J Rheum Dis.  2021 Oct;28(4):192-201. 10.4078/jrd.2021.28.4.192.

Rheumatoid Hand Surgery in the Era of Biologic Therapy: A Rheumatologist-oriented Overview

• Park JW
• Hwang JS
• Gong HS

• KMID: 2520432
• DOI: http://doi.org/10.4078/jrd.2021.28.4.192

Abstract

Rheumatoid arthritis (RA) can cause significant hand and wrist damage and dysfunction. The aim of medical treatment is to eradicate inflammation and prevent damage to joints and soft tissues. Advances in newer biological therapies over the last two decades have resulted in greater remission rates and lower disease activity status. Despite these improvements, surgical intervention is still indicated in cases of disability, irreversible deformities, and severe pain. However, there are large variations in the surgical rates of common rheumatoid hand procedures, which may indicate clinical uncertainty or disagreement between treating rheumatologists and hand surgeons. In this review, we provide a basic overview of common problems of the hand and wrist in RA patients. The target audience is rheumatologists for their better understanding of surgical options and for better informed patient consultation before referring to hand surgeons.

Keyword

Rheumatoid arthritis; Biologic therapy; Surgery; Hand; Wrist

Figure

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  Figure 1 Reconstruction options for ruptured extensor tendon in rheumatoid arthritis according to the involved fingers. (A) For involvement of the little finger only, the extensor digitorum minimi (EDM) function is restored by reattaching its distal part to the 4th extensor digitorum communis (EDC) by end-to-side suture, so that the 4th EDC can extend both the 4th and 5th fingers. (B) For involvement of the little and 4th finger, the 4th EDC function is restored by reattaching its distal part to the 3rd EDC by end-to-side suture, so that the 3rd EDC can extend both the 3rd and 4th fingers. The EDM function is restored by transferring the extensor indicis proprius (EIP) by end-to-end suture, so that the EIP can extend the little finger instead of the index finger. The remaining 2nd EDC extends the index finger without the EIP. (C) Involvement of the little, 4th, and 3rd finger is difficult to treat satisfactorily. The authors’ favorite method is to restore the EDM function by transferring the EIP to the EDM by end-to-end repair, and to restore the 3rd and 4th EDCs by transferring the extensor carpi radialis longus (ECRL, wrist extensor) by end-to-end suture (Drawings are authors’ own artwork).

• 

  Figure 2 (A) Arthritic change in the distal radioulnar joint results in dorsal subluxation of the ulnar head or ulnocarpal impingement. (B) In the Darrach procedure, the ulnar head is resected and the proximal stump is stabilized by extensor carpi ulnaris. (C) In the Sauvé-Kapandji procedure, the ulnar support of the wrist is preserved by arthrodesis of the distal radioulnar joint. The resection of the ulna is made proximal to the arthrodesis, which creates a pseudarthrosis to allow forearm rotation (Drawings are authors’ own artwork).

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  Figure 3 (A) The carpal bones have migrated ulnarly with arthritic changes mainly in the radiocarpal joint, with relatively preserved midcarpal joint. (B) The scaphoid was resected and arthrodesis was done between the lunate and the radius (radiolunate fusion) so that the carpal bones do not migrate further ulnarly. Partial wrist motion can occur in the midcarpal joint.

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  Figure 4 In rheumatoid arthritis hand, synovitis at the metacarpophalangeal joint destructs stabilizing ligaments, which results in extensor tendon displacement ulnarly. Moreover, the proximal phalanx subluxates in a volar direction and contracture of intrinsic muscles of the hand results in permanent flexion deformities. The deformity can deteriorate one’s quality of life by affecting hand grip function and by causing cosmetic problems (Drawings are authors’ own artwork).

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  Figure 5 For early stages of ulnar drift hand deformity, the following procedures aim to restore the normal position of the fingers. Through a square bracket-shaped incision at dorsal capsule of the metacarpophalangeal joint (A), a thorough synovectomy of the joint is performed (B), followed by plication of the capsule (C). (D) The subluxated extensor tendon is divided longitudinally on the radial side of sagittal band, relocated to the normal site, and plicated. (E) The intrinsic tendons at ulnar side are detached and transferred to the radial side of the next finger, thus changing a deforming force into a correcting force (Drawings are authors’ own artwork).

