Trends in Rheumatoid Hand Surgery: Indications, Techniques, and Outcomes

Abstract

Rheumatoid arthritis (RA) causes persistent synovitis and arthritis, resulting in joint deformity and destruction throughout the body. As RA medications have evolved over the past 30 years, the surgical indications and techniques for RA joint deformities have changed. The aim of this review article is to summarize the recent trend of surgery for rheumatoid hand/finger deformities in previous reports and to present our recent surgical methods and outcomes for these deformities. A typical hand and finger deformity caused by RA is ulnar deviation, which is mainly caused by joint laxity and dislocation of the metacarpophalangeal joints, in addition to extensor tendon dislocation and/or wrist joint deformity. Although the incidence of hand/finger deformity and ulnar deviation caused by RA is decreasing due to advances in RA medications, patients with long-term RA or those with difficult-to-treat RA may still develop hand/finger deformity and ulnar deviation. If the hand/finger deformity is mild, it can be reduced manually, and conservative treatment with orthoses or splints may be required. If joint pain is severe despite good medical control of RA, or if the patient hopes to improve the appearance of the hand or fingers, surgical intervention is required. If there is only subluxation of the joints, which preserves their structure, reconstruction with only soft tissue surgery may be required. For example, for swan-neck deformity and boutonniére deformity, two of the most typical finger deformities due to RA, when the joint structures are almost intact and can be corrected manually, we opt for a surgical procedure that involves only soft tissue manipulation without the use of prosthetic implants. For ulnar deviation without joint destruction, we usually use a soft tissue-only surgical procedure. Our results have shown that the soft tissue-only surgery for ulnar deviation is as effective as joint replacement with implants. If the destruction of the joint has occurred and its dislocation/subluxation cannot be reduced manually, implant arthroplasty becomes necessary. If the joint destruction is severe, only intra-articular arthrodesis is required. In the era when RA can be controlled by medication, the hand surgeon should not overlook the change in the stage of the rheumatoid hand and should perform surgical intervention via the appropriate surgical method.

Keywords: hand and finger deformity; joint replacement; joint-preserving arthroplasty; rheumatoid arthritis; ulnar deviation.

Figure 1

The Matev method for boutonniére deformity of the little finger. One side of the lateral band was cut and sutured to the central slip, and the other side of it was also cut and sutured to the proximal contralateral edge.

Figure 2

Skin incision line for the buttonhole deformity of the thumb. A longitudinal skin incision is made through 3 cm at the center of the MCP joint.

Figure 3

Inverted capsule and detached collateral ligaments. The capsule is cut and inverted distally (black arrow), and both the radial and ulnar collateral ligaments (white arrows) are detached from the metacarpal bone head.

Figure 4

A 1.2 mm Kirschner wire is used to create two holes on both the radial and ulnar sides of the distal end of the metacarpal bone to allow the sutures for the collateral ligaments to pass through.

Figure 5

Suturing the collateral ligaments to the metacarpal bone after implant placement. After the insertion of the implants (black arrow), the radial and ulnar collateral ligaments are sutured to the metacarpal bone. In this figure, the ulnar collateral ligament is sutured using 3–0 absorbable sutures that were previously passed through the bone holes.

Figure 6

Radiographs of “hybrid finger arthroplasty” ((left): preoperative; (right): postoperative). The MCP joints of the index and middle fingers were replaced with implants, and the ring and little fingers underwent joint-preserving arthroplasty.

Figure 7

Our skin incision line for MCP joint arthroplasty. Two skin incisions are made vertically between the metacarpal heads of the index and middle fingers and between those of the ring and little fingers.

Figure 8

Exposed metacarpal bone head. The capsule is cut and inverted distally, and the radial and ulnar collateral ligaments (with sutures as markers) are shown.

Figure 9

A Pre-Flex-type Sutter silicone implant is inserted into the MCP joint of the little finger. Suture threads for the later suturing of the radial collateral ligament are visible.

Figure 10

Preoperative and postoperative appearance and radiographs for MCP joint replacement with silicone implants ((left): preoperative; (right): postoperative). Ulnar deviation is improved both in appearance and in the radiographs.