Reconstructive Hand Surgery for Arthritis

Reconstructive hand surgery has become a vital part of managing rheumatoid arthritis, offering significant relief and improved function for patients. While it doesn't fully restore normal function, it effectively alleviates pain, corrects or prevents severe deformities, and enhances both appearance and utility of the hands. This comprehensive guide will explore the various aspects of reconstructive hand surgery for arthritis, including common procedures, specific considerations for different types of arthritis, and the critical role of a multidisciplinary approach.

Understanding Reconstructive Hand Surgery for Arthritis

It's crucial to understand that reconstructive hand surgery, while transformative, does not restore normal function, motion, or dexterity to arthritic hands; some weakness will remain. However, it can dramatically improve a patient's quality of life by reducing pain and improving the hand's ability to perform daily tasks. Due to the complexities, careful judgment is essential when recommending surgery, and it should be part of an overall management plan.

Modern disease-modifying medical therapies have reduced the need for extensive surgery, but a complete hand surgeon still needs a thorough understanding of rheumatoid hand and wrist deformities and their treatment. This involves appreciating the natural history of the disease, recognizing specific deformities, and understanding each patient's functional needs and limitations.

A collaborative approach is paramount, involving rheumatologists, orthopaedic surgeons, and physical, occupational, and hand therapists. This ensures a holistic understanding of the patient's condition and the provision of the best possible care.

General Surgical Considerations for Arthritic Hands

Caring for a hand affected by rheumatoid arthritis differs significantly from treating a traumatic injury. Rheumatoid arthritis involves an ongoing process of joint and tendon destruction that can persist for many years. This systemic condition primarily affects synovial tissue, which then destroys articular cartilage, invades subchondral bone, and stretches supporting soft tissues. It also invades flexor and extensor tendons, disrupting the normal architecture and delicate balance of forces in the hand and wrist unit.

The manifestations of the disease vary greatly among individuals, underscoring the need for individualized treatment plans. The presence of deformity alone isn't always an indication for surgery, as many patients maintain good function despite significant changes. We believe that reconstructive rheumatoid hand surgery requires extensive experience and should not be undertaken by the occasional hand surgeon. Building good rapport with the patient is also essential, as the reconstructive program often spans months or even years.

Five Main Categories of Hand Surgery for Arthritis

Nearly all surgical procedures performed on the rheumatoid hand and wrist fall into one of five main groups:

• Synovectomy: Removal of diseased synovial tissue.
• Tenosynovectomy: Removal of diseased synovial tissue surrounding tendons.
• Tendon Surgery: Procedures like repair, grafting, or transfer to restore tendon function.
• Arthroplasty: Joint reconstruction, often with implants, to restore motion and alignment.
• Arthrodesis: Joint fusion to provide stability and eliminate pain.

Stages of Rheumatoid Joint Involvement

Rheumatoid joint involvement is typically categorized into four stages:

1. Stage 1: Synovitis without deformity.
2. Stage 2: Synovitis with a passively correctable deformity.
3. Stage 3: Fixed deformity without joint changes.
4. Stage 4: Articular destruction.

Prioritizing Surgical Interventions for Rheumatoid Hand Deformities

When planning reconstructive surgery, certain considerations help optimize outcomes:

• MP vs. PIP Joint Priority: Correcting metacarpophalangeal (MP) joint deformities first often simplifies subsequent treatment of proximal interphalangeal (PIP) joints. Restoring MP joint alignment and motion can significantly improve hand function, even if PIP joint function remains imperfect. The reverse is not usually true.
• Extensor Tendon Reconstruction: If extensor tendon reconstruction is needed alongside MP joint surgery, the MP joints are typically treated first. This facilitates postoperative rehabilitation, as MP extension can be provided with a dynamic splint. Extensor tendon reconstruction can then be performed in a second stage without compromising the initial MP joint surgery.
• Bilateral Hand Problems: For patients with bilateral hand problems, we encourage them to participate in deciding which hand to operate on first. The non-operated hand will need to perform additional work during rehabilitation, which could induce a flare of synovitis. Sometimes operating on the less involved hand first is prudent.
• Staged Approach: It's best to begin a reconstructive program with procedures that have predictable outcomes, progressing in stages to less predictable ones. This means procedures like thumb MP joint fusion, finger distal interphalangeal (DIP) fusion, and wrist fusion might come before distal ulnar excision and MP joint arthroplasty.
• Proximal and Distal Joint Function: Shoulder or elbow reconstruction, if indicated, should precede hand reconstruction to prevent proximal problems from impeding hand rehabilitation. For example, if elbow flexion is limited, the wrist might need to be fused in a neutral or slightly flexed position to allow the hand to reach the mouth.
• Lower Extremity Considerations: If painful or deformed hands prevent the use of ambulatory aids (like crutches or walkers), upper extremity surgery might be necessary before lower extremity surgery, often involving wrist fusion for stability.

