Rheumatoid arthritis is a chronic disease caused by complex and insufficiently known causes and mechanisms, so it is not surprising that its treatment is equally complex and prolonged.
Unfortunately, the currently available treatment does not allow curing the disease, although it does notably alleviate the intensity of the manifestations, reduce or even curb inflammatory activity and prevent the sequelae, once characteristic of advanced stages.
Treatment basically consists of the combination of non-pharmacological therapy and pharmacological therapy. In addition, surgery is sometimes used, for example to reconstruct affected tissue or to replace a severely damaged joint with a prosthesis.
Non-pharmacological therapy involves observing a series of recommendations related to rest and performing certain exercises aimed at improving the flexibility of the affected joints. Also, follow-up of physical therapy techniques or temporary immobilization of a body segment is often indicated, for example through the use of resting splints.
Pharmacological therapy consists of the administration of a wide range of medications, usually in combination and over long periods of time. Pain relievers and anti-inflammatories, which work by decreasing pain and inflammation, are among the most widely used, particularly non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. The most important drugs in the treatment of RA, however, are the so-called disease-modifying antirheumatic drugs (DMARDs), which receive this name because their action tends to stop inflammatory activity, so they can improve the course of the disease. disease.
DMARDs are usually indicated for prolonged periods of time, or even for life, since this seeks to achieve the “clinical remission” of the disorder, that is, to interrupt the inflammatory activity causing the lesions. Some of these drugs, such as methotrexate, leflunomide, sulfasalazine, and those known as antimalarials, have been used for many years, and are therefore known as “traditional” DMARDs.
For their part, the so-called “biological” DMARDs, which have recently appeared, represent a new generation of this type of medication and have represented a decisive advance in the treatment of RA. The main drugs in this group work by blocking substances that intervene in inflammatory processes, such as TNF or IL-1, or by inactivating molecules related to the activation of lymphocytes. In recent times, the introduction of these therapies has greatly modified the natural history of the disease and slowed the structural damage that it causes.
Thanks to the combination of traditional and biological DMARDs, an important improvement in the prognosis of RA is currently being achieved. Although, yes, to obtain these results it is essential to start the recommended treatment in each individual case early, if possible before three months have elapsed since the onset of symptoms.
The medications used in the treatment of RA can be more or less effective, depending on many circumstances; but they can also generate a wide variety of adverse effects, more or less pronounced. Therefore, it is very common that throughout the treatment the doses are adjusted and modifications are made to the therapeutic plan as many times as necessary, taking into account the characteristics and needs of each patient.
Control visits are a central pillar of treatment, as they allow the rheumatologist to assess the evolution of the disease, assess the results of treatment and inquire about the presence of adverse effects caused by medications. During these visits, which are scheduled with a periodicity adjusted to the circumstances of each particular case, the rheumatologist will question and examine the patient and, if he deems appropriate, request blood tests, radiographs or other complementary examinations.
The care of the RA patient is in the hands of a healthcare team made up basically of the rheumatologist – who is the referring doctor -, the general practitioner, the rehabilitative doctor, the occupational therapist, the physical therapist, the nursing staff and the social worker. However, the true protagonist of the healthcare team is the patient himself, who is not only the recipient of all care but also the first person who can notice the appearance of any symptom attributable to the disease or the various adverse effects it may generate. the medication administered. This is why, once again, it is so convenient for RA patients to have a sufficient degree of knowledge about the disease and its treatment.
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2 Non-pharmacological therapy
Non-pharmacological therapy plays a very important role in the treatment of RA because it can help the affected person feel better and enjoy a better quality of life.
It should be clear that in no case can non-pharmacological therapy substitute pharmacological therapy, which is what can modify the course of the disease and, therefore, constitutes the fundamental pillar of RA treatment. In fact, thanks to the new medication available for the treatment of RA, the prognosis and quality of life of affected people are being remarkably improved, making the role of non-pharmacological therapy less important. than it was just a few years ago.
