Rheumatoid Arthritis Surgery

Arthroscopic synovectomy of the shoulder joint

• Indication: arthritis or pain refractory to conservative treatment (of 3 to 6 months) in a joint with cartilage remaining
• Assess the possibility of intensifying antirheumatic medication and intra-articular glucocorticoid injection before referral to a specialist in surgical treatment of rheumatoid arthritis.

Rotator cuff repair

• The primary mode of treatment for rotator cuff rupture is rehabilitation.
• Results of surgical repair are worse in patients with rheumatoid arthritis.
• A young patient with rheumatoid arthritis in remission and acute traumatic rupture of the rotator cuff should be referred for assessment by a specialist according to the same principles as patients with no rheumatoid arthritis.

Arthroplasty

• Most typically, patients with rheumatoid arthritis and shoulder symptoms have injuries of both the rotator cuff tendon and joint cartilage, making arthroplasty the surgical treatment of choice.
• If the rotator cuff is functional, anatomic total arthroplasty should be performed, as far as possible, as this achieves better pain relief and a better range of motion than the hemiendoprostheses that were commonly used in the past.
• Arthroplasty provides four patients in five with good pain relief, and rest pain is alleviated in nearly all; anterior elevation is improved by a mean of 30-40°.
• In patients with extensive rupture of the rotator cuff, reverse shoulder replacement should be performed, shifting the centre of movement to utilize the deltoid muscle instead of the rotator cuff muscles.
  • The range of motion will improve, on average, by 50-70°, i.e. from a low position of 40-50° to possibly above the horizontal level.
  • Studies of more than 10 years are already available and the success rate is, at least, on the level of traditional prosthetic joints.
  • Due to the limited possibility for debridement after reverse shoulder replacement, the indications for the procedure in young patients should be critically considered.
• The mean survival of shoulder endoprostheses is good, approx. 90% 10 years after installation.
• There must be a sufficient amount of bone remaining in the scapula to be able to perform anatomic total arthroplasty or reverse shoulder replacement.
• Hemiarthroplasty is often possible even if bone destruction proceeds past the stage for total arthroplasty.
  • As the prosthetic joint models have evolved and the fixation and bone grafting possibilities have improved, the use of hemiarthroplasty has been widely abandoned also in patients with rheumatoid arthritis.

Debridement

• Indication: arthritis or pain / restricted motion refractory to conservative treatment (3 to 6 months) in a joint with cartilage remaining

Arthroplasty

• Indication: elbow where rheumatoid arthritis has caused cartilage degeneration and there is pain and/or restricted motion.
• Unsuitable for young patients whose arms are subject to heavy exertion.
• Good pain relief, stability and range of motion are achieved in more than 90% of patients.
• Survival is not as good as with hip or knee endoprostheses but at 12 years 94% of endoprostheses survive.

Debridement

• Indication: inflammation not responding to antirheumatic medication and local glucocorticoid injections in 3 to 6 months
• The aims of joint debridement include alleviation of pain and improvement of the range of motion but also avoiding the stretching of soft tissue so as not to disturb the sensitive balance of extensor and flexor tendons, which might cause finger malpositions.
• Rheumatoid tendinitis always carries the risk of tendon rupture.
  • At wrist level, impingement of the median nerve may be the sole symptom of flexor tendinitis but restricted active finger flexion compared to the passive range of motion can often be seen.
  • Debridement of flexor tendons should always be done in connection with surgical release of the carpal tunnel nerve.
  • Inflammation of extensor tendons or the wrist joint, associated with a dorsally prominent ulnar head carries a significant risk of tendon rupture and is an indication for referring the patient for surgical assessment.
• If tendon injury is detected in one finger, an appointment for urgent surgical operation should be made to avoid rupture of the adjoining tendons.

