Surgical Repair and Reconstruction in Rheumatoid Disease

Over a decade has passed since the publication of the First Edition; we have yet to understand the pathogenesis of rheumatoid arthritis and there is still no cure. A wide range of developments in techniques, materials, imaging and understanding of biological processes justify this rewrite. Above all, the experience of many colleagues worldwide with commitments to a particular anatomical or technical area has led to a more balanced and refined approach to the problems of rheumatoid surgery. It has also highlighted areas where we need radically new solutions. The two additional authors, apart from their relative youth, bring expertise in their respective fields: Steve Copeland, on the shoulder and Jo Edwards on the mechanisms of tissue damage and the rationale of medical measures. We are conscious of the importance of communication between orthopaedic colleagues worldwide and the need to use a language shared with rheumatologists and histopathologists. We consider it is for the surgeon to know more of this disease than the narrow confines of surgical technique. We are doctors with a special interest in rheumatoid arthritis and we aim to maintain the broader view rather than be confined by the limitations of over specialisation. Although joint replacement is at present a major weapon for the relief of suffering we appreciate that it is an unphysiological procedure and there are other directions for progress.

1 General Considerations.- The Route to the Surgeon.- Diagnosis and Assessment.- Course of the Disease.- Communication.- Assessment of the Results of Surgery.- Bacterial Infection and Septic Arthritis.- Corticosteroids.- Bed Rest.- Psychological Factors.- Physiotherapy.- Surgical Trends.- 2 Aetiology and Pathology.- Aetiology.- The Causes of Rheumatoid Arthritis.- Disease Mechanisms.- The Nature of the Connective Tissue Lesion.- Cartilage and Bone Damage.- Vasculitis.- A General Disease Mechanism.- Targets for Drug Action.- Rationale for Synovectomy.- Synovitis Following Arthroplasty.- Synovial Biopsy.- Tissue Sampling.- Synovial Fluid Examination.- Lesions in Other Tissues.- Cardiac Involvement.- Associated Pathology.- Seronegative Spondarthropathies.- Systemic Lupus Erythematosus.- 3 Selection.- Assessment of the Specific Problem.- Surgical Selection.- Indications for Surgery.- Contraindications to Surgery.- Which Operation?.- How Soon?.- What Order?.- How Many?.- Recording a Decision.- 4 The Link with Medical Management.- The Physician’s Plan of Care.- Prognosis.- Physical Activity.- Local vs. General Measures.- Aspiration and Lavage.- Injection.- Radionuclide Injection.- Systemic Drug Therapy.- Systemic Features and Associated Medical Problems.- Anaemia.- Gastrointestinal.- Osteopenia.- Neuropathy.- Cervical Myelopathy.- Haemodynamic and Renal.- Skin.- Respiratory.- Sepsis.- Rheumatological Emergencies.- Children with Rheumatic Disease.- Summary.- 5 Perioperative Care.- Preoperative Assessment.- Preoperative Investigation.- Blood Tests.- Radiology.- The Immediate Preoperative Period.- Drugs in the Perioperative Period.- Care During Surgery.- Postoperative Care.- Splints.- 6 Synovectomy.- Damage Produced by Synovitis.- Treatments of Synovitis and Synovial Hypertrophy.- Simple Physical Means.- Antirheumatic Drugs.- Intra-articular Cytotoxic Agents.- Physical Agents.- Osteotomy.- Surgical Synovectomy.- The Shoulder.- The Elbow.- The Wrist.- Metacarpophalangeal and Proximal Interphalangeal Joints.- The Hip.- The Knee.- Metatarsophalangeal Joints.- The Ankle.- Tendons.- Recurrent Synovitis after Synovectomy.- Children.- Seronegative Arthropathies.- Conclusion.- 7 Osteotomy.- Jaw.- Shoulder.- Metacarpophalangeal Joints.- Hip.- Knee.- Ankle.- Foot.- Action of Osteotomy.- Operative Technique.- Internal Fixation.- Wedges.- Total Replacement or Osteotomy?.- 8 Arthroplasty.- Excision Arthroplasty.- The Lateral and Medial Ends of the Clavicle.- Excision Arthroplasty Following Failed Total Joint Replacement.- Soft Tissue Interposition Arthroplasty.- Replacement by Massive Cadaveric Grafts.