Non-pharmacological therapy includes a wide range of general recommendations and complementary therapies with objectives as varied as adapting life habits to the patient’s abilities, alleviating and / or knowing how to coexist with pain, improving joint flexibility or feeling more energy and optimism.
The healthcare team, with the rheumatologist at the forefront, ensures that the patient with RA knows these general recommendations and tries to adopt them in their daily life. It also assesses the need for the patient to undergo physical or other complementary therapy.
2.1 Patient education and lifestyle advice
It is convenient that all people with RA know, from the moment of diagnosis, what are the most relevant aspects of their disease and the repercussions that this may have on their lives, since this will allow them to participate actively and effectively in taking of decisions. Thus, the “education” of the patient in relation to RA is one of the tasks to which the healthcare team is devoted from the early stages of the disease.
Once the diagnosis has been established and the prognosis outlined, the healthcare team will inform the patient about the characteristics of the disease and will gather information on the patient’s particular circumstances, such as his or her work situation, lifestyle habits, and family and social support with the one that counts.
In this way, with the active participation of the patient, a “treatment plan” is outlined in the medium and long term. A plan in which, in addition to considering pharmacological therapy, general recommendations are individualized, and potentially suitable complementary therapies are suggested according to the severity of the manifestations and personal circumstances.
General recommendations in patients with mild or controlled RA
In general, in patients who are in the initial stages or who only have mild manifestations, as well as in those who have achieved remission (absence of pain, stiffness and joint inflammation ) and do not present joint damage, the health recommendations are similar to those of the general population:
- Follow a healthy diet.
- No Smoking.
- Sleep a minimum of eight hours a day.
- Perform moderate aerobic physical exercise (30 minutes, three times a week).
- Moderation in the consumption of alcoholic beverages.
- Avoid, as much as possible, work or leisure activities that involve too intense or sustained physical effort.
Recommendations in patients with overt symptoms and / or injuries
In people with more overt symptoms or who have limitations in mobility, the recommendations are more strict and specific, establishing a plan of rest and individualized exercise according to the intensity of the symptoms and the skeletal areas affected.
In these cases, it is also recommended to avoid jobs or occupations that require intense or continuous physical effort, stay several hours in a fixed position – either standing or sitting – or perform repetitive movements with the affected joints, especially if they have to be done vigorously. For the same reason, it is recommended to interrupt more or less every half hour the activity that is being carried out, in order to avoid overexertion in the involved joints.
2.2 Importance of rest
Adequate rest is an essential part of non-pharmacological therapy since it allows the body to recover better and faster from the wear and tear of persistent inflammatory activity, helps to combat tiredness and muscle weakness, so common in people with RA, and contributes to the joints working less.
The need for rest varies according to individual characteristics and circumstances but also depending on the occupations and physical exercise performed by the patient. For this reason, the healthcare team draws up a personalized “plan of rest and physical exercise”, which precisely considers all these variables.
In general terms, during the phases of increased inflammatory activity, it is recommended to increase rest and suspend physical exercise, or at least reduce its intensity, while in phases of less inflammatory activity or symptomatic remission, the reverse is recommended, although with nuances: reduce to a certain extent the time spent resting and resume or increase physical exercise.
It is convenient for people with RA to try to sleep about 8-10 hours a day at night and, in periods of increased inflammatory activity, to allocate an additional 30-60 minutes to rest in the middle of the morning and first thing in the afternoon.
It is advisable to maintain a certain regularity in regard to the time allocated for rest and sleep schedules. Baths with hot water and relaxation exercises are also advisable both before night rest, because they help to fall asleep, and when getting up in the morning, since they reduce both the intensity and duration of pain and morning stiffness.
Also, it is convenient to use a firm mattress, place the pillow in such a way that it supports the head without flexing it upwards, arrange cushions under the knees so that they are not flexed and also, if you sleep on your side, below the waist, in this case to keep the body well aligned.
2.3 Physical exercise
Activity and physical exercise can contribute to improving the general and articular state of people with RA, as long as they are practiced in a moderate way, taking into account the particular circumstances that each patient goes through and, of course, with the consent of the doctor.
