Outcomes of hand surgery in the patient with rheumatoid arthritis

Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act

Importance

Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear.

Objective

To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA.

Design, Setting, and Participants

This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023.

Exposures

Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods.

Main Outcomes and Measures

Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA.

Results

Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (-70.5 [95% CI, -112.6 to -28.3] days; P < .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P < .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P < .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P < .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change.

Conclusions and Relevance

Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.

Factors Associated With Quality Care Among Adults With Rheumatoid Arthritis

IMPORTANCE

Although quality care markers exist for patients with rheumatoid arthritis (RA), the predictors of meeting these markers are unclear.

OBJECTIVE

To explore factors associated with quality care among patients with RA.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using insurance claims from 2009 to 2017 was conducted, and 6 sequential logistic regression models were built to evaluate quality care markers. Quality care markers were measured at 1 year post-RA diagnosis for each patient. The MarketScan Research Database, which contains commercial and Medicare Advantage administrative claims data from more than 100 million individuals in the US, was used to identify patients aged 18 to 64 years with a diagnosis claim for RA. Patients with conditions presenting similar to RA and missing demographic characteristics were excluded. Data analysis occurred between February 18 and May 5, 2022.

EXPOSURES

Success or failure to meet selected RA quality care markers within 1 year after RA diagnosis.

MAIN OUTCOMES AND MEASURES

Prevalence of meeting successive quality care markers for RA.

RESULTS

Among 581 770 patients, 430 843 (74.1%) were women and the mean (SD) age was 48.9 (11.3) years. Most patients (236 285 [40.6%]) resided in the South and had an income less than or equal to $45 200 (490 366 [84.3%]). Of the total study population, 399 862 individuals (68.7%) met at least 1 quality care marker and 181 908 (31.3%) met 0 markers. Most commonly, patients met annual laboratory testing (299 323 [51.5%]) and referral to a rheumatologist (256 765 [44.1%]) markers. The least met marker was receiving hepatitis B screening prior to initiation of disease-modifying antirheumatic drug (DMARD) therapy (18 548 [3.2%]). Women were most likely to meet all quality care markers except receiving DMARDs with hepatitis B screening (odds ratio, 1.14; 95% CI, 1.12-1.16). Individuals with lower median household income had lower odds of receiving a rheumatologist referral, an annual physical examination, or annual laboratory testing, but greater odds of receiving the other quality care markers. Patients with Medicare and those with comorbidities were generally less likely to meet quality care markers.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with RA, findings indicated downstream associations with rheumatologist referral and receiving DMARDs and varied associations between meeting quality care markers and patient characteristics. These findings suggest that prioritizing early care, especially for vulnerable patients, will ensure that quality care continues.

Long-term Outcomes of MCP Surface Replacement Arthroplasty in Patients With Rheumatoid Arthritis

Background: Surface replacement arthroplasty (SRA) can be used in the treatment of rheumatoid arthritis (RA) affecting the metacarpophalangeal (MCP) joint. The authors of this study sought to investigate the outcomes of MCP SRA in patients with RA. Methods: Retrospective review of medical records and an institutional joint registry were used to gather data on 80 MCP SRAs performed in 27 patients with RA. Data collected included demographics, SRA revisions, reoperations, complications, pain, and MCP arc of motion. Results: The mean postoperative follow-up was 9.5 years (range, 2.1-20.5 years), with all SRAs achieving at least 2 years of follow-up. Thirteen digits (16%) underwent revision arthroplasty, and 29 (36%) required reoperation. The 5-, 10-, 15-, and 20-year rates of survival from implant revision were 95%, 85%, 80%, and 69%, respectively. The 5-, 10-, 15-, and 20-year rates of survival from overall reoperation were 80%, 65%, 55%, and 46%, respectively. Metacarpophalangeal joint arc of motion, grip strength, and pain levels significantly improved following surgery. Conclusions: Metacarpophalangeal SRA can offer benefit to patients with RA for improvement in function and pain. High overall reoperation rates remain concerning; however, most do not involve arthroplasty revision.

Extensor tendon ruptures in rheumatoid wrists

Background and aims

Rheumatoid arthritis is a chronic inflammatory disease. The associated involvement of hands and tendons is over 90% and impairs overall function. In the course of the disease, the joints are often operated on. During this operation, ruptures of the extensor tendons are found by chance without the patients noticing them. The aim of this retrospective study is the prevalence of extensor tendon rupture. Which tendon is destroyed most frequently? How can the functional outcome be measured after reconstruction?

Materials and methods

From 1572 operations on rheumatoid wrists, 61 extensor tendon ruptures were identified in 41 patients. The average time between the first rheumatic symptoms of the hand and surgery was 6.4 years. The average duration of RA was 7.8 years. 26 patients with 27 tendon reconstructions were included in the follow-up with an average postoperative duration of 4.6 years (3 to 14.2 years).

