(i) The principles of surgery in the rheumatoid hand and wrist

Adverse outcomes following hand surgery in patients with rheumatoid arthritis

Background

Up to 70% of patients with long-standing rheumatoid arthritis (RA) may present with rheumatic hand disease and benefit from hand surgical procedures (HSPs).

Objective

Through retrospective review, the present study aimed to report HSPs in RA patients at a tertiary care centre to identify patient adverse outcomes (AOs) and their predictors.

Methods

From 1989 to 2013, 96 patients who underwent ≥1 HSP(s) were identified from two local registries; their clinical records were independently reviewed by two trained physicians (surgeon and clinical) who used a standardized format. AOs were defined by consensus; data abstracter agreement was found in 90% of cases. Descriptive statistics were used in addition to Kaplan-Meier curves to determine the time to each AO, while logistic regression models were used to determine predictors of AOs.

Results

At first HSP, 89.6% of patients were female, had a mean (± SD) age of 49.1±12 years, a disease duration of 12.2±7.2 years, 93.6% were positive for rheumatoid factor and 24% were receiving intensive treatment. A total of 130 HSPs were performed: the most frequent interventions were arthrodesis (25.4%), resection of the ulnar head (15.4%) and tenorrhaphy (14.6%). During follow-up, 33 AOs were reported in 27 (28.1%) patients, 87% of which occurred after the first HSP. The most frequent AO subsets were impaired wound healing (18.2%) and exposed pin (15.2%). Longer disease duration at first HSP (OR 3.07 [95% CI 1.04 to 9.08]; P=0.04) and intensive treatment (OR 1.08 [95% CI 1.002 to 1.156]; P=0.045) were predictors of AOs. The optimal disease duration cut-off to predict AOs was 20.1 years.

Conclusion

Early referral of long-standing RA patients for hand surgery, along with less aggressive treatment, favoured improved surgical outcomes.