Michael M. Alexiades, MD, associate attending orthopedic surgeon at Hospital for Special Surgery and associate professor of clinical orthopedic surgery at Weill Cornell Medical College in New York City, met with Rheumatology Advisor to discuss the surgical management of inflammatory arthritides.
This is part 4 of a video series on this topic. To view the first video dealing with timely referral of patients to orthopedic surgeons, please click here. To view the second video covering the surgical staging of multijoint inflammatory arthritides, click here. To view the third video covering disease-modifying antirheumatic drug management in the perioperative period, click here.
Please scroll down to view the text transcript beneath the video
Another topic to consider is the role of allied health professionals in the treatment of patients with rheumatoid arthritis (RA), [including] physical therapists, rehabilitation specialists, pain management (although we do not want to mask certain types of pain that may indicate things that need to be treated), and case managers/social workers to make sure that patients get adequate care in a timely fashion and that they get the services that they need so that they can be more functionally independent. Whether they are living alone or with family, we certainly want these patients to stay as active as possible.
I can say that we are especially proud of [the rehabilitation department at Hospital for Special Surgery], which is attuned to not only lower extremity reconstructions but also upper extremity and occupational therapy, where the use of the hands for daily activities such as feeding oneself, hygiene, etc. are very important. Our therapists can be very good at making patients who otherwise would be considered candidates for surgery very, very functional with the deformities they may have, particularly in the hands, that may obviate the need for surgery at any significant time point. It is important to get the entire team of specialists involved.
I believe that one of the best indicators of how well patients with RA do long term really is their education level. The more educated patients usually get to these services and treatments much earlier, so their long-term outcomes are better. The less educated patients are the challenging ones, where you need to get out into the community and [reach] these patients who… [often times] come in once the joints are completely destroyed and the reconstructive options are extensive. Then the results functionally are certainly not going to be as good.
So, getting back to the long-term functional improvement of patients, I think that the key thing is early treatment medically for patients that is aggressive in terms of disease-modifying antirheuamtic drugs (DMARDs), very often going with methotrexate or one of the other tumor necrosis factor (TNF)-inhibitors or new DMARDs, and doing it early so that patients get their inflammatory changes decreased or eliminated completely before the joint destruction occurs.
Unfortunately, some patients – particularly patients again who come from poor communities, or who might be less educated or come from foreign countries and then moved to the United States but don’t really access the care in a timely fashion – they start to show up when they can’t walk anymore or they can’t pick up a glass to drink water. Those are the patients who if you identified them sooner when the tendons in their hands, their ligaments, and their muscles are still working well, even if the joint gets destroyed to the point where you have to do a reconstruction, you do the procedure (whether it is a wrist, shoulder, elbow, hip, or knee replacement), they will do much, much better functionally.
If you look at scoring of the results of surgery in patients with osteoarthritis compared to those with RA, if you get to those patients with RA early, their pain relief and their functional return get very close to those of a patient with osteoarthritis who has otherwise normal joints. However, if you get to that patient with RA late, you can still do the joint reconstruction and their pain relief will be as good as for the patient with osteoarthritis, but their functional outcome won’t be as good.
For example, for someone who has a shoulder replacement, their pain may get better, but they will be unable to raise their arm because the rotator cuff muscles were completely destroyed from the disease. However, if their rotator cuff muscles are intact when you do their shoulder replacement, suddenly they are raising their arms following surgery and are very close to normal. Certainly, the long-term function and also long-term survival of the implant will improve dramatically.