Surgical management of rheumatoid arthritis aims to relieve pain, improve function, and correct deformities for patients who have not responded well to medical management. Procedures include joint preservation surgeries like synovectomy to remove inflamed synovium and prevent further damage, as well as joint replacement surgeries like arthroplasty. While medical advances have reduced the need for surgery, it remains an important option for late-stage rheumatoid arthritis patients seeking functional gains and improved quality of life.

1. SURGICAL
MANAGEMENT
IN
RHEUMATOID
ARTHRITIS (RA)
MODERATOR’S : PROF. DR. ARUN HS
ASSOCIATE PROF. DR. HARI PRASAD S

2. Lesson plan
Introduction : 1 min
Larsen score : 2 mins
Joint preservation surgeries : 3 mins
Joint replacing surgeries : 3 mins
Summary : 1 min

3. INTRODUCTION
• Advancement in the medical management of Rheumatoid
Arthritis (RA), has markedly decreased the incidence of
surgeries in patients with RA.
• However, the prime indications for surgery in patients with
Rheumatoid Arthritis, are those who seek for functional gain,
pain relief and aesthetic improvement
Ref: Chung KC, Kotsis SV, Kim HM, et al. Reasons why rheumatoid arthritis patients seek surgical treatment for hand
deformities. J Hand Surg Am 2006;31: 289e94

4. LARSEN SCORE
0 Normal joint, no changes
1 Osteoporosis and swelling
2 Joint space narrowing and erosion
3 Significant erosion, moderate destruction
4 Loss of joint space, severe destruction
5 Ankylosis

5. Osteoporosis and swelling Joint space narrowing and erosion

6. Significant erosion, moderate destruction Loss of joint space, severe destruction

7. Ankylosis

8. JOINT
PRESERVATION
SURGERIES
Synovectomy
Teno - Synovectomy
Osteotomy

9. SYNOVITIS: Inflammation of the
synovium leading to joint destruction

10. Activated neutrophils from the Pannus release lysosomal
enzymes and free radicals destroy the articular surfaces

11. Knee effusion

12. SYNOVECTOMY
• Surgical removal of synovium that lines a joint
• The aim of synovectomy to stop or decrease joint damage
• Is indicated if pain, swelling and radiological changes do not
resolve despite of sufficient therapy within 3–6 months
Ref:Trieb K, Hofstaetter SG. Treatment strategies in surgery for rheumatoid arthritis. Eur J Radiol. 2009 Aug;71(2):204-
10. doi: 10.1016/j.ejrad.2009.04.050.

13. ARTHROSCOPIC SYNOVECTOMY

14. INTRA OP IMAGES OF THE HYPERTROPHIED SYNOVIUM
“ANGRY
SYNOVIUM”

15. ADVANTAGES OF ARTHROSCOPIC
SYNOVECTOMY
1. Incision is minimal
2. Quadriceps muscle remains intact
3. Incidence of infection is less
4. Incidence of hemarthrosis is less
5. Postoperative physio therapy is minimal

16. OPEN ANTERIOR
SYNOVECTOMY
• Hyperemic and
hypertrophic synovium
can be appreciated
• “Angry synovium”

17. Early synovectomy can
reduce pain and
swelling
But the progression of
intraarticular cartilage
destruction cannot be
completely stopped but
can be delayed
Ref:Trieb K, Hofstaetter SG. Treatment strategies in surgery for rheumatoid arthritis. Eur J Radiol. 2009 Aug;71(2):204-
10. doi: 10.1016/j.ejrad.2009.04.050.
WHAT HAPPENS AFTER SYNOVECTOMY ?

18. WHERE SYNOVECTOMY PREFERRED?
Shoulder
Elbow
Wrist
Knee

19. RADIOSYNOVIORTHESIS (RSO)
• It is a minimally invasive therapeutic method of treatment
• By injecting radioisotopes in to the joint it destroys the
hypertrophied synovial tissue in situ

20. • Such therapy is today considered an appropriate for
Larsen classification is stage 1 without joint
destruction
• Yttrium- 90 is used for knee
• Rhenium - 186 used for elbow, wrist, ankle
• Erbium- 169 used for fingers
Ref:Trieb K, Hofstaetter SG. Treatment strategies in surgery for rheumatoid arthritis. Eur J Radiol. 2009 Aug;71(2):204-
10. doi: 10.1016/j.ejrad.2009.04.050.

