Setting priorities: The timing and indications for rheumatoid surgical procedures

The proper selection of rheumatoid surgical candidates and performance of the correct procedure at the appropriate time are often of greater importance than the specific surgical technique used. This chapter will seek to provide the reader with an understanding of the operative indications and guidance in individualizing surgical goals for the rheumatoid patient. The first priority is establishing patient concerns with the symptoms. These are then correlated with physical exam findings and radiographic analysis. Four indications set the basis for surgical intervention: (1) pain, (2) loss of function, (3) prevention of disease progression, and (4) aesthetic consideration. A thorough work-up and perioperative medical management plan should be in place prior to proceeding to surgery. The entire upper extremity, from the shoulder to the distal interphalangeal joints, should be assessed for evidence of rheumatologic change. In many circumstances, proximal disease or deformities impacting more distal joints should be addressed prior to correction of distal disease processes. A treatment plan that addresses the patient’s concerns and reduces the number of surgical procedures can be formulated and tailored to each individual patient. For the rheumatoid patient, the surgeon should correct as many patient concerns as possible in a single operation.