Although RA is generally an inflammatory process of the synovium,structural or mechanical derangement is a frequent cause
of pain or loss of joint function. Pain and joint mobility may be improved by a surgical approach. The primary physician,the
rheumatoligist,and the orthopedist all help the patient to understand the risks and benefits of the surgical procedure.
The decision to have surgery is a complex one that must take into consideration the motivation and goals of the patient
their ability to undergo rehabilitation,and their general medical status.
Synovectomy is ordinary not recommended for patients with RA primarily because relief is only transient. However an exception
is synovectomy of the wrist,which is recommended if intense synovitis is persistent despite medical treatment over 6 to 12
months.
Persistent synovitis involving the dorsal compartments of the wrist can lead to extensor tendon rupture resulting in
severe diability of hand function. Total wrist joint replacement has a way to go.
In the past,surgical synovectomy (the cutting out of inflamed joint linings) was often carried out in joints such as
the knee. This is not done much nowadays because 1) the tissue often grows right back,2) rehabilitation is slow and
difficult. 3) infection is a real worry and often the same result can be achieved with the injection of a radioactive form
of yttrium,which burns and scars the inflamed lining.
Total joint arthroplasties,particularily of the knee,hip,wrist,and elbow,are highly successful. Arthroplastry of the
MCP joints,can also reduce pain and improve function. Other operations include release of nerve entrapment (e.g., carpal tunnel
syndrome),arthroscopic procedures,and occasionally of a symptomatic rheumatoid nodule.
Arthroscopy is a common therapy. With the aid of a arthroscope (miniture T.V. camera that transmits the image of a joint
to a monitor) plus two small surgical incision,surgeons can remove (scrape) some damaged cartilage. It can be used for
diagnosis and treatment of some types of joint injury.
Arthrograpy is an x-ray procedure that provides a detailed image of the joint when air or a contrast substance is injected
into the joint space.
Osteotomy uses a more conventional surgical procedure in which the whole joint area is exposed. In such cases the surgeon
will remove damaged bone, and may remodel existing bone structure.
Delay in joint replacement surgery:-Traditionally,surgeons have performed total knee replacements only after all other
options-including medications,exercise and therapy have been exhausted.
The reason for the delay is understandable; joint replacement like all major surgery carries the risk of complications
says rheumatoligist P.Fortin, MD, McGill University Health Centre Montreal , furthermore "if the procedure
is done early,the prosthesis may fail and so a second surgery will be required" but surgeons with good intentions may sometimes
wait too long to replace a damaged joint.
Dr.Fortin with American and Canadian colleagues studied 222 patients slated for total knee or hip replacement and surgery
at either Bingham and Women's hospital in Boston or Montreal,Canada. The patient's answered questionnaires to assess their
pain level and disability before surgery and then six months after surgery.
Patients who had the least disability before surgery,the high function group, mproved the same amount as their disabled
counterparts means that the low function group never caught up,said Dr Fortin.
In fact six months after their surgery,patients in this group were just as disabled as members of the high function group
had been before their surgery. One reason is that prolonged joint pain lead to muscle weakness that is hard to reverse after
surgery,says Dr. Fortin."
Recent surgery has advanced to the point where there was a operation on the hip for inserting a artificial "ball-joint"
in the hip,and a recent report was that the patient left the hospital on the same day. The manufacturing aspects
of "ball-joints" is also improving with respect to durability (encouragement for younger patients).
MIRs and CAT scans are often performed for detailed analysis. The limitation may be cost,and availability of facilities.
MRI is a diagnostic technique that provides high-quality cross-sectional images of a structure of the body without x-rays
or other radiation.
Computed Tomography (CT or CAT)--is a diagnostic technique that uses a computer and an x-ray machine to take a series
of images that can be transformed into a clear and detailed image of a joint.
Joint replacement,pioneered in Britain in the late '60s,has revolutionized orthpedics,bone and joint surgery. It's undoubtedly
the greates single contribution to the welfare of arthritis patients that has been made over the last 3 decades. The first
problem to be solved was osteoarthritis of the hip.
Prior to the 1960s,artificial joints had been developed,there was no way of keeping the parts from slipping A new "glue"
solved the problem. Methyl methacrylate, a bone cement,proved to be quick-setting,solid attachment for the metal parts,and
the rush in joint replacement began.
Since then,the original techniquess have been modified many times over, because even with the discovery of bone cement
there were still problems. The bond between bone and glue and metal occationally failed.
The metal components themselves,fractured. If either happened,the pain returns,and eventually that joint had to be replaced.
Second surgeries have shown that they are not as good as the first one,in most cases.