The recommendations regarding physical exercise are part of a personalized “plan of rest and physical exercise” prepared by the healthcare team, taking into account aspects as varied as the age and physical condition of the patient; the intensity of inflammatory activity, pain and joint stiffness; the presence of a greater or lesser degree of movement limitations, and the individual preferences of each person.
The benefits that physical exercise can bring to people with RA include:
- Improve overall fitness.
- Prevent and decrease joint stiffness.
- Strengthen the muscles that mobilize the affected joints.
- Increase the flexibility of the body in general and of the affected joints in particular.
- Ease the pain.
- Preserve bone and articular cartilage.
- Improve mood and self-esteem.
In general, it is recommended to reduce activity and avoid physical exercise during periods of intense inflammatory activity, while, on the contrary, it is recommended to restart it and increase it when symptoms are less pronounced and in periods of remission.
It is advisable to avoid physical exercises and sports activities that involve carrying out intense and sustained efforts. In contrast, aerobic exercises, such as walking, cycling and swimming, performed in moderation for a minimum of about 30 minutes and three times a week, are among the most recommended.
It is also often convenient to perform certain types of specific exercises for the affected joints. Thus, isometric exercises, in which a muscle contracts without the involved joint moving (for example, keeping one leg extended without moving it), serve to strengthen the muscles without overloading the joints. Or so, dynamic exercises, in which all the movement that allows a joint to one direction or the other is repeatedly carried out (for example, alternately flexing and stretching the arm), can be useful to prevent limitation of movement (in this case, the elbow).
Physiotherapy corresponds to the use of a set of physical means for the treatment of diseases, including cold, heat or electric currents, as well as certain types of physical exercises and massages. It also includes tests to diagnose and monitor the evolution and results of treatments.
People with RA may require the help of physical therapy at various stages and circumstances of the disease, in particular, to relieve pain, reduce stiffness, and increase joint flexibility. In general, these therapies are considered to be a complement to pharmacological treatment and physical exercise, since they only have a temporary and temporary effect.
The surface heat is applied by bags, pads or blankets hot, infrared lamps, paraffin baths or hot baths. It is usually indicated when getting up in the morning and before physical exercise and can be carried out in the patient’s own home. It is important that the application of superficial heat does not last more than 20 minutes and that in no case produces pain. For the same reason, sleeping with a warm bag or blanket is discouraged.
The deep heat is applied by special devices that convert electricity into heat or ultrasound. This is a procedure that must be carried out in specialized sites since it requires the guidance and help of the physical therapist.
Electrical stimulation of a given nerve through the skin (transcutaneous electrical nerve stimulation, or TENS), which is also performed with a special device and under the control of a physical therapist, may be helpful in relieving pain and stiffness. articulate.
For its part, the application of local cold, for example through ice packs, is indicated for cases of sudden and intense inflammation or to prevent a joint from becoming inflamed and painful after physical exercise or performing repeated movements with a joint.
2.5 Orthopedic devices
Throughout the course of the disease, people with RA may require the use of various types of orthopedic devices. What is pursued through the use of these devices is:
- Temporarily immobilize a certain skeletal segment, such as a finger, hand, leg, or neck.
- Avoid overloading a certain joint, particularly the ankles, knees, and hips.
- Accelerate the functional recovery of a joint with limitations in mobility.
- Avoid adopting so-called “vicious positions”.
- Prevent the development of skeletal deformities.
Some orthopedic devices are indicated temporarily, until the affected joint is deflated and no longer painful, and can, therefore, be mobilized again. This is the case of the resting splints that are placed on the extremities (for example, on the fingers) or that of the collars that are used to protect the neck. On the other hand, orthopedic devices that are used to prevent deformations, such as insoles for the feet, are usually necessary for very long periods of time.
Some of these devices are only used for certain activities. Thus, the use of a cane is sometimes recommended to avoid overloading the knees and hips when walking, or the use of a knee brace to go up and down stairs or perform some sport activity.
