Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists

Outcomes of hand surgery in the patient with rheumatoid arthritis

PURPOSE OF REVIEW

Surgeons have long been striving to develop new surgical procedures to improve functional outcomes for a variety of hand and wrist deformities resulting from rheumatoid arthritis (RA). The purpose of this review is to assess the latest surgical outcomes related to hand and wrist surgery in the patient with RA.

RECENT FINDINGS

There is a lack of outcome studies in RA hand and wrist surgery to justify many of the surgical procedures proposed for the treatment of the rheumatoid hand. However, advances made by the silicone metacarpophalangeal arthroplasty (SMPA) group regarding hand reconstruction for RA patients have improved patient care for this widely used procedure. Prophylactic versus therapeutic procedures are also discussed.

SUMMARY

Rheumatoid hand is one of the earliest presentations of RA, and the progression of rheumatoid hand disease can be unpredictable. There are a number of surgical treatments for the rheumatoid hand and careful sequential planning of the surgical procedures can maintain patients' hand function and in many cases should enhance outcomes of the rheumatoid hand by correcting existing deformities. An early introduction to a hand surgeon can inform patients of available options and allow longitudinal assessment of structural and functional changes that could be treatable by future surgical interventions.

Reconstructing the rheumatoid wrist: a utility analysis comparing total wrist fusion and total wrist arthroplasty from the perspectives of rheumatologists and hand surgeons

Rheumatologists and hand surgeons have historically demonstrated strikingly divergent attitudes toward the benefits of surgical intervention, either total wrist fusion or total wrist arthroplasty, for the rheumatoid wrist. A utility analysis was conducted to compare a national random sample of hand surgeons and rheumatologists regarding their opinions about surgical management of severe rheumatoid wrist disease. A web-based trade-off utility survey was developed, and participants were presented with survey scenarios comparing well-controlled rheumatoid arthritis with operative and non-operative management. Utility values were calculated for each scenario, and a decision analytic model was constructed. Utility values for rheumatologists and hand surgeons did not differ significantly for any scenario. Total wrist arthroplasty was associated with the highest expected gain in quality-adjusted life-years for each subgroup. This decision analytic model demonstrates similar opinions between two subspecialties that have historically demonstrated divergent attitudes towards rheumatoid hand surgery.

Clinical research in hand surgery

Clinical research designed to enhance the quality of health care has always received a great deal of national attention. Outcomes studies, clinical trials, and evidence-based research are key components of clinical research that have advanced the field of hand surgery. The purpose of the Weiland Award is to encourage innovations and progress in clinical research in hand surgery for the betterment of patients and to promote hand surgery's visibility in American medicine. This article will highlight my efforts in clinical research through 3 specific research themes: (1) outcomes research, (2) economic analysis, and (3) evidence-based research and quality assessment in health care.

Correlation between range of motion and implant fracture: a 5 year follow-up of 72 joints in 18 patients in a randomized study comparing Swanson and Avanta/Sutter MCP silicone prosthesis

Eighteen out of 18 rheumatoid patients (at one centre of a two-centre 30 patient study previously reported) with a mean age of 56 years, and 72/72 operated joints were randomized to Avanta/Sutter or Swanson MCP prostheses and followed for 5 years. Both ulnar deviation and extension lag were improved already at 6 weeks and remained improved at 5 years. The Avanta prosthesis had a better range of motion (ROM) than the Swanson. Six of nine patients with Avanta/Sutter implants had at least one implant fracture compared to 1/9 patients with the Swanson implant (P = 0.05) but fracture did not change the outcome subjectively. The ROM at 3 months correlated with the occurrence of an implant fracture at 5 years and a greater early ROM may be related to implant fracture. At 5 years patients remained satisfied and the deformities remained corrected.

