Surgery: When Splinting Isn't Enough for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an inflammatory condition that causes significant damage to the articular cartilage of the joints. This can cause pain, deformity and loss of function. The goals of treatment are to relieve the pain, correct the deformity, and restore the function.

In the past 20 years, many new medications have become available for treating RA. We now have: nonsteroidal anti-inflammatory drugs (NSAIDs), including the COX-2 inhibitors, which are gentler on the GI tract; corticosteroids such as prednisone, methotrexate and other immunosuppressants; and the new biologics, such as etanercept and infliximab. These have made a significant difference in patient care and markedly reduced the need for splinting and surgery.

When to Operate

Only three reasons are valid for surgery:

• Pain, primarily of the joint, although tendons and nerve compression also may be involved;
• Deformity, abnormal position of the bones due to joint destruction,
• Loss of function, such as tendon rupture.

These are not necessarily independent of each other but rather are interrelated. While the rheumatologist and orthopaedic surgeon provide information to the patient on when surgery may be advisable, it is the patient who makes the decision on when to operate.

What is a joint?

A joint is where two bones meet. Each bone end is capped with articular cartilage. The entire joint is surrounded by a joint capsule. That capsule has an inner lining called the synovium.

If you take an X-ray of the joint, you only see the hard bone. You don’t see the softer cartilage nor the joint capsule and synovium.

But if the bones are closer together on the X-ray than expected, that tells you something about destruction of the cartilage by the arthritis. And you also may see some abnormal positioning of the bones that tells you about the arthritis.

What Surgeons Treat

Surgery involves very concrete thinking processes. Surgeons have specific reasons why they do things. They make physical corrections to change the position of things, replace something, or remove something – always with specific goals. The parts of the body they work with are joints, tendons, nerves, bones, and others.

Joint Surgery

In the joints, abnormalities can cause pain, deformity and loss of function. The goal is to relieve pain, which will indirectly improve function. These four techniques may be used:

• Injections – For example, corticosteroid injections reduce inflammation, swelling and pain.
• Synovectomy – This is removal of the joint lining. It reduces inflammation, swelling and pain. It makes the joint healthier but has no impact on the cartilage. It is good for early stages of joint damage but cannot prevent further damage. Synovectomy can be done by an open procedure (cutting the skin to look into the joint) or arthroscopically (inserting the arthroscopic tube into the joint and visualizing the joint on the computer screen).
• Arthrodesis – This is fusing of a joint. The diseased cartilage is removed, the bone ends are cut off, and the two bone ends are fused into one solid bone with screws and wires. There is no further motion in the joint, but there is no further pain.
• Arthroplasty – This is total replacement of the joint. Diseased cartilage is removed. The ends of the bone are replaced with metal, plastic and/or silicone. The result is a replacement that provides movement in much the same way the original joint did, with reduced or no pain. The trade-off is that these parts may wear down over many years, and there may be a need for replacement 10 or 20 years later. Good arthroplasties are now available for the hip, knee, shoulder, elbow, and some of the finger joints. Newer arthroplasties are becoming available for the wrist and other fingers, although our experience with them is shorter term.

Tendon Surgery

In the tendons, RA can cause tenosynovitis, trigger finger, and tendon ruptures.

• Tenosynovitis – The tendon sheath around the tendons becomes very inflamed and painful. The treatment is to clean out the diseased inflammatory tissue, which may have occurred either on the flexors (palmar) side or on the extensors side of the hand. This is essentially like a synovectomy.
• Trigger finger - This is a problem that most of us encounter at one time or another, whether or not we have RA. The leading edge of the tendon, right at the edge of the knuckle, is held closely to the bone. As we age, this tendon can become thicker and form a knot. Trying to get the knot through the pulley to pull the pulley can become painful. Thus it causes locking. The initial treatment is steroid injections. If that doesn’t work, we can surgically cut the top of the pulley.
• Tendon rupture - This is a more serious problem. If tenosynovitis is untreated, the enzymes and inflammation can eat away at the tendons and, in combination with rough bone ends, can lead to rupture – breakage – of the tendons. Surgery is needed to reconnect the tendons.

Nerve Surgery

Two main nerve problems require surgery, in people with and without RA: carpal tunnel syndrome and cubital tunnel syndrome.

• Carpal tunnel syndrome – This is the most common, but there is a lot of misunderstanding about what it is. Carpal tunnel syndrome is just compression of (pressure on) a single nerve. The nerve is the median nerve that extends through the wrist. The median nerve is surrounded by all of the tendons that go to the fingers. And the nerve and the tendons all go through the same tunnel – the carpal tunnel. This tunnel is bound on three sides by bone. The roof of it is the transverse carpal ligament. This provides a very tight space for the median nerve and all the tendons go through to reach the hand. The median nerve has a very important function. It supplies all of the sensation to the thumb, index finger, middle finger, and part of the ring finger. Loss of sensation to these fingers happens very slowly, and is due to pressure on that median nerve. So when tenosynovitis occurs and the tendons enlarge due to inflammation, the nerve gets squeezed – there’s not enough room for it, and it doesn’t get to send its messages to the fingers properly. The treatment is to cut the roof – the transverse carpal ligament – to provide more space for the median nerve below. This can make a big difference in the function of the hand.
• Cubital tunnel syndrome – This is due to compression of a similar nerve – the ulnar nerve – that is in a different place – up near the elbow. The problems and solutions are similar.

Bone Surgery

There are no specific treatments on bones that we do for people with RA that are particularly different for people with RA. Most are related to fractures. The most common fractures we see are fractures of the wrist, metacarpal, and elbow.

For most people, when the fracture is stable, we use conservative treatment by putting the patient in a splint or cast for six weeks of immobilization followed by rehabilitation. For fractures are unstable, sometimes surgery is necessary and plates, screws, etc. are used. This depends on the fracture location and other problems.

Other Surgery

"Lumps and Bumps" are the rheumatoid nodules that patients sometimes get. These are not medically necessary to remove. However, patients sometimes decide that they want them to be removed – either because they cause physical or cosmetic discomfort. Sometimes they recur, other times they do not.

On the Horizon

Rheumatologists have made phenomenal progress in the medical management of RA. They will continue to reduce the number of patients who need surgery. However, on the surgical front, we are developing:

• better implants (lower friction rates, better design properties);
• implantable biologic agents (to treat fractures and loss of cartilage);
• materials for cartilage replacement.

It is hoped that research in the field of developmental biology will yield new findings that can eventually be applied to bone and joint development, particularly fracture healing and cartilage, and hand/arm development, with a focus on tendons, nerves, and ligaments.

About HSS' Living with RA Workshop

Summary prepared by Diana Benzaia

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