• Pathophysiology
• -RA is a common inflammatory arthritis resulting from a Tcell driven autoimmune process à this results in an inflammatory response within synovium with upregulaton of TNF-a and IL-1à causes synovial hypertrophy (pannus)  that erodes cartilage, bone, and soft tissue
• Associated with HLADR4

 

• Diagnosis
•   4 of 7: 
• 1. morning joint stiffness
• 2. soft tissue swelling of 3+ joints
• 3. symmetrical joint involvement
• 4. involvement of MP, PIP, or wrist joints
• 5. rheumatoid nodules
• 6. seropositive RF
• 7. radiographic findings

 

• Labs
• –  RF positive in 70-80% 
• – Anticitrullinated peptide antibody has high specificity for RA

 

• Medical Management: This is managed by rheumatologists. Treatment aims for the containment of chronic inflammation as well as structural protection for the joints.
• There are 3 general classes of medications.
• NSAIDS: This reduces acute inflammation thus relieving pain.
• Corticosteroids
• DMARDS (disease modifying antirheumatic drugs): used after a diagnosis of RA to reduce structural damage early on.
• Splinting
• Surgery only if fails 6-12 months of medical management and have functional limitations or pain
• TNF inhibitors should stop 1 month prior to OR
• MTX and other meds should continue (no benefit in stopping)

 

• Imaging
• – joint space narrowing
• – marginal erosions
• – characteristic deformities- ulnar translocation of carpus, ulnar deviation at MP joints

 

• Order of procedures: elbow arthroplasty –> wrist arthrodesis –> MP joint arthroplasties 
• Presenting Hand Deformities: Wrist, MCP, Tendon Involvement, and Finger Deformities. Remember, a stable wrist sets the foundation for future reconstruction of the hand (start proximal and work distal)
• Wrist: The wrist is the most commonly affected joint in RA. 
• Synovitis of the wrist joint weakens the ligamentous support of the DRUJ à causes collapse of radial column of the carpals à Palmar/ulnar carpal subluxation, supination of carpus, prominent distal ulna (caput ulnae–> can lead to extensor tendon rupture), radial deviation of metacarpals, ulnar deviation of distal fingers results in relative lengthening of distal ulna compared to distal radius
• Caput ulnae (ulnar head dislocates dorsally) results in DRUJ incongruity and impaction of the distal ulna on the carpus
• (Corrective) DRUJ: Darrach and Sauve-Kapandji. The Darrach procedure was first described in 1912 and involves resectin of distal ulna. This provides pain from DRUJ and distal ulna impingement on the carpus. The main concern of Darrah procedure is for continued ulnar translocation of the carpus in patients with weak ligamentous support.
• Sauve-Kapandji: fuses distal radioulnar joint in combination with proximal ulna ostectomy to provide rotary function. This preserved ulnar head gives support to the carpus and prevents ulnar translocation. 
• Debilitating pain can be corrected with wrist arthrodesis vs arthroplasty. 
• If bilateral wrists are involved- it is recommended for arthroplasty of dominant wrist and arthrodesis of nondominant wrist in neutral to 15 degrees extension. Problems with arthroplasty include loosening, implant fracture, or periprosthetic bone problems. – wrist arthrodesis
• MCP Joints: typical deformity in RA resulting in volar subluxation of proximal phalanges and ulnar deviation of the fingers (distal to MCP). 
• Pathophysiology: chronic synovitis at the MCP disrupts the ligamentous support, radial stress of the fingers with pinch drives the fingers in the ulnar direction. Also has inability to extend the fingers leading to limitation of fine pinch and ability to the cup the fingers. Most distressing is usually the aesthetic appearance of this deformity
• Treatment: arthrodesis vs arthroplasty. Arthrodesis rarely performed because of arc of motion of the fingers is initiated at the MCP joint
• MCP arthroplasty- usually silicone arthroplasty combined with shortening to relax tension and improve positioning of fingers. Silicone preferred due to ease of placement and relative accessibility. Does not change range of motion
• Transfer of interosseous muscle performed for correction of ulnar drift in RA

 

• Tendon Rupture: 2 reasons for tendon rupture 1) abrasion of the tendon over bony prominences (eroded distal ulna or distal pole of scaphoid), and 2) weakening of the tendon by synovial invasion.
• Tendon problems include: Trigger finer due to focal tenosynovitis or rheumatoid nodule within sheath/tendon; FPL rupture- most common flexor tendon rupture, secondary to wear against volar scaphoid osteophyte, called Mannerfelt lesion; Extensor tendon ruptures- due to extensor tenosynovitis, attrition over sharp edges caused by DRUJ and radiocarpal arthritis as well as ulnar translocation of extensor tendons and dorsal subluxation of distal ulna (caput ulna syndrome)
• small finger firstà ring, long, index extensors (Vaughn-Jackson syndrome
• Small finger EDC most commonly ruptures- commonly crosses head of ulna à  Definitive operative management includes Darrach and excision of synovial tissue over extensor tendon. 
• Extensor tendon reconstruction follow principles of tendon transfer. Small finger à distal end can be transferred end to side to intact ring. When ring/little ruptured à use EIP to power ring and small. When long,ring, small ruptured à EIP to power ring and small and long EDC distal end to side index EDC. 
• Other strategies include transfer of FDS from long or ring to power ring and small finger while EIP used to power long. 
• If all 4 extensor tendons ruptured à options include using both FDS from long and ring to power index/middle and ring/little.
• For EPL rupture use EIP
• Other reasons for the inability to extend at MCP à extensor subluxation ulnarly (can hold fingers in extension when placed in extension); MCP joint dislocation, PIN palsy (wrist extension intact)
• Finger Deformities: Boutonniere versus Swan-Neck
• Boutonniere deformity: PIP flexion, DIP hyperextension, pathology originates at PIP jointà patients present mainly an aesthetic concern. Typically starts as elongation of the central slip from SYNOVITIS (this is the primary pathology in RA). The lateral bands sublux below the axis of rotation (volar), resulting in shortening of the retinacular ligaments. This causes flexion of the PIP and extension of the DIP (from tightening of the lateral bands).
• Two different deformities (flexible or fixed). For flexible deformities may use soft tissue reconstruction including joint synovectomy, tightening of the stretched central tendon, and dorsal fixation of the lateral bands. 
• Fixed deformities, or evidence of articular destruction require arthrodesis or arthroplasty. Arthrodesis is typically favored in boutinneire given that arthroplasty requires excision and removal of collateral ligaments thus destabilizing the joint.
• – Swan neck deformity: PIP hyperextension, DIP flexion à patients report problems making a fist
• – DIP: erosion of terminal tendon (mallet type finger)
• – PIP: stretching of volar plate, rupture of FDS insertion à PIP hyperextension
• -MCP level- subluxation of the joint and extensor tendon mechanism can result in ulnar intrinsic tendon tightness 
• Type I: Flexible PIP joint deformity, regardless of MCP joint position
• Type II: Limited PIP joint flexion with the MCP extended because of intrinsic tightness
• Type III: Limited PIP joint flexion in all MCP joint positions because of a fixed dorsal position of the lateral bands
• Type IV: PIP joint destruction

