Operative Technique in Plastic Surgery – Kevin C.Chung

• 1 large joint
0
• 2–10 large joints
1
• 1–3 small joints (with or without large joint involvement)
2
• 4–10 small joints (with or without large joint involvement)
3
• Greater than 10 joints
5
Note: “Large” joints refer to shoulders, elbows, hips, knees, and ankles;
“small” joints refer to MCPJ, PIPJ, 2nd–5th MTPJ, thumb IPJ, and
wrists.

B. Serology (at least 1 test result is needed for classification)

• Negative RF and negative ACPA
0
• Low-positive RF or high-positive ACPA
2
• High-positive RF or high-positive ACPA
3
C. Acute-phase reactants (at least 1 result is needed for classification)

• Normal CRP and normal ESR
0
• Abnormal CRP or abnormal ESR
1
D. Duration of symptoms

• <6 weeks
0
• ≥6 weeks
1
CMCJ, carpometacarpal joint; DIPJ, distal interphalangeal joint; IPJ,
interphalangeal joint; MCPJ, metacarpophalangeal joint; MTPJ,
metatarsophalangeal joint; RF, rheumatoid factor; ACPA, anti–
citrullinated protein antibody; CRP, C-reactive protein; ESR,
erythrocyte sedimentation rate.
From Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis
classification criteria: an American College of Rheumatology/European
League Against Rheumatism collaborative initiative. Arthritis Rheum.
2010;62(9):2569-2581.
■ Polymyalgia rheumatic
■ Crystalline arthritis (eg, gout, pseudogout)
■ Infectious arthritis

■ Osteoarthritis
■ Paraneoplastic disease
■ Multicentric reticulohistiocytosis
■ Sarcoid arthropathy
■ Fibroblastic rheumatism
IMAGING
■ When evaluating the upper extremities, PA, oblique, and lateral radiographs of
the hands should be obtained to assess the condition of the proximal
interphalangeal joints (PIPJ) and metacarpophalangeal joints (MCPJ).
■ Radiographs of the wrist will further serve to evaluate the distal radioulnar
joint (DRUJ), midcarpal joint, and radiocarpal joint.
■ Characteristic findings of RA include periarticular osteopenia, joint space loss,
and marginal joint erosions (FIG 1). Often, these changes are not seen in early
disease.
■ MRI can be useful in detecting RA before radiographic changes can be
detected. MRI can also identify bone marrow edema and synovial hypertrophy,
which predict the development of erosive disease.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients typically present between the third and sixth decades of life.
Symptoms begin insidiously and grow over weeks to months. Patients
complain of fatigue, malaise, generalized stiffness, and generalized arthralgias
or myalgias.
■ In a small subset (10%–15%) of patients, the onset of RA is sudden, with
fever, polyarthritis, lymphadenopathy, and splenomegaly developing over
days to weeks.
■ Inflammation of the synovial tissues (synovitis) develops gradually and often
symmetrically in the hands, wrists, knees, and feet. Synovial hypertrophy
(pannus) ultimately results in the destruction of ligaments, tendons, cartilage,
and bone. Examination of affected joints reveals swelling, tenderness, warmth,
and painful motion.
■ In the upper extremity, RA tends to affect the MCPJ, PIPJ, and wrists earlier
and more frequently than it does other joints in the body. This is in part due to
their high synovium-to-joint surface area ratio.
■ The distal interphalangeal joints (DIPJ) are typically spared from RA.

FIG 1 • Radiographs of rheumatoid hand and wrist
showing periarticular osteopenia, joint space loss, and
marginal joint erosions. A. AP view. B. Oblique view. C.
Lateral view.
FIG 2 • Rheumatoid nodule on elbow.
■ Patients may also present with rheumatoid nodules, vasculitis, pericarditis,
pleural effusion, interstitial pulmonary disease, peripheral neuropathy, and

keratoconjunctivitis sicca.
■ Rheumatoid nodules tend to develop on extensor surfaces or areas of contact
pressure, such as the olecranon process at the elbow (FIG 2).
■ RA also affects the synovial lining of tendons, which can result in carpal
tunnel syndrome, tendon rupture, tendonitis, and trigger digits.
Key Findings
■ Wrist (carpus)
■ Midcarpal extension
■ Ulnar translocation of the carpus
■ DRUJ instability
■ Caput ulna (ulnar head dorsal dislocation, ECU subluxation, carpal
supination)
■ Extensor tendon rupture, Vaughn-Jackson syndrome
■ Flexor pollicis longus (FPL) rupture (Mannerfelt lesion)
■ Carpal tunnel syndrome
■ Hand
■ MCPJ and PIPJ arthritic changes
■ MCPJ volar subluxation and ulnar deviation
■ Sparing of the DIPJ
■ Swan-neck deformity
■ Boutonniere deformity
Wrist Joint
■ Arthritic radiographic changes are initially noted at the scaphoid waist, the
ulnar styloid, and the DRUJ and progress into the radiocarpal and midcarpal
joints.
■ In later stages, severe erosion of the volar lip of the distal radius leads to
lunate malposition (proximal migration, volar translation, volar angulation)
and compensatory midcarpal extension.
■ Three patterns of end-stage carpal arthritis can be encountered, depending on
the degree of bony destruction and ligamentous instability.
■ First, wrist ankylosis (bony joint fusion) can occur, sometimes in acceptable
alignment.
■ Second, the wrist can be arthritic but stable over time with limited
ligamentous destruction.
■ Third, the wrist is unstable, characterized by progressive misalignment,

whether ligamentous or bony in etiology.
Carpal Ligaments
■ Normal carpal ligament anatomy is shown in FIG 3A,B.
■ In RA, synovitis attenuates the radioscaphocapitate (RCC) ligament and the
scapholunate (SL) ligament, causing ulnar translocation of the carpus.
■ At the DRUJ, the triangular fibrocartilage complex (TFCC), including the
dorsal and palmar radioulnar ligaments, is also destroyed by synovitis, leading
to DRUJ instability and eventual dorsal dislocation of the ulnar head. The
extensor carpi ulnaris (ECU) sheath is also destroyed, resulting in volar ECU
subluxation and contributing to the supinated and radially deviated posture of
the wrist (FIG 3C).
■ The term caput ulna refers to the combination of dorsal ulnar head dislocation,
volar ECU subluxation, and carpal supination (FIG 3D,E).
Tendons at the Wrist
■ Synovitis develops within the extensor tendon compartments on the dorsal
aspect of the wrist (FIG 4).

FIG 3 • Palmer (A) and dorsal (B) views of normal
anatomy of carpal ligaments and TFCC. C. Wrist
changes in RA. D,E. Caput ulna of the right hand.
■ Pannus can be seen bulging proximally and distally from underneath the
extensor retinaculum, taking on an hourglass appearance.
■ Tendon rupture in RA results from direct pannus invasion and/or attritional
wear over eroded bony edges.
■ In regions where the tendon is covered by tenosynovium (eg, extensor
retinaculum, carpal tunnel, and digital flexor sheaths), tendons may be
directly invaded by synovial pannus.
■ In regions where tendon is closely related to joints (eg, the DRUJ, radiocarpal
joint, and PIP joints), underlying proliferative synovitis may cause pressure
ischemia leading to tendon rupture.