A prospective study comparing outcomes after reconstruction in rheumatoid arthritis patients with severe ulnar drift deformities

BACKGROUND

It has been stated by hand surgeons that rheumatoid arthritis patients often are referred "too little and too late." The purpose of this prospective study was to evaluate outcomes of rheumatoid arthritis patients with metacarpophalangeal joint deformities (subluxation and ulnar deviation). The authors hypothesized that patients with more severe deformities would have worse outcomes after silicone metacarpophalangeal joint arthroplasty.

METHODS

Seventy patients who each had combined metacarpophalangeal joint ulnar drift and extensor lag greater than 50 degrees were recruited into this three-center study of silicone metacarpophalangeal joint arthroplasty. Patients were categorized into two groups based on degrees of deformity: less than 100 degrees or greater than or equal to 100 degrees. Outcomes were assessed at 6 months and 1 year based on the Michigan Hand Outcomes Questionnaire, grip/pinch strength, metacarpophalangeal joint deviation angles, the Jebsen-Taylor test, and the Arthritis Impact Measurement Scales 2 questionnaire.

RESULTS

There was no difference in outcomes at the 1-year follow-up between the two groups, after controlling for age, gender, and baseline values. Each of the outcome scores was not different between the two groups, including the six domains in the Michigan Hand Outcomes Questionnaire, grip/pinch strength, the Jebsen-Taylor test, and the Arthritis Impact Measurement Scales 2 questionnaire. However, patients with more severe hand deformities have worse ulnar drift and extensor lag after reconstruction.

CONCLUSIONS

Rheumatoid arthritis patients with more severe metacarpophalangeal joint diseases will attain similarly good outcomes after reconstruction when compared with those with less severe deformities. Despite the potential barriers to silicone metacarpophalangeal joint arthroplasty in rheumatoid arthritis patients with more severe hand deformities, surgical treatment is still beneficial.

A multicenter clinical trial in rheumatoid arthritis comparing silicone metacarpophalangeal joint arthroplasty with medical treatment

PURPOSE

Metacarpophalangeal (MCP) joint deformities caused by rheumatoid arthritis can be treated using silicone metacarpophalangeal joint arthroplasty (SMPA). There is no consensus as to whether this surgical procedure is beneficial. The purpose of the study was to prospectively compare outcomes for a surgical and a nonsurgical cohort of rheumatoid arthritis patients.

METHODS

The prospective study was conducted from January 2004 to May 2008 at 3 referral centers in the United States and England. Over a 3-year period, 70 surgical and 93 nonsurgical patients were recruited. One year data are available for 45 cases and 72 controls. All patients had severe ulnar drift and/or extensor lag of the fingers at the MCP joints. The patients all had 1-year follow-up evaluations. Patients could elect to have SMPA and medical therapy or medical therapy alone. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales, grip and pinch strength, Jebson-Taylor test, and ulnar deviation and extensor lag measurements at the MCP joints.

RESULTS

There was no difference in the mean age for the surgical group (60) when compared to the nonsurgical group (62). There was also no significant difference in race, education, and income between the 2 groups. At 1-year follow-up, the mean overall MHQ score showed significant improvement in the surgical group but no change in the nonsurgical group, despite worse MHQ function at baseline in the surgical group. Ulnar deviation and extensor lag improved significantly in the surgical group, but the mean Arthritis Impact Measurement Scales scores and grip and pinch strength showed no significant improvement.

CONCLUSIONS

This prospective study demonstrated significant improvement for RA patients with poor baseline functioning treated with SMPA. The nonsurgical group had better MHQ scores at baseline, and their function did not deteriorate during the 1-year follow-up interval.

A survey of north american hand surgeons on their current attitudes toward hand transplantation

PURPOSE

Although composite tissue allotransplantation (CTA) is unparalleled in its potential to reconstruct "like with like," the risk-benefit ratio and clinical indications are difficult to determine. We examined current attitudes regarding the emerging field of CTA from those who treat complex hand injuries.

