Will You Need Surgery for Psoriatic Arthritis?

Treatments for psoriatic arthritis, a potentially debilitating autoimmune disease, have greatly improved in recent years. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) can work for milder cases, while disease-modifying antirheumatic drugs (DMARDs) and biologic medication help manage severe cases. Exercise, including yoga, as well as physical and occupational therapy, dietary modifications and even weight loss can also alleviate symptoms. A treat-to-target approach can be very effective, says Delamo Bekele, MBBS, a rheumatologist and an assistant professor of medicine at the Mayo Clinic in Rochester, Minnesota. And a greater awareness among rheumatologists, dermatologists, and primary care providers has led to earlier diagnoses.

Still, when these therapies aren’t enough, you and your doctor may need to discuss surgery. Research shows that almost 12 percent of patients with psoriatic arthritis require surgery. “Typically, we will consider it when someone has pain accompanied by joint damage and functional limitations that fail to respond to multiple medications 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.”

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The Most Common Psoriatic Arthritis Surgery: 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, related to psoriatic arthritis and/or coexisting osteoarthritis,” says Bekele.

Hip replacement — otherwise known as total hip arthroplasty — is the most common surgery for people with psoriatic arthritis, according to a study published in the Annals of the Rheumatic Diseases, 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,” notes 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.”

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A Less Common Option: Joint Fusion in the Hands, Feet, or Spine

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 or address other psoriatic arthritis concerns such as skin and nail involvement, cautions Bekele. “So patients need to continue taking medication like biologics to keep symptoms from progressing.”

Psoriatic Arthritis Surgery Risks

Another reason to consider surgery carefully is the infection risk, which may be higher for people with psoriatic arthritis who are on immunosuppressive medications.

Research suggests that people with psoriasis do have an increased risk of surgical infection, though it is still relatively low. Most people with psoriasis take medications that suppress the immune system, which can increase the risk of infection. It’s important to discuss how to handle medications with your medical team before any surgery.

Surgery is “something you turn to at the end of the road, once you’ve tried a lot of different measures and medical treatments, especially if there’s no improvement or there's worsening with progressive joint damage,” says Bekele. “Really, it’s a last resort.”

Additional reporting by Deborah Shapiro.