Rheumatoid Arthritis of the Wrist, An Issue of Atlas of the Hand Clinics (The Clinics: Orthopedics)

127 Pages·2005·5.81 MB·English

by  Barry Katzman MD

Atlas of the Hand Clinics
Copyright © 2006 Saunders, An Imprint of Elsevier

Volume 10, Issue 2 (September 2005)
Issue Contents: (Pages ix-325)

ix-ix
1 Rheumatoid Arthritis of the Wrist
Osterman AL
xi-xii
2 Rheumatoid Arthritis of the Wrist
Katzman B
199-207
3 Synovectomy of the Wrist and Tenosynovectomy of the Extensor Tendons
Shaikh-Naidu N
209-222
Reconstruction of Extensor Tendons
4
Williams DP
223-229
5 Carpal Tunnel Syndrome in Rheumatoid or Inflammatory Arthritic Patients
Terrono AL
231-250
6 Flexor Tendons and the Mannerfelt Rupture
Tang P
251-255
7 Arthroscopic Synovectomy in Rheumatoid Arthritis
Weiss L
257-262
Extensor Carpi Radialis Longus to Extensor Carpi Ulnaris Tendon Transfer
8
for Rheumatoid Arthritis of the Wrist
Lutsky K
263-270
9 Total Wrist Arthroplasty
Adams BD
271-279
Complications of Wrist Arthroplasty
10
Adams BD
281-288
Radiolunate and Radioscapholunate Fusion for Rheumatoid Arthritis of the
11 Wrist
Quinn M
289-305
Rheumatoid Wrist Arthrodesis Using Plate Fixation
12
Graham TJ
307-317
Wrist Arthrodesis with Steinman Pins
13
McEwen LK
319-325
Distal Radioulnar Joint Reconstruction: Hemiresection-Interposition
14
Technique and Sauvé-Kapandji
Zelouf DS
AtlasHandClin10(2005)ix
Foreword
Rheumatoid Arthritis of the Wrist
A.LeeOsterman,MD
ConsultingEditor
The prevalence of rheumatoid arthritis is 860 per 100,000. More than 60% of patients have
initial symptoms and inflammation in their hands and wrists. The ravages of the disease create
classic deformities and are often a major source of patient disability. Twenty-two percent of
employedpatientsmaybecomeworkdisabledwithinfiveyearsofonset.Fortunately,thenewer
medications, such as infliximab, etanercept, and methotrexate, have had a major impact on
controlling the disease. Given such medical treatments, hand surgeons are seeing fewer severe
deformities and more effective surgical treatments.
Drs. Feldon and Katzman have organized a monograph that carries on the tradition of the
giants of rheumatoid hand surgery: Drs. Flatt, Nalebuff, and Millender. They are worthy
successors. They and their coauthors have updated and refined common procedures as well as
madenewtechniques,suchasarthroscopicsynovectomyandwristreplacement,intostandards
ofcare.Everychapterisfullofpracticalpointers.Kudostotheauthorsfortheirsharedwisdom.
Kudos to the editors for their shared vision.
A. Lee Osterman, MD
The Philadelphia Hand Center
834 Chestnut Street
Philadelphia, PA 19107, USA
Thomas Jefferson University Hospital
111 South 11th Street
Philadelphia, PA 19107, USA
E-mail address: [email protected]
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AtlasHandClin10(2005)xi–xii
Preface
Rheumatoid Arthritis of the Wrist
BarryKatzman,MD PaulFeldon,MD
GuestEditors
Treating the rheumatoid wrist has been a formidable challenge for the hand surgeon for
many years. Although considerable progress as been made in the techniques of rheumatoid
reconstruction,thetreatmentofhandsaffectedbyrheumatoidarthritisanditsvariantsremains
a challenge to the upper extremity surgeon. Factors such as the variable expression of the
disease in each individual, the ongoing process of joint and tendon destruction, which can
persistforyears,andtheunpredictablerecurrenceofdiseaseanddeformitythatcannullifythe
effects of previous surgery contribute to the complexity and frustration of caring for patients
with these diseases. Because the surgeon rarely is confronted with an isolated deformity, the
entireupperextremitymustbeviewedasafunctionalunit.Eachhandmustbeconsideredinits
relationshiptotheother,andbothupperextremitiesmustbeconsideredintheirrelationshipto
the lower extremities when planning reconstructive surgery.