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3 Pharmacological therapy
Pharmacological therapy forms the basis of RA treatment. Its objectives are to alleviate symptoms, achieve the interruption of inflammatory activity, prevent joint injuries, and prevent loss of joint function.
The main drugs used in the treatment of RA are pain relievers, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, traditional disease-modifying antirheumatic drugs (DMARDs), and biological DMARDs.
Joint injuries typical of RA begin to develop as early as the first two years of the disease. For this reason, it is advisable to start pharmacological therapy early, ideally in the first months after the diagnosis of the disease, especially with DMARDs, since this can significantly improve the prognosis and quality of life of the patient. patient.
Pharmacological therapy for RA can be very complex since it has to adjust to the evolution of the disease, the circumstances in which the patient is, the results achieved with previous treatments and the possible appearance of adverse effects or existence of contraindications.
The drugs used in the treatment of RA can cause various adverse effects, some of them relevant enough to interrupt the administration of one drug and replace it with another. However, beyond fears that such adverse effects may arise, it should always be borne in mind that medicines, when used appropriately, are always “allies” and can never be considered “enemies”.
Using medication properly means, above all, not self-medication, that is, never taking medications without taking into account the doctor’s prescriptions and indications.
It is especially important that the patient never modify or suspend treatment with corticosteroids or DMARD on his own (as would happen, for example, if he took a different amount than prescribed or if he did not respect the duration of treatment indicated by the specialist), since This could significantly reduce the effectiveness of the treatment and even lead to the presentation of adverse effects.
Not self-medicating means not making decisions about the medication outside the doctor, but this does not imply not knowing the medication being taken. On the contrary, it is convenient for people with RA to familiarize themselves with the drugs that they will probably have to use for long periods of time: they know what is expected of them, how and at what times of the day they should take them, which drugs cannot be used. combine with each other or what are its main adverse effects.
At control visits, the rheumatologist will collect information on all variables related to treatment, with special emphasis on pharmacological therapy. Thus, these visits provide the ideal framework for the patient to raise all the doubts and concerns that they may have in relation to the medication they are taking.
So-called simple pain relievers, such as acetaminophen, work by decreasing pain and fever. In RA they are sometimes indicated occasionally to reduce these symptoms, but they do not usually integrate basic treatment plans because they do not act on inflammation and because they can alter the activity of other drugs. For all these reasons, although these drugs can be purchased without a prescription, people with RA should not take them without the doctor’s prior consent.
The most powerful painkillers, such as morphine and derivatives, are very effective in mitigating pain, but have the drawback of inducing addiction, so they are reserved for extreme situations where discomfort is really intolerable.
3.2 Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs) include a large group of drugs that act by various mechanisms, relieving pain, and reducing inflammation.
NSAIDs do not interrupt the underlying inflammatory activity that exists in RA, and therefore do not prevent the development of joint injuries or improve the prognosis of the disease. Furthermore, they can give rise to various types of significant adverse effects and only effectively relieve inflammation when indicated in high doses and for at least a 2-4 week period of treatment. For all these reasons, the physician takes into account all possible benefits and potential risks before indicating treatment with an NSAID, as well as when adjusting doses or substituting one NSAID for another.
Non-selective NSAIDs and selective NSAIDs
“Non-selective NSAIDs” have been in use for decades, including acetylsalicylic acid (aspirin), ibuprofen, diclofenac, naproxen, and indomethacin.
Selective NSAIDs are so named because they act specifically on an enzyme that participates in the inflammatory process known as cyclooxygenase-2 (COX-2). These drugs include colecoxib, rofecoxib, valdecoxib, and etoricoxib.
Both types of NSAIDs are equally effective in relieving pain and reducing inflammation, although selective NSAIDs generate fewer gastrointestinal adverse effects than non-selective NSAIDs, so they are indicated in people with RA who already have this type. from problems.
NSAIDs can lead to a wide range of adverse effects. Some of them are irrelevant or extremely infrequent, while others appear more frequently or can be more serious, especially in certain types of patients, for whom they are not recommended.