Specific Surgical Techniques for Rheumatoid Hand

Synovectomy and Tenosynovectomy

• Synovectomy: Indicated for patients with mild, drug-controlled disease and persistent synovitis in one or two joints. It's contraindicated in rapidly progressive disease where frequent observation and early reconstructive surgery are preferred.
• Tenosynovectomy: Early tenosynovectomy may be necessary in rapidly progressive disease to prevent tendon rupture. Communication between rheumatologist and hand surgeon is especially important for patients on anti-TNF therapy.

Dorsal Tenosynovectomy

Indications: Persistent dorsal tenosynovitis after 4-6 months of medical management, or extensor tendon rupture.

Procedure: A straight midline incision with transverse extensions exposes the extensor tendons. Hypertrophic synovium is meticulously removed from each tendon sheath. The posterior interosseous nerve is resected to partially denervate the wrist for pain relief. The wrist joint is evaluated for synovitis, and bone spicules that could cause attrition ruptures are removed. The distal ulna is resected if dislocated. The dorsal retinaculum is often passed deep to the extensor tendons to provide a smooth gliding surface.

Postoperative Care: Hand motion begins 24-48 hours post-surgery, emphasizing active extension and flexion. The MP joint is splinted in extension to prevent extensor lag, and the wrist is supported with a volar splint for two weeks.

Complications: Skin necrosis or sloughing, often due to hematoma formation, is the most serious. Postoperative adhesions can lead to extensor lag or loss of finger flexion, which is addressed with hand therapy.

Flexor Tenosynovectomy

Indications: Symptoms of median nerve compression, persistent tenosynovitis after injection/medical management, or flexor tendon rupture.

Procedure: An incision parallel to the thenar crease, extended proximally in a zigzag manner, exposes the median nerve and flexor tendons. The transverse carpal ligament is divided, and hypertrophic tenosynovium is excised. Care is taken to protect the palmar cutaneous and motor branches of the median nerve. The floor of the carpal canal is inspected, and any scaphoid osteophytes are removed and covered with soft tissue.

Postoperative Care: The wrist is splinted in neutral, and immediate active finger motion is encouraged. Smooth motion of fingers and thumb should be present. Catching indicates nodules in the palm or digits, requiring further exploration.

Digital Tenosynovectomy

Indications: Digital tenosynovitis, rheumatoid trigger finger, or limited motion due to flexor tendon nodules.

Procedure: Zigzag incisions on the volar aspect of the digits expose the flexor tendon sheaths. Synovium and any nodules are excised. As much annular pulley as possible is preserved. Often, half of the superficialis tendon is excised to allow free excursion of the remaining tendons.

Tendon Surgery for Ruptures

Tendon ruptures are a significant complication of rheumatoid arthritis, often occurring from attrition against prominent bone or synovial invasion. Early diagnosis and treatment are crucial.

Extensor Tendon Ruptures

• Extensor Pollicis Longus (EPL) Rupture: Common. Leads to loss of MP joint extension of the thumb. Treatment: Tendon transfer is preferred, typically using the extensor indicis proprius (EIP) tendon from the index finger. The EIP is rerouted and woven into the thumb extensor mechanism.
• Single Finger Extensor Rupture (e.g., small finger): Treatment: Adjacent suture of the distal stump to the long finger extensor or EIP transfer to the small finger. The EIP is preferred because the small finger extensor may be too short for direct suturing.
• Double Rupture (e.g., ring and small fingers): Treatment: EIP transferred to the small finger extensor, and the ring finger extensor stump sutured to the long finger extensor.
• Triple Rupture (e.g., long, ring, and small fingers): Treatment: EIP transfer combined with a flexor digitorum superficialis (FDS) transfer. The FDS of the middle finger is often routed through the interosseous membrane or subcutaneously around the radial aspect of the forearm to avoid scarring.
• Quadruple Rupture: Two FDS transfers are used: one for index/middle fingers and one for ring/small fingers. Tension adjustment is critical to allow both extension and flexion.
• Multiple Ruptures with MP Joint Disease: Staged reconstruction is often necessary. MP arthroplasty first, followed by dynamic splinting, then tendon transfers in a second stage. Combined procedures are possible but may yield less complete motion.
• Tendon Transfers with Fused Wrists: Wrist extensors (e.g., ECRB) or even flexors can be used for finger extension, as they are expendable when the wrist is fused.

