The definitive treatment for advanced joint destruction in the late stages of rheumatoid arthritis can be successfully treated with total joint arthroplasty. Total knee arthroplasty has been shown to be a well-proven modality that can provide pain relief and restoration of mobility for those with debilitating knee arthritis. It is important for rheumatologists and orthopedic surgeons alike to share an understanding of the special considerations that must be addressed in this unique population of patients to ensure success in the immediate perioperative and postoperative periods including specific modalities to maximize success. 1. Introduction Over the past thirty years, major advances have been realized in the understanding of the pathogenesis and treatment of rheumatoid arthritis (RA). As an immune mediated process, all joints are affected, as synovitis leads to destruction of cartilage, which may ultimately result in bone loss and joint deformity. Joint contractures, fixed flexion and valgus deformities, and ligamentous laxity are especially evident in large joints, complicating treatments. With the advent of highly effective biologic therapies, fewer individuals with rheumatoid arthritis suffer this end-stage joint destruction [1]. Despite this success, approximately 20–25% of afflicted individuals develop advanced arthritis in their joints, with the knee being one of the most commonly affected joints contributing to patient pain and overall disability [2, 3]. Total knee arthroplasty (TKA) has proven to be a highly successful treatment for advanced rheumatoid arthritis. The orthopedic surgeon must pay special attention to the unique challenges presented by this population of patients during preoperative, intraoperative, and postoperative planning in order to maximize successful outcome and quality of life for these patients. 2. Preoperative Considerations Rheumatoid arthritis is a systemic disease, which creates a unique set of challenges and considerations when treating patients afflicted with this disease. Care is often delivered by a variety of specialty physicians, including rheumatologists and orthopedic surgeons. Preoperative communication is vital among these providers to maximize outcomes. Surgeons and anesthesiologists alike must be aware of the increased risk to the cervical spine as 80% of patients have atlantoaxial instability [4]. The cervical spine also is at elevated risk of basilar invagination and subaxial instability, and thus preoperative radiographic investigation via flexion and extension images should be obtained, as intubation
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