While the incidence of hand surgery in RA may have changed, the indications for surgical intervention have not
The role of the hand surgeon in the treatment of rheumatoid arthritis (RA) has changed in response to the increased effectiveness of novel medical management of this chronic condition.
However, there is still no cure for the condition, and while the frequency of procedures appears to have reduced, the hand surgeon still has a significant amount to offer the rheumatoid patient in a multidisciplinary setting.
Disease modifying anti-rheumatic drugs (DMARDs) have reduced the need for some traditional RA hand operations1 and undoubtedly a reduction in presentations of patients with severe deformity by way of preventing progression and inducing remission.
However, with symptom improvement comes an increase in use of a limb with asymptomatic synovitis, which may result in an increased risk of deformity, osteoarthritis, tendon rupture and nerve compression symptoms.
There has been insufficient time since the introduction of the newer biologic DMARD agents to see the impact on later complications of the condition. Therefore, it is likely that there will always be a role for surgery, despite vastly improved disease control.
While the incidence of hand surgery in RA may have changed, the indications for surgical intervention have not. The goals of surgical treatment include:
- To reduce pain
- Preserve or improve function
- Prevent or correct severe deformity
- Improve appearance
- Assist disease control
The adage that surgical interventions should be performed as late as possible, but early as necessary to avoid serious joint and soft tissue damage should not be universally applied.
Staging is always difficult as RA is a progressive condition with variable presentation between individuals. The functional requirements of the patient is the primary concern and patient involvement in the decision-making process is paramount.
Patients seek treatment at different stages of their disease for different reasons. Given the protracted course of treatment, we need to consider keeping the patient engaged with their treatment process and therefore prioritise operations with relatively predictable outcomes over less reliable procedures.
Early surgery (in combination with optimal medical management) may prolong function. Surgery for late stage changes rarely improve function.
Our patients need to be adequately educated to make informed decisions on:
- What to operate on (and knowing the implications of surgery)
- When to operate (not always the most severe deformity first)
- Knowledge of the post-operative requirements (and compliance)
- Effects on the unoperated side (increased demands and potential to exacerbate symptoms on the unoperated side)
Commonly offered surgical procedures include:
- Synovectomy
- Nerve compression
- Excision of Rheumatoid nodules
- Tenosynovectomy (tendon transfers or grafts)
- Arthroplasty
- Arthrodesis
Synovitis is universal in RA and if left unchecked, is the cause of cartilage destruction, the alteration of bony integrity, invasion and weakening of tendons as well as loss of soft tissue support. In practical terms, this can result in the patient experiencing pain, swelling, stiffness, triggering and disfunction.
The presence of synovitis can result in compression of the median nerve at the wrist and ulnar nerve at the elbow and wrist. Nerve decompressions need priority to prevent permanent nerve dysfunction.
While synovectomy may not be recommended for rapidly progressive synovitis, surgery may still benefit the patient with mild disease with persistent synovitis in one or two joints as early surgical intervention may produce better outcomes compared to waiting until a fixed deformity or joint subluxation occurs.
Rheumatoid nodules are common, and may be painful. They commonly occur at the olecranon, along the subcutaneous ulnar border and on the dorsum of the hand and fingers.
They may occur as subcutaneous deposits that are easily removed, but patients need to be warned of recurrence after excision. Rheumatoid nodules also are found within the tendons, can be found in both the dorsal and volar wrist and are responsible for extensor tendon ruptures as well as the Mannerfelt lesion (rupture of the thumb long flexor tendon).
In the fingers, the tendons involved are predominantly volar, and may be responsible for triggering. Steroid injections for triggering, a common first-line treatment in the non-RA population, may cause necrosis of nodule and increase risk of rupture, and is therefore not recommended.
While in no way curing the disease, tenosynovectomy may reduce the risk of tendon ruptures and delay loss of function.
Tenosynovitis is likely a common cause of tendon rupture (especially extensor tendons) and is often painless. Surgical treatment of the ruptured tendon consists of tendon transfers, grafts or arthrodesis.
The patient often presents late following a tendon rupture and the delay in presentation as well as synovitis involving the tendon often makes primary repair not possible.
Tendon rupture is usually multifactorial and in addition to tenosynovitis, joint capsule laxity and subluxation as well as osteophyte formation can all contribute.
Tendon transfers are the mainstay of treatment of rupture, but the reliability of tendon transfers is reduced in the RA patient as a result of poor joint stability, suboptimal wound bed for transfer and suboptimal tendons available for transfer.
Tendon grafting is an alternative if transfers are not possible and a combination of transfers and grafting may be required in a more extensive presentation.
Tendon grafting requires a functional motor unit. Following tendon rupture, the muscle contracts (and tendon retracts) and fibroses, so grafting is really only possible with a relatively acute presentation (less than three months).
One of the best-known hand operations for RA is a metacarpophalangeal (MCP) joint arthroplasty. Chung et al 2 published the results of a survey sent to both surgeons and rheumatologists on whether or not MCP joint arthroplasty improved function. While 83% of surgeons responded yes, only 34% of heumatologists responded with the same optimism.
