Hand Surgery for Rheumatoid Arthritis.
Edited By: Thomas Trumble, M.D.
Last updated Thursday, October 14, 2004
Figure 1 - Post-operative plaster splint Review of the conditionCharacteristics of arthritis of the hand True arthritis in the hand manifests as swelling over the wrist and the
metacarpal phalangeal joint (the knuckles of the hand) with deformity
of the fingers as they drift away from the thumb.Incidence and risk factors The hand is one of the most likely areas for rheumatoid arthritis to cause symptoms.Diagnosis Clinical examination and X-rays provide most of the useful information
regarding the diagnosis and treatment for rheumatoid arthritis of the
hand.Medications Medications have made a major impact in the severity of the symptoms of rheumatoid arthritis. The use of methrotrexate has dramatically slowed the rate of deformity in the hand.Exercises Exercises
can help maintain the strength and dexterity of the hand. Night splints
can be helpful to decrease the progression of deformity of the hand.Possible benefits of hand surgery Surgery
can be extremely helpful in decreasing the rate of tendon ruptures,
particularly when swelling has developed in the wrist. When pain and
deformity develop in the fingers, surgery can be helpful in relieving
pain and correcting the deformity.Who should consider hand surgery? Patients who have had persistent swelling over the wrist despite
medical treatment should consider having a removal of the diseased
tissue. Patients with progressive deformity or increasing symptoms of
pain involving the fingers or wrist also should consider surgery if the
symptoms have progressed despite appropriate medical treatment.What happens without surgery? Once the deformity in the fingers become so severe it becomes very
difficult to restore function with joint replacements. Patients with
persistent swelling due to their synovitis will have tendon ruptures.
Tendon ruptures result in loss of hand function, particularly in loss
of the ability to extend the fingers.Surgical options Synovectomy with removal of the diseased tissue from the wrist joint
region can be very helpful in preventing tendon ruptures. When tendons
have ruptured, tendon transfers can be done to balance the hand and
restore function. When there are painful joints involving either the
wrist or fingers, joint replacement can help relieve pain and restore
function.Effectiveness The surgeries can permanently improve function of the hand and prevent significant complications such as tendon ruptures.Urgency The most urgently needed procedures occur in patients with persistent
swelling about the wrist and imminent tendon rupture. Patients with
rapidly progressing deformity also should be considered for urgent
surgery.Risks Complications are rate but can include wound infections, particularly
in patients on high doses of steroids and delayed healing. When fusions
are performed to stabilize joints, delayed healing can occur especially
with patients with marked bone loss due to steroid use or serious bone
destruction from the disease.Managing risk Treatment of wound infections with intravenous antibiotics can resolve
most problems, and careful therapy programs can help to protect the
joints and prevent excessive stress on the sites of the surgical
incisions.Costs Our patient care coordinators can provide rough estimates of the
surgical costs. More exact estimates are performed by matching the
patient's diagnosis and surgical procedure with that of a patient with
a similar diagnosis and surgical procedures to more carefully estimate
the total cost of anesthetic, hospital care, therapy, etc.Surgical team The procedure should be performed by a board certified hand surgeon in
a setting of a medical facility that has trained staff who regularly
deal with patients who have rheumatoid arthritis to manage the special
needs in terms of anesthetics, medications, and medical consultations.Finding an experienced surgeon The faculty page on this web site has information on the board certified hand surgeons affiliated with the University of Washington. In addition, the American Society for Surgery of the Hand maintains a directory of hand surgeons with the certification nationwide.Facilities The procedure is usually performed in operating rooms in a medical
center that has the ability to have both inpatient and outpatient
procedures to help accommodate for patients who may have special
medical needs.Technical details Three major classifications that are performed and these can be performed in different sites.
- Synovectomy is removal of the diseased tissue.
This is most commonly done at the level of the wrist and sometimes is
accompanied by the removal of portions of bones that have been
destroyed by the disease. Occasionally these surgeries to remove the
diseased tissue are combined with surgeries to transfer tendons if
tendons have already ruptured. A tendon that duplicates another tendon
function is removed and physically moved to attach to the end of the
tendon that has ruptured. The ruptures cannot be repaired in an
end-to-end fashion because the disease destroys a segment of the tendon.
