Screening for extensor tendon rupture in rheumatoid arthritis

Radiographic study of the distal ulna in rheumatoid arthritis with extensor digitorum communis ruptures

OBJECTIVES

Extensor digitorum communis (EDC) rupture of the wrist often occurs in patients with rheumatoid arthritis (RA). Early operation is desirable for patients with a high risk of rupture; therefore, rheumatologists should diagnose it during daily examinations. This study aimed to clarify radiographic changes in the distal ulna and related factors associated with EDC rupture in patients with RA.

METHODS

We analysed plain radiographs of 40 patients with RA associated with EDC rupture and 62 healthy controls. We investigated the deformation of the distal ulna, Larsen grades, and radiological parameters such as ulnar variance (UV), ulnar bowing angle, dorsal protrusion (DP), and dorsal bowing angle.

RESULTS

The ratios of the ulna head deformation, Larsen grades, UV, DP, and dorsal bowing angle were significantly larger in the ruptured group than in the control group. Multiple logistic regression analysis revealed that DP and Larsen grades were significantly associated with EDC rupture.

CONCLUSIONS

Deformity of the distal ulna is evident in patients with an EDC rupture. Ulnar head deformation, high Larsen grades, and large DP are the potential risk factors for EDC rupture.

Risk factors for rupture of extensor tendons in the rheumatoid wrist

This study assessed the risk factors for spontaneous extensor tendon rupture in the rheumatoid wrist. The rupture group consisted of 25 wrists that had rupture of the extensor tendons and later received tendon reconstruction. The non-rupture group included 77 rheumatoid wrists without extensor tendon rupture. We assessed patients' pain at the distal radioulnar joint and swelling in the extensor tendon compartments clinically, matrix metalloproteinase-3 level in blood samples, and radiographic findings. We found that swelling in the extensor tendon compartments, the scallop sign, and severe dorsal subluxation are significantly associated with spontaneous extensor tendon rupture, but serum matrix metalloproteinase-3 level is not.Level of evidence: IV.

Extensor tendon ruptures in rheumatoid wrists

Background and aims

Rheumatoid arthritis is a chronic inflammatory disease. The associated involvement of hands and tendons is over 90% and impairs overall function. In the course of the disease, the joints are often operated on. During this operation, ruptures of the extensor tendons are found by chance without the patients noticing them. The aim of this retrospective study is the prevalence of extensor tendon rupture. Which tendon is destroyed most frequently? How can the functional outcome be measured after reconstruction?

Materials and methods

From 1572 operations on rheumatoid wrists, 61 extensor tendon ruptures were identified in 41 patients. The average time between the first rheumatic symptoms of the hand and surgery was 6.4 years. The average duration of RA was 7.8 years. 26 patients with 27 tendon reconstructions were included in the follow-up with an average postoperative duration of 4.6 years (3 to 14.2 years).

Results

Extensor tendons ruptures typically occurred at mechanically stressed sites. The most frequent rupture was found in the extensor pollicis longus tendon (21 tendons), followed by the small finger extensor tendon (14 tendons). A transfer was performed on 7 tendons. Fifty-five tendon lesions were sutured at other intact tendons. Free grafts were not used. The results in Clayton and QuickDASH scores were significantly different. Functional improvement was consistent with the results of tendon reconstructions in healthy control groups.

Conclusion

In rheumatoid patients, a rupture of an extensor tendon must be expected at 4%. Patients tolerate and compensate this damage for a long time. The function of the hand including the tendon function is the most important factor in assessing the success of the operation. The subjective patient acceptance depends on the progress of the underlying disease, postoperative care (ergotherapy, physiotherapy, orthosis) and the patients' demands.

Electronic supplementary material

The online version of this article (10.1007/s00590-020-02731-1) contains supplementary material, which is available to authorized users.

