INTRINSIC IMBALANCE IN

RHEUMATOID ARTHRITIS

6TH ANNUAL MEETING:

HAND THERAPY ASSOCIATION OF NORTHERN

CALIFORNIA

Andrew J. Watt MD

The Buncke Clinic

DISCLOSURES:

I have no personal or financial interest in the products contained

within this presentation.

All identifiable photos utilized with permission.

GOALS & OBJECTIVES:

• To review the pathophysiology of Rheumatoid Arthritis

• To understand the basic finger deformities that result from

longstanding Rheumatoid Arthritis

• To understand the Management of Chronic Deformities

Resulting from Rheumatoid arthritis

– Techniques

– Indications

– Contraindications

– Optimizing Success

RHEUMATOID ARTHRITIS

• Chronic, systemic inflammatory

disease of unknown cause

– Autoimmune Disease

– Articular Manifestations

– Extra-articular Manifestations

– Female >>Male (3:1)

– Onset 20-40

– Inflammatory Target:

Synovium

RHEUMATOID ARTHRITIS:

PATHOLOGY

• Characteristic Pathologic

Finding: Chronic

Synovitis with Pannus

Formation

• Inflammatory Pannus Erodes:

– Cartilage

– Bone

– Ligament

– Tendon

RHEUMATOID ARTHRITIS:

PATHOLOGY

RHEUMATOID ARTHRITIS:

DISTRIBUTION

RHEUMATOID ARTHRITIS:

DEFORMITY

• Classic Finger

Deformities:

– Ulnar Drift

• MCP Subluxations

• Ulnar Subluxation /

Dislocation of Extensor

Tendon

– Boutonniere Deformity

– Swan Neck Deformity

The extensor mechanism is an inter-related

system of intrinsic and extrinsic

components in harmonious balance.

Disruption of this balance leads to

mechanical compensation (deformity).

OPPOSITES!

• Rheumatoid Deformities

represents movement in

opposing directions: – Radial Deviation vs. Ulnar

Deviation

– Flexion vs. Extension

• The system will always

try to reach equilibrium

• Deviation occurs at the

next available joint.

THE RHEUMATOID WRIST

• Characteristics:

– Dorsal Subluxation of the Ulnar

Head

• Loss of Dorsal joint

capsular support and TFCC

• Really volar subluxation of

the radius

– Palmar and Ulnar Translation

of the Carpus

– ECU subluxes volarly

– Radial wrist Extensors

unopposed

– Metacarpals move with the

wrist and become radially

deviated

THE RHEUMATOID WRIST

ULNAR DRIFT

• Characteristics:

– Metacarpophalangeal Joint

Volar Subluxation

– Ulnar Subluxation /

Dislocation of Extensor

Tendon

ULNAR DRIFT

MCP Arthritis with Synovitis

1. Loss of ulnar wrist support

2. Attenuation of Dorsal Joint Capsule & Volar Plate

3. Attenuation of Radial Collateral Ligament

4. Radial Deviation of MC

Volar & Ulnar Subluxation of MCP Joint

1. Introduces laxity into the extensor mechanism

- Radial intrinsic placed on stretch

- Ulnar intrinsic lax

2. Attenuation of the Radial Sagittal Band

Ulnar Subluxation / Dislocation of Extensor Tendon

New Equilibrium

• Ulnar intrinsic at shorter resting length, tightens

• Radial intrinsic at longer resting length, attenuates

ULNAR DRIFT

MCP Arthritis with Synovitis

1. Loss of Ulnar Wrist Support

2. Attenuation of Dorsal Joint Capsule & Volar Plate

3. Attenuation of Radial Collateral Ligament

4. Radial Deviation of MC

Volar & Ulnar Subluxation of MCP Joint

1. Introduces laxity into the extensor mechanism

- Radial intrinsic placed on stretch

- Ulnar intrinsic lax

2. Attenuation of the Radial Sagittal Band

Ulnar Dislocation of Extensor Tendon

New Equilibrium

• Ulnar intrinsic at shorter resting length, tightens

• Radial intrinsic at longer resting length, attenuates

BOUTONNIERE DEFORMITY

• Characteristics:

– Weakness and loss of

extension at PIP joint

– Hyperextension and

diminished active and

passive flexion at the DIP

joint

BOUTONNIERE DEFORMITY

PIP Arthritis of Central Slip

1. Synovial inflammation attenuates central slip

Disruption of Triangular Ligament

1. Attenuated in setting of inflammatory pannus

Volar Migration of Lateral Bands

* Move volar to the axis of rotation of the PIP joint.

Mechanically become a flexor of the PIP joint rather than an extensor

Contracture of ORL, CL & Volar Plate

SWAN NECK DEFORMITY

• Characteristics:

– Loss of DIP extension

– Imbalance of Extension force at the PIP joint.

– Hyperextension and diminished active and passive flexion at the PIP joint

SWAN NECK DEFORMITY

• What causes a swan neck

deformity in Rheumatoid

Arthritis?

