Arthritic Hand

Rheumatoid Arthritis

Rheumatoid arthritis is the most common idiopathic inflammatory arthritis, affecting approximately 0.8% of the population, and it is two to four times more common in women than in men. The disease is characterized by hypertrophic synovitis that leads to joint laxity from soft-tissue attenuation, which may lead to joint subluxation and dislocation. Joint cartilage destruction usually ensues and may lead to attritional tendon rupture. However, isolated nodular tendon involvement may exist independent of overt joint pathology, leading to joint motion limitation, such as triggering or locking of flexor tendons. Similarly, extensor tendon nodularity may limit wrist extension from impingement on the extensor retinaculum. Despite preservation of function, socialization sometimes is altered by disfiguring deformities, especially of the hands.

At various times in the disease course, treatment of patients with rheumatoid arthritis involves a management team, including a rheumatologist, internist, other medical specialists, surgeon, therapist, and counselor. Operative treatment should be considered a part of the general disease management.

Since the introduction of medical therapies, such as disease modifying antirheumatic drugs in the mid-1990s and biologics in the early 2000s, there has been an 83% reduction in rheumatoid hand surgery in the United Kingdom. This indicates that medical treatments and strategies have been successful at preventing disease progression. Patients with rheumatologic diseases, however, may present initially to a hand surgeon with varied symptoms and signs without a specific diagnosis. When the history, physical examination, and radiographs suggest a rheumatologic condition, nonsurgical management may be more appropriate.

Rheumatoid arthritis patients may be treated with one or more medications, such as nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, and disease-modifying antirheumatic drugs, which may have significant side effects. Because of their effect on platelets, salicylates usually are discontinued 1 to 2 weeks before surgery; NSAIDs should be discontinued 2 to 5 days before surgery. Patients who have taken corticosteroids for more than a 3-week period in the previous 12 months should receive supplemental corticosteroid therapy before, during, and after surgery. Side effects of patient prescription and nonprescription medications, including those used for their arthritic condition, should be considered before surgery. In some cases, perioperative medical management by an internist is warranted.

If a general anesthetic is to be used during an operation on a patient with rheumatoid arthritis, the alignment and stability of the cervical spine should be investigated before surgery. If the disease has been generalized and prolonged, radiographs of the cervical spine are indicated to discover any subluxations. The degree of cervical spine instability alerts the anesthesiologist to the possibility of spinal cord injury that may result from hyperextension or hyperflexion of the neck during intubation or while maintaining a free airway. Extensive involvement of the temporomandibular joint also may influence the approach to endotracheal intubation.

Procedures usually considered for patients with rheumatoid arthritis include tenosynovectomy, tendon repair or realignment, synovectomy, arthroplasty, and arthrodesis. The goals of surgery are to relieve pain, restore function, correct or prevent deformity, and inhibit disease progression. If pain is not the primary consideration, the surgeon should have a reasonable level of confidence that the selected procedure can restore enough function to justify the surgery. Conversely, if pain can be significantly relieved by a surgical procedure, it is worthwhile when adequate medical treatment has failed to do so. Although patients may complain principally of pain, cosmesis is an important consideration for some, if not most. Hand appearance and pain relief are highly correlated with patient satisfaction. If rheumatoid synovitis or tenosynovitis persists despite good medical treatment and supervision, synovectomy and tenosynovectomy are worthwhile prophylactic procedures that may help delay further distention of the joint capsule and ligament, as well as prevent tendon rupture.

Before surgery, the patient is advised of the details of the anticipated procedure. This usually includes information about (1) the location of incisions, (2) anticipated implants required for the surgical procedure(s), (3) the expected appearance after surgery, (4) the type of anesthesia, (5) the alternatives to and risks of surgery, (6) the postoperative care and the rehabilitation period, and especially (7) the expected benefit from the operation. Patients with severe deformities may have developed substitution patterns that enable them to perform their daily tasks; these should not be interrupted without careful analysis of the pathologic anatomy and functional patterns. This is especially true in older, retired individuals who have no pain. The patient should be advised emphatically that surgery neither cures the disease nor restores the hand to normal. It is helpful for the patient to understand that although many deformities are correctable, the local progression of the disease may not be altered by surgical procedures.

Rheumatoid hand deformities usually are bilateral and symmetric. Each deformity must be analyzed in detail before surgery is considered. Although combinations of deformities occur, involvement of the fingers, thumb, and wrist is typical. The metacarpophalangeal joints and the wrist are affected early in rheumatoid arthritis, whereas the distal joints usually are affected later. The metacarpophalangeal is the most important joint affecting finger function in rheumatoid disease. Finger ulnar deviation with metacarpophalangeal palmar subluxation or dislocation typifies the rheumatoid hand deformity. Ligamentous, osteochondral, and intraarticular damage and the forces applied through the intrinsic and extrinsic muscles at the metacarpophalangeal joint affect the metacarpophalangeal joint deformities and at the proximal and distal interphalangeal joints. The disease extent and wrist deformity affect finger joint deformities. In addition to the typical metacarpophalangeal deformities, the proximal interphalangeal joints may develop boutonniere or swan-neck deformities, and the distal interphalangeal joints, when affected, usually develop a mallet or hyperflexed deformity, depending on the extent of capsular disruption ( Fig. 73.1 ).

Thumb involvement can cause a variety of deformities, depending on the joint in which synovitis begins. Synovitis beginning in the thumb metacarpophalangeal joint frequently leads to a boutonniere deformity of the thumb, with palmar subluxation of the proximal phalanx and subsequent metacarpophalangeal joint flexion, and interphalangeal joint hyperextension ( Fig. 73.2 ). When synovitis begins in the thumb carpometacarpal (CMC) joint, the deformity includes dorsal subluxation of the metacarpal base and hyperextension of the metacarpophalangeal joint (swan-neck deformity). Another thumb deformity caused by synovitic destruction of the capsuloligamentous supports on the ulnar side of the metacarpophalangeal joint is the gamekeeper thumb, which results from laxity of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Involvement of the metacarpophalangeal joint also can result in laxity of the capsuloligamentous structures in the volar plate, leading to hyperextension of the metacarpophalangeal joint and interphalangeal hyperflexion, but with a stable CMC joint. Other, more severe deformities of the fingers and thumb can be caused by an erosive rheumatoid disease, leading to the “main en lorgnette” (opera-glass hand; Fig. 73.3 ).

Significant flexor and extensor tendon tenosynovitis in the digits, palm, and over the wrist flexor and extensor surfaces can lead to erosive and attritional changes and tendon ruptures. Rheumatoid wrist deformities have a significant effect on hand function, especially the metacarpophalangeal joint finger position. Rheumatoid synovitis can result in intercarpal ligament disruption, especially the radioscaphocapitate ligament, leading to rotatory instability of the carpal scaphoid and subsequent destructive changes throughout the entire wrist. The distal radioulnar joint stabilizing ligaments are destroyed in a similar fashion, leading to ulnar head dorsal dislocation and subluxation of the extensor carpi ulnaris tendon with secondary ulnar translocation of the carpus.