21. A SEVERELY DEFORMED RHEUMATOID HAND
Ulnar deviation of the
digits

22. TENO-SYNOVECTOMY
• Inflammation of the synovial lining of extensor tendons over
the dorsal hand and wrist
• Results in synovial tissues invade the tendons, cause them to
rupture
• Recommended when synovitis persists for 3 to 6 months despite
aggressive medical management
Ref: Kozlow JH, Chung KC. Current concepts in the surgical management of rheumatoid and osteoarthritic hands and
wrists. Hand Clin. 2011 Feb;27(1):31-41. doi: 10.1016/j.hcl.2010.09.003.

23. INTRA-OP IMAGES OF EXTENSOR TENOSYNOVECTOMY
Extensor
tenosynovitis
with rice
bodies
Excision of
extensor
tenosinovium
Ref: Kozlow JH, Chung KC. Current concepts in the surgical management of rheumatoid
and osteoarthritic hands and wrists. Hand Clin. 2011 Feb;27(1):31-41. doi:

24. EXTENSOR TENSON RUPTURE
TENDON TRANSFER

25. OSTEOTOMY
• Proximal tibial osteotomy is useful for correcting varus or
valgus deformities of an arthritic knee
• It realigns the weight-bearing axis the less involved
compartment

26. • But, contraindicated in rheumatoid arthritis because the disease
evenly distributed
• In addition, the osteoporotic bone in RA makes the procedure
more demanding

27. JOINT
REPLACING
SURGERIES
Resection-
Arthroplasty
Arthroplasty
Arthrodesis

28. RESECTION- ARTHROPLASTY
Indicated in patients who has high risk for hip replacement due to
underlying comorbidities

29. THE SHOULDER ARTHRITIS IS ADDRESSED WITH
REVERSE SHOULDER ARTHROPLASTY

30. TOTAL ELBOW ARTHROPLASTY
Considered for Larsen Score 4 - 5

31. TOTAL WRIST ARTHROPLASTY

32. ULNAR DEVIATION OF THE DIGITS

33. `
SWANSON SPACERS-
FINGER JOINTS

34. METACARPOPHALANGEAL JOINT
REPLACEMENT

35. BOUTONNIERE DEFORMITIY

37. TREATMENT
• Splinting
• Primary tendon repair +splinting
• Lateral band relocation
• Arthrodesis

38. TOTAL HIP REPLACEMENT

39. UNI-COMPARTMENTAL KNEE ARTHROPLASTY
“Uni-compartmental” refers to resurfacing only one
compartment which is affected
It restores the knee kinematics without significantly
altering the natural alignment or ligament balance
It provides a faster recovery time

40. UNICOMPARTMENTAL KNEE ARTHROPLASTY

41. INTRA–OP IMAGES OF TOTAL KNEE
ARTHROPLASTY

42. Rheumatoid arthritis of bilateral knee with valgus deformity with
TKR both the joint pathology and valgus mal-alignment is
addressed at the same time

43. ARTHRODESIS
• Primary arthrodesis for treatment of the rheumatic joint will
result in a fixed joint without inflammation and pain
• In the last two decades the frequency is decreasing
because of the good experiences with arthroplasties
• However few joints are better do well with arthrodesis
Eg : wrist arthrodesis

44. WRIST ARTHRITIS WITH ULNA
SUBLUXATION

45. a. A global forefoot
deformity secondary to
Rheumatoid arthritis
b. Deformity correction
with forefoot arthrodesis
Ref: Roukis T.S., Davidson D. (2019) Fifth Toe Proximal Interphalangeal Joint Arthrodesis. In: Cook E., Cook J. (eds) Hammertoes.
Springer, Cham. https://doi.org/10.1007/978-3-319-16552-3_21

46. PATIENT WITH C1- C2 INSTABILITY
C1-C2 trans-articular screws with Magerl technique

47. SUMMARY
• Rheumatoid disease is an autoimmune progressive
inflammatory disease
• Advancement in the medical management the joint destruction
and disability's have been reduced grossly
• But there are patients who do not respond well with medical
management ending up in joint destruction with disability
• So, for a pain free joint and deformity correction, surgery
and joint replacement are the only aid at the END!

48. Thank You
Towards A Disability Free Society