Orthopedic surgery in rheumatic diseases -especially in the lower limbs- has always been of utmost importance in restoring function in patients refractory to medical treatment. In more recent years with more efficacious treatment strategies especially in rheumatoid arthritis (RA) it seems that major salvage surgery is less frequently seen although non-joint sacrificing surgery is still many times needed in order to optimise function and control painful joint destructions. At the same time the field of RA surgery has changed on the background of biologicals. A learning curve on handling biologicals perioperatively is still needed and careful preventive measures especially towards joint arthroplasty infections are mandatory. On the other hand preventive measures towards other postoperative risk situations are not different in the biological era compared to previous times. High quality comprehensive decision making towards indication for surgery in arthritis patients is needed with a central role for a well informed patient and with a rheumatologist in close collaboration with orthopaedic surgeons. Traditional indication is shifting from only pain improvement to also restoration of function and preservation of patients independency. Forefoot surgery is perhaps the best example of arthritis surgery associated with a high satisfaction rate and also in an era of more effective therapies timely decision making as for instance for a preventive tenosynovectomy of persistent tibialis anterior tenosynovitis and extensor digits 4 and 5 tenosynovitis of the hand is crucial to avoid major disabilities. Preservation of shoulder function in arthritic joints by surgical interventions is calling for more study to avoid functional loss in these joints that are critical for the function of the upper limbs. Current evidence in this field is scarce and lacking distinction of different pathologies. Timely neck surgery in RA and major spine surgery in ankylosing spondylitis (AS) are still challenges also in the new millennium.
RA treatment is not just a cascade of novel medical therapies but a multidisciplinary effort including timely surgery. Despite more effective therapies in recent years, still patients are seen in the Western world with polyarticular destructions that need a global rheumatological/orthopaedic plan including a functional and rehabilitation view in order to restore quality of life. Moreover we should not forget the need in developing countries for making available efficacious medications and proper quality orthopaedic surgery. In the future more emphasis on a close collaboration with orthopaedic surgery is needed beyond traditional indication making. A destructive hip arthritis of a RA patient is different from a destructive hip in an AS patient regarding postoperative stiffness, so communication about the disease process is needed. Evidence has to be gathered in the field of orthopaedic surgery that is more specific for distinct pathologies. Probably future regenerative medicine will also increase the need for another type of orthopaedic surgery especially but probably not exclusively in osteoarthritis. The future is in restoring cartilage and bringing joints to a new homeostasis.
To conclude, even in an era of more efficacious medical treatments in rheumatic diseases, there is a need for incorporating surgical techniques in comprehensive treatment strategies for our patients. The specificity of our current treatments moreover appeals towards more intensive collaboration of rheumatologists and allied health professionals with orthopaedic surgeons as their role in indication making but also peri- and postoperative management seems crucial. It is to be expected that our patients will benefit from more refined surgical techniques in the future along their optimised medical treatments.
Disclosure of Interest None Declared
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