Rheumatoid Hand

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-Rheumatoid Arthritis affects 1% of the US population. RA is more common in women.
-Etiology of RA is unknown, but it is thought to be multifactorial with both genetic (particularly HLA DR4) and environmental factors playing a role. 

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

–  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

–  RF positive in 70-80% 
– Anticitrullinated peptide antibody (anti CCP) has high specificity for RA

Medical Management: This is managed by rheumatologists. 

  • Medical management has improved significantly in recent years with advent of biologics, may see LESS rheumatoid hand in your clinic but the cases you do see are likely to be more severe 
  • Treatment aims for the containment of chronic inflammation as well as structural protection for the joints.

There are 3 general classes of medications.

  • NSAIDS: treatment only and does not alter course of disease or prevent joint destruction. (ex: ibuprofen)
  • Corticosteroids: prednisone and methylprednisone used to reduce inflammation and regulate immune system activity when NSAIDS are no longer able to control symptoms or during flares. 
  • DMARDS (disease modifying antirheumatic drugs): used after a diagnosis of RA to reduce structural damage early on. These drugs have anti-inflammatory effects along with structurally modifying properties. This is used for long lasting control of RA and have two types: nonbiologic (IE methotrexate) and biologic.

Holding medications for surgery:

  • Methotrexate and other DMARDS – typically are continued, but should be discussed with rheumatology
  • Steroids – continued at normal preoperative dosage, and may require a stress dose at time of surgery if taking 5-10mg/day or more
  • Biologics – May need to be held for 2-4wks before and after surgery 

Imaging- typically radiographic examination. This will exhibit: 
– joint space narrowing
– marginal erosions
– characteristic deformities- ulnar translocation of carpus, ulnar deviation of fingers.

Surgical Intervention:

  • Surgery recommended after failure of conservative management with 6-12 months of medical management
  • Principles:
    • Principal indication for surgery is PAIN, and function is secondary. Many patients have compensated for these deformities and minimal functional complaints
    • Start with PROXIMAL procedures before distal – for example you would address a wrist deformity prior to the digits as the wrist deformity likely exacerbates the digital deformity 

Presenting Hand Deformities: Wrist deformities, metacarpal phalangeal joint deformities, Tendon Involvement, and Finger Deformities. Remember, a stable wrist sets the foundation for future reconstruction of the hand!

  • Wrist: The wrist is the most commonly affected joint in RA. 
    • Synovitis of the wrist joint weakens bot the intrinsic and extrinsic wrist ligaments which leads to deformities such as ulnar translocation of the carpus, DRUJ disruption and ulnar dislocation, ECU tendon attenuation 
      • This resutls in the “Caput ulnae” deformity (*ulnar head dislocates dorsally) results in DRUJ incongruity and impaction of the distal ulna on the carpus which can lead to arthric changes and PAIN
    • Surgical Correction: This can be considered prophylactic or corrective.
      • Prophylactic: RL (radiolunate) arthrodesis procedure (only if midcarpal joint is free from disease)- stabilizes wrist and allows better motion through the midcarpal joint
      • (Corrective) DRUJ: Darrach and Sauve-Kapandji. 
        • The Darrach procedure involves resection of distal ulna. This provides pain relief from DRUJ and distal ulna impingement on the carpus. 
        • SK: Ostectomy of the proximal ulna with FUSION of the DRUJ fuses distal radioulnar joint in combination with proximal ulna ostectomy to provide stable rotary function. This preserved ulnar head gives support to the carpus and prevents ulnar translocation. 
      • Finally debilitating pain can be corrected with wrist arthrodesis vs arthroplasty.
        • Limited arthrodesis can slow progression of deformities. 
        • Total wrist fusion can achieve stable wrist and decrease pain. This is used with a combination of pins or plates. 
          • If bilateral wrists are involved- it is recommended for arthroplasty of dominant wrist and arthrodesis of nondominant wrist in neutral to 15 degrees extension. 

  • MCP Joints: typical deformity in RA is volar subluxation of proximal phalanges and ulnar deviation of the fingers and this is secondary to attrition of the RADIAL SAGGITAL BAND
    • Classic finding – these patients will not be able to actively extend digits at MCP on their own but if you passively extend them they are able to hold MCPS in extension. This limitation is due to this radial saggital band rupture and subluxation of the extensor mechanism. When they are passively corrected this centralizes the extensor mechanism and they are then able to hold in extension. — ASKED PREVIOUSLY on exam 
    • Treatment: arthrodesis vs arthroplasty. Arthrodesis rarely performed because of arc of motion of the fingers is initiated at the MCP joint
      • One way to address this MCP deformity with a “cross intrinsic transfer” where the ulnar lateral band to a digit is divided and transferred to adjacent digit radial saggital band, alternatively could preform only a “intrinsic release”
  • Another common finding in RA is Tendon Rupture: 
    • 2 reasons for tendon rupture 
      • 1) abrasion of the tendon over bony prominences (eroded distal ulna or distal pole of scaphoid)
      • 2) weakening of the tendon by synovial invasion.
    • Tendon problems include: Trigger finger due to focal tenosynovitis or rheumatoid nodule within sheath/tendon; 
      • don’t perform A1 pulley release, surgically debride tenosynovitis and nodules
    • Flexor Tendon Ruptures -FPL rupture is the most common, secondary to wear against volar scaphoid osteophyte, called Mannerfelt lesion
      • Surgery includes removing osteophyte at level of scaphoid and index FDS transfer to FPL or arthrodesis of thumb IP joint
    • Extensor tendon ruptures- due to extensor tenosynovitis, attrition over sharp edges caused by DRUJ and radiocarpal arthritis
      • Extensor tendon involvement typically progress from ulnar to radial. Small finger followed by ring, long, index extensors (Vaughn-Jackson syndrome)
      • Diagnosis of small finger EDQ rupture comes from testing EDQ independent of EDC (extend small finger while other fingers flexed). Definitive operative management includes Darrach and excision of synovial tissue over extensor tendon. 
      • Additionally, EPL rupture can occur- typically reconstructed with EIP 
    • Other extensor deficits:
      • If patient is unable to actively extend the digits, but extensor tenodesis is intact, an additional cause may be PIN Syndrome due to compression of this nerve around the elbow at the radiocapitellar joint 
  • RA Finger Deformities: Boutonniere versus Swan-Neck
    • Boutonniere deformity: PIP flexion, DIP hyperextension, pathology always originates at PIP joint patients present mainly an aesthetic concern. Typically starts as elongation of the central slip. The lateral bands sublux below the axis of rotation, 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. 
      • Arthrodesis is typically favored in fixed boutinneire given that arthroplasty requires excision and removal of collateral ligaments thus destabilizing the joint.
    • – Swan neck deformity: PIP hyperextension, DIP flexion
      • Pathology can originate at several different levels
        • DIP: erosion of terminal tendon (mallet type finger)
        • PIP: stretching of volar plate or rupture of FDS insertion resulting in PIP hyperextension
        • MCP: subluxation of the joint and extensor tendon mechanism can result in ulnar intrinsic tendon tightness 
      • Surgical correction of swan neck depends on its origin and if it is flexible or fixed. 
        • Flexible PIP joint can be treated with splinting
        • Limited PIP joint flexion with MCP extended (intrinsic tightness) – Tx with splint +/- intrinsic release
        • If joint is fixed then options include arthroplasty or arthrodesis
  • Thumb Deformities: 
    • Most common deformity is boutonniere (MCP flexed IP extended) or more rare swan neck deformity
    • Treatments:
      • Boutonniere- MCP fusion 
      • Swann- Neck CMC arthroplasty or arthrodesis

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