Osteoarthritis

Osteoarthritis is the most common arthritic hand disorder. The condition may be unilateral but occurs as frequently in the nondominant hand as in the dominant one. Although it can be associated with tendon ruptures and triggering of fingers, these are not seen as frequently in osteoarthritis as in rheumatoid arthritis. It frequently is seen at the trapeziometacarpal joint, more often in women, and sometimes as a single joint involvement. Osteophytes that form at the distal interphalangeal joint are known as Heberden nodes. Mucoid cysts may form at the joint margins. At the proximal interphalangeal joint, such osteophytes are known as Bouchard nodes ( Fig. 73.4 ). Spur formation, cartilage fragmentation, and limited motion without dislocation are common. During the active phase, pain is severe and the joints and overlying skin may be inflamed; direct trauma to an inflamed joint is especially painful. Osteoarthritis may be the natural consequence of longevity; however, the etiology of early onset of osteoarthritis and its prevention remain elusive. Moreover, osteoarthritic radiographic signs often do not correlate with symptoms or the severity of patient’s pain complaints. Asymptomatic scapho-lunate advanced collapse wrist deformities are common, as are thumb basal and finger joint degeneration, and explanations and effective initial treatments must be individualized.

Systemic Lupus Erythematosus

Systemic lupus erythematosus, one of the diffuse connective tissue diseases, can affect many organ systems. Pericarditis, pleuritis, and renal disease represent involvement of major organ systems. Cutaneous involvement is present in 85% of patients with this condition. Musculoskeletal involvement is characterized by stiffness, swelling, tenderness, and pain, with tendons, joint capsules, and ligaments particularly involved. Joint surface destruction can occur late in the disease process. Hand involvement may be among the earliest manifestations. Usually the metacarpophalangeal and proximal interphalangeal joints are involved, as first manifested by ligamentous laxity. Raynaud phenomenon, with tissue necrosis, ulceration, and cold intolerance, also is seen. Although the hand deformities of systemic lupus erythematosus are similar to rheumatoid hand deformities, they result primarily from soft-tissue abnormalities unrelated to proliferative synovitis, and the articular cartilage is well preserved ( Fig. 73.5 ). Soft-tissue procedures (capsulodesis, tenodesis, tendon realignment), bone procedures (arthrodesis, arthroplasty), and digital sympathectomy for relief of the digital ischemia of Raynaud phenomenon may be necessary in patients with systemic lupus erythematosus.

Psoriatic Arthritis

An estimated 25% of patients with psoriatic arthritis have polyarthritis similar to rheumatoid arthritis; 5% to 10% have distal interphalangeal joint involvement. About 15% to 20% develop the typical psoriatic rash after they develop the arthritis. Almost 95% of patients with psoriatic arthritis have asymmetric peripheral joint involvement. Fusiform swelling of the entire digit may occur. Uniquely, the nails may separate from the nail bed and have a white, flaking discoloration near their distal borders; they also may be ridged. Fingernail changes, the most common of which is pitting, are reported to be present in about 15% of patients with joint involvement ( Fig. 73.6 ). Radiographic changes in psoriatic arthritis of the hand include erosion of terminal phalangeal tufts (acro-osteolysis), tapering of the phalanges and metacarpals, cupping of the proximal ends of phalanges and metacarpals (“pencil-in-cup” deformity), severe destruction or ankylosis of isolated small joints, and a predilection for the interphalangeal joints with sparing of the metacarpophalangeal joints. Contractures of the proximal interphalangeal joints most often require surgical treatment, usually arthrodesis. Patients with psoriatic arthritis can, in general, be placed into three groups, depending on the timing of the onset of the arthritis and the skin lesions. Patients with type 1 disease have early onset of joint involvement with late development of skin lesions. Those with type 2 disease have late joint involvement and early skin changes. In type 3, there is almost simultaneous onset of joint and skin involvement. In patients with type 1, the arthritic involvement is mild, whereas in type 2 the arthritis is more severe. In patients with type 3, the severity of arthritic involvement is unpredictable. Although fusion or arthroplasty may improve hand function, infection may occur more frequently after implant arthroplasty in these patients than in patients with rheumatoid disease. Scheduling surgical procedures during summer months has been recommended, because the skin lesions tend to be smaller and may be less likely to pose a significant risk of infection.

Reiter Syndrome

Reiter syndrome is described as a triad of conjunctivitis, urethritis, and synovitis. The synovitis usually involves asymmetrically four or fewer joints. Heel pain, back pain, and nail deformities may occur in this syndrome, sometimes making it difficult to distinguish it from psoriatic arthritis. It affects the lower extremity more often than the upper, and 90% of patients have remission of symptoms after several weeks; in about 10%, the disease may become chronic. It is typically found in young men. Surgery rarely is indicated.

Gout

Gout usually causes an erythematous, painful joint in men. The attack often is sudden with severe pain around a single joint. The joint is swollen, hot, and tender, suggesting a severe cellulitis or abscess. In chronic gout, massive deposits of monosodium urate crystals can be found around the joints and tendon sheaths, causing nerve compression, such as carpal tunnel syndrome. Intratendinous monosodium urate crystal deposition can lead to tendon rupture. The skin may be ulcerated by pressure from within ( Fig. 73.7 ). Amputation may be necessary because of the extreme bony disruption resulting from gout. The deposits may be visible on radiographs. Women rarely have gouty arthritis until after menopause; however, the typical patient with tophaceous gout is an elderly woman. The presence of hyperuricemia alone does not establish the diagnosis of gout; the uric acid level may be elevated, and an acute attack of gout may never occur. Conversely, during an acute attack of gout, the uric acid level may be normal. Joint aspiration provides the only definitive diagnosis of gout, and polarized microscopy usually shows negatively birefringent crystals in the joint fluid. Surgery for tophaceous deposits rarely is indicated, unless an important structure is compressed or if the patient cannot tolerate uric acid–lowering measures. In addition to tophus excision and debridement, other procedures that may benefit a patient with gout include tenosynovectomy, tendon repair, or transfer for tendon ruptures, carpal tunnel release, and appropriate management of destroyed gouty arthritic joints.

