Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: long-term results

Effect of a Flexor Digitorum Superficialis Hemitenodesis on Reducing Volar Plate Strains for Swan Neck Deformities

BACKGROUND

Flexor digitorum superficialis (FDS) hemitenodesis is a common procedure to treat swan neck deformity (SND). We hypothesize that this surgical technique is a biomechanically effective way to reduce strain in the volar plate at the proximal interphalangeal joint (PIPJ).

METHODS

Fifteen digits from 5 cadaveric specimens were tested using a novel in vitro active finger motion simulator under 4 finger conditions: intact, SND, FDS hemitenodesis, and FDS hemitenodesis with distal interphalangeal (DIP) joint fusion. Tensile loads in FDS and flexor digitorum profundus (FDP) and joint ranges of motion were measured by electromagnetic tracking. In addition, strain gauges were inserted under the volar plate to measure strain during PIPJ hyperextension. Results were analyzed using 1-way repeated-measures analysis of variance tests.

RESULTS

The SND condition increased volar plate strain by 176% ± 25% (P < .001) compared with the intact condition. The FDS hemitenodesis repair relieved more than 50% of the SND strain, restoring it to within no statistical difference from intact. The DIP fusion further reduced strain with no further statistical significance. At full flexion, FDS and FDP tendon loads diverged as a function of the test condition (P < .001). With the FDS hemitenodesis, the FDP load increased by 2.1 ± 1.5 N from the SND condition (P < .001), whereas the FDS load decreased by 1.3 ± 1.3 N (P = .012).

CONCLUSION

The FDS hemitenodesis repair restored strains to within 3.0 milli-strain of the intact condition with no significant difference. Application of DIP fusion did not further protect the PIPJ from increased hyperextension and further exacerbated the imbalance of flexor tendon loads.

Correction of rheumatoid swan-neck deformity of the finger using the modified Thompson-Littler method

OBJECTIVES

To investigate the outcomes of the modified Thompson-Littler (m-TL) method, a corrective surgical method utilising a dynamic tenodesis, in patients with rheumatoid swan-neck deformity.

METHODS

Twenty-seven fingers in 10 patients with rheumatoid arthritis (RA) underwent surgical correction. The mean age at the time of surgery was 60.3 (45-77) years, the mean duration of RA was 19.3 (4-34) years, and the mean postoperative follow-up period was 2.4 (0.5-6) years.

RESULTS

The deformity was corrected and the proximal interphalangeal (PIP) joint pain disappeared in all operated fingers. The mean pinch power between the thumb and the operated finger increased. The active extension decreased, the active flexion increased, and the total arc of motion decreased. Comparing the range of motion by Nalebuff's type classification, the postoperative arc of motion decreased as the type advanced.

CONCLUSIONS

The m-TL method provided a favourable outcome in cases of Type ≤III rheumatoid swan-neck deformity without severe joint deterioration at the PIP joint. Aesthetic and functional improvements were observed and the patients were satisfied with the operation.

Extension Mechanism of the Proximal Interphalangeal Joint of the Human Phalanx: A Cadaveric Biomechanical Study

Our purpose was to compare the contributions of these two systems to assess PIP joint extension in fresh cadaver models. Nine middle fingers of fresh cadavers were used. The PIP joint angle was measured while an extension load was applied on the extensor tendons. Specimens on which extension load was applied on the extrinsic extensors were classified as the extrinsic group, and those on which extension load was applied on the intrinsic extensors were classified as the intrinsic group. Linear regression analyses were performed to obtain regression equation and the extension load-PIP joint angle curve. The mean of slope of the curve was compared between the two groups using paired t-test. The same experiments were done for the metacarpophalangeal (MP) joint in 0° and 60° flexion to evaluate the effect of MP joint flexion on PIP joint extension. The mean slope of the extension load-PIP joint angle curve of the extrinsic group was significantly greater than that of the intrinsic group. With the MP joint in 0° flexion, the mean slope of the extrinsic and intrinsic groups was -0.148 and -0.117, respectively (greater absolute value means greater slope, p = 0.01). With the MP joint in 60° flexion, the mean slopes were -0.147 and -0.104, respectively (p = 0.015). The contribution of the intrinsic extensor for PIP joint extension shows decreasing trends with MP joint flexion. The extrinsic extensors have greater contribution for PIP joint extension compared with the intrinsic extensors.

