Will You Need Surgery for Psoriatic Arthritis?
Some people with psoriatic arthritis may benefit from surgery to fix joint damage. Find out when and why this could be the best option.
No one likes to hear the word surgery. But for about a third of patients with?psoriatic arthritis, it may eventually become a necessity, according to a?Danish study published in 2019 in?Annals of Rheumatic Diseases. Indeed, people with psoriatic arthritis are twice as likely to end up getting joint surgery as those without the condition, the study found.
“Psoriatic arthritis is a potentially debilitating autoimmune disease that can present in a variety of ways,” says?Robert Koval, MD, a?rheumatologist?at Texas Orthopedics in Austin. It most often affects the fingers and toes, and it can also cause pain, stiffness, and swelling in other joints like the knees, back, neck, and ankles.
Most patients don’t end up getting surgery. “That’s because we have so many great?treatments?now, as compared with in the past,” says?Delamo Bekele, MBBS, a rheumatologist and assistant professor of medicine at the Mayo Clinic in Rochester, Minnesota.
Typically, those therapies begin with?nonsteroidal anti-inflammatory drugs (NSAIDs)?for milder cases and can progress to?disease-modifying anti-rheumatic drugs (DMARDs) and?biologic medications. Exercise, including?yoga, as well as?physical and occupational therapy?and even?weight loss, can also help relieve?symptoms.
But when those therapies aren't enough, you and your doctor may need to discuss surgery.
“Typically, we will consider it when someone has pain that fails to respond to medication and other nonsurgical therapies,” says Dr. Bekele. “We do it when the arthritis and joint pain are getting progressively worse to the point that it is affecting someone’s ability to function.”
The Most Common Surgery for Psoriatic Arthritis: Joint Replacement
A number of surgical options are available for psoriatic arthritis, depending on the joints affected and a person’s unique circumstances.
Joint replacement, also known as arthroplasty, may be the best choice when there's severe joint damage in the hips and knees. “Very often, people with psoriatic arthritis have hip and knee involvement that gets worse over time,” says Bekele.
Hip replacement — otherwise known as total hip arthroplasty — is the most common surgery for people with psoriatic arthritis, according to the Danish review, followed by knee replacement.
Patients usually do well after allowing time for recovery and rehabilitation. “Joint replacement can help people regain mobility for a decade or more,” according to Bekele.
But, he warns, it’s best to delay surgery until absolutely necessary. “That’s because these artificial joints have a 20- to 30-year shelf life. And since young people can often get PsA, you don’t want to do the surgery so early that, at some point, those artificial joints wear out and a second surgery is needed.”
One potential way to delay joint replacement is to first turn to a procedure called synovectomy, or removal of the synovium —?a layer of tissue that lines and lubricates the joints.
When psoriatic arthritis aggravates this lining, it creates an excessive amount of fluid that erodes the cartilage. This causes pain and stiffness and eventually bone rubbing against bone. A synovectomy can help stop this joint pain.
“We used to do this a lot when we had fewer medications available,” says Bekele.
A Less Common Option: Surgery for Joints in the Hands and Feet
Sometimes, people with psoriatic arthritis find that the joints in their hands and feet are affected. And while doctors typically don’t replace these smaller joints, according to Bekele, there are other options for easing the worst symptoms of psoriatic arthritis.
One is called joint fusion, or arthrodesis, which may be done when there’s joint damage from psoriatic arthritis in the hands, ankles, or spine.
Recovery from this type of hand surgery takes about six months, but people undergoing ankle and spinal fusion should expect a 12-month recovery. This option has its drawbacks, however. “When you fuse the joints, you may reduce pain, but you also reduce mobility,” says Bekele.
Another issue with any joint surgery: “While it may address pain in one or two joints, it will not get rid of symptoms in other areas of the body,” cautions Bekele. “So patients need to continue taking medication like biologics to keep symptoms from progressing.”
Surgery Raises the Possibility of Infection
Another reason to consider surgery carefully is the infection risk, which may be higher for people with psoriatic arthritis.
According to an?article published in 2018 in the Australasian Journal of Dermatology, people with psoriasis do have an increased risk of surgical infection, though it is still relatively low. The researchers note: “Given that most people with psoriasis take medications that suppress the immune system, [which can increase the risk of infection], it’s important to work with your medical team prior to surgery, to discuss the best way to handle medications.”
“Really, surgery should be a last resort,” says Bekele. “It’s something you turn to at the end of the road, once you’ve tried a lot of different measures and medical treatments, and there’s no improvement.”