Results

Extensor tendons ruptures typically occurred at mechanically stressed sites. The most frequent rupture was found in the extensor pollicis longus tendon (21 tendons), followed by the small finger extensor tendon (14 tendons). A transfer was performed on 7 tendons. Fifty-five tendon lesions were sutured at other intact tendons. Free grafts were not used. The results in Clayton and QuickDASH scores were significantly different. Functional improvement was consistent with the results of tendon reconstructions in healthy control groups.

Conclusion

In rheumatoid patients, a rupture of an extensor tendon must be expected at 4%. Patients tolerate and compensate this damage for a long time. The function of the hand including the tendon function is the most important factor in assessing the success of the operation. The subjective patient acceptance depends on the progress of the underlying disease, postoperative care (ergotherapy, physiotherapy, orthosis) and the patients' demands.

Electronic supplementary material

The online version of this article (10.1007/s00590-020-02731-1) contains supplementary material, which is available to authorized users.

Long-term outcomes of silicone metacarpophalangeal arthroplasty: a longitudinal analysis of 325 cases

An analysis was conducted of 325 consecutive metacarpophalangeal arthroplasties prospectively collected using a single institution's total joints registry over a 14-year time period to characterize long-term radiographic and functional outcomes. Patients were followed for a mean of 7.2 years (2-18) or until revision. The 5-, 10- and 15-year survival free from revision were 98%, 95% and 95%, respectively. The 5-, 10- and 15-year survival rates free from radiographic implant fracture were 93%, 58% and 35%, respectively. The 5-, 10- and 15-year survival rates free from coronal plane deformity greater than 10° were 81%, 37% and 17%, respectively. Patients had significant improvements in their postoperative pain levels and metacarpophalangeal arc of motion. Neither implant fracture, nor coronal plane deformity >10° had a significant association with worse function. Overall, pain relief and functional improvement are reliable, though silicone implants do not protect from progression of coronal plane deformity and have a high fracture rate. Level of evidence: IV.

Radiocarpal fusion and midcarpal resection interposition arthroplasty: long-term results in severely destroyed rheumatoid wrists

BACKGROUND

The aim of this retrospective study is to evaluate distal resection interposition arthroplasty of the wrist as a tool to restore mobility as well as to restore stability in severely destroyed wrist joints.

METHODS

Thirty-four wrists in 28 rheumatoid arthritis patients were included. The mean follow-up time was 9 years after surgical treatment with clinical and radiological examination. The results were accessed based on a modification of Clayton ́s scoring system as well as a functional questionnaire.

RESULTS

71% patients were satisfied with pain, function and activities of daily life. Better results were reported by patients with a young age, early surgical intervention, a shorter duration of the disease, and lesser involvement of other joints.

CONCLUSIONS

The results for radiocarpal arthrodesis were comparable to those of synovectomy or arthrodesis of the wrist. The results after total wrist joint arthroplasty varies probably as the result of different patient groups, implant types and evolution of prosthetic designs, and are not comparable with the present study.

Medium-term outcomes of the Universal-2 total wrist arthroplasty in patients with rheumatoid arthritis

AIMS

The aims of this study were to evaluate the clinical and radiological outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients with rheumatoid arthritis.

PATIENTS AND METHODS

This was a retrospective review of all 95 Universal-2 TWAs which were performed in our institution between 2003 to 2012 in patients with rheumatoid arthritis. A total of six patients were lost to follow-up and two died of unrelated causes. A total of ten patients had bilateral procedures. Accordingly, 75 patients (85 TWAs) were included in the study. There were 59 women and 16 men with a mean age of 59 years (26 to 86). The mean follow-up was 53 months (24 to 120). Clinical assessment involved recording pain on a visual analogue score, range of movement, grip strength, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) and Wrightington wrist scores. Any adverse effects were documented with particular emphasis on residual pain, limitation of movement, infection, dislocation and the need for revision surgery. Radiographic assessment was performed pre-operatively and at three, six and 12 months post-operatively, and annually thereafter. Arthroplasties were assessed for distal row intercarpal fusion and loosening. Radiolucent zones around the components were documented according to a system developed at our institution.

RESULTS

The mean worst pain was 8.1 (3 to 10) pre-operatively and 5.4 (0 to 10) at latest follow-up (p < 0.001). Movements were preserved with mean dorsiflexion of 29^o (0 ^o to 70 ^o) and palmar flexion of 21^o (0^o to 50^o). The mean grip strength was 4.8 kg (1.7 to 11.5) pre-operatively and 10 kg (0 to 28) at final follow-up (p < 0.001). The mean QuickDASH and Wrightington wrist scores improved from 61 (16 to 91) to 46 (0 to 89) and 7.9 (1.8 to 10) to 5.7 (0 to 7.8) (p < 0.001). A total of six patients (7%) had major complications; three required revision arthroplasty and three an arthrodesis. The Kaplan-Meier probability of survival using removal of the components as the endpoint was 91% at 7.8 years (95% confidence interval 84 to 91).

