There's no doubt that improved medical treatment has reduced the number (and severity) of hand, finger, and thumb deformities caused by rheumatoid arthritis. But these and other problems still do crop up and may require surgical intervention.
In this article, the role of surgery in the management of rheumatoid arthritis affecting the hand is reviewed. Each area of the hand from the wrist to the finger tips is discussed. Treatment of specific deformities such as boutonniere or swan-neck of the fingers and thumb is highlighted. Tendon rupture, a common problem with rheumatoid arthritis is also reviewed.
As the author of this publication, Dr. Chung hopes to show that surgeons should be called in as consultants early in the management of rheumatoid arthritis. Rheumatologists treating this condition with medications such as the newer disease-modifying anti-rheumatic medications (DMARDs) should not view the need for surgery as a failure of medical treatment.
There are some patients who don't respond to these medications but who could still benefit from surgical intervention to improve joint alignment, motion, and function. Coordinating treatment between the rheumatologist and the surgeon can be vital in providing the best possible outcomes for these patients.
What kind of surgery is available for hand conditions caused by rheumatoid arthritis? Let's start with the wrist and work our way down to the thumb and finger tips. The wrist is affected in 70 per cent of all patients with rheumatoid arthritis of the hand.
Inflammation of the fluid inside the joint (a condition called synovitis) weakens the ligaments and other soft tissue support structures of the wrist. Without the support from these connective tissues, the bones of the wrist collapse. Dislocation of the wrist is the next step.
Surgery can be done to realign the bones and reduce pain (when present). Correcting alignment and minimizing deformities may help improve motion and function. Surgery doesn't have to wait until the damage is done.
The surgeon can take action once evidence is seen that the wrist bones are migrating (shifting). Partial fusion of the wrist may prevent shifting of the bones, thus reducing the risk of hand and finger deformities. Total fusion may be needed to decrease pain and stabilize the wrist.
The health of the bones can impact surgical decisions. Weak, brittle, or insufficient bone stock can limit surgical options (e.g., making the use of an implant for joint replacement impossible). Studies are ongoing to find ways to improve wrist replacement surgery. Problems with implant loosening, fracture, and degeneration have resulted in new designs being developed.
Next, let's look at surgical options for the metacarpophalangeal (MCP) joints (the big knuckles you see across the back of the hand when you form a fist). Synovitis associated with rheumatoid arthritis often causes a shift of the fingers off to the side called ulnar deviation or ulnar drift.
You can imagine how difficult it is to grasp objects, open doors or jars, get dressed, or pick up items when your fingers won't straighten out. And that doesn't even begin to address the cosmetic appearance that is so distressing to many patients. What can be done surgically for this problem?
Fusion of the metacarpophalangeal (MCP) or other finger joints doesn't work -- the loss of motion would only make daily functions even more difficult. Some surgeons are trying to remove the affected synovium (called a synovectomy) and transfer ligaments to hold the joints in place. The transfer procedure is called a cross-intrinsic transfer. It can be done if damage to the joints caused by the synovitis is not too great.
It is possible to replace the MCP joints. This joint replacement surgery is recommended when the joints sublux (partially dislocate) or completely dislocate. When enough joint damage has been done that the joints can't recover or it's too late for reconstructive surgery, then joint replacement may be the next step.
Long-term studies do show a high rate of implant breakage. The implants are made of silicone and they don't seem to hold up as well as hoped for. Still, patients say the improved hand function in the short- and mid-term period is worth having the procedure done.
This brings us to the treatment of tendon ruptures so common among patients with rheumatoid arthritis. With the shifting position of bones, tendons can get caught between two bones or rub against bony edges shredding them until they break. Tendon weakening from synovitis also contributes to tendon ruptures with minor injuries or mechanical trauma.
Surgical treatment removes the problem causing the tendon rupture. The surgeon then repairs or reconstructs the damaged tendon. Sometimes a tendon can be sewn to another tendon so that movement of the intact tendon assists the torn tendon. In other cases, a tendon transfer can be done. With this procedure, one tendon is split and a portion of that tendon is moved over and attached where the ruptured tendon used to be.
In the final section, Dr. Chung addresses the problem of finger and thumb deformities. Any changes or problems in the wrist and hand will affect the fingers and thumb. Collapse of any bone above the digits (if untreated) will cause a zig-zag shift throughout the rest of the hand and fingers. Finger deformities are an even greater challenge than wrist and hand problems.
Surgical intervention will depend on the specific joint affected and whether or not the deformity is still flexible (finger joints can still be moved passively) versus "fixed" (joints are stuck in one position). The two main choices are soft tissue reconstruction (best for flexible deformities) and joint replacement (recommended for fixed deformities). Fusion of unstable joints presents a third option but this is a last resort effort.
When making treatment decisions regarding the thumb and fingers, the surgeon must take into account whether the problem is one of appearance or function. It's important to avoid making function worse in order to improve the appearance. Many patients are more concerned about how their hands look and will sacrifice function for a more normal looking hand.
In summary, the author suggests there is a great need for research to really provide evidence that identifies which medical and/or surgical treatments of rheumatoid arthritis of the hand are most effective.
Until that is available, disagreements between these two specialties may hamper efforts to improve wrist and hand function. Dr. Chung presents a very clear argument for hand surgery to aid patients with rheumatoid arthritis maintain or regain hand function and improve quality of life. Communication between surgeons and rheumatologists may help educate the medical community of the need for an individual plan of coordinated care for each patient.
Reference: Kevin C. Chung, MD, MS, and Allison G. Pushman, BA. Current Concepts in the Management of the Rheumatoid Hand. In The Journal of Hand Surgery. April 2011. Vol. 36A. No. 4. Pp. 736-747.