Rheumatoid arthritis is a common, chronic autoimmune disease. Its clinical presentation includes both articular and extra-articular manifestations. The past few decades have seen significant developments in our understanding of RA pathogenesis, leading to the development of effective novel targeted treatment options. This article reviews the clinical presentation, pathogenesis, and treatment of RA, along with specific treatment considerations related to reproductive health, vaccination, and the perioperative period.

Rheumatoid arthritis (RA) is an inflammatory disease for which the exact cause is unknown. It is an autoimmune disorder that primarily affects such joints which allows free movement in different directions, but also has many other severe complications related to mortality. On the other hand, this disease is responsible for digital deformities, arising out of a combination of synovitis, intrinsic muscles, and extrinsic tendons impairment, ligament rupture, joint dislocation, and final ankylosis. Articular swelling due to synovial proliferation is the first manifestation, but later deformity, subluxation, instability, contracture, and ankyloses can be visible with joint degeneration. Rupture of the capsular and tendon often happens at the wrist. Intrinsic and extrinsic muscle contractures are associated with typical hand joint malalignment. Osteoarthritic involvement has changed with the introduction of biologic disease-modifying anti-rheumatic drugs (bDMARD).

Rheumatoid arthritis (RA) of the hand results in the progressive, inflammatory destruction of multiple tissue types resulting in significant functional deficit. Occupational therapy for the hand often plays a synergistic role in the improvement of health-related quality of life outcomes when employed alongside biological, disease-modifying antirheumatic drugs, and surgical regimens. Furthermore, postoperative therapeutic rehabilitation protocols in patients with RA have been shown to optimize surgical outcomes. While significant clinical data exist to support the role of occupational therapy in RA, further investigation is warranted to compare treatment protocols to further improve functional outcomes for the rheumatoid hand.

Deformities of the thumb in the context of rheumatoid arthritis are not uncommon and lead to early functional limitations due to the great importance of the first ray in almost all gripping functions. The various deformities of the thumb were already classified by Nalebuff in 1968, and this classification is still valid today. The treatment of a thumb deformity depends on the functional limitations, the number of affected joints, and the patient's requirements. In addition to tendon reconstructions, arthrodesis and arthroplasty are used. The decision is made individually depending on the status of the neighboring joints and the disease activity.

Patients with rheumatoid arthritis often undergo multiple surgical interventions throughout their lives, underscoring the importance of collaboration between surgeons and rheumatologists to stay abreast of medical advancements and ensure comprehensive patient care. The author aims to share insights into approaches and procedures that have proven effective overtime, while acknowledging those with less predictable outcomes. These insights are gleaned from the collective wisdom of hand surgery luminaries whose technical prowess and compassionate care have shaped our practice. The care of the rheumatoid hand represents the intersection of art and science in hand surgery, where skillful execution meets patient-centered care.

This article focuses on hand and wrist deformities arising from rheumatoid arthritis. The pathogenesis is synovitis and pannus formation, leading to direct tissue invasion and mass effect resulting in stretching and attenuation of ligaments. The typical deformity of a rheumatoid wrist is a dorsal subluxation of the ulna head (or more aptly, volar translation of the radius given that the ulna is fixed in position), with volar subluxation, ulnar translocation and supination of the carpus, eventually leading to carpal collapse. For each of these deformities, the pathogenesis is discussed, along with their assessment.

Synovectomy refers to the removal of all or part of the hypertrophied soft tissue membrane on the inside of the joint capsule or around tendons. Historically, this was typically performed for rheumatoid arthritis and other inflammatory conditions of the hand, but following the development of more advanced medical treatments, the role of synovectomy has come into question. In this article, the authors outline the biologic basis for synovectomy and then consider its present and future role in the management of joint and tendon disease, followed by what further research is needed.

This review outlines the natural history, diagnosis, and management of juvenile idiopathic arthritis involving the hand and wrist. The discussion of management considers both nonoperative and surgical management to preserve functionality and mitigate long-term articular damage in children and adolescents. The review describes the current literature and identifies areas for further study.

The number of patients presenting to the hand surgeon with severe rheumatoid disease has decreased with the introduction of more effective medical management. However some rheumatoid patients will undergo disease progression despite this. MCPJ and PIPJ replacement can be effective surgical treatments in these patients but patient selection is crucial. Patients undergo surgery hoping to achieve improvements in pain, hand function and appearance. Multiple types of implant have been introduced over the years; however, silicone remains the most reliable option in terms of survivorship, complications and achieving the aims of rheumatoid patients.

