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

Development of a Machine Learning Model to Predict the Use of Surgery in Patients With Rheumatoid Arthritis

OBJECTIVE

One in five patients with rheumatoid arthritis (RA) rely on surgery to restore joint function. However, variable response to disease-modifying antirheumatic drugs (DMARDs) complicates surgical planning, and it is difficult to predict which patients may ultimately require surgery. We used machine learning to develop predictive models for the likelihood of undergoing an operation related to RA and which type of operation patients who require surgery undergo.

METHODS

We used electronic health record data to train two extreme gradient boosting machine learning models. The first model predicted patients' probabilities of undergoing surgery ≥5 years after their initial clinic visit. The second model predicted whether patients who underwent surgery would undergo a major joint replacement versus a less intensive procedure. Predictors included demographics, comorbidities, and medication data. The primary outcome was model discrimination, measured by area under the receiver operating characteristic curve (AUC).

RESULTS

We identified 5,481 patients, of whom 278 (5.1%) underwent surgery. There was no significant difference in the frequency of DMARD or steroid prescriptions between patients who did and did not have surgery, though nonsteroidal anti-inflammatory drug prescriptions were more common among patients who did have surgery (P = 0.03). The model predicting use of surgery had an AUC of 0.90 ± 0.02. The model predicting type of surgery had an AUC of 0.58 ± 0.10.

CONCLUSIONS

Predictive models using clinical data have the potential to facilitate identification of patients who may undergo rheumatoid-related surgery, but not what type of procedure they will need. Integrating similar models into practice has the potential to improve surgical planning.

Substantial Variation in Decision Making to Perform Subacromial Decompression Surgery for Subacromial Pain Syndrome Between Orthopaedic Shoulder Surgeons for Identical Clinical Scenarios: A Case-Vignette Study

Purpose

To provide further insight into the variation in decision making to perform subacromial decompression (SAD) surgery in patients with subacromial pain syndrome (SAPS) and its influencing factors.

Methods

Between November 2021 and February 2022, we invited 202 Dutch Shoulder and Elbow Society members to participate in a cross-sectional Web-based survey including 4 clinical scenarios of SAPS patients. Scenarios varied in patient characteristics, clinical presentation, and other contextual factors. For each scenario, respondents were asked (1) to indicate whether they would perform SAD surgery, (2) to indicate the probability of benefit of SAD surgery (i.e., pain reduction), (3) to indicate the probability of harm (i.e., complications), and (4) to rank the 5 most important factors influencing their treatment decision.

Results

A total of 78 respondents (39%) participated. The percentage of respondents who would perform SAD surgery ranged from 4% to 25% among scenarios. The median probability of perceived benefit ranged between 70% and 79% across scenarios for respondents indicating to perform surgery compared with 15% to 29% for those indicating not to perform surgery. The difference in the median probability of perceived harm ranged from 3% to 9% for those indicating to perform surgery compared with 8% to 13% for those indicating not to perform surgery. Surgeons who would perform surgery mainly reported patient-related factors (e.g., complaint duration and response to physical therapy) as the most important factors to perform SAD surgery, whereas surgeons who would not perform surgery mainly reported guideline-related factors.

Conclusions

Overall, Dutch orthopaedic shoulder surgeons are reluctant to perform SAD surgery in SAPS patients. There is substantial variation among orthopaedic surgeons regarding decisions to perform SAD surgery for SAPS even when evaluating identical scenarios, where particularly the perceived benefit of surgery differed between those who would perform surgery and those who would not. Surgeons who would not perform SAD surgery mainly referred to guideline-related factors as influential factors for their decision, whereas those who would perform SAD surgery considered patient-related factors more important.

Clinical Relevance

There is substantial variation in decision making to perform SAD surgery for SAPS between individual orthopaedic surgeons for identical case scenarios.

Barriers to Upper Extremity Reconstruction for Patients With Cerebral Palsy

BACKGROUND

Reconstructive surgery for upper extremity manifestations of cerebral palsy (CP) has been demonstrated to be safe and effective, yet many potential candidates are never evaluated for surgery. The purpose of this study was to determine barriers to upper extremity reconstruction for patients with CP in a cohort of upper extremity surgeons and nonsurgeons.

METHODS

We sent a questionnaire to 4167 surgeons and nonsurgeon physicians, aggregated responses, and analyzed for differences in perceptions regarding surgical efficacy, patient candidacy for surgery, compliance with rehabilitation, remuneration, complexity of care, and physician comfort providing care.

RESULTS

Surgeons and nonsurgeons did not agree on the literature support of surgical efficacy (73% vs 35% agree or strongly agree, respectively). Both surgeons and nonsurgeons felt that many potential candidates exist, yet there was variability in their confidence in identifying them. Most surgeons (59%) and nonsurgeons (61%) felt comfortable performing surgery and directing the associated rehabilitation, respectively. Neither group reported that patient compliance, access to rehabilitation services, and available financial resources were a major barrier, but surgeons were more likely than nonsurgeons to feel that remuneration for services was inadequate (37% vs 13%). Both groups agreed that surgical treatments are complex and should be performed in the setting of a multidisciplinary team.

CONCLUSIONS

Surgeons and nonsurgeons differ in their views regarding upper extremity reconstructive surgery for CP. Barriers to reconstruction may be addressed by performing higher level research, implementing multispecialty educational outreach, developing objective referral criteria, increasing surgical remuneration, improving access to trained upper extremity surgeons, and implementing multidisciplinary CP clinics.

Collaboration in Hand Surgery: Experiences From Silicone Arthroplasty in Rheumatoid Arthritis, Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness, Wrist and Radius Injury Surgical Trial, and Surgery of the Ulnar Nerve

Outcomes research has historically been driven by single-center investigations. However, multicenter studies represent an opportunity to overcome challenges associated with single-center studies, including generalizability and adequate power. In hand surgery, most clinical trials are single-center studies, with few having randomized controls and blinding of both participants and assessors. This pervasive issue jeopardizes the integrity of evidence-based practice in the field. Because healthcare payers emphasize applying the best available evidence to justify medical services, multicenter research collaborations are increasingly recognized as an avenue for efficiently generating high-quality evidence. Although no study design is perfect, the potential advantages of multicenter trials include generalizability of the results, larger sample sizes, and a collaboration of experienced investigators poised to optimize protocol development and study conduct. As the era of single-center studies shifts toward investment in multicenter trials and clinical registries, investigators will inevitably be faced with the challenges of conducting or contributing to multicenter research collaborations. We present our experiences in conducting multicenter investigations to provide insight into this demanding and rewarding frontier of research.

