People with rheumatoid arthritis, or RA, in their hands or wrists often have swelling in the lining of the joints or tendons, called synovium. Sometimes, inflammatory cells form tissue that pushes joints out of position and changes their shape.
Medications and other treatments can help keep RA under control. But if you notice pain, swelling, changes, or distortion even as you’re sticking to your treatment plan, it’s time to see a hand surgeon right away. Surgery can ease pain and help your wrist or hand function better. It also can bring back your confidence and personal freedom, as well as improve how your hand or wrist looks.
Surgical treatments for RA of the hand and wrist include:
- Tendon transfer
- Tendon release
Most of the irritation that happens with RA is in the synovium. If you still have swelling during treatment, a skilled surgeon can remove the inflamed joint lining by open surgery or arthroscopic surgery. If a smaller amount of tissue needs to be removed, you might have a partial synovectomy. In a complete synovectomy, all of the synovium will be cut out.
Synovectomy can make a drastic difference in how your hand or wrist works and get rid of pain. A day or two after surgery, you’ll start rehab to work on flexing the joint. You’ll keep taking meds to keep swelling down so the condition doesn’t happen again.
Complication rates are low for synovectomy. You may have some stiffness, especially if you have open surgery. Physical therapy will help relax the joint.
Arthroscopic synovectomy. This type of surgery uses miniature surgical instruments and a tiny camera to see inside your joint. Your surgeon will make an incision about the size of a buttonhole. The procedure can ease pain and revive function in your wrist or hand. This type of surgery requires a shorter hospital stay than for open surgery. You can start rehab sooner and your recovery will be faster, too.
Arthroscopy requires more time and skill than standard open surgery. Experts also disagree about how well it works and recommend getting a second opinion if your doctor suggests it. Others consider it a better fit for active people who are younger than 40.
Arthrodesis treats arthritis pain in the distal interphalangeal (DIP) joint – the joint near the end of your fingers. Your surgeon will cut out the diseased cartilage, snip the ends of your joint bones, and use hardware – like plates, pins, or rods – to fuse your joint bones together. The “new” joint will be stronger and more stable. You won’t have much flexibility or movement in it, but your finger still might function better with less pain.
Over time, the bones grow together and lock the joint in place. Sometimes the fused bones don’t grow together or properly align, though. Then more surgery may be needed.
Arthrodesis works best for people with severe joint damage.
Arthroplasty is usually used to repair your metacarpophalangeal (MCP) joints where your fingers join your hand – aka your knuckles. Your surgeon will replace your damaged joint with an artificial one made of silicone, plastic, or metal (or a combo). You can have the procedure on several fingers at the same time, too. This will quell pain and bring back some function and shape in your hand. Several points to keep in mind with arthroplasty:
- How well the procedure works depends on how much soft, healthy tissue you have. People who’ve had RA for a long time usually have less than an ideal amount.
- Silicone rubber flexes easily, but it slips and breaks easily, too. It won’t act like your natural joint.
- As much as 30% of this type of joint implant doesn't last more than 10 years – even more of a drawback if you’re young.
- Your doctor might choose arthrodesis or arthroplasty based on factors that include your age, which joint needs to be repaired, and how much stiffness you can live with. Both procedures are sometimes performed on different joints in the same hand.
Tenosynovitis is inflammation of your tendon sheath, the slippery synovial tissue that surrounds and protects your tendons. Fluid buildup and swelling can thicken the tissue in your wrist or fingers, causing not only swelling and pain but tendon weakness and even rupture.
A tenosynovectomy can keep this from happening. Your surgeon will remove the tenosynovium – the swollen lining tissue – from your tendons. That will cut inflammation, increase your blood flow, and give your tendon space to move freely again.
The procedure can be performed with open or arthroscopic surgery. It’ll take several weeks to a month to recover. You’ll likely need a splint or cast to keep your wrist still as it heals. Physical therapy can help you regain strength and movement in your wrist. Some surgery centers report excellent results.
Tendon Transfer Surgery
If you have tendon damage that can’t be repaired, or a rupture, your doctor might recommend tendon transfer surgery. The procedure can restore lost hand function and rebalance your wrist and fingers. A working tendon is taken from one place and sewn to the damaged tissue. Your surgeon can transfer more than one tendon in a single surgery.
Your newly placed tendon will take 1 to 2 months to heal. You might wear a splint or cast to stabilize your wrist in the meantime. Physical therapy can help get back some function. Your doctor likely will hold off on exercises until healing is complete so the tendon doesn’t rupture.
Complications can include bleeding or infection near the site. Over time, you might have hand stiffness, weakness in the tendon that was transferred, or possible rupture. This would require another surgery.
Tendon Release Surgery
In this procedure, your surgeon will split or detach ligaments to ease pain and help you get back movement and function.