METHODS

A web-based survey regarding CTA was sent to members of the American Society for Surgery of the Hand, which identified their demographic data and practice profiles. Respondents' support for CTA and their assessment of the level of risk associated with these procedures were addressed. Additional questions focused on the clinical application of CTA with current immunosuppression, ethical issues surrounding CTA, and the indications for hand transplantation. Finally, 2 clinical situations that closely mirrored past hand transplantations were presented, and members evaluated their suitability for allotransplantation.

RESULTS

A total of 474 surgeons responded to the survey (22% response rate), who were divided in their opinion of hand transplantation with 24% in favor, 45% against, and 31% undecided. The majority (69%) consider this surgery to be a high-risk endeavor; however, a large percentage (71%) still believe it to be an ethical procedure when performed on properly selected patients. The most accepted indications for hand transplantation were loss of bilateral hands (78%) and amputation of a dominant hand (32%). Only 16% were in favor of performing transplants with the immunosuppression available today. In response to the clinical situation, 66% would offer transplantation to a bilateral hand amputee, whereas only 9% would offer transplantation to a patient with diabetes who had lost his or her dominant hand.

CONCLUSIONS

This survey demonstrates support for hand allotransplantation as a solution for dominant-hand and bilateral hand amputees. However, surgeons continue to be concerned about the adverse effects of immunosuppression and the risks of acute and chronic rejection, and many want to wait for the development of better immunologic treatment options.

Knowledge translation: putting the "practice" in evidence-based practice

Knowledge translation (KT) is an iterative process that involves knowledge development, synthesis, contextualization, and adaptation, with the expressed purpose of moving the best evidence into practice that results in better health processes and outcomes for patients. Optimization of the process requires engaged interaction between knowledge developers and knowledge users. Knowledge users include consumers, clinicians, and policy makers. KT is highly reliant on understanding when research evidence needs to be moved into practice. Social, personal, policy, and system factors contribute to how and when change in practice can be accomplished. Evidence-based practitioners need to understand a conceptual basis for KT and the evidence indicating which specific KT strategies might help them move best evidence into action in practice. Audit and feedback, knowledge brokering, clinical practice guidelines, professional standards, and "active-learning" continuing education are examples of KT strategies.

Measuring outcomes in hand surgery

Outcomes research in hand surgery provides patients and providers with objective, reliable information to assist in making medical decisions. Endpoint measures in outcomes research and the instruments used to evaluate these endpoints are often specific to a particular disease or region. Hand surgery has many different measurable outcomes that can be used to monitor the quality of surgical practice, inform practice guidelines, and aid in the appropriate allocation of healthcare resources. In this article, we review some research techniques available to study the following surgical outcomes of the hand: national trends in surgical care, surgical complications, objective measures of hand function, patient-reported measures of hand function, and economic burden.

Treatment of the wrist in rheumatoid arthritis

Wrist involvement is common in rheumatoid arthritis and affects up to 50% of patients within the first 2 years after the onset of the disease, including bilateral involvement. It is a progressive disease that destroys the articular cartilage and surrounding soft tissues, thus leading to severe deformities. Radiological changes are characteristic and include narrowing of the joint line, cysts, and periarticular osteoporosis. Clinical changes are characterized by different scoring systems, indicating different therapeutic options. Surgical orthopedic treatment options include joint-preserving techniques to prevent further damage (radiosynoviorthesis, synovectomy, or axial correction with tendon transfers in earlier stages) and joint replacing techniques to restore function (arthrodesis, resection arthroplasty or total joint arthroplasty in later stages). This article reviews pathologic changes in the rheumatoid hand and their surgical treatment alternatives.

