Soft-Tissue Surgery in Rheumatoid Arthritis: Synovectomy, Tendon Repair, and Carpal Tunnel Release
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.
Swelling from rheumatoid arthritis can contribute to the development of carpal tunnel syndrome. If DMARDs, anti-inflammatory drugs, or steroid injections into the wrist have not decreased the swelling and resolved the complications of CTS, carpal tunnel release surgery may become necessary.
In carpal tunnel release, the surgeon cuts the carpal ligament to help reduce pressure on the median nerve and provide for more space in the carpal tunnel. Surgery may be conducted through an open incision (up to 2 inches) or with endoscopic technique. Endoscopic surgery may minimize post-operative pain and scarring. If synovium covering the tendons traveling through this small space are inflamed, they may be removed.
View an animated video which explains the anatomy of the carpal tunnel and demonstrates carpal tunnel release surgery. (Warning: Graphic images of open wrist surgery are available for viewing here.)
Full recovery may take months and some patients may experience infection, nerve damage, stiffness or pain. Occasionally the wrist may lose strength when the carpal ligament is cut. Physical therapy can help to restore wrist strength.
Synovectomy: An Interview with Dr. Mark Figgie and Dr. Daniel Green © Hospital for Special Surgery, New York, NY.
Sung-Jae Kim and Kwang-Am Jung. Arthroscopic Synovectomy in Rheumatoid Arthritis of Wrist. AClin Med Res. 2007 December; 5(4): 244-250.
Adult Hand Patient Guides at OrthoPod.com