Among the main adverse effects of NSAIDs are digestive discomfort, gastrointestinal ulcer, digestive bleeding, fluid retention, high blood pressure, some liver disorders, and allergic reactions.
NSAIDs are used with special caution in patients:
- With more than 65 years of age.
- With congestive heart failure.
- With liver cirrhosis.
- With alterations in kidney function.
- They take diuretics.
- Following anticoagulant treatment.
- With an allergy to acetylsalicylic acid.
Corticosteroids are medications with a powerful anti-inflammatory effect and very effective in relieving pain, stiffness and joint inflammation.
Among the corticosteroids most used in RA, prednisone, methylprednisone and deflacort stand out. In general, they are administered orally, although they can also be administered by intramuscular or intravenous injections, and they can even be injected directly into the joint, using a procedure known as infiltration.
Corticosteroids can cause relevant adverse effects, especially when administered in high doses and for prolonged periods of time. Such effects include fluid retention, increased body weight, the appearance or worsening of diabetes, the formation of cataracts in the eyes, infections and osteoporosis or loss of bone density.
In people with RA, corticosteroids are usually administered in low doses and in the periods of greatest intensity of symptoms, while the anti-inflammatory action of other drugs, particularly DMARDs, is expected to bear fruit. Thus, they are generally indicated in the early stages of the disorder and in periods of symptomatic exacerbation.
Despite this, it is sometimes necessary to administer them in high doses, especially when there is a potentially serious extra-articular complication, such as pericarditis.
Corticoid Joint Infiltrations
Injecting corticosteroids directly into a joint and its surrounding tissues is a procedure that is used quite often in the treatment of RA. It is indicated to reduce inflammation, joint pain and stiffness in any joint that is noticeably affected and does not respond well to oral drug therapy.
It is a simple procedure that is carried out on an outpatient basis, does not require special preparation, does not entail major risks and is usually very effective, although its effects are temporary.
It is considered that the same joint should not be infiltrated more than once every three months and that repeated injections into the same joint or the need to infiltrate several joints are indicative that pharmacological therapy is not proving effective, so it should be modified. .
3.4 Traditional disease modifying antirheumatic drugs (DMARDs)
Traditional disease-modifying antirheumatic drugs (DMARDs) have long been used in the treatment of RA and have been found to be not only effective in reducing symptoms, but may also delay disease progression.
Another positive aspect of traditional DMARDs is that there is considerable experience in their use, so their possible adverse effects and their interactions are well known, that is, the effects they have on other types of medications and vice versa. However, among its disadvantages it is worth mentioning that they act slowly (they take between one and six months to start acting), that their impact on quality of life is sometimes limited, and that dose adjustment requires evaluations that only They can be done through blood and urine tests.
The main objective of the indication of DMARDs is to improve the course of the disease and, if possible, achieve its remission, that is, to interrupt the underlying inflammatory activity. This goal can only be achieved if treatment with DMARD is started in the early stages of the disease and is maintained for long periods of time. So much so that in many cases treatment with DMARD is maintained even though remission of the disease has been achieved.
DMARDs act slowly and are not used to relieve symptoms. Therefore, whenever necessary, they are administered in combination with NSAIDs or corticosteroids, which act quickly to reduce pain, stiffness and joint inflammation.
Among traditional DMARDs, the most widely used is methotrexate, since it is the one that has been shown to have a better profile in terms of efficacy and adverse effects, as well as greater convenience of administration (a single weekly dose is administered, either orally or by subcutaneous or intramuscular injection).
Other traditional DMARDs that are frequently used in the treatment of RA are leflunomide, sulfasalazine, and so-called antimalarials (chloroquine and hydroxychloroquine).
Sometimes, to optimize the effects of pharmacological therapy with DMARDs, methotrexate and another traditional DMARD are co-administered, methotrexate with a biological DMARD or other combinations of DMARDs.
Table 3. Characteristics of the main traditional FAME
3.5 Biological disease modifying antirheumatic drugs (DMARDs)
Biological DMARDs are part of a group of very novel drugs that are made using genetic engineering procedures and that are very effective both to stop the inflammatory process of the synovial membrane and to prevent joint damage in RA, especially when administered in combination with methotrexate or another FAME.
