Reasons Why Rheumatoid Arthritis Patients Seek Surgical Treatment for Hand Deformities

Purpose: The purpose of the study was to determine which factors influence patients with rheumatoid arthritis (RA) to choose surgical reconstruction for hand deformities. Previously, function and pain have been the main factors influencing physicians to recommend surgery. However, this study attempts to answer the question, “what prompts patients to seek surgical reconstruction?” A recent study published in the Journal of Rheumatology in 2002 by Mandl et al. found that hand appearance is the factor that correlated most highly with patient satisfaction after metacarpophalangeal (MCP) joint arthroplasty. This study examined how function, pain, and hand appearance (aesthetics) rank in order of importance to rheumatoid patients choosing hand surgery for MCP joint reconstruction.

Method and Materials: The patients were part of a larger National Institute of Health-funded study evaluating the outcomes of MCP joint arthroplasty. Three sites (two from the United States and one from England) provided a diverse group of patients from all ethnic and socioeconomic backgrounds. Patients who were eligible for MCP joint arthroplasty were invited to participate in the study and chose whether to have surgery (surgical group) or no surgery (nonsurgical group). Specific inclusion criteria included a diagnosis of RA, age of 18–75 years, and the ability to answer questions in English. Exclusion criteria included patients who were deemed nonsurgical candidates due to other medical conditions, patients requiring more extensive hand reconstruction than just MCP joint arthroplasties, and those taking antirheumatic drugs. The Michigan Hand Outcomes Questionnaire (MHQ) was used as one of the outcome tools during the baseline evaluation. This is a hand specific outcomes questionnaire that addresses six components including overall function, activities of daily living (ADL's) pain, work performance, aesthetics, and patient satisfaction. The MHQ is of particular interest as it measures areas that are important in hand therapy and is very suited to outcome measures for the rheumatoid population. The final sample size in this study consisted of 33 surgical patients and 28 nonsurgical patients. Forty-nine women and 12 men participated. The mean age was 58.5 years (range 29–73 years) for surgical patients and 63.4 years (42–75 years) for nonsurgical patients.

Statistical Analysis: Baseline scores from the MHQ in the areas of pain, function, and aesthetics were used as the predictors in logistic regression analysis of patients' choice for proceeding with hand surgery. High scores in pain indicate more pain, high scores in function indicate better functioning, and high scores in aesthetics indicate better hand aesthetics. The scores from the MHQ were also examined for correlations. More pain was associated with lower functioning and lower aesthetics, and better functioning was associated with better aesthetics. Both age and gender were found to be associated with choosing MCP joint arthroplasty. After controlling for age and gender, the variables of pain, function, and aesthetics were found to be associated significantly or marginally significantly with choosing surgery. The results of the analysis indicate that patients with lower functioning, more pain, and lower aesthetics were more likely to choose surgery. Function was the most significant predictor for choosing surgery followed by pain. Esthetic consideration was not found to be statistically significant as a predictor.

Discussion: This study found that for RA patients, the most important factor in choosing to proceed with hand surgery was decreased hand function followed by significant pain. Hand aesthetics was not found to be a statistically significant predictor. The authors cite several past outcomes studies of patients with RA and raise various questions about the findings. A study of women with RA by Minnock et al. published in Rheumatology (2003;42) stated that women perceive pain as the predominant impairment in their health status. Souter found that most RA patients rate pain relief as the most important goal of hand surgery. Still other studies have shown improved functional ability to be the most important reason for patients choosing hand surgery. Patients may consider their surgery a failure if they perceive that their function has not improved according to a study by Masey-Westropp et al. from the Journal of Hand Therapy (2003;16). These patients had improved pain and improved aesthetics. Yet objective, functional tests such as the Jebsen-Taylor test, which simulates ADL, and grip and pinch strength tests actually show little to no improvement after MCP joint arthroplasty. Most patients do, however, experience pain relief and improved hand appearance; these two variables may influence patients' overall satisfaction after surgery and lead them to a perceived improved functional status.

Conclusion: This study is important because it recommends that hand surgeons assess and address their patients' expectations prior to surgery. The surgeon needs to make the patient understand the expected outcome of the proposed surgery and help them develop realistic goals. Also, the patient needs to be informed of the necessary rehabilitation period following the surgery to achieve those goals. The authors suggest periodic follow-up evaluations to determine whether goals and expectations are being met.