Surgical Management of the Rheumatoid Hand: Consensus and Controversy Among Rheumatologists and Hand Surgeons

AMY K. ALDERMAN, PETER A. UBEL, H. MYRA KIM, DAVID A. FOX, and KEVIN C. CHUNG

ABSTRACT.

Objective. Rheumatoid arthritis (RA) is a common cause of debilitating hand deformities, but management of these deformities is controversial, characterized by large variations in the surgical rates of common RA hand procedures. We conducted a national survey evaluating potential differences in physicians' management of RA hand deformities.

Methods. We mailed a survey instrument to a random national sample of 500 rheumatologists and 500 hand surgeons in the US. We evaluated physicians' attitudes toward the other specialties' management of common RA hand deformities and toward the indications for performing rheumatoid hand surgery.

Results. We found 70% of rheumatologists consider hand surgeons deficient in understanding the medical options available for RA, while 73.6% of surgeons believe rheumatologists have insufficient knowledge of the surgical options for RA hand diseases. However, 66.9% of surgeons and 79.5% of rheumatologists had no exposure to the other specialty during training. The 2 physician groups disagree significantly on the indications for commonly performed RA hand procedures such as metacarpophalangeal joint arthroplasty (p < 0.001), small joint synovectomy (p < 0.001), and distal ulna resection (p = 0.001). When physicians do not agree with others' management of RA hand deformities, only 62.4% of surgeons and 61.9% of rheumatologists relay their concern to the other specialty.

Conclusion. Rheumatologists and hand surgeons have minimal interdisciplinary training, communicate with each other infrequently, and significantly disagree on the indications for RA hand surgery. Research must focus on the surgical outcomes of RA hand procedures and on improving communication between rheumatologists and hand surgeons. (J Rheumatol 2003;30:1464-72)

Key Indexing Terms:

PHYSICIAN SURVEY
RHEUMATOID ARTHRITIS
VARIATIONS IN CARE
HAND SURGERY
RHEUMATOLOGY

---

From the Section of Plastic Surgery, Department of Surgery, University of Michigan; VA Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System; Center for Statistical Consultation and Research, Department of Biostatistics; and Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.

Supported in part by a grant from the Robert Wood Johnson Foundation and an Outcomes Studies Grant from the American Society for Surgery of the Hand.

A.K. Alderman, MD, MPH, Robert Wood Johnson Clinical Scholars Program, Section of Plastic Surgery, Department of Surgery; P.A. Ubel, MD, VA Health Services Research and Development Center of Excellence, Division of General Internal Medicine, Program for Improving Health Care Decision Making; H.M. Kim, ScD, Center for Statistical Consultation and Research, Department of Biostatistics; D.A. Fox, MD, Division of Rheumatology, Department of Internal Medicine; K.C. Chung, MD, MS, Section of Plastic Surgery, Department of Surgery.

Address reprint requests to Dr. A.K. Alderman, 6312 Medical Science Bldg. 1, University of Michigan Medical Center, 1150 W. Medical Center Drive, Ann Arbor, MI 48109-0604. E-mail: aalder@umich.edu

Submitted July 4, 2002; revision accepted December 31, 2002.

---