Now we're going to launch into rheumatoid arthritis, which is a topic that brings sleep to many people's brains, so try to stay awake for this one. These are the common deformities that you will see in rheumatoid arthritis, and this is what they ask about. The carpus follows the slope of the radius, and it tends to fall off ulnar and volar, and it supinates. Because the carpus goes ulnar, it deviates, pointing radially, and then the MP joints go ulnarly. So they get ulnar drift at the MPs, the radial sagittal bands stretch out, which accentuates the deformity at the MP joints, and the proximal phalanges dislocate palmarward. The thumb most often has a boutonniere deformity. The finger IP joints can be swan-necked or boutonniere, and you get synovitis and tendon ruptures of the flexors or the extensors. The common surgeries performed in rheumatoid arthritis are wrist fusions and DARRER procedures, tendon reconstruction or transfers, thumb MP fusion, MP arthroplasties, IP joint fusions, and synovectomies, which are usually temporary. And that's pretty much all you need to know, but now we'll talk for a longer period of time about it. So this is tenosynovitis seen in rheumatoid arthritis. It's a systemic autoimmune disease, and 70% of patients have wrist or hand involvement within the first two years of diagnosis, and the majority get it by ten years out. It's a clinical diagnosis, and this is how the rheumatologists make it. You have to have four of these seven criteria present for at least six weeks. Morning stiffness, swelling in three or more joints, rheumatoid nodules, characteristic X-ray changes, symmetrical arthritis, a positive rheumatoid factor, and now they also send it for the anti-CCP and a couple of other ones. I used to send labs, and then the rheumatologists have new ones that they keep coming up with, so I just have the rheumatologists send the labs now. And then they get arthritis of the MP, PIP, and wrist joints, but the DIP joints are usually spared in contrast to osteoarthritis. The disease-modifying agents, the DMARDS, have ruined our rheumatoid practice, and the Swedish study showed a decline in rheumatoid surgery by 30% over the years of 98 to 2004. In the hand and wrist, the cartilage gets bad, the ligaments become lax, and the synovium erodes into the bones and the joints. So the erosion starts in areas of high blood flow, and in the wrist, that involves the ulnar styloid. So in the pre-styloid recess, which is an area of vascularization, you'll see erosions as the pannus starts to invade it. The TFCC detaches and becomes incompetent, and the ulna then becomes prominent dorsally and you get synovitis, and ECU involvement falls off, and then you get a dorsal ulna dislocation, the caput ulna, and then it starts to erode through your extensor tendons, causing the Von Jackson deformity that we'll talk about. On the vulnar side of the wrist, the vulnar ligaments become involved with the pannus, they become weak, and the radius has a slope, as you know, and the carpus follows that slope. So the radial inclination angle of 22 to 23 degrees and the palmar tilt of 10 to 12 degrees form a nice slope for the carpus just to slide down when it no longer is tethered by the ligaments, and that's the direction it tends to go. It goes vulnar, ulnar, and it supinates. And at the hand, the MP joint becomes involved at the collateral ligaments with synovitis, and this allows the joint to swell. The sagittal bands on the radial side become incompetent, and the extensor tendons fall off into the ulnar side, and that drives your proximal phalanges down, and so you get the characteristic ulnar deviation of the fingers. The MP joint is worsened by the wrist involvement. So as the carpus tends to slide ulnarly, the ulnar drift is exacerbated, and that's why it's very helpful to do something to stabilize the wrist if you're going to try to correct the MP joints. So if you don't stabilize the wrist, it tends to recur. The PIP joints also become swollen, and this can result in either a boutonniere, which usually starts at a primary PIP focus, or a swan neck, which can start at either the DIP or the PIP or the MP, actually. The boutonniere deformity, the central slip in the triangular ligament, must attenuate, and that leads to lateral band subluxation, PIP flexion, and DIP hyperextension. Now when they ask you what to do with these, what you're looking for in the fingers is that is there a fixed deformity, okay? If you see something that is not passively correctable, or bad arthritic, you're going to fuse it. If they give you a scenario where they have full motion, and there's just a little problem, those are the ones that you might consider doing some kind of a reconstruction for the PIP joint when it comes to