Surgery in patients with RA is often 'too little, too late'

June 2, 2009

A new study published by the American Society of Plastic Surgeons reveals that one of the most common conditions caused by Rheumatoid Arthritis (RA) is best treated surgically, sooner rather than later.

Patients with RA frequently experience a debilitating condition known as metacarpophalangeal joint disease, which is usually treated by replacing the knuckle joints with solid silicone joints. However, this treatment (and others like it) has spurred great disagreement between hand surgeons and rheumatologists regarding the indications, timing and perceived outcomes of the procedure; rheumatologists tend to refer late-stage patients for surgery whereas hand surgeons believe that earlier intervention can yield more positive outcomes.

In the largest cohort study of its kind, researchers from Michigan, Maryland, and the United Kingdom evaluated the surgical outcomes of 70 RA patients who suffered from varying degrees of hand deformities. Following reconstruction, patients were separated into two groups based on the degree of deformity, and the outcomes of the reconstruction were assessed at 6 months and at years 1, 2 and 3. After reconstruction, both groups had positive self-reported hand outcomes and showed statistically significant improvement from baseline. However, researchers found that the more severe group still had significant deformities - showing that the more serious the malformation, the more difficult it is to correct.

This study acknowledges that the management of rheumatoid hand and wrist problems is challenging because of the lack of evidenced-based research regarding the management of these difficult patients. Findings from this study support the general view of hand surgeons that surgery is beneficial to both the early stage and late stage patients. Both specialties agree that working together in a team approach will enhance the quality of life for the RA population. This study appears in the June issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of (ASPS).

By the Numbers:

According to the Foundation, nearly 1.3 million Americans suffer from RA. In 2008, more than 8,000 hand surgeries were performed due to complications from Arthritis, according to ASPS statistics.

Source: American Society of Plastic Surgeons

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not rated yet Jun 03, 2009
I'm a little confused in classifying this as "plastic and reconstructive" surgery. Its orthopedic when joint replacement even in small joints is involved, it is also therapeutic in an attempt to restore functionality vs a cosmetic result.

RA is a systemic disease and affects more than small joints. RA affects body systems and can include organs, eyes, spine, etc. Feet and ankles are important in focus for surgical intervention as it is common in RA patients and affects mobility; therefore, the overall function/disability status of RA patients. Frequently feet and ankles are the first indicator of destructive joint disease in RA. Bilateral Hallux Valgus and other foot deformities also affect gait and therefore knees, hips and back at the minimum producing pain and perhaps also producing quicker erosion in the large joints.

Its important that RA is treated by a multi-disciplined team to aggressively mitigate disability, pain and functional loss of joints, large and small. Currently Physical Therapy for RA patients is underutilized as insurance companies do not see the benefit of routine therapy which minimizes joint destruction, muscle wasting in using warm pool exercises guided by a physical therapist. This is exceptionally short sighted. RA patients usually are challenged financially, options are limited in transportation, time and funding for self-directed physical therapy. Pain frequently is a limiting factor in routine self-directed exercise.

Support by a team of practitioners in treatment, early surgical intervention before erosions are so severe its effectiveness in restoration of function is limited, effective pain/fatigue management and physical therapy interventions early would improve outcomes over time, keep patients more active longer and therefore, mitigate overall disease costs and increase the quality of life for these individuals.

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