Background By tight control of disease activity using biological agents, patients’ motivation to undergo orthopedic surgery is raised to achieve higher level of activities in daily living (ADL) and quality of life (QOL).

Objectives The objective of this study is to clarify the effectiveness of upper extremity surgery for the disabled patients with established rheumatoid arthritis (RA) under biologic treatment.

Methods Surgical reconstruction of the structurally damaged joint was performed on 53 joints in the upper extremity of 42 patients (male 6, female 36) with RA. Average age was 56 (26-79) years and average duration of the disease was 14 (2-30) years. Twelve joints (23%) in 11 patients were in low disease activity [disease activity score (DAS) 28 <3.2] and 6 joints (11%) in 6 patients were in remission (DAS28<2.6). Surgical procedures (with duplication) included 9 total elbow arthroplasties (TEAs), 4 elbow synovectomies with decapitation, 14 partial or total wrist arthrodeses, 7 wrist synovectomies with ulnar head resection, one Sauvé-Kapandji operation, 7 finger joint fusions, 9 finger joint replacements, 2 finger joint tenodeses or capsulodeses, and one thumb carpometacarpal joint arthroplasty. Infliximab was used in 15 patients, etanercept in 23, tocilizumab in 11, adalimumab in 3, and abatacept in one. Biologic treatment was withheld for 2-4 weeks before the surgery in accordance with Japan College of Rheumatology guideline. Average follow-up period after the surgery was 1.5 (0.3-5.8) years. Clinical assessment was performed just before the surgery and at the latest follow-up.

Results There was neither surgical site infection nor delayed wound healing. t the latest follow-up, significant improvement was noted in disabilities of the arm, shoulder and hand (DASH) score (51.8 to 45.4, p<0.01: average before surgery to average at the follow-up, p value), modified health assessment questionnaire (mHAQ) (0.92 to 0.81, p<0.05), grip power (mmHg) (115.7 to 128.2, p<0.05), DAS 28 (3.7 to 2.8, p<0.01), C-reactive protein (CRP) (0.53 to 0.12, p<0.01), and general health-visual analogue scale (GH-VAS) (30.8 to 27.8, p<0.05), respectively. Decrease in DASH score (45.6 to 38.1, p<0.05) and mHAQ (0.71 to 0.47, p<0.01) was prominent in the patients with elbow surgeries. Decrease in DAS28 was not significant in the patients with hand surgeries (3.5 to 2.9, p=0.07). During the follow-up period after the surgery, medication could be reduced or unchanged in 29 joints (55%), because of well controlled disease activity. Reduction of medication means decrease the dosage of biologic/non-biologic disease modifying anti-rheumatic drugs (DMARDs) and/or prednisolone (PSL). In this group, decrease in mHAQ (0.79 to 0.59, p<0.01) and DAS28 (3.5 to 2.5, p<0.01) was conspicuous compared to that in the group of increased or switched medication.

Conclusions To achieve true remission in the established RA with structural damage, combination of biologic treatment and orthopedic upper extremity surgery was performed. It was not only effective to restore physical function and health-related QOL, but also effective to attenuate systemic disease activity.

1. Hayashi M, Kojima T, Funahashi K, et al. Effect of total arthroplasty combined with anti-tumor necrosis factor agents in attenuating systemic disease activity in patients with rheumatoid arthritis. Mod Rheumatol. 2011 Oct 7. [Epub ahead of print]

Disclosure of Interest None Declared