Soft tissue reconstruction

• Arthroplasty of the carpometacarpal thumb joint is indicated to treat a painful CMC I joint with limited range of motion or looseness if cartilage degeneration has already developed.
  • Subluxation and restricted range of motion of the CMC I joint lead to compensatorily excessive extension of the MCP joint, which in the long-term will damage the cartilage in the MCP joint causing instability; in this case, MCP arthrodesis will be needed in addition to arthroplasty of the CMC joint.
  • Tendon interposition is most commonly used, with several surgical techniques described.
  • Surgical treatment gives good results, improving the stability of the thumb and the range of motion and alleviating pain.
• Surgical soft tissue balancing is used to correct ulnar deviation and palmar subluxation of the MCP joints when there is still some cartilage remaining in the joints.
  • The indication for surgery is usually restricted function due to malposition or restricted range of joint motion.
  • Malposition can usually be well corrected, improving the grip, but in some patients it will recur within a few years.
• Surgical repair of swan-neck and boutonnière deformities of the fingers aims at improving the use of the hand when there is still a good amount of cartilage remaining in the joints.
  • Repair of swan-neck deformity (hyperextension of the PIP joint with hypoextension of the DIP joint) provides better results than the repair of boutonnière deformity (hypoextension of the PIP joint and hyperextension of the DIP joint).
  • Because of the multiple causes of malposition and the great variation in the aggressiveness of rheumatoid arthritis, there is rather wide variation in the results of surgical treatment and their stability.

Arthrodesis

• Indications: pain, restricted function, malposition, instability or progressive bone destruction in a joint with clearly damaged cartilage
• Partial arthrodesis of the wrist will correct any malposition or looseness of the wrist. This procedure is possible if there is still some cartilage remaining in the midcarpal joint.
  • Good pain relief can be achieved, leading to a range of motion sufficient for daily tasks, 40-60°.
  • A dorsally prominent distal ulna and imminent tendon rupture are among the indications for partial arthrodesis.
• Total arthrodesis of the wrist should be performed if there is cartilage destruction in both the radiocarpal and proximal interphalangeal joints.
  • A painless and stable wrist can be achieved but without the extension-flexion range of motion.
  • Pronation and supination rotational movements are improved in most patients compared with before surgery.
• Arthrodesis of the finger jointsis used to treat painful, instable or malpositioned (proximal or distal interphalangeal) joints.
  • A small procedure often provides significant help, particularly in the treatment of instability of the thumb.
• When considering arthrodesis, total functionality of both hands and arms should be considered.

Arthroplasty

• Wrist arthroplasty should be considered as an alternative to total arthrodesis if the position of the wrist and soft tissue balance are well preserved and the patient uses her hand only for light tasks.
  • Wrist endoprostheses are under development; results vary and survival is clearly worse than with other types of endoprostheses.
• Metacarpophalangeal joint arthroplasty is indicated to improve hand performance or to treat pain if there is significant malposition or degeneration of metacarpophalangeal joints.
  • It improves the functionality and appearance of the hand and facilitates the performance of daily tasks.
  • The total range of motion is not significantly improved but reduced loss of extension facilitates opening the hand and grasping larger objects.
  • Metacarpophalangeal joint arthroplasty is most often done using silastic endoprostheses.
  • Fractures of silastic metacarpophalangeal endoprostheses are seen frequently in long-term follow-up but the rate of repeat arthroplasty is less than 20% in 10-year follow-up.
• PIP arthroplasty can be considered as an alternative to arthrodesis if there is no significant malposition and the soft tissue balance is sufficiently good.
  • PIP endoprostheses are associated with a high rate of complications, such as detachment, dislocation and contracture. Their use is therefore quite limited.

Arthroscopic hip debridement

Arthroplasty

• Indication: hip pain or restricted hip function with radiologically confirmed degeneration
• The patient should be urgently referred for orthopaedic assessment if there is
  • significant bone destruction (malformation of the femoral head or the acetabulum)
  • rapidly progressing cartilage or bone degeneration (often cystic)
  • severe pain or functional limitation.
• Hip arthroplasty often significantly improves the quality of life, alleviating pain and improving the range of motion.
• The risks associated with surgery are still somewhat higher in patients with rheumatoid arthritis than in those with osteoarthritis, particularly as regards infection and intraoperative complications.
• In Finland, 9.1% of patients undergoing total hip replacement are reoperated on within 10 years and 16.5% within 15 years.

Arthroscopic knee debridement

• Indication: arthritis not responding to appropriate conservative treatment in a joint with no significant radiologically confirmed degeneration
• Debridement alleviates the pain effectively, often improving the range of motion, but there is no evidence of its slowing down the progress of joint destruction.

Arthroplasty

• Indication: knee with pain or restricted function (limited range of movement or instability) and radiologically confirmed degeneration
  • In patients with rheumatoid arthritis, instability of the joint may cause significant symptoms even if cartilage degeneration is still relatively insignificant.
• The patient should be urgently referred for orthopaedic assessment if there is
  • significant or progressive bone destruction
  • significant (> 15°) or progressive valgus/varus malposition
  • severe debilitating pain.
• The results are excellent or good in 52-100% of patients (mean 89%). The range of motion is improved by an average of 8°, and 95% of patients have only mild or no pain.
• The risk of infection is higher (1.5- to 4-fold) in patients with rheumatoid arthritis than in those with osteoarthritis.
• The average survival of the endoprosthesis at 10 years is about 95%; no difference has been observed compared to patients with osteoarthritis.