Patient characteristics affecting knowledge of the possibility of surgical reconstruction for rheumatoid hand and wrist deformities

OBJECTIVES

We aimed to investigate patient characteristics affecting their knowledge of surgical reconstruction for rheumatoid hand and wrist deformities, and to investigate such characteristics affecting their hope of receiving hand surgery if patients with rheumatoid arthritis (RA) knew surgical reconstruction options.

METHODS

We carried out a questionnaire survey for all patients with RA who came to our outpatient department of rheumatology. Multivariate logistic regression analysis was performed to examine significant characteristics associated with the knowledge of surgical reconstruction and patients' hope of receiving hand surgery.

RESULTS

In total, 687 patients were evaluated in this study and 337 (49%) reported knowledge about surgical reconstruction. A multivariate logistic regression analysis showed that patients with good control of disease activity and with long-lasting hand and wrist deformities were significantly associated with having knowledge of surgical reconstruction. Among the 337 patients with knowledge, only 122 (36%) expressed a hope of receiving hand surgery. The statistical analysis showed that younger age and surgical history were significantly associated with the hope of receiving surgery.

CONCLUSION

Surgeons and rheumatologists should enlighten patients about the importance of hand surgery to achieve functional remission in this new era of treatment for patients with RA.

Rheumatoid Hand and Wrist Surgery: Soft Tissue Principles and Management of Digital Pathology

Since the advent of disease-modifying antirheumatic drugs for rheumatoid arthritis, orthopedic surgeons see fewer patients in the office who require hand surgery. However, a significant number of patients still seek surgical intervention to improve pain and function. These patients often present with isolated soft tissue pathologies, but even bone and joint pathology require meticulous soft tissue handling in this cohort. This review highlights the principles and techniques relevant to the management of soft tissue deformity in rheumatoid hand and wrist surgery, as exposure in training and practice continues to decrease.

MR and ultrasound of the hands and wrists in rheumatoid arthritis. Part II. Added clinical value

Advanced imaging has become just as vital for diagnosing, staging, and monitoring disease in rheumatoid arthritis (RA) patients as it is for cancer patients. Part 1 of this review discussed synovitis, tenosynovitis, erosions, and osteitis-key imaging findings that occur in patients with RA. Part 2 will now show how these features, in combination with clinical and serologic data, can assist clinical decision-making at various stages of a patient's disease course. Specifically, assessing current disease activity and prognosticating future aggressiveness inform treatment decisions at initial presentation, during medical treatment, and at clinical remission. In addition to summarizing the current literature on advanced imaging in RA, clinical examples from different stages throughout the disease course will illustrate practical approaches for applying these research results. Last, this review will describe potential future roles of imaging in RA patients.

LIFE QUALITY EVALUATION USING "TIME TRADE OFF" METHOD FOR RHEUMATOID HANDS

Objective:

Rheumatoid arthritis is a prevalent disease in the population (range 0.5% to 1%) and involves both orthopedic and rheumatologic treatment. The Time Trade-Off (TTO) technique, which determines the number of years the patient or the professional would be allowed before a successful procedure in terms of life expectancy and value of the procedure, has been gaining ground in clinical protocols. From this standpoint, we sought to compare evaluations provided by the patients, orthopedists, and rheumatologists in determining the TTO and to correlate their responses with the clinical repercussions using previously established scores such as the Brief Michigan Hand Questionnaire and the Disease Activity Score-28 (DAS-28).

Methods:

A prospective study was conducted that involved 37 patients with rheumatoid arthritis, orthopedists, and rheumatologists. The TTO questionnaire was administered by an independent evaluator for evaluation using the DAS-28 and the Brief Michigan Hand Questionnaire.

Results:

The descriptive analysis revealed similar medians between the orthopedists, rheumatologists, and patients for single assessments. However, there was a weak correlation between the results from the patient and rheumatologist, the patient and Brief Michigan Questionnaire, and those of the orthopedic surgeon and the DAS-28.

Conclusion:

Similar median values demonstrated equivalent TTO among the orthopedist, rheumatologist, and patient. However, given the weak correlations between the scores, it was not possible to substitute results using a single evaluation scale. Level of Evidence II, Prognostic Studies.

Functional and Radiographic Outcomes of the Sauvé-Kapandji and Darrach Procedures in Rheumatoid Arthritis

Background Deterioration of the distal radioulnar joint (DRUJ) in rheumatoid arthritis (RA) manifests as pain, weakness, and reduced range of motion. The Darrach and Sauvé-Kapandji (S-K) procedures are used when medical management fails to control these symptoms. However, there is a paucity of literature comparing the outcomes of these procedures. The purpose of this study is to compare the clinical and radiographic outcomes of the Darrach and S-K procedures in RA patients. Materials and Methods This is a retrospective, single institution cohort study of RA patients who underwent the Darrach or S-K procedure between 2008 and 2016. Ulnar translation, range of motion, and functional improvement were compared. Results Nine patients (13 wrists) underwent the Darrach procedure, and nine patients (11 wrists) underwent the S-K procedure. The average length of follow-up was 1.3 years. Pain, function, and range of motion improved in both groups. The degree of ulnar translation did not significantly change after either procedure. Conclusion Given their similar outcomes, we found no evidence that the S-K procedure is superior to the Darrach procedure or vice versa. However, when surgery is indicated for younger RA patients with DRUJ disease and ulnar translation, the S-K may be better suited to prevent radiocarpal joint dislocation.