■ Attritional rupture frequently involves the extensor digiti minimi (EDM) at
the ulnar head, the extensor pollicis longus (EPL) at the Lister tubercle, and
the FPL in the carpal tunnel, which is caused by a flexed, eroded scaphoid.
An attritional FPL rupture is termed a Mannerfelt lesion.
FIG 4 • Extensor tendons of the hand and wrist.
Table 3 Examining the Tendons of the Hand
Tendon
Examination Maneuver
Interpretation and Pearls
Extensor
pollicis longus
(EPL)
• With the patient’s palm flat on
a table, ask the patient to lift
the thumb off the table.
If able to lift the thumb off the
table (retropulsion), EPL is
intact.
Extensor
indicis
proprius (EIP)
• Test independent extension
of the index finger with the
remaining fingers held in
flexion.
It is important to test the
integrity of EIP, as it is a
common donor in tendon
transfer procedures.
Extensor
digitorum
communis
• With the finger passively
placed in extension, ask the
patient to maintain the finger
• One must differentiate
extensor tendon rupture from
(1) ulnar subluxation of the

(EDC)
in extension. If unable to
maintain finger extension,
there is either a tendon
rupture or nerve palsy.
• Next, test the tendodesis
effect by passively flexing the
patient’s wrist and looking for
concomitant finger extension.
If the finger does not extend,
tendon rupture is the
diagnosis, as the tenodesis
effect is preserved in nerve
palsy.
extensor tendon over the
head of the metacarpal and
(2) posterior interosseous
nerve (PIN) palsy secondary
to elbow synovitis.
• Patients with rupture of the
EDC to one finger may still
be able to extend that finger
due to the juncturae
connecting it to the adjacent
fingers.
• Usually, the finger cannot be
extended if more than one
EDC is ruptured.
Extensor digiti
minimi (EDM)
Test independent extension of
the small finger with the other
fingers flexed.
• Patients may still be able to
extend the small finger while
extending the remaining
fingers through an intact
EDC or the juncturae
connecting it to the ring
finger.
Flexor pollicis
longus (FPL)
Holding the thumb MCPJ in
extension, ask the patient to
flex the thumb IP joint.
• Intact thumb IP flexion
indicates an intact FPL
tendon.
Flexor
digitorum
superficialis
(FDS)
FDS is checked for each
finger by holding the patient’s
other fingers in extension and
allowing the patient to actively
flex the finger in question.
• If FDS is intact, the finger will
bend at the PIPJ.
• It is important to test the
integrity of FDS to the ring
and long fingers, as they are
commonly used in tendon
transfer procedures.
Flexor
digitorum
profundus
(FDP)
FDP is checked for each
finger by holding the PIPJ
straight and asking the patient
to flex the DIPJ.
• If FDP is intact, the finger will
bend at the DIPJ.
■ The most frequently ruptured tendons are the EDM, followed by the extensor
digitorum communis (EDC) tendons of the small, ring, long, and index fingers;
the EPL; the FPL; and, least commonly, the flexor digitorum superficialis

(FDS) and profundus (FDP) tendons.
■ Extensor tendon ruptures often progress from ulnar to radial, eventually
affecting all digits, referred to as Vaughn-Jackson syndrome. Tendon ruptures
occur suddenly, may not be painful, and must be differentiated from volar
subluxation of the MCPJ, radial nerve palsy, and extensor tendon subluxation
at the MCPJ. Flexor tendon ruptures occur less often.
■ A thorough tendon examination (Table 3) is warranted to determine
reconstructive options after tendon rupture (Table 4).
Table 4 Tendon Transfer Options for Rheumatoid Attritional Ruptures
Physical Findings
Ruptured
Tendon(s)
Reconstructive Options
Lack of small finger extension
• EDM at ulnar
head
• End-to-side repair of EDM to
ring finger EDC
Lack of small and ring finger
extension
• EDM at ulnar
head
• EDC to small
finger
• EDC to ring
finger
• EIP transfer to EDM and ring
finger EDC
Lack of small, ring, and long
finger extension
• EDM at ulnar
head
• EDC to small
finger
• EDC to ring
finger
• EDC to long
finger
• EIP transfer to EDM and ring
finger EDC
• End-to-side repair of long
finger EDC to index finger
EDC
Lack of small, ring, long, and
index finger extension
• EDM at ulnar
head
• EDC to small
finger
• EDC to ring
finger
• EDC to long
finger
• EDC to index
• Long finger FDS to index and
long finger EDC
• Ring finger FDS to ring finger
EDC and small finger
EDC/EDM (whichever
tendon is more robust)

finger
• EIP
Lack of thumb extension
(retropulsion)
• EPL at Lister
tubercle
• Preferred: EIP transfer to
EPL
• Alternatives:
○ ECRL to EPL
○ EDM to EPL
Lack of thumb, index, long,
ring, and small finger
extension
• EDM at ulnar
head
• EDC to small
finger
• EDC to ring
finger
• EDC to long
finger
• EDC to index
finger
• EIP
• EPL at Lister
tubercle
• Long finger FDS transfer to
EPL and index finger EDC
• Ring finger FDS transfer to
long and ring finger EDC and
small finger EDC/EDM
(whichever tendon is more
robust)
Lack of thumb IPJ flexion
• FPL in carpal
tunnel
• Preferred: BR transfer to FPL
• Alternatives:
○ ECRL transfer to FPL
○ Long finger FDS transfer to
FPL
○ Thumb IPJ fusion
Lack of independent PIPJ
flexion (of any finger)
• FDS (any
finger)
• PIPJ synovectomy (to
prevent FDP rupture)
Lack of DIPJ flexion (of any
finger)
• FDP (any
finger)
• Preferred: DIPJ arthrodesis
• Alternative: DIPJ tenodesis
Inability to flex PIPJ and DIPJ
(of any finger)
• FDS and
FDP (any
finger)
• Staged flexor tendon
reconstruction
BR, brachioradialis; DIPJ, distal interphalangeal joint; ECRL, extensor
carpi radialis longus; EDC, extensor digitorum communis; EDM,
extensor digiti minimi; EIP, extensor indicis proprius; EPL, extensor

pollicis longus; FDP, flexor digitorum profundus; FDS, flexor digitorum
superficialis; FPL, flexor pollicis longus; IPJ, interphalangeal joint;
PIPJ, proximal interphalangeal joint.
Carpal Tunnel Syndrome
■ Within the carpal tunnel, synovial pannus and tenosynovitis can proliferate to
the point of median nerve compression, causing carpal tunnel syndrome.
■ Synovitis between the scaphoid and lunate can cause SL ligament rupture and
scaphoid collapse with its distal pole protruding into the carpal tunnel.
Joints of the Hand
■ In RA patients, the MCPJs and PIPJs are primarily affected, with relative
sparing of the DIPJs. Radiographs reveal joint space narrowing from cartilage
degradation and marginal bony erosions from pannus invasion. Joint capsules
and collateral ligaments are stretched and invaded by pannus as well, leading to
joint instability and deformity.
■ The radial and ulnar sagittal bands stabilize the extensor tendon over the dorsal
midline of the MCP joint (FIG 5A,B). When the radial sagittal band is
attenuated, the extensor tendon subluxes ulnarly, leading to ulnar deviation of
the finger (FIG 5C). The MCPJs in RA patients are typically characterized by
volar subluxation and ulnar deviation (FIG 5D,E). The MCPJ is a condylar
joint, allowing for flexion, extension, radial deviation, and ulnar deviation. The
extensor tendon is stabilized over the dorsal midline of the MCPJ by the radial
and ulnar sagittal bands. The sagittal bands are connected to the volar plate.
Because the lateral bands pass volar to the MCPJ and dorsal to the PIPJ,
intrinsic muscle contraction through the lateral bands results in MCPJ flexion
and PIPJ extension.