Pseudogout, also known as calcium pyrophosphate dihydrate crystal deposition disease, although more common in the knee, may involve the hands and can mimic septic arthritis. Clinically, it is characterized by intermittent acute attacks resembling acute gouty arthritis. It may be associated with a flexor tenosynovitis, leading to carpal tunnel syndrome. Calcium pyrophosphate crystal deposition may be visible on routine radiographs as opaque areas in the articular cartilage or the fibrocartilaginous disc of the distal radioulnar joint, and definitive diagnosis is made by the identification of calcium pyrophosphate crystals in the joint aspirate. As with gout, initial management is medical.

Scleroderma (Progressive Systemic Sclerosis)

Two types of scleroderma are recognized: progressive systemic sclerosis and CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome. Diffuse scleroderma, or progressive systemic sclerosis, is usually more severe and affects the extremities and the trunk. The disease may involve not only the skin but also the gastrointestinal tract, especially the esophagus, heart, lungs, and kidneys. Telangiectasia also may be seen. The hand surgeon may see these patients because of calcinosis of the fingertips, ulcerations, or Raynaud phenomenon. The age at onset usually is older than 40 years.

Arthritic involvement usually causes finger contractures, but synovial thickening is minimal. Involvement of hand tendons and tendon sheaths can cause a palpable tendon friction rub or a leathery crepitus, as distinguished from the coarse, gritty crepitus palpable in osteoarthritis. Extensor tendons may rupture at the interphalangeal joint as they become attenuated, the overlying skin breaks down, and the joint may be exposed. Changes at the distal interphalangeal joint include skin ulceration, joint contracture, gangrene, and osteomyelitis. The usual surgical choices for these changes at the distal joint are amputation and arthrodesis.

At the proximal interphalangeal joint, scleroderma changes lead to the previously mentioned flexion contractures. Because the severe contracture of all structures limits the potential for movement, arthrodesis is usually the best choice for the proximal interphalangeal joint.

Metacarpophalangeal joint flexion or hyperextension deformities may occur. Resection arthroplasty has been found to be an effective method to preserve joint motion. If there is a flexion deformity, the metacarpophalangeal joint is approached through a dorsal incision. If the metacarpophalangeal joint is hyperextended with proximal interphalangeal joint flexion, Nalebuff recommended approaching the metacarpophalangeal joint through a palmar incision to perform the metacarpal head resection, followed by proximal interphalangeal joint fusion.

Thumb web adduction contractures may require adductor pollicis muscle release with trapezial excision. Thumb metacarpophalangeal and interphalangeal joint fusions may be required.

Fingertip ulceration from vascular impairment is best treated by an extremely conservative approach, including waiting for the tips to amputate spontaneously, because this retains digital length. Surgical sympathectomies and intraarterial injection of vasodilating drugs have been effective in improving digital circulation. Although recurrence of ischemic changes may follow procedures on the vessels, the short-term result can be beneficial for wound healing and pain relief. Calcification around the eroded fingertip pulps may be excised through a lateral incision, or they may be curetted, but healing may be slow.

Nonoperative Treatment of Synovitis and Tenosynovitis

Persistent tenosynovitis or arthritis with obvious swelling that persists for several weeks even when treated with antiinflammatory drugs can be treated by local injections of a steroid preparation and a local anesthetic. In many instances, pain may be relieved and surgery delayed by this technique.

This treatment is especially applicable to trigger fingers, carpal tunnel syndrome, and trapeziometacarpal joint osteoarthritis. Osteoarthritis of the distal interphalangeal joints and rheumatoid arthritis of the proximal interphalangeal joints also respond favorably to injections for several weeks; however, after repeated injections, the response may be less dramatic. If synovitis and tenosynovitis persist after 4 to 6 months of adequate medical therapy, consideration should be given to synovectomy or tenosynovectomy.

Rheumatoid Nodules

Rheumatoid subcutaneous nodules occur on the dorsum of the hand, palmar surface of the fingers and thumb, subcutaneous border of the ulna, and in the olecranon bursa ( Fig. 73.8 ). They may interfere with finger motion because of their size; they may be uncomfortable and are at risk for ulceration. If the nodules cause sufficient symptoms, they can be removed. Care should be taken to avoid injuring neurovascular structures, which may be adherent to the larger masses.

Staging of Operations

When considering operative procedures for patients with rheumatoid arthritis, all aspects of the musculoskeletal involvement should be considered. The extent to which pain limits function is given high priority. Patients who function well despite significant deformity may be less inclined to have a surgical procedure than patients whose activities are limited by pain. Souter recommended starting with a procedure that is likely to succeed, beginning with the least involved hand. He grouped hand procedures from the most effective (group I) to the least effective (group V) ( Table 73.1 ). In addition, Souter advocated correcting significant disease and deformity in the elbow and shoulder before correcting hand deformities. Surgical priorities are, in descending order of importance, the spine, foot, hip, knee, wrist, shoulder, thumb, elbow, and fingers. Each patient should be considered individually, and the patient’s requirements and the forces and demands on the extremity should be considered.

When several operations are indicated on a single hand, their order of priority must be considered. Persistent tenosynovitis, tendon rupture, and nerve compression are high-priority problems. In general, when wrist arthroplasty or arthrodesis is indicated, it should be done first because the position of the wrist determines the balance of the digital flexor and extensor tendons. At the time of wrist surgery, an additional procedure, such as arthrodesis of the metacarpophalangeal joint of the thumb, can be done. Other, more extensive surgery usually is best delayed.

When multiple small joint procedures, such as metacarpophalangeal arthroplasties or proximal interphalangeal joint fusions, are to be performed, they can be done at the same time. Frequently, a patient with rheumatoid arthritis requires surgery not only on the opposite hand but also on the feet, the hips, and other joints. Usually, surgery is performed on only one hand at a given time because of the requirements for daily independent living and personal hygiene. If the lower extremities require external support, a platform or forearm crutch should be provided.

Finger Deformities Caused by Rheumatoid Arthritis

Finger deformities can be caused by the normal forces applied to damaged joints by the extrinsic flexors and extensors, tightness of the intrinsic muscles, displacement of the lateral bands of the extensor hood, central slip rupture, or rupture of the long extensor or long flexor tendons. Abnormal forces also act on joints already weakened by the disease. In addition, flexor tenosynovitis may produce limitation of interphalangeal joint motion, so the range of active flexion of these joints is significantly less than passive flexion.