Reconstruction and repair of atraumatic extensor tendon ruptures in rheumatoid wrists: Less extension lag after direct repair than interposition tendon grafting

The purpose of this study was to investigate the outcomes of extensor tendon repair involving the original stump in atraumatic extensor tendon rupture of rheumatoid wrists. For this study, 16 cases were reviewed involving 14 patients with rheumatoid arthritis. A total of 52 ruptured tendons impacted 36 fingers; 51 tendons were repaired in 35 fingers. The ruptured tendon stumps were repaired either directly by end-to-end suture or by free interposition tendon graft. The 8- to 10-strand core suture method was used for direct repair with a looped 4-0 nylon suture. In all patients, the extensor retinaculum was released and repaired under the tendons. Postoperatively, a volar splint with the wrist and fingers extended was applied for 3 to 4 weeks, followed by a removable splint and gentle active flexion until 6 weeks. The mean follow-up period was 32 months. All fingers recovered active metacarpophalangeal (MCP) joint extension, including independent and active extension of the little finger. Overall, the mean extension lag at the MCP joint was 1.7°. The mean fingertip-to-palm distance with the MCP joint flexed was 0.24mm. The mean extension lag at the MCP joint was significantly greater after interposition tendon grafting (3.2°) than after direct repair (0°). There was no significant difference in the mean fingertip-to-palm distance between direct repair (0.38mm) and interposition tendon grafting (0.13mm). No re-rupture or additional extensor tendon rupture was observed. Repair of the original extensor tendon stump yields satisfactory outcomes and appears to be a viable alternative to tendon transfers in patients with rheumatoid wrists with atraumatic extensor tendon ruptures. Direct repair reduces postoperative extension lag without a significant difference in flexion deficit when compared with interposition tendon grafting.

MRI of the Extensor Tendons of the Wrist

OBJECTIVE

This article reviews the normal anatomy of the extensor tendons of the wrist as well as the clinical presentation and MRI appearances of common tendon abnormalities, such as tears, tenosynovitis, intersection syndromes, and associated or predisposing osseous findings. Treatment options are also discussed.

CONCLUSION

We review the anatomy and normal MRI appearance of the clinically important dorsal extensor tendons of the wrist, in addition to the spectrum of abnormalities associated with these tendons.

Ultrasound definition of tendon damage in patients with rheumatoid arthritis. Results of a OMERACT consensus-based ultrasound score focussing on the diagnostic reliability

OBJECTIVE

To develop the first ultrasound scoring system of tendon damage in rheumatoid arthritis (RA) and assess its intraobserver and interobserver reliability.

METHODS

We conducted a Delphi study on ultrasound-defined tendon damage and ultrasound scoring system of tendon damage in RA among 35 international rheumatologists with experience in musculoskeletal ultrasound. Twelve patients with RA were included and assessed twice by 12 rheumatologists-sonographers. Ultrasound examination for tendon damage in B mode of five wrist extensor compartments (extensor carpi radialis brevis and longus; extensor pollicis longus; extensor digitorum communis; extensor digiti minimi; extensor carpi ulnaris) and one ankle tendon (tibialis posterior) was performed blindly, independently and bilaterally in each patient. Intraobserver and interobserver reliability were calculated by κ coefficients.

RESULTS

A three-grade semiquantitative scoring system was agreed for scoring tendon damage in B mode. The mean intraobserver reliability for tendon damage scoring was excellent (κ value 0.91). The mean interobserver reliability assessment showed good κ values (κ value 0.75). The most reliable were the extensor digiti minimi, the extensor carpi ulnaris, and the tibialis posterior tendons. An ultrasound reference image atlas of tenosynovitis and tendon damage was also developed.

CONCLUSIONS

Ultrasound is a reproducible tool for evaluating tendon damage in RA. This study strongly supports a new reliable ultrasound scoring system for tendon damage.

Sonographic appearance of nontraumatic tear of flexor carpi radialis muscle-a case report

We present an unusual case of a man with a nontraumatic tear of the flexor carpi radialis muscle after a regular swimming exercise, without known precipitation factors. The muscle tear was diagnosed by ultrasonography, which showed a cystic mass with increased peripheral vascularity, and was confirmed by magnetic resonance imaging. After conservative treatment, follow-up ultrasonography showed resolution of the hematoma. The patient was able to continue swimming without pain or limitation of function.

Extensor tendon rupture in rheumatoid arthritis: a survey of patients between 2005 and 2010 at five Korean hospitals

BACKGROUND

Recent medical advancements in the treatment of rheumatoid arthritis (RA) can prevent joint damage and tendon involvement. The authors evaluated patterns of extensor tendon ruptures in RA patients that presented to hand surgeons over a recent five-year period.