doing something for the boutonniere or the swan neck. And the swan neck deformity is due to PIP hyperextension, intrinsic overpull, and they get the swan neck deformity. The thumb involvement in rheumatoid, the CMC can be considered to be the MP of the fingers. And so the CMC becomes arthritic, and there are various nail-above classifications of rheumatoid thumb deformities, which I will not recommend that you memorize. But do know that the most common deformity is a boutonniere, which turns out to be a nail-above type 1. And so that starts at the MP joint. The second most common deformity you would figure would be a nail-above type 2, but you would be wrong. The second most common is a type 3. This is why you don't have to memorize it, which is a swan neck deformity of the thumb. The type 2 actually is a boutonniere of the thumb when the metacarpal is also flexed at the CMC joint. Don't worry about that one. So this is a typical rheumatoid deformity, and this would be the second most common, the swan neck rheumatoid deformity. And how you would address that usually is with a CMC arthroplasty and an MP joint fusion. The treatment of rheumatoid non-operative involves usually medical management. There are some studies on splinting, which show that in early disease, it doesn't seem to help. And so these resting splints are nice, but they don't seem to retard the progress of the disease. Cortisone injections can also be very helpful for reducing local synovitis or tenosynovitis. There was a Cochran review that recommended not splinting the wrist after injecting it. Not very helpful. Cortisone injections into rheumatoid arthritic joints are that 75% of the injected joints had sustained clinical relief over a seven-year period. But as a confounding factor, most of these patients were also receiving DMARs. So injecting them does have some help. Why do rheumatoid patients visit surgeons for their MP deformities? This has been looked at, and Dr. Chung from Michigan has been quite interested in this issue, and he wrote an article, Reasons Why Rheumatoid Patients Seek Surgical Treatment for the Hand Deformities. And the number one reason, or one of the top reasons, was pain, followed by impaired hand function, and lower on the list was aesthetic appearance. But that's what they say preoperatively, and what they actually want is that what determines satisfaction with surgery is largely correlated with the way the hand looks. So the cosmetic appearance of the hand following rheumatoid surgery is very important. So the postoperative hand appearance is important. And hand function turned out to be only moderately correlated with satisfaction. So a reasonable approach that they might ask about on the board exam to rheumatoid is to provide a stable wrist, mobile MP joints, a mobile thumb CMC, and a solid MP and IP joint. Therefore, wrist fusion, MP, silicone arthroplasty, because the newer ones have not been shown to be any better, and they tend to have more complications. The thumb gets an arthroplasty, and the MP gets fused, and the IP joints usually get fused. Other procedures involve tenosynovectomy, the DARA procedure, and tendon reconstructions and repairs. And in the fingers, the MP joints, the extensors need to be centralized, and tenosynovectomies can be performed, and the nodules can be excised. Now examining these patients, you want to note their motion, and have they ruptured their FPL or the EPL? Those are important things to look for. Are they triggering? Is that why they can't make a fist? And do they have carpal tunnel? And ask them what bothers them, really. They may come in with a horrible looking hand, and all they want is their thumb IP joint fused so that they can pinch a little better. So you really have to ask them what it is that they're really looking for. And do they have a rheumatologist? A lot of these people don't have a rheumatologist, and they've never been treated. So where to start operating? Well in general, it's good to go proximal to distal, but in practice I usually follow Willie Sutton's law, and I go where they're telling me to go, and go where the money is. Remember to check out the cervical spine, and don't pith the patients. Usually these are done under regional anesthetic, but occasionally it doesn't work, and they'll have to do general. And so in that case, you want to get flexion extension views of their C-spine, because they can get atlantoaxial instability, and if they hyperextend their neck, they might not be happy with that. Any of you take the general surgery exam, the general surgery review course before this? Maybe some people did. So the atlantodense interval should be less than, I think it's 10 millimeters or so. They won't ask you that either. And if they do have an unstable