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  Figure 6 (A) This patient presented with swan neck deformity of the thumb. In this type of deformity, the metacarpal bone is progressively adducted and flexed, which results in inconvenience in opening of the first webspace. (B) The radiograph shows dorsoradial subluxation of the trapeziometacarpal (TMC) joint indicative of severe synovitis, and resultant metacarpal adduction and compensatory hyperextension of the metacarpophalangeal (MCP) joint (zigzag deformity). Resection of the trapezium (dotted circle) and volar capsulodesis of the MCP joint (curved arrow) was performed. (C) Deformities of the TMC and MCP joints were corrected. Improved thumb abduction and pinching was observed along with cosmetic improvement.

Reference

1. McInnes IB, Schett G. 2011; The pathogenesis of rheumatoid arthritis. N Engl J Med. 365:2205–19. DOI: 10.1056/NEJMra1004965. PMID: 22150039.

2. Aletaha D, Smolen JS. 2018; Diagnosis and management of rheumatoid arthritis: a review. JAMA. 320:1360–72. DOI: 10.1001/jama.2018.13103. PMID: 30285183.

3. Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance R, et al. 2004; Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. Lancet. 364:263–9. DOI: 10.1016/S0140-6736(04)16676-2. PMID: 15262104.

4. Chung KC, Pushman AG. 2011; Current concepts in the management of the rheumatoid hand. J Hand Surg Am. 36:736–47. DOI: 10.1016/j.jhsa.2011.01.019. PMID: 21463736. PMCID: PMC3086569.

5. Fevang BT, Lie SA, Havelin LI, Engesaeter LB, Furnes O. 2007; Reduction in orthopedic surgery among patients with chronic inflammatory joint disease in Norway, 1994-2004. Arthritis Rheum. 57:529–32. DOI: 10.1002/art.22628. PMID: 17394183.

6. Kievit W, Fransen J, de Waal Malefijt MC, den Broeder AA, van Riel PL. 2013; Treatment changes and improved outcomes in RA: an overview of a large inception cohort from 1989 to 2009. Rheumatology (Oxford). 52:1500–8. DOI: 10.1093/rheumatology/ket166. PMID: 23657913.

7. Louie GH, Ward MM. 2010; Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis. 69:868–71. DOI: 10.1136/ard.2009.112474. PMID: 19581279. PMCID: PMC2859109.

8. Dafydd M, Whitaker IS, Murison MS, Boyce DE. 2012; Change in operative workload for rheumatoid disease of the hand: 1,109 procedures over 13 years. J Plast Reconstr Aesthet Surg. 65:800–3. DOI: 10.1016/j.bjps.2011.11.050. PMID: 22182594.

9. Momohara S, Inoue E, Ikari K, Ochi K, Ishida O, Yano K, et al. 2014; Recent trends in orthopedic surgery aiming to improve quality of life for those with rheumatoid arthritis: data from a large observational cohort. J Rheumatol. 41:862–6. DOI: 10.3899/jrheum.131018. PMID: 24692532.

10. Weiss RJ, Ehlin A, Montgomery SM, Wick MC, Stark A, Wretenberg P. 2008; Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients. Rheumatology (Oxford). 47:491–4. DOI: 10.1093/rheumatology/ken009. PMID: 18296481.

11. Saleem B, Brown AK, Keen H, Nizam S, Freeston J, Karim Z, et al. 2009; Disease remission state in patients treated with the combination of tumor necrosis factor blockade and methotrexate or with disease-modifying antirheumatic drugs: a clinical and imaging comparative study. Arthritis Rheum. 60:1915–22. DOI: 10.1002/art.24596. PMID: 19565512.

12. de la Mata Llord J, Palacios Carvajal J. 1998; Rheumatoid arthritis: are outcomes better with medical or surgical management? Orthopedics. 21:1085–6. DOI: 10.3928/0147-7447-19981001-06. PMID: 9801231.

13. Chung KC, Burns PB, Wilgis EF, Burke FD, Regan M, Kim HM, et al. 2009; A multicenter clinical trial in rheumatoid arthritis comparing silicone metacarpophalangeal joint arthroplasty with medical treatment. J Hand Surg Am. 34:815–23. DOI: 10.1016/j.jhsa.2009.01.018. PMID: 19410984. PMCID: PMC4381953.

14. Simmen BR, Kolling C, Herren DB. 2007; (iv) The management of the rheumatoid wrist. Curr Orthop. 21:344–57. DOI: 10.1016/j.cuor.2007.09.003.

15. Schindele SF, Herren DB, Simmen BR. 2011; Tendon reconstruction for the rheumatoid hand. Hand Clin. 27:105–13. DOI: 10.1016/j.hcl.2010.10.004. PMID: 21176805.

