Rheumatoid hand surgery: is there a decline? A 22-year population-based study

Contemporary View on the Care of the Rheumatoid Wrist

SUMMARY

Rheumatoid arthritis (RA) is a common inflammatory condition that can lead to debilitating hand and wrist deformity. Since the introduction of disease-modifying antirheumatic drugs in the 1990s, the rate of surgery for rheumatoid arthritis has dramatically decreased. Nonetheless, surgical intervention remains an important tool in the management of patients with RA, and young surgeons must seek out expertise in this domain due to diminished exposure during their training. In this article, the authors provide a comprehensive review of the evaluation and management of patients with wrist pathology attributable to RA as well as surgical technical pearls.

Outcomes of Small Joint Arthroplasty for the Rheumatoid Hand

The number of patients presenting to the hand surgeon with severe rheumatoid disease has decreased with the introduction of more effective medical management. However some rheumatoid patients will undergo disease progression despite this. MCPJ and PIPJ replacement can be effective surgical treatments in these patients but patient selection is crucial. Patients undergo surgery hoping to achieve improvements in pain, hand function and appearance. Multiple types of implant have been introduced over the years; however, silicone remains the most reliable option in terms of survivorship, complications and achieving the aims of rheumatoid patients.

Role of Synovectomy in Rheumatoid Hand and Wrist

Synovectomy refers to the removal of all or part of the hypertrophied soft tissue membrane on the inside of the joint capsule or around tendons. Historically, this was typically performed for rheumatoid arthritis and other inflammatory conditions of the hand, but following the development of more advanced medical treatments, the role of synovectomy has come into question. In this article, the authors outline the biologic basis for synovectomy and then consider its present and future role in the management of joint and tendon disease, followed by what further research is needed.

Radiolunate Arthrodesis in the Rheumatoid Wrist: A Retrospective Clinical and Radiologic Long-Term Follow-Up

PURPOSE

This study aimed to determine the results of radiolunate arthrodesis for rheumatoid arthritis (RA) after a long-term follow-up period of up to 20 years under tight postoperative medical control of RA. We also compared the results between patients with and without degenerative changes in the midcarpal joints at follow-up. We determined the radiologic factors predictive of secondary degenerative changes in the midcarpal joint.

METHODS

This was a long-term retrospective analysis of 16 wrists of 14 patients with RA treated with radiolunate arthrodesis first reported in 2013. The mean follow-up period was 14 years (range, 8-23 years; SD, 4.6 years). Ten wrists had a Larsen classification of grade III, whereas 6 wrists had grade IV. The range of motion was assessed, and clinical outcomes were graded using the Mayo Wrist Score and Stanley classification system. The Carpal Height Index, Ulnar Translation Index, and changes in the midcarpal joint contour were determined from radiographs. We categorized the changes in the midcarpal joint as unchanged or degenerative.

RESULTS

At final follow-up, the clinical scores improved; however, the extension and flexion range of motion was significantly reduced compared with that before surgery. The Carpal Height Index and Ulnar Translation Index improved immediately after surgery and remained stable at final follow-up. The changes in the midcarpal joint were categorized as unchanged in 6 wrists and degenerative in 10 wrists. The clinical outcomes were similar between the groups. The mean preoperative Ulnar Translation Index was significantly higher in the degenerative group than in the unchanged group.

CONCLUSIONS

Radiolunate arthrodesis in patients with RA maintained good clinical results and corrected alignment, even during long-term follow-up. Preoperative severe ulnar translation deformity was a risk factor for postoperative degeneration of the midcarpal joint, and pre-existing degenerative changes at the midcarpal joint might lead to loss of wrist range of motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Physician practices in referring rheumatoid hand and thumb carpometacarpal arthritis cases to hand surgeons

OBJECTIVES

To investigate the referral practices across different medical specialties and identify possible barriers to hand surgery referral. Rheumatoid hand deformities (RHDs) and thumb carpometacarpal (CMC) arthritis may require surgery once deformities occur. However, in Saudi Arabia, the rate of referrals to hand surgeons remains low.

METHODS

This was a cross-sectional study that included 102 consultants of family medicine, rheumatology, and orthopedics across various regions of Saudi Arabia. A total of 30 institutions were contacted and requested to distribute a survey questionnaire to their physicians; these institutions included 8 private hospitals, 16 government hospitals, and 6 primary healthcare centers. The survey included questions on the incidence, rate, management, knowledge, and referral of patients with RHD and CMC arthritis using a 5-point Likert scale. The Kruskal-Wallis H test was utilized in our analysis to evaluate the differences in responses among the 3 specialties.