spine, you want to get it checked out in advance, and they might require a nasotracheal intubation or something like that. This tenosynovitis can become a surgical indication when it lasts more than six months, despite medical management. And the tux sign, this is not a ganglion cyst. As you know, when they extend the fingers, and this tux underneath the retinaculum, that is tenosynovitis of the EDC, and it's commonly seen in inflammatory disorders. So when patients come in with bilateral tux signs, you want to send them to the rheumatologist. Or it may be that they're banging their hand against the wall and they want to get out of work, in which case they may need another specialty. And this is an extensor tenosynovitis of the EDC you might see in rheumatoid arthritis. You go in, try to make some attempt to reconstruct the retinaculum, put some underneath it, and take out all the tenosynovium. The next step is, are you going to continue going into the joint? And it depends, is there a tenosynovitis in the joint? It's not a big deal to open up the joint and clean that out as well. So the wrist synovectomy can be done at the time of extensor tenosynovectomy. And then the question becomes, well, should you stop there? Should you just go on and fuse the wrist at this point in time if it's so bad? And that's a judgment call as to when you should do a tenosynovectomy and when you should fuse the wrist. Some studies show no long-term benefit from doing synovectomies in that it tends to come back. So in general, if the wrist is painful, if it's painful and arthritic on x-ray, you should probably fuse it. There are some that recommend doing a Chamais fusion, the radiolunate fusion in early stages of the disease in order to fuse the radius and lunate so it prevents the carpus from continuing to slide off. And that does have some proponents. So this is a radiolunate fusion, which might be done for mild to moderate arthritic changes in order to prevent it from getting worse. And for early wrist disease, some people also recommend joint synovectomy and a tendon transfer of the ECRL to ECU to try to rebalance the wrist and bring the carpus back into alignment. Now what about doing a total wrist arthroplasty versus a wrist fusion? For the purposes of the boards, I would suggest doing a wrist fusion. In rheumatoid arthritis, the bones are soft, they don't hold implants well, and they tend to get loose. While a wrist fusion is pretty reliable, and a wrist arthroplasty may look in the recovery room something like this on the right. I think that was my case when I was a fellow, actually. Alex was not happy with that one. Techniques of wrist fusion, there are longitudinal pins. You can use an intermedullary pin from the third metacarpal to the radius, or you can use two pins in the intermetacarpal spaces. In rheumatoid patients, that will usually allow a fusion, because they tend to fuse well. But if you have solid bone, then you can do the standard AO wrist fusion. A lot of these patients have very thin bones and not good bone, and they are not tolerating of a plate. And this is one that actually did have good bone, and we did a standard wrist fusion. The Vaughan-Jackson lesion, Dr. Kleiman would always ask, is that one person or two when there was a hyphenated last name? Is this one person or two? Anybody know? One person, Englishman, I believe. And this is the extensor tendon ruptures of the ring and small EDC and EDM over the distal ulna. And you want to make sure that the post-neurosis nerve is not involved, and that's what's knocking out, because you can get a partial PIN. So you do a tenodesis effect of the wrist to make sure that the tendons are intact. And this was OJ Vaughan-Jackson, and he described the rupture of extensor tendons as the ulna erodes through the joint capsule, and it rubs through the tendons. So this is a Vaughan-Jackson patient. This is one where more have ruptured. There are five things that I am aware of that can produce an inability to extend at the MP joint. The EDC tendons are the only ones that extend the MP joint. But there are other problems that you can run into. So one is an extensor tendon rupture, like the Vaughan-Jackson. That will cause an inability to extend at the MP. The second would be if the proximal phalanx is volarly dislocated. Sometimes the tendons are intact, and you have a hard time telling that they're intact because the joint is so dislocated, and the extensor tendons are subluxated, which is the third reason why you can't extend it, because the sagittal band has ruptured and the tendon is dislocated into the ulnar groove. The fourth reason would be a PIN palsy. And the fifth would be the so-called locked MP joint, where the collateral ligament snags over an osteophyte