Background By a remarkable advance in the medical treatment of rheumatoid arthritis (RA), uncontrollable synovitis in the past has been well comtrolled. However, some patients still have a problem in their wrist due to structural damage and smoldering synovitis. Surgical reconstruction for the wrist is required, if the conservative treatment failed. Recently, patients desired to achieve functional remission aiming at the higher level of quality of life (QOL) and the mental wellness.
Objectives The objective of this study was to clarify the systemic effect of wrist surgery on the disabled patients with RA using the assessment of patient-reported outcome (PRO) and disease activity.
Methods Surgical reconstruction was scheduled on 74 wrists in 74 patients (male:10, female:64) with RA between October 2012 and September 2014. The average age was 62 (19–88) years old and the average duration of the disease was 14 (1–60) years. Correction of the thumb and the finger deformities were combined in 18 wrist surgeries. The procedure included Darrach procedure (ulnar head resection) in 55 wrists, radiolunate arthrodesis in 31, Sauvé-Kapandji operation in 11, extensor tendon reconstruction in 11 etc. Steinbrocker stage I, II, III, IV was 2, 22, 29, 21 patients, and Steinbrocker class I,II, III, IV was 7, 47, 20, 0 patient(s), respectively. MTX was used in 48 patients (65%) with the average dose of 8.7mg/w, and PSL was used in 45 patients (61%) with the average dose of 4.1mg/d. Biologics was used in 12 patients (16%) including ETN:2, TCZ:3, IFX:3, ADA:3 patients. PRO was assessed by Health Assessment Questionnaire-Disability Index (HAQ-DI), EuroQol-5 Dimensions (EQ-5D), Beck Depression Inventory-II (BDI-II), and patient's general health using visual analogue scale of 100mm (Pt-GH). Upper extremity function was assessed by Disabilities of the Arm, Shoulder and Hand (DASH). Disease activity was assessed by 28-joint Disease Activity Score using C reactive protein (DAS28-CRP). They were measured just before surgery (baseline), at 6 and 12 months after surgery.
Results As a whole, physical function (HAQ-DI, DASH), QOL (HAQ-DI, EQ-5D, Pt-GH) and mental wellness (BDI-II, Pt-GH), disease activity (DAS28-CRP) significantly improved at 6 and 12 months after surgery compared to those at baseline (p<0.01) (Table1,Figure1). The rate of clinical remission in DAS28-CRP (<2.3) at baseline, 6 and 12 months after surgery was 14%, 60% and 57%, respectively. The rate of functional remission in HAQ-DI (<0.5) was 28%, 35% and 41%, respectively. The rate of minimal depression in BDI-II (≤13) was 54%, 70% and 68%, respectively.
Conclusions Favorable effects of wrist surgery on QOL and mental wellness as well as physical function were confirmed in the disabled patients with RA. To improve QOL and mental wellness, surgical treatment for the damaged wrist should be considered in combination with tight medical control. It also had an ameliorating effect on disease activity.
Ishikawa H, Murasawa A, Nakazono K, et al. The patient-based outcome of upper-extremity surgeries using the DASH questionnaire and the effect of disease activity of the patients with rheumatoid arthritis. Clin Rheumatol 2008;27:967–973.
Disclosure of Interest None declared