What to Expect With Rheumatoid Arthritis Surgery

If you’re living with rheumatoid arthritis (RA), most of the time, your symptoms can be managed with medication. Sometimes, though, that’s not enough to keep the pain of RA in check. Although medications have become increasingly effective, if the disease has caused significant damage in your RA-affected joints, meds alone will not be able to undo the source of your discomfort. If that’s your experience, surgery could be a viable next step.

Who Needs RA Surgery?

Surgery is much less common than years ago, thanks to non-surgical rheumatoid arthritis treatments that have gradually become more effective. “When I was in training more than 25 years ago, we frequently operated on patients with RA,” says Brian J. Cole, M.D., a shoulder, knee, and elbow surgeon in Chicago. Today surgery is used only when “some patients develop problems that medical management cannot prevent or treat effectively, and occasionally surgery is warranted.”

Together with your rheumatologist, you’ll decide whether surgery is an option you want to consider. If rheumatoid arthritis surgery is the most appropriate choice, surgeons typically perform one of several types of procedures.

Rheumatoid Arthritis Surgery Options

One or more surgical procedures of varying degrees of invasiveness and intensity may be appropriate for your RA-damaged joints. Dr. Cole says that post surgery you should experience a reduction (or even elimination) of pain. You should also see a restoration of function and activity levels.

Arthroscopy for RA

An orthopedic surgeon often performs an arthroscopic procedure on a patient’s hip, knee, or shoulder. After making a small incision, the surgeon uses small tools and a thin lighted tubular camera called an arthroscope to clean and remove joint debris. The procedure may also include removal of loose bone or cartilage and smoothing out of joint surfaces.

Often performed on larger joints, an arthroscopy may offer some pain relief and improve joint function. However, the procedure is less effective in cases of advanced joint deterioration and won’t stop rheumatoid arthritis progression.

Bone or Joint Fusion

Some people with rheumatoid arthritis undergo a bone or joint fusion (or arthrodesis). This procedure addresses arthritis in wrists, finger joints, ankles, or toes. In arthrodesis, the surgeon removes the damaged joint and fuses the surrounding bones together. Afterward, you should have more joint stability and less joint pain.

One study in the World Journal of Orthopedics found the procedure to be highly effective lowering pain in patients with RA of the wrist. However, the fused bones will result in less range of motion.

Carpal Tunnel Release

Carpal tunnel release is a surgical procedure that ideally heals painful carpal tunnel syndrome in your wrist. This condition can be a complication of rheumatoid arthritis caused by inflammation in the wrist that leads to swelling and nerve compression.

During the carpal tunnel release surgery, the surgeon cuts apart the ligament that forms the roof of the carpal tunnel, giving the nerves running through your wrist more space and hopefully relieving painful nerve compression. This often results in improved function and decreased pain, per Johns Hopkins Medicine.

Synovectomy for RA

Most of the human body’s 300 joints are synovial joints. That means these joints have an inner lining called the synovium that facilitate movement and can be impacted by RA (which is, essentially, inflammation of this synovial lining in one or more joints). During a synovectomy, the orthopedic surgeon removes most of the inflamed synovial tissue around the joint.

This procedure ideally reduces (or even eliminates) your symptoms. One study in the journal International Orthopaedics found the procedure effective at restoring knee functionality in RA patients while improving their quality of their post-op life. However, it’s impossible to remove every bit of compromised tissue, so symptoms may return.

Total Joint Replacement (Arthroplasty)

For severely damaged joints, a total joint replacement (or TJR) surgery, also known as an arthroplasty, can be a last resort. It may be appropriate for people whose non-surgical treatment has not improved their joint function and/or reduced their pain. As medications have improved, rates of arthroplasty in RA patients have decreased in the last 20 years, according to research in the journal Arthritis & Rheumatology.

“I have found that it is not nearly as common as it was early in my practice 20 years ago because the newer, disease-modifying medications work well,” agrees Texas-based orthopedic surgeon Scott A. Smith, M.D. “The incidence of really severe destructive changes in appropriately treated RA patients is much less.”

If you do opt for this joint replacement surgery, frequent targets include damaged knee or hip joints. Here, the surgeon replaces the worn-out joint with a metal and plastic implant. The replacement joint should function like a healthy natural joint.

Special Considerations for Spine RA Surgery

Certain surgical procedures remove pressure from the spinal cord at the cervical spine (neck) and provide spinal stabilization in people with rheumatoid arthritis. Per Johns Hopkins Medicine, you may need to have surgery if you have:

• Uncontrollable pain combined with neurologic dysfunction such as tingling or numbness in a limb or extremity

• Myelopathy (spinal cord compression)

• Severe weakness resulting in functional disability

Different surgical procedures are used to decompress the spinal cord. The goal in this surgery is to remove the offending tissue pressing on the spinal cord or nerves. The surgeon will make recommendations based on many variables, including the specifics of your condition.

Spinal Fusion

This surgical procedure may be used to correct spinal deformity and to provide permanent stability to the spinal column. RA does not affect the lumbar spine (lower back) or thoracic spine (mid back), so if you need spinal fusion, you'll need it in your neck.

During this procedure, medically designed hardware such as rods, bars, wires, and screws may be inserted in or around your spine. These devices hold the spine straight during fusion.

In spine stabilization by fusion, the surgeon creates an environment where the bones in your spine will fuse together over time (usually over several months or longer). The surgeon uses a bone graft (usually using bone from your own body, but it's possible to use donor bone as well) or a biological substance (which will stimulate bone growth).

The fusion will stop movement between the vertebrae, providing long-term stability. A drawback of the procedure is that your joints, once fused, will lose a decent amount of range of motion.

Recovery from Surgery for RA

Living with rheumatoid arthritis involves learning to adapt and making lifestyle changes that include a good diet, exercise, and rest. Here are some ways to deal with RA, per the Cleveland Clinic:

• A physical therapy (PT) program can help restore muscle strength, flexibility, improve mobility, coordination, and maintain body functions through exercise. Massage, hydrotherapy, and other modalities can relieve pain.

• Occupational therapy (OT) teaches you how to cope with everyday life. OT encourages independence by helping you relearn how to do daily tasks such as dressing, bathing, food preparation, going to the toilet, and other activities of daily living.

• A personal medical diary can help keep track of doctor appointments, medications taken on a daily basis including supplements (vitamins, herbs), drugs that alleviated symptoms, side effects, flare-ups, and remissions.

Depending on rheumatoid arthritis disease progression, surgery can be an essential procedure or an elective option. By consulting with a skilled, empathetic orthopedic surgeon, each patient can make the decision that’s best for them.