7 Rheumatoid Arthritis Surgery Options for You

Rheumatoid arthritis (RA) is an autoimmune disease in which a person's immune system attacks their joints, leading to joint swelling, pain, and stiffness. In certain cases, when other treatment options like disease-modifying antirheumatic drugs (DMARDs) or biologics have not worked, surgery may be the only remaining option to improve a person's quality of life.

This article reviews the different types of surgeries that may benefit people with RA.

When Is Surgery Right for You?

Surgery is typically a last-resort treatment for rheumatoid arthritis and should be considered only when others have failed.

It may be time to speak to your rheumatologist about surgery if your RA is worsening despite various treatment options. Oftentimes, rheumatologists and orthopedists will work together to ensure a person with RA has a promising and positive result with surgery.

Surgical Options for RA

The following are some surgical options for rheumatoid arthritis.

Arthroplasty

Arthroplasty is also known as joint replacement surgery. It has become a more common surgical option. The knees and hips are the most common areas for this type of surgery.

Total knee and hip replacements may be a good treatment for people with significant joint damage. This can occur as a result of injury, osteoarthritis, or uncontrolled inflammation and thickening of the synovial membrane. Uncontrolled inflammation will destroy the cartilage around the joints, leading to stiffness, pain, and decreased mobility and range of motion.

This type of surgery should be considered when other treatments have failed, such as:

• Nonsteroidal anti-inflammatories (NSAIDs)
• Physical therapy
• Cortisone injections
• Viscosupplementation (injecting fluid into the joint)
  

Total Knee Arthroplasty (TKA)

Total knee arthroplasty (TKA), also known as a knee replacement, is performed under general anesthesia and may last a few hours.

Typically, an orthopedic surgeon will create an eight- to 12-inch incision on the front of the knee. From there, the damaged cartilage lining the femur (thigh bone) and tibia (shin bone) will be removed, along with some of the surrounding bone.

Then, metal prosthetic components will be placed where the cartilage and bone have been removed. A medical-grade plastic spacer is then placed in between the prosthetics to create a surface that improves the natural gliding motions of the knee.

Finally, the incision is closed and the surgery is complete.

Total Hip Arthroplasty

Total hip arthroplasty (hip replacement) is performed similarly to that of a total knee replacement.

After a person is put to sleep, the orthopedic surgeon will decide the best place to make the incision. The damaged femoral head (the hip's ball joint) and the damaged surface of the acetabulum (the hip's socket) will be removed.

A metal stem is then inserted into the femur bone. The stem may then be cemented or press-fit (joined without using cement) into the bone depending on the surgeon's preference. A metallic or ceramic ball is then placed at the head of the stem, becoming the new "ball" of the joint, and a metal socket is either screwed or cemented in place. A spacer is placed between the new ball and socket to allow for normal movement, and the incision is closed.

Arthrodesis

Arthrodesis is a procedure in which two or more bones of a joint are fused together, often called joint fusion surgery. This type of surgery essentially eliminates the joint space, which is permanent.

Arthrodesis can be performed on many joints, including:

• Fingers
• Wrists
• Spine
• Ankles
• Toes

Arthrodesis is not recommended on joints critical for mobility such as shoulders, hips, or knees.

Synovectomy

A synovectomy is a surgical procedure in which part or all of the synovium (soft tissue in the joint) is removed. This membrane is responsible for hydrating and lubricating the joint. Adequate lubrication helps protect cartilage and keeps the overall joint healthy.

Sometimes people with rheumatoid arthritis may develop synovitis, or inflammation of the synovium, which can lead to swollen and painful joints.

Synovectomy can be done as either an open procedure or arthroscopically (inserting a small camera into an incision). Results are best noted in people whose cartilage is still intact.

 Arthroscopy

Arthroscopic surgery refers to the practice of using a small camera (arthroscope) to visualize a joint space and aid in the diagnosis and treatment of a wide variety of orthopedic conditions.