DIP PIP MCP A Terminal tendon Triangular ligament Transverse retinacular ligament Central slip Conjoint lateral band Medial band of intrinsic tendon • Lateral band of intrinsic tendon Central slip of long extensor tendon Lateral slip of long extensor tendon Common intrinsic tendon Arciform sheet Interosseous tendon Deep transverse metacarpal ligament Sagittal band Lumbrical tendon Long extensor tendon Extensor tendon Sagittal band MCP Central slip Lateral band DIP Lumbrical m. Interosseous mm. B Transverse retinacular ligament Oblique retinacular ligament

FIG 5 • A,B. AP and lateral views of normal anatomy of
extensor tendons of the finger. C. Anatomy of ulnar
deviation deformity. D,E. MCPJ volar subluxation with
ulnar deviation of the fingers.
■ In RA patients, ulnar deviation at the MCPJ is due to three things:
■ Erosion of the dorsoradial aspect of the joint capsule
■ The radially deviated wrist position causing an ulnar approach of the extensor
tendons
■ Attenuation of the radial sagittal bands leading to ulnar subluxation of the

extensor tendons
Swan-Neck Finger Deformity
■ The swan-neck finger deformity (FIG 6) is characterized by PIPJ
hyperextension with DIPJ flexion.
■ This deformity is functionally debilitating due to loss of PIPJ flexion, which
impedes pinching and grasping.
■ Swan-neck deformities can result from pathology at the MCPJ, PIPJ, or DIPJ
(Table 5).
FIG 6 • A,B. Swan-neck deformity.
Table 5 Three Mechanisms Resulting in the Swan-Neck Deformity
Originating Joint
Mechanism of Swan-Neck Deformity
DIPJ
• Initially, the terminal tendon attenuates or
erodes, resulting in a mallet finger.
• This leads to increased extension at the PIPJ
through the central slip, which is accentuated
by MCP flexion.
• Further attenuation of the PIP volar plate from
synovitis leads to PIPJ hyperextension.
PIPJ
• Initially, the synovial pannus stretches and
erodes the volar plate and capsule, allowing
for PIPJ hyperextension.
• The lateral bands slide dorsally, leading to
extra slack in the extensor mechanism.
• Slack in the extensor mechanism, combined
with tightening of the flexor digitorum

profundus (FDP) tendon, leads to DIPJ
flexion.
MCPJ
• The volarly subluxed MCPJ posture leads to
excessive pull through the extensor
mechanism.
• When the lateral bands migrate dorsally, the
resulting tendon imbalance leads to PIPJ
hyperextension and DIPJ flexion.
Boutonniere Finger Deformity
■ Boutonniere deformities are less common than swan-neck deformities. They
are also less debilitating given that PIPJ flexion, and thus, pinch and grasp are
preserved.
■ The pathology of boutonniere deformities always starts at the PIPJ, where
disruption of the central slip at the base of the middle phalanx occurs. The
dorsal capsule, transverse retinacular ligament, and triangular ligament also
attenuate. As such, the lateral bands sublux to a position volar to the axis of the
PIPJ, flexing the PIPJ.
■ Hyperextension at the DIPJ occurs because the lateral bands continue to pull
distally on the extensor mechanism at the terminal tendon (FIG 7).
FIG 7 • A,B. Boutonniere deformity.
Thumb Deformity (Types I to V)
■ The boutonniere deformity (type I) is the most common thumb deformity in
RA patients, characterized by MCPJ flexion, interphalangeal (IP)
hyperextension, and radial abduction of metacarpal (FIG 8).

■ Synovial pannus at the MCPJ erodes dorsally, causing eventual rupture of the
extensor pollicis brevis (EPB) tendon insertion and displacing the EPL ulnarly
and volarly. This leads to MCPJ flexion and volar subluxation. IP joint
hyperextension occurs secondarily and is exacerbated in patients with FPL
rupture.
■ A type II thumb deformity in RA is less common, characterized by thumb
MCPJ flexion and IP extension in the setting of carpometacarpal joint (CMCJ)
dislocation or subluxation.
■ The swan-neck deformity (type III) is the second most common deformity of
the thumb, with MCPJ hyperextension, IP flexion, and a metacarpal adduction
contracture (FIG 9).
■ The volar beak ligament attenuates at the CMCJ, leading to CMCJ
subluxation or dislocation and metacarpal adduction. MCPJ hyperextension
occurs secondarily as the thumb compensates for the adducted metacarpal and
is exacerbated by volar plate attenuation or erosion from pannus invasion.
■ The type IV thumb deformity is termed the gamekeeper deformity, which
develops secondary to synovial pannus destruction of the ulnar collateral
ligament at the MCPJ.
■ The type V thumb deformity is similar to the swan-neck deformity, with MCPJ
hyperextension and IP flexion, but without the metacarpal adduction
contracture.
Trigger Finger
■ Trigger fingers in RA patients have a mechanism that is distinct from
nonrheumatoid trigger fingers, occurring secondary to synovitis or small
rheumatoid nodules in the flexor tendon.
■ If the nodule is proximal to the A1 pulley, it can present similarly to a
nonrheumatoid trigger digit, with locking in flexion or extension. However, a
nodule just distal to the A2 pulley can result in locking in extension or
triggering during flexion. Also, multiple nodules or diffuse tenosynovitis can
lead to loss of flexion and extension altogether.

FIG 8 • A,B. Thumb boutonniere deformity.
■ Treatment for trigger fingers in patients with RA involves flexor tendon
synovectomy through windows in the flexor tendon sheath, along with excision
of the rheumatoid nodule, if present.
■ The A1 pulley should not be completely released, as doing so would redirect
the pull of the flexor tendon and contribute to ulnar deviation.
FIG 9 • A–C. Thumb swan-neck deformity.
NONOPERATIVE MANAGEMENT
■ The mainstay of RA treatment is medical, particularly with disease-modifying

antirheumatic drugs (DMARDs): glucocorticoids, methotrexate (MTX),
conventional DMARDs, and biologic DMARDs.7 These medications prevent
or reduce joint destruction, maintain or improve function, and can improve
other aspects of the patient’s general health. The goal of medical management
in RA is not only clinical remission but also to prevent joint destruction with
early medical intervention.6
■ Oral glucocorticoids suppress inflammation and preserve joint structure.
Glucocorticoids can also be injected into actively inflamed joints for pain
relief.
■ MTX, a folic acid antagonist, is often considered the first-line therapy for RA
treatment, as it has been shown to decrease radiographic progression of the
disease. MTX is potentially hepatotoxic, and the patient’s liver enzymes
should be checked at regular intervals. Since MTX is renally cleared, patients
with chronic renal insufficiency should not be treated with MTX.
■ Conventional DMARDS include hydroxychloroquine, sulfasalazine, and
leflunomide, which are mild anti-inflammatory agents. These can be used
single agents in mild RA or in combination with MTX or other agents.
■ Biologic DMARDs include anti-TNF agents, such as etanercept, infliximab,
and adalimumab. These are often used as second-line therapy for RA and can
be added to MTX or other ongoing therapies. Anti-TNF agents are highly
immunosuppressive and must be discontinued if an infection is encountered.
Other biologic agents include abatacept and rituximab, which are safe when
combined with MTX, and can be used if anti-TNF therapy has failed.
■ Nonsteroidal anti-inflammatory drugs (NSAIDs) and other analgesics can be
used in combination with DMARDs in the symptomatic treatment of pain in
RA patients, but they do not have any significant impact on disease progression
or function and should not be used as the primary or sole therapy in RA
patients.
■ Patients with RA should also be monitored for osteopenia and osteoporosis,
which are common comorbid conditions in RA and can be accelerated with
glucocorticoid therapy.
■ Patients should also participate in physical and occupational therapy to
maintain joint mobility and function, improve strength and endurance, and
enhance cardiovascular fitness.
■ Patients should be educated on the safe use of assistive devices, joint
protection, and rest.