METHODS

Medical records and radiographs were retrospectively reviewed, and telephone interviews were conducted with 38 patients that had experienced extensor tendon ruptures in a rheumatoid hand during the study period and were operated on at one of five tertiary referral hospitals in South Korea. Patterns of tendon ruptures were compared in patients that did or did not receive medical treatment.

RESULTS

Twenty-nine of the 38 patients (76%) had tendon ruptures in more than two digits. When multiple digits were involved, mean duration between first and latest rupture was 2.9 months. When patients treated with medications by rheumatologists (24 patients) were compared with those not treated (14 patients), no significant differences were found for; number of ruptured tendons, time from first to last rupture, disease duration, or radiographic RA severity.

CONCLUSIONS

RA patients who once experienced a tendon rupture are still at risk of sequential tendon ruptures despite recent advancement of medical treatment. Education of the risks of sequential tendon ruptures and timely consultation to hand surgeons continue to be necessary in RA patients.

Volar dislocation of the extensor carpi ulnaris tendon on magnetic resonance imaging is associated with extensor digitorum communis tendon rupture in rheumatoid wrists

PURPOSE

Extensor tendon rupture in rheumatoid wrists is a common problem and causes immediate dysfunction of the digits. The best treatment for tendon rupture may be prophylactic management, although the factors associated with tendon rupture must first be identified. The purpose of this study was to evaluate structures around rheumatoid wrists using magnetic resonance imaging with forearm rotation and to identify factors associated with extensor tendon rupture as indications for prophylactic surgery.

METHODS

The subjects were 34 patients (40 wrists) with active rheumatoid arthritis. The extensor digitorum communis (EDC) tendons were ruptured in 15 wrists. Magnetic resonance imaging of the wrists was performed in maximally pronated and supinated positions of the forearm. Axial images of the distal radioulnar joints (DRUJs) were selected to evaluate DRUJ synovitis, dorsal tenosynovitis, volar dislocation of the extensor carpi ulnaris (ECU) tendon, sigmoid notch angle, and the radioulnar ratio (RUR) (ie, the degree of DRUJ subluxation).

RESULTS

No significant correlations were found between EDC tendon rupture and DRUJ synovitis, dorsal tenosynovitis, or RUR in pronation. Extensor digitorum communis tendon rupture correlated significantly with volar ECU tendon dislocation, sigmoid notch angle, and RUR in supination. Radioulnar ratio correlated significantly with volar ECU tendon dislocation only in supination and not in pronation. Thus, DRUJ subluxation was advanced even in the supinated wrist with volar ECU tendon dislocation. As a factor associated with EDC tendon rupture, volar ECU tendon dislocation had 87% sensitivity and 76% specificity.

CONCLUSIONS

Volar ECU tendon dislocation is associated with increased RUR in supination and EDC tendon rupture. Volar ECU tendon dislocation can thus be considered a factor associated with EDC tendon rupture, and its presence may indicate the need for prophylactic surgical intervention in a subset of rheumatoid arthritis patients.

The rheumatoid wrist

Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.

Tissue repair in rheumatoid arthritis: challenges and opportunities in the face of a systemic inflammatory disease

Rheumatoid arthritis (RA) is a systemic inflammatory disease that can elicit a variable disease course, can influence a variable number of joints, and can exhibit a variable response to treatment. All of these factors contribute to the degree and extent of damage to joint components, as well as the potential for repair of other injured joint tissues/components. Furthermore, some of the RA treatments/drugs themselves can influence repair and injury responses, as well as the outcome of surgical interventions for advanced disease. However, as treatments and interventions become more sophisticated and successful in patient populations, the opportunity to initiate the repair/replacement of the damaged joint tissues also becomes more of a reality. This review will address the current clinical findings in the literature, and then discuss the issues and opportunities to initiate repair of damaged or injured joint tissues in order to restore joint function. These include growth factors, gene therapy, and bioengineered tissues, alone or in combination to augment endogenous repair or replace tissue damaged beyond such repair capabilities.