Back to list of Clinical Conditions

Rheumatoid arthritis

The hands are very frequently affected in rheumatoid arthritis and related conditions, and are often involved early in the disease. The various forms of inflammatory arthritis are chronically destructive of joints and tendons within the hands and elsewhere, and are not curable but may be beneficially influenced by drug treatment and other forms of therapy.

During the active inflammatory phase, the thickened synovial membrane in joints and tendon sheaths causes damage to the structures that guide the mechanical function of these vital components, resulting in joint pain, instablility and ultimately collapse, and loss of precise control of tendon function, causing disorganized movement. The patterns of functional loss and deformity resulting from this process are tremendously variable, and assessment of the hand affected by arthritis requires painstaking evaluation of  function and analysis of how deformity has developed.

In the early phase of the condition, surgery may be of value when a local area of synovitis persists in spite of otherwise effective treatment. Local structural damage and be limited by removal of such persistent active synovium. Usually this requires a small open operation, for example in one or more joints of the finger, or of the flexor tendon sheaths in the finger, palm or carpal tunnel area (the heel of the hand). In the wrist joint, synovectomy is possible via arthroscopy, or keyhole surgery.

When joint destruction has progressed, reconstructive surgery may be possible, either aimed at reconstituting the mechanical stability of the joint, or of that is no longer possible, replacing it. Joint replacements have been most successful in treating the metacarpophalangeal (MP) joints at the bases of the fingers, and less effective in the smaller joints further down the finger, although they can be very helpful there too. As with all forms of joint replacement, mechanical failure is eventually likely, after an average period of 10-20 years. The type of joint most often used in rheumatoid arthritis is a silicone rubber spacer (Swanson prosthesis) with stems that fit inside the bone on either side of the joint.

An alternative procedure is joint fusion, resulting in no movement of that joint. This is most appropriate when treating joints in the thumb. Joint fusion is carried out using implanted wires or fine screws.

Tendons affected by arthritis may need freeing, protection from bone irregularities around the wrist, release from triggering or synovial thickening, or if they have already ruptured, reconstruction by tendon transfer or grafting.

The wrist may be badly destroyed by progressive arthritis. A common early occurrence is prominence, instability and pain in the head of the ulna, the prominent bone on the little finger side of the wrist. This bone may be one of the factors leading to extensor tendon rupture with dropped fingers, and should be treated early to prevent that. Disease around the lower end of ulna also causes pain and loss of rotational movement, and is effectively treated by removal of the prominent bone.This can cause instability, and to prevent that, replacement of the head of the ulna with a mechanical prosthesis is gaining in popularity (Avanta or Herbert ulnar head prostheses).

Damage to the wrist joint itself causes pain, deformity and loss of function. Rest and working splints can help with these problems, but progressive disease may lead to the need for surgical treatment. Sometime partial joint fusion is all that is needed, but more often the whole wrist needs to be stiffened by joint fusion, eliminating flexion and extension of the wrist, but preserving all-important rotation. Until now total wrist joint replacement has had limited application and success due to mechanical failure requiring further surgery, but technological developments may change this.

All patients undergoing surgery for rheumatoid arthritis need rehabilitation, and surgical management should always be undertaken in collaboration with the rheumatology team overseeing general management.

Top of page