Systemic condition affecting synovial tissue Hypertrohied synovium destroys. Synovectomy. Tenosynovectomy Tendon Surgery Arthroplasty Arthrodesis

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1 Surgical Options for Rheumatoid Arthritis of the Wrist Raj Bhatia Consultant Hand & Orthopaedic Surgeon Bristol Royal Infirmary & Avon Orthopaedic Centre Rheumatoid Arthritis Systemic condition affecting synovial tissue Hypertrohied synovium destroys Articular cartilage Invades subchondral bone Stretches soft tissues (ligaments) Invades flexor and extensor tendons Rheumatoid Arthritis Surgery Synovectomy Loss of balance of flex/ext forces across adjacent joints of the hand-wrist unit Deformity Tenosynovectomy Tendon Surgery Arthroplasty Arthrodesis Patient Deformity not itself an indication for surgery Individual treatment plan for each patient Patient Better results if reconstruction performed prior to development of: fixed contractures, subluxation or dislocation Patients expectations must match surgeons goals and anticipated results 1

2 Medical Considerations C-spine instability (fusion/decompression) TMJ involvement compromise intubation Pulmonary involvement Felty s syndrome (splenomegaly and neutropenia) Systemic corticosteroids affect wound healing Methotrexate can affect liver function (anaesthesia) Anti-TNFα Relieve pain Restore function Indications Alter progression of disease Improve appearance Souter Pre-op Planning Wrist fusion Darrachs Thumb MCPJ Fusion DIPJ Fusion MCPJ Arthroplasty Predictable Less Predictable Shoulder/Elbow reconstruction before hand reconstruction Painful hand/wrist prevents use of ambulatory aids. Perform hand reconstruction prior to lower limb surgery. Hand Feb;11(1):3-16 Common hand/wrist problems in RA Tenosynovitis Flexor/Extensor tendon rupture Rheumatoid wrist MCPJ Pain Dysfunction Tenosynovitis Tendon rupture (invasion of tendon by proliferating synovium) 2

3 Tenosynovitis Can precede symptoms of intra-articular disease Dorsal Wrist Palmar Wrist Flexor sheaths of digits Tenosynovitis-TreatmentTreatment Spontaneous remission Rest Steroid injection Drugs Surgical synovectomy (no improvement 4-6 months with medical therapy) Dorsal Synovectomy Dorsal Synovectomy Arthroscopic Synovectomy Flexor Synovectomy 3

4 Tendon Ruptures Direct invasion of tendon by synovium Ischaemic necrosis (pressure from proliferative synovium) Attrition Vaughan-Jackson Lister s tubercle Mannerfelt Lesion (FPL rupture) Treatment Direct repair? possible if acute Tendon transfers Joint fusions Flexor Tendon Ruptures Palmaris Longus graft FDS ring transfer to FPL Joint Fusion Extensor Tendon Ruptures Differential Diagnosis MCPJ dislocation (lack of passive MCPJ extension & palpable extensor tendons) Subluxation of extensor tendons (maintains MCPJ extension actively after passive extension) PIN palsy (unable actively extend fingers, radial deviation on wrist extension due to paralysis of ECU) Extensor Rupture 4

5 Extensor Rupture Rheumatoid Wrist Keystone of the hand Painful, unstable deformed wrist impairs hand function Wrist deformity Finger deformity Rheumatoid Wrist Ulnar styloid, ulnar head, mid-scaphoid affected early by RA Caput Ulna Syndrome Destruction of ligs, TFCC Dorsal dislocation of ulna Supination of the carpus Palmar subluxation of ECU (acts as flexor) Weakness, pain and disability 1/3 of RA patients undergoing hand surgery Precursor to Vaughan-Jackson syndrome Rheumatoid Wrist Radio-carpal involvement Begins beneath RSC ligament ( sling ) RSC destruction causes rotatory instability of scaphoid Scaphoid flexes Loss of carpal height and radial deviation of carpus and MC Common pattern of wrist collapse Extensor tendon imbalance, radial shift of MC and ulnar deviation of the fingers Radioscaphocapitate (RSC) ligament sling ligament lax in radial deviation (scaphoid flexes) taut in ulnar deviation (scaphoid supported) 5

6 End-stage Rheumatoid Wrist Palmar dislocation Complete destruction of carpal bones Complete dissociation of DRUJ Rheumatoid Wrist Wrist Fusion + Darrachs Wrist Arthroplasty Wrist Arthroplasty MCPJ Key joint for function of the finger Condylar, allow motion in 2 planes Less stability than IPJ More vulnerable to deforming forces in rheumatoid 6

7 MCPJ Rheumatoid synovitis begins in the recess between the MC head and collateral ligament Fraying and destruction of collateral ligaments Decreased MCPJ stability Palmar subluxation/dislocation & ulnar deviation Synovectomy MCPJ Preventative Soft tissue Reconstruction (Extensor tendon re-alignment) MCPJ MCPJ Arthroplasty Indications difficult to define? Affect natural history of disease? Arrest local disease or slow progression Recurrence Swanson (1960 s) Flexible silicone hinge implant Functions as internal splint Stimulates capsular response encapsulation Combination of implant and tendon balancing provides joint stability, alignment and allows motion 7

8 MCPJ Arthroplasty Outcomes Active ROM b/w Improvement in hand function tests Improvement in pain relief Improvement in appearance Baltimore quantitative test of upper extremity function Significant improvement within 6 weeks Maintained for upto 4 years Common for patients to request MCPJ arthroplasties for other hand Questions 8