Intrinsic Plus Deformity

The intrinsic plus deformity is caused by excessive intrinsic muscle tension, in which the proximal interphalangeal joint cannot be flexed fully when the metacarpophalangeal joint is fully extended. Often, the deformity develops in combination with volar subluxation of the metacarpophalangeal joints and ulnar deviation of the fingers. The Bunnell test is a test for intrinsic tightness; the degree of passive proximal interphalangeal joint flexion is compared with the metacarpophalangeal joint in full extension (intrinsic muscles stretched) and full flexion (intrinsic muscles relaxed). Variable degrees of passive proximal interphalangeal joint flexion loss with the metacarpophalangeal joint in extension indicates intrinsic tightness ( Fig. 73.9 ). With ulnar drift of the fingers, this intrinsic tightness may be present only on the ulnar side. To test this accurately, axial alignment of the finger with the metacarpal should be maintained in checking intrinsic tightness. Any ulnar deviation at the metacarpophalangeal joint during the test slackens the intrinsics on the ulnar side of the finger and may confuse the findings. A tight first volar interosseous muscle pulls the extended index finger ulnarward, but if the finger is held in line with the second metacarpal during the test, then tightness of this muscle can be shown.

Tightness in the oblique retinacular ligament can be shown by maintaining the proximal interphalangeal joint in extension while testing the distal interphalangeal joint resistance to passive flexion ( Fig. 73.10 ). This can be helpful when evaluating a digit with a boutonniere deformity.

When indicated, intrinsic tightness can be released in conjunction with synovectomy by lateral band mobilization. When degeneration of the metacarpophalangeal joints requires arthroplasty, there may be sufficient resection of bone to relax the intrinsic mechanism; however, it must be determined specifically at the time of surgery when a release is necessary. A specific tendon release of the intrinsics may be indicated (see Technique 73.5).

Swan-Neck Deformity

Swan-neck deformity is characterized by a flexion posture of the distal interphalangeal joint and hyperextension posture of the proximal interphalangeal joint ( Fig. 73.11 ). It is caused by muscle imbalance and may be passively correctable, depending on the original and secondary deformities ( Fig. 73.12 ). Although usually associated with rheumatoid arthritis, swan-neck deformity may occur in patients with volar plate laxity and in patients with conditions such as Ehlers-Danlos syndrome.

This deformity may begin as a mallet deformity associated with extensor tendon disruption at the distal joint with secondary overpull of the central slip, causing secondary proximal interphalangeal joint hyperextension This deformity also may begin at the proximal interphalangeal joint because synovitis causes capsular disruption, tightening of the lateral bands and central tendon, and eventual adherence of the lateral bands in a fixed dorsal position, so they can no longer slide over the condyles when the proximal interphalangeal joint is flexed, thereby limiting proximal interphalangeal flexion. The dorsally and centrally displaced lateral bands become relatively slack and may be ineffective in extending the distal interphalangeal joint, which may secondarily assume a mallet deformity. This mallet deformity usually is not as severe, however, as that produced by terminal slip tendon rupture. A swan-neck deformity may require proximal interphalangeal joint synovectomy, mobilization of the lateral bands, and release of the skin distal to the proximal interphalangeal joint. Wrinkles and normal laxity of the skin are lost at the proximal interphalangeal joint level after several weeks. Nalebuff, Feldon, and Millender categorized swan-neck deformities into four types and recommended treatment for each type. Type I deformities are flexible and require dermodesis, flexor tenodesis of the proximal interphalangeal joint, fusion of the distal interphalangeal joint, and reconstruction of the retinacular ligament. Type II deformities are caused by intrinsic muscle tightness and require intrinsic release in addition to one or more of the aforementioned procedures. Type III deformities are stiff and do not allow satisfactory flexion but do not have significant joint destruction radiographically. These deformities require joint manipulation, mobilization of the lateral bands, and dorsal skin release. Type IV deformities have radiographic evidence of destruction of the joint surface and stiff proximal interphalangeal joints, which usually can be best treated with arthrodesis of the proximal interphalangeal joint or, in the ring and small fingers, possibly proximal interphalangeal joint arthroplasty if the metacarpophalangeal joints are well preserved. Proximal interphalangeal capsulotomy and lateral band mobilization may improve interphalangeal flexion by changing the arc of motion of the proximal interphalangeal joint.

Flexor tenosynovitis results in ineffective support by the flexor digitorum sublimis tendon and may be an important factor in initiating the development of swan-neck deformity in the rheumatoid hand. The overpull of the central tendon slip, combined with synovitis of the proximal interphalangeal joint, stretches the surrounding tissue, resulting in a swan-neck deformity. A tenodesis can be created across the proximal interphalangeal joint, using one half of the flexor sublimis tendon. If there is marked proximal interphalangeal joint hyperextension and a normal radiographic joint space appearance, tenodesis with the flexor sublimis tendon can be combined with release of the lateral bands and the distal skin. Either the Curtis technique of sublimis tenodesis (see Technique 72.13) or the technique described by Beckenbaugh (Technique 73.1; Fig. 73.13 ) can be used.

Temporary pinning of the proximal interphalangeal joint may be indicated for most reconstructions; however, postoperative immobilization of the joint may be unnecessary at times, allowing immediate movement of the joint without protective splinting. A complication of this technique is flexion contracture of the proximal interphalangeal joint, which may exceed 30 degrees. If there is marked proximal interphalangeal joint extension associated with joint destruction on radiographs, arthrodesis may be best if metacarpophalangeal joint arthroplasty is anticipated. Numerous fixation techniques have been described to obtain successful proximal interphalangeal joint arthrodesis in arthritic joints, including a single Kirschner wire, crossed Kirschner wires, intraosseous or tension band wiring, bone pegs, miniplates, compression plates, and subchondral screws.

Intrinsic Release

For intrinsic release, see Chapter 74 ( Fig. 74.11 and Technique 74.7).

Correction of Proximal Interphalangeal Joint Hyperextension Deformity

Technique 73.1

(BECKENBAUGH)

• ▪

  Make a zigzag incision over the proximal interphalangeal joint ( Fig. 73.13A ). Avoid damaging the digital nerves that may adhere to the pulley system volar to the hyperextended proximal interphalangeal joint.

• ▪

  Expose the pulley system over the proximal and middle phalanges by elevating the neurovascular bundles medially and laterally.

• ▪

  Expose the A2 pulley ( Fig. 73.13B ).

• ▪

  Incise the first cruciate pulley between the distal end of the A2 and proximal end of the A4 pulleys and expose the flexor tendons.

• ▪

  Retract the profundus tendon and release any adhesions; expose the sublimis tendon and its adhesions and perform a synovectomy ( Fig. 73.13C ).

• ▪

  Pull the sublimis tendon distally and incise the decussation, splitting the tendon into two slips.

• ▪

  Pull the divided sublimis tendon distally and incise the ulnar slip, leaving a 5-cm slip of tendon attached to the ulnar side of the middle phalanx ( Fig. 73.13D ). Pull the slip firmly to ensure that its insertion is not weakened by synovitis. In the little finger, both slips are incised because a single slip usually is too small.

• ▪

  Puncture the A2 pulley 3 to 4 mm from its distal border ( Fig. 73.13E ).

