Rheumatoid arthritis is an inflammatory process that affects the synovium, and its symptoms generally respond to the various anti-inflammatory medications that constitute the armamentarium of the rheumatologist. Sometimes, however, RA-induced changes to the structural or mechanical alignment of a joint may cause pain, disfigurement, or loss of joint function. In these cases, the pain, function, and appearance of the joint may be improved by surgery. Several types of surgery are available to patients with severe joint damage, including total or partial joint replacement, tendon reconstruction, and synovectomy.
Joint Replacement
Total joint replacement, also known as joint arthroplasty, involves replacing the damaged natural joint with an artificial joint. Joint replacements are the most commonly performed surgery for RA and are highly successful in relieving pain, improving joint appearance, and preserving joint function. They are most commonly applied to the knee (total knee replacement), hip (total hip replacement), shoulder, and knuckles of the hands. The new joint, called a prosthesis, is made of metal alloys, plastics, and sometimes ceramic. Such joints are highly durable and sometimes last more than 20 years. Unfortunately, artificial joints can wear out with excessive use, so they may not be the best option for younger people.
Arthroplasty
Implantation of a mechanical joint to replace a diseased or damaged joint; also called total joint replacement surgery.
Total knee replacement
A surgical procedure in which damaged parts of the knee joint are replaced with artificial parts, which are usually made of plastic and steel.
Total hip replacement
A type of surgery in which the diseased ball and socket of the hip joint are completely removed and replaced with artificial materials. Also called a hip arthroplasty.
Complications can occasionally arise following joint replacement surgery if the artificial joint does not attach well, the bones are damaged, or the joint becomes infected or loosened through wear or inflammation. Nevertheless, most artificial joints work well, and many people experience significant pain relief from them.
Tendon Reconstruction
Tendons are strong, fibrous tissues that attach muscles to bones. The inflammatory process of RA can damage and even rupture tendons, particularly the extensor tendons of the hand or wrist. If that happens, the affected finger cannot be fully extended unless surgical repair of the tendon is undertaken. Tendon reconstruction repairs the damaged tendon by attaching an intact tendon to it. This procedure can restore joint function, particularly if it is done early, before the tendon becomes completely ruptured.
Synovectomy
Synovectomy is a procedure to remove the joint lining (synovium) that has been damaged by RA. In two medical studies that followed the long-term results of synovectomy in patients with RA, researchers found that most patients continued to experience improved joint function for as long as eight or nine years. Unfortunately, some patients' joints continued to deteriorate after surgery owing to the regrowth of the synovium.
Synovectomy
Removal of the synovial membrane of a joint.
The timing of synovectomy is important, because this surgery is more effective in improving function if it is performed before significant bone and cartilage destruction occurs. Function is also improved when synovectomy is done in combination with tendon reconstruction.
Other Surgical Procedures
Other operations performed in patients with RA include removal of tissue that presses on nerves, such as the nerve entrapments that occur with carpal tunnel syndrome; arthroscopic procedures to the knee and hip; and skin surgery to remove a symptomatic rheumatoid nodule.
Issues to Consider Before Surgery
Surgery is not appropriate for all people who have RA. As with any treatment, there are risks to consider. Your primary care physician, rheumatologist, and orthopedist should help you to understand the risks and benefits of having the surgical procedure as well as the risks and benefits of not having surgery. Be sure to discuss the following issues with your physician before you make your decision:
Surgery is not appropriate for all people who have RA.
- The need for joint replacement
- The likely outcome of the surgery
- The cost of the surgery
- Insurance reimbursement
- Your motivation and goals
- Your ability to undergo rehabilitation (this is sometimes more difficult than the surgery itself)
- Lost work and lost wages associated with rehabilitation
- Your general medical status
- Surgical- and anesthesia-related risks
- The functional life of the joint prosthesis and the possible need for its replacement (Replacement of the replacement is sometimes called a “revision” procedure.)
After a thorough discussion of these issues, you and your doctor can decide whether surgery is right for you.