SURGERY OF THE RHEUMATOID WRIST AND HAND

Abstract

We distinguish three phases of rheumatoid arthritis:

1. the phase of hypertrophic synovitis;

2. the phase of joint disorganization;

3. the phase of joint destruction.

During the synovitis phase, expansion of the synovial membrane leads to changes in the neighboring tissues with distension of the joint capsule and ligaments and destruction of the cartilage tissue. Tumefaction and increased volume of the tenosynovial membrane interferes with tendon gliding, giving rise to limited motion and pain. As the phase advances, tendon tears may appear because of invasiveness of the tenosynovial tissue. Surgical treatment during the synovitis phase can include synovectomy or tenosynovectomy.

During the phase of joint disorganization, capsule and ligament distension induce the deviations and instabilities characteristic of rheumatoid arthritis. The basic objective of surgery is to realign the joints and restore the anatomic relations.

Cartilage is lost during the phase of joint destruction and surgical reconstruction is the only option (arthroplasty, arthrodesis) but with inevitable loss of function.

Wrist lesions should be treated before more distal joints. The principle of repairing the most proximal joint first applies for the entire upper limb.

For the dorsal aspect of the fingers, injury to the extensor system gives rise to three characteristic deformities: mallet finger, swan-neck finger, and button hole finger. A detailed knowledge of the extensor system is needed to better understand the origin of these deformations. Briefly, the extensor system is composed of three tendon elements: the lateral bands, the median bands and the common tendon, and two retinacular elements: Landsmeer’s oblique retinacular ligament and Cleland’s transverse retinacular ligament.

The objectives of surgery are:

1. achieve pain relief;

2. improve function (motion, stability);

3. prevent disease progression; and

4. improve the aesthetic aspect.