SURGICAL MANAGEMENT
■ Although excellent clinical and radiographic results in patients with mild
deformities or tenosynovitis have been obtained since the introduction of
DMARDs, patients who develop severe joint deformities, tendon ruptures, and
recalcitrant tenosynovitis will require surgical intervention.
■ The management of rheumatoid hand problems requires an integrated
approach involving both the rheumatologist and the hand surgeon. Once
medical management is optimized, the patient can be considered for surgery
in an effort to provide pain relief, improve function, prevent disease
progression, and improve appearance.
■ Common surgeries for the rheumatoid hand include tendon reconstruction,
correction of swan-neck deformities, correction of boutonniere deformities,
and silicone arthroplasty of the MCP joints.
■ Tendon transfers are indicated if there is rupture of the long digital flexor or
extensor tendons. A thorough tendon examination (FIG 10; see Table 3) is
critical in determining the appropriate reconstructive options (see Table 4).
■ Although the typical swan-neck deformity involves a flexion contracture of the
MCPJ, hyperextension of the PIPJ, and dorsally displaced lateral bands (see
FIG 6), treatment is based on the flexibility of the PIPJ and condition of the
joint cartilage. One must test active and passive PIPJ motion with the MCPJ in
extension and flexion in order to evaluate intrinsic muscle involvement.
■ The Nalebuff classification8 is useful for surgical decision-making (Table 6).
■ Flexor tendon adhesions are suspected if PIPJ active motion is not nearly
equal to its passive motion. On the other hand, if the PIPJ remains flexible
regardless of MCPJ position (type I), a PIPJ extension-blocking splint may
be enough to correct the deformity. If PIPJ flexion is restricted with MCPJ
extension and radial deviation, ulnar intrinsic muscle tightness is present.
■ Reconstructive surgery can be performed for a boutonniere deformity provided
that the PIPJ has full passive extension. The Nalebuff classification of
boutonniere deformities (see Table 6) classifies this as stage I or II. However, if
a severe fixed flexion contracture exists, or if articular destruction is present
(stage III), arthrodesis or arthroplasty of the PIPJ is recommended.
■ In RA patients, silicone metacarpophalangeal joint arthroplasty (SMPA) is
indicated to treat MCPJ contracture, subluxation, or dislocation. However,
SMPA is not indicated in patients with other rheumatic conditions such as
lupus, in which soft tissue laxity is present without the underlying joint

destruction. In such patients, joint replacement would inevitably lead to joint
dislocation due to the absence of healthy supporting ligaments.
■ In RA patients with no evidence of MCP joint subluxation or arthritis, soft
tissue reconstruction for correction of ulnar deviation finger deformities can be
performed using the crossed intrinsic tendon transfer. The ulnar deviation
deformity must be passively correctable. As such, this procedure is also useful
in patients with lupus who do not have any underlying joint destruction.
Preoperative Planning
■ Preoperative evaluation of RA patients is critical in reducing surgery-related
morbidity and mortality.
■ Many surgeons advocate that all RA patients should be seen in the
preoperative anesthesia clinic due to a high incidence of comorbid conditions.
■ A thorough evaluation with an electrocardiogram, complete blood count and
differential, metabolic panel, chest radiograph, and cervical spine radiographs
should be obtained.
■ From a cardiac standpoint, RA can be associated with pericardial effusion,
constrictive pericarditis, or conduction blocks, thereby impacting cardiac
function. In addition, RA patients are at increased risk of coronary artery
disease.
■ Pulmonary involvement may include rheumatoid nodules, pleural effusions, or
interstitial lung disease.
■ Long-standing RA can be associated with Felty syndrome (splenomegaly,
neutropenia, and secondary thrombocytopenia).
■ Cervical spine flexion-extension radiographs are imperative as atlantoaxial
instability is common in RA patients, placing patients at risk for spinal cord
injury with routine procedures such as endotracheal intubation.
■ Patients with cervical instability should undergo fiberoptic intubation.
■ RA may also involve the cricoarytenoid and the temporomandibular joints,
which can further complicate airway management.

FIG 10 • Tendon examination maneuvers. A. Check
EPL by placing patient’s palm down on tabletop and
asking patient to lift the thumb. B. Check EIP and EDM
by asking patient to extend the index and small fingers
only. C. Check FDS of each digit by blocking all other
digits and asking the patient to bend the digit in
question. D. Check FDP by blocking the patient’s

middle phalanx and asking patient to bend the fingertip.
E. Check FPL by blocking the patient’s thumb proximal
phalanx and asking patient to bend thumb. F. Check the
extensor tendons by flexing the patient’s wrist and
seeing if the fingers extend (the tenodesis effect).
Table 6 The Nalebuff classification for swan-neck deformities and surgical
options
Type
Description
Surgical Goals/Options
I
PIPJ is flexible in all
positions of the MCPJ
Must limit PIPJ hyperextension (splint,
dermodesis, FDS tenodesis) and
restore DIPJ extension
(tenodermodesis, fusion)
II
PIPJ flexion is limited in
certain MCPJ positions
Intrinsic release and/or MCPJ
arthroplasty, in addition to procedures
required for type I deformities
III
PIPJ flexion is limited
irrespective of MCPJ
positions
Restore PIPJ flexion by manipulation,
lateral band mobilization, and
lengthening of central slip
IV
PIPJ joints are stiff, with
poor radiographic
appearance
Arthrodesis of PIPJ is preferred, but
implant arthroplasty may be
considered
DIPJ, distal interphalangeal joint; FDS, flexor digitorium superficialis;
PIPJ, proximal interphalangeal joint; MCPJ, metacarpophalangeal joint.
■ Perioperative medication management should be discussed with the patient’s
rheumatologist. In general, corticosteroids can be continued, but patients may
require a stress dose at the time of surgery.
■ MTX and other conventional DMARDs can generally be continued.
■ Biological DMARDs, on the other hand, are typically discontinued for 2 to 4
weeks before and after surgery. Again, discussion with the patient’s
rheumatologist is imperative.
Positioning
■ Patients are positioned supine with the upper extremity abducted on a hand

table.
■ Care is taken to provide the appropriate neck support.
■ A tourniquet is placed on the upper arm.
T E C H N I Q U E S
■ Tendon Transfers for Tendon Ruptures
Imaging and Planning
■ Radiographs of the wrist to evaluate the DRUJ, midcarpal joint, and
radiocarpal joint should be obtained.
■ Should these joints be involved, they must be addressed at the time of
tendon reconstruction to prevent progressive deformity and rerupture of the
reconstructed tendons.
■ If tendon rupture is diagnosed, surgical reconstruction is indicated to restore
function. Because the ruptured tendon ends are of poor quality, direct repair
is usually not possible. Furthermore, myostatic contraction eventually leads
to loss of the proximal end of the ruptured tendon, preventing the use of
tendon grafts. Tendon transfer is the preferred reconstructive option.
■ Depending on the number of ruptured tendons, surgery may involve a simple
end-to-side repair to an intact adjacent tendon, or it may require transfer of a
new motor-tendon unit (Table 5). It is also important to address the cause of
tendon rupture at the time of tendon reconstruction to prevent rerupture.
■ If synovitis is the cause, a synovectomy must also be performed.
■ If joint instability or bony erosion is the cause, a procedure to address this
should be performed as well.
Tendon Transfers for Extensor Tendon Ruptures
■ After tourniquet inflation, a 6-cm longitudinal incision is made over the
dorsal wrist in line with the long finger.
■ Skin flaps are raised to expose the extensor retinaculum.
■ The retinaculum is incised and elevated using a stair-step design (TECH
FIG 1A).
■ The stair-step incision effectively lengthens the retinaculum to permit
closure over the reconstructed tendons in the presence of swelling.

