In the previous post, we discussed different types of surgeries which are used in patients with rheumatoid arthritis.  This week I’d like to talk more about surgeries involving soft-tissue, specifically synovectomy, tendon repair, and carpal tunnel release.

What is a Synovectomy?

The synonium is a membrane surrounded a joint, usually only one or two cell layers thick, which produces synovial fluid to help lubricate the joint.  In rheumatoid arthritis, the synovium becomes inflamed and may grow excessively, producing too much synovial fluid containing an enzyme that can eat away at the cartilage on the joint surface.  Disease-modifying anti-rheumatic drugs (DMARDs) are used to control the abnormal growth of synovium.

If DMARDs do not work, a patient’s rheumatologist may suggest steroid injections into a joint or a needle aspiration of excess synovial fluid.  If these strategies do not work, then the patient may be referred to an orthopedic surgeon to discuss the removal of the synovium.  This surgery is called a synovectomy and can be done as an open surgical procedure or through arthroscopic surgery.

Synovectomies are performed are knees, elbows, wrists, finger joints, and hips.  The surgery typically produces better results when the patient’s cartilage has not been eroded, thus it is recommended for patients who are in earlier stages of their disease.  Note that over time the synovium may grow back and require repeat surgery.

View an animated video of arthroscopic knee surgery including a synovectomy.

What is Tendon Repair?

Tendons connect muscles to bones, allowing you to flex and extend various bones and make a wide range of physical movements.  The severe swelling of rheumatoid arthritis may cause tendons to rupture (split) or become strained, especially in the hands.  The result can lead to loss of normal hand function.

If extensor tendons (which run across the back of the hand) are damaged, you may be unable to straighten one or more of your fingers.  If flexor tendons (which run along the wrist and palm) are damaged, you may be unable to bend your fingers, make a fist, or grip objects.  Other distinctive damage may include Swan Neck or Boutonierre Finger deformities.

When tendon damage occurs, you will likely need to undergo tendon repair surgery which involves locating the split tendons, making an incision in your hand, then stitching the tendon back together.  In general extensor repair is easier than flexor repair due to location and accessibility of the tendons.  An experienced orthopedic surgeon specializing in hands would be recommended for flexor tendon repair.

Additionally, in some instances a tendon transfer may be useful in repairing the damage caused by tendon rupture.

What is Carpal Tunnel Release?

The carpal tunnel is a narrow, rigid passageway of ligament and bones at the base of the hand.  The median nerve runs through the carpal tunnel from the forearm into the hand.  Carpal tunnel syndrome (CTS) occurs when thickening from irritated tendons or other swelling narrows the tunnel causing compression of the median nerve.  Symptoms include burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers.  Sharp pain often radiates up the arm and the patient’s grip strength may be decreased.