- Replacements
are done by removal of the disease joint surfaces that are producing
the pain and interposing an artificial joint that is usually made of a
soft synthetic material. These joints typically have a stem on either
end with a spacer in the middle. The stems are placed in the ends of
the bone on either side of the joint that has been removed.
- Joint
fusions mean removing the joint and stimulating the bones to grow
across the site of the joint surface to create a solid segment of bone.
This is usually done by adding bone graft material with bone from
another site of the body such as the pelvis or wrist and using metal
plates or pins to stabilize the bones while the fusion takes place.
Anesthetic Patients can either have a regional anesthetic where the arm is blocked
or made numb by the use of a local anesthetic injected near the
shoulder or a general anesthetic can be used.Length of hand surgery The time length can vary from one to two hours depending on the number
of separate procedures that have to be done to address the individual
patient's needs.Pain and pain management The amount that patients have can be related to the severity of
their deformity prior to surgery. Most patients can manage these
surgeries on an outpatient basis but some patients need to stay in the
hospital over night to receive stronger pain medication.
Most patients with rheumatoid arthritis only take the medication for
two to three day after the surgery. For some of the larger joint
replacement surgery or when multiple joints are involved, the patients
will need to stay over night and have intravenous pain medicines
administered. When only one or two joints are involved, the patient can
be managed on an outpatient basis with oral medication.
Medication typically relieves pain but can cause drowsiness. Because
of the drowsiness caused by these medications, it is recommended that
the patient does not drive a car or operate machinery while taking pain
medication. Hospital stay In the hospital, the patients typically have intravenous fluids so they
do not become dehydrated and they receive pain medications that are
adjusted to their pain level. In come cases, therapy is begun but in
most cases therapy is delayed until the swelling subsides, which takes
one to two weeks.Recovery and rehabilitation in the hospital Rehabilitation is typically delayed until the patient is evaluated in
the office one to two weeks after the surgery. The recoveries vary
tremendous depending on the type of surgery performed and what
combinations of surgery are required.Hospital discharge Most patients are discharged with a plaster splint that limits their
motion (see figure 1). For most patients, elevation of the hand is
important to decrease the swelling. When the patient is discharged,
they should have oral pain medication that is successful in relieving
symptoms as well as having appointments for their office follow-up. It
is important that the patient has a plan for where they would like to
have the therapy for their outpatient therapy, as this is usually an
essential part of the patient's rehabilitation.Convalescent assistance We would typically recommend therapy for joint replacements, joint
fusions, or synovectomies over a course of approximately six weeks
following the surgery. The patients can nearly always be discharged to
their home and they do not require a convalescent facility. Because the
patients have limited hand function, assistance with cooking and
cleaning for the first three to four weeks after the surgery is advised.Physical therapy Most patients will require therapy at least once or twice a week for a
period of four to six weeks. Therapy begins one to two weeks after the
surgery once the swelling has subsided and there is sufficient healing
to allow early motion.Rehabilitation options The rehabilitation program should be under the care of a therapist
who is skilled in hand therapy. Most therapists have a special
certification in hand therapy. Typically we maintain a list of skilled
therapists throughout the five-state region to manage the needs of
patients regardless of where they live. The therapy needs to be done
close to their home where it is convenient.
Although it is important to continue the exercise program at home,
we recommend that the patients have a program supervised by a skilled
therapist with their visit adjusted according to their needs.
The program varies somewhat depending on what types of surgery where
performed as different combinations result in the patient's individual
program. We recommend that the patients have access to therapy for at
least four to six weeks from their surgery.
Returning to ordinary daily activities We encourage patients to use their hands, although this is sometimes
has to be done while the patient is wearing a splint to do some of
their simplest activities such as dressing and eating. Most patients
are free from splints and casts within six weeks from time of surgery
and can perform most of their daily functions. It generally requires
two to three months from time of surgery before patients regain the
type of strength that they need to perform all of their pre-surgery
activities.Long-term patient limitations In general, we try to minimize the restrictions on the patients. In
many cases, the patient's surgery has been tapered to their expected
activity level. For example, joint replacement surgeries cannot
withstand heavy lifting and we do not recommend these in patients who
can otherwise pursue heavy physical activities. Overall, the goal of
the surgery is to enhance the patient's life style and increase the
number of activities that they can perform. Patients can generally use
their own judgement as to which activities they feel comfortable
pursuing.Surgery for arthritis of the hand at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4537 to make an appointment.
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