Arthritis of the hands: Rheumatoid Arthritis

What we got here is failure to communicate.  Some men you just can’t reach, so you get what we had here last week, which is the way he wants it.  Well he gets it!

Stother Martin as “The Captain” in the movie Cool Hand Luke

Rheumatoid arthritis is a unique and very different type of arthritis.  It is much rarer than osteoarthritis, and the treatment is much more specific and specialized.  Rheumatoid arthritis can involve practically every joint in the body, but the joints of the hand and feet are commonly involved.  There have a number of incredible advances in the medical treatment of rheumatoid arthritis and I think the general opinion among hand surgeons is that we are seeing fewer patients with severe deformities of the hand which will require surgery, which is certainly a good thing.  However enough patients still have the disease progress to the point that surgery is needed.

Rheumatoid arthritis is an auto-immune disease, which is a fancy way of saying that your own bodies immune system attacks tissue in your body.  Nothing can be done to reverse the activity that the immune system initiates, but there are more and more medications being found that can effectively control the way your body reacts and help prevent many of the progressive deformities that are seen.  Since these medications are very specialized and are constantly changing the treatment of Rheumatoid Arthritis is usually best done by a specialist in arthritis called a Rheumatologist.

There are several reasons to see a hand surgeon if you have Rheumatoid Arthritis.  Most commonly people develop severe deformities at the joint where the fingers join the hand called the metacarpal-phalangeal joint or MPJ.  The arthritis attacks the joint and causes stretching of the ligaments of the joint.  Due to the forces acting on the joint the fingers drift downward and away from the thumb.  This is known as ulnar drift.  Once the ligaments stretch out and the joint surfaces become destroyed then the only way to correct the deformity is through surgery.  Fortunately many patients can adapt and function fairly well even with severe deformities so surgery is not automatically needed in many patients.  Patients that develop severe deformity and pain will consider surgery to straighten the fingers to improve function and relieve pain.  The surgery involves removing the joint surfaces, releasing contractures around the joint and then replacing the joint with a silicone spacer joint replacement.  This is a tedious and difficult surgery that should only be done by a surgeon with special training in hand surgery.  After the surgery there is usually an extensive period of splinting and therapy that requires a great deal of effort from the patient and therapist. It is important to have a therapist who is trained in dealing with hand problems.  The surgery usually results in excellent correction of the deformities, but there is a tendency for the deformities to recur over time.  The next joint out in the finger, known as the proximal inter-phalangeal joint, can also be damaged in Rheumatoid Arthritis.  Problems at this joint don’t have to be corrected as often as problems at the MPJ, and if surgery is needed it can often be done at the same time that the MPJ’s are corrected.

Another problem patients with Rheumatoid Arthritis get in the hands is tendon swelling, or synovitis.  This can result in the tendons rupturing, or popping, and the patients loses the ability to bend the fingers.  Most often this happens on the top of the hand and the patient can’t straighten out the fingers.  This can be very disabling, and surgery is needed to remove the swollen tendon tissue and repair the tendons.  The ruptured tendons can’t be sewn back together so tendon either has to be grafted or spliced in, or more commonly another tendon is borrowed to do the job of the tendon which ruptured.  This is called a tendon transfer.  This surgery works well to restore the function lost by a tendon rupture.  One other factor that leads to tendon ruptures are bone spurs caused by the arthritis.  If spurs are involved they have to be removed, and sometimes entire pieces of bone have to be removed.

The other tendon that is prone to rupture in Rheumatoid Arthritis is the tendon that bends the thumb down.  This tendon can be grafted or a tendon transferred just like on the back of the hand.

Rheumatoid arthritis can involve the wrist, and if the joint becomes very painful surgery can be used to help with pain relief.  Joint replacements are available for the wrist but they aren’t done very often due to high complication rates.  Modifications and improvements in the design of the joints are occurring, and one day wrist joint replacement may be done more often.  The most common surgery that is done for Rheumatoid Arthritis of the wrist is a fusion, or arthrodesis, where the joint surfaces are cleaned out and immobilized so that they fuse together.  This is a great way to relieve pain but results in a stiff wrist.

Hopefully this information can help you get started learning about Rheumatoid Arthritis.

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