Introduction

The systemic inflammatory poly-arthropathy known as Rheumatoid Arthritis (RA) damages the body's joints' functionality and appearance. Autoantibody production, synovial inflammation and hyperplasia, bone and cartilage degeneration, and other systemic problems are all brought on in RA by an autoimmune-mediated process.^[1] It is a painful autoimmune disease that affects 0.5-1% of the population.^[2] The joints of the hand and wrist are frequently affected in the upper extremities. Within two years of diagnosis, up to 50% of patients get wrist involvement, and ten years after diagnosis, up to 90% of patients experience it.^[3] RA in the hands and wrists might make it difficult for the patient to the capacity to work and carry out regular tasks.^[4], ^[5] Unfortunately, the lack of spontaneous remission that RA exhibits means that, in the absence of medical therapy, the condition typically results in a progressive decline in hand function.^[6]

Surgery for RA aims to rectify and prevent deformity, restore function, and relieve pain.^[7] Surgery is often indicated by persistent pain and refractory synovitis lasting 3–6 months, while the timing and criteria for surgery are still up for debate.^[8], ^[9]

Prophylactic and therapeutic surgical treatments can be used to treat RA.^[10] In an effort to improve the condition, prophylactic surgeries (synovectomy or tenosynovectomy, respectively) remove inflammatory synovial or tenosynovial tissue to maintain joint health or avoid tendon rupture.^[11], ^[12] Therapeutic operations concentrate on enhancing function and reducing pain in circumstances where tendon rupture and joint destruction are already present; such procedures include joint fusions and joint replacements.

In general, more proximal joints are treated during surgery before distal joints. In most cases, lower extremity treatment comes before hand or wrist surgery. Patients with quiescent disease are not excluded from surgery, but it is crucial to coordinate the patient's medication management throughout surgery and the recovery period with the rheumatologist. The use of disease-modifying drugs, especially those that suppress TNF-alpha, can impair healing and increase the chance of infection following surgery. ^[13], ^[14], ^[15], ^[16] Successful care in these circumstances depends on the collaboration between the surgeon and the rheumatologist.

Most patients with RA are sent to the surgeons late in the course of their disease. Joint destruction is frequently visible in patients with chronic illness; in such instances, many preventive operations are not possible. Lack of level I outcome studies to support surgical intervention over routine medicinal care and inadequate communication between rheumatologists and Orthopaedic/Hand Surgeons have both been blamed for the delay in surgical referrals. ^[10], ^[17], ^[18] There is lack of standardization in the operative management of Rheumatoid Hand. There are very few published randomised studies of the various operative procedures and their outcomes. Hence there is also lack of operative guidelines. This review tries to look into the available literature on the various operative procedures and their efficacy.

Materials and Methods

According to the approach outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins Julian and Green, 2011a), ^[19] this study was carried out and is presented in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Higgins et al., 2015).^[20]

Results

In Divelbiss et al., ^[22] All range-of-motion values improved after surgery and The DASH scores improved significantly from before surgery at the 6-month and 1-year follow-up visits, with an average improvement of 14 points at 1 year ([Table 1]).

In Radmer et al., ^[23] After a positive short-term result, the outcomes got worse over time. The following issues developed: 33 loosening or dislocations, 2 infections, 3 implant failures, and 2 prosthesis migrations. Revision surgery was performed on all patients (39 of 40), and in every case, substantial titanium wear in the soft tissues was discovered during surgery. Evidently, even in a non-weight-bearing when utilized as a bearing surface of the implant, titanium alloy may deteriorate and cause tissue metallosis in a joint like the wrist. All patients had an arthrodesis as a salvage treatment after the prosthesis was removed. According to the 18-month data, all patients showed an increase in ulnar wrist deviation, which clinically caused a significant malposition and a sharp decline in grip strength and range of motion ([Table 1]).

In Rauhaniemi et al., ^[24] Preoperatively, the average pain score in the operated wrist was 3.6 (range, 1-4); at 6 weeks, it was 1.9 (range, 1-4); and at 1 year, it was 1.3 (range, 1-4). At one year after the right wrist's fusion, the right hand's grip strength was 24% higher than it was on the left, which had not undergone surgery. At one year after the left wrist was fused, the left hand's grip strength was 20% stronger, but the right hand's grip strength was just 4% better ([Table 1]).