Management depends on the extent of the PIP joint deformity. Type I swan-neck deformities generally respond to figure-of-eight splinting. DIP arthrodesis can be considered for swan-neck deformity resulting from a mallet. Type II swan-neck deformities may be managed by a figure-of-eight splint or by an intrinsic release if the intrinsics are tight without MCP joint subluxation or degeneration. Type III swan-neck deformities are treated with translocation of the lateral bands, PIP joint capsulectomy and collateral ligament release. Type IV swan-neck deformities are treated with PIP joint arthrodesis or PIP joint silicone arthroplasty.

• Thumb Deformities: Most common deformity is boutonniere (MCP flexed IP extended) or more rare swan neck deformity
• Boutonniere- MCP fusion – originates from synovitis at the MCP joint–> EPL subluxates ulnarly and volarly
• Swann- Neck CMC arthroplasty or arthrodesis
• Hyperextension of MCP can affect thumb basal joint and inhibit reconstructive efforts, address if >30 degrees

 

• Surgical Management (Miscellaneous) : coordination of care between a rheumatologist and hand surgeon. 
• – flexor tendon rupture
• – FPL- remove osteophyte at level of scaphoid, flexor tenosynovectomy, index FDS transfer into FPL/tendon graft of FPL (like palmaris)/arthrodesis of thumb IP joint
• – FDS- suture stump to adjacent finger FDS
• – FDP- suture stump to adjacent finger FDP
• Both FDS/FDP- staged tendon recon with Hunter rod (poor outcomes in RA) or DIP/PIP fusion
• – trigger finger- don’t perform A1 pulley release, removed tenosynovitis and nodules –> removal of slip of FDS last option
• – carpal tunnel- extensive exposure, flexor tenosynovectomy
• Rheumatoid nodules do not need to be resected
• PIN palsy- due to inflammation and synovitis at elbow; patients lack active extension but tenodesis still exists (subluxation from rupture of sagittal band, cannot extend but can hold extension); extensor tendon rupture lacks tenodesis effect, recurrent synovitis wound be difficult to extend MP joint
• Release of radial tunnel useful for PIN syndrome
• Can still perform trapeziectomy in those with CMC athritis

 

• Atypical Arthritidis
• Psoriatic Arthritis-
• Plaques on extensor surfaces, have dactylitis (sausage fingers), PIP flexion contractures, MCP stiff and hyperextended, arthritis mutilans
• “pencil in cup deformity on DIP”
• Rapid onset psoriatic arthritis, reiter’s syndrome:  HLA B 27, will present as acute swelling of digits, DIP (arthritis, conjunctivits, uveitis), can co-exist with HIV infection
• Surgical management similar to RA
• SLE-
• ANA positive, symmetric hand edema, malar rash, pleuritis etc
• Joint spaces preserved, in SLE there is subluxation of joints (swann-neck and lupus)
• Surgical treatment (after splinting, silver ring splints)–> limited fusions
• Scleroderma- limited skin and joints, diffuse cutaneous (internal organs)
• ANA, women, CREST (limited cutaneous- calcinosis, raynauds, esophageal, shiny skin, telangectasias), anti SCL-70
• Systemic- perisympathectomy 
• Integra can be used in patients with scleroderma and exposed joint when local flaps cannot be used because of diseased tissue; PIP arthrodesis used for flexion contractures of PIP joints
• Gout- the great mimicker- deposition of crystals via monoarticular deposition (DIP, RC, mimics septic arthritis)
• Peri-articular erosions, or punched out lesions
• Affects abnormal joints
• Aspriation of joints (negatively bifringerent), positively is CPPD, monosodium urate crystals (needle shaped)
• Can invade SL/LT joint and result in SLAC wrist (pseudogout TFCC)
• Acute management- NSAIDS (indocin), cochicine
• Chronic- xanthine oxidase inhibitors (allopurinol)
• Acute Calcific Periarthritis (calcific depositions)
• Sarcoidosis-non caseating granulomas (bilateral hilar lymphadenopathy)-treat with steroids
• Lyme Disease- mid to late- migratory arthralgias and polyneuralgia (doxy)