Background Hand functional, aesthetic and symptomatic compromised are the most common manifestations of RA and may affect up to 70% of the patients with longstanding disease1. In such clinical context, surgery is indicated although perception of successful hand surgical procedures (HSP) between rheumatologists and hand surgeons has been a matter of debate2. Making decisions about HSP should be performed in a combined medical/surgical clinic.
Objectives To perform a retrospective chart review and to report HSP in RA patients at a tertiary care level center, with emphasis in identifying patient's AO and their potential predictors our population with distinctive characteristics.
Methods From 1989 to 2013, 96 RA patients with ≥1HSP were identified from 2 local registries and their clinical records independently reviewed by 2 trained physicians (surgeon and clinical), who used a standardized format for data abstraction. AO were previously defined after a literature review and by consensus; data abstracter agreement was found in 90% of the cases.
Student t test and X2 were used for normally distributed variables and Mann-Whitney U for non-normally distributed variables. Time to each AO was assessed using the Kaplan-Meier curves. Logistic regression's model were used to identify predictors of AO at first HSP.
Results At first HSP, 89.6% were female, had (mean ± SD) age of 49.1±12 years, disease duration of 12.2±7.2 years, 93.6% had RF and 24% were receiving intensive treatment (IT) as defined by ≥2DMARDs + oral corticosteroids.
One hundred and thirty HSP were performed; 71 patients (74%) had one intervention. All patients received a single dose of intravenous antibiotic as induction, had indicated standard post-operative rehabilitation and continued taking their RA-medication throughout the perioperative period. Most frequent interventions were arthrodesis (25.4%), resection of ulnar head (15.4%) and tenorraphy (14.6%). Years of disease duration-up to hand surgery were similar when compared according to specific HSP.
Among the 130 interventions, 33 AOs were described in 27 patients (28.1% of the RA patients with AOs), 87% of them after the first HSP. Most frequent subsets were impaired wound healing (18.2%) and exposed hardware (15.2%).
We tested different models to investigate predictors of first AO; longer disease duration at first HSP (OR: 3.07; 95% CI: 1.04-9.08, p=0.04) and IT (OR: 1.08, 95% CI: 1.002-1.156, p=0.045) predicted first AO. According to ROC curve, the best cut-off for disease duration to predict AO was 20.1 years.
Conclusions RA patients with longer disease duration and intensive treatment had a higher risk of adverse outcomes after HSP. Rheumatologists should refer patients for potential hand interventions early during their disease's course and select them when disease activity is under control with conservative treatment.
McKee A, Burge, P. The principles of surgery in the rheumatoid hand and wrist. Orthopaedics and Trauma 2010;24:171-180.
Alderman AK, Chung KC, Demonner S. The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns. Arthritis Rheum 2002;47:537-42.
Disclosure of Interest None declared