Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Types of Prostheses
Prostheses are classified as passive or active devices. Passive prostheses are worn primarily for esthetic
improvement. Active prostheses are used to improve function. The two main categories of active
prostheses are body-powered and myoelectric.
Body-powered prostheses use cables, pulleys, and hooks to transmit function from the patient’s intact
shoulder and scapular movement to the distal prosthesis. Generally, only one joint can be controlled at a
time. For example, patients need to lock the elbow joint to transmit the cable excursion to open the hand.
These prostheses are generally stronger, lighter, and less costly than myoelectric prostheses, but they are
more cumbersome to operate and wear and have limited range of operation because of the harnessing.
They are often preferred by patients who require a prosthesis for heavy labor.
Myoelectric prostheses are powered by small motors. They are more intuitive than body-powered
prostheses, using electromyography signals from the residual limb for control. They require muscle
activity of the residual limb and can therefore improve health of the limb, and also do not require
harnessing or strapping for control. Myoelectric prostheses are larger and heavier as they require space
for batteries and motors. They are difficult to place for distal amputations, for example, at the level of a
wrist disarticulation. Most patients prefer the appearance of a myoelectric prosthesis compared with a
body-powered prosthesis. 16 Newer devices provide options of multiple grasp patterns that are not
possible with body-powered devices.
Hybrid prostheses can also be used, for example, body-powered for the elbow and myoelectric for the
hand in a patient with a transhumeral amputation. 17
Standard body-powered prosthetic function is poor for those with proximal amputations as patients
cannot simultaneously control their elbow and hand. 18 Similarly, with conventional myoelectric
prostheses the myoelectric elbow and hand cannot be controlled simultaneously, and the user must
sequentially switch from one joint to the next. For this reason, typically for patients with amputations
above the elbow, TMR is recommended. 18 TMR permits precise motor control of a myoelectric prosthesis,
as well as simultaneous operation of multiple prosthetic joints. Amputated nerves are neurotized to
nearby muscles. When the muscle contracts, its electromyogram (EMG) signal can be detected
transcutaneously to direct the function of the prosthesis. A concurrent brachial plexus injury with an
amputation typically precludes a TMR procedure.
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Neuroma Management
Prevention and treatment of symptomatic neuromas is a critical part of amputation management.
Surgical technique, postoperative rehabilitation, and patient education are important.
Symptomatic neuromas develop in 25% of patients with major limb amputations, causing pain, difficulty
with prosthesis wear, reductions in quality of life, and decreases in function. 19 Neuromas can be localized
using Tinel sign. When pressure is applied over the neuroma, the patient will describe discomfort at the
area and radiating dysesthesias in the area that the nerve had previously innervated. Diagnostic localized
injections can be helpful. Phantom sensations are present when the patient feels that their amputated
body part is still present following their amputation. Phantom pains are ongoing painful sensations felt
coming from the amputated limb and may occur with or without neuromas.
Symptomatic neuromas can be treated surgically. Often, surgeons attempt to bury the nerve end by
performing a traction neurectomy and positioning of the nerve end deep in the soft tissues, muscle, or
bone. Other options include resection of the neuroma and then using the centro-centralization technique
to divide the nerve 5 to 10 mm proximal to the neuroma and performing an additional repair as an
autologous transplantation 20 or suturing the distal nerve to an allograft. However, TMR or RPNI
techniques appear to be more reliable solutions, providing amputated nerves with new functions and
preventing neuroma recurrence.
For amputations of the fingers, traction neurectomy is most commonly performed, resecting the digital
nerves 5 to 10 mm proximal to the end of the preserved bone. For amputations at the wrist and more
proximal, TMR or RPNI are recommended to prevent symptomatic neuromas at the time of the
amputation or in a delayed fashion. 21 Small cutaneous nerves can be transposed deep to nearby muscle
to protect them from pressure from a prosthesis.
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Targeted Muscle Reinnervation
TMR was developed by Kuiken et al. at the Rehabilitation Institute of Chicago to create a new biological
neural machine interface. 22,23 Residual nerves from an amputated limb, of the upper or lower extremity,
are transferred to muscles that are no longer biomechanically functional owing to the loss of the limb.
Over time, these muscles will be reinnervated by the transferred nerves. The muscles will amplify the
amputated nerve motor commands. Success rates of 95% for muscle reinnervation with detectable EMG
signals using the TMR nerve transfer technique have been reported. 24 Neuromas are prevented (primary
TMR, performed acutely) or effectively treated with TMR (secondary TMR, can be performed years after
the injury). 24 Phantom pain is improved. Phantom sensation is unchanged. The TMR technique is tailored
to each individual patient, by a multidisciplinary team including a plastic surgeon, physiatrist,
prosthetist, biomedical engineer, and therapist. TMR is useful for well-selected, motivated patients
interested in using a myoelectric prosthesis and, on a much broader scale, to prevent and manage
symptomatic neuromas.
For a patient with a transhumeral amputation, for example, the median nerve can be coapted to the
medial head of the biceps and the ulnar nerve can be coapted to the brachialis (hand close signals). The
distal radial nerve can be coapted to the lateral head of the triceps (hand open signal). The
musculocutaneous nerve is left intact to the lateral head of the biceps (elbow flexion signal) and the
proximal radial nerve is left intact to the long head of the triceps (elbow extension signal).
For a shoulder disarticulation patient, the musculocutaneous nerve can be transferred to the clavicular
head of the pectoralis major (elbow flexion signal), the median nerve can be transferred to the upper
sternal head of the pectoralis major (hand close signal), the radial nerve can be transferred to the lower
sternal head of the pectoralis major (hand open signal), and the ulnar nerve can be transferred to the
pectoralis minor (hand close signal) (Figure 91.8). The axillary nerve innervation to the deltoid and teres
minor is kept intact. EMG signals from each of these muscles can be detected by a myoelectric prosthesis
permitting intuitive, multidirectional, and simultaneous control of multiple joints of an advanced
prosthesis. Alternative reinnervation targets have been described (Table 91.1). 25,26
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FIGURE 91.8 A common shoulder disarticulation targeted muscle reinnervation design is shown. The nerve targets are chosen
based on each individual patient’s injury.
TABLE 91.1
Reinnervation Muscle Target Examples for Shoulder Disarticulation Targeted Muscle Reinnervation34
Nerve
Example Reinnervation Target
Signal/Function
Case 1
Case 2
Axillary
Left intact to deltoid and teres minor
Shoulder abduction and external
rotation
Musculocutaneous
Clavicular head of pectoralis
major
Lateral half of the clavicular head of
pectoralis major
Elbow flexion
Median
Upper sternal head of pectoralis
major
Sternal head of the pectoralis major
Hand close
Ulnar
Pectoralis minor
Medial half of the clavicular head of
pectoralis major
Hand close
Radial
Lower sternal head of pectoralis
major
Inferior three slips of serratus anterior
Hand open
Patients can resume wearing their existing prosthesis 4 to 6 weeks after TMR. Three months after TMR,
the first signs of muscle reinnervation are often noted and patients can be evaluated for a custom TMR
prosthesis. Strong muscle contractions are visible and palpable 5 months postoperatively. Six months
postoperatively, the EMG sites have begun to stabilize and EMG testing is performed to record and map
out the signals at the nerve transfer sites. Strengthening of the amputated limb and control of the
reinnervated muscles is guided by a therapist.
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Targeted Sensory Reinnervation
Recent advancements in targeted sensory reinnervation (TSR) may permit sensory feedback back to the
patient, with the goal of improving the ease of use and function of the prosthesis. 27-29 Rather than relying
on visual and auditory clues, the patient can feel objects grasped, although the technology to integrate
sensory feedback is not yet available as a commercial prosthetic system. TMR and TSR surgery can be
performed acutely at the time of the patient’s initial amputation or later in the subacute or chronic phase.
During TMR, the subcutaneous tissues under the skin overlying the anticipated EMG sites are thinned to
minimize impedance and improve signal strength recording of the surface myoelectric signals. This
results in local denervation of the skin. Competitive reinnervation of the skin then occurs from the
underlying afferent nerve fibers. This process can be unpredictable and variable, resulting in intermixed
skin sensations from the transferred nerves below and the native anatomic skin sensation.
To create distinct reinnervated sensory territories, cutaneous nerve end-to-side nerve transfers were
developed by Kuiken et al. 28 In one patient with an amputation through the humeral neck, the
supraclavicular cutaneous nerve was cut and coapted to the side of the ulnar nerve. The
intercostobrachial nerve was cut and coapted to the median nerve. Six months later, the anterior chest
skin had been reinnervated by both the median and ulnar afferents. However, a mixture of digit and
native chest sensations were present.
To further refine TSR and to create the most discrete sensory patches of reinnervation for the ulnar and
median nerves, Hebert et al. from the University of Alberta used a technique of sensory fascicle end-to-
end TSR. 19,20 Somatosensory-evoked potentials are used intraoperatively to identify sensory fascicles of
the main reinnervating nerves and target cutaneous nerves. Once a predominantly sensory fascicle is
identified, it is cut and coapted to the cutaneous sensory target. The remainder of the main nerve is
coapted to the motor branch of the target muscle. For example, in a transhumeral subject, a sensory
fascicle of the median nerve is coapted to the intercostobrachial nerve and a sensory fascicle of the ulnar
nerve is coapted to the cutaneous axillary nerve. This technique resulted in exclusive sensory patches in
the designated territories, with no overlap. 30 Initial sensation was detected 4 to 8 months postoperatively
and stable reinnervation occurred 1 year postoperatively.
Following TSR, experimental devices for providing feedback from the prostheses are being investigated.