Seven-Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study

OBJECTIVE

Rheumatoid arthritis (RA) causes destruction of the metacarpophalangeal (MCP) joints, leading to hand deformities, pain, and loss of function. This study prospectively assessed long-term functional and health-related quality-of-life outcomes in RA patients with severe deformity at the MCP joints.

METHODS

RA patients between ages 18 to 80 years with severe deformity at the MCP joints were referred to 1 of the 3 study sites. Subjects who elected to undergo silicone metacarpophalangeal joint arthroplasty (SMPA) while continuing with medical management were followed in the SMPA cohort. Subjects who elected to continue with medical management alone without surgery were followed in the non-SMPA cohort. Objective measurements included grip and pinch strength as well as arc of motion, ulnar drift, and extensor lag of the MCP joints. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Radiographs of SMPA implants were assessed and graded as intact, deformed, or fractured.

RESULTS

MHQ scores showed large improvements post-SMPA, and baseline-adjusted expected outcomes in the SMPA group were significantly better at year 7 in function, aesthetics, satisfaction, and overall score compared to non-SMPA. SMPA subjects did not improve in grip or pinch strength, but achieved significant improvement and maintained the improvement long term in ulnar drift and extensor lag.

CONCLUSION

Benefits of the SMPA procedure are maintained over 7 years with low rates of implant fracture or deformity. Non-SMPA patients remained stable in their hand function over the 7-year study duration.

Survey of hand surgeons' and therapists' perceptions of the benefit of common surgical procedures of the hand

OBJECTIVE

The objectives of this survey were (1) to study if surgeons' perceptions of the benefit of six surgical procedures differ if they consider themselves as patients instead of treating a patient, (2) to evaluate the role of five predetermined factors that may influence decision-making, and (3) to assess how uniformly hand surgeons and hand therapists perceive the benefits of the surgical treatments.

METHODS

The members of the national societies for Hand Surgery and Hand Therapy were asked to participate in the survey. Six patient cases with hand complaint (carpal tunnel syndrome, flexor tendon injury, dorsal wrist ganglion, thumb amputation, boxer's fracture, and mallet fracture) and a proposed operative procedure were presented, and the respondents rated the procedures in terms of the expected benefit. Half of the surgeons were advised to consider themselves as patients when filling out the survey.

RESULTS

A survey was completed by 56 surgeons (61%) and 59 therapists (20%). Surgeons who considered themselves as patients had less confident perception on the benefit of carpal tunnel release compared with surgeons, who considered treating patients. Hand surgeons and hand therapists had similar perception of the benefits of surgery. The expected functional result was regarded as the most important factor in directing the decision about the treatment.

CONCLUSIONS

Surgeons tended to be more unanimous in their opinions in cases, where there is limited evidence on treatment effect. The agreement between surgeons and therapists implies that the clinical perspectives are similar, and probably reflect the reality well.

Identifying barriers to the care of the rheumatoid hand in China: comparing attitudes of rheumatologists and hand surgeons

AIM

In China, hand surgeons treat fewer rheumatoid arthritis (RA) patients compared to other countries. We investigated whether physician and surgeon knowledge, attitudes and practices regarding RA hand deformities reflect current evidence and may contribute to the low utilization of surgery.

METHOD

We surveyed hand surgeons and rheumatologists at three tertiary hospitals in Beijing, China. Questionnaires were developed from literature and expert review to assess their knowledge, attitudes and practice patterns related to rheumatoid hand surgery.

RESULTS

Thirty-five hand surgeons and 59 rheumatologists completed the survey. Roughly one-third felt that the rheumatologists and hand surgeons agree on how to manage RA hand deformities. One-fifth of rheumatologists and 29% of hand surgeons believed that drug therapy can correct hand deformities, which contradicts current evidence. Likewise, 30% and 14%, respectively, recommended surgery for early-stage hand sequelae that do not meet current indications for surgery. Over 80% of surgeons and rheumatologists had no exposure to the other specialty during training and felt their training on the treatment of rheumatoid hand deformities was inadequate.

CONCLUSION

Although we found similar interspeciality disagreement in China as is seen in the United States, there appears to be less interaction through training and consultations. Our results also indicate potential deficits in training and unawareness of evidence and indications for rheumatoid hand surgery. These findings help to explain why surgery for rheumatoid hand deformities is rare in China; doctors have fewer opportunities to collaborate across specialties and may not be able to select appropriate candidates for surgery.

Barriers to Reconstructive Hand Surgery for Rheumatoid Arthritis in China: A Multicenter Survey of Patients and Physicians

BACKGROUND

China has a similar rheumatoid arthritis (RA) disease burden compared with other countries, yet RA patients rarely receive surgical treatment for hand deformities that limit function and impact appearance. We investigated potential barriers to rheumatoid hand surgery in China.

METHODS

Patients with RA, rheumatologists, and hand surgeons at 3 large tertiary hospitals in Beijing completed questionnaires that assess knowledge and attitudes surrounding RA hand surgery. We calculated descriptive statistics and compared responses among groups using chi-square and Fisher exact tests as appropriate.

RESULTS

One hundred RA patients with hand deformities and 94 physicians completed the surveys. No patients had received hand surgery, and just 13% were aware of this treatment option. Patients and physicians most frequently cited uncertain effectiveness of surgery, high cost, and risk of surgical complications as potential barriers to hand reconstruction. Rheumatologists reported low rates of referral to hand surgeons (39% referred <5% of the time and 31% never referred). Most hand surgeons (69%) had not performed metacarpophalangeal arthroplasty, a common procedure for RA hand deformities, within the past year. Some had never performed this operation.

CONCLUSIONS

This survey revealed multiple barriers that support previous observations of infrequent reconstruction of RA hand deformities in China. These obstacles can be addressed through patient education, coordination between specialists, and more robust hand surgeon training in common RA procedures through the application of international plastic surgery collaborations.

