The Rheumatoid Patient


Rheumatoid patients are unique. Their form of arthritis (inflammatory arthritis) is very debilitating and they often have high pain thresholds as they have had to deal with significant joint inflammation and degeneration for long periods of time. The inflammatory arthritis affects not only their joints, but their tissues, immune and other organ systems. This requires attentive medical and surgical care of their condition.

Thankfully the number of patients that are referred to orthopaedic surgeons for rheumatoid related conditions is decreasing due to the advances in medical management and specifically the ‘biologicals’ the GP or rheumatologist prescribes.

Rheumatoid arthritis very commonly affects the upper limb, involving the hands, wrists, elbows and shoulders. It may progress to affecting their ability to perform simple daily tasks such as opening a jar, or keep them awake at night due to pain. In the hands and wrists, it typically creates progressive deformities at each joint level. It is crucial to understand how deformity at one level influences the next, as digital balance in the hand is the most complex musculoskeletal equilibrium in the body.


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  • Management
Management

Non-operative

Non-operative management of the rheumatoid patient involves pain management strategies, custom splints, braces or slings, accommodative or assistive devices to aid with daily activities, and crucially recognizing when there is a need for intervention.

Operative

Operative management is directed at the afflicted joint/s. In the hands and wrists, it might be removing the inflamed synovium, debriding the joint osteophytes and re-routing the tendons to prevent their irritation or rupture. Ruptured tendons require reconstruction. End stage disease of the joint almost invariably requires a replacement, that removes the pain and maintains motion.

In the elbow and shoulder end stage rheumatoid disease is equally debilitating, but the results of joint replacement are remarkable in these patients. Complete alleviation of pain and return of functional range of motion in both is the norm.

Postoperative recovery is sometimes a deterrent to the patient due to the perceived long rehabilitation process in elbow or shoulder replacement surgery. However, advancement in our understanding of the mechanics and fixation methods used in elbow replacement for example, result in at least half of patients able to kiss their thumb one week after the operation and say that their pain is significantly improved.

This procedure is also long lasting, with 8 in 10 patients still having their original prosthesis 10 years after the surgery.

Shoulder replacements in patients with end stage arthritic disease has been revolutionized in the last 30 years with the advent of the reverse total shoulder arthroplasty. This allows patients with completely deficient rotator cuffs to have shoulder replacement surgery and achieve good outcomes. 

Conditions Managed



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