Most people can successfully manage rheumatoid arthritis with medication, exercise, rest and joint protection. But sometimes despite these measures, or perhaps because management did not begin early enough, joint damage occurs, causing excessive pain or loss of function. For these patients, surgery may be the answer. Surgery is to be approached cautiously, and patients should always seek a second opinion when surgery is recommended.

For RA patients, surgery is most frequently performed on the wrists, hands, hips, elbows, feet, shoulders and knees. Procedures on the cervical spine are less common. Most people have surgery because they are seeking relief from pain. Others undergo surgery to improve movement and function so as to enhance their quality of life. Surgery is also sometimes done to prevent further joint damage from occurring. A secondary benefit of surgery can be an improvement in the appearance of the joints, particularly the hand joints.

Orthopedic surgeons specialize in joint surgery. They can perform several procedures that benefit people with rheumatoid arthritis. These are:

Arthrodesis

Arthrodesis is the surgical fusion of two bones. This procedure is done when a patient is experiencing extreme pain or has lost function, usually in the fingers, thumbs, wrists or ankles. Arthrodesis forms a new joint that is less flexible, but more stable and pain-free, than the old one.

Arthroplasty

Arthroplasty is the procedure of rebuilding joints. When RA has destroyed the cartilage and bone of joints, the ends of the bones can be resurfaced or relined. This creates a "new," fully functional joint. In more serious cases, the joint is actually removed, in part or completely, and replaced with man-made components. When prosthetic parts are made of metal, ceramic or plastic they can be cemented to the adjoining bones. Alternatively, prosthetic parts can be made of a special porous material that allows the natural bone to actually grow into the replacement part, eventually securing it in place. If replacement parts will come in contact with each other, to reduce erosion, parts made of different materials are used. For example, using a metal part along with a plastic part will reduce friction in the new joint.

Hips and knees are the most commonly replaced joints. Seventy percent of the time, joints are replaced because pain has begun to restrict normal daily activities. Joints can be custom made with a high degree of accuracy, using the natural joint as a model. Like natural joints, artificial joints can wear out. When joint replacement surgery is done in a younger, more active patient, often the surgery must be repeated later on in the patient's life.

Synovectomy

Synovectomy is surgical removal of the inflamed synovial tissue that lines the joints. Today, synovectomy is rarely performed as a stand-alone procedure because synovial tissue tends to grow back after surgery. Synovectomy is usually done a part of reconstruction surgeries, most commonly those involving the knee.

Surgeons may perform some of these procedures using arthroscopy. This surgical technique involves making two small incisions over a joint. An arthroscope, a thin, lighted fiber optic tube containing a tiny camera, is inserted through one incision; the other incision is for the operating instruments. The camera transmits images of the injured joint to a closed circuit TV, allowing the doctor to operate with great precision. Compared to standard surgery, arthroscopy requires less anesthesia and involves less cutting, so patients usually have a much easier recovery. However, depending upon the type of surgery and which joint is involved, complete recovery can take as long as 12 weeks.

Patients will be given pain medication and antibiotics after surgery. Some physicians feel that methotrexate and penicillamine can interfere with healing, so if these drugs were stopped before the operation, they will not be started again immediately after surgery. If prednisone was given at a low level prior to surgery, patients may now be given an increased dose to boost the body's response to the stress of surgery. The patient may be catheterized immediately after surgery so that bed rest will not be disturbed by trips to the bathroom.

Pain is to be expected after surgery and during post-operative physical therapy. Pain will lessen with healing, but it must not deter the patient from following the directions of the physical therapist. Passive range of motion exercises, then more active exercises are crucial to the ultimate success of the surgery. Devices like crutches, canes or splints may be employed during the recuperation period. Long term, patients may need to modify certain activities, perhaps learning new ways to get out of the car or bed, or foregoing heavy lifting.

Some doctors will advise a patient not to have surgery if the patient is unwilling to commit ahead of time to the post-operative exercise regimen. Patients must be mentally prepared to exercise as needed in spite of pain. Other reasons not to have surgery have to do with the patient's general overall physical health. Those with serious heart, kidney or lung problems, diabetes or diseases that interfere with blood clotting may be advised against surgery. Any condition that increases the risks of general anesthesia may also rule out surgery. Anyone with an infection, such as a urinary tract infection or inflamed gums, must delay surgery until the infection is cleared up.

During and after surgery there is a risk of blood clots, especially for joint replacement patients. Blood-thinning medication is given to help guard against this problem. Patients are also at increased risk for infection, also especially following joint replacement surgery. Sometimes antibiotics are added to the cement used to secure prosthetic parts during joint replacement surgery. Antibiotics are given immediately following surgery, and since infection can occur up to a year after the operation, antibiotics should be taken as a precautionary measure for routine procedures such as dental work. Another possible risk of joint replacement surgery is nerve injury. Finally, those with problems related to the cervical spine may be at increased risk during positioning for intubation.

Total hip arthroplasty has a very high success rate. More than 90% of patients enjoy complete relief from pain and greatly improved joint function following surgery. Total knee arthroplasty, is the next most successful surgery, followed by the other joint replacement surgeries.

Patients whose surgeons are highly experienced are more likely to have successful surgeries. When choosing a surgeon patients should not hesitate to ask how many times a surgeon has performed the operation in question. Surgery success rates are also higher and patient complications are lower at hospitals where a given surgery is performed many times each year.

Success is also dependent on the kind of care the patient receives after the operation. Expert physical therapy and occupational therapy are essential to optimal function after surgery, especially for procedures involving the knees, hands and shoulders. Prior to surgery patients should inquire about experience of these rehabilitation professionals as well.

References

First published September 1, 1999
Last updated December 16, 2002
Copyright © 1999 Accordant Health Services, Inc. All Rights Reserved.

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