The knee and shoulder, being large joints, are the most common sites for arthroscopic surgery. In the knee, a small set of incisions are made to allow the arthroscope and a few instruments to repair or remove damaged areas of the joint.

Carpal Tunnel Release

Carpal tunnel syndrome is commonly seen in people with rheumatoid arthritis. Inflammation and swelling within the carpal tunnel can put pressure on the median nerve and cause symptoms of numbness, tingling, and pain from the wrist to the fingers. These symptoms can become so aggravating that surgery may be the best option.

A person will be awake during carpal tunnel release surgery, but the wrist area will be numbed prior to the procedure. Then, a small incision is made on the palm near the wrist and the transverse carpal ligament is cut, relieving tension and pressure on the median nerve. The skin is then closed with stitches.

Tenotomy

Tendon release surgery, or tenotomy, is commonly performed on the hands of people with De Quervains tenosynovitis and trigger fingers.

During this procedure, a small incision or cut is made in the skin and the tissue surrounding the affected tendon. Once the tissue is cut, the tendon no longer feels pressure or stress, which relieves symptoms. The skin is then closed to complete the procedure.

Tendon Transfer Surgery

Occasionally, long-standing untreated rheumatoid arthritis can lead to muscle injury. In some cases, particularly in the hands, tendon transfer surgery may be an option.

In this procedure, a working tendon is transferred to the site of the improperly working muscle or tendon. Depending on the location of the injury this procedure may be done under gentle sedation or general anesthesia.

Potential Risks

All treatments, including surgical procedures, have potential risks and complications. While many of the procedures previously discussed are relatively safe, risks are always present. Common surgical risks include:

• Bleeding
• Infections
• Nerve or tissue damage
• Deep vein thrombosis (blood clot in a large vein)
• Pulmonary embolism (blood clot in the lung)
  

What to Ask Your Rheumatologist

Prior to surgery, it's important to meet and speak with your rheumatologist. RA is a complex disease and proper treatment can be complicated. Some questions to ask your rheumatologist before surgery include:

• Are there any other medications or therapies we can try before surgery?
• Will surgery permanently fix this problem?
• Do I have to stop any of my rheumatoid arthritis medications before or after surgery?
• Will I likely need surgery again in the future?

Having a good understanding of how surgery can help your RA and knowing what to expect beforehand can make the experience less stressful.

How to Prepare

Before undergoing any procedure, it's important to make your rheumatologist and orthopedic surgeon aware of any and all over-the-counter, prescription, and recreational drugs you use. In some cases, certain supplements and medications will need to be stopped before the procedure.

Most orthopedic surgeries require some form of physical or occupational therapy afterward. That's why it's important to have as much done before the procedure, to ease the recovery process.

Speak to your surgeon before the surgery to find out how long before the operation you should stop eating and drinking. Fasting prior to surgery helps decrease the risk of severe complications during surgery, like aspiration and choking.

What to Expect After Surgery

Recovery time from surgery varies depending on what kind of surgery you get. Total joint replacement recovery can take several months and may require physical therapy. After carpal tunnel release, a few weeks of splinting and occupational therapy may be sufficient.

It's important to have an open discussion about recovery with your healthcare provider or rheumatologist prior to the procedure. In some instances, especially with total joint replacement surgeries, medications may need to be stopped a few weeks before and after surgery. Sometimes, once the medication is restarted, it may not be as effective. In this situation, a person will change their medication.

Summary

Rheumatoid arthritis is a complex systemic inflammatory illness. Depending on the affected joints and the severity of the illness, surgery may be an option. There are a number of orthopedic surgeries that can be beneficial to people with RA. These include arthroplasty (in the knees or hips), arthrodesis, synovectomy, arthroscopy, carpal tunnel release, tendon transfer surgery, and more.

People with RA should talk to their healthcare provider or rheumatologist about the best treatment option for their individual case.

A Word From Verywell

Rheumatoid arthritis can be a debilitating condition, but there are many treatment options available. If those fail, surgery may be necessary. Discuss these options with your healthcare provider or rheumatologist to determine which surgery is right for you.