Digital Sympathectomy in Patients With Scleroderma: An Overview of the Practice and Referral Patterns and Perceptions of Rheumatologists

PURPOSE

Periarterial sympathectomy is a treatment option for patients with systemic sclerosis (SSc) suffering from digital vasculopathy. Despite potential benefits of ulcer healing, pain improvement, and amputation prevention, this operation appears to be infrequently performed. The aims of our study are as follows: (1) to assess national digital sympathectomy rates in patients with SSc and (2) to improve our understanding of referring physicians' perceptions of operative management and access to hand surgeons. Our hypothesis is that rheumatologists' practices largely influence their referral patterns for digital sympathectomy.

METHODS

To determine the rates and demographics of hospitalized patients with SSc who had undergone digital sympathectomy, we queried the Nationwide Inpatient Sample from 2006 to 2010. Additionally, we mailed a self-administered survey to a national sample of 500 board-certified rheumatologists to elicit their practice patterns and perceptions of digital sympathectomy. Using logistic regression, we analyzed potential predictor variables associated with rheumatologists performing the following: (1) routinely counseling patients about digital sympathectomy and (2) expressing the desire to refer these patients for operative evaluation.

RESULTS

Of 348,539 hospitalizations associated with a diagnosis of SSc, only 0.2% were for digital sympathectomy. Our questionnaire revealed that only 50% of rheumatologists routinely counseled, whereas 67% expressed the desire to refer. Factors associated with increased rheumatologists' interest in surgical management for patients with SSc included positive perception of the operation's efficacy, comfort with postoperative management, and interdisciplinary relationship with a hand surgeon.

DISCUSSION

Critical components to increasing appropriate utilization of digital sympathectomy include enhancing rheumatologists' understanding of the operation, comfort with postoperative management, and promoting strong, interdisciplinary relationships with hand surgeons. Increasing education and awareness, as well as establishing a solid referral network of hand surgeons may thereby improve patient access to digital sympathectomy.

Avanta Versus Swanson Silicone Implants in the MCP Joint—A Prospective, Randomized Comparison of 30 Patients Followed for 2 Years

The results of Swanson and Avanta metacarpophalangeal joint arthroplasties in rheumatoid patients were compared in a prospective, randomized study of 30 patients (120 implants). At 2-year follow-up, grip strength was measured, hand function was assessed with the Sollerman test and the subjective outcome was determined with visual analogue scores. With both implants ulnar deviation and flexion deformities decreased, and there was no difference between the groups. The increase in range of motion was 7° greater with Avanta implants than with Swanson implants. Grip strength and hand function were unaltered but the visual analogue scales showed decreased pain levels and subjective improvements in hand function, grip strength and cosmesis. Twenty-four of 30 patients were satisfied. Fracture of the silicone spacer occurred with 12 Avanta (20%) and eight Swanson implants (13%), with a higher fracture frequency in men.

Manual Ability Measure (MAM-16): A Preliminary Report on a New Patient-Centred and Task-Oriented Outcome Measure of Hand Function

The purpose of this study was to develop an easy-to-use and psychometrically sound outcome instrument that is task-oriented and patient-centred. One hundred fifteen patients with a variety of hand impairments completed a rating scale of perceived manual ability (i.e., the Manual Ability Measure). The first 70 patients also completed two other questionnaires about physical health and psychological well-being. Rasch Analyses were conducted to transform the ordinal ratings into linear measures; Rasch statistics were used to evaluate its measurement properties at both scale and item levels. Eighty-three original items were reduced to 16 common tasks; Rasch reliabilities were good; the easy-to-difficult item hierarchy makes sense clinically. Moderate correlations were found between manual ability, physical function and general sense of well-being. The results of this preliminary study suggest that the MAM is a promising outcome measure that has adequate psychometric properties and can be used to complement other objective clinical measurements.

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.

A 5-Year Cost-Effectiveness Analysis of Silicone Metacarpophalangeal Arthroplasty in Patients with Rheumatoid Arthritis

BACKGROUND

There is a paucity of research evaluating the cost-effectiveness of surgical interventions for rheumatoid arthritis patients. Previous reports have challenged the sustainability of improved outcomes after silicone metacarpophalangeal arthroplasty. The authors conducted an economic evaluation of the long-term health outcomes after silicone metacarpophalangeal arthroplasty.

METHODS

The authors performed a 5-year prospective cohort study of 170 patients with rheumatoid arthritis (73 surgical and 97 nonsurgical). Objective functional measurements and patient-rated outcomes using the Michigan Hand Outcomes Questionnaire and the Arthritis Impact Measurement Scale 2 were collected at 3 and 5 years. A cost-effectiveness analysis using direct costs from Medicare outpatient claims data (2006 to 2010) was performed to estimate the incremental cost-effectiveness ratios for both the Michigan and Arthritis Impact Measurement Scale 2 measurements.

RESULTS

At 5 years, the authors observed a statistically significant difference in upper extremity outcomes (Michigan Hand Outcomes Questionnaire) between the two groups, with surgical patients having higher outcomes. Costs associated with improved outcomes 5 years after surgery were $787 to $1150 when measured by the Michigan Hand Outcomes Questionnaire and $49,843 to $149,530 when measured by the Arthritis Impact scale. The incremental cost-effectiveness ratios did not substantially increase with their observed surgical revision rate of 5.5 percent (approximately 4 percent increase in incremental cost-effectiveness ratio) or with previously published long-term revision rates of 6.2 percent (approximately 6 percent increase in incremental cost-effectiveness ratio).

CONCLUSIONS

Short-term improvements in upper extremity outcomes after silicone metacarpophalangeal arthroplasty are maintained over the 5-year follow-up period. These outcomes are achieved at a relatively low cost, even with the addition of potential surgical complications.

The incidence of upper and lower extremity surgery for rheumatoid arthritis among Medicare beneficiaries

BACKGROUND

For elderly patients with rheumatoid arthritis, aggressive immunosuppression can be difficult to tolerate, and surgery remains an important treatment option for joint pain and deformity. We sought to examine the epidemiology of surgical reconstruction for rheumatoid arthritis among older individuals who were newly diagnosed with the disorder.