Specifically, touch and pressure sensors to convey object contact and grip can be matched to actuators
over the reinnervated skin to apply proportional pressure stimuli back to the skin of the TSR site,
providing the patient with matched sensory feedback. The sense of prosthetic hand movement has also
been explored through vibration of the reinnervated muscles. 30 Further development of these techniques
to clinical prostheses may allow the prosthesis user to “feel objects” with their prosthesis rather than
having to rely on visual guidance and auditory cues.
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Regenerative Peripheral Nerve Interfaces
Cederna et al., at the University of Michigan, developed the technique of RPNI to treat symptomatic
neuromas and to permit myoelectric prosthesis control. 21,31,32 Motor RPNIs are fabricated by securing the
distal end of a mixed or motor peripheral nerve within a small skeletal muscle graft. Dermal sensory
interfaces are created by securing a sensory peripheral nerve fascicle within a small dermal skin graft. 33
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Hand Transplantation
For select patients, hand transplantation is an alternative to prosthetic use, in particular for patients with
bilateral amputations. The risks of immunosuppression must be weighed against the benefits of restoring
appearance and function with a transplanted arm. Dumanian and Kuiken stated that patients with
amputations at the transhumeral level and proximal would likely do better with TMR, and those with
amputations at the transradial level and distal would do better with hand transplantation. 10
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Questions
1. A 25-year-old male carpenter returns for follow-up 1 year after undergoing an amputation of his
index finger at the level of the mid-proximal phalanx. He complains of difficulty grasping small
objects (the objects fall out of the radial aspect of his hand) and holding a pencil and precision tools.
What surgery would you recommend?
a. Revision amputation of the index finger at the metacarpophalangeal (MCP) joint
b. Ray amputation of the index finger at the metacarpal base
c. Fusion of the index finger MCP joint in 45° of flexion
d. Distraction osteogenesis of the index finger proximal phalanx
e. Toe transplant to the index finger
2. A 35-year-old man presents to the emergency department at 03:00 following an injury at a
manufacturing plant at 02:15. He sustained a sharp, clean shoulder disarticulation. The amputated
arm has been placed on ice and is with the patient. How would you treat the patient?
a. Pressure dressing, plan for exploration and possible closure in operating room at 07:30
b. Emergent angiogram
c. Emergent attempt at replantation
d. Emergent surgery for exploration with no attempt at replantation
3. An 8-year-old girl is brought in with a traumatic elbow disarticulation from a boating accident.
The amputated arm was not recovered by the emergency medical personnel. How would you treat
the patient?
a. Soft tissue closure over the distal humerus
b. Revision to a transhumeral amputation
c. Revision to a shoulder disarticulation amputation
d. Distraction osteogenesis of the humerus
e. Free fibula osteocutaneous flap to replace the forearm
4. A 40-year-old woman presents for a transradial amputation 10 years after sustaining a C8-T1
preganglionic brachial plexus injury, resulting in the loss of all hand function. She has intact elbow
flexion and extension. What is the appropriate surgical management of distal amputation residual
limb?
a. Permit the distal residual limb to heal by secondary intention. Place an antimicrobial dressing.
b. Perform tertiary closure of the residual limb. Place an antimicrobial dressing, permit time for
tissue demarcation, and then return to the operating room for final closure.
c. Permit proximal retraction of the forearm musculature. Perform layered closure of the
subcutaneous tissues and skin.
d. Perform a myodesis of the flexor and extensor musculature to the distal radius and ulna.
Perform layered closure of the subcutaneous tissues and skin.
e. Perform a pedicled radial forearm flap, from the ipsilateral forearm, for closure of the residual
limb.
5. A 28-year-old man presents with a symptomatic neuroma over his transradial amputation residual
limb 1 year following his amputation. How would you manage this patient?
a. Perform a physical examination and a diagnostic local anesthetic block to confirm the site of
the neuroma.
b. Refer the patient to a therapist to learn about scar desensitization and other nonoperative
modalities to manage the neuroma pain.
c. Consider consultation with a multidisciplinary pain management team.
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d. Discuss operative management of the neuroma with the patient, including traction
neurectomy, burying the nerve, creation of a regenerative peripheral nerve interface, or targeted
muscle reinnervation.
e. All the above
1. Answer: b. A ray amputation will functionally correct the patient’s concerns and esthetically
improve the appearance of the hand. A short amputated index finger often limits hand function. The
residual digit is in the way, interfering with pinch between the thumb and middle finger. The index
finger does not contribute to grip strength of the hand; this is provided by the middle, ring, and
small fingers. Revision amputation at the MCP joint results in a less esthetically pleasing appearance
than a ray amputation. A ray amputation provides increased soft tissue for tension-free closure and
reconstruction of the first webspace. Fusion of the MCP joint would result in the index finger being
even more limiting, blocking prehensile pinch between the thumb and middle finger. Distraction
osteogenesis is a demanding, lengthy procedure for patients and would result in small gains in
length but no additional joints to improve finger flexion and hand function.
A toe transplant should be reserved for restoration of a radial or ulnar post of the hand for
prehension following complex hand injuries.
2. Answer: d. A traumatic shoulder disarticulation is a life-
 threating injury. Exsanguination can
occur owing to lacerations in the axillary artery and vein. Advanced trauma life 
 support protocols
must be followed. Aggressive resuscitation with blood products is often required. The patient must
be rapidly evaluated for other serious injuries, including thoracic and abdominal trauma.
Hemorrhage can be temporarily controlled with hemostats and direct pressure in the emergency
room, and then the patient should be emergently transferred to the operating room for definitive
vascular control.
Postponing treatment or performing investigations such as an angiogram increases patient mortality.
Replantation is contraindicated for shoulder disarticulation level amputations.
3. Answer: a. In children, preservation of length and physes is of utmost importance. Retention of the
distal humeral physis will permit ongoing growth of the humerus, albeit at a decreased rate
compared to the contralateral uninjured side. At skeletal maturity, the patient is likely to have a
shortened humerus. This is ideal for a transhumeral prosthesis with replacement of the elbow joint
and hand. If a transhumeral or a more proximal amputation was performed, at skeletal maturity, the
humerus would likely be too short for a prosthesis because of the absence of distal physeal growth.
An elbow prosthesis would be more functional than a long humerus without an elbow joint.
Similarly, a free fibula flap would not restore the elbow joint.
4. Answer: d. A myodesis reestablishes an insertion for the amputated muscles. This permits the
muscles to contract and to transmit a signal to a prosthesis. It provides soft tissue coverage over the
distal bone. An elective amputation should be carefully planned with the patient and a
multidisciplinary team, to determine the ideal amputation level for function, the best incision
placement for comfortable prosthetic wear, and to permit durable, tension-free soft tissue coverage
over the residual limb. Secondary or tertiary healing is inappropriate. There is no zone of injury
requiring time for demarcation in this case. Proximal retraction of the forearm musculature will
cause the muscles to shorten and become fibrotic. Without an insertion, they will be nonfunctional.
Flap closure is unnecessary in an elective transradial amputation. The local, sensate distal tissues are
best used for closure. Flaps have a role in traumatic injuries with a loss of soft tissue and the need to
preserve bone length.
5. Answer: e. Symptomatic neuromas are common following amputations. A multimodal treatment
approach is best. Nonoperative management is typically recommended first, including
desensitization therapy, neuropathic pain medications, prosthetic socket modifications, and
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occasionally psychiatric evaluation. If the neuroma is well localized and does not respond to
nonoperative measures, surgery can be pursued.
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Acknowledgments
The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-
AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health. The authors would like to
thank Dr. Jacqueline Hebert for her valuable review of this manuscript.
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References
Langer, V. Management of major limb injuries. Sci World J. 2014;2014:640430.
Pet, MA, Morrison, SD, Mack, JS, et al. Comparison of patient-reported outcomes after traumatic upper extremity amputation: replantation
versus prosthetic rehabilitation. Injury. 2016;47(12):2783-2788.This multicenter study compared 9 patients who underwent successful replantation
with 22 amputee patients who underwent prosthetic rehabilitation. Those in the replantation group reported better overall function and satisfaction and
had higher DASH scores.
Graham, B, Adkins, P, Tsai, TM, et al. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late
functional outcomes study. J Hand Surg Am. 1998;23(5):783-791.
Otto, IA, Kon, M, Schuurman, AH, van Minnen, LP. Replantation versus prosthetic fitting in traumatic arm amputations: a systematic
review. PLoS One. 2015;10(9):e0137729.The outcomes of 301 replantation and 172 prosthetic patients were compared. Replantation patients had
improved function and higher satisfaction scores compared to patients with amputations and prostheses. Sensation and psychological well-being were
the two major advantages of replantation.
Tintle, SM, Baechler, MF, Nanos, GP, et al. Traumatic and trauma-related amputations. Part II: upper extremity and future directions. J Bone
Joint Surg Am. 2010;92A:2934-2945.
Soucacos, PN. Indications and selection for digital amputation and replantation. J Hand Surg Br. 2001;26(6):572-581.
Bhat, AK, Acharya, AM, Narayanakurup, JK, et al. Functional and cosmetic outcome of single-digit ray amputation in hand. Musculoskel
Surg. 2017;101(3):275-281.Forty-five patients were assessed after a single-ray amputation. There was a 43% decrease in grip strength (greatest after
middle finger ray amputations) and a 34% loss of pinch strength (greatest after index finger ray amputations); 83% of patients reported good or
excellent cosmetic outcomes.
Puhaindran, ME, Healey, JH, Athanasian, EA. Single ray amputation for tumors of the hand. Clin Orthop Relat Res. 2010;468(5):1390-1395.
Marchessault, JA, McKay, PL, Hammert, WC. Management of upper limb amputations. J Hand Surg Am. 2011;36(10):1718-1726.
Dumanian, G, Kuiken, T. Treatment of the upper extremity amputee. In: Neligan, P , ed. Plastic Surgery. Vol. 6. 3rd ed. Philadelphia, PA:
Elsevier; 2013:870-880.e872.
de Luccia, N, Marino, HL. Fitting of electronic elbow on an elbow disarticulated patient by means of a new surgical technique. Prosthet Orthot
Int. 2000;24(3):247-251.