New and stronger metal alloys have been developed. Special surface coating have been bonded to metal to miinimize body
tissue reaction to these foreign substances Components have been fbricated of new,porous materials designed to encourage new
bone to grow into the implanted parts,avoiding the use of glue,and hopefully,providing an even stronger bond.
Total Hip replacement: This surgery was the first,and still is the best. Patients begin to put weight on the joint almost
immediately after surgery,and the long-term results have proved excellent. At least 90 % of THRs are functioning well after
15 years. With today's model 30 years of use in not an unreasonable expectation,unless the patient is grossly overweight or
unusually physical active.
Total knee replacement: This surgery is almost as good in terms of long-term outcome,although some patients who had a
second operation,if necessary,have said the second operatin is not as frequently or as completely successful as second THR
surgery
The only other major joints replaced are shoulders and elbows. I understand that these operations have not been quite
as successful as the others. Shoulder replacement is usually very successful for pain relief. As long as the ligaments and
tendons around the shoulder (the rotator cuff) have not been severely damaged by the disease process,functional recovery is
also said to be quite good. Unfortunately,in RA the rotator cuff is frequently damaged and so pain relief,but usually not
completely restored function,is the major goal of surgery.
Elbow replacement: This is done less frequently,and still has a long way to go. Movements of the elbow is complex. Unlike
the hip and shoulder,the elbow is not protected by a thick covering of muscle. The older "hinge" type of elbow replacement
was not so successful--patients with disabling pain is only considered. It didn't move like a real elbow,especially in twisting
movements.
The most common type of surgery in RA is carpel tunnel release It is generally uncomplicated and very successful.
Repair of ruptured tendons (almost always the ones that straighten out the fingers ) is worthwhile and usually success
ful. It should be done as soon as possible after the rupture occurs.
Finger-joint surgery can improve the look of the hand,but ususally doesn't improve finger flexibility.
But recently three-piece elbow joint,looking very much like the three bones that come together at the elbow,have
been introduced. Some patients have been delighted with the results-not just with the absence of pain,but with the improvement
in function I sincerely hope they continue to be just as happy as time and use rest the limits of the hardware--Hey,tomorrow
they may discover another major change!!
The decision to have surgery is a major one. It is not a decision to be made quickly or without good reasons.
Before you decide to have surgery, be sure to learn what operation is being suggested, what are the alternatives, what
are the risks and what is involved in the recovery process. Don't be shy about asking lots of questions of your surgeon, including
information on his or her success record with the particular procedure.
As you consider whether or not to have surgery, keep in mind that every person's needs are different. Your doctor may
inform you that surgery won't give you the results you want. If your doctor thinks that surgery can help you, there are still
many things you need to know.
Preparing mentally and physically for surgery is an important step toward a successful result. People who understand
and are knowledgeable about the process have swifter recoveries and fewer problems.
Sometimes it may be hard to remember what you want to ask the doctor unless you write down your questions. Here are some
questions you may want to ask.
About the surgery
What other kinds of treatment may I have other than surgery?
How successful will these treatments be?
Can you explain the operation?
Do you have written materials or videotapes on this surgery that I can review?
How long will the surgery take?
Can surgery be performed as an outpatient?
What risks are involved in the surgery? How likely are they?
Are blood transfusions necessary, and if so, can I donate my own blood?
What type of anesthesia will I have? What are the risks?
How much improvement can I expect from the surgery?
Will more surgery be necessary?
If surgery is chosen, will you contact my family doctor? Will he or she be involved in my hospital stay? In what
way?
Are you Board Certified, and do you have a special interest in arthritis surgery?
What is your experience doing this type of surgery?
Would you give me the name of another person who has undergone this surgery who would talk to me about it?
Is an exercise program recommended before and after the operation?
Must I stop any of my medications before surgery?
What happens if I delay surgery?
What are the risks if I don't have the surgery?
After the surgery
How long will I stay in the hospital?
How much pain will there be?
Will I receive medication for it? What kind of pain is normal to expect? How long will this pain last?
How long do I have to stay in bed?
When do I start physical therapy? Will I need home or outpatient therapy?
May I review written materials or videotapes concerning this phase
of my care?
Are physical therapy, occupational therapy, and home health care covered by insurance? (You may need to address this
question to your insurance company.)
Will I need to arrange for special help at home? If so, for how long? Is it covered by my insurance?
What medications will I need at home, and how long will I need to take them?
What limits will there be on my activities-driving, using the toilet, climbing stairs, bending, eating, sex?
How often will I have follow-up visits with you?
Are they covered by insurance? Are they included in the cost of the surgery?
If you have serious problems with your lungs or heart disease, the strain of some types of surgery may be too much
for you. Before any kind of surgery, it's important to have other health problems under control.