Incompilingthisissue,wehaveaskedphysicianswhohaveexperiencewithvariousaspectsof
rheumatoid arthritis in the wrist to contribute their expertise. Although each article stands
alone, using the various sections in concert will maximize the reader’s benefit.
Wehavetriedtoprovideacomprehensiveseriesofarticlescoveringthemajoraspectsofthe
rheumatoid wrist. This includes time-honored procedures such as tenosynovectomy, tendon
transfers, and wrist fusion as well as newer treatments such as arthroscopic synovectomy and
wrist arthroplasty. The articles in this issue cover the spectrum of rheumatoid wrist recon-
structive surgery including tendon, nerve, and joint problems.
It is the hope of the editors that as technology and the medical management of rheumatoid
arthritisimprovethatourcombinedeffortswillresultinlong-lastingpatientsatisfactioninthis
challenging patient population. We look forward to the day of gene modification treatment
retarding this progressive disease as an enhancement to our surgical procedures.
IthasbeenaprivilegetoserveastheguesteditorsforthisissueoftheAtlasofHandClinics.
Weareindebtedtoeachoftheauthorswhocontributedsomuchoftheirtimeandenergytothis
project as well as Dr. Ostermann for his guidance and allowing us the opportunity to work on
this issue.
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doi:10.1016/j.ahc.2005.06.006 handatlas.theclinics.com
xii PREFACE
We will consider this issue successful if it serves as a guide in the care of patients with
rheumatoid arthritis and its variants and stimulates continued work to improve our
understanding of these diseases and to develop better treatment methods.
Barry Katzman, MD
Katzman Orthopedics
1575 Hillside Avenue
New Hyde Park, NY 11040, USA
E-mail address: [email protected]
Paul Feldon, MD
Hand Center
125 Parker Hill Avenue
Converse 7
Boston, MA 02120, USA
E-mail address: [email protected]
AtlasHandClin10(2005)199–207
Synovectomy of the Wrist and Tenosynovectomy
of the Extensor Tendons
Nina Shaikh-Naidu, MDa, David J. Bozentka, MDa,*,
Barry Katzman, MDb, Pedro Beredjiklian, MDa
aDivisionofHandSurgery,DepartmentofOrthopaedicSurgery,HospitaloftheUniversityofPennsylvania,
OneCupp,PresbyterianMedicalCenter,38thandMarketStreetsPhiladelphia,PA19104,USA
bKatzmanOrthopedics,1575HillsideAvenue,NewHydePark,NY11040,USA
Rheumatoid arthritis is fundamentally a disease of the synovium. Synovial proliferation
within the tendon sheath is extremely common and may occur before other symptoms of the
disease are noted. The incidence of tenosynovitis in patients with chronic rheumatoid arthritis
hasbeenreportedtobeashighas64%[1].Initially,thesynovialsheath,retinaculum,andskin
maybecomedistendedfromfluid.Subsequently,thesynoviumthickensandformsadhesionsto
the extensor tendons. The synovium may continue to proliferate and infiltrate the tendon,
weakeningitandpotentiallyleadingtorupture.Furtherchangeswillleadtofirmtissueunlikely
to respond to medication [2]. Persistent tenosynovitis for more than 6 months has been
associated with a significantly higher rate of tendon rupture [3].
Synovial proliferation of the wrist joint can also have severe consequences. Shapiro [4] has
cited three factors in the development of the rheumatoid wrist: cartilage degradation, synovial
expansionwitherosion,andligamentouslaxity.Thinningofthecartilageissecondarytointra-
articular lysosomal enzymes and free-oxygen radicals [5]. Synovial expansion may cause bony
erosion,whichin turnmayresultinbony spiculesthat attenuatetendons.Finally, ligamentous
laxity is secondary to the stretching effect of both cartilage loss and synovitis.
