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Arthritis Today

Treatment Advances Help to Make Deformities in RA a Thing of the Past

Early, aggressive rheumatoid arthritis treatment may mean no more joint deformities. 

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In the past, rheumatoid arthritis (RA) took no prisoners. Once the disease grabbed hold, bony deformities — some with such telltale names such as hitchhiker’s thumb, swan neck deformity or curly or clawed toe deformity — were almost inevitable. These deformities made writing, walking and often overall functioning difficult, if not impossible, for many people with RA. In fact, many people ended up in a wheelchair due in part to these distortions and the pain they caused.

But today, earlier diagnosis and aggressive treatment are making such abnormalities in the bones a thing of the past. It’s not that rheumatologists don’t see these bony deformities anymore or that people with RA no longer develop them, it’s that they have become the exception instead of the rule.

“Bony deformities still do occur, and [they] are what we seek to prevent or reduce the incidence of when we treat RA,” says Eric Matteson, MD, chair of the department of rheumatology at the Mayo Clinic in Rochester, Minn. “We see fewer of them, and we see less severe ones today because of earlier recognition of the disease and earlier and more effective interventions.”

The whole RA treatment paradigm has changed. “We used to start treatment with disease-modifying antirheumatic drugs when bony erosions occurred, not before,” he says. “That is a thing of the past.”

Now the goal is to prevent these deformities from occurring in the first place. “Bony deformities are, in large measure, avoidable, if not totally avoidable by hitting RA early and hard,” Dr. Matteson says.

What Are Bony Deformities?

The inflammation of RA causes a rapid-fire division and growth of cells (pannus). The pannus then causes the synovium that lines your joints to thicken and releases enzymes that may chew up bone and cartilage. This is the destructive process that causes the involved joint to lose its shape and alignment. These deformities lead loss of function and the need for joint replacement surgery.

Some people with RA may be at increased risk for these deformities. For example, high levels of the inflammatory marker C-reactive protein (CRP) and a high rheumatoid factor (RF) may be risk factors. RF is an auto-antibody that is present in the majority of people with RA in varying amounts.

“Bone deformities are a sign of joint damage that is ultimately related to erosion of the joint structures,” explains David Pisetsky, MD, PhD, chief of rheumatology at Duke University Medical Center in Durham, N.C. “These are the end result of damage to the joint structures including the ligaments.”

If there is joint damage, there could be deformity, but the goal of RA therapy is to avoid this damage. “I don’t see deformities anywhere near as frequently,” Dr. Pisetsky says.

Treating Bone Deformity in RA

If joint or bone deformities do occur, however, treatment is available.

“If there is joint damage in the hands, we intervene earlier to prevent ligaments and tendons from getting eroded,” Dr. Pisetsky says. The reason that rheumatologists take finger and hand deformities so seriously is because hands are integral to daily functioning. You need your hands to do everything from writing and cooking to getting dressed and brushing your teeth.

Michael E. Weinblatt, MD, codirector of clinical rheumatology at Brigham and Women’s Hospital, division of rheumatology, immunology and allergy, in Boston, adds, “In patients with severe hand disease, it’s important that their rheumatologists refer them to an occupational therapist to provide an exercise program, as well as splinting, to improve function and perhaps, decrease the potential for deformity.”

Other treatment options include silver rings that serve as finger splints for finger deformities. These devices can help keep the fingers stable and stave off any hyperextension. “There was a lot of splinting that went on in the past for these deformities, but we don’t see that so much anymore,” Dr. Pisetsky says.

In extreme cases, finger joint replacement surgery is needed to correct some RA finger deformities. Your metacarpophalangeal joints are the knuckles that join your fingers to your hand. If this joint becomes deformed by RA, it can affect your ability to manipulate your fingers, and surgery may be recommended. Finger replacement surgery uses artificial joints to replace damaged joints. Dr. Weinblatt stresses that joint replacement surgery is NOT a cure; it is only therapeutic.

RA often strikes the feet, and toe misshapenness may occur, making walking or wearing shoes difficult. Surgeons will often correct these deformities with surgery or orthotics.

In the past, joint replacement surgery was done on people with RA, but now 97 percent of joint surgery is done for osteoarthritis (OA), the “wear-and-tear” form of the disease, Dr. Pisetsky says. “RA surgery is no longer common because therapy works, and people get treated early so deformities don’t happen,” he adds.

Common RA Deformities and Their Treatments

Name: Boutonniere deformity
What it Looks Like: The middle finger joint bends toward the palm while the outer finger joint may bend opposite the palm
Rx: Splinting to keep the middle joint extended, or surgery

 Name: Swan-neck deformity
 What it Looks Like: The base of the finger and the outermost joint bend, while the middle joint straightens
 Rx: Finger splints or surgery

Name: Hitchhiker’s thumb
What it Looks Like: The thumb flexes at the metacarpophalangeal joint and hyperextends at the interphalangeal joint below your thumb nail. It is also called Z-shaped deformity of the thumb.
 Rx: Splinting or surgery

Name: Claw toe deformity
What it Looks Like: The toes are either bent upward from the joints at the ball of the foot, downward at the middle joints, or downward at the top toe joints and curl under the foot.
Rx:  Stretching exercises, special shoes or surgery

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