Marquardt, E, Neff, G. The angulation osteotomy of above-elbow stumps. Clin Orthop Relat Res. 1974(104):232-238.
Abraham, E, Pellicore, RJ, Hamilton, RC, et al. Stump overgrowth in juvenile amputees. J Pediatr Orthop. 1986;6(1):66-71.
Wright, TW, Hagen, AD, Wood, MB. Prosthetic usage in major upper extremity amputations. J Hand Surg Am. 1995;20(4):619-622.
Kistenberg, RS. Prosthetic choices for people with leg and arm amputations. Phys Med Rehabil Clin North Am. 2014;25(1):93-115.
Carey, SL, Lura, DJ, Highsmith, MJ. Differences in myoelectric and body-powered upper-limb prostheses: systematic literature review. J
Rehabil Res Dev. 2015;52(3):247-262.This systemic review determined there is no significant advantage of a myoelectric prosthesis compared to a body-
powered prosthesis. A patient’s needs, preferences, and previous prosthetic experience should be considered. Body-powered prostheses are more durable,
require less training time, and provide greater feedback. Myoelectric prostheses offer greater cosmesis, reduce phantom-limb pain, and are better for
light-intensity work.
Lake, C, Dodson, R. Progressive upper limb prosthetics. Phys Med Rehabil Clin North Am. 2006;17(1):49-72.
Dumanian, GA, Ko, JH, O’Shaughnessy, KD, et al. Targeted reinnervation for transhumeral amputees: current surgical technique and update
on results. Plast Reconstr Surg. 2009;124(3):863-869.
Bowen, JB, Wee, CE, Kalik, J, Valerio, IL. Targeted muscle reinnervation to improve pain, prosthetic tolerance, and bioprosthetic outcomes in
the amputee. Adv Wound Care (New Rochelle). 2017;6(8):261-267.
Gorkisch, K, Boese-Landgraf, J, Vaubel, E. Treatment and prevention of amputation neuromas in hand surgery. Plast Reconstr Surg.
1984;73(2):293-299.
Urbanchek, MG, Kung, TA, Frost, CM, et al. Development of a regenerative peripheral nerve interface for control of a neuroprosthetic limb.
Biomed Res Int. 2016;2016:5726730.
Kuiken, TA, Dumanian, GA, Lipschutz, RD, et al. The use of targeted muscle reinnervation for improved myoelectric prosthesis control in a
bilateral shoulder disarticulation amputee. Prosthet Orthot Int. 2004;28(3):245-253.
Cheesborough, JE, Smith, LH, Kuiken, TA, Dumanian, GA. Targeted muscle reinnervation and advanced prosthetic arms. Semin Plast Surg.
2015;29(1):62-72.The TMR technique for transhumeral and shoulder disarticulation amputees is reviewed by the creators of this technique. Prosthetic
arm technologies are discussed.
Souza, JM, Cheesborough, JE, Ko, JH, et al. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop
Relat Res. 2014;472(10):2984-2990.
Kuiken, TA, Miller, LA, Lipschutz, RD, et al. Targeted reinnervation for enhanced prosthetic arm function in a woman with a proximal
amputation: a case study. Lancet. 2007;369(9559):371-380.
Gart, MS, Souza, JM, Dumanian, GA. Targeted muscle reinnervation in the upper extremity amputee: a technical roadmap. J Hand Surg Am.
2015;40(9):1877-1888.
Hebert, JS, Elzinga, K, Chan, KM, et al. Updates in targeted sensory reinnervation for upper limb amputation. Curr Surg Rep. 2014;2(3):1-
9.The evolution of TSR is discussed. The technique for sensory fascicle end-to-end is outlined.
Hebert, JS, Olson, JL, Morhart, MJ, et al. Novel targeted sensory reinnervation technique to restore functional hand sensation after
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transhumeral amputation. IEEE Trans Neural Syst Rehabil Eng. 2014;22(4):765-773.
Schofield, JS, Evans, KR, Carey, JP, Hebert, JS. Applications of sensory feedback in motorized upper extremity prosthesis: a review. Expert
Rev Med Devices. 2014;11(5):499-511.
Marasco, PD, Hebert, JS, Sensinger, JW, et al. Illusory movement perception improves motor control for prosthetic hands. Sci Transl Med.
2018;10(432).
Woo, SL, Kung, TA, Brown, DL, et al. Regenerative peripheral nerve interfaces for the treatment of postamputation neuroma pain: a pilot
study. Plast Reconstr Surg Glob Open. 2016;4(12):e1038.This is the first series to report on the outcomes of RPNI, in 16 patients. A reduction in
neuroma pain, phantom pain, and narcotic use was observed. 75% of patients were satisfied or highly satisfied with their RPNI surgery. Minimal
complications were reported.
Irwin, ZT, Schroeder, KE, Vu, PP, et al. Chronic recording of hand prosthesis control signals via a regenerative peripheral nerve interface in a
rhesus macaque. J Neural Eng. 2016;13(4):046007.
Sando, IC, Gerling, GJ, Ursu, DC, et al. Dermal-based peripheral nerve interface for transduction of sensory feedback. Plast Reconstr Surg.
2015;136(4 suppl):19-20.
Kuiken, TA, Marasco, PD, Lock, BA, et al. Redirection of cutaneous sensation from the hand to the chest skin of human amputees with
targeted reinnervation. Proc Natl Acad Sci USA. 2007;104(50):20061-20066.
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C H A P T E R 9 2
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Rheumatoid Arthritis and Inflammatory
Arthropathies
Brian P. Kelley and Kevin C. Chung
Key Points
Rheumatoid arthritis is a systemic disease affecting the synovium that may lead to multiple
derangements of the hands and wrists.
Inflammatory arthropathies are a spectrum of autoimmune diseases that require immunomodulatory
medical treatment.
For rheumatoid hand and wrist deformities, care should be taken to optimize the patient medically
and to manage more proximal disease before correction of distal derangements to prevent disease
flares and early recurrence.
Synovectomy, joint balancing procedures, and joint stabilizing procedures are the mainstays of
surgical treatment for rheumatoid arthritis.
Radiographic changes of the hand, including erosions and decalcification.
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Rheumatoid Arthritis
Rheumatologic and inflammatory arthroses are a broad spectrum of chronic, systemic diseases that often
involve the joints of the upper extremity and the skin. The most prevalent of the rheumatologic
conditions is rheumatoid arthritis (RA), but other diseases can result in an inflammatory arthritis of the
hand or other issues that generate consultations for plastic surgeons. RA affects about 1% of adults based
on population-level studies. 1-10 Importantly, the clinical presentation and severity can vary greatly among
patients and populations, but upper extremity complaints are a hallmark of the disease. Over the past
30 years, the medical management of RA has improved dramatically and, therefore, small joint disease
has also diminished in prevalence over those years. This is true of other diagnoses within the spectrum of
inflammatory joint disease, including RA, psoriatic arthritis, juvenile idiopathic arthritis (JIA, formerly
juvenile RA), or systemic lupus erythematosus (SLE). Despite a decrease in prevalence, upper extremity
inflammatory joint disease can be debilitating and can drastically reduce the quality of life for patients
due to recalcitrant pain and functional losses. Thus, hand surgeons and plastic surgeons should be aware
of surgical management options because these remain an important adjunct to systemic therapy for these
patients. Furthermore, in addition to a basic knowledge of typical RA, an understanding of other
inflammatory arthropathies will help the surgeon to guide the patient through treatment.
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Historic Background
Reconstructive surgery and hand surgery for patients with inflammatory arthritis have been established
as a key component in the overall care of rheumatoid arthritis, specifically for improvement in physical
deformity, ongoing functional loss, and pain. However, reconstructive procedures are not curative and
should not be viewed as such. Instead, reconstructive hand surgery may serve a prophylactic, functional,
or symptom-reducing role in managing the rheumatoid disease process. Before the 1950s, few surgeons
advocated surgery due to the risk of wound-healing complications, and physicians feared that surgical
intervention could reactivate the disease process. 11 However, the field became more prominent in the
1950s to 1960s. This coincided with surgical innovations in small joint surgery, improvements in systemic
management, and a better understanding of the disease process. Over the next decade, surgeons began
advocating prophylactic debulking of synovial nodules, small joint replacements, and tendon
reconstruction. Early options for small joint arthroplasty were described as early as 1961 by Adrian E.
Flatt. 12 The doctrines for management of RA-affected soft tissues, tendons, and joints have not changed
significantly since then. In a review of the current principles of rheumatoid surgery in 1962, Dr. Flatt
noted key factors in successfully navigating patients through rheumatoid surgery:
1. Treat the Systemic Disease: “No doubt drugs rather than the scalpel will ultimately conquer
rheumatoid disease… Although rheumatoid arthritis of the hands cannot be cured by surgery, it
seems wrong to stand aside and let crippling deformities develop.”
2. Prevent Progression of the Deformity: “Treatment of rheumatoid hand should be prophylactic.
Splinting, drug therapy, and physiotherapy have their place in the care of patients.”
3. Establish the Foundation Proximally: “… to correct a deformity within the hand is profitless if the
(wrist) elbow and shoulder are so badly afflicted that the hand cannot be moved …”
4. Do Not Overcomplicate Simple Interventions: “Simple mechanical problems such as tendon rupture,
stenosing tenovaginitis, and trigger tendon can be solved by basic principles.”
