orthopaedic surgeon at HSS, addressed the SLE Workshop regarding lupus and joint replacement surgery.
They presented on what is involved in this major elective surgery taking into account lupus-related concerns including the recovery period. The goal of their presentation was to help members make informed decisions about undergoing surgery.
Ms. Adams, LCSW began the presentation by discussing the ways in which patients with lupus can best prepare and most effectively recover from joint replacement surgery. She pointed out the ways in which patients can prepare for, and make the most of, their visit with an orthopedic surgeon.
Additional points that should be considered when talking with the surgeon include:
Ms. Adams also spent time focusing on “Ask Me 3” which she outlined as three simple questions to ask during each health care interaction. If a patient finds themselves with little time with their physician, or if they are only comfortable asking a few questions, Ask Me 3 lists the three questions that should not be forgotten. These include:
Learn more about the Ask Me 3 patient education program.
Once the initial appointments are finished and the patient is able to schedule their joint replacement surgery, Ms. Adams discussed how to best plan for surgery. In the days before surgery, patients have different appointments at the hospital which may focus on:
For patients planning for surgery, after they are discharged from the hospital or rehabilitation center, certain preparations should be made for the home to make space safe and comfortable. Ms. Adams gave numerous tips for making the recovery period go smoothly.
Once the patient has completed preparations, including necessary testing, appointments with the surgeon and home preparations, surgery can be scheduled. Dr. Boettner discussed the kinds of diagnoses associated with lupus that may lead to the need for total joint replacement surgery, the process of undergoing surgery, the types of hip and knee joint replacements that are offered, and the ways surgeons work with rheumatologists.
Dr. Boettner drew attention to arthritis being a common presenting feature of SLE. Synovitis, which is characterized as inflammation of the synovial membrane, (the lining tissue of our joints) is often the earliest sign of lupus. Synovitis is most frequent in joints of the hands, knees and wrists, but can involve almost any of our joints. Unlike rheumatoid arthritis, the arthritis of SLE is typically not erosive or destructive of the bone. However, Dr. Boettner expressed, some studies have highlighted erosive arthritis which has occurred in SLE patients, which suggests that features similar to RA can, in some patients, be seen in lupus.
Additionally, Dr. Boettner shared other reasons why SLE patients may need orthopedic surgery. Treatments that are common amongst SLE patients include:
a) NSAIDs which control pain, swelling and fever
b) Antimalarials, which are generally used to treat fatigue, joint pain, and skin rashes
c) Corticosteroids (such as prednisone), used to suppress inflammation
Corticosteroids can at times affect bone in a way that leads to a need for joint replacement (avascular necrosis). Corticosteroids can also increase the risk of infection and of osteoporosis.
Dr. Boettner discussed why people with SLE are at a higher risk for osteoporosis. The loss of bone density during osteoporosis including mass and strength, leads to increased porousness and vulnerability to fracture. This, he explained, is due to multiple factors in the lupus patient - the amount of corticosteroid treatment SLE patients have taken, decreased physical activity due to fatigue or arthritis, and premature ovarian failure due to medication. Also, as people with SLE often have a reaction to sunlight, they are encouraged to avoid sunshine, which can lead to Vitamin D deficiency, additionally adding to the possibility of osteoporosis, and potential fractures.
Osteonecrosis, which is bone death resulting from poor blood supply to an area of bone, can also be a reason for SLE patients to need orthopedic surgery. Osteonecrosis, as Dr. Boettner explained, can be caused by corticosteroid treatments that people with SLE often undergo. Through an unknown mechanism, corticosteroids can cause osteonecrosis and ultimately a collapse of the articular cartilage.
Many different conditions can lead to osteonecrosis. Although SLE in itself is a risk factor for osteonecrosis development, the common use of corticosteroids remains the main reason for the development of osteonecrosis.
“Drilling” of the necrotic bone can sometimes be utilized in very early stages of the disease to “buy time until total joint replacement.” It however, does not have a predictable outcome in patients with SLE. Most patients with more advanced osteonecrosis will ultimately require a total hip replacement.
Osteoarthritis is another condition that may lead to the need for joint replacement surgery in patients with SLE. It is characterized by a progressive deterioration of the joint cartilage and can develop secondary to SLE.
Non-operative treatment options include:
Dr. Boettner pointed out that “the ultimate solution for the destruction of the joint by osteonecrosis or arthritis is total joint replacement.” Although joint replacement surgery may be necessary, there is no evidence that one’s age at the onset of SLE, Raynaud’s phenomenon, smoking habits, the number of vascular risk factors, or organs affected by SLE, has a correlation to the need for total joint replacement.
For many years there has been a debate on how surgery, including total joint replacement surgery, can affect a patient with SLE. Dr. Boettner discussed that over the years there has been concern about patients with lupus experiencing complications during surgery. However, a study in 2010 found that elective procedures for joint replacements in people with SLE have the same mortality rate as those without lupus.
The experience at HSS supports this finding by suggesting that if modern techniques and careful management of recovery are used, joint replacement surgery can provide functional improvement for people who have SLE. When considering one’s quality of life, studies have also shown that patients with SLE have significant improvement in their lives after joint replacement. These findings suggest that if a patient’s rheumatologist approves, and if the surgery is planned appropriately, the patient will have an excellent opportunity for a successful joint replacement.
Some risks associated with SLE and surgery include the need to monitor certain organs affected which can be affected by lupus throughout the surgery, as well as taking precautions regarding blood clotting. After joint replacement surgery, 10-35% of lupus patients have some risk of deep venous thrombosis due to the presence of the lupus anticoagulant, which is linked to an increased risk of clotting. If the anticoagulant is present, deep venous thrombosis is usually prevented by more aggressive pharmacologic thrombosis prophylaxis.
Although there is risk associated with surgery in people with SLE, studies have found that overall, there are excellent outcomes in the Harris Hip Function scores and hip flexion.
Dr. Boettner also addressed how orthopedic surgeons and rheumatologists collaborate closely with each other in order to provide the best outcomes. Both surgeons and rheumatologists take into consideration the patient’s steroid intake and monitoring body functions during and after surgery, including heart and kidney function. Often, surgeons look to the rheumatologist for insight, as they have an established relationship with the patient, as well as expertise in treating the disease.
After surgery, the patient’s work with their health care team continues. Ms. Adams gave some examples of how to effectively cope with the recovery process. Before leaving the hospital, here are some things to keep in mind.
Once a patient is discharged from the hospital, and has arrived home, Ms. Adams said, prescribed exercise is the best way to recover quickly from joint replacement surgery.
When exercising, patients should be aware of any physical restrictions they may have and they should be fully aware of their body and the reactions that they have to the exercise, as the lupus may complicate this process. Overall, the pain relief achieved by joint replacement, combined with the correct regimen of exercise, should improve a patient’s overall health and quality of life.
Just remember, Ms. Adams reiterated, “If or when you plan to proceed with joint replacement surgery, make sure you review and fully understand all the instructions your surgeon gives you so you are fully informed and prepared.”
Learn more about the SLE Workshop, a free support and education group held monthly for people with lupus and their families and friends.