The most widely used biological DMARDs are those that act by counteracting or blocking TNF-α, a protein that participates very actively in inflammatory processes, such as inflammation of the synovial membrane. There are currently three anti-TNF-α biological DMARDs available: adalimubab, etanercept, and infliximab.
The appearance of these new drugs has represented a decisive change in the treatment and prognosis of RA. Thus, it has been shown that around a third of the patients treated with them go into remission, another third follows a reasonably benign course and only the remaining third do not respond to this medication.
Biological DMARDs are not administered orally, but by subcutaneous or intravenous injections with a frequency of once or twice a week in the case of etanercept, one every two weeks in the case of adalimubab and one every eight weeks in the infliximab case.
Biological DMARDs do not usually cause serious adverse effects, although they often cause itching or mild allergic reactions in the areas of the skin where the injection is given; on the other hand, they can favor the development of infections, especially in the lungs. It should be noted that these drugs may not be recommended in some patients with RA, for example in those with advanced heart failure.
There are currently other biological DMARDs, with various mechanisms of action, that are sometimes used in the treatment of RA, such as rituximab, abatacept, and tocilizumab. Furthermore, new drugs of this type are being developed, and it is expected that some of them, specifically golimumab and certolizumab pegol, will begin to be marketed in Spain imminently.
Naturally, it is the rheumatologist who will be in charge of indicating and combining them with other drugs when deemed appropriate, although it is always convenient for the patient to know the medications they can use and participate in decision-making regarding the treatment of their disease.
Table 4. Characteristics of the main anti-TNF-α biological DMARDs used in RA.
3.6 Gastric protectors
Many of the drugs used in the treatment of RA can cause adverse effects on the digestive tract, in particular stomach heaviness, nausea, vomiting, irritation and inflammation of the gastric mucosa (gastritis) and development of erosions or ulcers (gastroduodenal ulcer ).
To prevent or lessen the intensity of these adverse effects, it is advisable to carefully follow the instructions related to the administration of the medication. Thus, in the case of many of the drugs that are administered orally, such as NSAIDs, it is advisable to avoid taking them on an empty stomach, but rather after breakfast or meals, to facilitate their dissolution before contacting the gastric wall. On the other hand, corticosteroids can also generate gastrointestinal adverse effects, specifically because they increase the acid secretion of the stomach, something that not only occurs when taken orally, but also when administered by injection.
In any case, when a person has to follow intense or prolonged treatments with medications that can generate adverse effects of those already mentioned, it is common for a “gastric protective” drug to be prescribed to prevent this eventuality, especially if there is a history of gastritis or ulcer. gastroduodenal.
The most used gastric protectors at present are omeprazole and derivatives. These drugs decrease the secretion of acid by the stomach wall itself, relieve the feeling of heaviness in the stomach after meals, in many cases prevent nausea and vomiting, and prevent the development of erosions or ulcers.
Another widely used gastrointestinal protector is misoprostol, which is especially effective in preventing gastrointestinal bleeding in people on prolonged NSAID treatment.
4 Role of surgery
When RA cannot be adequately controlled by treatment, inflammation can eventually lead to severe and irreversible damage to the synovial membrane, articular cartilage, and bone. Such injuries, in turn, can cause pain, significant limitations in joint mobility, skeletal deviations, and marked difficulty in carrying out work, leisure, or even elementary activities, such as dressing, washing, combing, eating, or moving autonomously. .
It is in these cases that orthopedic or restorative surgery is usually used, the purpose of which is precisely to reduce pain, improve the mobility of the affected joints and provide greater autonomy to the patient with RA. Occasionally, surgery is also used to prevent any major complications, for example to improve the stability of the spine.
A few years ago it was considered that more than a third of people with RA would need to undergo one or another type of surgical intervention throughout their lives. However, today, as more and more RA patients benefit from early diagnosis and start treatment with highly effective medications in the early stages of the disease, it is highly likely that the surgical indications will be significantly reduced.