A multidisciplinary hand clinic for patients with rheumatic diseases: a pilot study

To describe the characteristics, management strategies and outcomes of patients with rheumatic diseases and complex hand function problems referred to a multidisciplinary hand clinic. Assessments (baseline and after three months of follow-up) included sociodemographic and disease characteristics and various hand function measures. The most frequently mentioned impairments and limitations of the 69 patients enrolled in the study pertained to grip, pain, grip strength, and shaking hands. Fifty-six patients received treatment advice, conservative therapy (n=39), surgery (n=12), or a combination of both (n=5). In 38 of 56 patients (68%) the recommended treatment was performed, and 33 completed the follow-up assessment. On average, patients improved, with an increase in grip strength and the Michigan Hand Outcomes Questionnaire scores reached statistical significance. Two-thirds of patients with rheumatic conditions visiting a multidisciplinary hand clinic reportedly followed the treatment advice (recommendations), with an overall trend toward a beneficial effect on hand function. To further determine the added value of a structured, multidisciplinary approach a controlled comparison with other treatment strategies is needed.

Opinions on the treatment of people with tetraplegia: contrasting perceptions of physiatrists and hand surgeons

BACKGROUND/OBJECTIVE

Upper-extremity reconstruction for people with tetraplegia is underused, and we felt that physicians' beliefs could be contributing to this phenomenon. This research sought to determine whether (a) physicians underestimate the importance of upper-extremity function for people with tetraplegia, (b) physiatrists and hand surgeons disagree on the quality of life of those with tetraplegia, (c) surgeons believe that social issues make people with tetraplegia poor surgical candidates, and (d) the 2 specialties disagree on the benefits of upper-extremity reconstruction.

METHODS

A self-administered questionnaire was mailed to a national sample of 384 physiatrists and 379 hand surgeons. The data were analyzed with bivariate statistics.

RESULTS

The response rate was 62%. 65% of surgeons and 49% of physiatrists (P < 0.001) ranked upper-extremity function as the most important rehabilitative goal for people with tetraplegia. Both specialties believed the quality of life with tetraplegia was low (less than 60 on a scale of 0 to 100, with 100 representing perfect health). The 2 specialties have significantly different opinions regarding patient compliance, social support, and the effectiveness of surgery.

CONCLUSIONS

The majority of physicians believe that upper-extremity function is a rehabilitative priority for people with tetraplegia. However, physiatrists and hand surgeons have significantly different views about people with tetraplegia and the benefits of reconstructive surgery. Physician preconceptions and interdisciplinary divergence may be contributing to the underuse of these procedures, and these issues should be considered when designing programs to improve access to these procedures.

An analysis of women's and men's surgical priorities and willingness to have rheumatoid hand surgery

PURPOSE

Our prior national study showed gender differences in the rates of rheumatoid arthritis hand surgery. This project evaluated whether men's versus women's preferences, as opposed to physician biases, contribute to these variations.

METHODS

A self-administered questionnaire was administered to 126 patients with rheumatoid arthritis at our institution; 117 (93%) of these patients completed the questionnaire. Chi-square tests, t tests, the Wilcoxon rank sum test, and multiple logistic regressions were used for the analyses. The results were compared with our national mailed survey of 500 rhematologists and 500 hand surgeons in the United States that evaluated physicians' attitudes toward the indications and outcomes of rheumatoid hand surgery.

RESULTS

When we asked physicians who values hand aesthetics more, 378 (73%) chose women compared with less than 2 (1%) who chose men; when asked who values hand function more, 35 (7%) chose women, 83 (16%) chose men, and 396 (77%) thought there was no difference; and when asked who is more willing to have hand surgery, 219 (43%) chose women compared with 6% who chose men. In this patient survey, however, women and men were equally willing to have hand surgery, and they placed equal value in hand appearance, function, and pain. Women, however, appeared more risk adverse and concerned about the potential pain and inconvenience from surgery.

CONCLUSIONS

Physicians' biases appear to conflict with patient preferences regarding rheumatoid hand surgery. Physicians should understand patients' preferences during the shared decision-making process for surgery.

