rheumatoid arthritis & surgical management

rheumatoid arthritis & surgical management

1. SURGICAL MANAGEMENT IN RHEUMATOID ARTHRITIS (RA) MODERATOR’S : PROF. DR. ARUN HS ASSOCIATE PROF. DR. HARI PRASAD S

2. Lesson plan

3. INTRODUCTION Advancement in the medical managemen t of Rheumatoid Arthritis (RA), has markedly decreased the incidence of surgeries in patients with RA . However, the prime indications for surgery in patients with Rheumatoid Arthritis, are those who seek for functional gain, pain relief and aesthetic improvement Ref: Chung KC, Kotsis SV, Kim HM, et al. Reasons why rheumatoid arthritis patients seek surgical treatment for hand deformities. J Hand Surg Am 2006;31: 289 e 94

4. LARSEN SCORE 0 Normal joint, no changes 1 Osteoporosis and swelling 2 Joint space narrowing and erosion 3 Significant erosion, moderate destruction 4 Loss of joint space, severe destruction 5 Ankylosis

5. Osteoporosis and swelling Joint space narrowing and erosion

6. Significant erosion, moderate destruction Loss of joint space, severe destruction

7. Ankylosis

8. JOINT PRESERVATION SURGERIES

9. SYNOVITIS: Inflammation of the synovium leading to joint destruction

10. Knee effusion

11. SYNOVECTOMY Surgical removal of synovium that lines a joint The aim of synovectomy to stop or decrease joint damage Is indicated if pain, swelling and radiological changes do not resolve despite of sufficient therapy within 3–6 months Ref:Trieb K, Hofstaetter SG. Treatment strategies in surgery for rheumatoid arthritis. Eur J Radiol . 2009 Aug;71(2):204-10. doi : 10.1016/j.ejrad.2009.04.050.

12. ARTHROSCOPIC SYNOVECTOMY

13. INTRA OP IMAGES OF THE HYPERTROPHIED SYNOVIUM “ANGRY SYNOVIUM”

14. ADVANTAGES OF ARTHROSCOPIC SYNOVECTOMY 1. Incision is minimal 2. Quadriceps muscle remains intact 3. Incidence of infection is less 4. Incidence of hemarthrosis is less 5. Postoperative physio therapy is minimal

15. OPEN ANTERIOR SYNOVECTOMY Hyperemic and hypertrophic synovium can be appreciated “Angry synovium ”

16. Ref:Trieb K, Hofstaetter SG. Treatment strategies in surgery for rheumatoid arthritis. Eur J Radiol . 2009 Aug;71(2):204-10. doi : 10.1016/j.ejrad.2009.04.050. WHAT HAPPENS AFTER SYNOVECTOMY ?

17. WHERE SYNOVECTOMY PREFERRED? Shoulder Elbow Wrist Knee

18. RADIOSYNOVIORTHESIS (RSO) It is a minimally invasive therapeutic method of treatment By injecting radioisotopes in to the joint it destroys the hypertrophied synovial tissue in situ

19. Such therapy is today considered an appropriate for Larsen classification is stage 1 without joint destruction Yttrium- 90 is used for knee Rhenium - 186 used for elbow, wrist, ankle Erbium- 169 used for fingers Ref:Trieb K, Hofstaetter SG. Treatment strategies in surgery for rheumatoid arthritis. Eur J Radiol . 2009 Aug;71(2):204-10. doi : 10.1016/j.ejrad.2009.04.050.

20. A SEVERELY DEFORMED RHEUMATOID HAND Ulnar deviation of the digits Extensor tenosynovitis over the MCP joints Boutonniere deformity of the thumb

21. TENO-SYNOVECTOMY Inflammation of the synovial lining of extensor tendons over the dorsal hand and wrist Results in synovial tissues invade the tendons, cause them to rupture Recommended when synovitis persists for 3 to 6 months despite aggressive medical management Ref: Kozlow JH, Chung KC. Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists. Hand Clin. 2011 Feb;27(1):31-41. doi : 10.1016/j.hcl.2010.09.003.

22. INTRA-OP IMAGES OF EXTENSOR TENOSYNOVECTOMY Extensor tenosynovitis with rice bodies Excision of extensor tenosinovium Ref: Kozlow JH, Chung KC. Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists. Hand Clin. 2011 Feb;27(1):31-41. doi : 10.1016/j.hcl.2010.09.003.

23. EXTENSOR TENSON RUPTURE TENDON TRANSFER

24. OSTEOTOMY Proximal tibial osteotomy is useful for correcting varus or valgus deformities of an arthritic knee It realigns the weight-bearing axis the less involved compartment

25. But, contraindicated in rheumatoid arthritis because the disease evenly distributed In addition, the osteoporotic bone in RA makes the procedure more demanding

26. JOINT REPLACING SURGERIES

27. RESECTION- ARTHROPLASTY Indicated in patients who has high risk for hip replacement due to underlying comorbidities

28. THE SHOULDER ARTHRITIS IS ADDRESSED WITH REVERSE SHOULDER ARTHROPLASTY

29. TOTAL ELBOW ARTHROPLASTY Considered for Larsen Score 4 - 5

30. TOTAL WRIST ARTHROPLASTY

31. ULNAR DEVIATION OF THE DIGITS

32. ` SWANSON SPACERS- FINGER JOINTS

33. METACARPOPHALANGEAL JOINT REPLACEMENT

34. BOUTONNIERE DEFORMITIY 

35. TREATMENT Splinting Primary tendon repair +splinting Lateral band relocation Arthrodesis

36. TOTAL HIP REPLACEMENT

37. UNI-COMPARTMENTAL KNEE ARTHROPLASTY

38. UNICOMPARTMENTAL KNEE ARTHROPLASTY

39. INTRA–OP IMAGES OF TOTAL KNEE ARTHROPLASTY

40. Rheumatoid arthritis of bilateral knee with valgus deformity with TKR both the joint pathology and valgus mal-alignment is addressed at the same time

41. ARTHRODESIS Primary arthrodesis for treatment of the rheumatic joint will result in a fixed joint without inflammation and pain In the last two decades the frequency is decreasing because of the good experiences with arthroplasties However few joints are better do well with arthrodesis Eg : wrist arthrodesis

42. WRIST ARTHRITIS WITH ULNA SUBLUXATION

43. a. A global forefoot deformity secondary to Rheumatoid arthritis b. Deformity correction with forefoot arthrodesis Ref: Roukis T.S., Davidson D. (2019) Fifth Toe Proximal Interphalangeal Joint Arthrodesis. In: Cook E., Cook J. (eds) Hammertoes. Springer, Cham. https:// doi.org /10.1007/978-3-319-16552-3_21

44. PATIENT WITH C1- C2 INSTABILITY C1-C2 trans-articular screws with Magerl technique

45. SUMMARY Rheumatoid disease is an autoimmune progressive inflammatory disease Advancement in the medical management the joint destruction and disability's have been reduced grossly But there are patients who do not respond well with medical management ending up in joint destruction with disability So, for a pain free joint and deformity correction, surgery and joint replacement are the only aid at the END!

46. Thank You Towards A Disability Free Society