METHODS

We identified a 5% random sample of Medicare beneficiaries (sixty-six years of age and older) newly diagnosed with rheumatoid arthritis from 2000 to 2005, and followed these patients longitudinally for a mean of 4.6 years. We used univariate analysis to compare the time from the diagnosis of rheumatoid arthritis to the first operation among the 360 patients who underwent surgery during the study period.

RESULTS

In our study cohort, 589 procedures were performed among 360 patients, and 132 patients (37%) underwent multiple procedures. The rate of upper extremity reconstruction was 0.9%, the rate of lower extremity reconstruction was 1.2%, and knee arthroplasty was the most common procedure performed initially (31%) and overall (29%). Upper extremity procedures were performed sooner than lower extremity procedures (fourteen versus twenty-five months; p = 0.02). In multivariable analysis, surgery rates declined with age for upper and lower extremity procedures (p < 0.001).

CONCLUSIONS

Knee replacement remains the most common initial procedure among patients with rheumatoid arthritis. However, upper extremity procedures are performed earlier than lower extremity procedures. Understanding the patient and provider factors that underlie variation in procedure rates can inform future strategies to improve the delivery of care to patients with rheumatoid arthritis.

Variation in rheumatoid hand and wrist surgery among medicare beneficiaries: a population-based cohort study

OBJECTIVE

To examine the rate and variation in rheumatoid arthritis (RA)-related hand and wrist surgery among Medicare (elderly) beneficiaries in the United States, and to identify the patient and provider factors that influence surgical rates.

METHODS

Using the 2006-2010 100% Medicare claims data of beneficiaries with RA diagnosis, we examined rates of rheumatoid hand and wrist arthroplasty, arthrodesis, and hand tendon reconstruction in the United States. We used multivariate logistic regression models to examine variation in receipt of surgery by patient and regional characteristics (density of providers, intensity of use of biologic disease-modifying antirheumatic drugs).

RESULTS

Between 2006 and 2010, the annual rate of RA-related hand and wrist arthroplasty or arthrodesis was 23.1 per 10,000 patients, and the annual rate of hand tendon reconstruction was 4.2 per 10,000 patients. The rates of surgery varied 9-fold across hospital referral regions in the United States. Younger patient age, female sex, white race, higher socioeconomic status (SES), and rural residence were associated with a higher likelihood of undergoing arthroplasty and arthrodesis. We observed a significant decline in rate of arthroplasty and arthrodesis with increasing density of rheumatologists. Tendon reconstruction was not influenced by provider factors, but was correlated with age, race, SES, and rural status of the patients.

CONCLUSION

Surgical reconstruction of rheumatoid hand deformities varies widely across the United States, driven by both regional availability of subspecialty care in rheumatology and individual patient factors.

Update on the surgical treatment for rheumatoid arthritis of the wrist and hand

Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.

Functional and patient-reported outcome of partial wrist denervation versus the Mannerfelt wrist arthrodesis in the rheumatoid wrist

INTRODUCTION

Wrist arthrodesis offers high success rates in patients with rheumatoid arthritis; however, loss of residual mobility may cause unnecessary disability. This makes wrist denervation an appealing alternative. However, there is a distinct lack of patient-reported outcome measure studies comparing these two procedures. The aim of this study was to report any change in function, pain and satisfaction following wrist arthrodesis compared to denervation in a single surgeon series of rheumatoid patients.

PATIENTS AND METHODS

The results of 16 wrist arthrodesis in 15 patients and 14 partial (PIN) wrist denervations in 13 patients were compared with a mean follow-up period of 39 and 22 months, respectively. The primary outcome measures were the same for both groups and included the validated patient-rated wrist evaluation questionnaire and a satisfaction questionnaire.

RESULTS

Wrist arthrodesis significantly improved the mean total pain and functional outcome scores by 54 and 36 %, respectively, at the time of follow-up. Wrist denervation patients also reported significant improvements of 44 and 42 % in total pain and functional outcomes, respectively; 87 % reported being very satisfied with their wrist arthrodesis procedure compared to 78 % in the denervation group. No statistically significant difference in response between the groups was observed in this series of patients.

CONCLUSIONS

Both procedures enjoyed favourable results amongst patients with excellent satisfaction outcomes. PIN denervation is a simple procedure with low complication rates and we therefore consider it a valid alternative to more difficult treatment options, such as partial or total wrist arthrodesis.

Number of Ruptured Tendons and Surgical Delay as Prognostic Factors for the Surgical Repair of Extensor Tendon Ruptures in the Rheumatoid Wrist

Objective.

Extensor tendon ruptures in the rheumatoid wrist are usually restored by extensor tendon reconstruction surgery. However, the factors significantly correlated with the outcomes of extensor tendon reconstruction have not been defined. We examined factors showing a statistically significant correlation with postoperative active motion after tendon reconstruction.

Methods.

Spontaneous extensor tendon ruptures of 66 wrists in patients (mean age, 52.6 yrs) with rheumatoid arthritis (RA) were evaluated. All patients underwent tendon reconstruction surgery with wrist arthroplasty or arthrodesis. Active ranges of motion of the affected fingers were evaluated at 12 weeks postsurgery. Statistical significance was determined using multiple and single regression analyses.

Results.

Forty-six (69.6%) wrists had “good” results, while 13 (19.7%) and 7 (10.6%) wrists had “fair” and “poor” results, respectively. In multiple regression analysis, an increased number of ruptured tendons and the age at operation were independent variables significantly correlated with the postoperative active motion of reconstructed tendons (p = 0.009). Single regression analysis also showed a significant association between the number of ruptured tendons and surgical delay (p = 0.02).

Conclusion.

The number of ruptured extensor tendons was significantly correlated with the results of tendon reconstruction, and the number of ruptured tendons was significantly correlated with preoperative surgical delay. Our results indicate that, in patients presenting with possible finger extensor tendon rupture, rheumatologists should consult with hand surgeons promptly to preserve hand function.