16. Shannon FT, Barton NJ. 1976; Surgery for rupture of extensor tendons in rheumatoid arthritis. Hand. 8:279–86. DOI: 10.1016/0072-968X(76)90015-2.

17. Nakamura S, Katsuki M. 2002; Tendon grafting for multiple extensor tendon ruptures of fingers in rheumatoid hands. J Hand Surg Br. 27:326–8. DOI: 10.1054/jhsb.2002.0755. PMID: 12162969.

18. Asano K, Shinohara T, Iwatsuki K, Yamamoto M, Tatebe M, Hirata H. 2020; Risk factors for rupture of extensor tendons in the rheumatoid wrist. J Hand Surg Eur Vol. 45:1087–92. DOI: 10.1177/1753193420928481. PMID: 32493113.

19. Hsueh JH, Liu WC, Yang KC, Hsu KC, Lin CT, Chen LW. 2016; Spontaneous extensor tendon rupture in the rheumatoid wrist: risk factors and preventive role of extended tenosynovectomy. Ann Plast Surg. 76 Suppl 1:S41–7. DOI: 10.1097/SAP.0000000000000685. PMID: 26808746.

20. Ryu J, Saito S, Honda T, Yamamoto K. 1998; Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. J Hand Surg Br. 23:658–61. DOI: 10.1016/S0266-7681(98)80022-3. PMID: 9821614.

21. The British Society for Surgery of the Hand. 2016. Flexor tendon injury [Internet]. The British Society for Surgery of the Hand;London: Available from: https://www.bssh.ac.uk/patients/conditions/26/flexor_tendon_injury. cited 2021 Apr 3.

22. Jain A, Ball C, Freidin AJ, Nanchahal J. 2010; Effects of extensor synovectomy and excision of the distal ulna in rheumatoid arthritis on long-term function. J Hand Surg Am. 35:1442–8. DOI: 10.1016/j.jhsa.2010.04.034. PMID: 20673615.

23. Van Gemert AM, Spauwen PH. 1994; Radiological evaluation of the long-term effects of resection of the distal ulna in rheumatoid arthritis. J Hand Surg Br. 19:330–3. DOI: 10.1016/0266-7681(94)90082-5. PMID: 8077821.

24. Bieber EJ, Linscheid RL, Dobyns JH, Beckenbaugh RD. 1988; Failed distal ulna resections. J Hand Surg Am. 13:193–200. DOI: 10.1016/S0363-5023(88)80047-9. PMID: 3351241.

25. Condamine JL, Lebreton L, Aubriot JH. 1992; The Sauvé-Kapandji operation. Analysis and results of 69 cases. Ann Chir Main Memb Super. 11:27–39. French. DOI: 10.1016/S0753-9053(05)80050-X. PMID: 1375491.

26. Kobayashi A, Futami T, Tadano I, Fujita M, Watanabe T, Moriguchi T. 2005; Radiographic comparative evaluation of the Sauve-Kapandji procedure and the Darrach procedure for rheumatoid wrist reconstruction. Mod Rheumatol. 15:187–90. DOI: 10.3109/s10165-005-0396-8. PMID: 17029060.

27. McQueen F, Beckley V, Crabbe J, Robinson E, Yeoman S, Stewart N. 2005; Magnetic resonance imaging evidence of tendinopathy in early rheumatoid arthritis predicts tendon rupture at six years. Arthritis Rheum. 52:744–51. DOI: 10.1002/art.20947. PMID: 15751075.

28. Lillegraven S, Bøyesen P, Hammer HB, Østergaard M, Uhlig T, Sesseng S, et al. 2011; Tenosynovitis of the extensor carpi ulnaris tendon predicts erosive progression in early rheumatoid arthritis. Ann Rheum Dis. 70:2049–50. DOI: 10.1136/ard.2011.151316. PMID: 21515919.

29. Rizzo M, Cooney WP 3rd. 2011; Current concepts and treatment for the rheumatoid wrist. Hand Clin. 27:57–72. DOI: 10.1016/j.hcl.2010.09.004. PMID: 21176801.

30. Honkanen PB, Mäkelä S, Konttinen YT, Lehto MU. 2007; Radiocarpal arthrodesis in the treatment of the rheumatoid wrist. A prospective midterm follow-up. J Hand Surg Eur Vol. 32:368–76. DOI: 10.1016/J.JHSE.2007.04.006. PMID: 17950192.