• ▪

  Pass a small curved hemostat through the hole distally into the sheath and clamp the tip of the sublimis tendon slip and pull it proximally through the A2 pulley ( Fig. 73.13F ).

• ▪

  Bring the slip of tendon distally and suture it to itself with nonabsorbable 4-0 sutures ( Fig. 73.13G and H ).

• ▪

  Adjust the tension so that the proximal interphalangeal joint is held at only 5 degrees of flexion. A tenodesis is accomplished with this slip of tendon fixed across the joint.

• ▪

  Repair the cruciate pulley if feasible.

• ▪

  Several fingers can be operated on at one sitting.

• ▪

  If the distal interphalangeal joints are fixed in a flexed position, they can be manipulated and pinned in extension for 3 weeks.

• ▪

  Close the skin over a small drain. Apply a bandage, supported by a dorsal splint to prevent proximal interphalangeal joint hyperextension.

Postoperative Care

Motion is begun on day 3 after removal of the dressing. A static splint is worn at night for 6 weeks to hold the metacarpophalangeal joints in extension and the proximal interphalangeal joints in slight flexion.

Lateral Band Mobilization and Skin Release

Technique 73.2

(NALEBUFF AND MILLENDER)

• ▪

  Begin a slightly curved dorsal incision at the midportion of the proximal phalanx, continue it distally from this point over the dorsolateral aspect of the proximal interphalangeal joint and over the middle of the middle phalanx, and traverse obliquely dorsally ( Fig. 73.14A ).

  

• ▪

  Elevate the skin carefully, taking with it the veins.

• ▪

  Make a longitudinal incision between each lateral band and the central tendon, releasing them from their fixed dorsal position ( Fig. 73.14B and C ).

• ▪

  Passively flex the proximal interphalangeal joint to observe that the lateral bands now slip volarward, sliding over the condyles of the joint ( Fig. 73.14D ).

• ▪

  A synovectomy can now be done, and good passive motion usually is established.

• ▪

  Suture the skin incision proximally. Distally, suturing may not be possible; the distal incision, being placed obliquely across the middle phalanx, gapes open and releases skin tension. The open portion of the incision usually heals without a graft in about 2 weeks.

• ▪

  Ensure in the preoperative evaluation that active motion can be established by evaluating active flexion of the joint by the profundus and sublimis tendons. When active flexor function is not confirmed, check the tendons by making an incision in the palm and pulling on the tendons through the palm to see that they are not stuck and are not held by rheumatoid nodules.

• ▪

  Pass a Kirschner wire across the proximal interphalangeal joint to maintain this joint in flexion postoperatively for approximately 3 weeks.

Boutonniere Deformity

A finger with the so-called boutonniere deformity has a flexed proximal interphalangeal joint, with a hyperextended distal interphalangeal joint. It is commonly seen in patients with rheumatoid arthritis, although this tendon imbalance is not unique to rheumatoid disease. In a patient with rheumatoid arthritis, it is thought to be caused by synovitis of the proximal interphalangeal joint with a stretching out of the central slip, allowing the lateral bands to begin subluxating volarward. As the deformity progresses, the lateral bands are forced farther over the proximal interphalangeal joint condyles. They finally become fixed in a subluxated position volar to the joint rotation axis and act as proximal interphalangeal joint flexors. This tightening causes a secondary hyperextension deformity of the distal interphalangeal joint. The flexion deformity of the proximal interphalangeal joint is compensated for by an extension of the metacarpophalangeal joint ( Fig. 73.15 ). The metacarpophalangeal joint deformity does not become fixed, as do the distal two joints. Nalebuff and Millender categorized boutonniere deformities on the basis of the radiographic appearance of the joint surface and the amount of active and passive motion. The mildest deformities, with satisfactory motion and normal-appearing radiographs, can be treated with repositioning the lateral bands, proximal interphalangeal joint synovectomy, and extensor tenotomy over the middle phalanx (Dolphin-Fowler procedure). For moderate deformities with a passively correctable proximal interphalangeal joint, normal flexor tendon function, and satisfactory preservation of joint space radiographically, a soft-tissue procedure with central slip reconstruction using the lateral band or a tendon graft is an option. For severe deformities with stiff joints, the long, ring, and little fingers can be treated with extensor reconstruction and possible implant arthroplasty; in the index finger, arthrodesis of the proximal interphalangeal joint may be a more durable procedure.

In mild boutonniere deformities, there is a flexion deformity at the proximal interphalangeal joint with lessened ability to flex the distal joint fully, but the joint is not fixed in hyperextension. The flexion deformity at the proximal interphalangeal joint is passively correctable from a position of approximately 15 degrees of flexion. In these deformities, treatment may consist of releasing the lateral tendons near their insertion into the distal phalanx.

A moderate boutonniere deformity has an approximately 40-degree proximal interphalangeal joint flexion contracture, most of which is passively correctable, and the distal interphalangeal joint is hyperextended. The lateral bands are fixed in their subluxated position volarward by virtue of the contracted transverse retinacular ligament. To correct this deformity, there must be functional restoration of the central slip and correction of the lateral band subluxation. Radiographs of these joints should show no severe joint destruction. If the proximal interphalangeal joint is destroyed and fixed, but the distal interphalangeal joint is preserved, this deformity can be treated with proximal interphalangeal joint arthroplasty or fusion.

A fixed boutonniere deformity usually has joint changes on radiographs and a passively uncorrectable proximal interphalangeal joint flexion contracture. Kiefhaber and Strickland found central extensor tendon reconstruction for rheumatoid boutonniere deformities unpredictable and recommended arthrodesis for severe boutonniere deformities.

Correction of Mild Boutonniere Deformity by Extensor Tenotomy

Technique 73.3

• ▪

  Make a dorsal transverse or oblique incision over the distal third of the middle phalanx and expose the extensor tendon.

• ▪

  Divide this tendon obliquely to enable it to lengthen and remain partially in apposition after the distal interphalangeal joint is flexed.

• ▪

  Carefully stretch the distal interphalangeal joint into flexion. This uncommonly may become overstretched and develop a mallet deformity that requires splinting.

• ▪

  Do not suture the extensor tendon.

• ▪

  Close the wound and begin motion in the next several days, ensuring that active motion is carried out by the patient. Splint only if there is a mallet deformity.

Correction of Moderate Boutonniere Deformity

Technique 73.4

• ▪

  Make a curved, dorsal, longitudinal incision over the proximal interphalangeal joint and extend it distally to the distal interphalangeal joint.

• ▪

  Mobilize the lateral bands by incising the transverse retinacular ligament longitudinally and dissecting underneath the displaced lateral slips.

• ▪

  Tenotomize the terminal slips of the two lateral tendons just proximal to the distal interphalangeal joint.

