Rheumatoid Hand & Wrist

Definition

• An autoimmune systemic disease causing an inflammatory symmetric polyarthropathy primarily affecting synovial lined structures
• In hand typically spares DIPJ

Classic X-Ray Features

• Peri-articular erosions
• Osteopenia
• Joint subluxation and deformity

Medical Treatment

3 Groups of Drugs

1. NSAIDS
2. Corticosteroids
3. Disease modifying drugs
   • Only DMARDs can prevent joint destructions

DMARDs

• Split into Non-biologic and Biologic

Non-Biologic:

• Methotrexate
  • Traditionally the only DMARD
  • Best used as an anchor drug in combination with biologic agent

Biologic DMARDs:

• Further split into two categories:
  • TNF-alpha inhibitors
    • Etanercept
  • Interleukin-1 antagonists
    • Anakinara (shown to improve radiographic outcomes)

Classification of RA Joint Disease: Larsen Staging

1. Normal joint
2. Periarticular osteopenia, minimal narrowing
3. Joint erosions, mild narrowing
4. Moderate destructive narrowing
5. End-stage joint destruction but preservation of joint surfaces
6. Mutilating disease, complete articular destruction

Surgical Concepts

• Many patients have adapted to severe deformities
• Be specific in what the functional deficit you are trying to improve is
• Not all deformities need correcting simultaneously
• Patients often happy enough after one procedure

Wrist

Natural History

• Soft tissue attenuation, synovitis, and rupture lead to bony deformities
• Carpus:
  • Synovitis around wrist & extensor tendons
  • Scapholunate ligament degeneration
  • Extrinsic volar ligament attenuation and rupture
  • Scaphoid flexion
  • Radial column collapse
• DRUJ:
  • Caput ulna syndrome
  • ECU subsheath rupture
  • Allows carpus to supinate
  • Stretches dorsal DRUJ restraints
  • Ulna head prominence – piano key sign
  • Eventually:
    • Midcarpal instability and collapse
    • Pan-carpal arthritis

Causes of DRUJ Instability

• High vascularity in pre-styloid recess leads to rapid synovitis
• Attenuates ulna-sided ligament supports – ECU subsheath
• ECU tendon infiltration - instability
• Arthritic destruction of DRUJ articular surfaces

Extensor Tendon Problems

• Synovial infiltration of tendon sheaths – tenosynovitis
• Tendon rupture – especially at wrist level
• Tendon subluxation at MCP level

Wrist Synovitis

• ‘Hourglass swelling’ on dorsum of wrist
• Indicates impending tendon rupture
• Synovium proximal and distal to extensor retinaculum

Tendon Rupture at Wrist

• Infiltration of the tendons themselves
• Attrition at bony prominences – DRUJ, Lister’s tubercle
  • DRUJ typical because of Caput Ulna prominence
• Palmar subluxated carpus
• Dorsal subluxated Ulna head
• Rupture occurs sequentially from ulna to radial
  • EDM then EDC and so on

Vaughan Jackson Syndrome

• EDM rupture due to caput ulna
• Test by holding other fingers flexed-inability to extend little finger
  • Eliminates any juncturae or an EDC to little finger

MCPJ Tendon Problems

• Loss of extension at MCPJ may be caused by:
  1. Subluxation
  2. Tendon rupture
  3. Joint dislocation
  4. PIN palsy
• On examination they can be differentiated by:
  • Subluxation: tendon palpable and relocates with extension
  • Rupture: No palpable tendon or power in any position
  • Dislocation: XR and palpable + visible deformity
  • PIN Palsy: Other muscles affected - Tenodesis retained
    • (slight extension of fingers with maximal passive flexion at wrist)

Flexor Tendon Problems

Tenosynovitis

• Painful thickened volar aspect fingers
• Unable to pinch skin on examination
• Crepitus and pain
• Inject with steroid
• Oral drugs
• Splintage
• Surgical synovectomy if no improvement to prevent rupture
• Be fairly aggressive at preventing tendon rupture

Tendon Rupture

• FDS, FDP, or both at any level
• Primary repair or grafting has poor results
• Consider DIPJ fusion if FDP alone
• Buddy to adjacent flexor if at wrist level
• Tendon grafting may be needed if both ruptured in finger – unpredictable
• All tendon procedures should have a synovectomy concurrently