Currently available metacarpophalangeal prostheses: their designs and prospective considerations

Although implanted for over 40 years, finger prostheses have failed to match the success achieved by artificial hip and knee prostheses, despite a myriad of designs having been proposed and implanted. This article looks at the currently available designs of metacarpophalangeal prosthesis, both single-piece and multicomponent implants. An appraisal of their designs and the clinical results, where available, are provided. The review also considers the challenges that are still faced by bioengineers and surgeons concerned with improving the success of metacarpophalangeal prostheses. In addition, key current areas of concern such as in vitro testing and contemporary issues in rheumatology, which may be diminishing the amount of metacarpophalangeal arthroplasty taking place, are discussed.

Applying evidence in the care of patients with rheumatoid hand and wrist deformities

The traditional approach in managing rheumatoid hand deformities is based on the individual surgeon's experiences. In the current era of evidence-based medicine, formulating treatment for the rheumatoid hand fits perfectly within the framework of evidence-based medicine by leveraging the best evidence from the literature, incorporating surgeons' experience and considering patients' preferences. In this Special Topic article, we use a case example to illustrate how evidence-based medicine can be practiced within the framework of treating rheumatoid hand deformities by distilling the best evidence from the literature to guide surgeons in a rational approach for treating this common condition.

Clinical and radiological results of radiolunate arthrodesis for rheumatoid arthritis: 22 wrists followed for an average of 7 years

PURPOSE

To evaluate the clinical and radiological results of radiolunate (RL) arthrodesis for rheumatoid arthritis (RA) patients treated with disease-modifying antirheumatic drugs and/or biologicals with an average of 7 years of follow-up. In addition, we compared the results in advanced stages with those in less advanced stages in patients with comparatively low disease activity of RA.

METHODS

This study included RL arthrodesis for 22 wrists in 19 patients with comparatively low disease activity of RA. The mean follow-up period was 7 years (range, 2-16 y). Fourteen wrists with Larsen classification grade III and 8 wrists with grade IV were included in this study. The range of motion was calculated, and clinical scores were graded using the Mayo wrist score and the Stanley classification. The carpal height ratio (CHR) and ulnar translation (UT) were determined from the radiographs.

RESULTS

All wrists achieved radiographic fusion. Clinical scores were markedly improved, although there was a decrease in flexion. The Larsen grade did not deteriorate during follow-up. CHR and UT improved immediately after operation and remained good through the final follow-up. Although the flexion/extension range of motion of the grade IV wrists was smaller than that of the grade III wrists at follow-up, both groups obtained good clinical results.

CONCLUSIONS

Our results for RL arthrodesis were clinically and radiologically better than those of previous reports. Control of the disease activity of RA could theoretically be a factor in obtaining good long-term clinical and radiographic outcomes. RL arthrodesis is our recommended procedure for the RA wrist even in the advanced stage.

LEVEL OF EVIDENCE

Therapeutic IV.

Long-term followup for rheumatoid arthritis patients in a multicenter outcomes study of silicone metacarpophalangeal joint arthroplasty

OBJECTIVE

Rheumatoid arthritis (RA) often results in deformities at the metacarpophalangeal (MCP) joints. Patients with severe deformities can be treated by silicone metacarpophalangeal joint arthroplasty (SMPA). The objective of the study is to prospectively compare long-term outcomes for an SMPA surgical and a nonsurgical cohort of RA patients.

METHODS

A total of 67 surgical and 95 nonsurgical patients with severe subluxation and/or ulnar drift of the fingers at the MCP joints were recruited from 2004-2008 in this multicenter prospective cohort study. Patients could elect to undergo SMPA or not. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales 2 (AIMS2), grip/pinch strength, Jebsen-Taylor Test, ulnar deviation, extensor lag, and arc of motion measurements at the MCP joints.

RESULTS

There was no significant difference in the mean age, race, education, and income at baseline between the 2 groups. Surgical subjects had worse MHQ function and functional measurements at baseline. At 3 years, the mean overall MHQ score and the MHQ function, activities of daily living, aesthetics, and satisfaction scores showed significant improvement in the surgical group compared to the nonsurgical group. Ulnar deviation, extensor lag, and arc of motion in the MCP and proximal interphalangeal joints also improved significantly in the surgical group. No improvement was seen in the mean AIMS2 scores and grip/pinch strength. Complications were minimal with a fracture rate of 9.5%.

CONCLUSION

RA patients with poor baseline functioning showed long-term improvement in hand function and appearance following treatment with SMPA compared to nonsurgical controls.

Extensor tendon rupture in rheumatoid arthritis: a survey of patients between 2005 and 2010 at five Korean hospitals

BACKGROUND

Recent medical advancements in the treatment of rheumatoid arthritis (RA) can prevent joint damage and tendon involvement. The authors evaluated patterns of extensor tendon ruptures in RA patients that presented to hand surgeons over a recent five-year period.

METHODS

Medical records and radiographs were retrospectively reviewed, and telephone interviews were conducted with 38 patients that had experienced extensor tendon ruptures in a rheumatoid hand during the study period and were operated on at one of five tertiary referral hospitals in South Korea. Patterns of tendon ruptures were compared in patients that did or did not receive medical treatment.

RESULTS

Twenty-nine of the 38 patients (76%) had tendon ruptures in more than two digits. When multiple digits were involved, mean duration between first and latest rupture was 2.9 months. When patients treated with medications by rheumatologists (24 patients) were compared with those not treated (14 patients), no significant differences were found for; number of ruptured tendons, time from first to last rupture, disease duration, or radiographic RA severity.

CONCLUSIONS

RA patients who once experienced a tendon rupture are still at risk of sequential tendon ruptures despite recent advancement of medical treatment. Education of the risks of sequential tendon ruptures and timely consultation to hand surgeons continue to be necessary in RA patients.

Reconstruction of the rheumatoid hand

Previous studies have shown large variation in the rate of common surgical procedures performed for the rheumatoid hand. This article provides a comprehensive overview of each surgical treatment option for rheumatoid hand reconstruction.