• ▪

  When the central tendon appears to be stretched, shorten it by suture after tenotomy, taking care not to create a proximal interphalangeal joint extension contracture.

• ▪

  Align the lateral bands with the central slip at the middle phalanx base.

• ▪

  Be certain of 80 degrees of proximal interphalangeal joint passive flexion to ensure that an extension contracture is not being created. Tendon balance is crucial in this operation.

• ▪

  Perform a synovectomy after mobilizing the lateral bands.

• ▪

  Pass a small-caliber transfixing Kirschner wire obliquely through the joint to hold it in extension.

• ▪

  After 3 to 4 weeks, remove the wire and place the joint in a dynamic extension splint if it is indicated. Active motion should be initiated promptly to achieve and maintain active joint flexion.

Correction of Severe Boutonniere Deformity

Technique 73.5

• ▪

  When proximal interphalangeal joint arthrodesis is indicated, release the distal interphalangeal joint by oblique tenotomy of the lateral tendons just proximal to the joint and use the technique of arthrodesis described in Technique 73.15.

• ▪

  The resection arthroplasty and implant technique can be used as an option if the flexion contracture is not so severe that it requires extreme bone shortening to accommodate the implant.

Distal Interphalangeal Joint Deformities

The rheumatoid deformities at the distal joint include a mallet, hyperflexed distal interphalangeal joint, which may occur in conjunction with a swan-neck deformity or as a result of attenuation of the terminal slip, and a hyperextensible distal interphalangeal joint, which also may be related to attenuation of capsuloligamentous structures or to flexor tendon rupture. Usually either of these deformities can be treated with distal interphalangeal joint arthrodesis. In a patient who has had a proximal interphalangeal joint arthrodesis, the distal interphalangeal joint mallet deformity might be left untreated because the small amount of mobility remaining in the distal interphalangeal joint can contribute significantly to fingertip function.

Ulnar Drift or Deviation of the Fingers

Ulnar drift or deviation of the fingers ( Fig. 73.20 ) is found in conditions other than rheumatoid arthritis. In the normal hand, predisposing factors include (1) metacarpophalangeal joint ulnar deviation, especially of the index finger; (2) smaller and sloping ulnar condyles of asymmetric metacarpal heads, especially those of the index and middle fingers; (3) the approach of the long flexor and extensor tendons from the ulnar side of the metacarpophalangeal joints; (4) greater ulnar deviation than radial deviation of the digits permitted by the radial collateral ligaments when the metacarpophalangeal joints are flexed; and (5) greater strength of the abductor digiti quinti and flexor digiti quinti than the third volar interosseous. Pathologic changes in the rheumatoid hand accentuating ulnar deviation and drift include (1) metacarpophalangeal joint synovitis that weakens the dorsoradial capsular restraints; (2) stretching of the metacarpophalangeal joint collateral ligaments by the volarly directed forces of the flexor tendons, permitting volar displacement of the proximal phalanges; (3) stretching of the accessory collateral ligaments that permits ulnar displacement of the flexor tendons within their tunnels; (4) stretching of the flexor tunnels that permits even more ulnar displacement of the long flexor tendons; (5) interosseous muscle contracture that causes ulnar deviation and proximal interphalangeal joint hyperextension, as well as metacarpophalangeal joint flexion and eventually subluxation; (6) attenuated radial sagittal bands that allow long extensor tendon ulnar displacement; and (7) long extensor tendon rupture at the wrist level that increases the possibility of metacarpophalangeal joint dislocations.

Mild-to-Moderate Ulnar Drift

In the surgical treatment of mild-to-moderate ulnar drift, reasonable success is possible only when the major deforming forces have been properly evaluated. This type of ulnar drift implies the absence of severely diseased articular surfaces of dislocated joints ( Fig. 73.21 ). Often, however, the flexor and extensor tendons are displaced ulnarward, the intrinsic muscles are imbalanced, and the joints are swollen. Surgical procedures that may be indicated are intrinsic release or transfer for balance, extensor tendon realignment, and metacarpophalangeal joint synovectomy. No operation has been devised to realign easily the ulnarly displaced flexor tendons and their sheaths.

Extensor tendon realignment procedures ideally are performed under local anesthesia so that the effectiveness of the construct can be verified. The presumed tension on the realigned tendon often requires adjustment for proper tendon tracking over the metacarpophalangeal joint. Release of the tightened sagittal band and transfer of this into the radial collateral ligament or use of a distally based portion of the extensor tendon or juncture around the lumbrical tendon or collateral ligament are common extensor tendon realignment techniques.

Extensor Tendon Realignment and Intrinsic Rebalancing

Technique 73.9

• ▪

  Make a transverse dorsal incision over the metacarpal heads or longitudinal incisions between the metacarpophalangeal joints. If multiple common extensor tendons are to be realigned and longitudinal incisions are preferred, incisions between the index and middle and ring and small metacarpophalangeal joints will allow access to all four metacarpophalangeal joints. Identify and preserve the dorsal veins.

• ▪

  Enter each metacarpophalangeal joint through a longitudinal incision on the ulnar side of the extensor hood (radial if the tendons are subluxing radially).

• ▪

  Dissect the extensor hood from the underlying capsule to release the ulnarly displaced extensor mechanism.

• ▪

  Preserve the joint capsule as possible, and remove the synovium, especially that herniating out through the capsule and over the dorsal neck of the metacarpal.

• ▪

  Reposition the displaced extensor mechanism.

• ▪

  Realign the extensor tendon over the metacarpophalangeal joint by taking a distally based portion of the extensor tendon and passing it around the radial lumbrical tendon or collateral ligament with nonabsorbable sutures.

• ▪

  When the index finger is markedly deviated, a transfer of the extensor indicis proprius tendon to its radial side may be beneficial ( Fig. 73.22 ). In addition, the intrinsic ten dons can be transferred from the ulnar side of the digits to the radial side of the adjacent joint, as shown in Figure 73.23 .

  
  

• ▪

  Have the patient actively flex and extend the finger to ensure that the common extensor tendon remains over the metacarpophalangeal joint.

Postoperative Care

At 2 weeks, the sutures are removed and the hand is continually supported in a splint to avoid recurrence of ulnar deviation for another week. Supervised therapy is then begun with intermittent splint wear and progressive metacarpophalangeal joint flexion. The splint is worn for another 3 to 4 weeks.

Severe Ulnar Drift and Metacarpophalangeal Dislocation

In severe ulnar drift, often one or more metacarpophalangeal joints have dislocated; consequently, this type of drift and dislocation of these joints are discussed together. Metacarpophalangeal joint dislocations in effect release the soft-tissue tension across the joint and thus decrease tension more distally and protect, at least partially, the proximal interphalangeal joint. Conversely, the proximal interphalangeal joints may dislocate first. It should be emphasized, however, that the long flexor tendons are a major deforming force that drifts ulnarward, either within or without their sheaths, exerting an ulnar and palmarly directed force leading to metacarpophalangeal joint dislocation. For this type of ulnar drift, surgery is done mainly on the metacarpal head and its surrounding ligaments and tendons.