To understand improvements in rheumatoid hand surgery, an awareness of historical advancements in
systemic treatment is also necessary. Epidemiologically, the number of patients with RA seeking care for
rheumatoid hand disease has slowly declined with the increase of disease-modifying antirheumatic drugs
(DMARDs). The term disease-modifying drug has been used to describe both synthetic and biologic
medications used to reduce the disease burden as adjuncts to glucocorticoid therapy. 13 Synthetic options,
such as gold (1930s), hydroxychloroquine (1950s), azathioprine (1960s), methotrexate, or sulfasalazine
(1980s), have been present for a long period. The newer of which still have roles in multimodal disease
treatment. With the advent of biologic DMARDs in the 1990s, the prevalence of hand and wrist deformity
began to fall more dramatically resulting in fewer patients with deforming hand disease. 14,15
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Epidemiology and Disease Impact
In the past decade, studies have shown a prevalence of rheumatoid arthritis of approximately 1%,
ranging from 0.33% to 6.8%. 16 The overall trend, however, is a decreasing prevalence of RA since the
1960s. 17,18 In the United States, there is a growing population of elderly patients with RA compared with
decreasing prevalence in younger age groups compared with the prevalence in prior decades. 18 A small
percentage of patients with systematic disease advance to symptomatic hand deformity, and hand
disease progression is often used as a marker of disease severity. In studies of Medicare beneficiaries with
a diagnosis of RA between 2006 and 2010, hand and wrist joint procedures were performed at an annual
rate of approximately 23.1 per 10,000 patients and tendon reconstruction occurred at a rate of 4.2 per
10,000 patients. 19 Therefore, surgical interventions for hand reconstruction, even in patients with a
diagnosis of RA, remain infrequent. This result is likely a combination of variations in disease prevalence
and availability of subspecialty care in different regions. 20,21 However, the true impact of RA includes loss
of work production, loss of capital, higher healthcare costs, decreased quality of life, and opportunity
costs. RA, like osteoarthritis, is associated with higher rates of depression than the general population.
Pooled data from meta-analysis suggest depression in 16.8% of patients with RA. 22
RA usually manifests in the third to sixth decade of life, but disease severity is commonly linked to the
age of onset. 23 Earlier age of onset has also been associated with higher economic burden for both
patients and health systems. There have been links to suggest high prevalence of RA in northern
latitudes, but, interestingly, younger age of onset is associated with females and latitudes at the Tropic of
Cancer. 24 The relationship to the tropics may represent geographic, environmental, or socioeconomic
factors, and the causal relationship is unclear. Finally, certain ethnic groups such as the Pima Indians
have demonstrated higher prevalence compared with the general population. 1
There is a genetic component to RA, but a single, explicit hereditary etiology has not been found. A
family history of RA increases the lifetime risk from three-fold to five-fold. 25 Furthermore, twin
concordance rates also suggest genetic factors in inheritance. 26 Prior studies have estimated the genetic
contribution to rheumatoid disease to be between 40% and 65% for rheumatoid factor (RF) seropositive
disease, but less than 20% for RF seronegative disease. 16 This uncertainty is complicated by evidence
from genome-wide analysis identifying more than a hundred gene loci associated with rheumatoid
arthritis risk, many with overlapping loci for other inflammatory conditions. 27
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Diagnosis, Pathophysiology, and Medical Treatment
When untreated, RA may induce multiple pathologic abnormalities in the upper extremity. Other
arthropathies are discussed in this chapter in brief, but rheumatoid arthritis will be covered in more detail
because it is the most common presentation of inflammatory hand arthropathy. Appropriate diagnosis of
joint pain can be difficult when patients present with symptoms but no prior medical workup. Surgeons
should be prepared to recognize inflammatory conditions and make appropriate diagnoses in these cases.
In patients with unexplained upper extremity joint pain and no clear history of trauma, laboratory
evaluation and appropriate specialty referrals are critical to improving the patient’s overall condition. In
general, symmetric hand pain lasting 6 weeks or longer without a known etiology should prompt
consideration of inflammatory arthropathy in the differential diagnosis. 28 Table 92.1 lists common
laboratory studies in the diagnosis of rheumatoid arthritis and other inflammatory arthropathies.
Diagnosis requires consistent history and physical exam, a history of polyarthropathy for 6 weeks or
more, laboratory analysis, and the exclusion of other causes of arthropathies. 29 Table 92.2 provides
diagnostic criteria used to confirm RA.
TABLE 92.1
Common Laboratory Testing for Inflammatory Arthropathies
Test Name
Diagnosis b
Implications
Other Conditions a
RF
RA
Nonspecific, must correlate
clinical history.
MCTD (50%–60%), cryoglobulinemia (40%–
100%), Sjogren’s (75%–95%), SLE (20%–30%),
healthy subjects (5%–10%)
High titers (>50 IU/mL) 91%–96% specific,
but low sensitivity (45%–54%). May suggest
late disease severity
ESR
Nonspecific
Acute phase reactant,
inflammatory marker
Many
CRP
Nonspecific
Acute phase reactant,
inflammatory marker
Many
ANA
SLE
High sensitivity (93%), but
nonspecific
RA (41%), scleroderma (85%), polymyositis
(61%), MCTD (100%), healthy subjects (up to
5% even with high titers)
High ANA titer (>1:160) and
positive RF, likely to develop
RA over SLE
High ANA titer and negative
RF, inconclusive
Low ANA titer (<1:80), low
probability of SLE, but may
develop other disease
Anti-dsDNA
SLE
25%–85% sensitive, 99%
specific
Drug-induced or infection-induced anti-
dsDNA can occur in RA, but is not related to
the disease
Anti-SSA/Ro
Sjogren’s
syndrome
Seropositive in 30% of SLE
with skin involvement
SLE
Anti-SSB/La
Sjogren’s
syndrome
Anti-CCP1
RA
44%–56% sensitive, 90%–97%
specific
Used in combination are becoming standard
for early RA diagnosis
Anti-CCP2
RA
64%–89% sensitive, 88%–99%
specific
Anti-Smith
SLE
26% sensitive, 99% specific
Confirmatory test for SLE
Anti-MCV
RA
62% sensitive, 92.9% specific
Psoriatic arthritis, spondyloarthropathy
Scl-70
Scleroderma
20%–43% sensitive, 90%–
99.6% specific
Confirmatory test for scleroderma
aDenotes other conditions in which this test may be positive.
bDenotes most common diagnosis the test is ordered for or classically thought to imply.
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RF, rheumatoid factor; ESR, erythrocyte sedimentation rate; CRP, C reactive protein; ANA, antinuclear antibody; anti-dsDNA, double-
stranded DNA; anti-SSA/Ro, anti-Sjogren’s syndrome antigen A; anti-SSB/La, anti-Sjogren’s syndrome antigen B; anti-CCP, cyclic
citrullinated peptides anti-MCV, anti-modified citrullinated vimentin; Scl-70, anti-topoisomerase 1; RA, rheumatoid arthritis; SLE, systemic
lupus erythematosus; MCTD, mixed connective tissue disease.
TABLE 92.2
American College of Rheumatology/EULAR Collaborative Diagnostic Criteria for Rheumatoid Arthritis
Criterion/Symptom
Score b (0–10)
A. Joint involvement a
1 large joint
2–10 large joints
1–3 small joints
4–10 small joints
>10 joints (at least 1 small)
0–5
0
1
2
3
5
B. Serology (at least 1 necessary)
Negative RF and negative anti-CCP
Low-positive RF or low-positive anti-CCP
High-positive RF or high-positive anti-CCP
0–3
0
2
3
C. Acute-phase reactants (at least 1 necessary)
Normal CRP and normal ESR
Abnormal CRP or abnormal ESR
0–1
0
1
D. Duration of symptoms
<6 weeks
>6 weeks
0–1
0
1
aLarge joints are shoulder, elbow, hips, knees, and ankles; Small joints are MCP, PIP, metatarsophalangeal, and wrist joints.
bScore ≥6 indicates definite RA. Score <6 may develop RA later, but cannot be diagnosed.
As a systemic disease, RA is classically associated with chronic polyarthritis; however, extra-articular
manifestations should not be overlooked. These include, but are not limited to, vasculitis, pericarditis,
pleural effusion, interstitial pulmonary disease, neuropathy, keratoconjunctivitis sicca, and osteopenia.
Rheumatoid nodules are a common cause for referral to plastic surgeons but are present only in a
minority of RA patients. Nodules are commonly located on extensor pads associated with synovitis but
can appear in multiple extra-articular tissues including eyes, lungs, or vocal cords.
Medical management of RA is the cornerstone to both long-term disease control and surgical risk
reduction. Table 92.3 outlines common medications used in the management of inflammatory
arthropathies, mechanism of action, and perioperative considerations. Medications used in the treatment
of RA and other inflammatory arthropathies are not without risks. For instance, corticosteroids and
DMARDs are typically used to halt synovitis and slow disease progression. However, these drugs target
the patient’s immune system and reduce their ability to respond to antigens and pathogens. Thus, these
may predispose the patient to infections, malignancy, or wound-healing issues. Other medications,
including over-the-counter antiinflammatory drugs or pain medications, may be frequently used in the
treatment of disease-associated pain. Nonsteroidal antiinflammatory drugs (NSAIDs) may predispose
patients to gastrointestinal and renal adverse events. Narcotics are discouraged for chronic use given
their risks for addiction/dependence, tachyphylaxis, and overdose.
TABLE 92.3
Medical Treatment of Inflammatory Arthropathies
Medication
Mechanism of Action
Perioperative Management
Corticosteroids
Steroid hormone
Continue at normal dosing
Alters gene activation
Consider stress-dose corticosteroid at time
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of surgery
Methotrexate
Inhibition of dihydrofolate reductase
(DHFR)
Continue at normal dosing
Synthetic DMARDs
Various
Discuss with rheumatologist, many are seldom used
Biologic DMARDs
Tumor necrosis factor alpha (TNF-α)
inhibitor
Discuss with rheumatologist, in general consider
holding 2–4 weeks
Etanercept, adalimumab, infliximab
Anakinra
Interleukin-1 (IL-1) inhibitor
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Anatomy, Disease Progression, and Surgical Options
In the setting of poor systemic control, rheumatoid arthritis often progresses in a predictable pattern.