CONCLUSION

The Universal-2 TWA is recommended for use in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:1642-7.

Patient rated outcomes study into the surgical interventions available for the rheumatoid hand and wrist

INTRODUCTION

A multitude of surgical interventions are recognised for the treatment of the rheumatoid hand and wrist, however there seems to be a distinct lack of patient rated outcome measures (PROMs) studies reporting on the efficacy of these procedures. The aim of this study was to assess the PROMs related to hand and wrist surgery in patients with rheumatoid arthritis (RA).

MATERIALS AND METHODS

A single surgeon series identified 94 patients (133 hands) with RA who had undergone one of eight surgical procedures (Swanson's arthroplasty, finger joint or wrist arthrodesis, carpal tunnel decompression, posterior interosseous nerve denervation, RA nodule excision, synovectomy/tenosynovectomy and tendon repair/release) with a mean follow-up period of 3 years. The primary outcome measures were the same for all patients and comprised the validated modified score for the assessment and quantification of chronic rheumatoid affections of the hand (M-SACRAH) and a separate satisfaction questionnaire.

RESULTS

Highly significant improvements in both function and pain scores are reported across the cohort as a whole following hand surgery, with this pattern replicated within all of the operative subgroups. In keeping with these favourable results very high levels of overall satisfaction were reported with 93 % of patients reporting themselves to be very or fairly satisfied with their procedure.

CONCLUSIONS

Overall, patient reported outcomes in functional, stiffness and pain domains of the M-SACRAH questionnaire appear very favourable across the range of surgical procedures that can be performed in the rheumatoid hand. We believe this data supports the use of all the procedures explored, and will be helpful in patient guidance.

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.

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.

The future of rheumatoid arthritis and hand surgery - combining evolutionary pharmacology and surgical technique

Rheumatoid arthritis is a systemic autoimmune disease of uncertain aetiology, which is characterized primarily by synovial inflammation with secondary skeletal destructions.Rheumatoid Arthritis is diagnosed by the presence of four of the seven diagnostic criteria, defined by The American College of Rheumatology.Approximately half a million adults in the United Kingdom suffer from rheumatoid arthritis with an age prevalence between the second and fourth decades of life; annually approximately 20,000 new cases are diagnosed.The management of Rheumatoid Arthritis is complex; in the initial phase of the disease it primarily depends on pharmacological management. With disease progression, surgical input to correct deformity comes to play an increasingly important role. The treatment of this condition is also intimately coupled with input from both the occupational therapists and physiotherapy.

Objective functional outcomes and patient satisfaction after silicone metacarpophalangeal arthroplasty for rheumatoid arthritis

PURPOSE

Patient satisfaction is an essential measure of quality of care for rheumatoid arthritis. Prior research demonstrates that patient satisfaction improves after silicone metacarpophalangeal arthroplasty (SMPA) despite minimal change in hand function. The purpose of this study was to identify the level of objective functional recovery that yields satisfaction after SMPA. We hypothesized that measurable gains in objective hand function after SMPA will discriminate between satisfied and dissatisfied patients.

METHODS

In this prospective, multicenter, cohort study, we observed 46 patients with rheumatoid arthritis and metacarpophalangeal (MCP) joint subluxation for 2 years after reconstructive surgery. We derived satisfaction scores from the Michigan Hand Outcomes Questionnaire, ranging from 0 (least satisfied) to 100 (most satisfied), and dichotomized them using the Cohen large effect size. We measured hand function at baseline and follow-up including strength (grip strength and pinch strength), finger position (extensor lag and ulnar drift), and MCP arc of motion. We constructed receiver operating characteristic curves to identify optimal cutoffs in hand function that correspond with satisfaction.

RESULTS

At 2 years of follow-up, patients who achieved an extension lag of 30° or less were considered satisfied, which represented a 52% improvement (preoperative lag = 63°). Similarly, patients who gained improvement in ulnar drift from an average of preoperatively 62° to 9° postoperatively were satisfied. Finally, patients who achieved an improvement in MCP arc of motion from an average of 21° to 31° postoperatively were satisfied. No improvements in grip or pinch strength corresponded with postoperative patient satisfaction.

CONCLUSIONS

Patients were satisfied with only modest gains in grip and pinch strength after silicone metacarpophalangeal arthroplasty. However, maintaining finger position, without recurrence of ulnar drift or extensor lag, and MCP arc of motion corresponded with patient satisfaction in the postoperative period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.