Nutrition and diet is an important factor in general health and becomes especially important in times of stress, such
as around the time of surgery. It is best to eat foods that are rich in nutrients prior to surgery and during the entire first
year after surgery. Vitamin C is especially important because it enhances the healing process.
Do not take aspirin like medications or aspirin for three days before surgery. These medications interfere with
blood clotting. If you take cortisone, prednisone, or any steroid medication, you must tell your surgeon before the operation.
These medications should not be stopped before or after surgery
.
Occasionally people develop blood clots in their legs or arms after surgery. The risk of this may be decreased by using
blood-thinning drugs. Discuss this and other potential problems with your surgeon.
Being overweight may put extra stress on the heart and lungs. Also, if the surgery is on a weight-bearing joint (like
a hip or knee), recovery of the joint may be slower. Excess weight puts added strain on the joint and makes it harder to do
the exercises needed to make the joint stronger after surgery.
Before you decide on surgery, you must be aware that you have to follow a strict treatment plan after the operation.
It's important to realize that the operation is only the first step toward restoring joint function.
The amount of work you put into the recovery process often makes the difference between success and failure.
Your doctor's orders regarding medication, joint protection, rest, exercise, physical therapy, and the possible use of
splints must be followed very carefully. If you don't believe you can follow through on all your prescribed care, then surgery
may not be the best treatment for you.
After the surgery:
Depending on the type of surgery, your doctor will usually prescribe a period of rest, physical therapy, and limited
activity. Before you decide on surgery, make sure your household can be arranged so that your full recovery is possible.
You may need days or weeks of rest. In addition, you may need to use splints, a cane, a walker, a wheelchair, or crutches
before you are able to perform your usual tasks. Talk with your doctor about any short-term limitations and what you can expect
during the recovery period.
You may also be referred to an occupational therapist for advice on how to do your daily activities in ways that are
safe for your joints.
If your surgery involved your hand(s) or arm(s), you will most likely be able to get up the first day after the operation.
If it involved one or both legs, how soon you are allowed out of bed will depend on the surgery.
Often, you will be able to get up the first day after surgery, but it may be longer. Once your doctor has given permission
for you to get up, you will begin to feel better the more you move around.
Physical therapy:
As soon as you're able and depending on the type of surgery you've had, you will begin physical therapy consisting of
various exercises. You must dedicate yourself to this program and be prepared to work hard. If you don't, your repaired joint
may be less useful than it could be.
Some pain is common during the early stages of physical therapy. This pain usually comes from the muscles, not the joint.
Some of your muscles have not been used much or may have been working in abnormal ways to protect a sore joint.
Some muscles may have been cut and stitched during surgery. It is important to realize that muscles strengthen in response
to exercise. An exercise that hurts today may hurt a little less tomorrow. You will see improvements in range of motion, along
with decreased pain, as time goes on.
You will have to work hard for the first few weeks after surgery to achieve range of motion, and a little less so for
several months after that to regain strength. As time goes on, keeping up with your physical therapy requires dedication.
You may find that you're bored with the exercises, and you may be tempted to slack off. Don't! Remember that it takes
time, but the rewards can be great. You should start to see some encouraging results, such as the ability to perform a task
that was too painful to do before surgery.
The combined efforts of your doctors, nurses, therapists--and most important--yourself are essential to success.
Costs will vary depending on the surgeon, anesthesiologist, admitting physician, hospital, type of surgery performed,
medication, physical therapy requirements, types of implants used, and any other special tests or treatments.
Check with your doctor, insurance company, and if you qualify. Do this before the surgery so you won't have any unpleasant
surprises. A hospital stay is expensive.
If you've already spent time in the hospital during the year, you should check your insurance policy for benefits coverage
during the remainder of the year. You will probably want to check on the managed care requirements of your policy, which may
include second surgical opinions and assigned length-of-stay designations.
Joint surgery is not for everybody. Even if your doctor and surgeon determine your condition would be improved by surgery,
the decision to have the operation is up to you.
You need to weigh your options and understand what the surgery will involve--before, during, and after surgery, and over
the months of physical therapy. It will require patience and the willingness to follow through with physical therapy. Your
commitment is the key ingredient in the success of joint surgery.
If you're not sure about having surgery, ask for a second opinion from another doctor. Ask your doctor to suggest a surgeon
with arthritis experience. Sign a release form and ask that your medical records and X-rays be sent to the consulting physician.
Consider the advice of all your doctors carefully. Doctors, nurses, physical and occupational therapists,
and social workers are part of the team that will work to make the surgery a success.
Your family and friends are also members of the team. Look to them for emotional support and for assistance during your
recovery. But the most important team member is you.
