Surgical Techniques for RA
With the introduction of disease-modifying anti-rheumatic drugs (DMARDs), joint inflammation and damage can be minimized or stopped in most people with rheumatoid arthritis (RA). However, medications aren’t sufficient in all cases, and some people with RA may need surgery. Modern surgical techniques to correct damage to joints and related structures can be effective in alleviating pain, correcting deformities, and improving joint function.
However, the decision of whether to undergo surgery can be a difficult one. Even though a surgical procedure may be performed painlessly using some form of anesthesia, there will be some pain and discomfort after the procedure as the surgical site heals. Additionally, surgery is always associated with certain risks, such as infection and a chance that the procedure will not go as planned and provide the desired outcome. However, the upside of surgery for patients with RA is that available interventions can result in dramatic benefits.
If you are considering undergoing surgery for an RA-related joint problem, you will need to consult with a qualified doctor who specializes in the treatment of conditions that affect the joints, muscles, and bones: an orthopedic surgeon. If you are contemplating surgery, chances are you have already talked to your rheumatologist about options. Your rheumatologist will be able to recommend experienced orthopedic surgeons for you to consult with to learn more about what type of surgery you should consider. Make sure that you get at least a couple different opinions and that you are comfortable with whomever you choose to perform your surgery.
Types of surgery used in RA
A range of surgical approaches are used to address musculoskeletal problems in RA. Types of approaches will vary depending on the joint(s), bones, and connective tissues involved and the nature of the damage. Common surgical approaches include1:
- Removal of the lining of the joint (called synovectomy)
- Tendon repair
- Cutting and resetting of bone (called osteotomy)
- Fusion of bone to immobilize a joint (called arthrodesis)
- Joint reconstruction or replacement (called arthroplasty)
Advances in surgery in recent decades have given orthopedists some amazing methods to perform certain surgical procedures and assessments on joints in a minimally invasive way. Arthroscopic surgery is one of these methods. It allows your surgeon to examine the inside of a joint and make certain repairs without having to open the joint up.1,2
Synovectomy involves removal of part of the lining of the joint, called the synovium. In RA, inflammation can cause a thickening of the synovium. In fact, the synovium can become overgrown to the point where it encroaches on related joint structures, including bones, cartilage, ligaments, and muscles. The inflamed synovium releases enzymes that can destroy cartilage and bone. The goal of synovectomy is to prevent or stop further damage to the joint. The procedure may be considered for alleviating persistent pain and swelling if drug treatment fails to resolve these symptoms in 3 to 6 months.
During synovectomy, part of the synovium is left intact so that it can still perform its function of releasing synovial fluid, which serves as a lubricant in the joint. Synovectomy can be performed by making a large incision that exposes the entire joint or it can be done using minimally invasive, arthroscopic methods. The choice of approach depends on the joint involved and the extent of repair required. While synovectomy will provide relief of pain and swelling, it is only a temporary fix. As long as RA inflammation continues, the synovium will continue to become overgrown.1
Swelling and inflammation of joints and related changes to bones and other structures in RA can often result in tendon rupture. Ruptures are particularly common in tendons located in the wrist and hand. Surgical repairs, including end-to-end and end-to-side reconstructions, involve the use of tendons from other areas in the body.1
Inflammation and joint involvement in RA can sometimes result in changes in the alignment of joints. These changes can cause pain, lead to uneven wear on bones and joint structures, and result in deformity and loss of joint function. Osteotomy involves the removal of a section of bone and the use of screws or other hardware (plates are often used) to reconnect the bone so that it can grow together. The goal of osteotomy is to restore correct joint alignment and relieve symptoms and functional problems related to misalignment. The procedure is often used in conjunction with synovectomy. The period of recovery for osteotomy can be long (6 to 12 months) and changes in joint alignment resulting from the procedure may make later joint replacement difficult. With certain joints, such as the hip, joint replacement is preferred.1
Arthrodesis is a surgical procedure that involves fusion of bones to achieve permanent immobilization of a joint. During the procedure, cartilage and the surface layer of bone is removed from the ends of the bones that are to be joined. The joint is then positioned in an alignment that is most functional and locked into place using rods, pins, and screws. Arthrodesis is most useful in cases where joint stability has been lost and joint movement causes pain. It provides relief of pain and even preserves some limited joint function. Arthrodesis is typically preferred for certain joints, including the wrist, first toe, hindfoot, ankle, and thumb. It is not preferred (but can be used) with the hip, elbow, and knee. Recovery from this procedure may take several months.1
Arthroplasty or joint replacement has been a revolutionary treatment for patients with RA. It is useful in instances where the joint has degenerated to an extent where pain is severe and function is limited. Replacement of damaged joints can both relieve pain and restore joint function. Success rates for arthroplasty are quite high. In nine out of ten cases, joint replacement surgery is successful.1
There are several different options for joint replacement. Arthroplasty can involve use of different combinations of artificial (prosthetic) and natural components, depending on joint location and the nature of damage to joints and related structures. The procedure is performed under general anesthesia by an orthopedic surgeon. The surgeon will open the joint and detach tendons and ligaments from the bone. The joint is then dislocated and damaged parts of the bone are removed. The surgeon will preserve as much of the bone as possible. In general, with arthroplasty, the more bone that remains, the greater the stability of the replacement joint. The bones are reshaped and the prosthetic joint (made out of metal or plastic) is then cemented into place, and tendons and ligaments are reattached.2
Although great advances have been made in the safety of arthroplasty, there are risks associated with joint replacement surgery. Risk of infection at the site of surgery is one of the major concerns with arthroplasty. In the worst case, such an infection may require removal of the prosthetic joint. Other complications include the formation of blood clots and nerve damage in the area of surgery. Additionally, the replacement joint may loosen or dislocate. Over time, prosthetic joints can wear out. For instance, hips may last for 10 to 15 years, while knees may last up to 20 years.1