Synovitis presents around multiple joints leading to bony erosions, joint instability, and tendon attrition.
Synovium is the pathologic tissue affected in RA. In affected synovium, a pannus of proliferating
synovitis expands. This can cause both a compressive and enzymatic joint injury. Ongoing growth and
inflammation propagate the subsequent joint and soft-tissue destruction. Proteolytic enzymes released
within the joint can directly damage bone, cartilage, and synovium. Any synovial joint may be affected,
but hand involvement is often seen as a hallmark of disease development. The metacarpophalangeal
(MCP) joint, proximal interphalangeal (PIP) joint, and wrist are often affected first, presumably due to the
relatively high synovial surface area. Secondarily, large joints such as the elbows, knees, hips, shoulders
are affected. Even small articular surfaces, such as the ossicles of the middle ear, can be involved.
Plastic surgeons are seldom called on to manage the orthopedic pathology of the large joints in RA but
may be consulted if the soft tissues are tenuous. In these cases, wound-healing issues may prompt a need
for flap coverage in elbow or knee operations. In other cases, patients may present with synovitic
rheumatoid nodules around large joints. Rheumatoid nodules may be unsightly, painful, irritating to
adjacent tendons, or cause nerve compression. In most cases, rheumatoid nodules can be simply excised
alone or as part of a procedure to correct comorbid issues (Figure 92.1). For example, a cubital tunnel
decompression may be necessary if the ulnar nerve is impinged at the elbow and may include removal of
synovitis and osteophytes. Synovectomy should be combined with other joint and tendon repairs to
prevent recurrence of the deformity due to continued attrition.
FIGURE 92.1 A. Rheumatoid nodules often affect the extensor surfaces or the elbow. B–D. Synovitis of the wrist and digits
can often be surgical excised at the time of other procedures.
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In contrast to large joint afflictions, most deformities associated with rheumatoid arthritis involve the
hands and wrist. There are many pathologic abnormalities that can develop at each of the joints of the
hands, but the distal interphalangeal joint (DIP) joint is often spared in RA (Figure 92.2). Bony erosions
are first noted on radiographs at joint edges and vascular channels for nutrient vessels because of
synovitis’ direct access to the bone. On radiographs, early wrist erosions appear at the scaphoid waist,
ulnar styloid, and the distal radioulnar joint (DRUJ). In RA, synovitis typically affects the radiocarpal
joint more than the midcarpal joint. Eventually, as the severity worsens, the wrist demonstrates
radiocarpal collapse, volar translation, and angulation of the lunate with compensatory midcarpal
extension (Figure 92.3). End-stage arthritis of the wrist generally falls into one of three categories:
ankylosis, arthritic stable, or arthritic unstable (which can be due to osteolysis or ligamentous
attenuation). Ankylosis, or autofusion of the radiocarpal joint, is often in acceptable alignment and
interventions can be minimized. For arthritic stable or unstable joints, fusion or salvage procedures are
often necessary to improve wrist stability and preserve function (Figure 92.4).
FIGURE 92.2 In RA, there is progressive collapse of the upper extremity with joint deviation secondary to attenuation of
supporting ligaments. Radial deviation and dorsal translocation of the ulna contribute to ulnar deviation at the MCP joints due to
attenuation of the radial sagittal band. Attenuation of the volar plate and digital extensor apparatus may lead to boutonniere or
swan-neck deformity. Rheumatoid nodules from synovitis may attenuate the radial sagittal band leading to ulnar deviation of the
MCP joint and ulnar subluxation of the extensor tendons.
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FIGURE 92.3 Wrist and hand plain PA radiographs demonstrating severe hand and wrist deformities associated with chronic,
poorly controlled RA.
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FIGURE 92.4 PA radiographs for selected wrist salvage procedures for DRUJ or radiocarpal arthritis. A. Darrach procedure
(ulnar head excision). B. Suave-Kapandji procedure (distal radio-ulnar fusion). C. Total wrist arthroplasty. D. Total wrist
arthrodesis.
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Synovitis around the wrist joint often involves the extensor compartments and may grow around the
tendons within the extensor retinaculum. This can lead to attritional ruptures. This process is
compounded by dorsal prominence of caput ulnae leading to progressive tendon ruptures from ulnar to
radial along the dorsal wrist. This process is known as Vaughan-Jackson syndrome (Figure 92.5). Tendon
ruptures are often sudden and are usually painless, though synovitis may be painful at the site before the
rupture. Osteophytes on the radius or carpus can also lead to tendon attrition. For example, scaphoid
osteophytes or synovitis can lead to attrition of the flexor pollicis longus (FPL) tendon, also known as a
Mannerfelt lesion. Synovitis in this area may also contribute to carpal tunnel syndrome or triggering
digits. Tendon reconstruction is most often achieved through tendon transfers. In general, once a
musculotendinous unit has ruptured, that muscle is no longer useful in the setting of RA. Therefore,
tendon transfers offer reconstruction of the motor unit at the cost of some strength to the donor site. The
principles behind tendon transfers are covered in more depth elsewhere, but the key points are to borrow
tendons with redundancy and to progress along an algorithm with care to preserve options for future
transfers (Table 92.4).
FIGURE 92.5 A. Vaughn-Jackson syndrome with progressive ulnar-to-radial rupture of extensor tendons. B. In this case, EIP
and EDC to small, ring, and middle were ruptured. C. EDC to index was preserved, and ECRL was transferred to reconstruction
small, ring, and middle extension.
TABLE 92.4
Tendon Transfers for Attritional Rupture
Finger Impairment
Diagnosis
First Line Transfer
Rescue
Small extension
Rupture of EDM/EDC to small
End-to-side EDM and SF EDC to
EDC of ring
Small, ring extension
Rupture of EDM and EDC to small and
ring
EIP transfer to EDC of ring and
small
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Small, ring, and middle extension
Rupture of EDM and EDC to small, ring,
and middle
EIP transfer to EDM, EDC of ring
and small
End-to-side of EDC to middle to
EDC index
Small, ring, middle, and index
extension
Rupture of EDM, EIP, and EDC to all
digits
FDS middle to EDC index and
middle
FDS ring to EDM, EDC of ring and
small
Thumb extension
EPL rupture
EIP to EPL
ECRL to EPL
EDM to EPL
Thumb, small, ring, middle, & index
extension
EPL rupture
FDS middle to EPL & EDC index
and middle
Rupture of EDM, EIP, and EDC to all
digits
FDS ring to EDM, EDC of ring and
small
Thumb flexion
FPL rupture
BR to FPL
ECLR to FPL
FDS long to FPL
Thumb IP joint
fusion
Independent PIP joint flexion
FDS rupture
PIP joint synovectomy to protect
FDP
No transfer
DIP joint flexion
FDP rupture
DIP joint arthrodesis
Tenodesis of DIP
joint
Loss of PIP and DIP joint flexion
FDP and FDS rupture
Staged flexor tendon
reconstruction
EDM, extensor digiti minimi; EDC, extensor digitorum communis; EIP, extensor indicis proprius; EPL, extensor pollicis longus; FDS, flexor
digitorum superficialis; FDP, flexor digitorum profundus; BR, brachioradialis; ECRL, extensor carpi radialis longus; PIP, proximal
interphalangeal joint; DIP, distal interphalangeal joint.
Deformity of the digits is common with involvement of the MCP and PIP joints and relative sparing of
the DIP joints. At the MCP joint, patients often complain about the inability to fully extend their fingers.
This can be secondary to ulnar subluxation of the extensor tendon due to attenuation of the radial sagittal
band or due to progressive subluxation and volar translation of the proximal phalanx on the metacarpal
head. A combination of ulnar forces during key pinch and radial deviation at the wrist often contribute to
the ulnar vector on the tendons and digits. Very rarely, loss of extension can be due to compression on
the posterior interosseous nerve that innervates all the extensor tendons. Ulnar subluxation of the tendon
between the metacarpal heads causes a relative loss of mechanical advantage thus making full extension
difficult. To rule out tendon ruptures, the digits can be passively reduced. If the patient can maintain the
finger in extension once passively corrected, then the tendon must be intact. Before treating the acquired
deformity, surgery to correct the wrist and extensor retinaculum synovitis should be performed to
prevent early recurrence of the MCP deformities. Once the proximal issues are stabilized, surgery to
correct MCP joint deformities depends on the state of the articular surface. Passively correctable ulnar
translation of the joint or tendons can be corrected with soft-tissue surgeries such as extensor tendon
centralization (typically a synovectomy and radial sagittal band imbrication) or a cross-intrinsic tendon
transfer to apply more dynamic radial force. However, if the digit is shortened, irreducible, or the
articular erosions are severe (Figure 92.6), first-line management is often joint replacements with silicone
metacarpophalangeal arthroplasty (SMPA; Figure 92.7). In contrast, the PIP joint, wrist, and elbow are
treated with joint replacement in only select cases.
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FIGURE 92.6 A. Patient radiographs with irreducible ulnar-volar subluxation of the MCP joint of multiple digits. B. After
silicone implant arthroplasty, improvement is seen, with alignment of the MCP joint.
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FIGURE 92.7 Silicone implant arthroplasty of the MCP joints demonstrating implant appearance and placement.
The two most common intrinsic digital imbalances are the swan-neck and boutonniere deformities. Both
deformities can occur in the same hand in different digits (Figure 92.8), but swan-neck is more common
than boutonniere. A swan-neck deformity is characterized by flexion of the DIP joint, hyperextension of
the PIP joint, and flexion of the MCP joint (Figure 92.9). In swan-neck, the anatomic derangement can
occur at any of the three joints of the finger (MCP, PIP, or DIP joints), and Table 92.5 lists possible
etiologies for swan-neck deformity at each joint. Treatment depends on the severity of the deformity and
whether the PIP joints are actively and passively reducible. Treatment options include figure-of-eight ring
splints and therapy (actively reducible joints, mild deformity), soft-tissue reconstruction (passively
reducible joints, minimal arthritic changes), and arthrodesis (PIP joint changes, irreducible joint).