■ Also, if there is eroded bone exposed at the radiocarpal joint, half of the
retinaculum can be used as a protective layer between bone and tendon,
while the other half is closed over the tendons.
■ Next, the septa between the second and sixth extensor compartments are
divided, bringing the tendons together, typically revealing hypertophic
synovial tissue encasing the tendons (TECH FIG 1B).
■ Synovectomy is then sharply performed. Tendons that are invaded by
synovial tissue are also completely excised (TECH FIG 1C).
■ Tendon reconstruction then proceeds based on the tendons involved (see
Table 4). All tendon junctures are secured with nonabsorbable braided suture
(TECH FIG 1D).
■ If EPL is to be addressed, a separate incision is made at the level of the
thumb metacarpal, to identify the distal EPL tendon (TECH FIG 1E).
■ The EIP tendon is often weaved into the EPL tendon (TECH FIG 1F),
thereby restoring EPL function (thumb retropulsion).
■ If three or more extensor tendons are ruptured, the FDS is used for the
transfer.
■ The FDS tendon is identified through a transverse incision in the distal
palm and divided. The proximal end of the tendon is retrieved via a
separate longitudinal incision in the distal volar forearm and passed in a
subcutaneous tunnel radially in order to reach the extensor tendons on the
wrist dorsum.
■ A single FDS tendon can be transferred to up to three extensor tendons. If
more than three extensor tendons are ruptured, however, transfer of both
the ring and long finger FDS tendons should be considered.
■ Once all tendons are addressed, the dorsal wrist capsule is closed using
braided sutures. If the capsule is lax, it can be imbricated with these sutures.
■ The forearm is placed in supination, and the capsule over the distal ulna is
closed tightly with 3-0 braided sutures in a horizontal mattress fashion.
■ Next, the extensor tendons are re-examined for laxity.
■ If lax, the extensor tendons can be tightened with horizontal mattress
braided sutures.
■ Tension is set with all fingers in fully extended posture, as some
postoperative stretching is anticipated.
■ The extensor retinaculum is then repaired. If needed, the distal half can be
used to augment the wrist capsular repair, placing it underneath the extensor

tendons, and the proximal half is sutured over the tendons, recreating the
pulley (TECH FIG 1G).
■ The tourniquet is then released, hemostasis is achieved, and the skin is
closed with 4-0 nylon simple interrupted sutures.
■ Fingers are immobilized in fully extended position for 4 weeks, and then
active range-of-motion (ROM) exercises are initiated.
Reconstruction of Ruptured Flexor Tendons
Grafting for FPL Rupture
■ For the treatment of an FPL rupture caused by attritional wear against an
eroded scaphoid (Mannerfelt lesion), exposure of the tendon is performed at
the palm-wrist junction, and initially, a flexor tenolysis is performed.
■ The osteophyte is then removed with a rongeur, and the capsule is closed to
provide a smooth gliding surface.
■ If the proximal and distal ends of the ruptured FPL tendon can be found
within the palm-wrist incision, a small bridge graft from the palmaris longus
(PL) is used in a Pulvertaft weave with 3-0 nonabsorbable braided horizontal
mattress sutures (TECH FIG 2).
■ As an alternative, a strip of the FCR can be used instead of the PL.
Tendon Transfer for FPL Rupture
■ If grafting within the palm or wrist is not possible, a tendon transfer is
required. Here, the long finger FDS tendon transfer for FPL reconstruction is
described.
■ A zigzag incision is made in the palm and the long finger FDS tendon is
identified (TECH FIG 3A).
■ The long finger FDS is divided and brought into the palmar wound (TECH
FIG 3B,C).
■ Through a Bruner incision on the thumb, the flexor tendon sheath is
sharply opened and divided transversely, leaving enough tendon distally for
suturing.

E G

TECH FIG 1 • Tendon transfer for extensor tendon
reconstruction. A. Extensor retinaculum with stair-step
design. B. Hypertrophic synovial tissue encasing
extensor tendons. C. Extensor tendon ends after
debridement (prior to reconstruction). D. Extensor
tendon reconstruction with sutures in place. E.
Exposure of EPL through separate thumb incision. F.
EIP woven into EPL tendon. G. Reconstruction of
extensor retinaculum (half under and half over the
extensor tendons).
TECH FIG 2 • Ruptured flexor pollicis longus tendon
reconstruction with PL. A. Planned skin incisions. B.

Ruptured FPL tendon is identified at the wrist. C. FPL
with excellent excursion. D. FPL is attached to PL. E.
PL to FPL tendon reconstruction. F. Pulvertaft weave.
■ The FDS is then delivered into the flexor tendon sheath of the thumb using
a pediatric feeding tube.
■ Nonabsorbable braided suture is then used to sew the FDS tendon to the
distal FPL tendon (TECH FIG 3D). Tension should be set so that IP
extension occurs with wrist flexion, and full flexion into the palm occurs
with wrist extension.
Isolated FDS or FDP Ruptures
■ If an isolated FDS rupture occurs within the palm or carpal tunnel, an end-
to-side suture using a Pulvertaft weave to an adjacent FDS is performed,
along with flexor tenosynovectomy and the smoothing of any sharp bony
edges.
■ However, if the FDS rupture occurs within the finger, a tenosynovectomy
with resection of the FDS should be performed.
■ Similarly, if an isolated FDP rupture occurs within the palm or wrist, an end-
to-side suture to an adjacent FDP is performed.
■ If FDP rupture occurs within the finger, as long as FDS is still functional, the
FDP is resected.
■ If the DIPJ hyperextends during pinch or grip, DIP arthrodesis is performed
as well.
Combined FDS and FDP Ruptures
■ If occurring within the palm or wrist, the combination rupture of both FDS
and FDP is treated with end-to-side suturing of the FDP to an adjacent
tendon.
■ Alternatively, a bridge graft from the ruptured FDS can be used to repair
the FDP tendon.
■ If both FDS and FDP have ruptured within the flexor tendon sheath, a staged
reconstruction should be considered, though outcomes in patients with RA
are often disappointing due to limited recovery of motion.
■ In patients with IPJ arthritis, the best option is arthrodesis of the PIP and DIP
joints in a functional position, with preservation of some finger motion at the
MCPJ via the intrinsic system.

TECH FIG 3 • Long finger FDS tendon transfer for
ruptured flexor pollicis longus tendon reconstruction.
A. Long finger FDS is identified through a palmar
incision. B. The FDS is divided and retracted into
palmar wound. C. The FDS is transferred from the
long finger to the FPL tendon through a Bruner
incision on the thumb. D. The reconstructed FPL
tendon is shown.
■ Postoperative Care
■ If tendon transfers are performed for flexor reconstruction, the hand and
fingers are immobilized in a dorsal blocking splint to take tension off the
transfers for 3 to 4 weeks.
■ After this period, ROM exercises are gradually initiated, as guided by the
hand therapist.

■ Correction of Swan-Neck Deformity
■ It is imperative to understand the anatomy of the extensor apparatus of the
finger (see FIG 5).
Correction of PIPJ Hyperextension (Type I to III Deformities)
FDS Tenodesis (“Lasso”)
■ This is the authors’ preferred technique.
■ A slip of FDS is divided proximal to the A2 pulley (TECH FIG 4A).
■ A hole is made in the distal third of the proximal phalanx, from the volar to
lateral surface (TECH FIG 4B).
■ The FDS slip is passed through the hole, from volar to lateral (TECH FIG
4C), and is sutured with the PIPJ at 20 to 30 degrees of flexion (TECH FIG
4D).
■ This procedure can be combined with removal of a small ellipse of skin at
the PIPJ to reinforce the tenodesis, particularly in lupus patients.
Retinacular Ligament Reconstruction
■ The ulnar lateral band at the midproximal phalanx is divided and dissected
distally (TECH FIG 5A).
■ It is passed volar to the Cleland ligament, such that the ulnar lateral band can
maintain the PIPJ in flexion (TECH FIG 5B).
■ The lateral band is sutured to the A2 pulley or into the bone of the proximal
phalanx to maintain PIPJ flexion at 20 to 30 degrees (TECH FIG 5C).
■ An extension block pin is placed to protect the reconstruction.
Bone Anchor Repair of Volar Plate
■ A Bruner (zigzag) incision is made on the volar finger surface.
■ The accessory collateral ligament is identified and incised in order to retract
the volar plate and flexor sheath laterally, exposing the head of the proximal
phalanx.

