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Hand Surgery in rheumatoid arthritis: An Overview

Surgery to the hands can be performed on either the joints or the soft tissue, such as nerves and tendons.

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Rheumatoid arthritis is a disease with widespread effects. Whilst it is natural to think of surgery to joints as being the most significant surgical intervention, it is, in fact, soft tissue problems which cause the surgeon most concern – these include nerve compression syndrome due to inflammation and soft tissue swelling, tendon ruptures and skin problems such as rheumatoid nodules and ulceration. 

Joint replacement surgery in the hand is indicated when there is pain which does not respond to medical management, progression of deformity, and loss of function. Removal of the inflamed tissue within joints (synovectomy) is often very helpful in not only reducing tense joint swelling but also reducing inflammation and pain. Tendons can be repaired or switched, joints can be realigned, postural deformities corrected, and if necessary joint replacement surgery can be undertaken. In some cases, however, joints are so unstable or so significantly damaged or displaced that rather than a joint replacement, fusion (a procedure to stabilise and stiffen the joint in a functional position) can improve function dramatically.

Of course, many patients have as their chief concern the appearance of the hands. Doctors tend to think of pain relief and functional improvement as being the first treatment priorities, but nonetheless, rheumatoid hand surgery does also bring about an improvement in appearance (as the pictures with this article show).

Surgical procedures vary in duration and complexity. Many hand operations can be undertaken under local anaesthetic. For example, carpal tunnel decompression, which relieves pressure on a pinched nerve at the wrist, is routinely undertaken as an outpatient procedure under local anaesthetic, and will usually take less than 10 minutes. Multiple joint replacement procedures can be undertaken in the upper limb, and deformities in the feet can also be corrected. Specialised orthopaedic surgeons may be consulted if there are spinal or other large joint problems.

Increasingly, collaboration between rheumatologists and hand surgeons allows patients the opportunity for early surgical consultation and assessment. Even if surgery is not advised at this initial stage, possibilities for the future can be discussed.

It is not always possible to stop progression of the disease, but surgery is a useful part of a combined approach to control the disease and correct its effects, with a good success rate in controlling pain and correcting deformity. There is now encouraging evidence from large studies that even when rheumatoid hand deformities present late, with established deformities, surgical interventions such as joint replacement can still be beneficial.

These pictures show the results of metacarpophalangeal (MCP) joint replacement surgery in a patient with rheumatoid arthritis. The ‘after’ photo shows the great improvement in the alignment of the fingers post-operatively, but was taken before the stitches had been removed and before the incisions have healed. (Please note that different surgical approaches are in use, so other surgeons may align scars differently). Of course, physiotherapy, splintage and supervised mobilisation are also very important and contribute greatly to the success of a surgical procedure.

Hand surgery: Before operation	Hand surgery: Shortly after operation

Further reading:

British Society for Surgery of the Hand website

NRAS article on the role of the occupational therapist
_{References available on request}

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