Hand surgery in rheumatoid arthritis: state of the art and suggestions for research.

OBJECTIVE: The role of surgery in the clinical management of patients with rheumatoid arthritis (RA)-associated hand dysfunction is still a subject of controversy. The efficacy of surgery in RA-associated hand dysfunction is assessed through an exhaustive review of published studies.
METHODS: A high-sensitivity search strategy was used to identify in MedLine and CENTRAL original studies related to hand and wrist surgery in RA patients. We selected articles including at least two adult RA patients which evaluated clinical outcomes through an observational or experimental design. Eligible studies were evaluated by standardized criteria. Two investigators independently used a pre-defined form to extract data about patient population, intervention, follow-up and clinical outcomes. Disagreements were discussed and resolved.
RESULTS: One hundred and ninety-six papers met inclusion criteria. Only five were randomized trials, while most studies followed an observational design, often of poor quality. As such, we could not pool data for statistical analysis; however, we were still able to provide a best evidence synthesis. A positive trend suggesting the efficacy of total carpal arthrodesis and metacarpophalangeal arthroplasty in reducing pain and improving function seemed to emerge from the published studies.
CONCLUSIONS: Despite recent advances in medical treatment, surgery still plays a role in the clinical management of RA-associated hand dysfunction. However, the majority of the available studies showed methodological flaws that prevented a clear definition of both surgical indications and criteria for choosing any specific procedure. Suggestions for further investigations are also provided.