TECH FIG 4 • FDS tenodesis for correction of swan-
neck deformity. A. An FDS slip is divided proximal to
A2 pulley. B. A hole is drilled in the proximal phalanx
(distal third), from volar to lateral surface. C. FDS slip
is passed through the hold from volar to lateral. D.
FDS slip is sutured with PIPJ at 15 to 20 degrees of
flexion.
■ A drill hole is made in the center of the volar surface of the proximal
phalanx, approximately 5 to 7 mm proximal to the joint line.
■ A bone anchor, which is connected to two needled sutures, such as the Mitek
Mini (Mitek Surgical Products Inc., Norwood), is placed into the hole.
■ One needled suture is passed from the dorsolateral volar plate, emerging at
the central volar plate, and then passed through the edge of the previously
divided accessory collateral ligament. The suture is tied with the goal of
maintaining 10 degrees of PIPJ flexion.
■ The other needled suture is then passed in a similar fashion on the other side
and then tied with the PIPJ at about 20 to 30 degrees of flexion.
■ Note that this procedure is technically difficult to perform and is not the

authors’ preferred technique.
TECH FIG 5 • Retinacular ligament reconstruction for
correction of swan-neck deformity. A. The ulnar lateral
band is exposed at midproximal phalanx. B. The ulnar
lateral band is passed volar to the Cleland ligament.
C. The ulnar lateral band is sutured to the A2 pulley.
Correction of DIPJ Flexion Deformity (Type I to IV Deformities)
Dorsal Tenodermodesis of the DIPJ
■ A transverse ellipse of skin is excised at the dorsal DIPJ.
■ A 3-0 nylon horizontal mattress suture is placed through the skin and
underlying extensor tendon in order to close the skin gap. With the DIPJ held
in extension, the suture is tied.
■ A K-wire is inserted obliquely through the extended DIPJ and is cut off
beneath the skin.
■ In general, this technique is not preferred because patients have thin skin and
tend to experience complications.
DIPJ Arthrodesis

■ An H- or Y-incision over the dorsal DIPJ is made to expose the extensor
tendon.
■ The extensor tendon and collateral ligaments are divided, allowing the joint
to be hinged open.
■ The joint surfaces are sculpted with a small bur, creating a “trough” distally
and a “crest” proximally.
■ The bone is fit together, and a compression screw is placed across the joint
to support bony fusion. (See chapter on Degenerative Disease of the Hand
and Wrist for details).
Correction of a Stiff Swan-Neck Deformity (Type III Deformity)
Lateral Band Mobilization
■ A curved incision is made over the extensor apparatus overlying the
proximal phalanx to the mid middle phalanx (TECH FIG 6A).
■ The lateral bands are typically found to be dorsally displaced and adherent to
the central slip, causing the extension contracture. The lateral bands are
sharply dissected from the central slip (TECH FIG 6B), distal to proximal,
preserving a wide central slip, particularly when the demarcation between the
central slip and lateral bands is unclear.
■ A wider central slip can better resist accidental rupture during joint
manipulation and is easier to lengthen.
■ Next, the PIPJ is flexed to enable the lateral bands to move laterally and
volarly (TECH FIG 6C).
■ If it is difficult to flex the PIPJ, the dorsal capsule and dorsal aspects of the
collateral ligaments may need to be release.
■ Care must be taken to monitor the tension of the central slip during PIPJ
manipulation to avoid rupture.
Step-Cut (Z) Central Slip Lengthening
■ This procedure can be considered if the central slip continues to restrict PIPJ
flexion after release of the lateral bands and attempted PIPJ manipulation. It
is generally not necessary, however, because the central slip tends to stretch
over time with therapy.
■ A Z-incision of the central slip is made, starting 3 to 4 mm proximal to its
insertion at the middle phalanx. It is extended 1 to 1.5 cm proximally.
■ If not yet performed, the dorsal capsule and dorsal portions of the collateral
ligaments are sharply released.

■ With the PIPJ in slight flexion, the central slip is then repaired with at least
three or four horizontal mattress sutures to prevent rupture during early
mobilization.
TECH FIG 6 • Lateral band mobilization for correction
of stiff swan-neck deformity. A. Exposure of extensor
apparatus from proximal to mid middle phalanx. B.
The lateral bands are identified and separated from
the central slip. C. The PIPJ is flexed, allowing the
lateral bands to fall volarly
■ Postoperative Care
■ Active motion is initiated on the 2nd postoperative day.
■ A dorsal extension block splint is applied for 2 weeks until the skin has
healed. Then, a thermoplastic figure-eight splint is applied for an additional 8
weeks.
■ After lateral band mobilization and manipulation of the PIPJ for a type III
deformity, the PIPJ should be splinted in flexion in order to stretch the dorsal

soft tissue.
■ Patients should continue active flexion exercises, except in cases in which
central slip lengthening was also performed.
■ Ligament Reconstruction to Correct Boutonniere
Deformity
■ Once the patient is made comfortable with a wrist or digital block, a dorsally
placed curved incision over the PIPJ is made to expose the extensor
apparatus.
■ The lateral bands and transverse retinacular ligaments are identified.
■ The radial and ulnar transverse retinacular ligaments are sharply divided
from their insertions on the volar plate of the PIPJ.
■ The transverse retinacular ligaments are then turned over dorsally on either
side of the PIPJ and sutured together.
■ Tension of the suture is determined by asking the patient to actively extend
the PIPJ.
■ Tension should be set at the near-full extended position.
■ Next, active flexion of the DIPJ must be checked. If DIPJ flexion is limited,
small transverse cuts into the lateral bands to lengthen them between the PIPJ
and DIPJ (overlying the distal half of the middle phalanx) should be made,
until the DIPJ can be actively flexed to 30 degrees.
■ The PIPJ is then immobilized in full extension with a K-wire for 2 weeks.
■ Postoperative Care
■ Within 3 days of surgery, active DIPJ flexion exercises are initiated, while
the PIPJ remains immobilized.
■ At about 2 weeks, active PIPJ flexion exercises are begun, while active
extension exercises should be avoided.
■ To keep the PIPJ in full extension, a daytime dynamic splint and nighttime
static splint should be provided.
■ The splint is gradually weaned, and active finger exercises are slowly
advanced under the guidance of a hand therapist.

■ Silicone Metacarpophalangeal Joint Arthroplasty
■ The patient is positioned supine with the extremity abducted on a hand table.
■ Under tourniquet control, a transverse incision is made over the heads of the
second through fifth metacarpals, taking care to preserve the dorsal veins and
sensory nerves (TECH FIG 7A).
■ The radial sagittal bands are divided to expose the MCPJs. Synovectomy is
performed sharply.
■ The collateral ligaments are divided at the metacarpal neck, taking care to
preserve the radial collateral ligament insertion on the proximal phalanges for
later reconstruction.
■ With an oscillating saw, the metacarpal heads are resected at the proximal
origin of the collateral ligaments (TECH FIG 7B).
■ After metacarpal head resection, the fingers are brought into alignment.
■ Using a twisting motion, an awl is used to perforate the medullary cavities
of the metacarpals and proximal phalanges (TECH FIG 7C).
■ Next, sequentially sized broaches are used to enlarge the medullary cavities
of the proximal phalanges first, then the metacarpals, since the size of the
phalangeal cavity usually determines the implant size to be used.
■ The exception is the ring metacarpal, which is typically narrower than the
ring finger proximal phalanx and should thus be prepared first to avoid
over-reaming the proximal phalanx.
■ It is important that the broach is inserted straight without twisting, making
a rectangular trough to accommodate the shape of the silicone implants.
■ The largest implants that will fit into the medullary cavity are then selected.
■ Prior to implant insertion, two drill holes are made with a 0.035-in. K-wire
on the radial edge of the metacarpal (TECH FIG 7D)
■ 3-0 braided permanent sutures are placed through these drill holes to
reconstruct the radial collateral ligaments (TECH FIG 7E).
■ Next, the implants are inserted (TECH FIG 7F).
■ The radially placed sutures are used to reattach the radial collateral ligament,
bringing the fingers into slight radial deviation (TECH FIG 7G).
■ If still tight, the ulnar lateral bands can be released, though this is usually not
necessary.
■ The position of the extensor tendons should be re-evaluated. If they cannot
be centralized easily, the ulnar sagittal bands may also need to be released.