Rheumatoid Hand and Wrist Surgery: Soft Tissue Principles and Management of Digital Pathology

Since the advent of disease-modifying antirheumatic drugs for rheumatoid arthritis, orthopedic surgeons see fewer patients in the office who require hand surgery. However, a significant number of patients still seek surgical intervention to improve pain and function. These patients often present with isolated soft tissue pathologies, but even bone and joint pathology require meticulous soft tissue handling in this cohort. This review highlights the principles and techniques relevant to the management of soft tissue deformity in rheumatoid hand and wrist surgery, as exposure in training and practice continues to decrease.

Treating the Proximal Interphalangeal Joint in Swan Neck and Boutonniere Deformities

Swan neck and boutonniere deformities of the proximal interphalangeal (PIP) joint are challenging to treat. In a swan neck deformity, the PIP joint is hyperextended with flexion at the distal interphalangeal (DIP) joint. In a boutonniere deformity, there is flexion the PIP joint with hyperextension of the DIP joint. When the deformities are flexible, treatment begins with splinting. However, when the deformity is fixed, serial casting or surgery is often necessary to restore joint motion before surgical correction. Many surgical techniques have been described to treat both conditions. Unfortunately, incomplete correction and deformity recurrence are common.

Volar Tenodesis for the Treatment of Swan-neck Deformity; A Systematic Review

BACKGROUND

Swan-neck deformity is a common problem particularly in patients with Rheumatoid arthritis. Mobile swan-neck deformities (Nalebuff types I,II) can be treated non-operatively and operatively. In this paper we report on a systematic review of the treatment of swan-neck deformities with volar tenodesis.

METHODS

We performed a literature search and analysed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only eight papers were eligible. None was of high quality. The data reporting was very variable. Therefore, no meta-analysis could be performed, but only a descriptive analysis.

RESULTS

The techniques work in preventing proximal inter-phalangeal joint hyperextension between 60 and 100% in these studies. There appears to be some recurrence of hyper-extension with time so that papers with longer follow-up tend to have poorer results.

CONCLUSIONS

There is no good evidence that one technique is superior to another. The choice of technique is likely to remain based on surgeon preference for the foreseeable future. Future studies should be at least comparative and preferably part of a trial.

Intrinsic contracture of the hand: diagnosis and management

Intrinsic contracture of the hand may result from trauma, spasticity, ischemia, rheumatologic disorders, or iatrogenic causes. In severe cases, the hand assumes a posture with hyperflexed metacarpophalangeal joints and hyperextended proximal interphalangeal joints as the contracted interossei and lumbrical muscles deform the natural cascade of the fingers. Considerable disability may result because weakness in grip strength, difficulty with grasping larger objects, and troubles with maintenance of hygiene commonly encumber patients. Generally, the diagnosis is made via history and physical examination, but adjunctive imaging, rheumatologic testing, and electromyography may aid in determining the underlying cause or assessing the severity. Nonsurgical management may be appropriate in mild cases and consists of occupational therapy, orthoses, and botulinum toxin injections. The options for surgical management are diverse and dictated by the cause and severity of contracture.

The future of rheumatoid arthritis and hand surgery - combining evolutionary pharmacology and surgical technique

Rheumatoid arthritis is a systemic autoimmune disease of uncertain aetiology, which is characterized primarily by synovial inflammation with secondary skeletal destructions.Rheumatoid Arthritis is diagnosed by the presence of four of the seven diagnostic criteria, defined by The American College of Rheumatology.Approximately half a million adults in the United Kingdom suffer from rheumatoid arthritis with an age prevalence between the second and fourth decades of life; annually approximately 20,000 new cases are diagnosed.The management of Rheumatoid Arthritis is complex; in the initial phase of the disease it primarily depends on pharmacological management. With disease progression, surgical input to correct deformity comes to play an increasingly important role. The treatment of this condition is also intimately coupled with input from both the occupational therapists and physiotherapy.

Treatment of boutonniere finger deformity in rheumatoid arthritis

Boutonniere finger deformities occur frequently in patients with rheumatoid arthritis. The deformity consists of flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint. Treatment decisions are based on the degree of joint deformity, joint motion, passive joint correctability, and the status of the articular surface. Treatment options can then be based on the classification of the deformity; options consist of corrective splinting, injections, synovectomy, terminal tenotomy, extensor reconstruction, or salvage surgery (arthrodesis or arthroplasty).

Reconstruction of digital deformities in rheumatoid arthritis

Digital deformities result from rheumatoid synovitis. These deformities are easier to treat in the early stage, when the deformity is passively correctable. Treatment options become limited as the disease progresses and the deformity becomes fixed. Surgical treatment of digital deformities is last in the priority of surgical procedures for the rheumatoid hand and wrist. It is therefore important to understand the patient's needs and expectations for improvement and attempt to match them with the surgical options that can predictably improve the patient's function. A close collaboration with the patient's rheumatologist is helpful in the overall management of patients.

