Background The hand is the most frequently involved site in rheumatoid arthritis (RA). The treatment aim of RA is achieving and maintaining remission (REM) or low disease activity (LDA) via tight medical control. However, despite remarkable advances in medication, progressive deterioration and/or deformity of the hand, if adequate medication is not administered in the early stage. Surgical reconstruction is still required in hands with functional loss and/or a grotesque appearance caused by joint deterioration or tendon rupture. Recently, patients have expressed a desire to achieve functional REM with a higher quality of life (QOL) and improved mental wellness.
Objectives The objective of this study was to clarify the systemic effects of surgical intervention in the impaired hand, even in patients with well-controlled disease who have achieved REM or LDA.
Methods A prospective cohort study was performed in 119 hands of 119 patients with functional loss and/or a grotesque appearance due to RA who underwent primary elective surgery between October 2012 and September 2014. A total of 42 hands in 42 patients (males: 2, females: 40) had a disease activity of REM or LDA just before surgery. In the REM/LDA group, the average (range) age was 61 (29–82) years, and the average (range) disease duration was 15 (2–35) years. The procedures performed included Darrach procedure (ulnar head resection) in 17 hands, radiolunate arthrodesis in 10, extensor tendon reconstruction in 6, thumb/finger metacarpophalangeal joint arthroplasty (Swanson) in 14, proximal interphalangeal (interphalangeal) joint fusion in 4, and thumb CM joint arthroplasty (Thompson) in 4 and so on. The patient-reported outcome (PRO) was assessed using the Health Assessment Questionnaire-Disability Index (HAQ-DI), EuroQol-5 Dimensions (EQ-5D), Beck Depression Inventory-II (BDI-II), Patient's General Health using visual analogue scale of 100 mm (Pt-GH), and the Disabilities of the Arm, Shoulder and Hand (DASH). The 28-joint Disease Activity Score using C reactive protein (DAS28-CRP) and Grip power (GP) were also examined. All of these items were investigated just before surgery (baseline) and again at 6 and 12 months after surgery.
Results On the whole, the physical function (HAQ-DI, DASH, GP), QOL (HAQ-DI, EQ-5D, Pt-GH), mental wellness (BDI-II, Pt-GH), and disease activity (DAS28-CRP) were significantly improved at 6 and 12 months after surgery compared to baseline (p<0.05)1). In the REM/LDA group, a significant improvement was noted in the upper-extremity function (DASH), QOL (EQ-5D), and disease activity (DAS28-CRP) at 6 and 12 months after surgery; however, we did not observe any significant changes in any other items (Table1).
Conclusions Achieving REM or LDA is not the ultimate goal of treatment for patients with functional loss and/or a grotesque appearance of their hands. Further “wellness” can be achieved by surgical intervention in the affected hand, even for patients with well-controlled RA. Such intervention can also ameliorate the 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