■ Next, the extensor tendons are centralized by imbricating the radial sagittal
bands with 3-0 braided horizontal mattress sutures.
■ The tourniquet is released, and hemostasis is achieved.
■ The skin is closed with absorbable dermal sutures followed by 4-0 horizontal
mattress nylon sutures (TECH FIG 7H).
■ A volar resting short-arm splint is applied.

stryker G H

TECH FIG 7 • Silicone metacarpophalangeal joint
arthroplasty. A. A transverse incision is made over the
metacarpal heads. B. The metacarpal heads are
resected with an oscillating saw. C. An awl is used to
perforate the medullary cavities of the metacarpals
and proximal phalanges. D. Two drill holes are made
on the radial edge of the metacarpal. E. Sutures are
placed through the drill holes. F. The silicone implants
are inserted. G. The sutures are tied down, thereby
reconstructing the radial collateral ligament. H. Skin
closure, improved alignment of fingers
■ Postoperative Care
■ The patient is placed in a dynamic extension splint 1 week postoperatively.
■ While in the splint, the patient is to begin active flexion exercises for 6
weeks under the guidance of a hand therapist. The splint is adjusted as
necessary to align the fingers.
■ Crossed Intrinsic Transfer for Correction of Ulnar
Deviation Deformity
Pertinent Anatomy
■ The radial and ulnar sagittal bands stabilize the extensor tendon over the
dorsal midline of the MCP joint (see FIG 5A). When the radial sagittal band
is attenuated, the extensor tendon subluxes ulnarly, leading to ulnar deviation
of the finger (see FIG 5C).
■ On the ulnar side of the digit, the common intrinsic tendon is formed by the
tendons of the palmar and dorsal interosseous muscles. On the radial side, the
common intrinsic tendon is formed by the tendons of the interosseous
muscles as well as the lumbrical.
■ The common intrinsic tendon then passes volar to the MCP joint and divides
into a medial band (which inserts into the central slip at the dorsal base of the
middle phalanx) and a lateral band (which inserts at the dorsal base of the

distal phalanx).
■ Thus, intrinsic muscle contraction results in MCP joint flexion and IP joint
extension.
■ In a cross intrinsic transfer, the common intrinsic tendon is divided distally
(slanted lines) and sutured to the extensor tendon of the adjacent finger
(TECH FIG 8).
TECH FIG 8 • Cross intrinsic transfer for repair of the
index finger radial sagittal band. The common intrinsic
tendon is divided distally (slanted lines) and sutured to
the extensor tendon of the adjacent finger (arrows).
■ Transfer Procedure
■ Under tourniquet control, the extensor apparatus over the MCP joint is
exposed through a lazy-S incision if only one finger is involved or through a
dorsal transverse incision over the MCP joints if multiple fingers require
correction (TECH FIG 9A).

■ A longitudinal incision paralleling the extensor tendon is made through the
attenuated radial sagittal band (TECH FIG 9B).
■ The MCP joint is opened. A synovectomy is performed.
■ On the ulnar side, the common intrinsic tendon is identified (TECH FIG
9C) and divided from its attachment to the extensor mechanism at the
midproximal phalanx.
■ The tendon is rerouted across the adjacent web space to reach the extensor
tendon of the digit ulnar to it (TECH FIG 9D). It is then passed through a slit
made at the midportion of the extensor tendon overlying the MCP joint and
sutured to itself using 3-0 braided nonabsorbable suture.
■ Note that the ulnar common intrinsic tendon of the index finger is used to
correct the long finger; the tendon of the long finger is used to correct the
ring finger; and the tendon of the ring finger is used to correct the small
finger.
■ The index finger is then corrected by a double-breasted repair of the radial
sagittal band (TECH FIG 9E).
■ The skin is closed with simple interrupted horizontal mattress sutures
(TECH FIG 9F).

TECH FIG 9 • A. Planned skin incision over the MCP
joints. B. The attenuated radial sagittal band of the
long finger is incised to access the MCP joint to
facilitate synovectomy. C. The ulnar common intrinsic
tendon of the long finger is identified. D. The ulnar
common intrinsic tendon of the ring finger has been
rerouted to the small finger to be sutured to the

extensor tendon. The intrinsic tendon is being held by
the clamp in this photo. E. Final appearance of
multiple cross intrinsic tendon transfers to the long,
ring, and small fingers. A double-breasted repair of the
radial sagittal band of the index finger is also shown.
F. Skin closure.
■ Postoperative Care
■ A volar hand splint is placed to support the reconstruction with the MCP
joint in extension.
■ At 10 days, a removable splint is placed.
■ At 4 weeks, a gradual mobilization protocol is initiated with protective
splinting for another 4 weeks.
PEARLS AND PITFALLS
TENDON TRANSFERS FOR TENDON RUPTURES
Extensor tendon
exposure
■ Skin flaps are raised superficial to the extensor retinaculum,
taking care to preserve the longitudinal dorsal veins (improves
postoperative swelling) and superficial sensory nerve branches.
■ Skin must be handled as gently as possible, as skin quality and
vascularity are already impaired by rheumatoid disease and/or
medications.
Stair-step
incision of
extensor
retinaculum
■ Facilitates closure of the extensor retinaculum at the end of the
case, as swelling under retinaculum is common.
■ Can be useful to shield the extensor tendons from the
radiocarpal joint in cases of bony erosion (half the retinaculum
is placed under the extensor tendons, and the other half is used
to close over them).
Treatment of
combined ring
and small finger
extensor tendon
ruptures
■ Treatment options include EIP transfer or end-to-side repair of
the ring and small finger extensor tendons to the long finger
extensor tendon.
■ EIP transfer is preferred due to the line of pull.
■ End-to-side repair to the long finger extensor tendon results in

an oblique pull that can cause unwanted abduction of the small
finger.
Transferring
FDS tendons
■ For extensor tendon reconstruction, a subcutaneous transfer is
preferred over a transfer through the interosseous membrane
(high risk of adhesions).
■ A subcutaneous transfer on the radial side is preferred over the
ulnar side, because the direction of pull helps to correct the
ulnar deviation deformity.
Thumb
interphalangeal
joint (IPJ) fusion
■ Can be considered as long as the MCPJ is stable and functional
and the strength of intrinsic muscles is adequate. If not, the
patient will not achieve satisfactory pinch strength.
Darrach
procedure
■ Defined as the resection of the head of the ulna.
■ May be required if the distal ulna is the source of tendon
attrition and rupture.
■ If performed concomitantly with tendon reconstruction, a
supination splint should be placed for 4 weeks postoperatively.
CORRECTION OF SWAN-NECK DEFORMITY
Exposure
■ Avoid injury to the digital nerve at the tip of the flap where it is
just beneath the skin by identifying the nerve at the base of the
flap.
Dorsal DIPJ
tenodermodesis
■ Generally, soft tissue reconstruction for DIPJ extension is
discouraged, and arthrodesis is preferable.
■ However, tenodermodesis combined with DIPJ pinning for
greater than 2 months can create a generally stiff DIPJ allowing
for slight motion.
LIGAMENT RECONSTRUCTION TO CORRECT BOUTONNIERE
DEFORMITY
Preoperative
management
■ Passive PIPJ mobility is critical to optimize surgical outcomes
after correcting a boutonniere deformity.
■ If a severe PIPJ flexion contracture is present, rehabilitation
and extension splinting should be performed prior to surgery.
Imaging
■ Radiographs are required to evaluate MCJP, PIPJ, and DIPJ
status prior to surgery. PIPJ destruction indicates the need for
arthrodesis or arthroplasty, as opposed to ligament
reconstruction.
■ MRI may be helpful in identifying synovitis of the PIPJ but is
expensive and not usually necessary to make the diagnosis.