- Replacement by Prosthesis.- Partial.- Total.- Total Prosthetic Joint Replacement After Osteotomy.- Anatomical Placement.- Complications of Prosthetic Joint Replacement.- Failure of Total Joint Replacement.- Infection.- Urinary Tract Problems.- Skin Flap Necrosis.- Metal Sensitivity and Toxicity.- Cement Toxicity.- Loosening and its Diagnosis.- Material Problems.- Design of Cementless Implants.- Dislocation.- Fat Embolus.- Fractures Around Prostheses.- Surgery After Failure of a Prosthesis.- Revision.- Excision Arthroplasty.- Arthrodesis.- 9 Arthrodesis.- Cervical Spine.- Shoulder.- Elbow.- Wrist.- Carpometacarpal Joint of the Thumb.- Metacarpophalangeal Joint of the Thumb.- Interphalangeal Joint of the Thumb.- Proximal Interphalangeal Joints of the Fingers.- Distal Interphalangeal Joints of the Fingers.- The Hip.- The Knee.- The Ankle.- Subtaloid Joint.- Midtarsal Joints.- Metatarsophalangeal Joints.- Proximal Interphalangeal Joints of the Toes.- Distal Interphalangeal Joints of the Toes.- 10 The Spine.- Pathology.- Clinical Features.- Imaging of the Rheumatoid Spine.- Conservative Management.- Psychological Support.- Surgical Management.- Dorsal and Lumbar Spine.- Ankylosing Spondylitis.- Spinal Osteotomy.- 11 The Shoulder.- Progression of Joint Damage.- Rotator Cuff Impingement.- Acromioclavicular Joint.- Sternoclavicular Joint.- Glenohumeral Joint.- Shoulder Synovectomy.- Osteotomy.- Arthrodesis.- Glenoidectomy.- Interposition Arthroplasty.- Hemiarthroplasty.- Total Shoulder Replacement.- Conclusion.- 12 The Elbow.- Extra-articular Disease.- Fasciitis.- Tendinitis.- Bursitis.- Nerve Compressions.- Intra-articular Disease.- Synovitis.- Erosive Disease with Instability.- Arthrodesis.- Arthroplasty.- Excision Arthroplasty.- Fascial or Skin Arthroplasty.- Silicone Rubber Interposition Arthroplasty.- Prosthetic Replacement.- Conclusion.- 13 The Wrist.- The Carpal Tunnel.- The Long Flexor Tendons.- The Long Extensor Tendons.- De Quervain’s Disease.- Deformity at the Wrist.- The Z Deformity.- Volar Subluxation of the Wrist.- Articular Pain.- Surgical Options.- Ulnar Head Excision.- Fibrous Stabilisation.- Limited Arthrodesis.- Arthrodesis.- Arthroplasty.- Surgical Technique: A Few Suggestions.- 14 The Hand.- Assessment and Priorities in Rheumatoid Hand Surgery.- Patterns of Disease.- Soft Tissue Swellings.- Rheumatoid Nodules.- Synovial Swellings.- Synovitis.- The Flexor Apparatus.- Synovitis of the Joints.- Genesis of Joint Deformity.- Finger Deformities.- Arthroplasty in the Hand.- Arthroplasty of the Metacarpophalangeal Joints.- Arthroplasty of the Interphalangeal Joints.- Arthrodesis.- The Rheumatoid Thumb.- The Jaccoud Hand.- Operative Techniques.- Conclusion.- 15 The Hip.- Surgical Priority.- Synovectomy.- Adductor Tenotomy.- Osteotomy.- Excision Arthroplasty.- Hemiarthroplasty.- Total Hip Replacement.- Indications.- Special Problem Groups.- Preoperative Considerations.- Technical Considerations.- Surgical Approach.- Prosthetic Designs.- Complications.- Advice for Patients Following Total Hip Arthroplasty.- Long-Term Outlook and Assessment of Total Joint Replacement.- 16 The Knee.- Examination.- Conservative Treatment.- Quadriceps Exercise.- Plaster Immobilisation.- Flexion Deformity.- Steroid Injection.- Operative Treatment.- Soft Tissue Release.- Patellectomy.- Debridement, Cheilectomy and Pridie’s Procedure.- Synovectomy.- Osteotomy.- Bone and Cartilage Transplantation.- Total Replacement.- Conclusion.- 17 The Ankle and Foot.- Clinical Assessement.- Aims of Surgery.- Perioperative “Tips”.- Ankle and Hindfoot.- Hindfoot Signs.- The Valgus Hindfoot.- Tibialis Posterior.- Mid-foot.- Forefoot.- Metatarsal Osteotomy.- Sesamoids.- Morton’s Metatarsalgia.- Toe Deformities.- The Hallux.- The Lateral Four Toes.- Claw Toes and Plantar Prolapse of Metatarsal Heads.- Vascular and Neurological Problems.- Conclusion.- 18 The Rheumatoid in Society.- Prevalence.- Aids to Daily Living.- Walking Aids.- Chairs.- Wheelchairs.- Footwear.- Chiropody.- Diet.- Work.- Mobility.- Recreation.- Sexual Problems.- Planned Motherhood.- The More Disabled Person.- Conclusion.- Author Index.