on the metacarpal neck or head, and it is stuck. And it's quite difficult to get that up. You can jiggle it around. There's an article in JBS showing you which direction to rotate, and every time I have a patient with one of these, which is once every few years, I have to look up the article and see what I'm supposed to do for it. And it usually unlocks. So the treatment of Von Jackson is that you do a DARA procedure if the DREJ is bad. If they give you a case where the DREJ is pristine and there's no pain in the DREJ, you don't have to do a DARA procedure. But usually it's bad, in which case you're going to take off the ulna and do a synovectomy and then a tendon reconstruction. And the extensor tendon ruptures, you usually can't repair these primarily. Usually you have to do tendon grafts or transfers. You can do a side-to-side for single ruptures, and then as things start to rupture more, you can bring in the EIP, you can bring in the FDS, you can do a big graft from the tendons to the proximal muscles if you want. This is the standard EIP to EPL, and you can transfer it over to the EDM as well. You check out the flexor side of the wrist, the carpal tunnels, there's a lot of tenosynovitis that occurs there sometimes. And try not to, if it's a scarred en masse, start to tease things apart, because if they had the ability to make a fist before surgery and you start picking things apart, you may end up with a lot of loose ends not connected. And check out the FPL, because there is a condition that we'll come to in a minute. This is a patient with proliferative tenosynovitis. This is a patient that had a heart transplant, was on maximum immunosuppressives, and somehow got rheumatoid arthritis despite that. And I kept having to go back and squeeze out this cream of wheat type stuff that kept reaccumulating. So the Mannerfeldt lesion is a sharp bone spike on the volar side of the scaphoid entropism that leads to rupture of the FPL and the FTP of the index, typically. And this is it here, and what happens is that you go in, you want to ronger that down, try to get some capsule over it so it doesn't keep happening, and then you can reconstruct the FPL. And how do you reconstruct the FPL? Well, you can maybe do an intercalary graft if there's enough on both sides. You can transfer the FDS of the ring. If there's no good proximal muscle belly, you can go into the brachioradialis proximally. But sometimes the IP fusion of the thumb is the simplest and easiest thing to do, and much less morbid. So a little IP fusion of the thumb may be all that's required for that. For the FTP of the index, it's easy enough just to sew it side-to-side to the adjacent FTP, and that will take care of that problem. Trigger fingers in rheumatoid arthritis are not your standard trigger finger because the tendons are all gummed up with this pannus. And so you can try injecting them, and that frequently will work with cortisone. But if you're going to operate on them, you don't want to just cut the A1 pulley. You want to actually try to preserve the pulleys, and it involves a fairly extensive dissection where you go in between the pulleys and dig out the pannus and try to debulk it as opposed to cutting the pulleys. So it frequently ends up being a fairly involved procedure, and one in which you probably should resect the ulnar slip of the FDS to debulk that flexor tendon sheath. This is a patient who couldn't make a very good fist because of pannus all up and down the flexor tendons, and this is after we got done with her. She was delighted with this procedure. She could make a fist, a little stiff, but after this was done, we were able to do a traction pull, a traction tenolysis, and after cleaning out all the stuff, the triggering went away, and so did she. MP joint arthroplasty. Usually the MP joints are bad, and they need to be replaced and rebalanced. Silicone is the commonly used product. Regular implant materials are not better, and they have more complications in general, and it's important to make sure that the extensors are not ruptured because they may be, and then you have to do something for that. You want to centralize the extensors and repair maybe the radiocollateral of the index, so that's somewhat debatable, and make sure that there's enough room for the implants. What's not necessary are titanium grommets around the silicone stems or a complicated post-op rehab protocol. Maybe I'll just splint them out in extension at the MPs for four weeks and let them move the IPs, and they seem to do just as well with that. If the extensor tendons are ruptured, you can either do a two-stage procedure, or you do the MP arthroplasty first, get passive motion back, come back and do the extensor reconstruction, or you can do it all at one