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Orthopaedic surgeons must be decision makers for surgical RA treatment
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One negative aspect of the current trend toward increasing subspecialization within orthopaedic surgery is the decreasing number of generalist surgeons able to manage injuries and diseases affecting the whole skeleton. At the same time, there is a demand for more specialist surgeons trained and experienced in the use of the high-technology methods now available for the treatment of more complex bone and joint disorders.
Patients, however, who are afflicted by a disease with a prolonged clinical course and involving multiple sites require a more holistic approach to their surgical management. The most classic example of this is the polyarthritis associated with rheumatoid arthritis (RA), particularly when the onset of the disease occurs in childhood or early adult life.
The emergence of rheumatology as a medical specialty in its own right was largely a response to the demand of providing coordinated care for these unfortunate patients. Although rheumatologists also provide care to large numbers of patients with degenerative joint disease, their primary focus in terms of research and drug treatment remains on inflammatory joint disease, which only affects 1% to 2% of the total population.
Perhaps it is time to look closer look at how orthopaedic surgeons who have an interest in RA can combine this with a special interest in an anatomical region like the upper or lower limb, and call in other specialist colleagues when a joint problem falls outside their specialty area.
A model of combined care
The unique nature of the surgical problems posed by these patients led a number of surgeons to develop a special interest in their combined care during the early 1960s. This multidisciplinary care was usually based in major centers or dedicated rheumatology clinics such as the Rheumatism Foundation Hospital, developed by Kauko Vainio in Heinola, Finland.
The model was copied in many other parts of the world and emphasized the key role of the surgeon in coordinating the timing and priority of surgical procedures, as well as the postoperative rehabilitation program. At that time, surgery was simpler and largely confined to soft tissue procedures, osteotomies and arthrodesis. Arthroplasties were primitive by today’s standards, and the results were less satisfactory than those in osteoarthritis because of the osteoporotic bone and reduced immunity to infection associated with the disease.
The extent of this combined approach to care has always varied among countries and their health care systems. It reached greatest popularity in the countries of northern Europe where the disease is most prevalent, particularly in Scandinavia, though even here the availability of this specialized multidisciplinary care appears to be lessening.
One factor leading to this change has been the successful development of joint replacement techniques for most of the joints affected by the disease. However, to produce results that are now as good as those with osteoarthritic joints demands a high level of technical expertise and experience, which can only be acquired by subspecialization.
Is there a decreased need for surgery?
Proponents of surgical care provided by an appropriate expert in a given anatomical region might argue that improvements in the drug management of the early inflammatory process in the joints has led to a dramatic reduction in the need for early surgical interventions. With the improved control of local joint pain and swelling by steroidal and nonsteroidal anti-inflammatory drugs, the requirement for the once-common operation of synovectomy to remove the hypertrophied destructive joint lining has virtually vanished.
Certainly, published figures would support the view that the number of surgical procedures per patient with rheumatoid arthritis has fallen in the last 10 years. Conversely, the number of joint replacements may be increasing, with 25% of patients requiring at least one arthroplasty within 20 years of the disease onset.
What is uncertain is whether the newer anti-inflammatory drugs and cytokine antagonists will reduce the need for replacement of “burnt-out” joints due to the possible development of secondary degenerative arthritis.
Introducing specialist teams
The compromise solution may be to maintain specialist units for the treatment of rheumatoid arthritis in larger regional orthopaedic units that already have a range of specialist surgeons capable of dealing with individual joints. This would depend on the availability of rheumatologists to provide the overall coordination of patient care, ideally in combined clinics with collaboration from surgeons who have a special interest in the disease.
Even where this is possible, there will still be a need for some secondary referrals for more expert opinion, particularly in the management of cervical spine instability with neurological involvement. The alternative is to leave an inappropriate burden on the physician to decide on the priorities and timing of surgical interventions, with the surgeon adopting an increasingly isolated role as a specialist technician.
For your information:
- David L. Hamblen, PhD, FRCS, is emeritus professor of orthopaedic surgery at the University of Glasgow and visiting professor to the University of Strathclyde in the Prosthetics and Orthotics Centre in Scotland. He is chairman of the Orthopaedics Today Editorial Advisory Board for 2003.