Wrist synovitis begins ulnarly with involvement of the distal radio-ulnar joint and extensor
carpi ulnaris tendon. Expansion of the synovium erodes the ligamentous support of the distal
ulna including the triangular fibro-cartilage complex. The distal ulna gradually subluxates
dorsallytoformaprominencebeneaththeextensortendons.Thediseaseprogressestotheother
extensor tendon sheaths and the midcarpal joint with both the interosseous ligaments and
articularcartilageaffected.Carpalcollapseoccursasthedistalrowsubluxatesvolarwardonthe
proximalrow,followedbyvolarsubluxationandsupinationoftheproximalrowontheradius
[6].
Presentation
Onthedorsalaspectofthehandandwrist,thetendonswithinthesixextensorcompartments
are surrounded by synovium, which begins proximal to the extensor retinaculum sheath and
extends tothemetacarpalbases.Dorsaltenosynovitis presentswithmildor significant swelling
onthedorsalwrist,withinvolvementofoneoralltendons,andmaybethefirstmanifestationof
disease. A soft, painless, nonfluctuant mass may be present distal to the extensor retinaculum
[7]. Once the mass abuts the retinaculum, it may produce pain, which is exacerbated by
* Correspondingauthor.
E-mailaddress:[email protected](D.J.Bozentka).
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200 SHAIKH-NAIDUetal
simultaneous wrist and digital extension (Fig. 1). Isolated tenosynovitis, however, can remain
painless and present instead when the tendon ruptures (Fig. 2).
Patients with synovitis of the wrist joint most commonly present with pain and weakness,
which affects hand function. Physical examination is less remarkable for bulging, but rather
warmth, dorsal fullness, and painful limited range of motion. Patients will have tenderness to
palpation over the radiocarpal joint and with stress of the wrist.
Indications
The initial treatment of dorsal tenosynovitis is immobilization and corticosteroid injection.
Tenosynovectomy is indicated for persistent synovitis after 4 to 6 months of medical therapy,
tendon rupture, a rapid increase in the area of synovitis, or recurrent tenosynovitis [7]. One
study in which tenosynovectomy was performed before tendon rupture reported a 50% rate of
tendoninvasion[8].Additionalriskfactorsfortendonruptureincludedorsaldislocationofthe
distal end of the ulna, persistent synovial swelling, and the ‘‘scallop sign’’ (erosive changes in
radioulnar joint) on radiologic examination [3].
The indications for synovectomy of the wrist, as opposed to that of the extensor tendons,
have not been clearly established in the literature. Dorsal wrist synovectomy, combined with
extensortenosynovectomy,distalulnaexcision,andplacementoftheextensorretinaculumdeep
to the extensor tendons, is considered to be effective treatment for both pain relief and
preventionoftendonrupture[6,7,9,10].MillenderandNalebuff[7]suggestthatsynovectomyis
mosteffectiveinpatientswithchronicbutlow-leveldiseasethatdoesnotcompletelyrespondto
medication but also does not rapidly progress to joint destruction. However, chronic synovial
irritation can destroy the cartilage and attenuate the wrist capsule, leading to further joint
destructionsecondarytoinstability.Therefore,theindicationsfordorsalwristsynovectomyare
persistent wrist synovitis and pain without response to steroid injections, splinting, and
medication for 6 to 8 months. Radiographs should rule out significant joint involvement,
which would prompt early wrist fusion rather than synovectomy.
Operative treatment
Dorsal tenosynovectomy
The procedure is performed under general or regional block anesthesia with the patient
supine.Aneschmarchisusedforexsanguinationsofthelimbandanarmtourniquetiselevated
to 250 mm Hg. A longitudinal incision is made over the dorsal wrist, and the dorsal sensory
branchesoftheradialandulnarnervesandthevenousnetworkshouldbeelevatedwiththeskin
flaps.Theincisionisextendedthroughthedeepfasciatotheextensorretinaculum andtheskin
Fig. 1. Clinical photo of extensor tenosynovitis distal to the extensor retinaculum more prominent with digital
extension.