RESULTS

For RHD and thumb CMC arthritis, the referral rate was higher among orthopedic surgeons compared to rheumatologists and family medicine physicians. The main barriers to referral were patient refusal, medical treatment alone being deemed adequate, and a lack of awareness of surgical options for management.

CONCLUSION

Our findings highlight discrepancies in patterns of physician referral of RHD and thumb CMC arthritis cases to hand surgeons, indicating the need for targeted interventions to improve referral rates and enhance patient outcomes.

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act

Importance

Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear.

Objective

To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA.

Design, Setting, and Participants

This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023.

Exposures

Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods.

Main Outcomes and Measures

Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA.

Results

Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change.

Conclusions and Relevance

Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

Perioperative management of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society for Rheumatology

BACKGROUND

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.

METHODS

After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.

RESULTS

The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.

CONCLUSION

Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.

Long-term clinical outcome of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands

Purpose

To evaluate the objective and subjective long-term clinical outcomes of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands.

Methods

We evaluated the long-term clinical outcomes of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands of 37 patients (43 hands) followed up for a mean of 14 years (range, 10–21 years).

Results

The mean time from rupture to surgery was 13.1 weeks (range, 3–48 weeks). The mean extension lag of the metacarpophalangeal joint was 8.7° (range, 0–40°), the mean pulp-to-palm distance was 0.4 cm (range, 0–3 cm), and the mean overall satisfaction rate was 86.5 (range, 70–100). There were no significant differences in clinical outcomes between tendon transfers and tendon grafts. There was a significant correlation between extension lag of the metacarpophalangeal joint and overall satisfaction rate (R² = 0.155; p = 0.009). Time to surgery was significantly correlated with extension lag of the metacarpophalangeal joint (R² = 0.437; p = 0.001) in the tendon graft group.

Conclusions

Both tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands achieve satisfactory results that are maintained for an average of 14 years. In cases of tendon graft, the time to surgery should be considered, and there is concern over extension lag of MP joint.

Level of Evidence

IV

Surgical Intervention for Patients With Rheumatoid Arthritis is Declining Except for Foot and Ankle Surgery: A Single-Center, 20-Year Observational Cohort Study

OBJECTIVE

A global downward trend in the number of rheumatoid arthritis (RA)-related surgeries has been reported. The purpose of our study was to investigate the latest trends in RA-related surgeries in a single-center Japanese RA cohort.

METHODS

This study was a retrospective analysis of RA-related surgeries between 2001 and 2020 in the Institute of Rheumatology Rheumatoid Arthritis cohort. An average of 4,944 patients per semiannual survey was included in the study. The primary goal was to analyze the half-year period prevalence proportion (HPP) of RA-related surgeries in a 20-year period, and the secondary goal was to analyze the HPP of surgeries by site or by categories of disease activity.

RESULTS

There has been a downward trend in the HPP of RA-related surgeries in the 20-year study period. The total HPP of RA-related surgeries decreased by 50.3% during the 20-year study period. There was a significant decrease in knee, hip, shoulder/elbow, and hand procedures. Only foot/ankle joint surgeries significantly increased in volume during this period (p=0.001). The HPP of RA-related surgeries remained unchanged in patients with remission or low disease activity.

CONCLUSION

The number of RA-related surgeries decreased over a 20-year period, but foot/ankle joint surgeries increased in the site-specific evaluation.

Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis

Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.

[Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]

BACKGROUND

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.

METHODS

After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.

RESULTS

The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.

CONCLUSION

Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.

Union of Radiocarpal Fusion With and Without Proximal Row Carpectomy: A Systematic Review

PURPOSE

Wrist fusion provides a solution to the painful, arthritic wrist, and can be concomitantly performed with or without a proximal row carpectomy (PRC). The benefits of combining a PRC with fusion include a large amount of local bone graft for fusion and a lower number of joints needed to fuse. We hypothesized that wrist fusion combined with PRC will have a higher fusion rate than wrist fusion performed without PRC.

METHODS

A systematic review was performed to identify all papers involving wrist arthrodesis using the following databases: PubMed, Ovid, Scopus, Web of Science, and COCHRANE. A literature search was performed using the phrases "wrist" OR "radiocarpal" and "fusion" OR "arthrodesis". Inclusion criteria included complete radiocarpal fusion performed for rheumatoid, posttraumatic, or primary arthritis; union rates available; English-language study. Studies were excluded if case reports; diagnoses other than the ones listed previously; inability to abstract the data. Data collected included wrist fusions with PRC or without PRC, union rate, patient age, underlying diagnosis, and method of fixation.