Anesthesia:
wrist or digital
block
■ The surgery is done under a wrist or digital block such that the
patient can perform active finger motion during the operation to
allow for proper tension setting.
Tension setting
■ The transverse retinacular ligaments are sutured together at the
dorsal aspect of the PIPJ when it is in near-full extension.
■ If set too tight, the tension may lead to extension contracture of
the PIPJ and DIPJ.
PIPJ contracture
■ If a contracture exists at the PIPJ, the accessory collateral
ligament and proximal volar plate should be released to obtain
full passive PIPJ extension.
■ Care must be taken to preserve the true collateral ligaments to
prevent PIPJ instability.
Achieving DIPJ
flexion
■ In some cases, dividing the oblique retinacular ligament is
necessary to obtain DIPJ flexion.
■ Avoid releasing the lateral bands too far, as this can result in
DIPJ extension lag.
PIPJ
synovectomy
■ For patients with active RA, PIPJ synovectomy is required.
SILICONE METACARPOPHALANGEAL JOINT ARTHROPLASTY
Surgical
considerations
■ If the patient’s fingers are ulnarly drifted without evidence of
MCPJ dislocation, soft tissue reconstruction can be performed
instead of SMPA.
■ A crossed intrinsic transfer may be performed to correct finger
misalignment of the small, ring, and long fingers (see crossed
intrinsic transfer for ulnar deviation technique below).
■ For the index finger, the radial sagittal band must be tightened
to centralize the extensor tendon, given that there is no ulnar
intrinsic tendon available for transfer.
■ Thumb MCPJ laxity is best treated with MCPJ fusion.
■ Patients with wrist collapse and radial deviation of the
metacarpals should first have their wrists addressed by fusion
or arthroplasty. Not only will this enhance the outcome of
SMPA, but also it will prevent early postoperative ulnar
subluxation of the fingers after SMPA.
Imaging
■ PA, lateral, and oblique radiographs of the hand and wrist are
important in order to evaluate joint alignment, joint congruity,
and bony erosions.

Metacarpal head
resection
■ Resection of the metacarpal heads decreases the tightness of
the ulnar intrinsic tendons that contribute to ulnar deviation of
the fingers. As such, ulnar lateral band release is usually not
necessary.
Preparing the
medullary
canals for
implant
insertion
■ The medullary canals of the proximal phalanges, which are
typically narrower than those of the metacarpals, should be
prepared first since they usually determine the implant size to
be used.
■ The exception to this rule is the ring finger. The ring
metacarpal typically has a narrower canal than does the
proximal phalanx and should therefore be prepared first to
avoid over-reaming the proximal phalanx.
CROSSED INTRINSIC TRANSFER FOR CORRECTION OF ULNAR
DEVIATION DEFORMITY
Indications
■ The crossed intrinsic transfer may also be considered for lupus
patients with ulnar deviation deformities, as they do not have
underlying joint destruction.
Surgical tips
■ Try to preserve longitudinal dorsal veins during surgical
exposure to minimize postoperative swelling.
■ Avoid dividing the common intrinsic tendon too proximally, as
it may not reach the extensor tendon of the adjacent finger if
too short.
■ Take care to preserve the neurovascular bundle volar to the
common intrinsic tendon.
■ Division of the abductor digiti minimi for correction of a small
finger ulnar deviation deformity may be necessary.
■ A double-breasted repair of the radial sagittal band is facilitated
by leaving a 2- to 3-mm cuff of the sagittal band when
longitudinally incising it at the beginning of the case.
OUTCOMES
■ Tendon transfers in patients with preserved MCPJs reliably achieve restoration
of MCPJ extension. However, in patients with volarly subluxed and arthritic
MCPJs, arthroplasty and soft tissue reconstruction to restore joint alignment
prior to performing tendon transfers are critical for optimizing outcomes.
■ In general, tendon transfers for extensor tendon reconstruction achieve good
results, though more extension lag is observed when more tendons are
involved. For flexor tendons, patients with isolated ruptures in the palm or

wrist have the potential to maintain good finger function, provided that their
prerupture finger function was good. However, if preruptured function was
limited, outcomes will be poor regardless of the treatment provided.
■ Outcomes after the combined rupture of FDS and FDP are also poor,
regardless of prerupture finger function or method of treatment.
■ To optimize outcomes, correcting the underlying causes of tendon rupture,
such as extensor tenosynovitis, rough bony surfaces, and the caput ulna
deformity, is critical in preventing the rerupture of reconstructed tendons.
■ For advanced swan-neck deformities, the results of surgery can be
unpredictable. Still, even if motion is lost, the flexed PIPJ position is
functionally preferable to the hyperextended position. As such, as long as PIPJ
hyperextension is prevented, there should be no hesitation in performing
surgery for advanced swan-neck deformities.
■ Patients who undergo SMPA typically gain 30 to 40 degrees of active motion
at the MCPJ. Grip strength and pinch strength are unaffected by surgery, while
ulnar drift, extension lag, and arc of motion significantly improve (FIG 11).
■ The crossed intrinsic transfer can provide long-term correction of ulnar
deviation deformities but may be associated with decreased active ROM at the
MCP joint.
FIG 11 • Results 2 months (A–F) and 5 months (G–L)
after silicone metacarpophalangeal joint arthroplasty.

D G H

REFERENCES
1. Stastny P. Association of the B-cell alloantigen DRw4 with rheumatoid
arthritis. N Engl J Med. 1978;298(16):869-871.
2. Feldmann M, Brennan FM, Maini RN. Role of cytokines in rheumatoid
arthritis. Annu Rev Immunol. 1996;14:397-440.
3. Kirkham BW, Lassere MN, Edmonds JP, et al. Synovial membrane cytokine
expression is predictive of joint damage progression in rheumatoid arthritis: a
two-year prospective study (the DAMAGE study cohort). Arthritis Rheum.
2006;54(4):1122-1131.
4. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism
Association 1987 revised criteria for the classification of rheumatoid arthritis.
Arthritis Rheum. 1988;31(3):315-324.
5. Nishimura K, Sugiyama D, Kogata Y, et al. Meta-analysis: diagnostic
accuracy of anti–cyclic citrullinated peptide antibody and rheumatoid factor for
rheumatoid arthritis. Ann Intern Med. 2007;146(11):797-808.
6. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification
criteria: an American College of Rheumatology/European League Against
Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):2569-2581.
7. Nam JL, Winthrop KL, van Vollenhoven RF, et al. Current evidence for the
management of rheumatoid arthritis with biological disease-modifying
antirheumatic drugs: a systematic literature review informing the EULAR
recommendations for the management of RA. Ann Rheum Dis. 2010;
69(6):976-986.
8. Rehim SA, Chung KC. Applying evidence in the care of patients with
rheumatoid hand and wrist deformities. Plast Reconstr Surg. 2013;132(4):885-
897.
9. Nalebuff EA, Millender LH. Surgical treatment of the boutonniere deformity
in rheumatoid arthritis. Orthop Clin North Am. 1975;6(3):753-763.