31. Raven EE, Ottink KD, Doets KC. 2012; Radiolunate and radioscapholunate arthrodeses as treatments for rheumatoid and psoriatic arthritis: long-term follow-up. J Hand Surg Am. 37:55–62. DOI: 10.1016/j.jhsa.2011.10.012. PMID: 22137064.

32. Ishikawa H, Murasawa A, Nakazono K. 2005; Long-term follow-up study of radiocarpal arthrodesis for the rheumatoid wrist. J Hand Surg Am. 30:658–66. DOI: 10.1016/j.jhsa.2005.02.005. PMID: 16039354.

33. Borisch N, Haussmann P. 2002; Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up. J Hand Surg Br. 27:61–72. DOI: 10.1054/JHSB.2001.0681. PMID: 11895349.

34. Cavaliere CM, Chung KC. 2008; A systematic review of total wrist arthroplasty compared with total wrist arthrodesis for rheumatoid arthritis. Plast Reconstr Surg. 122:813–25. DOI: 10.1097/PRS.0b013e318180ece3. PMID: 18766045.

35. Bhamra J, Bhamra K, Hindocha S, Khan W. 2017; The role of wrist fusion and wrist arthroplasty in rheumatoid arthritis. Curr Rheumatol Rev. 13:23–8. DOI: 10.2174/1573397111666151026223636. PMID: 26496781.

36. Ogunro S, Ahmed I, Tan V. 2013; Current indications and outcomes of total wrist arthroplasty. Orthop Clin North Am. 44:371–9. ixDOI: 10.1016/j.ocl.2013.03.008. PMID: 23827839.

37. Murphy DM, Khoury JG, Imbriglia JE, Adams BD. 2003; Comparison of arthroplasty and arthrodesis for the rheumatoid wrist. J Hand Surg Am. 28:570–6. DOI: 10.1016/S0363-5023(03)00182-5. PMID: 12877842.

38. Kanbe K, Inoue K. 2006; Efficacy of arthroscopic synovectomy for the effect attenuation cases of infliximab in rheumatoid arthritis. Clin Rheumatol. 25:877–81. DOI: 10.1007/s10067-005-0129-6. PMID: 16374576.

39. Nakamura H, Nagashima M, Ishigami S, Wauke K, Yoshino S. 2000; The anti-rheumatic effect of multiple synovectomy in patients with refractory rheumatoid arthritis. Int Orthop. 24:242–5. DOI: 10.1007/s002640000168. PMID: 11153450. PMCID: PMC3619912.

40. Ochi T, Iwase R, Kimura T, Hirooka A, Masada K, Owaki H, et al. 1991; Effect of early synovectomy on the course of rheumatoid arthritis. J Rheumatol. 18:1794–8. PMID: 1795314.

41. Mathews AL, Burns PB, Chung KC. 2016; How rheumatoid arthritis patients make decisions regarding hand reconstruction: a qualitative study from the Silicone Arthroplasty in Rheumatoid Arthritis Project. Plast Reconstr Surg. 137:1507–14. DOI: 10.1097/PRS.0000000000002083. PMID: 26796370.

42. Waljee J, Zhong L, Baser O, Yuce H, Fox DA, Chung KC. 2015; The incidence of upper and lower extremity surgery for rheumatoid arthritis among Medicare beneficiaries. J Bone Joint Surg Am. 97:403–10. DOI: 10.2106/JBJS.N.00802. PMID: 25740031. PMCID: PMC4344595.

43. Chung KC, Kotsis SV, Burns PB, Burke FD, Wilgis EFS, Fox DA, et al. 2017; Seven-year outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study. Arthritis Care Res (Hoboken). 69:973–81. DOI: 10.1002/acr.23105. PMID: 27696739. PMCID: PMC5376377.

44. Brulard C, Sauvage A, Mares O, Wavreille G, Fontaine C. 2012; [Treatment of rheumatoid swan neck deformity by tenodesis of proximal interphalangeal joint with a half flexor digitorum superficialis tendon. About 23 fingers at 61 months follow-up]. Chir Main. 31:118–27. French. DOI: 10.1016/j.main.2012.04.010. PMID: 22647791.

45. Borisch N, Haubmann P. 2011; [Littler tenodesis for correction of swan neck deformity in rheumatoid arthritis]. Oper Orthop Traumatol. 23:232–40. German. DOI: 10.1007/s00064-011-0028-8. PMID: 21725663.

46. Tonkin MA, Hughes J, Smith KL. 1992; Lateral band translocation for swan-neck deformity. J Hand Surg Am. 17:260–7. DOI: 10.1016/0363-5023(92)90402-B. PMID: 1564271.