RESULTS

A total of 50 studies were included in the analysis. There were 41 studies with no PRC, 8 studies with PRC, and 1 study with and without PRC. There were 347 patients with a PRC and 339 patients had a successfully fused wrist (97.7%). There were 1,355 patients who had a wrist fusion with no PRC, and1,303 patients had successful wrist fusion (96.2%). The difference in fusion rate between the 2 groups, 97.7% versus 96.2%, was not statistically significant.

CONCLUSIONS

There is no statistically significant difference with regards to union rate in wrist fusion with a PRC versus wrist fusion without a PRC.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Arthroscopic Synovectomy of Wrist in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting multiple joints. Wrist involvement is common. Patients with persistent symptoms despite medical management are candidates for surgery. Synovectomy can provide pain relief and functional improvement for rheumatoid wrist. Arthroscopic synovectomy is a safe and reliable method, with minimal postoperative morbidity. This article reviews the role, technique, and results of arthroscopic synovectomy in the rheumatoid wrist.

Total Wrist Arthroplasty Versus Wrist Fusion: Utilization and Complication Rates as Reported by ABOS Part II Candidates

BACKGROUND

The aim of this study was to assess national trends in the utilization and complication rates of total wrist arthroplasty (TWA) and total wrist fusion (WF) as identified via review of the American Board of Orthopedic Surgery (ABOS) Part II candidate database.

METHODS

The ABOS Part II candidate database is a collection of cases reported by candidates of the ABOS Part II board certification oral exam. The ABOS database was queried for all TWA and WF cases performed from 2005 to 2014. Linear regression analyses were used to assess trends in procedure utilization. Treatment diagnoses, patient characteristics, and reported complications were also compared between the 2 treatment cohorts.

RESULTS

No significant increases in the proportion of candidates performing TWA or WF, number of TWA or WF cases, nor the number of TWA or WF cases performed per candidate performing those procedures were noted during the study period. Significantly less TWA cases were performed when compared with WF cases (68 vs 327; P = .006). Patients undergoing TWA were significantly older ( P = .005), more likely female ( P < .001), and more likely to have a diagnosis of osteoarthritis ( P = .003) than patients undergoing WF. There were no significant differences in complication rates, including postoperative infection, nerve palsy, or rate of secondary surgery, between the TWA and WF cohorts.

CONCLUSIONS

Utilization of both TWA and WF has remained unchanged among emerging career orthopedic surgeons. Although WF is performed nearly 5 times more frequently than TWA, our short-term findings suggest that TWA compares favorably with WF.

The latest treatment strategy for the rheumatoid hand deformity

With a remarkable improvement in the pharmacotherapy of rheumatoid arthritis (RA), severely handicapped patients are very rare to see. Healing, repair and drug-free, and toward radical cure are coming to be possible. In the clinical practice, more than 50% of the patients are in remission. However, some patients are still difficult to reach remission due to comorbidities and economic burden. In the patient with clinical remission, smoldering synovitis so called "silent destructor" is often detected by ultrasonograpy or by synovial histology in the small joints of the hand. In recent years, over use with "no pain" increases the risk of deformity, osteoarthrosis, tendon rupture and entrapment neuropathy. Highly motivated patients, who concern about the appearance of the hand, hope to get a higher level of activities of daily living and quality of life (QOL). A prospective cohort study was performed for the purpose of knowing whether rheumatoid hand surgery affects the patient's QOL and mental health as well as upper extremity function. A primary hand surgery was scheduled in 119 patients with RA. Synovectomy and Darrach procedure, radiolunate arthrodesis, reconstruction of the extensor tendons, arthroplasty at the metacarpophalangeal (MP) using Swanson implant, fusion at the proximal interphalangeal (PIP) joint, suspensionplasty at the carpometacarpal (CM) joint of the thumb (Thompson method) et al. were performed. As a result, Japanese version of the Stanford Health Assessment Questionnaire (J-HAQ:physical function,QOL), EuroQOL-5 dimension (EQ-5D:QOL), Beck Depression Inventory-II (BDI-II:depression, mentality) at 6 months and at 12 months after surgery improved significantly compared to those just before surgery (p < 0.01). Disease activity score 28- C reactive protein 4 (DAS28-CRP (4)) decreased significantly (p < 0.01). Latest hand surgery with tight medical control is possible to raise QOL and to provide mental wellness for the patient with RA.