Design and Preliminary Evaluation of a Novel Brace for Boutonniere Deformity

Boutonniere deformities are a common injury to the extensor mechanism of the finger. The deformity results in fixed contraction in the middle finger joint and is severely debilitating to functionality. Due to the complexity of the extensor mechanism, surgical repair is difficult, which usually requires multiple procedures, and in some cases is unsuccessful. Nonsurgical treatment of the deformity has not dramatically improved in many years and usually requires long-term use of braces and physical therapy. This work is focused on design and preliminary evaluation of an improved boutonniere brace to correct the deformity with emphasis on lower costs, integrating therapeutic techniques such as heat and motion to increase blood flow and patient comfort. A review of the current state of the art is presented along with the design approach used to develop an improved device. Experimental test results are also presented. This work demonstrates a new device and approach for treatment of boutonniere deformities that may translate to treatment of other conditions such as arthritis.

Correction of swan neck deformity in rheumatoid arthritis using a new lateral extensor band technique

Swan neck deformity is a progressive and disabling condition that commonly affects rheumatoid arthritic hands. During a 4-year period, 101 fingers in 43 patients had this deformity corrected using a new procedure combining the distally based extensor lateral band technique described by Littler and the flexor digitorum superficialis (FDS)-palmar plate pulley introduced by Zancolli. The ranges of motion of the metacarpophalangeal, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were assessed pre-operatively and 12 months after surgery. An average PIP joint hyperextension of -13.3 degrees was converted to +13.4 degrees . The ranges of motion of the proximal and DIP joints were significantly different (Student's t-test). No patient suffered recurrence of the deformity during an average follow-up of 20 months. This new technique improves some unappealing aspects of previous techniques and provides a stable and reliable correction of swan neck deformity.

[Classification of finger deformities due to muscle-tendon imbalance]

We have developed a 4 stages classification comprising: purely dynamic imbalance (Stage 1); tenodesis effect (Stage 2); articular rigidity without cartilage lesion (Stage 3); articular rigidity with bone and cartilage destruction (Stage 4). This classification is easy to remember and general enough to be used for most deformities due to musculo-tendinous imbalance, whatever their type or etiology. We believe that this assessment will help to clarify the therapeutic indications and allow better interpretation of the results.

Soft tissue surgery in rheumatoid arthritis of the hand

All surgery in patients with rheumatoid arthritis of the hand involves careful consideration and planning of the soft tissue component of the disease. The planning must include acknowledgment of the patient's functional requirements and surgical requirements. Multiple surgeries are common in patients with rheumatoid disease and must be planned carefully to avoid conflicting postoperative rehabilitation programs. Joint replacement and other surgery are only an adjunct to the soft tissue treatment. The progressive nature of rheumatoid arthritis is not a barrier to early surgery and may prolong the function of the patient. The logical approach to the surgical requirements is discussed and specific soft tissue surgeries are described. Some details of specific surgical techniques also are included.

Operative correction of swan-neck and boutonniere deformities in the rheumatoid hand

A swan-neck or boutonniere deformity occurs in approximately half of patients with rheumatoid arthritis. The cause of boutonniere deformity is chronic synovitis of the proximal interphalangeal joint. Swan-neck deformity may be caused by synovitis of the metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joints. Numerous procedures are available for the operative correction of these finger deformities. The choice of surgical procedure is dependent on accurate staging of the deformity, which is based on the flexibility of the proximal interphalangeal joint and the state of the articular cartilage. The patient's overall medical status and corticosteroid use, the condition of the cervical spine, the need for operative treatment of large joints, and the presence of deformities of the wrist and metacarpophalangeal joints must also be considered when planning treatment. In the later stages of both deformities, soft-tissue procedures alone may not result in lasting operative correction.

Determining surgical priorities in rheumatoid arthritis

Rheumatoid arthritis often affects multiple joints simultaneously with pain, deformity and loss of function. The indications for surgical treatment are presented along with guidelines for determining the surgical priorities along with guidelines for determining the surgical priorities when multiple joints require surgery.

Decision making in rheumatoid arthritis. Determining surgical priorities

Consideration of the individual, his or her needs, and what he or she hopes to gain through surgery is of primary importance in determining a surgical plan for the rheumatoid patient. Nevertheless, procedures undertaken to save life or prevent neurologic demise must, of course, take precedence. Alleviation of pain and correction of disabling deformity take next priority. Many other considerations go into the formulation of the list of surgical priorities. A full understanding of these considerations and a well-integrated team approach to the rheumatoid patient provide the best chance for optimal outcome following surgery.