Arthritis of the distal radioulnar joint is a frequent source of pain and disability for patients with rheumatoid arthritis despite advances in medical treatment. Treatment options include distal ulna resection, distal radioulnar joint fusion, and distal radioulnar joint arthroplasty. Before surgery, careful evaluation should be performed for concurrent pathology, including extensor tendon rupture and involvement of the cervical spine. Patients' age and activity level must be considered when determining the ideal treatment.

Total wrist fusion (TWF) and total wrist arthroplasty (TWA) are viable treatment options for the rheumatic wrist. TWF fuses through the carpus to stabilize the wrist in 10° to 15° of extension and neutral coronal alignment. Although TWF can be performed with many implants, dorsal fusion plates are best supported. TWA has the advantage of preserving wrist motion but has historically had unacceptable complication rates. The current fourth and fifth generation implants represent significant improvements and have acceptable long-term survivorship and complication rates. Both TWF and TWA can improve quality of life and hand function in patients with rheumatoid arthritis.

Rheumatoid arthritis (RA) is a common autoimmune condition affecting approximately 0.5% to 1% of the global population. A significant percentage of these patients will develop hand deformities and dysfunction. Additionally, the hand is one of the earliest manifestations of the disease. Hand surgeons will often encounter patients with rheumatoid arthritis before the patients have received a diagnosis. Therefore, the hand surgeon must be vigilant recognizing RA's clinical signs and to have a thorough understanding in the initial assessment of these patients.

Rheumatoid arthritis profoundly affects hand function and quality of life. Standardized outcome measures are lacking, hindering comparison between studies. Clinical assessment traditionally relies on performance-based tests like range of motion, grip, and the Jebsen-Taylor Hand Function Test, crucial for evaluating treatment effects, especially surgery. Patient-reported outcome measures have gained significance in assessing post-surgery results, with tools like Cochin Hand Disability Scale and Michigan Hand Outcomes Questionnaire proving effective. However, generic instruments and disease-specific ones also play roles in follow-up. Combining objective measures with patient-reported outcomes is essential for comprehensive evaluation and postoperative care in rheumatoid hand patients.

Customarily, academic chairs have embodied the triple role of excellence in clinical work,education and research. With the rapid changes in healthcare, it has become clear that surgical expertise and academic achievements do not necessarily translate into leadership greatness. Currently to successfully run an academic department the chairperson must also be an experienced manager, with an understanding of business administration, financial restrictions, productivity goals, and medical ethics. A successful chair needs to be able to balance variable tasks and diverse people, and be proficient in managing uncertainty and change. In this review we summarize the clinical, academic and administrative challenges associated with running an academic department.

Cost-effective hand specialty practice is based in ethical principles and evidence. Visits, tests, and treatments are limited to those with specific, notable improvements in capability and comfort. Critical thinking, culture change, and growth mindset principles manifested in a learning health system can help improve cost-effectiveness. The limited moral distress of providing cost-effective care has the potential to improve joy in practice.

The successful team concept extends beyond the operating room and into many areas of hand surgery practice. Effective leadership is critical in creating highly effective teams. Evidence suggests that leadership skills can be learned and developed. The authors synthesize and translate findings from organizational psychology to provide insight and recommendations for clinical practice. Specifically, the role of broad emotional intelligence in leadership is explored. This includes self-awareness (eg, understanding one's strengths, challenges, behavioral tendencies, and emotional reactions), emotion regulation, managing others' emotions (eg, supporting others' needs, managing interpersonal conflict, and displaying empathy), and high-quality communication and establishing/maintaining boundaries.

Organization culture and ethical behavior are clearly important in creating an environment conducive to high-quality care for patients. As surgeons, we have a duty to our patients, colleagues and profession, as well as society at large, to uphold values that promote a safe, just and equitable workplace. This article explores concepts associated with leadership, diversity, and patient care.

The authors provide a simple primer for hand surgeons to further educate themselves on the basics of investing, tax reduction strategies that are completely legal, insurance protection, especially in your formative years, and unusual options available for further consideration. There are many ways for further education including publications related to finance, investment clubs of like-minded individuals, mentors that have extensive experience in these areas, and formal courses sponsored by business schools or other venues. The opportunities and regulatory environment are ever-changing, so one needs to constantly keep up with taxation rules and newer investment options.