SYNOVECTOMYOFTHEWRIST 201
Fig.2. Clinicalphotooftenosynovitislocalizedtotheradialwristwithanextensorpollicuslongustendonrupture.
flapsareelevatedatthislevel.Eachextensorcompartmentisopenedandthetendonisexamined
(Fig. 3). The first dorsal compartment is generally spared from dissection unless it is involved
with disease, as this creates larger flaps and increases the risk of skin necrosis. The terminal
branch of the posterior interosseous nerve, which lies in the deep radial surface of the fourth
extensorcompartment,isresectedintheproximalaspectofthewound.Hypertrophicsynovium
is removed from each tendon with a rongeur or fine scissor (Fig. 4). The tendons should be
examined for any evidence of infiltration, fraying, attenuation, or rupture and should be
repaired if necessary (Fig. 5). After tenosynovectomy, the wrist joint is examined for synovitis,
andthedistalradiusandulnaareexaminedforbonyspicules,whichmightcauseattritionofthe
tendons.Distalulnaresectionisrequiredifthereisevidenceofsubluxation,tendonruptureover
abonyprominence,orpainsecondarytotheradioulnararticulation(Fig.6)[7].Stabilizationof
the remaining ulna should be performed using local soft tissues, retinaculum, or tendon [2].
Before closure, the extensor carpi ulnaris tendon is placed more dorsally with a strip of
retinaculum to act as a sling.
The tourniquet is released, and hemostasis is obtained before closure of the dorsal
retinaculum. A penrose drain is considered to prevent a hematoma. The distal half of the
dorsal retinaculum is often passed deep to the extensor tendons before repair to provide a
smooth gliding surface for the tendons. A portion of the retinaculum however should be
Fig.3. Diagramshowingelevationoftheextensorretinaculum.(FromMurrayPM,BergerRA.Synovitisofthewrist.
In:CooneyWP,LinscheidRL,DobynsJH,editors.Thewristdiagnosisandoperativetreatment.Philadelphia:Mosby;
1998.p.1144;withpermission.)
202 SHAIKH-NAIDUetal
Fig.4. Intraoperativephotographoftenosynovitistoextensordigitorumcommuniswithtendoninvasion.
retained over the extensor tendons to prevent bowstringing. The skin is closed with an
interrupted or running subcuticular suture. A volar wrist splint is placed with the wrist in
neutral and the metacarpophlangeal joints in extension to prevent extensor lag, with the inter-
phalangeal joints left free.
Dorsal wrist synovectomy
Mannerfelt [11] stresses that dorsal tenosynovitis is often combined with radiocarpal,
intercarpal and radio-ulnar synovitis and therefore that a dorsal wrist synovectomy should
include notonlytenosynovectomybutalsoanarticularsynovectomyandulnar headresection.
Forthisprocedure,alongitudinalincisionismadeovertheulnarheadthroughthefloorofthe
fifth compartment and care is taken to preserve the dorsal radio-ulnar ligament. If the ulnar
head is arthritic, it is excised. A complete synovectomy of the distal radio-ulnar joint is then
possible. If the cartilage of the ulnar head has been destroyed, this is removed. A transverse
radiocarpalarthrotomyisthenperformedinwhichthejointcapsuleisraisedasadistallybased
flap along the dorsal radiocarpal and dorsal intercarpal ligaments (Fig. 7). The wrist may be
flexed to expose the joint space and allow a radiocarpal synovectomy. The area between the
radialstyloid,radialcollateralligament,andscaphoidiscleanedofallsynovitictissue,andany
bony erosion is noted (Fig. 8). Distraction of the hand allows visualization of the intercarpal
space for synovectomy of the midcarpal and scaphotrapezial joints. In cases in which joint
destruction is apparent on entering the radiocarpal joint, it is generally recommended that
synovectomy not be performed. If there is carpal shift or collapse, or bony destruction,
synovectomy should be abandoned and wrist fusion performed instead.
Thedistalradio-ulnarjointcapsuleisthenreconstructedwithboththeremainingcapsuleand
part ofthe extensorretinaculum that isplaced beneaththe extensortendons.The tourniquet is
Fig.5. Intraoperativephotographofextensortenosynovitis.Thescissorsliebelowtheextensordigitorumcommunis
tendons and the forceps are holding the proximal and distal ends of an extensor pollicis longus rupture. The
tenosynovitisisdebridedwitharongeurorcurvedscissors.