Mannerfelt Syndrome

• Isolated rupture of FPL or sometimes index FDP
• Attrition on volar STT joint osteophyte
• May be confused with AIN palsy
• Treat with thumb IPJ fusion
  • FDS transfer or tendon grafting has poor results

Triggering

• Usually due to tenosynovitis rather than A1 pulley thickening
• Preserve pulleys if possible (maintain stability of tendon)
• Excise synovitis

Carpal Tunnel Syndrome

• Either concurrent or due to synovitis in tunnel
• Explore carpal tunnel fully if RA present
• Excise synovitis and decompress nerve

Surgery for Wrist RA

Goals:

• Prophylactic or corrective
• Pain relief
• Prevention of tendon rupture
• Correct deformities contributing to functional impairment
• Restore function

DRUJ Procedures

• Darrach’s: Distal ulna resection - often leave styloid tip
  • Possible in older low demand patients
  • Comparable pain relief but grip strength poor
  • Complications:
    • Ulna translation of the carpus into defect
    • Can do concurrent RL fusion to prevent
• Suave Kapanji: DRUJ fusion with Ulna osteotomy to maintain rotation
  • Main complication: Stump pain - abutment against radius
  • Lower complication rate than Darrach
  • Better for younger patients
• DRUJ Arthroplasty:
  • No long-term results and loosening/pain are problems

Radiocarpal Arthritis

Fusion or Arthroplasty

Fusions: Limited or Total

Radiocarpal Fusion (Chamay) (Radius to Lunate and Scaphoid)

• Prophylactic to prevent ulna subluxation of carpus
• Halts natural progression outlined above
• Contraindicated in presence of midcarpal OA

Total Wrist Fusion

• Predictably good results with dorsal fusion plates/pins
• Some prefer not using dorsal plates because of poor bone
• AO locking wrist fusion plate is better though
• Pain relief good and function satisfactory
• Complication rate is low
• Pseudoarthroses tend to be pain free

Surgical Steps

• Longitudinal dorsal approach
• Dorsal half carpal bones and distal radius fragmented and used as graft
• IM pins, Steiman pins, or AO fusion plate
• For bilateral cases try and avoid bilateral fusion
• Consider arthroplasty of one wrist

Wrist Arthroplasty

• Better results but still evolving
• Rheumatoid arthritis is a possible indication
• Improved results with the Universal 2 wrist replacement
  • Should have:
    • Minimal deformity
    • Good bone stock
    • Intact extensors

MCP Joints

Typical Deformities

• Volar joint subluxation due to synovitis
• Ulna drift caused by tendon subluxation

Functional Problems

• Difficult to pinch if index drifted ulnar ward
• Difficulty cupping objects
• Aesthetically displeasing

Surgical Options

Soft Tissue or Bony Procedures

Synovectomy & Cross Intrinsic Transfer of Lateral Bands

• Early disease only
• Prevents subluxation

Relocation of Tendon

• Tightening of radial and release of ulna soft tissues
• Contraindicated if joint affected

Fusion

• Not usually good option as finger motion is initiated at MCPJ
• Fusion is functionally poor at MCPJ
• Last resort

Arthroplasty

• Usually the best solution
• Shortens digit > reduces soft tissue tension and deforming forces
• Must be combined with tendon relocation and soft tissue balance
• Concurrent wrist re-alignment to prevent chronic instability
• Better deformity correction in radial joints
• Silicone spacers most common
  • Traditionally the Swanson
  • Currently Neuflex is most common
  • Scar tissue formed stabilises joints despite loosening
• Pyrocarbon unconstrained joints not good for RA but good in OA

Surgical Principles

• Correct proximal wrist deformities and tendons first
• Multiple or single transverse or longitudinal incisions
• Release capsule and intrinsics
• Excise MCPJ head distal to collaterals
• Imbricate lax radial capsule and sagittal band in closure

Volar Plate Arthroplasty

• Interposition of volar plate in joint - pain relieving
• Unreliable correction of deformity
• Best reserved if bone too small for arthroplasty

