Doctor's Insight.

Hello and welcome to Doctor's Insight.

The treatment goal in patients with rheumatoid arthritis is achieving remission, which is to live their daily lives without being interfered by the disease.

In our previous episode, we explained that the most effective means for achieving this goal is using therapeutic drugs.

However, there are cases in which patients do not achieve effective results.

In such cases, they consider the option of... surgery.

Surgical technology has been improving over the past years and many patients are happy to have undergone surgery.

One of the latest advances is robotic-assisted surgery.

Today, we'll find out about the latest in the surgical treatment of rheumatoid arthritis.

Rheumatoid arthritis, or RA, is a disease in which immune cells, that normally work to protect our body, mistakenly attack healthy cells, especially the synovial membrane surrounding the joints.

When RA is left untreated, the disease progresses and further destroys your bones and cartilage, causing joint deformities.

It is said that one in every 100 people in the world, in Europe and the United States, suffers from rheumatoid arthritis, and the number continues to increase each year.

In Japan, the patient's onset age peaks in the 40s to 50s, and 80% of patients are women.

Moreover, the cause of the disease is not clearly known, and anyone can be affected by RA.

Dr.Kaneko Yuko investigates the mechanism of rheumatoid arthritis.

She not only conducts research but works with her patients to provide treatment.

Dr. Kaneko, thank you for joining us again today.

I'm happy to be back.

So... rheumatoid arthritis can be treated not only with drugs, but there's also the option of surgery?

There are many different types of surgeries.

For example, in 90% of patients, inflammation occurs in small joints such as fingers and toes.

Fingers are especially prone to constant movement and strain, and the tendons that support the joints can tear.

In the case of tendon rupture, "tendon repair" is performed.

I didn't know that the tendon can tear that way.

How is it treated?

The surgeon stitches the severed tendon back together with a healthy tendon.

There are several tendons in the hand, and the burden the surgery has on a patient depends on the number of severed tendons.

The surgery would be small for up to two tendons, and recovery is smooth after surgery.

I see.

But if the joints are severely deformed, it would require more than just repairing the tendon.

That's right.

Please take a look at this.

These are the hands of a patient about 10 years after the onset of the disease.

As the condition progresses, not only does the inflammation worsen, causing pain and swelling, but it can also lead to such deformities.

Moreover, larger joints such as the knees and hip joints can be destroyed.

If this happens, another surgery must be considered.

That all sounds very serious.

What kind of surgery would that be?

It depends on the type of joint destruction, but "artificial joint replacement" is often conducted on the knee, hip, shoulder, elbow, and ankle joints.

Replacing it with an artificial joint sounds like a major operation.

Yes, it is, but many patients are very satisfied with the results.

This is the result of a survey conducted on more than 1,600 patients in Japan.

In response to the question, "Are you satisfied with the surgery?"

For every joint type, over 50% were satisfied.

In particular, almost 90% were satisfied with the hip and knee joints sergery.

Why do patients feel so satisfied with the hip and knee joint replacement surgery?

Replacing joints that greatly affect walking, dramatically changes the lives for many.

That's really true.

Other reasons of good post-operative results are improvements in surgical precision and the quality of artificial joints.

Artificial joint replacement surgery is becoming increasingly more precise.

Let's take a look.

In Japan, robotic-assisted joint replacement surgery became available for insurance coverage in 2019.

Its greatest advantage is its accuracy.

By reflecting infrared rays and capturing the positional information of the joints, the robot accurately determines the shape of the joint surfaces and the movement of the joints.

Up until now, the margin of error was 3 mm in length and 3 degrees in angle, which was already considered to be sufficiently accurate.

But now with the assistive robot, the margin of error is only 1 millimeter!

And the angle of the prosthesis is off by only 1 degree.

The robot indicates in purple where the bone should be shaved.

Following the robot's instructions, the surgeon shaves the area until it turns white, and the procedure is complete.

To prevent over-shaving, the robot has a function to automatically stop the drill, so the procedure can be performed safely.

The improved precision has other advantages as well.

Up until now, the cruciate ligament had to be cut.

The reason is it got in the way when the bone was shaved.

However, robotic technology allows the bone to be shaved with the cruciate ligaments left intact.

That's a big advantage.

In the past, the cruciate ligament had already disappeared before the surgery due to the intense inflammation of RA.

But with improved treatment, the cruciate ligaments have remained.

Thus, keeping the ligaments uncut at joint replacement surgery is very beneficial, because it provides stability when playing golf, tennis and other sports, for example.

Even before robot-assisted surgery became available, the margin of error was 3 mm or 3 degrees, which seems to be pretty accurate.

Can you explain what this difference could mean?

The optimal angle to shave the bone varies from patient to patient, and even a one-degree difference in the angle can cause the prosthetic joint to loosen over the long term.

Oh, really.

With a one-degree margin of error, it is believed that robotic-assisted surgeries may be able to help extend the lifespan of artificial joints even longer.

In the video, the doctor mentioned the drug treatment has advanced and that many people have been able to keep their cruciate ligaments.

How does the cruciate ligament relate to the advances in treatment?

Inflammation in the joints by rheumatoid arthritis can damage not only the bones and cartilages, but also the ligaments.

Over the past 20 years or so, the drugs used to treat rheumatoid arthritis have advanced dramatically.

As a result, more and more people have been able to avoid tendon damage, even if their joints have been destroyed leading to surgery, as long as they continue their medication.

I see.

So even if a patient ends up having surgery, the drug treatment they have done thus far would be meaningful.

Exactly.

And performing surgery does not mean that the treatment is complete.

They have to continue with medication.

Are there any changes in the way a person takes medication when a surgery is scheduled?

According to the guidelines, it is recommended that patients continue to take anti-rheumatic drugs such as methotrexate, since the risk of postoperative infection does not increase.

With biologics, on the other hand, there may be an increased risk of postoperative infection, so it is currently recommended that they suspend the treatment before and after the surgery.

And how about the new drug, JAK inhibitor?

Although data on JAK inhibitors are still limited and guidelines are not yet available, it is believed that the drug should be suspended before and after surgery in the same way as biologic agents.

I understand.

I hope patients make good use of therapeutic drugs and surgery to achieve remission.

Yes.

Treatment options for rheumatoid arthritis are expanding, with advances in both drugs and surgery.

So, people suffering from deformities caused by rheumatoid arthritis, should not give up.

Decisions about treatment should be made by patients and rheumatologists, which will lead to better therapy.

Dr. Kaneko, thank you so much for sharing latest about surgical treatment for rheumatoid arthritis, and for being our show.

Thank you very much for having me.