Rheumatoid Arthritis Surgery Is Often Little, Late

Ruzanna Harutyunyan's picture
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Two University of Michigan studies supported by the National Institutes of Health may bridge the gap between rheumatologists and hand surgeons as they work toward the common goal of improving the quality of life for patients with rheumatoid arthritis.

A study appearing in the current issue of Plastic and Reconstructive Surgery reveals that one of the most common conditions caused by rheumatoid arthritis is best treated surgically, sooner rather than later.

Patients with RA frequently experience a debilitating condition known as metacarpophalangeal joint disease, which can be treated by replacing the knuckle joints with solid silicone joints.

However, this treatment 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, U-M researchers and their colleagues evaluated the surgical outcomes for patients from Michigan, Maryland and the United Kingdom who suffered from varying degrees of hand deformities.

”It is the first rigorous assessment of the outcomes of a commonly-performed major procedure for reconstruction of hands that have been damaged by rheumatoid arthritis,” says David A. Fox, M.D., professor of internal medicine at U-M Medical School and chief of the Division of Rheumatology. “This study informs rheumatologists, surgeons and patients with RA as to what they can expect from reconstructive hand surgery on the metacarpalphalangeal joints.”

Following reconstruction patients were separated into two groups based on the degree of deformity, and the outcomes of the reconstruction were assessed at six months, and at years one, two and three. After reconstruction, both groups had positive self-reported hand outcomes and showed statistically significant improvement from the start of the study.

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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 is a unique collaborative project between hand surgeons and rheumatologists to generate high-quality data to help rheumatoid patients,” says lead author Kevin C. Chung, M.D., M.S., professor in the Department of Surgery at the U-M Medical School. “We will continue to follow this unique group of patients over the course of seven years to get more pertinent outcomes data to guide the treatment of the rheumatoid hand.”

In the article, authors acknowledges that managing 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.

A second U-M led study appearing in the May-June issue of the Journal of Hand Surgery compares the surgical option with medical treatment.

While clinical trials routinely look at medical treatments for RA, such as anti-inflammatory drugs, corticosteroids, disease modifying anti-rheumatic drugs and new biologic agents that might actually prevent joint destruction altogether, few studies have evaluated surgical innovations.

For the study, a total of 163 RA patients were recruited and separated into two groups: those who would have surgery and medical treatment, and those who would have medical treatment only.

The effectiveness of treatment was measured using the Michigan Hand Outcomes Questionnaire, a tool developed by Chung that has been used in researching outcomes for RA, carpal tunnel syndrome, and other hand and joint problems. MHQ measures hand function, pain, work performance, hand appearance, patient satisfaction and activities of daily living.

After one year, RA patients with poor baseline functioning on MHQ had significant improvement after surgery. That’s not surprising, authors say, since those who report better hand function would not elect to have surgery. The non-surgical group started the study with better function and showed no significant improvement or deterioration in hand function after a year.

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