Tendon Rupture

• Sequentially occurs from EDM then each EDC
• All procedures should address the tendon deficiency and the cause

Tendon Transfer Options

• Only EDM ruptured
  • End-to-side transfer (stitch end of EDM to EDC of ring finger)
• If ulna 2 tendons ruptured
  • EIP transfer to power ring & little or,
  • EIP to EDM and buddy ring to middle EDC
• If ulna 3 tendons ruptured
  • EIP to ring and little
  • Middle finger end to side with Ext Indicis Communis
  • Weak extension as all fingers powered by index extensors
  • Alternative is to combine FDS into transfer
• If all 4 tendons gone:
  • FDS tendons transferred through interosseous membrane
  • FDS is not synergistic > function difficult to get used to
  • FDS has excellent excursion so is very useful

Boutonniere Deformity

Primary Cause

• Synovitis, attenuation, and rupture of central slip
• Volar subluxation of lateral bands and hyperextension of DIPJ
• Often not functionally too limiting but,
  • Patients don’t like appearance
• Correction to an extended position of PIPJ can actually impair function
  • Therefore avoid for aesthetics

Classification (Nalebuff)

• Mild: Mobile PIPJ, PIPJ extensor lag <15 degrees
• Moderate: Mobile PIPJ, PIPJ extensor lag 15-40 degrees
• Severe: Fixed PIPJ with loss of extension and arthritis

Management

Flexible Deformity:

• If acute: Capener splint – allows active DIPJ motion
• If chronic:
  • Extensor tendon tenotomy – at distal phalanx
  • Leaves ORL intact so no mallet finger develops
  • Tendon reconstruction
  • Passive motion must be restored
  • Re-location of lateral bands or,
  • Transfer of ulna lateral band to central slip

Fixed Deformity:

• Arthrodesis
  • Gold standard – reliable and durable
• Arthroplasty
  • Described but deformity often recurs – more difficult to salvage

Swan Neck Deformity

• More functionally limiting than Boutonniere
• Patient unable to flex finger and grip properly

Causes

• DIPJ: Mallet finger caused by DIPJ disease or trauma
• PIPJ:
  • Synovitis causes volar plate attenuation or FDS rupture
  • Dorsal subluxation of lateral bands
  • Transverse and oblique ligaments incompetent
• MCPJ: Joint or tendon subluxation causes intrinsic tightness

Classification (Nalebuff)

• Type 1: Fully flexible PIPJ with mild hyperextension
• Type 2: Intrinsic tightness, PIPJ tight with MCPJ extension only
• Type 3: PIPJ tight regardless of MCPJ position, No arthritis
• Type 4: Stiff, arthritic PIPJ

Management

• Treatment based on cause of deformity and functional deficit
• REMEMBER: Doing nothing may be the best option
• Optimization of medical treatment prior to surgery

Stage-wise Treatment

• Stage 1:
  • Extension restricting splint if PIPJ is problem
  • DIPJ fusion if DIPJ problem
• Stage 2:
  • Intrinsic release
  • FDS tenodesis or volar plate advancement to prevent hyperextension
• Stage 3:
  • Arthrodesis of PIPJ + intrinsic release
  • Can MUA PIPJ to restore motion then do as for stage 2
• Stage 4: Arthrodesis
• Arthroplasty: PIPJ results are poor in RA

Thumb Deformities

• Thumb Boutonniere (MCPJ problem)
• Thumb Swan Neck (CMCJ problem)
• Mainstay are fusion procedures to provide a strong post for grip
  • Instability rather than loss of motion causes the most symptoms
  • Fuse the appropriate joint
  • If both CMCJ and MCPJ unstable can fuse both but limits function badly
  • Consider CMCJ arthroplasty and MCPJ fusion or just fuse MCPJ

Classification of Rheumatoid Thumb (Nalebuff)

1. Type 1: Boutonniere (MCPJ flexion) – most common
2. Type 2: Boutonniere with CMCJ dislocation or arthritis (rare)
3. Type 3: Swan Neck (CMCJ adduction and flexion)
4. Type 4: Ulna collateral ligament laxity
5. Type 5: Swan Neck with no adduction of metacarpal (rare)
6. Type 6: Mutilating disease – gross joint destruction