This highlights differences in perception of success of surgery between the specialties, but also is likely biased by the follow-up between the two specialties (episodic versus long term).
However, there is little doubt that MCP joint replacement reduces pain and improves cosmesis. It possibly improves function. Therefore, “success” could depend on which question was asked.
Silicone MCP joint arthroplasty works well in moderate to severe joint deformity. However, good bone stock is required for success, and loss of hand bone mineral density in the RA patient has been demonstrated as a marker for poor functional outcomes3.
Arthroplasty procedures are often combined with other supplemental procedures such as synovectomy, intrinsic muscle release, crossed intrinsic muscle transfer, extensor tendon balancing and correction (sagittal band plication or repair).
The cause of the MCP joint abnormalities are often due, at least in part, by proximal pathology at the wrist. The areas of the wrist that are commonly involved include the ulnar styloid, distal radio-ulnar joint (DRUJ) and scaphoid.
The end-stage caput ulnae, consisting of instability of the DRUJ resulting in painful forearm rotation, volar subluxation of the carpus, radial shift of the metacarpals and ulnar deviation of the fingers is thankfully now the exception rather than the norm.
Areas in the hand that are of concern should never be addressed in isolation, as problems in one joint will affect others. We must be aware that surgery on one joint (eg MCP joint) will affect the more distal joints. Therefore, surgery on the MCP joint may prevent or delay requirements for surgery at the PIP joint.
Common thumb and finger pathology in the RA patient include the Swan neck and Boutonniere deformities. Again, patient expectations are important, as a Boutonniere deformity may still be relatively functional and therefore not require surgery.
The role of the hand therapists in the treatment of the RA patient is very important and cannot be overlooked. Hand therapy is a low-cost intervention that has benefits in the setting of the multidisciplinary treatment of RA. 4Most of the patients I see are sent to the hand therapist before any surgery is entertained. Education on behaviour modification and splinting are often very effective in maintaining function and, on occasion, for end-stage disease can offer alternatives to surgery if the patient is prepared to wear a splint full time as a trade-off.
The appeal of a surgical solution is often greatest only after all conservative options have been exhausted. Therapists also have a role in pre-operative education with regards to managing patient expectations following surgery as well as the vital role in the success of any surgical endeavour in maximising function post-operatively.
When considering referral to a hand surgeon for your RA patients there are a few considerations in addition to the presenting problem.
There would be few surgeons willing to operate on a patient that was not medically optimised and I would not recommend any elective procedure within three to six months of a change in medication or dosages.
My advice to patients is to continue medications during pre-operative period as it is better to have the possibility of slightly impaired wound healing rather than a flare of RA symptoms.
Although the risk may normalise with time, there has been evidence of an increase in infection rate within the first six months of commencing a biological DMARD.5
Temporomandibular joint and cervical spine involvement can result in limited neck extension and mouth opening which may have implications with regards to the type of anaesthetic available.
Similarly, the presence of pulmonary fibrosis may make regional anaesthetic options more appealing compared with a general anaesthetic.
In summary, the aim of surgery in RA is not curative as the disease will progress regardless. Soft tissue procedures only delay the inevitable and some recurrence should always be expected post-operatively.
However, hand and wrist surgery in the RA patient has been demonstrated to improve function and quality of life, decrease depression in addition to decreasing the activity of the disease.6
Well-defined aims are important in setting realistic outcomes from surgery. A patient with gross deformity with minimal pain and good function is not a candidate for surgery.
A referral to a hand surgeon in no way commits a patient to surgery, and often a significant amount of time is spent with patients explaining why surgery may not be in their best interests. Rather, timely referral allows the patient to be exposed to another specialist that is committed to well-proven as well as innovative use of best-practice medicine to ensure the best outcome for the patient.
Dr Wysun Wong is a specialist plastic surgeon working in private consultation and at St John of God Hospital in Perth, Western Australia. He has a sub-specialty interest in traumatic and degenerative hand and wrist problems
References:
Gogna, R. et al Rheumatoid hand surgery: is there a decline? A 22-year population-based study. HAND (2015) 10: 272-78
Alderman, AK et al Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists. J Hand Surg (2003) 28A: 3–11
Deodhar, AA et al Hand bond densitometry in rheumatoid arthritis, a five year longitudinal study: an outcome measure and a prognostic marker. Ann Rheum Disease (2003) 62: 767-70
Lamb, SE et al Exercises to improve function of the rheumatoid hand (SARAH): a randomised controlled trial. LANCET (2015) 385(9966): 421-429
Bongartz, T et al Anti-TNF Antibody Therapy in Rheumatoid Arthritis and the Risk of Serious Infections and Malignancies: Systematic Review and Meta-analysis or Rare Harmful Effects in Randomized Controlled Trials. JAMA (2006) 295: 2275-85
Ishikawa, H The latest treatment strategy for the rheumatoid hand deformity J Orthopaedic Science 2017) 22: 583-592
