Orthopedic surgery and its complication in systemic lupus erythematosus

Table 1 Pre-operative workup for patients with systemic lupus erythematosus planned for orthopaedic surgery

Workup and test	Description
Baseline kidney and liver function tests, fasting glucose and lipid profile	Anaesthetists should be alerted to abnormalities of the renal and liver functions as they may have implications on anaesthetics use. Patients need to fast for at least 8 h for fasting glucose and lipid tests. Endocrinologists should ideally be referred to assess diabetic patients in order to maintain stable glucose levels before and after operation by adjusting existing or starting new hypoglycaemic agents and/or insulin. Poor glycaemic control is associated with poor wound healing
Full blood count, peripheral blood smear (if hemolysis is suspected or proven) and clotting profile. Type and match if transfusion is contemplated or expected. Thrombophilic screen if there is history or suspicion of vascular thrombosis: Blood protein C and protein S levels, lupus anticoagulant, serum anti-cardiolipin antibodies and serum IgA level if IVIg infusion is required	Haematology or rheumatology consultation is necessary in case of anaemia, hemolysis, thrombocytopenia and evidence of thrombophilia, especially if patients have history of severe bleeding and/or vascular thrombosis, and if patients are on anti-platelet agents and/or anticoagulants
Resting 12-lead ECG	Patient should be referred for formal CVS assessment if ECG abnormalities such as ST segment changes, heart block or arrhythmia is evident
Chest radiograph	A plain chest radiograph is considered baseline pre-operative assessment in case general anaesthesia is required. In patients with SLE, a chest radiograph allows a crude assessment for pulmonary lesions such as interstitial lung disease and serositis. Assessment by pulmonologists may be required if lung pathology is suspected
Radiograph of the cervical spine (flexion and extension views)	Rarely required unless lupus patients have features of bone erosion in the peripheral joints which might heighten the chance C1-C2 disease
Treadmill test and coroangiogram	Patients with suspected or confirmed ischaemic heart disease may require these tests after assessment by cardiologists on a case-by-case basis. These tests allow diagnosis of coronary artery disease and risk stratification

CVS: Cardiovascular; ECG: Electrocardiogram; SLE: Systemic lupus erythematosus; IgA: Immunoglobulin A; IVIg: Intravenous immunoglobulins.