Total Knee Replacement in Young Rheumatoid Arthritis Patients

Key Considerations

The American College of Rheumatology recommends optimizing RA disease control before proceeding to surgery, as uncontrolled disease activity increases perioperative complications 1, 2
Young RA patients are at higher risk of infection, dislocation, and readmission compared to osteoarthritis patients, and should be evaluated for modifiable risk factors such as overall disability level, disease severity, and history of recurrent infections 1, 2, 3, 4, 5
The American College of Rheumatology suggests that RA patients have inherently higher infection rates, including prosthetic joint infection, than osteoarthritis patients undergoing TKR 1, 2, 3, 4

The American College of Rheumatology recommends continuing methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast through surgery without interruption, as these medications do not increase postoperative infection risk and prevent disease flares 2, 3, 6
The American College of Rheumatology suggests withholding all biologics prior to surgery and scheduling the procedure when the next dose would be due, to minimize infection risk while limiting time off medication 2, 3, 4, 6
The American College of Rheumatology recommends withholding tofacitinib, baricitinib, and upadacitinib for at least 3 days prior to surgery 6
The American College of Rheumatology suggests continuing the patient's current daily glucocorticoid dose through surgery, rather than administering supraphysiologic "stress doses" 4, 6

The American College of Rheumatology recommends resuming 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 4, 6

The American College of Rheumatology suggests that younger patients have longer life expectancy, raising concerns about implant survival and potential need for revision surgery 1, 2, 5
The American College of Rheumatology recommends discussing realistic activity levels post-TKR with young patients who may have higher functional demands, and balancing desire for activity with implant preservation 1, 2, 5

The American College of Rheumatology recommends ensuring close communication between the orthopedic surgeon and rheumatologist regarding medication timing and disease optimization 1, 2, 5, 6