Rheumatoid hand surgery: differing perceptions amongst surgeons, rheumatologists and therapists in the UK

Rheumatoid arthritis is a systemic disease that requires coordinated management by rheumatologists, surgical specialists and therapists working in a multidisciplinary team. Differences of opinion within the team may adversely affect patient care. Our aim was to assess differences in perception about rheumatoid hand surgery between rheumatologists, hand surgeons and hand therapists in the UK. We used a postal questionnaire to assess commonly performed rheumatoid hand operations. For each procedure, respondents rated the most important indication for surgery and scored effectiveness at reducing pain, improving function and aesthetics, and preventing deformity. Statistically significant differences were found between all three groups with regards to expected outcome and main indications for surgery. We concluded that significant differences do exist in the perceptions of rheumatologists, surgeons and therapists. Rheumatoid hand operations require more detailed study, clarifying indications and outcome to allow consistent advice to patients from all members of the multidisciplinary team.

The relationship between ASSH membership and the treatment of distal radius fracture in the United States Medicare population

PURPOSE

Internal fixation for distal radius fractures (DRFs) in the elderly has increased from 3% in 1997 to 17% in 2007. This increase has been uneven across regions of the United States. There is some evidence that patients treated by hand surgeons receive internal fixation at an increased rate and that hand surgeons might be driving the increased usage in regions where their presence is greatest. The specific aim of this study was to explore this relationship by analyzing Medicare beneficiaries treated by members of the American Society for Surgery of the Hand (ASSH).

METHODS

Surgeons who were members of ASSH in 2007 were matched with surgeons treating Medicare beneficiaries for DRFs in the same year. We then fit a series of multilevel models to estimate the proportion of total variance in internal fixation usage explained by ASSH membership status, patient demographic data, patient comorbidity, and/or type of fracture diagnosed.

RESULTS

Beneficiaries treated by ASSH members received internal fixation significantly more often than beneficiaries who were treated by surgeons who were not ASSH members. ASSH member status accounts for 12% of the total variance in internal fixation utilization.

CONCLUSIONS

Medicare beneficiaries who were treated by ASSH member surgeons receive internal fixation at a significantly higher rate than do patients of other physicians. When there is uncertainty about the optimal treatment for a condition, there is the possibility for specialty-related disparities. This specialty effect contributes to the national variations in the treatment of DRFs in the Medicare population.

Current concepts in the management of the rheumatoid hand

Hand surgeons are an integral part of the management team for patients with rheumatoid arthritis. There is now a greater understanding of the national use of rheumatoid hand surgery, which highlights the differences between hand surgeons and rheumatologists regarding the treatment of the rheumatoid hand. Advances in medical treatments have also decreased the prevalence of hand deformities caused by this disease. Hand surgeons today have less exposure to treating rheumatoid hand, but despite more effective medical options, surgery may still offer patients hope for improvement of hand function and appearance. This article summarizes the current state of rheumatoid hand surgery and discuss the surgical treatment strategies for optimizing outcomes for patients with rheumatoid arthritis.

Metacarpophalangeal joint arthritis

Arthritis of the metacarpophalangeal joint can result in considerable disability and pain. Inflammatory, posttraumatic, crystalline, and osteoarthritis are common etiologies of joint disease. A variety of nonsurgical treatment options have been shown to be effective, including activity modification, anti-inflammatory medications, splinting, and cortisone injections. In addition, newer generation disease-modifying antirheumatic drugs geared toward the treatment of rheumatoid arthritis have shown promise in retarding the inflammatory process. Another, relatively newer, conservative treatment option includes topical anti-inflammatories such as diclofenac sodium that are now approved by the Federal Drug Administration. Surgical treatment options most commonly include arthroplasty and arthrodesis. In the treatment of thumb metacarpophalangeal arthritis, arthrodesis is a popular and generally reliable surgical solution. In the fingers, arthroplasty remains the most common treatment option. Traditional constrained silicone joint replacements remain the most commonly used. Newer generation, unconstrained, surface replacement arthroplasties have shown promise in the treatment of osteoarthritis and select cases of inflammatory arthritis in which there is good bone stock, no or minimal deformity, adequate supporting soft tissues, and good disease control.

Current concepts and treatment for the rheumatoid wrist

Wrist involvement in rheumatoid arthritis (RA) is common. Within 2 years of diagnosis, more than half of patients will have wrist pain, and more than 90% will have wrist disease by 10 years. Although wrist involvement is generally thought to be less disabling than RA of the fingers and hand, it can be a significant cause of pain and disability. Severe disease with bony destruction and synovitis in the wrist can also result in soft-tissue problems including tendon ruptures. In addition to musculoskeletal involvement, systemic manifestations of RA can occur. Felty syndrome can result in a low white blood count and splenomegaly in association with RA. New generation, disease-modifying pharmacologic agents offer promise in controlling the disease progression. Surgical treatments for the diseased wrist are aimed at relieving pain and restoring function. Common procedures include: synovectomy and tenosynovectomy, tendon reconstruction, distal ulnar resection and/or distal radioulnar joint reconstruction, partial and full wrist arthrodesis, and total wrist arthroplasty.

Controversy in the treatment of the rheumatoid hand: perspective from hand surgery

Over the years there has been controversy between rheumatologists and surgeons regarding surgery for the correction of rheumatoid problems. There are many reasons for this controversy. This article explores the reasons for the controversy, presents the history of rheumatoid hand surgery, and offers some possible solutions to the problem.

The rheumatoid metacarpophalangeal joint

Rheumatoid metacarpophalangeal joint deformities remain an important cause of disability. Surgical intervention in carefully selected patients improves function and prolongs independence. This article discusses the commonly used reconstructive techniques and their benefits. Case selection through a combined clinic with rheumatologists and hand therapists is recommended.

Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists

Rheumatoid arthritis (RA) is a progressively destructive disease. Gradual loss of hand function in RA patients affects their ability for self-care and interferes with their productivity in society. The continuing improvement in the medical management of RA has markedly decreased the incidence of RA hand surgery. In contrast to RA, osteoarthritis (OA) has less inflammatory reaction in the joints and is characterized by degradation of cartilage, resulting in joint destruction and osteophyte formation. The initial treatment of OA is medication and therapy. Steroid injection into affected joints can provide short-term relief, though repeat injections carry a cumulative risk of weakening the soft tissue. In this article the authors share their extensive experience in RA and OA hand surgery to provide a clear discussion of the indications and outcomes of its practice.