time. The arc of motion at the MP joint is not significantly improved by MP arthroplasty, neither for that matter is PIP arthroplasty motion improved by arthroplasty at that joint, but you just do it for the MP, it changes the arc into more extension. At long-term follow-up, Kirshenbaum found an average of 43 degrees. Typically the MP and the PIP arthroplasties will get about 50 degrees of motion. You're not going to get back full motion usually. Peter Stern, who is famous for reporting his complications, had a 14-year follow-up of MP arthroplasties and reported that 63% of the implants broke, but only 40% were happy and 30% were pain-free, and so the results were not stellar, just indicating that down the road these don't do all that well. The technique is you can do a transverse or a couple of longitudinal incisions and take off the heads, and you have to watch out that the base of the proximal phalanx may be eroded distally on the palmar side, and you're going to have to cut that proximal phalanx flush with that erosion, otherwise the implant's not going to go down. It's not going to work out well. There it is. Repair the radial collateral ligament of the index, and it looks good, at least post-op. The PIP joints, the early boutonniere or swan necks can sometimes be rebalanced, and there are a lot of ways to do that, but if they give you the stiff or painfully arthritic joint, usually it needs to be fused. For example, for the swan neck, you can take a lateral band and bring it palmar to the axis of rotation of the PIP joint and either secure it to the flexor sheath or bring it around the other side of the finger to give yourself a tenodesis effect, like an oblique ligament reconstruction, and that's one way to do it. That's if it's a supple joint. You might consider doing this more often for the lupus patients that have good joints as opposed to the rheumatoid patients unless you get them early. Again, silicone is still the standard for the PIP arthroplasty. The PIP results also about 50 degrees of motion, good pain relief, but they need to be revised. Another article on PIP arthroplasty where the revision rate was about 13%. Fusion on the other hand can be reliable, can be done with screws or K-wires, and if you have a mobile MP joint and a stable IP joint, that works pretty well. Just to reiterate, when to fuse the PIP and when to reconstruct, if it's stiff or very arthritic and painful, fuse it. The thumb gets a CMC arthroplasty, a trapeziectomy, and an MP fusion and an IP fusion if necessary. The rheumatoid nodules usually do not need to be operated upon. I have injected these sometimes and occasionally they will melt away with the cortisone shot, which I was surprised by. Usually they, unless they're very big and symptomatic, they do not need to be removed. They are seen on the extensor surface of the forearms and the olecranon area, the dorsal hand, and this was a giant one that we thought was a ganglion cyst, but it turned out it was actually a huge rheumatoid nodule there. What do you do with rheumatoid medication in surgery? They do ask about this. You do want to continue steroids and give them stress doses, although it's not a major stressful operation like a hip surgery, it still may be stressful. You can hold the DMARDs for one dose prior to surgery, and it is safe to continue methotrexate. Juvenile rheumatoid arthritis, just a couple of words about that. It's now also called juvenile idiopathic arthritis, and it's different than the adult form, as you know. The most common is the Posse articular, where there are five or four or less joints involved. What they ask about this is the eyes. These kids get uveitis, and they need slit lamp examinations, otherwise they can go blind. So if you see rheumatoid arthritis in the kid, think about the eyes. It goes opposite. The wrist arthritis tends to produce, in JRA, flexion contractures, and instead of the carpus deviating radially, it tends to go ulnarly, and the MP joints also go opposite. They tend to go radial instead of ulnar, and they get stuck in extension rather than in flexion. Questions. The natural history of untreated end-stage RA disease results in destruction of the radiocarpal joint and subluxation in which direction? And the answer would be D, volar and supinated. A 36-year-old woman with rheumatoid arthritis has an isolated dysfunctional dominant right index bunion deformity with a 70-degree PIP extensor lag, which is passively correctable only to 40 degrees. So it's not that correctable. So already you're thinking here that the answer is going to be D, arthrodesis. It's a stiff joint. And what time are we starting the next one? Oh, then I can read this whole paragraph here. A 64-year-old woman presents with a recent history of loss