Rheumatoid arthritis: silicone metacarpophalangeal joint arthroplasty indications, technique, and outcomes

Silicone implant arthroplasty has been used for more than 40 years for severe rheumatoid disease at the metacarpophalangeal (MCP) joint. Multiple investigations have shown that silicone arthroplasty places the MCP joint in a more extended posture, with some improvement in the total arc of motion. Ulnar drift is also improved, but strength and other objective measures have not demonstrated marked changes postoperatively. The lack of prospective data and more complete outcome assessment has been, at least in part, responsible for the marked difference in opinions between rheumatologists and hand surgeons on the effectiveness of MCP arthroplasty. Recent reports using patient-centered outcome measures have shown that early outcome is favorable, with improvements in appearance, pain, and function.

Performance of the disabilities of the arm, shoulder and hand outcome questionnaire and the Moberg picking up test in patients with finger joint arthroplasty

OBJECTIVE

To compare the performance of the Disabilities of the Arm, Shoulder and Hand Outcome (DASH) Questionnaire and the Moberg Picking Up Test (MPUT) with other outcome measurement tools in assessing both hand function and aspects of general health in finger joint arthroplasty in patients with rheumatoid arthritis (RA).

DESIGN

Case series, with an average follow-up duration of 104.9 months.

SETTING

Orthopedic outpatient clinic at a university hospital.

PARTICIPANTS

Of 64 consecutive patients (21 dead, 6 lost to follow-up), 37 patients with 140 spacers in 107 metacarpophalangeal and 33 proximal interphalangeal joints of 51 hands were evaluated.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Hand function tests and general health measures.

RESULTS

The DASH correlated with both hand function (Health Assessment Questionnaire: r=.72, P<.01; MPUT: r=0.6, P<.01) and general health (Medical Outcomes Study 36-Item Short-Form Health Survey subscales: r range, -.73 to -.31; P range, <.001 to <.05). The MPUT was a suitable tool for precision grip testing.

CONCLUSIONS

The DASH has the advantage of being self-administered and assesses both functional and health aspects. It can be recommended as an instrument for a routine clinical follow-up for patients with hand surgery and RA. Additional tests should be applied when detailed information is needed.

Reasons why rheumatoid arthritis patients seek surgical treatment for hand deformities

PURPOSE

Previous studies have found that function and pain are the main factors that persuade physicians to recommend surgical reconstruction to patients with rheumatoid arthritis (RA). The factors that influence patients to choose surgical reconstruction, however, are not known fully. The purpose of this study was to determine how function, pain, and aesthetics rank in order of importance to RA patients who are considering metacarpophalangeal (MCP) joint arthroplasty for rheumatoid hand deformities.

METHODS

Study participants are part of a larger National Institutes of Health-sponsored study. Participants who are eligible to receive MCP joint arthroplasty are enrolled in our study using defined inclusion and exclusion criteria. All patients have RA and MCP joint extensor lag and/or ulnar deviation. Study participants choose whether they want to enroll in a surgical group to receive MCP joint arthroplasty or in a nonsurgical group. At enrollment all participants complete the Michigan Hand Outcomes Questionnaire. Function, pain, and aesthetic domains from the Michigan Hand Outcomes Questionnaire were used in a logistic regression model as predictors to determine the factors associated with patients choosing reconstruction for rheumatoid hand deformities.

RESULTS

Younger age and female gender were associated significantly with an increased likelihood for choosing MCP joint arthroplasty surgery. The age- and gender-adjusted odds ratios of choosing MCP joint arthroplasty were 0.50 for function, 1.47 for pain, and 0.83 for aesthetics. Patients with less function and greater pain were more likely to choose MCP joint arthroplasty. Aesthetic consideration was not a statistically significant predictor.

CONCLUSIONS

Impaired function had the strongest association with patients choosing reconstruction and pain relief was the next most important factor. Although aesthetic consideration was less important, it may prove to be an important factor in determining patient satisfaction after surgery. Understanding which factors are associated with choosing rheumatoid hand reconstruction is an essential component of patient preoperative counseling.

The rheumatoid wrist

Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.