Function of a dislocated and arthritic metacarpophalangeal joint may be improved by arthroplasty. Many different designs of metacarpophalangeal joint interposition arthroplasty implants are available. We have had more experience with the Swanson implant than any other. An average expected range of motion at the metacarpophalangeal joint is about 55 degrees, and usually this occurs in the functional range. Complications include an infection rate between 0% and 3%, a breakage rate between 2% and 82%, a subluxation rate of 20%, and a dislocation rate of 5%. Although obvious fractures of the prosthesis may occur, the function of the joint usually is not impaired because it is not only the prosthesis but also the encapsulating scar that provides joint stability. Metal sleeves or grommets, which have been added to diminish abrasion at the bone-prosthesis interface, do not seem to make a significant difference in the fracture rate. The prostheses are easily removed when necessary. Of the many alternative designs for metacarpophalangeal implant arthroplasty, the pyrolytic carbon design has shown promising results.

Pyrolytic carbon metacarpophalangeal joint arthroplasties have fared better than their proximal interphalangeal joint counterparts. Wall and Stern found satisfactory outcomes in pyrolytic carbon metacarpophalangeal arthroplasties at an average 4-year follow-up, with improved joint motion, good pain relief and patient satisfaction, and few complications. Radiographic outcomes revealed a consistent asymptomatic surrounding lucency with no evidence of implant failure or migration. Dickson et al. reported a mean arc of motion of 54 degrees (20 to 80 degrees) in 35 index and 16 middle metacarpophalangeal arthroplasties at an average follow-up of 103 months (range, 60 to 72 months). Good pain relief, a functional range of motion, and high satisfaction were seen in most patients, with an 88% survival rate at 10 years and average subsidence of 2 mm in the proximal and 1 mm in the distal component.

Metacarpophalangeal joint arthroplasty reliably relieves pain, maintains stability and alignment, and permits acceptable motion ( Fig. 73.24 ). Results deteriorate over time, however, and the patient should be advised that revision may be necessary. The presence of active infection is a contraindication to implant arthroplasty. Loss of bone stock, skin changes that prohibit good closure, and irreparable tendon damage also compromise the outcome of implant arthroplasty.

Metacarpophalangeal Joint Arthroplasty

Technique 73.10

(SWANSON)

• ▪

  Make a transverse incision on the dorsum of the hand, beginning on the radial aspect of the second metacarpophalangeal joint, and extend it ulnarward to the ulnar aspect of the fifth metacarpophalangeal joint. (Alternatively, two longitudinal incisions can be used for the metacarpophalangeal joint exposure, one between the index and middle and one between the ring and small fingers.) Preserve all sensory nerves and carefully observe the pattern of the superficial veins; preserve them as well when possible.

• ▪

  This transverse incision permits a flap that can be dissected proximally and folded back, exposing the heads of the metacarpals. Through this, incise the shroud ligament of the extensor mechanism on the radial aspect of each joint and, if necessary, on the ulnar aspect also. This permits entry into the joint capsule, which already may be ruptured dorsally with herniation of hypertrophied synovium.

• ▪

  Incise and preserve when possible the capsule longitudinally, and perform a synovectomy with small rongeurs before and after metacarpal head resection.

• ▪

  With a thin osteotome or an oscillating saw, resect each metacarpal head to shorten the bone sufficiently to permit easy reduction of the volarly dislocated proximal phalangeal base. This may require resection proximal to the collateral ligaments origin, necessitating radial collateral ligament repair or reconstruction.

• ▪

  After synovectomy, introduce into the metacarpal medullary canal an awl or, if necessary, a reamer to provide space for the prosthesis stem. The metacarpal head-neck region should be cut carefully so that it is at a 90-degree angle with the axis of the metacarpal shaft.

• ▪

  Do not resect the proximal phalangeal base, although deformity from the arthritic process may require recontouring to make the base perpendicular to the phalangeal shaft. Soft-tissue dissection from the proximal phalangeal base should be sufficient to ensure that the entry point in the phalangeal canal is appropriate, centered from medial to lateral and more dorsal than volar to prevent volar cortex perforation. Prepare the base to accept the distal stem of the prosthesis by appropriate drilling, reaming, and broaching.

• ▪

  Select the largest implant that can be inserted comfortably.

• ▪

  Place gentle traction on the finger with the metacarpophalangeal joint in full extension and examine the distance between the metacarpal head and the phalangeal base. This should be sufficient to accommodate the implant midsection. Moreover, bone resection should be sufficient to prevent prosthesis buckling and volar abutment with joint flexion.

• ▪

  To help correct or avoid index finger pronation, Swanson recommended that a radial slip of the proximal phalangeal volar plate be split off proximally and reattached to the radial aspect of the metacarpal neck ( Fig. 73.25 ).

  

• ▪

  Remove the prosthesis from the package after a trial prosthesis has been inserted and the desired size determined. Handle the prosthesis with instruments without sharp edges to avoid scoring or other damage.

• ▪

  Insert the prosthesis and check that metacarpophalangeal joint passive motion is from full extension to almost 90 degrees of flexion.

• ▪

  Check all fingers carefully for alignment and for rotary deformity.

• ▪

  Close any remaining capsule over the prosthesis and centralize the extensor tendon over the metacarpophalangeal joint. Check finally for the need for further intrinsic release by placing the metacarpophalangeal joint in full extension and passively flexing the proximal interphalangeal joint. Note that ulnar intrinsic release is commonly required in rheumatoid arthritis patients, especially for the ring and small fingers.

• ▪

  Insert a drain, close the wound, and apply a supportive dressing to splint the fingers in slight radial deviation.

Postoperative Care

The splint is removed, and the dressing is changed at 5 to 7 days after surgery. The fingers are held in extension and deviated radially in the postoperative splint for 7 to 10 days until sutures are removed at about 10 days or longer, depending on wound healing. After suture removal, a program of passive and active motion is begun under the supervision of a therapist. Dynamic splinting is used to assist metacarpophalangeal extension and radial deviation during the day and is combined with static volar wrist, metacarpophalangeal, and proximal interphalangeal extension splinting at night. The daytime static splint is discontinued at 6 to 8 weeks, and supervised therapy with static splinting at night is continued for at least 3 months.

Surface replacement arthroplasty is reserved for patients with stable metacarpal joints. Most rheumatoid arthritis patients, however, are not candidates for this technique because joint instability and joint dislocations are contraindications to this procedure. Thus surface replacement arthroplasty is more ideally suited for patients with osteoarthritis or posttraumatic disorders with intact and stable metacarpal joint collateral ligaments and volar plates.