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FIGURE 92.8 Patient with mixed finger deformities. There is swan-neck deformity of the middle and ring fingers. There is z-
deformity of the thumb and a boutonniere of the index and small fingers. MCP joint synovitis (*) and ulnar subluxation of the
extensor tendons (arrow) are also shown.
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FIGURE 92.9 Swan-neck deformity is a disturbance of joint balancing that may result from changes at any of the joints of the
finger. The finger is balanced by a combination of the intrinsic and extrinsic flexors and extensors. Specifically, the extensor
apparatus acts to coordinate fine distal motion. With RA, the balancing forces are perturbed and a deformity can occur. At the
MCP joint, flexion can result from tightness or flexion contracture on the volar surface or an extensor rupture at the level of the
proximal phalanx. At the PIP joint, attenuation of the volar plate or rupture of the FDS tendon can result in hyperextension. At
the DIP joint, classically a terminal tendon attenuation or traumatic mallet finger result in flexion. Any one of these, over time,
can influence the joints around it resulting in the swan-neck appearance.
(From Kelley, BP, Chung, KC. Correction of swan-neck deformity. In: Chung, KC , ed. Operative Techniques in Hand and Wrist Surgery . 3rd ed.
Philadelphia, PA: Elsevier; 2018:350.)
TABLE 92.5
Causes of Swan-Neck Deformity by Joint Location
MCP Joint
PIP Joint
DIP Joint
Dorsal
Attenuation
of
extensor
hood
attachments at P1 base
Skin tightness
Joint destruction
Rupture of terminal tendon
Attenuation of the oblique retinacular or
triangular ligaments
Volar
Attenuation of volar plate
Flexor tenosynovitis
Tendon adhesions
Intrinsic muscle contracture
Skin tightness
Attenuation of volar plate
Attenuation
of
transverse
retinacular ligament
Dorsal translation of conjoint
lateral band
Rupture of flexor digitorum
superficialis
In contrast to swan-neck, the boutonniere deformity is caused by pathology intrinsic to the PIP joint. In
boutonniere, the most common cause of deformity is attenuation and rupture of the central slip of the
extensor tendon leading to retraction of the proximal extensor apparatus and flexion of the PIP joint. Over
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time, the proximal and volar vector of force translates the collateral bands volar to the axis of the PIP
joint. This traction results in tightness along the triangular ligaments and hyperextension of the DIP joint
(Figure 92.10). Surgical correction of the boutonniere deformity also depends on the motion at the PIP
joint and the suitability of the patient for reconstruction. In general, this is accomplished by a
combination of central slip reconstruction and dorsal transposition of the lateral band/transverse
retinacular ligament (passively reducible defect, minimal arthritic changes), or extensor tenotomy and
volar plate release (intrinsic stiffness of PIP joint, minimal arthritic changes). Finally, arthrodesis can be
considered for cases with more severe arthritic changes at the PIP joint.
FIGURE 92.10 In contrast to swan-neck deformity, boutonniere deformity results from attenuation or rupture of the central slip
of the extensor tendon at the PIP joint. This causes flexion of the PIP joint. Retraction of the central slip and proximal extensor
apparatus tightens the collateral ligament and moves the axis of the joint volar. This tightening leads to DIP joint
hyperextension.
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Thumb deformities in RA are somewhat different than the phalanges. Derangements can be grouped into
five general categories:
Type I: Boutonniere deformity (most common)
Type II: Boutonniere deformity with carpometacarpal (CMC) joint dislocation or subluxation
Type III: Swan-neck deformity with metacarpal adduction
Type IV: Gamekeeper’s deformity (attenuation of MCP ulna collateral ligament)
Type V: Swan-neck deformity without metacarpal adduction deformity
Management for thumb anomalies is largely dependent on stabilization of the metacarpophalangeal (MP)
joint and tendon reconstructions. Often, arthrodesis of the MCP joint is the best solution to establish
stability of the MCP joint. CMC arthroplasty can be considered if the CMC joint is painful, but a focus
should be placed on maintaining palmar abduction for grip using the first webspace. 30-34
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Nonrheumatoid Inflammatory Arthropathies
Nonrheumatoid inflammatory arthropathies have a spectrum of diverse clinical findings, but often have
similar effects on function and appearance. It is important to keep the underlying systemic disease in
mind when developing a treatment plan, as subtle differences in pathophysiology may change surgical
options. For example, patients with SLE-related arthritis may present with similar findings as RA, such as
ulnar subluxation of the extensor tendons. However, SLE deformity is more likely to be the result of soft-
tissue attenuation and laxity with sparing of the MCP joints. Most patients complain of pain with
activities, but also note limited motion, dissatisfaction with appearance, and pain at rest. 35-37
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Epidemiology of Inflammatory Arthropathies
There are some epidemiologic differences in RA compared to other inflammatory arthropathies. For
example, JIA has an incidence of around between 2 and 20 cases per 100,000 people per year, and a
prevalence of around 16 to 150 cases per 100,000 in the general population. 38 The overall prevalence may
have decreased over recent decades from the 1980s to 1990s. 39,40 JIA also appears to occur less frequently
in African American and Asian populations compared to Caucasians. 17,41 JIA is a diagnosis made before
the age of 16 years and may have environmental and genetic contributions unique from typical RA.
Diagnosis of JIA includes a spectrum of similar conditions, including arthritis types: RF positive, RF
negative, polyarticular, systemic, psoriatic, and others. 38
SLE-related arthritis has an overall disease prevalence of between 40 and 103 per 100,000 with an
estimated 9- to 10-fold higher rate in women. 17 In an Egyptian population, arthritis was present in about
77.8% of patients with SLE, whereas Raynaud phenomenon was present in 14.7%. 42 Retrospective studies
estimate a rate of depression of approximately 13% in patients with SLE. 43 This compares to an estimated
6.7% prevalence of depression in the general population of the United States. This speaks to the
propensity of patients with inflammatory arthroses to experience higher rates of depression-related
disability.
Psoriatic arthritis, which is sometimes grouped with spondyloarthropathies, may affect about 101 per
100,000. 17 Approximately 5% of psoriatics may have a variation of inflammatory arthropathy, which can
present before cutaneous manifestations 15% to 20% of the time. Psoriatic hand deformity can include
nail deformities in about 80% of patients, but these are less frequent (15%) in patients with psoriatic
arthritis variants.
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Clinical Characteristics of Specific Conditions
Juvenile Idiopathic Arthritis (JIA; Juvenile RA)
Different from typical adult RA, JIA is not a single disease. JIA is a heterogenous group of related
diseases with onset before the age of 16 years with a constellation of arthritic changes. Disease etiology is
multifactorial, and the causal pathologic cell-type has been traced to multiple immunologic mediators,
including T cells and macrophages. Classic variants, which are still poorly categorized, include
polyarthritis, oligoarthritis, and systemic disease. Polyarticular disease is typically related to RF positivity
and affects about 5% of JIA patients. RF-positive polyarthritis is similar to adult RF-positive RA in natural
history and pathophysiology. However, JIA oligoarthritis can be subdivided into persistent oligoarthritis
(affects <4 joints without increase) and extended oligoarthritis (initially affects <4 joints but increases to >4
joints after first 6 months from onset). The systemic characteristics of JIA, termed Still disease, are well
characterized and include a constellation of features, such as fever, rash, and serositis. The adult variant
of this is termed Adult-Onset Still Disease and has a similar symptom pattern. Finally, about 35% to 40%
of JIA patients will be HLA-B27 positive. Ongoing monitoring at up to 3 to 6 month intervals for
functional loss and disease staging should be considered in cases of JIA, 44 but surgical interventions for
should be delayed until medical management is initiated. A delay in surgical intervention may also be
appropriate to allow patients to achieve skeletal maturity. However, in principle, specific anatomic
pathology is managed by the same techniques as adult RA.
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Psoriatic Arthritis
Psoriatic arthritis is an inflammatory arthropathy that affects around 30% of patients with psoriasis and is
associated with obesity, positive family history, and HLA-B27 positivity. 45 Classic hand-related clinical
features include fusiform swelling of fingers and toes, nail changes (pitting, thickening, or detachment),
and psoriatic skin plaques (typically hyperkeratotic, red, scaly plaques over extensor skin). Psoriatic
arthritis of the hands typically affects the DIP joint, in contrast to RA where the DIP joint is typically
spared. A severe form of inflammatory arthropathy of the hands, known as arthritis mutilans (Figure
92.11), is common in psoriatic arthritis. Arthritis mutilans causes acroosteolysis of the phalanges, pencil in
cup joint changes, and telescoping (opera-glass hands) of the digits. For arthritis of the DIP joint or in cases
of arthritis mutilans, surgical options may be limited. In many cases, arthrodesis is the only surgical
option that may maintain digit length and reduce pain.
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FIGURE 92.11 PA radiograph of patient with arthritis mutilans. Note acroosteolysis of PIP joints and calcinosis of the middle
finger PIP joint. The telescoping of the ring finger notable on the soft-tissue silhouette is indicative of opera glass deformity due
to the resemblance to classic opera binoculars.
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Systemic Lupus Erythematosus
Multiple systems may be affected in SLE, but joints and skin are involved in up to 90% of patients with
the disease. In fact, hand involvement is a common reason for patients to seek healthcare leading to the
diagnosis. 37 Common deformities are similar to RA and include swan-neck deformity, ulnar deviation of
digits, subluxation of the MCP joints, and boutonniere deformity of the thumb. In contrast to RA, erosive
arthritis and loss of articular surfaces are not typical. This clinical constellation results in a classic Jaccoud
arthropathy where the deformity is the result of soft-tissue laxity and ligamentous shortening rather than
from direct destruction of the joints. Systemic signs of SLE include malar rash, sun sensitivity, nail
deformity, kidney disease, gastrointestinal disease, nervous system complaints, and lymphadenopathy.