Logically, surgery is not indicated in all RA patients, but only in those who meet certain characteristics related to age, physical condition, occupation or lifestyle, in whom a certain surgical technique can offer improvement clear and predictable. Thus, before indicating a surgical intervention, the rheumatologist will explain to the patient the benefits and risks of the type of intervention suggested and will request inter-consultations with the orthopedic surgeon and the rehabilitative doctor.
There is a great diversity of surgical techniques used in patients with RA. The simplest can be carried out using a procedure called arthroscopy, but many others, such as when replacing a joint with a prosthesis, it is necessary to carry out a conventional surgical intervention, in which a wide incision must be made to be able to act on the affected tissues.
In general, once the immediate post-surgical period is over, the patient returns home and recovery begins. At this stage, under the indication of the rehabilitating doctor, the patient must follow an exercise and rest plan that will help normalize joint function.
As in other aspects of RA treatment, it is highly advisable for the patient to be interested and know the surgical options available to him since it is he who really knows what impact the disease is having on his daily life. and who, at the end of the day, must assess the particular risks and benefits of any operation.
Arthroscopy is a technique that involves inserting a tube into the joint through a small hole in the skin. The instrument, called an arthroscope, is a thin and flexible tube equipped with an illumination system and lenses that allow the articular structures to be clearly visualized and through which various utensils can be inserted which, when manipulated from the outside, serve to perform surgical procedures in the interior of the joint cavity.
In the treatment of RA injuries, arthroscopy is usually performed under general anesthesia, although it carries much less risk than conventional surgery and allows a faster recovery. It is indicated for the diagnosis and treatment of numerous types of injuries that affect the intra-articular tissues, particularly the large joints, such as the knees and hips.
The main therapeutic indications for arthroscopy in people with RA include repair or removal of injured joint tissue, ligament repair, and synovectomy or removal of the synovial membrane.
Synovectomy is the removal of part or all of the synovial membrane, the tissue in which the inflammatory process of RA begins. This surgical procedure can be performed by arthroscopy or by conventional surgical intervention and is indicated to eliminate pain and improve mobility of an affected joint.
At present it is not performed as frequently as in past decades, because it has been seen that in many cases the synovial membrane grows again after a few years, although it is still common to do it in a complementary way when carrying out conventional surgery. to repair tendons or other neighboring structures.
By contrast, an equivalent procedure, known as an “isotopic or radioactive synovectomy,” has recently become widespread, literally consisting of destroying the inflamed synovial membrane by introducing radioactive substances into the joint.
Arthroplasty is the replacement of a joint by a prosthesis and is one of the most widely used surgical options in patients with RA. Arthroplasty can be partial or total, depending on whether only some or all of the bone components of a joint are replaced. Logically, arthroplasty involves the repair or removal of other joint tissues, such as the synovial membrane, articular cartilage, and ligaments.
In general, this procedure is indicated when a joint is seriously compromised, in particular, because the pain, the limitation of movements or skeletal deformities are of such magnitude that they prevent the patient from carrying out activities as simple and necessary as walking.
Currently, arthroplasty is especially indicated in cases of knee and hip involvement, as these are the prostheses with which we have the most experience. However, in recent years there have been notable advances in the total replacement of other joints, particularly the shoulders and elbows.
Joint prostheses adapt with great precision to the parts and shapes of the bones they replace. In most cases they are made of a combination of metal and plastic, although some are covered with a layer of hydroxyapatite, a mineral that is part of bone tissue and allows the adjacent healthy bone to grow underneath and better fix the prosthesis.
During arthroplasty and in the postoperative period, some complications can occur that can be prevented by carefully selecting the patients who undergo this type of intervention and by rigorous control throughout the time the patient remains hospitalized.
Although the prostheses may not adapt well or may not remain in good condition after a certain time, very satisfactory results have recently been achieved with knee and hip arthroplasty, particularly in patients with RA. According to statistical data, these prostheses remain functional in up to 95% of patients after 10 years and up to 75% after 20 years.