Survey research: a primer for hand surgery

Survey research is an important and commonly used research tool. The findings of survey research help set national practice guidelines and guide health care policy decision making. The process of survey design and administration is rigorous, complex, and involved. The Journal of Hand Surgery contains on average 3 articles involving surveys per issue. This report serves as a reference for readers of the many survey articles published in this journal. It also provides a guide for hand surgeons or others interested in how to conduct survey research.

A qualitative assessment of rheumatoid hand surgery in various regions of the world

Differences in opinion between rheumatologists and hand surgeons result in disparate practice patterns among different states in the United States regarding the use of surgery for hand deformities in the rheumatoid population. The purpose of this project was to study the practices of rheumatoid hand surgery from countries in various regions of the world.

NeuFlex metacarpophalangeal prostheses tested in vitro

This paper describes the testing of three single-piece silicone NeuFlex metacarpophalangeal prostheses in a finger function simulator and describes the resulting modes of prosthesis failure. In all cases, failure was due to imminent fracture of the prosthesis across the pivot of the central hinge section. This result is in contrast with previous in-vitro and in-vivo experience with single-piece silicone Swanson and Sutter metacarpophalangeal prostheses, which both tend to fracture at the junction of the distal stem and the hinge. In comparison with earlier in-vitro simulator tests of the Sutter metacarpophalangeal prosthesis, the NeuFlex prostheses showed a greater longevity before fracture. To date, no other reports of fracture of the NeuFlex metacarpophalangeal prosthesis have been reported, either in vitro or in vivo.

Physician perceptions of upper extremity reconstruction for the person with tetraplegia

PURPOSE

Upper extremity reconstruction for people with tetraplegia can improve upper-limb function substantially and enhance independence; however, these surgical procedures rarely are performed. This study attempted to identify barriers preventing appropriate candidates from receiving these procedures.

METHODS

A questionnaire was mailed to a national sample of 379 hand surgeons and 384 physiatrists with an interest in spinal cord medicine. The statistical model assessed 2 main outcomes of the physician survey: (1) whether the provider had been involved in at least one of these procedures in the past year and (2) whether the provider desired to be more involved. We hypothesized that these outcomes were associated with provider attitudes and beliefs and failures of the health care system referral networks.

RESULTS

Most hand surgeons and physiatrists believed that these procedures were beneficial; however, few had either performed or referred even one case over the past year. Multivariable models suggested that a predominant factor in whether these procedures were being performed was the presence of a relationship between the surgeon and physiatrist.

CONCLUSIONS

A lack of coordinated cross-specialty relationships appears to present the largest barrier to the appropriate use of upper extremity reconstruction for people with tetraplegia.

A prospective outcomes study of Swanson metacarpophalangeal joint arthroplasty for the rheumatoid hand

PURPOSE

Destruction and dislocation of the metacarpophalangeal (MCP) joints are common occurrences in patients with rheumatoid arthritis (RA). Disruption of the support ligaments around the MCP joints and ulnar deviation of the fingers affect hand function and hamper the ability to perform activities of daily living. A common surgical intervention is the Swanson Metacarpophalangeal Joint Arthroplasty (SMPA), which restores alignment of the fingers.

METHODS

We conducted a prospective study with 16 patients to determine outcomes of this procedure. We present our data from the 6-month and 1-year follow-up periods.

RESULTS

Functional assessment by grip strength, pinch strength, and Jebsen-Taylor Test did not improve significantly when compared with preoperative values. Subjective assessment by the Michigan Hand Outcomes Questionnaire (MHQ), however, did improve significantly. Large improvements were seen in the function, activities of daily living, aesthetics, and patient satisfaction domains, with preoperative to 1-year postoperative score improvements of 26, 42, 57, and 43 points, respectively, based on a 100-point scale. Ulnar drift significantly decreased 1 year after surgery by an average of 24 degrees and MCP joint range of motion increased, but this change was not significant.

CONCLUSIONS

Our data show that patients with RA who underwent SMPA had significant improvements in patient-reported outcomes at the 1-year interval. Continued follow-up evaluation of this cohort will determine whether these improvements are maintained in the long term.