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Chapter 126 - Surgical procedures for rheumatoid arthritis
- from Section 24 - Orthopedic Surgery
- Edited by Michael F. Lubin, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Neil H. Winawer, Emory University, Atlanta
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- Book:
- Medical Management of the Surgical Patient
- Published online:
- 05 September 2013
- Print publication:
- 15 August 2013, pp 746-750
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Summary
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder that affects nearly 1% of the adult population, with women being affected earlier and more often than men. The disease typically strikes between the third and sixth decades of life, but children and the elderly can be affected as well.
Despite markedly improved and more aggressive medical management, rheumatoid arthritis continues to be, for many, a progressive disease that ultimately leads to significant joint destruction, severe disability, a lower quality of life, and a shorter life expectancy.
Patients with RA typically present with complaints of overall fatigue, morning stiffness that may improve throughout the day, joint swelling, and pain. Patients have serology positive for rheumatoid factor (Anti-IgG IgM antibodies) and antibodies to cyclic citrullinated peptides (CCP) in addition to plain radiographic findings including subchondral bony erosions, periarticular osteopenia, and soft-tissue edema. Synovial hypertrophy precedes joint destruction and can be diagnosed on ultrasound or MRI. Anti-CCP antibodies can be present and detected months to years before the autoimmune attack on the articular surfaces. These antibodies are positive in 50–60% of individuals with RA; antibodies may be present in otherwise seronegative patients (negative serology for rheumatoid factor). Clinical RA will develop in 95–98% of patients with a positive anti-CCP antibody screen. Early diagnosis is paramount as any delay can often lead to irreversible joint destruction and the resultant morbidity.
117 - Surgical procedures for rheumatoid arthritis
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- By Gary R. McGillivary, Emory University, School of Medicine, Atlanta, GA
- Edited by Michael F. Lubin, Emory University, Atlanta, Robert B. Smith, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Nathan O. Spell, Emory University, Atlanta, H. Kenneth Walker, Emory University, Atlanta
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- Book:
- Medical Management of the Surgical Patient
- Published online:
- 12 January 2010
- Print publication:
- 10 August 2006, pp 744-746
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Summary
Despite markedly improved and more aggressive medical management, rheumatoid arthritis continues to be, for many, a progressive disease that ultimately leads to significant joint destruction. The primary indication for almost all surgical procedures remains pain relief, with functional improvement and prevention of deformity being lesser goals.
Common operative procedures include the following.
Arthroplasty
Primarily joint replacement, such as total hip, knee, shoulder, elbow, wrist and metacarpophalangeal joints, but occasionally other anomalies such as interpositional arthroplasty.
Arthrodesis
Joint fusion remains an excellent procedure in some areas, such as the wrist, interphalangeal joints, ankle, spine, and selected others in certain clinical situations.
Soft tissue procedures
Synovectomy, tenosynovectomy, carpal tunnel release, tendon transfers, and tendon repair all have roles in certain patients. These occasionally are prophylactic and may help alter the course of the disease.
In general, the surgical stress involved is related to the magnitude of the specific procedure. On occasion, multiple procedures may be carried out at one time if they aren't too substantial. For more significant interventions, such as revision arthroplasty, isolated procedures tend to be the standard approach. Most primary procedures, alone or in combination, do not require more than two to three hours of anesthesia. Complicated operations, of course, may demand more.
Procedures on the distal portions of the extremities (below the shoulder and hip) are generally done with tourniquet control, with blood loss being minimal. Although shoulder surgery is done without tourniquet control, the amount of bleeding is usually not excessive and transfusion is fairly uncommon.