By Robert J. Snyder, MD
The patient who is diagnosed in 2015 with an auto-immune form of arthritis, such as Rheumatoid (RA) or Psoriatic Arthritis (PA), will most likely be treated by a team of physicians and ancillary providers. Overseen by a Rheumatologist, this multi-disciplinary team may include Orthopaedists, Physical and Occupational Therapists, Social Workers and Rehabilitation Specialists. Thankfully, these patients can be treated with an array of disease-modifying anti-rheumatic drugs (DMARD) with which their joint damage can be arrested or slowed. Today’s patient may be able to delay or avoid joint replacement because of the efficacy of the new treatments available and a better understanding of the inflammatory joint disease process.
Despite all of the good news, I still see patients regularly who need joint replacement surgery due to the destruction caused by long-term erosion of the articular cartilage. Although hips and knees are the most commonly-replaced joints, patients who have rheumatic variants of arthritis can need arthroplasty of the elbows, wrists, fingers, toes, ankles, and shoulders to relieve the pain, dysfunction and deformity caused by their disease. The cervical spine may also be impacted and require surgical intervention to alleviate symptoms.
Treating RA or PA patients differs from treating patients who present with Osteoarthritis or OA. RA/PA patients have an aggressive, chronic inflammatory disease which destroys the affected joints. If their disease has progressed to the point where they require a new joint then total joint replacement is usually the only option to address the damaged joint. Partial joint replacement is not an option because of the pathology of the disease; the synovium of the entire joint is affected. In OA patients, I often am able to address limited joint destruction in the knee by performing a partial joint replacement.
Viscosupplementation is useful and approved for RA/PA patients who have involvement of the knee. Some physicians will use these hyaluronic acid injections in off-label ways and inject into joints which have not been cleared by the FDA, but I do not see evidence supporting efficacy in any joint except the knee. At best, viscosupplementation buys us time before joint replacement and allows the patient to process the reality of needing the surgery to achieve real pain relief and restoration of function.
RA/PA patients also present with significant tendon issues that also may need to be addressed. Joint damage can cause these tendons to loosen or rupture and surgical repair may be the only option to relieve pain and dysfunction. This repair is usually performed concurrently with the arthroplasty particularly around the hand and wrist. In some cases joint fusion combined with arthroplasty, is the preferred option to restore stability and alignment.
Robert J. Snyder, MD is a Board certified Orthopaedic Specialist with Orthopaedic & Spine Center in Newport News, VA. Voted a “Top Doc” in both 2012 and 2013, Dr. Snyder specializes in Partial and Total Joint Replacement of the knee, Direct Anterior Hip Replacement, Sports Medicine and conditions pertaining to the Foot and Ankle. www.osc-ortho.com