Surgery for hand deformity in SLE is similar to RA, but there is less need for arthroplasty and arthrodesis
as these patients may be spared joint destruction. Soft tissue surgery and joint balancing are the mainstay
when joint degeneration is not present.
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Scleroderma (Systemic Sclerosis)
Scleroderma is an autoimmune connective tissue disease affecting about 191 per 100,000 people and
commonly presents with both cutaneous sclerosis and hand manifestations. Classically, scleroderma
involves soft-tissue fibrosis with collagen deposition, and vaso-occlusive changes. However, multiple
systems can be affected in the disease. For instance, CREST syndrome is an abbreviation for an expanded
variant with calcinosis, Raynaud phenomena, esophageal dysmotility, sclerodactyly (sclerosis of digital
skin causing flexion deformity), and telangiectasia. Surgical interventions for a plastic surgeon may
include lipotransfer,
46 wound management, excision of calcinosis, temporomandibular joint
reconstruction, and management of extremity effects of sclerosis and ischemia. Medical interventions
may include DMARDs and myeloablative stem cell transfers 47 —not to be confused with the loose
terminology of autologous fat graft as a stem cell source. Management of digital wounds may include
botulinum toxin or sympathectomy to reduce vasospasm, amputation of nonviable digits, debridement of
calcinosis, arterial bypass, or arterialization of the venous system in cases without distal targets.
However, outcomes in scleroderma are often poor in the long term, and patient mortality is high with
only a 70% to 80% 10-year survival rate.
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Reiter Syndrome (Reactive Arthritis)
This reactive autoimmune arthritis is also related to patients with HLA-B27 positivity. The syndrome
usually manifests 1 to 3 weeks after a known bacterial infection (common species include chlamydia,
ureaplasma, salmonella, shigella, yersinia, and campylobacter). The classic triad involves urethritis,
conjunctivitis/uveitis, and hand/foot arthritis. Dactylitis with fusiform swelling of a single digit (sausage
digit) is a hallmark finding. About 10% of patients with chronic reactive arthritis may develop cardiac
manifestations. Joints affected are typically monoarticular and often at the knees or sacroiliac joints. The
glabrous skin on the plantar feet and palms of the hands may develop keratoderma blennorrhagicum
(waxy, vesico-pustular skin lesions with a yellow-brown coloration or may appear similar to psoriatic
plaques), which is pathognomonic for reactive arthritis even in the absence of the triad. Reactive arthritis
may be self-limiting, but chronic changes and recurrent bouts of acute arthritis can occur in up to 15% to
30% of patients. Treatment is largely medical and can be similar to other inflammatory arthropathies.
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Mixed Connective Tissue Disease
This inflammatory arthropathy is often a mixed variant of SLE and RA. Systemic pulmonary and
gastrointestinal complaints are common. Compared to SLE, erosions do occur, but are often less severe
than those encountered in RA. However, swan-neck deformity and ulnar subluxation can be severe when
present and there is a connection with severe osteolysis leading to arthritis mutilans.
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Questions
1. A 38-year-old woman presents with a 6-month history of bilateral hand and wrist pain with dorsal
swelling. On examination, there is boggy swelling and extensor tenosynovitis. Laboratory analysis
reveals elevated erythrocyte sedimentation rate and positive rheumatoid factor. Which of the
following is most important for the patient’s long-term outcome?
a. NSAIDs and splinting
b. Surgical synovectomy
c. Kenalog injection into the symptomatic area
d. Referral to rheumatology
e. Observation and repeated labs in 6 months
2. Biological DMARDs, such as etanercept (Enbrel), infliximab (Remicade), or adalimumab (Humira),
used in treatment of rheumatoid arthritis work by what mechanism of action?
a. Binding of cell messenger protein IL-1
b. Antagonism of DNA modification
c. B-cell depletion
d. Blockade of T-cell activation
e. Tumor necrosis factor binding
3. A patient with known rheumatoid arthritis presents noting an inability to extend her right long
and ring fingers actively. The joints are noted to be supple, and she can hold the finger in extension
once passively extended to neutral. Which of the following is the most likely etiology of this
complaint?
a. Rupture of the junctura tendinae
b. Extensor subluxation at the MP joint
c. Posterior interosseous nerve compression
d. Extensor tendon rupture
e. Caput ulnae
4. A patient with boutonniere deformity secondary to rheumatoid arthritis is being evaluated for
extensor tendon reconstruction. Which of the following would be a contraindication to this
procedure?
a. Rheumatoid nodules at the surgical site
b. Mild degenerative joint changes
c. History of silicone MP joint replacements
d. Stiffness at the DIP joint
e. Stiffness at the PIP joint
5. A 35-year-old female smoker with juvenile idiopathic arthritis presents with painful cold
intolerance involving bilateral fingers and hands. On examination, there are ulcerations at the tips of
multiple digits. An angiogram is ordered and reveals no occlusive disease proximal to digit vessels
and no obvious bypass targets. Which of the following is the preferred initial treatment?
a. Oral calcium channel antagonist
b. Botulinum neurotoxin A
c. Avoidance of cold, tobacco, and vasoconstrictors
d. Surgical sympathectomy
e. Arterialization of the venous system
1. Answer: d. Wrist splinting, NSAIDs, and steroid injections are all conservative measures for
tenosynovitis. In this case, however, the clinical picture and laboratory findings are specific for RA.
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Studies have shown that initiating DMARDs within 3 months of diagnosis leads to a significant
decrease in disease morbidity. Options for medical treatment include anti-TNF alpha drugs or
recombinant IL-1 antagonists. These, used in concert with methotrexate, can be effective in
modifying the inflammatory response and subsequent joint destruction.
2. Answer: e. Multiple drugs can be used in combination to medically treat RA. DMARDs such as
infliximab, etanercept, or adalimumab are all considered biologic DMARDs and modify the patient’s
immune system by binding tumor necrosis factor using engineered antibodies.
3. Answer: b. Patients with RA may be unable to actively extend the fingers for a variety of reasons
and a clear understanding of the anatomy is necessary to make appropriate diagnoses in these cases.
Possible causes include rupture of extensor tendons, posterior interosseous nerve palsy, subluxation
of the extensor tendons over the metacarpal heads, and volar subluxation with contracture of the
metacarpophalangeal joints. In this case, subluxation of the tendon is the appropriate choice because
the other options can be ruled out. The extensor tendon is intact as the patient can maintain extension
once the finger is positioned, the joints are supple without subluxation or contracture, and the
muscles are functioning ruling out PIN nerve palsy. Caput ulnae can lead to tendon attrition or
rupture but is not typically associated with extensor lag.
4. Answer: e. Boutonniere deformity is a condition of the PIP joint and therefore reconstruction
options are limited in cases where the joint is not supple. Typically, tendon reconstructions are not
performed unless the joint has adequate range of motion. The other choices may add considerations
to reconstructive procedures but are not contraindications.
5. Answer: c. This patient presents with Raynaud’s phenomenon, and the initial primary treatment
should include lifestyle modifications such as avoidance of cold, tobacco or vasoconstrictors. Medical
therapy can be considered if symptoms persist or worsen beyond mild symptomatology. Botulinum
neurotoxin A is recognized now for use in Raynaud’s and is theorized to reduce perivascular
sympathetic response. Surgical sympathectomy and arterial reconstruction can be considered when
arterial occlusion is severe and bypass targets exist. Arterialization of the venous system is reserved
for last-chance efforts if arterial bypass sites are not available and limitations in flow are significant.
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Acknowledgments
The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24-
AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of Health.
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References
Jacobsson, LT, Hanson, RL, Knowler, WC, et al. Decreasing incidence and prevalence of rheumatoid arthritis in Pima Indians over a twenty-
five-year period. Arthritis Rheum. 1994;37:1158-1165.
Boyer, GS, Benevolenskaya, LI, Templin, DW, et al. Prevalence of rheumatoid arthritis in circumpolar native populations. J Rheumatol.
1998;25:23-29.
Cimmino, MA, Parisi, M, Moggiana, G, et al. Prevalence of rheumatoid arthritis in Italy: the Chiavari study. Ann Rheum Dis. 1998;57:315-318.
Saraux, A, Guedes, C, Allain, J, et al. Prevalence of rheumatoid arthritis and spondyloarthropathy in Brittany, France. Societe de
Rhumatologie de l’Ouest. 
 J Rheumatol. 1999;26:2622-2627.
Simonsson, M, Bergman, S, Jacobsson, LT, et al. The prevalence of rheumatoid arthritis in Sweden. Scand J Rheumatol. 1999;28:340-343.
Riise, T, Jacobsen, BK, Gran, JT. Incidence and prevalence of rheumatoid arthritis in the county of Troms, northern Norway. J Rheumatol.
2000;27:1386-1389.
Gabriel, SE. The epidemiology of rheumatoid arthritis. Rheum Dis Clin North Am. 2001;27:269-281.
Symmons, D, Turner, G, Webb, R, et al. The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century.
Rheumatol (Oxf). 2002;41:793-800.
Carbonell, J, Cobo, T, Balsa, A, et al. The incidence of rheumatoid arthritis in Spain: results from a nationwide primary care registry.
Rheumatol (Oxf). 2008;47:1088-1092.
Gabriel, SE, Michaud, K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res
Ther. 2009;11:229.
Lam, SJ. Surgery of the rheumatoid hand. Br Med J. 1965;1:1079-1080.
Flatt, AE. The prosthetic replacement of rheumatoid finger joints. Rheumatism. 1960;16:90-97.