Outcomes research in rheumatoid arthritis

Although rheumatoid arthritis causes significant disability for more than 1 million individuals in the United States, prior research regarding surgical treatment options has been limited by study sample size, study design, and methods of comparison. Furthermore, there is wide variation in the referral pattern for hand surgery consideration and type of surgical treatment of rheumatoid hand disease, yet the reasons for these differences are unclear. This review describes the role of outcomes research in rheumatoid hand disease by summarizing variations in surgical treatment, detailing current outcome assessment strategies, and offering potential strategies for designing future studies for rheumatoid hand disease.

Survey research

SUMMARY

Survey research is a unique methodology that can provide insight into individuals' perspectives and experiences and can be collected on a large population-based sample. Specifically, in plastic surgery, survey research can provide patients and providers with accurate and reproducible information to assist with medical decision-making. When using survey methods in research, researchers should develop a conceptual model that explains the relationships of the independent and dependent variables. The items of the survey are of primary importance. Collected data are only useful if they accurately measure the concepts of interest. In addition, administration of the survey must follow basic principles to ensure an adequate response rate and representation of the intended target sample. In this article, the authors review some general concepts important for successful survey research and discuss the many advantages this methodology has for obtaining limitless amounts of valuable information.

Effects of extensor synovectomy and excision of the distal ulna in rheumatoid arthritis on long-term function

PURPOSE

Objective outcomes data after excision of the distal ulna in rheumatoid arthritis are lacking. The aim of this study was to evaluate the functional results of this surgery in the long term.

METHODS

We prospectively collected data on range of motion (22 wrists), visual analog pain scores (14 wrists), and grip strength measured using a Jamar dynamometer (20 hands) in a group of 23 patients (26 wrists) preoperatively and at 3 months, 12 months, and a minimum of 5 years postoperatively (range, 5.3-10.4 y). The Jebsen-Taylor hand function test was administered to 9 patients at the same time points. A subgroup of patients also underwent extensor carpi radialis longus to extensor carpi ulnaris tendon transfer (11 wrists).

RESULTS

At one year, there were improvements in wrist pronation and supination, which were maintained at final follow-up. Active radial deviation decreased significantly at 3 months (p = .01) and one year (p = .02); this remained reduced at final follow-up (not significant). Wrist extension and active ulnar deviation showed slight improvements by one year, but reduced to levels below that measured preoperatively by final follow-up. Wrist flexion was significantly reduced at all time points postoperatively. Grip strength showed improvement from 10.0 kg (standard deviation [SD] 4.1 kg) preoperatively to 12.5 kg (SD 4.6 kg) 1 year after surgery and returned to preoperative levels (9.5 kg, SD 5.6 kg) by final follow-up. Wrist pain was significantly reduced from a mean score of 5 (SD 4) preoperatively to 2 (SD 2) postoperatively (p = .01). The Jebsen-Taylor hand function test showed improvements in writing and card turning.

CONCLUSIONS

In the long term, excision of the distal ulna in rheumatoid patients results in an improvement in some aspects of hand function. There is a significant (p = .01) reduction in wrist pain but a reduction of wrist flexion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Referring physicians' knowledge of hand surgery

Hand surgeons rely on referrals from general providers. Appropriate referral is dependent upon referring physicians having an understanding of the problem and available treatments. This study evaluates the referring physicians' knowledge and perceptions of basic hand problems and their treatment. This study also evaluates the impact of a brief lecture on our referring physicians' understanding of hand issues. A survey instrument was administered to referring physicians. The instrument addressed general hand knowledge and perceptions toward hand surgery. The physicians also attended a lecture on general hand problems and their treatments. The survey was repeated 2 weeks post-lecture. Subjects had a pre-lecture knowledge score of 65% correct and post-lecture a score of 85%, p < 0.05. The participants were knowledgeable about common hand problems, such as carpal tunnel syndrome. Knowledge gaps did exist, for example, only 37% recognized the symptoms of basilar thumb arthritis. Initially, the referring physicians had less positive views about surgical interventions, such as surgery to help the pain of basilar thumb arthritis. After the lecture, the responders had significantly more favorable attitudes toward surgery. This study found that referring physicians had variable knowledge about common hand problems, and they had doubts relating to the efficacy of some hand surgeries. This study also found that a directed lecture improved these providers' knowledge and their perceptions of hand surgical interventions. Hand surgeons can improve their referring physicians understanding and perceptions of hand surgery through a directed grand rounds type lecture.

Differences between the United States and the United Kingdom in the treatment of rheumatoid arthritis: analyses from a hand arthroplasty trial

Previous studies have found differences in rheumatoid hand surgical practice around the world. The specific aim of this study is to compare baseline characteristics of rheumatoid arthritis (RA) patients in the United States (US) and the United Kingdom (UK) that may be influenced by the two different health-care systems. Patients were recruited from three sites (two in the US and one in England) as part of a National Institutes of Health funded study to examine outcomes of silicone metacarpophalangeal joint (MCPJ) arthroplasty in RA patients. Outcomes measurements included biomechanical assessments (grip strength, pinch strength, and mean ulnar drift and extensor lag at the MCPJs of all four fingers), a health-related quality of life questionnaire (the Michigan Hand Outcomes Questionnaire), and a medication assessment. American patients have a significantly higher income level (p<0.001) and have completed higher levels of education (p<0.001) than British patients. There were no significant differences in terms of self-reported disease severity or deformity at the MCPJs. RA patients in the US are more likely to take biologic medications (p<0.001), steroids (p=0.02), and Cox-2 inhibitors (p=0.02). Patients in the UK are significantly more likely (p<0.001) to take nonsteroidal anti-inflammatory drugs. There are differences in the demographic characteristics and medication use of RA patients with hand deformities in the US and UK. These differences may be influenced by the private versus socialized health-care systems. However, the perception of hand disease severity in participants in this study appears to be comparable between these countries.