Flexor Tendon Ruptures

• Flexor Pollicis Longus (FPL) Rupture: Most common flexor rupture, often due to attrition from a carpal scaphoid osteophyte (Mannerfelt lesion). Treatment: Remove the bone spicule, cover exposed bone. Surgical choices include bridge graft (e.g., palmaris longus), standard tendon graft, or FDS transfer. FDS of the long finger can be transferred to the distal phalanx of the thumb.
• Flexor Digitorum Profundus (FDP) Rupture: If superficialis function is maintained, functional loss may be minimal. Treatment: Level of rupture is key. Palm/wrist ruptures: suture to adjacent intact tendon or small bridge grafts. Within fibro-osseous canal: remove diseased synovium, stabilize DIP joint if hyperextended.
• Flexor Digitorum Superficialis (FDS) Rupture: Minimal functional loss. Treatment: Suturing to adjacent tendons in palm or wrist is feasible; tenosynovectomy to protect FDP.
• Both Superficial and Deep Finger Flexor Tendons Rupture: Significant functional loss. Treatment: Early prophylactic tenosynovectomy is ideal to prevent this. For ruptures at the wrist: suture to adjacent tendons or bridge graft FDP. In the palm: adjacent suturing if possible, or FDS transfer to distal profundus stump. Within the fibro-osseous canal, results with free flexor tendon grafts are poor in rheumatoid patients; fusion of PIP and DIP joints in a functional position is often the wisest choice.

The Wrist: Keystone of Hand Function

The wrist is critical for hand function; a painful, unstable, or deformed wrist significantly impairs overall hand utility. Wrist deformity is also a major cause of finger deformity, and its alignment must be preserved or restored to maintain correction of finger deformities.

Natural History of Rheumatoid Wrist Involvement

Rheumatoid synovitis typically starts at the ulnar styloid, ulnar head, and mid-portion of the scaphoid. Progressive synovial proliferation leads to various deformities:

• Caput Ulna Syndrome: Destruction of the ulnar carpal ligamentous complex, including the triangular fibrocartilage, causing dorsal prominence of the distal ulna, supination of the carpus, and volar subluxation of the ECU tendon. This results in weakness, pain, and restricted forearm rotation, often leading to radial wrist deviation and attrition ruptures of ulnar extensor tendons.
• Radiocarpal Involvement: Synovitis beneath the radioscaphocapitate ligament leads to scaphoid instability (volar-flexed position), loss of carpal height, and radial rotation of the carpus. This often contributes to ulnar deviation of the MP joints.
• End-Stage Rheumatoid Wrist: Characterized by volar dislocation, complete carpal bone destruction, and complete dissociation of the radioulnar joint.

Operative Treatment of Wrist Deformities

Surgical procedures for the radiocarpal and radioulnar joints can be preventive or reconstructive.

• Preventive Procedures: Synovectomy of radioulnar and radiocarpal joints, balancing of wrist extensors, tenosynovectomy.
• Reconstructive Surgery: Distal ulnar excision, reconstruction of the ulnocarpal ligamentous complex, radiocarpal joint arthroplasty, partial wrist fusion, and total wrist arthrodesis.

Wrist Synovectomy

Indications: Persistent, painful wrist synovitis with minimal to moderate radiographic involvement, or as an adjunct to other wrist surgery. It can provide significant pain relief and may be more effective and durable in the era of biologics.

Procedure (Dorsal Approach): Exposure through a longitudinal incision. Resection of the posterior interosseous nerve (for pain relief). A transverse or U-shaped incision in the wrist capsule exposes the joints, allowing synovectomy with a rongeur. Periarticular erosions are curetted. The DRUJ is also exposed and synovectomy performed. Capsular incisions are closed with the forearm in supination to minimize ulnar subluxation.

Procedure (Volar Approach): Done when flexor tenosynovectomy is indicated, addressing volar wrist synovitis manifested by bulging of the volar capsule.

Postoperative Care: Wrist splinted in neutral, forearm in full supination for ~3 weeks, followed by range of motion exercises.

Distal Ulnar Excision and DRUJ Reconstruction

Indications: Common for disability from DRUJ involvement, symptoms of caput ulna syndrome, or in conjunction with dorsal tenosynovectomy/tendon transfer or wrist joint synovectomy/reconstruction.

Procedure: Involves limited resection of the distal ulna. Soft tissue reconstruction of the triangular fibrocartilage complex and DRUJ is crucial. The Sauve-Kapandji procedure, which fuses the distal ulna to the sigmoid notch of the radius with segmental ulnar resection, is an alternative, especially for younger patients or those with impending ulnar translocation (though we prefer radiocarpal fusion for established ulnar translocation in rheumatoid patients).

Other Connective Tissue Diseases Affecting the Hand

While rheumatoid arthritis is the primary focus, other connective tissue diseases, often called rheumatoid variants, also affect the hand and require distinct surgical approaches. These include psoriatic arthritis, systemic lupus erythematosus (SLE), and scleroderma.

Psoriatic Arthritis

Psoriatic arthritis is a seronegative spondyloarthropathy characterized by a scaly, erythematous rash and inflammatory arthritis. Hand involvement often presents with unique features:

• Skin Involvement: Psoriatic skin lesions can complicate surgery due to enhanced infection risk. Elective surgery may be scheduled during summer when skin conditions often improve.
• Nail Changes: Common, including pitting.
• Joint Involvement: Varies widely. Classic DIP joint disease with erosion of terminal phalanges, nail pitting, and onycholysis is characteristic. Osteolysis (bone destruction) is common, leading to a