Debridement

• Debridement of the talocrural joint, either arthroscopic or open, is indicated if the arthritis does not respond to appropriate antirheumatic medication and 2-3 glucocorticoid injections or, if the patient has a malpositioned ankle, by using orthotic shoe inserts for 2-3 months.
• Tendon debridement (posterior tibial or peroneal tendon) should be considered if arthritis does not respond to the above means of treatment in 3-4 months.
  • Risk of tendon rupture

Arthrodesis

• Ankle and foot pain in patients with rheumatoid arthritis is most often due to degeneration or looseness of the ankle joints.
• Triple arthrodesis is used for treatment, meaning arthrodesis of the talocalcaneal, talonavicular and calcaneocuboid joints.
  • If any of the three joints is well preserved and asymptomatic, arthrodesis of that joint is unnecessary.
  • Indications include pain, walking difficulties, significant malposition or imminent skin perforation.
  • Extension and flexion of the ankle will be preserved.
  • Good analgesic effect
  • This procedure corrects the ankle position with a favourable effect on the load on the talocrural joint.
• Arthrodesis of the talocrural joint is indicated for the treatment of a degenerated talocrural joint with pain interfering with daily life or walking, radiologically confirmed significant bone erosion, progressive destruction or malposition.
  • Good analgesic effect
  • After surgery, rocker sole shoes making the walking pattern nearly normal are recommended.
    • Patients with rheumatoid arthritis have more compensatory movement in the centre of the foot than patients with osteoarthritis.

Arthroplasty

• Arthrodesis of the talocrural joint can also be considered if joint destruction has not caused significant (> 15°) malposition or bone erosion.
• Due to the poorer long-term survival of ankle endoprostheses, they have not become as widely used as endoprostheses of hip or knee joints.
• Preserving the movement of the talocrural joint may, however, be particularly important for patients with knee, hip or other foot joint problems.
• Relatively good results have been reported for pain relief as well as functionality in patients with rheumatoid arthritis, and survival (77% at 10 years) is better than average.

Debridement

• Metatarsophalangeal joint debridement is indicated if arthritis does not respond to appropriate antirheumatic medication and 2-3 glucocorticoid injections or customized shoe soles reducing the load.

Reconstructive surgery

• To correct malposition of the foot or ankle and to balance the load, surgery involving breaking and repositioning bones or realigning tendons may be performed if the joints are well preserved.
• Surgery should be considered to correct malpositions of the toes in patients with pain in the ball of the foot or in the toes, problems with finding well-fitting shoes, walking problems or imminent or current skin perforation that cannot be managed by selecting appropriate shoes, individual support soles or silicone toe guides made by a chiropodist.
• In addition to the removal of the 2nd to 5th metatarsal heads that is typically used for the ball of the foot, joint-preserving osteotomy is beginning to be used for well preserved joints, but research-based evidence is still scanty.

Arthrodesis

• Arthrodesis of one or more joints is useful in the treatment of pain and malpositions in central foot joints if
  • conservative treatment is not sufficient to manage the pain
  • the malposition causes imminent skin perforation or symptoms due to increased stress on other joints.
• Arthrodesis of the metatarsophalangeal joint of the big toe is one of the typical surgical procedures for the feet of patients with rheumatoid arthritis.
  • The procedure alleviates pain and permanently corrects even significant malposition.
  • Gait is corrected by restoring weight-bearing of the first ray.
  • When standard surgical procedures are used for the treatment of hallux valgus, the malposition recurs more easily in patients with rheumatoid arthritis. This adds to the risk of recurrence of the lateral deviation of the 2nd to 5th toes that is typical for patients with rheumatoid arthritis.
  • Arthrodesis of the 1st MTP joint can be combined with procedures for correcting any malposition in other toes, as necessary.
• Arthrodesis is used as necessary to correct any malposition in other toe joints (distal or proximal interphalangeal joints) to alleviate pain and avoid imminent skin perforation.

Arthroplasty

• Endoprostheses have been developed for the metatarsophalangeal joint of the big toe but there are problems with their positioning and security of attachment and they are therefore hardly ever used for patients with rheumatoid arthritis.