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 timely referral of patients with inflammatory arthritides who may be candidates for operative intervention. 

Collaboration between rheumatologists and orthopedic surgeons can improve outcomes for patients with rheumatic disease. Early referral can help prevent further joint destruction and medication must be managed according to date of surgery in order to avoid negative effects on postoperative wound healing.

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In general, at our institution, the rheumatologists are very attuned to the fact that patients with rheumatoid arthritis (RA) do require surgery in a timely fashion to get the optimal functional benefits of the surgery. So, they very readily refer patients to us to determine whether surgery is indicated, and sometimes too soon. But I think that is preferable to sending a patient after the joint is so thoroughly destroyed that the musculature, ligaments, and soft tissue around the joint are so deconditioned or so damaged that any reconstructive procedure we do results in a suboptimal result. 

Probably the best rule of thumb for most rheumatologists is if the patient has joint swelling after being treated actively for 3 to 6 months and the joint is still swollen and has not responded to the disease-modifying antirheumatic drugs (DMARDs) and/or local injections they should probably be referred to the orthopedic surgeon to determine if a synovectomy (removal of the lining of the joint) is possible.  We do that typically in joints where the cartilage is still good, the alignment of the joint is still good, and we consider the joint to be [salvageable].

We remove the inflamed lining that eats away at the cartilage. We would like to be able to do that before the cartilage has become extensively damaged.  After that, with about 6 months of active treatment, if the joint is still inflamed and the rheumatologist continues to try drug after drug, and the joint continues to remain swollen, that joint is getting progressively more and more damaged.  It may get to the point where the arthroscopies or open synovectomies that we do may not benefit the patient and we need to go to joint replacement surgery. 

Typically, we’d like to get the patients before they get to the “joint destruction” phase, with synovectomies being very beneficial in that regard and very often can give that joint another 5 to 10 years of survivability before a joint replacement would be needed.  In some cases, the patient may not need the joint reconstruction at all.

There are [several] “urgent” type cases that should be done quickly and that the rheumatologist should look at. One that needs to be treated relatively aggressively is when there is involvement of the cervical spine, which occurs in many patients with RA. There can be instability of the spine where the bone blocks start to move. It puts pressure on the spinal cord and, in some cases, can cause instant death:  the patient is in a car, the car stops short, and suddenly the head moves forward and back (a “whiplash” type injury) and even a mild one in those cases can result in cord damage, quadriplegia, paraplegia, or death, depending on where it occurs in the neck. So, if a patient has neck symptoms, he or she should undergo radiographic examination of the neck to include flexion/extension views, to evaluate for instability. If the patient is unstable, they should be referred to a surgeon to have that stabilized.

Another situation is that of persistent hand swelling over the dorsum of the hand or wrist.  Patients can have that fairly early in [the disease course of RA.  That inflammation eats away at the tendons that extend the fingers.  If that goes on for a prolonged period of time, it can result in rupture of those tendons and an inability to straighten out whichever finger that tendon goes to.  So, the best time to have that treated is before the rupture occurs.  In the past I used to have patients sent to me where the rheumatologist would say, “This is urgent.  The patient can’t extend his finger. He ruptured his tendon.”  It is really too late at that point and we are looking at doing tendon transfers, which functionally are not as good as using the patient’s own original tendon to run that finger.  So, if the patient has swelling on the top of the hand and you’ve tried medical treatment but after 6 months it is still there, then send him to the surgeon.  We perform a tenosynovectomy, during which we remove all that inflamed tissue before the tendons are ruptured and the hand will still function much better long term as a result of that.

In conclusion, the key thing in RA:  if you are the caregiver – whether a rheumatolgoist, general practitioner, or orthopedic surgeon, you really have to have a high level of suspicion for potential complications or the need for potential surgery to avoid such destruction in those joints that result in permanent disability, even if you do some time of reconstructive procedure.  

For the rheumatologist, that would involve checking out the cervical spine to make sure it isn’t unstable, making sure that the persistent swelling is gone after you have started treatment with medications, and also to be aggressive in the treatment with these medications to try to get the joint swelling down as quickly as possible and make sure that it stays down.  Very often, if you end up stopping the drug and then restarting it for some reason, the patient may not respond as well the second time around. Therefore, your best shot at it is at the beginning.  If the patient is not responding to fairly aggressive medical treatment, then it is time to move the patient over to see the orthopedic surgeon. 

There are some patients who may come in with a really bad knee and they have other joints that are involved that are not as badly diseased.  However, if that knee is already destroyed on x-ray and they aren’t taking DMARDs, then have them see the orthopedist, get the joint reconstructed quickly, and then you can start the DMARDs to prevent destruction of the other joints.  However, some patients simply don’t respond to the drugs and they eventually need to be referred over as the joint gets too damaged as a result of persistent swelling and inflammation.

On the orthopedic side, for the “super-subspecialists” who deal with only one joint or two, think about the other joints.  Examine them and make sure that they are adequate to support any potential rehab that you need to do, and think about the staging long term for the best functional outcome for them.

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