Metacarpal Joint Surface Arthroplasty

Technique 73.11

(BECKENBAUGH)

• ▪

  If a single joint is to be replaced, make a curved longitudinal incision centered over the metacarpal joint dorsally; if multiple joints are involved, make a transverse incision across the metacarpal joints dorsally or longitudinal incisions between the joints to be addressed.

• ▪

  Incise the extensor hood on the radial side of the central tendon or through its center if no dislocation or subluxation of the tendon is present.

• ▪

  Dissect the extensor tendon free from the joint capsule when possible and split it longitudinally to expose the joint so that the proximal phalangeal dorsal base and the metacarpal head with the collateral ligament origins are visible. Preserve the capsule as much as possible for later repair.

• ▪

  Use an awl to puncture the metacarpal head in its dorsal third, centered in the width of the head and aligned with the long axis of the metacarpal medullary canal.

• ▪

  Attach the alignment guide and insert the alignment awl through the puncture and advance it into the medullary canal one half to two thirds the length of the metacarpal. The alignment guide should be parallel to the dorsal surface of the metacarpal shaft and in line with the long axis of the bone.

• ▪

  Begin a partial metacarpal osteotomy using the proximal osteotomy guide mounted on the alignment awl and complete it free hand by following the previously established osteotomy plane. Attach the proximal osteotomy guide ( Fig. 73.26A ) on the alignment awl and advance it until the cutting plane of the guide is positioned 1 to 2 mm distal to the dorsal attachments of the collateral ligaments. Keep the volar surface of the guide parallel to the dorsal metacarpal surface to maintain proper rotational alignment. Remove the alignment awl and complete the osteotomy by following the plane established by the guided cut.

  

• ▪

  Puncture the proximal phalangeal base volar to the dorsal surface of the proximal phalanx a distance one third of the sagittal height and centered across the base in line with the phalangeal medullary canal.

• ▪

  Advance the alignment guide one half to two thirds the length of the phalangeal medullary canal and attach the distal osteotomy guide. Advance until the cutting plane of the guide is positioned 0.5 to 1.0 mm distal to the dorsal edge of the proximal phalanx. Keep the volar surface of the guide parallel to the phalanx dorsal surface.

• ▪

  Make the phalangeal cut with a small sagittal saw through the blade slot of the osteotomy guide ( Fig. 73.26B ). Make the dorsal portion of the osteotomy, remove the alignment awl, and complete the osteotomy free hand.

• ▪

  Open the phalangeal opening with the starter awl and distally broach along the previously established medullary axis. Keep the dorsal surface of the broach parallel to the dorsal surface of the phalangeal bone. A side-cutting burr may be necessary to assist in proper seating of the broaches. Continue broaching until the seating plane of the broach is flush to 1 mm deeper than the osteotomy ( Fig. 73.26C, D ). During broaching, evaluate fit and movement resistance. Repeat the broaching process with the next larger size broach until the largest size possible can be inserted and properly seated.

• ▪

  Broach the metacarpal beginning with the size 10 proximal broach working up to the broach determined from the phalangeal broaching process. Continue broaching until the seating plane of the broach is 1 mm deeper than the osteotomy. Do not mismatch proximal and distal component sizes.

• ▪

  Assess range of motion with trial components. Tightness in extension can be relieved by further impaction or removal of more bone. Insert and impact the appropriate size distal component until the component collar is flush with the proximal phalangeal base.

• ▪

  Insert and impact the matching metacarpal component and assess stability and range of motion.

• ▪

  Repair the capsule, centralize the common extensor tendon, and perform intrinsic releases and transfers when indicated.

• ▪

  Apply a volar splint with the wrist in 10 to 15 degrees of extension, the metacarpal joints in full extension, and the proximal interphalangeal joints in slight flexion.

Postoperative Care

Active and passive range-of-motion exercises are begun under the supervision of a therapist within the first week following the procedure. The sutures are removed at 10 to 14 days after surgery. Supervised physical therapy is continued until satisfactory motion has been achieved and the patient understands various exercises sufficiently to perform them independently.

Extensor Tendon Rupture

Rheumatoid tenosynovitis is a common cause of tendon rupture and a major cause of deformity and disability. Distal ulna, dorsal subluxation contributes to extensor tendon rupture because the extensor tendons usually glide between the arthritic distal ulnar head and the tight, intact dorsal carpal ligament. The small finger usually is involved first and subsequently the ring (Vaughn-Jackson syndrome) and then sequentially more radial digital extensors ( Fig. 73.27 ). The long extensor tendon of the thumb, because of its tortuous course, frequently ruptures at Lister’s tubercle, where it angles through the third extensor compartment. At surgery, white strips of pseudotendon connective tissue may be seen between the more normal proximal and distal tendon ends, and although these are not true tendons, they may be responsible for some remaining limited metacarpophalangeal joint extension and clinically suggest less extensive tendon disruption.

A ruptured extensor tendon can be repaired by direct suture if found within a few days and if the remaining tendon is adequate. If surgery must be delayed for several days, it is well to splint the wrist in extension to relieve the constant tension on the remaining intact tendons. If the ruptured tendon is diagnosed after several weeks, a segmental tendon graft may be possible between the proximal and distal segments of the ruptured tendon to an adjoining intact tendon. Although attachment of the ruptured distal tendons to an intact tendon is possible ( Fig. 73.28 ), tendon transfers, such as extensor indicis proprius to power the ulnar ruptured tendons, are more often required. A synovectomy is always indicated in the region of the rupture and the repair.

If the tendon of the ring finger or little finger alone is ruptured, repair of the ring finger tendon may be possible by suturing its distal and proximal segments to the intact middle finger extensor tendon under appropriate tension. The extensor indicis proprius might be transferred for use as a motor to the little finger. Transfer of the extensor pollicis brevis is an alternative, unless there is an extension deficit of the thumb metacarpometacarpal joint. When three extensor tendons, those of the middle, ring, and little fingers, have been ruptured for an extended period, the transfer of a motor usually is indicated. An acceptable source for this motor is the sublimis of the ring finger. This tendon has enough excursion and might be even more effective because of the tenodesis effect when the wrist is flexed. Extensor pollicis longus tendon rupture can be repaired by transfer of the extensor indicis proprius, a common and useful transfer when the extensor pollicis ruptures from other causes.

As mentioned, the clinical examination usually underestimates the amount of tendon attenuation and rupture, and reconstruction may be more complex than anticipated. Moreover, surgery may be done as an attempt to identify and eliminate the source of tendon degeneration to limit further loss of metacarpophalangeal joint extension.