Orthopedic Surgery: The Forgotten Specialty In Rheumatoid Arthritis

Hello,

I have a finger joint that needs to be either replaced or fused together.  My ortho doc said that not very many replacements are done with fingers and he is advising me to do a fusion.  I would like to find people that have had both prodecures done.  Do you have any info on this?

hi - last year I actually had two (and a half, in a way) surgeries.  The first was a 'tendon reconstruction' of the Posterior Tibial Tendon in my right foot.  Even though this is not a "joint", I believe it relates to RA, because my already-somewhat-flat foot developed "adult-acquired flat-foot" after trying a) 'walking differently' b) orthotics c) iontophoresis with cortisone, followed by a diagnosis of RA when my wrist also developed problems, and other testing was done.  Before surgery I also used a) over-the-counter ankle brace(s), a couple of years in a terrific ankle-foot-orthotic (thought we had the problem solved, I could walk miles in it), followed by further deterioration.  although there was "no frank tear" when they finally went it, MRI had shown a tear of some kind, and I was getting increasing pain in different parts of the foot.

The above saga took place involving my GP (PCP), an orthopedist, a podiatrist, and a specialist in foot surgery (I acquired a rheumatologist along the way after the diagnosis, but he was not directly involved in my decisions about the foot!   Except for telling me (when I asked) to stay off Enbrel for several weeks before and after the sugery.  I actually exceeded his instructions out of caution.

     My second surgery was for carpal tunnel in the wrist opposite the one the RA had already affected.  It went very successfully.  My rheumatologist asked if I'd kept up on the Enbrel shots, because he said sometimes CT has gone away with the biologic drugs.  I had had to cut back due to sinus infection, but I had had mild tingling in some of the fingers for a long time anyway - just didn't realize it meant carpal tunnel because it seemed so mild, like the pins and needles of when you've sat on a limb.  At the same time, it took 7 weeks for the numbness to go away.  BUT   it has not returned!  Success...

     My 3rd surgery (half-surgery, Icall it!) was to remove an orthopedic screw from the foot that had the tendon reconstruction.  Why?  because the surgeon also did a calcaneal osteotomy (now this sounds terrible, but it's not really - they basically cut off part of your heelbone and move it over a certain distance to align it better to make the tendon hold up better.  Then, when it's healed they can remove the screw - although they don't have to, depending on if it bothers you.  I was discouraged at first that I had to go through another recovery period, but now I am doing very well.  So - it was really a full year to where I am now, not just 4 months or so. 

     Tips for lower limb surgery:   having a "Roll-A-Bout" saved my sanity.  I was able to buy one on eBay for $200 from R&R Discount MEdical Supply through eBay.  The rental would have cost about the same, however, I can keep this in case of any future problem.  It's adaptable for either left or right, and height adjustable. I could roll aroune the kitchen, put away dishes, even carry a laundry basket, or drag it, or push it, if necessary.  You do have to lift the front wheels if you're turning (unless you have a 'turning knee caddy' but they are less stable with only 3 wheels.

     Ellen

I'd like to follow up on question I posed about wrist fusion vs. wrist replacement:

Someone asked, "how could you still have arthritis in the joint, after it's replaced?"  I was told by the hand surgeon's P.A. that even if I had a replacement, the arthritis doesn't go away, and so it can still progress.  Which made sense to me (even tho' I didn't want to hear it) because - the replacement has to be ATTACHED to the bones that are left (i.e., radius and metacarpals), and they are subject to the arthritis as well, of course!  Replacements can come loose, and then need more work, or an eventual fusion anyway.  She recommended doing the  best I could with meds & splint for as long as possible before doing fusion.  Ironically her boss, the hand surgeon, when I said I didn't want the replacement because the arthritis would still progress, he replied, with slight impatience, "There won't be any more arthritis because the bones won't be there!"  At that point, I realized that there was a gap of understanding here, and that he might not be the best person to pursue this with - which had been my gut feeling from the beginning anyway....Someone else in the office later told me they did have patients doing well with replacements - but I'd already made my decision, on the basis of my GP, rheumatologist, and another hand surgeon all saying the fusion - at the appropriate time - would be a safer option.

Hi Dr. Boriginni,

It's really good to find an MD on this website -- I appreciate it.  I just wanted to ask a sort of general question.  I am really struggling with my RA, getting much worse all the time, and very depressed and scared about what my life is becoming.  I'm 55, was diagnosed about 25 years ago with what the doctors then thought was most likely juvenile onset.  I had had pain and stiffness since I was a child, but somehow thought that everyone felt that way.

For many years I managed well -- the disease was only in my upper body, so I could get around, hold a job, lead a pretty normal life.  Then I had early menopause at 38, and everything got drastically worse very fast.  Within a year I had my right elbow replaced (which saved my life -- before surgery I wasn't even able to write, and I'm a writer, and the constant severe pain was unbearable, so that surgery for me was a huge success.)

But in the years since, the RA has invaded just about every joint in my body.  Now I can hardly walk.  I do, very slowly and carefully with cane, but it's getting harder and harder.  I have to take pain meds every day, since without them I can't even manage to get out of bed, and life does not seem worth living.  I'm on Enbrel, and after a very very brief "honeymood", when I had the blissful experience of feeling almost "cured," it seems to be doing hardly anything now.  Previously I had started on Humira, but had a bad allergic reaction, so was switched to the Enbrel.  

I am quite afraid of these anti-TNF meds.  I know that they help so many people, but I'm not having that experience, and I'm getting sick all the time due to the partically suppressed immune system.  It is really worrying me.

I feel strongly that I could benefit a lot from more surgery now.  The worst pain now is in both hips (constant and severe -- keeps me from sleeping even on pain meds), and in one knee.  

And yet when I try to talk to my rhumatologist about surgery, I don't know why but she just sort of shakes her head like she thinks I'm exaggerating or something.  I don't understand it.  She doesn't order xrays or blood tests or anything, just tells me to stay on the Enbrel, and constantly tries to lower my dose of pain meds.  God forbid I should try to raise the subject of reasonable titration after years of treatment.

I'm sorry for sending such a long message, but I really don't know what to do.  

I don't have insurance, and can no longer work, and have not succeeding get disability in Colorado where I live.

Any advice at all that you might have to offer would be a great help.  For instance, is there any way that you know of for people without insurance to arrange to get surgery -- payment plans, or grants of some kind?  It's terribly to know that there are things that could help so much and that are not available because I can't afford them.

Thanks for reading this.

Susan Noel

Doc,

Any comments on foot neuromas?  I do OUTWARDLY agree that the surgeon must work with the Rheumatologist.  What if that surgeon is a fellow (you know what I mean) and snubs off the Rheumatologist?

I was desperate to get rid of my neuroma and very happy now, more than a year later that I did.  But the recovery was NOT three weeks.  It will be at least 2 years, even with aggressive physical therapy.  I am in very good shape, a personal trainer now gone jewelry designer.

But what do you think about this unwillingness for surgeons to want us to get second opinions on all fronts???????

Thanks!