of ring and small finger extension without history of trauma. She's had wrist swelling and deformity developing over the past two decades and has not sought medical care. She has no active MP extension of the ring and small fingers and a painless 50-degree lag. She has good motion of her fingers. On wrist exam, she has a minimally painful jog of motion and minimally painful pronosupination, boggy, slightly tender swelling at the dorsal wrist. The x-rays show severe radiocarpal and DREJ arthritis, but the MP joints are okay. Tendon transfers are planned. So they've told you that the DREJ joint is bad, so you're going to do a DARA and you're going to do a wrist fusion in this case, in addition to tendon transfers. A 40-year-old man presents to the office complaining of painless left elbow swelling. No history of trauma or evidence of infection. And the x-rays are going to show you a horrible joint, or they may show you a bilaterally horrible elbow joint, or they may show you bilaterally horrible shoulder joints that are not symptomatic. And what you're thinking here is a syrinx in the spine. The key is usually a painless, bad-looking joint on the x-ray or bilateral shoulder destruction. So the answer would be here to get a C-spine MRI. A 42-year-old woman with rheumatoid arthritis presents seven weeks after inability to extend her thumb. There's no arthritis. She has full passive range of motion, but she lacks IP extension, and you would do an EIP transfer for that one. Which of the following increases the risk of peri-op wound infection the most in patients with RA? Well, you would think that it might be steroids or methotrexate, but the actual answer, according to the test, was diabetes, diabetes. A 45-year-old man with a history of RA is unable to extend his ring finger. With active extension, he has a 60-degree extensor lag at the MP joint, but when the finger is passively extended, he can maintain it in a fully extended position. So this is the tip-off to a sagittal band rupture. They cannot initiate extension from a flexed position, but they can maintain it when the joint is held in extension. So in this case, you would do a sagittal band reconstruction. This is a woman with rheumatoid, suddenly unable to actively extend her ring and little fingers. This is the diagnosis, and it's usually an attritional rupture of the extensor tendons at the wrist, the Vaughan-Jackson deformity. A 35-year-old woman with rheumatoid is unable to extend her middle finger. And again, it's the same question. This is the extensor tendon reconstruction. She cannot initiate it from a flexed position. Answer three, the most common rheumatoid thumb deformity, which is the boutonniere, is characterized by MP flexion and IEP joint extension. And assays positive for anti-CCP and anti-MCV are most consistent with a diagnosis of rheumatoid arthritis. Answer D. Patient with eight-week history of morning stiffness, swelling in both wrists and elbows, x-rays show periarticular erosions and bumps on the dorsal forms. That's at least four of the criteria. So the answer there is C, rheumatoid arthritis. This is a 45-year-old woman with rheumatoid with ulnar-sided wrist pain, and there's swelling at the DREJ, but no arthritis at the DREJ. And so what you would do here is a synovectomy, and it's a little unusual to ask to do an ECRLD transfer, but they didn't do a DARA or some other procedure because there was no arthritis there. 54-year-old woman with rheumatoid cannot fully extend middle and ring fingers. And this is another sagittal band rupture question. Rheumatoid with resulting boutonniere deformity is treated with extensor tendon reconstruction. Which of the following is a contraindication for this procedure? And the answer is stiffness at the PIP joint or stiffness and painful arthritis or something like that. 76-year-old woman with rheumatoid for 10 years, suddenly unable to extend the pinky finger, then the ring finger goes. There's dorsal prominence of the ulnar head and arthritis. Recommended treatment would be to do the DARA, because it's a bad joint, and tendon transfers. This is a 69-year-old woman with an RA undergoing revision silicone ampiarthroplasty. What can be expected regarding pain relief five years after revision surgery? And the answer is pain is better, but motion is not different and there is a high rate of implant fracture. So pain can be better. The primary clinical difference between hands affected by lupus and rheumatoid is that the hands of lupus patients have the joint cartilage preserved. They get loose and they get all swan-necked, but they don't usually develop bad arthritis. Thank you.

rheumatoid arthritis

common deformities

ulnar drift

boutonniere deformity

MP joint deformities

surgery in RA patients