When a prosthesis is worn or for some other reason is no longer functional, the convenience of replacing the prosthesis may be considered, a procedure that requires an even more meticulous evaluation than the placement of the first prosthesis, although it is indicated in many cases.
4.4 Other types of surgical interventions
In some cases, the joint injuries characteristic of RA end up injuring a tendon or even leading to its rupture. In these cases, always after an individualized evaluation, tendon reconstruction can be recommended, a procedure that involves suturing the ends of the ruptured tendon and, if necessary, reconditioning the neighboring tissues. Tendon reconstruction is a fairly common practice, especially in relation to the tendons of the hands, wrists, and shoulders.
resection Bone resection, consisting of the surgical removal of a segment of bone, is also a fairly common surgical technique in RA. Thus, removal of a foot bone is sometimes recommended in order to facilitate gait, or that of a bone segment of the elbow, wrist, or finger to improve the function of the involved skeletal segment and relieve pain. .
Atrodesis is a surgical technique that consists of fusing two bones that are normally separated, basically in order to relieve pain. Although it is currently used less than it used to be, it is still recommended at times, especially in relation to the small bones of the hands, wrists and ankles. When the bones are fused, the joint loses mobility, but gains stability, supports weight and pressure better, and is less painful.
Osteotomy is a surgical technique that involves cutting and remodeling one or more bones. In patients with RA, it is usually only necessary to resort to this type of procedure in the advanced stages of the disease, in order to correct a skeletal deviation that is a serious problem from the aesthetic and / or functional point of view.
4.5 Main surgical indications according to locations
- Tendon reconstruction.
- Arthroplasty or placement of prostheses that replace the joints of the base of the fingers.
- Osteotomy or correction of finger deviations.
- Reconstruction of extensor tendons of the fingers.
- Tissue repair in case of carpal tunnel syndrome.
- Synovectomy or removal of the synovial membrane, accompanied by resection of the end of the ulna bone.
- Arthrodesis or fusion of the bones of the wrist.
- Synovectomy or removal of the synovial membrane, accompanied by resection of the head of the radio bone.
- Arthroplasty or placement of a prosthesis to replace the elbow.
- Synovectomy or removal of the synovial membrane.
- Arthroplasty or placement of a prosthesis to replace the shoulder.
- Arthrodesis or fusion of the vertebrae to prevent or treat nerve compression.
- Arthroplasty or placement of a prosthesis to replace the hip.
- Synovectomy or removal of the synovial membrane.
- Arthroplasty or placement of a prosthesis to replace the knee.
- Arthrodesis or fusion of the bones of the ankle joints.
- Achilles tendon repair.
- Removal of the heads of the bones from the bases of the fingers.
- Removal of hallux valgus (bunions).
4.6 Preparation for surgery
Before indicating an intervention, the members of the healthcare team – rheumatologist, orthopedic surgeon, and rehabilitation doctor – will proceed to review the patient and request and evaluate a series of complementary tests, such as blood and urine tests, plain radiographs, magnetic resonance imaging, and tomography. computerized.
Next, they will explain to the patient all the pros and cons of the surgical intervention in question, the suitability of performing or delaying it, the risks involved, the problems that may arise in the postoperative period, the type of rehabilitation that will have to be followed. the patient and what impact the intervention will have on their daily life.
This is the optimal time for the patient to inform the doctors if he has an allergy problem, if he has an infection or if he is taking any other medication, since in these cases it may be necessary to temporarily postpone the intervention or to suspend the administration or modify the dose of any medication.
It is also the right time for the patient to find out about the type of assistance, either personal or with devices (crutches, special handles) that he will need during recovery.
In the days prior to the intervention, a chest x-ray, an electrocardiogram, blood coagulation tests, and, if necessary, allergy tests will be requested.
Shortly before the operation, the anesthesiologist will have a chat with the patient to explain in more detail the procedure in question and to ask him to read, and if he agrees firmly, the “informed consent”, a form that informs the patient about the risks you assume when undergoing the intervention.
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