In Ward et al., ^[25] At the time of the most recent follow-up, the average DASH score had decreased from 62 points preoperatively to 40 points. At the time of the most recent follow-up, the average wrist flexion and extension were 42° and 20°, respectively, for a mean improvement in the whole flexion-extension arc of 14°. At the time of the most recent follow-up, nine wrists (or 45%) in eight patients had revision surgery due to a loose carpal component. Due to repeated wrist instability, one patient had wrist arthrodesis. At the time of the most recent follow-up, two more wrists in two patients revealed radiographic evidence of carpal component subsidence. The original prosthetic components' implant survival rates at five and seven years were, respectively, 75% and 60% ([Table 1]).

In Harlingen et al., ^[26] 7-year survival was 81% (95% CI: 64-91). There were 31 problems. Radiographs of 22 wrists revealed loosening. With the exception of pronation, all other range of motion were improved. The median postoperative pain score (from 0 to 10) was 0 (0-6) at rest and 0 (0-7) during activity, and the mean DASH score improved ([Table 1]).

In Herzberg et al.,^[27] In rheumatoid and non-RA group, visual analogue scale (VAS) pain score improved by 48 and 54 points, respectively, and Quick DASH score improved by 20 and 21 points, respectively, with no statistical differences. There is an improvement in Post op grip strength by 40% ([Table 1]).

In Pfanner et al., ^[28] Between 24 and 148 months, the mean follow-up lasted 82.3 months. The mean VAS score preoperatively was 9 and dropped to 0.82 after surgery in all patients, showing a considerable reduction in discomfort. All patients said they would have the operation again. In every patient, grip strength and hand dexterity improved; the mean grip strength postoperatively was 11 kg (Jamar Hydraulic Hand Dynamometer). ROM of radial-ulnar deviation was found to be 24.9 degrees (from 0 to 42 degrees) and the mean total postoperative flexion-extension ROM was 72.3 degrees (from 38 to 110 degrees). Quick DASH 49 and PRWHE 41.7 were recorded in the postoperative self-assessment for activities of daily life ([Table 1]).

In Philip et al.,^[29] Overall, patient reported outcomes in the M-SACRAH questionnaire's functional, stiffness, and pain categories seem to be quite favorable across the spectrum of surgical treatments that can be carried out in the rheumatoid hand ([Table 2]).

In Ishikawa et al., ^[30] Overall, there was a significant improvement in upper extremity function (DASH), physical function and QOL (J-HAQ), QOL (EQ-5D and GH), and depression/mental health (BDI-II) at 6 and 12 months following surgery compared to baseline. Following surgery, disease activity (DAS28-CRP (4) and SDAI) also decreased ([Table 2]).

In Okura et al., ^[31] According to their original patient-reported outcome assessment instrument, elbow, wrist, and hand surgery helped RA patients in the long run. Pain alleviation was the most beneficial result, despite the fact that effectiveness varied depending on the surgery site. The patient's perception of the results of the operation ten years later may have been modified by altered medical therapy ([Table 2]).

Discussion

The purpose of this review is to evaluate the effectiveness of surgery in the treatment of hand illness associated with RA. However, the majority of the studies that were found had methodological issues. The method of study (i.e., series of cases rather than randomized controlled trials), the patient recruitment (i.e., heterogeneity in terms of diagnosis), and the evaluation criteria. As a result, it has been challenging for us to come up with responses that are definitive to our original query. Even after taking into account all of these drawbacks, clinical efficacy for both total carpal arthrodesis and metacarpophalangeal arthroplasty can be seen as trending in the right direction. Both treatments have demonstrable short-term success in lessening pain and enhancing joint function.

It's interesting to note that the majority of the methodological challenges with these studies could be fixed in later research. Specifically, prospective studies with a control group should be planned to conclusively show if one operation is superior to another or to medical therapy alone (i.e. no surgery). In order to prevent the confusing effects of a heterogeneous patient population, patient recruitment should also be more uniform in terms of diagnosis, seriousness of disease, and kind and length of medical therapy. Additionally, the selection of outcome markers ought to emphasize clinical factors (such as pain reduction, functional progression, general patient comfort), rather than those with ambiguous therapeutic relevance (such as variations in joint arc motion). Similar to the existing markers of result for medical treatment, outcome markers for the surgical treatment of the RA-associated hand disease should be discovered and assessed. ^[32] Last but not least, patients should undergo post-operative evaluations at regular intervals. This would make it possible to compare short- and long-term outcomes as well as keep track of issues when they arise.

Conclusion

Even though the effectiveness of medicinal treatment for RA has decreased the need for surgery, there are still some cases of RA-related hand disease that need to be managed surgically. Future research should hopefully shed more light on the relative usefulness of the various surgical techniques, improving the clinical management of hand illness in RA patients.

Conflict of Interest

None.

Source of Funding

None.