Buer, JK. A history of the term “DMARD”. Inflammopharmacology. 2015;23:163-171.
Shourt, CA, Crowson, CS, Gabriel, SE, Matteson, EL. Orthopedic surgery among patients with rheumatoid arthritis 1980–2007: a population-
based study focused on surgery rates, sex, and mortality. J Rheumatol. 2012;39:481-485.
Gogna, R, Cheung, G, Arundell, M, et al. Rheumatoid hand surgery: is there a decline? A 22-year population-based study. Hand (NY).
2015;10:272-278.
Smolen, JS, Aletaha, D, McInnes, IB. Rheumatoid arthritis. Lancet. 2016;388:2023-2038.
Helmick, CG, Felson, DT, Lawrence, RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States.
Part I. Arthritis Rheum. 2008;58:15-25.
Myasoedova, E, Crowson, CS, Kremers, HM, et al. Is the incidence of rheumatoid arthritis rising?: results from Olmsted County, Minnesota,
1955–2007. Arthritis Rheum. 2010;62:1576-1582.
Zhong, L, Chung, KC, Baser, O, et al. Variation in rheumatoid hand and wrist surgery among medicare beneficiaries: a population-based
cohort study. J Rheumatol. 2015;42:429-436.
Alderman, AK, Chung, KC, Demonner, S, et al. The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns.
Arthritis Rheum. 2002;47:537-542.
Alderman, AK, Ubel, PA, Kim, HM, et al. Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists
and hand surgeons. 
 J Rheumatol. 2003;30:1464-1472.Hand surgery is not always been well accepted in the field of rheumatology. This study
clarifies the differences in opinions about the effectiveness of hand surgery and highlights the importance of working in interdisciplinary teams to treat
this condition.
Sambamoorthi, U, Shah, D, Zhao, X. Healthcare burden of depression in adults with arthritis. Expert Rev Pharmacoecon Outcomes Res.
2017;17:53-65.
Wolfe, F, Cathey, MA. The assessment and prediction of functional disability in rheumatoid arthritis. J Rheumatol. 1991;18:1298-1306.
GEO-RA Group. Latitude gradient influences the age of onset of rheumatoid arthritis: a worldwide survey. Clin Rheumatol. 2017;36:485-497.
Silman, AJ, Pearson, JE. Epidemiology and genetics of rheumatoid arthritis. Arthritis Res. 2002;4(suppl 3):S265-S272.
Silman, AJ, MacGregor, AJ, Thomson, W, et al. Twin concordance rates for rheumatoid arthritis: results from a nationwide study. Br J
Rheumatol. 1993;32:903-907.
Roberson, ED, Bowcock, AM. Psoriasis genetics: breaking the barrier. Trends Genet. 2010;26:415-423.
Farng, E, Friedrich, JB. Laboratory diagnosis of rheumatoid arthritis. J Hand Surg Am. 2011;36:926-927; quiz 928.
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;62:2569-2581.
Chung, KC, Kotsis, SV, Burns, PB, et al. Seven-year outcomes of the silicone arthroplasty in rheumatoid arthritis prospective cohort study.
Arthritis Care Res. 2017;69:973-981.The SARA trial involved a prospective cohort of patients with rheumatoid hand disease undergoing medical
management and SMPA. This article at 7 years follow-up demonstrates low rates of implant fracture and deformity by patient reported outcomes.
Chung, KC, Kotsis, SV, Kim, M, et al. Reasons why rheumatoid arthritis patients seek surgical treatment for hand deformities. J Hand Surg.
2006;31A:289-294.This classic article was part of the NIH SARA trial and prospectively enrolled patients were queried using the Michigan Hand
Outcomes Questionnaire. Patients noted that impaired function and pain relief were the most common factors leading to surgery.
Flury, MP, Herren, DB, Simmen, BR. Rheumatoid arthritis of the wrist: classification related to the natural course. Clin Orthop Relat Res.
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1999;366:72-77.The authors present a classification system for the rheumatoid wrist that is now commonly used and frequently referenced. This
classification system uses radiologic indicators to divide wrists into those that are stable (types I and II) and those that are unstable (type III).
Mannerfelt, L, Norman, O. Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel: a clinical
and radiological study. J Bone Joint Surg Br. 1969;51:270-277.Describes the classic lesion involving flexor tendon rupture from bone spurs within
the carpal canal.
Vaughan-Jackson, OJ. Attrition ruptures of the tendons in the rheumatoid hand. J Bone Joint Surg Am. 1958;40A:1431.This classic article
describes attritional rupture of the extensor tendons in rheumatoid hand disease.
Bleifeld, CJ, Inglis, AE. The hand in systemic lupus erythematosus. J Bone Joint Surg Am. 1974;56:1207-1215.
Dray, GJ. The hand in systemic lupus erythematosus. Hand Clin. 1989;5:145-155.
Malcus Johnsson, P, Sandqvist, G, Nilsson, JA, et al. Hand function and performance of daily activities in systemic lupus erythematosus: a
clinical study. Lupus. 2015;24:827-834.
Prakken, B, Albani, S, Martini, A. Juvenile idiopathic arthritis. Lancet. 2011;377:2138-2149.
Towner, SR, Michet, CJ Jr, O’Fallon, WM, Nelson, AM. The epidemiology of juvenile arthritis in Rochester, Minnesota 1960–1979. Arthritis
Rheum. 1983;26:1208-1213.
Peterson, LS, Mason, T, Nelson, AM, et al. Juvenile rheumatoid arthritis in Rochester, Minnesota 1960-1993. Is the epidemiology changing?
Arthritis Rheum. 1996;39:1385-1390.
Lawrence, RC, Helmick, CG, Arnett, FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United
States. Arthritis Rheum. 1998;41:778-799.
El Hadidi, KT, Medhat, BM, Abdel Baki, NM, et al. Characteristics of systemic lupus erythematosus in a sample of the Egyptian population: a
retrospective cohort of 1109 patients from a single center. Lupus. 2018;27:1030-1038.
Macedo, EA, Appenzeller, S, Costallat, LT. Gender differences in systemic lupus erythematosus concerning anxiety, depression and quality
of life. Lupus. 2016;25:1315-1327.
Farr, S, Girsch, W. The hand and wrist in juvenile rheumatoid arthritis. J Hand Surg Am. 2015;40:2289-2292.
Ritchlin, CT, Colbert, RA, Gladman, DD. Psoriatic arthritis. N Engl J Med. 2017;376:957-970.
Griffin, MF, Almadori, A, Butler, PE. Use of lipotransfer in scleroderma. Aesthet Surg J. 2017;37:S33-S37.
Sullivan, KM, Goldmuntz, EA, Keyes-Elstein, L, et al. Myeloablative autologous stem-cell transplantation for severe scleroderma. N Engl J
Med. 2018;378:35-47.
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C H A P T E R 9 3
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Osteoarthritis
Erin A. Miller and Jeffrey B. Friedrich
Key Points
First-line treatment of osteoarthritis (OA) is conservative management (rest, NSAIDs, steroid
injection); surgery is only offered for refractory pain
Surgical options for any hand arthritis relieve pain in exchange for loss of motion (fusion) or loss of
strength (arthroplasty)
Distal interphalangeal (DIP) arthritis is best managed with fusion in 10 to 20 degrees of flexion
Refractory carpometacarpal (CMC) arthritis is most frequently treated with excision of the trapezium
and surgeon’s choice of stabilization of the metacarpal base
Thumb metacarpophalangeal joint hyperextension and scaphotrapezoid arthritis must be treated to
achieve successful outcome when treating CMC arthritis
Treatment options for radiocarpal arthritis are dependent on the quality of the lunate fossa of the
distal radius; proximal row carpectomy (PRC) and four-corner fusion (4CF) have equivalent
outcomes in patients over 40 years of age
OA of the hand and wrist is a common reason for presentation to a surgeon. It is a disease of the articular
cartilage in which progressive degeneration causes changes throughout the entire joint. The articular
cartilage in joints is hyaline cartilage, and it is particularly susceptible to trauma given the slow turnover
rate of chondrocytes and its inability to heal. 1 Although age, obesity, metabolic syndrome, and trauma
are most commonly implicated in OA, current research demonstrates that the process is multifactorial
and highlights the importance of occupational, hormonal, biochemical, metabolic, and genetic factors. 2–4
No link between hand dominance and OA has been proved. The disease begins with cartilage erosion
and can progress to significant joint changes: thickening of adjacent bone (sclerosis), synovial
inflammation, ligament instability (laxity), reactive bone formation (bone spurs), and subchondral bone
erosion (cysts). 3
The population impact of OA of any joint is huge, and it is the leading cause of disability in individuals
over the age of 70 according to the World Health Organization. 1 Hand arthritis is most common in the
DIP joint with a prevalence of 35%, followed by thumb CMC joint at 21% and the proximal
interphalangeal joint (PIP) at 18%. 4,5 As expected, it has been shown that OA prevalence increases as age
increases: at the age of 40, DIP involvement is seen in 35% of individuals as opposed to 65% of
individuals over the age of 65. 3
Conservative management of the OA is usually the first-line treatment. Unlike inflammatory
arthropathies, such as rheumatoid arthritis, there are no known disease-modifying drugs.
Antiinflammatory agents are often effective in early disease and activity modification is recommended
with those of radiographic evidence of OA despite lack of level 1 evidence. Hand therapy yields short-
term reduction pain scores in several randomized control trials. Splinting with either prefabricated or
custom orthoses has been demonstrated to decrease pain but does not affect strength, function, or
dexterity. 6 Steroid injections are commonly used for early stage arthritis in any joint. Although there is
one trial suggesting they may provide permanent relief in early stage disease, 7 other randomized trials
have found only temporary pain relief when compared to placebo and hyaluronic acid injections. 8
Patients should be counseled on potential side effects of steroid injection, including skin pigment changes
and infection.
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