Surgical Arthritis Service

1. Overview
2. Conditions Treated
3. Non-Surgical & Surgical Treatment Options
4. For More Information

Overview

The Surgical Arthritis Service (SAS) at the Hospital for Special Surgery (HSS) is an innovative program designed to provide comprehensive care for patients with severe inflammatory arthritis. The service draws on expertise from the two major divisions at HSS: orthopaedics and rheumatology. According to Dr. Thomas Sculco, Chief of the Service and Director of Orthopaedic Surgery at HSS, "Formerly, these very ill patients with multiple problems had to consult a number of different physicians in different departments. Patients treated through the SAS can receive the treatment they need in a single setting." Physicians are joined by a dedicated team of medical and orthopaedic residents and fellows, nurses, physical and occupational therapists, and social workers who help to address the medical and surgical needs of patients and provide resources and support for the activities of daily life.

While the majority of the patients treated through the service have rheumatoid arthritis, patients with other types of inflammatory arthritis (and other autoimmune diseases) as well as patients with aggressive, multi-joint osteoarthritis are seen as well. "Patients who come to the SAS for care are usually those with very complex conditions in which many joints are affected. It is these individuals who benefit most from our interdisciplinary approach," notes Dr. Sculco.

Inflammatory arthritis is almost always a progressive condition that requires medical care over many years; the opportunity to obtain treatment from the same group of health care professionals offers a marked psychological benefit to patients. Moreover, for those patients who require more than one surgical procedure, the same orthopaedic surgeon can often perform these operations. (In cases where a patient requires a highly specialized surgery such as that involving the hand, a surgeon from outside the service may be called upon.)

Members of the SAS team and patients attend weekly clinics and conferences to discuss the status of the patient’s condition and treatment. "This collaboration between departments and patients results in a better coordinated, more focused treatment plan," explains Dr. Sculco. In addition to benefiting the patient, these clinics and conferences serve as an educational opportunity for physicians in each discipline. Orthopaedists gain insight into the other medical problems patients are experiencing as a result of their disease or its treatments--which can have a direct bearing on the patient’s ability to withstand surgery. Rheumatologists learn more about the specific musculoskeletal signs and symptoms of inflammatory arthritis and about the indications and expectations for surgical procedures appropriate for these patients.

Conditions Treated

As noted, the vast majority of patients treated through the SAS have rheumatoid arthritis, an autoimmune disease in which the body "perceives" the synovium and cartilage that line the joints as a foreign substance. An inflammatory response follows and the cartilage erodes, causing pain, stiffness and eventually destruction of the joint. Because rheumatoid arthritis is a systemic and progressive condition, over the course of time, many joints may be affected including hips, knees, ankles, shoulders, hands, and the neck.

Other conditions treated through SAS include:

• Juvenile rheumatoid arthritis: Similar to the condition seen in adults, but diagnosed when the patient is younger than 16 years old. (Rheumatoid arthritis in adults is usually diagnosed in the patient’s 20s, 30s or 40s)
  
  
• Lupus erythematosus: another autoimmune disease, in which joints, tendons, and other connective tissues (i.e., cartilage) and organs become inflamed. Damage to the joints can be considerable. Because lupus may affect so many systems in the body, the patient may be coping with a number of medical problems and may need to follow a complex treatment regimen.
  
  
• Psoriatic arthritis: a form of the disease in which skin rashes are accompanied by inflammation of the joints. Arthritic symptoms may be severe even when symptoms affecting the skin are mild.
  
  
• Ankylosing spondylitis: a disease of the connective tissues characterized by inflammation of the spine and the large joints (i.e., the hips, knees, and shoulders)
  
  
• Paget’s Disease: a condition in which bone loss results in weakened, deformed bones and decreased mass.
  
  
• Arthritis associated with inflammatory bowel disease (IBD) or other diseases: Although the primary symptom of IBD is inflammation of the intestine with corresponding gastrointestinal discomfort, inflammation of the joints constitutes one of many complications that may also develop.
  
  
• Complex osteoarthritis involving multiple joints.
  
  

SAS also provides treatment to patients with other diseases in which arthritis may develop as a secondary problem, including

• Arthritis in patients with hemophilia: patients with this disease, in which the body produces little or none of the clotting factor needed to prevent excessive bleeding following injury. While people with hemophilia do not necessarily develop arthritis, those that do, often experience very severe manifestations of the disease. Owing to their inability to heal properly, surgery entails considerable risk, even when clotting factor is administered to minimize bleeding. In addition, due to the high incidence of HIV infection in this population, a number of medical problems may complicate treatment.

Patients who require revision surgery also come to the SAS. A second joint replacement may become necessary when a previously implanted prosthetic joint loosens or wears out, infection has developed around the joint, or the adjacent bone is no longer able to support the device.

Non-Surgical & Surgical Treatment Options

A range of non-surgical treatments for inflammatory arthritis is available. However many of these drugs carry their own set of risks. In the case of rheumatoid arthritis (RA), some patients with milder cases may find symptomatic relief from nonsteroidal anti-inflammatory agents (a class of drugs that includes aspirin and ibuprofen, or one of the newer agents called Cox-2 inhibitors). Such drugs are generally well tolerated. However, patients with more severe RA often take drugs that suppress the immune system making them more vulnerable to infections of all kinds including those associated with surgery. Immunosuppressive drugs used in the treatment of rheumatoid arthritis include cortisone, methotrexate, and a newer generation of immunosuppressive drugs including etanercept, infliximab, and leflunomide. Patients taking these drugs require carefully monitoring.

If these drugs do not control the patient’s pain and disability, and when the loss of cartilage is significant, arthroplasty (joint replacement) may be recommended. For patients who have been severely disabled as a result of damage to their joints, these surgeries can result in a dramatic improvement in quality of life.

For More Information

The Surgical Arthritis Service at the Hospital for Special Surgery (also known as the Comprehensive Arthritis Program) was established more than 35 years ago and has treated tens of thousands of patients with a high degree of success. In addition to providing in-patient treatment, the SAS provides care through an outpatient clinic.

Medical residents and fellows also receive training through the service and a number of team members are involved in research projects on the causes and treatment of inflammatory arthritis and autoimmune diseases.