– Wrist in origin

– MCP in origin

– PIP in origin

– DIP in origin

SWAN NECK DEFORMITY:

DIP ORIGIN DIP Joint Arthritis

Attenuation of Terminal Tendon

Flexion of DIP Joint

1. Laxity Introduced into Lateral Bands

• Decreased functional length

2. Lateral Bands Migrate Dorsal to the Axis of Rotation of the PIP Joint

DIP Hyperextension

SWAN NECK DEFORMITY:

PIP ORIGIN PIP Joint Arthritis

1. Attenuation of Volar Plate

2. Rupture of FDS insertion

Hyperextension of PIP Joint

1. Lateral Bands Migrate Dorsal to the Axis of Rotation of the PIP Joint

2. Laxity Introduced into Terminal Tendon

• Decreased functional length

DIP Flexion

SWAN NECK DEFORMITY:

MCP ORIGIN MCP Joint Arthritis

1. Volar Subluxation & Ulnar Drift

2. Laxity introduced into extensor mechanism

PIP Hyperextension

1. Lateral Bands Migrate Dorsal to the Axis of Rotation of the PIP Joint

2. Volar Plate Attenuation

3. Laxity Introduced into Terminal Tendon

• Decreased functional length

DIP Flexion

ADDRESSING IMBALANCE

IN RA • Keys to Success:

– Recognize the 1° deformity

and distinguish from the 2°

deformity

• ie MCP Subluxation >>

Ulnar Subluxation

– Realign the skeletal

components.

– Rebalance the soft tissue

• Eliminate deforming

forces

• Augment corrective

forces

– Work Proximal to Distal

SURGICAL OPTIONS FOR

TREATING INTRINSIC

IMBALANCE IN RA

• Tools & Techniques:

– Joints:

• Arthroplasty

• Arthrodesis

– Soft Tissue:

• Rebalancing

• Tendon Transfer

• Soft Tissue

Reconstruction

SURGICAL OPTIONS FOR

TREATING INTRINSIC

IMBALANCE IN RA

• Surgical Considerations – Patient’s Goals:

• Pain Relief

• Functional Gains

• Aesthetics

– Durability:

• Stability over time

– Medical Control of

Disease

– Concordant Expectations

• ***Address the Wrist

First*** – Arthroplasty

– Arthrodesis

ULNAR DRIFT:

• Must Correct:

– Volar Subluxation of the Proximal Phalanx

– Ulnar Dislocation of the Extensor Tendon

• Critical Factors:

1. Is the MCP Joint Passively Correctable

2. MCP Joint Articular Surface

*If not passively correctable and / or articular destruction >>

MCP arthroplasty

MCP Joint

Passively

Correctable?

Yes No

MCP

Arthroplasty

Preserved

Articular

Surface?

Yes No

Soft Tissue

Reconstruction

ULNAR DRIFT: SOFT

TISSUE RECONSTRUCTION

• Crossed Intrinsic

Transfer

– Transfer of Ulnar

Intrinsic to the Radial

Side of the Adjacent

Finger

– Reefing of Radial

collateral ligament

– +/- Sagittal Band

Reconstruction Courtesy K. C. Chung

ULNAR DRIFT: SOFT

TISSUE RECONSTRUCTION

• EDC Tenodesis

– Central Slip of EDC

used to create a

restraint to ulnar

displacement

– Passed beneath MCP

RCL

– Reefing of Radial

sagittal band &

collateral ligament

PC Dell et al JHS (Br) 2001.

ULNAR DRIFT: SOFT

TISSUE RECONSTRUCTION

• Sagittal Band

Reconstruction

– Palmaris Longus

Tendon Graft + Bone

Tunnel

– Reefing of Radial

Sagittal Band &

Collateral Ligament

ULNAR DRIFT: JOINT & SOFT

TISSUE RECONSTRUCTION

• Silicone MCP Arthroplasty

• Crossed Intrinsic Transfer

BOUTONNIERE:

• Must Correct:

– Central Slip Incompetence

– Volar Migration of Lateral Bands

– PIP Flexion Deformity

• Critical Factors:

1. Is the PIPJoint Passively Correctable

2. PIP Joint Articular Surface

*Boutonniere corrections in RA are highly unpredictable and tend to fail.

PIP Joint

Passively

Correctable?

Yes No

PIP

Arthrodesis

Preserved

Articular

Surface?

Yes No

Trial of

Splinting

SWAN NECK:

• Must Correct:

– PIP Hyperextension

– DIP Flexion Deformity

• Critical Factors:

1. Is the PIP Joint Passively

Correctable

2. PIP Joint Articular Surface

*If not passively correctable

and / or articular destruction

>> PIP arthrodesis

PIP Joint

Passively

Correctable?

Yes No

PIP

Arthrodesis

Preserved

Articular

Surface?

Yes No

Soft Tissue

Reconstruction

SWAN NECK DEFORMITY:

• Treat Wrist and MCP joint

deformity first then move distally

• PIP Hyperextension:

– Create palmar restraint that

will allow flexion but prevent

hyperextension

– Tenodesis

• Conjoint lateral band

tenodesis

• FDS Tenodesis

• ORL (Littler) Tenodesis

SWAN NECK DEFORMITY:

SOFT TISSUE

RECONSTRUCTION • Conjoint Lateral Band Tenodesis

• Indications:

– Mild Swan Neck (<20° of PIP Hyperextension)

– Preserved PIP Joint Surface

– Adequate soft tissue integrity

• Lateral Bands mobilized and secured volar to the axis of PIP rotation

• Lateral bands become:

– Flexor of the PIP joint

– Extensor of the DIP joint

SWAN NECK DEFORMITY:

SOFT TISSUE

RECONSTRUCTION • FDS Tenodesis

• Indications:

– Supple Swan Neck, any

degree of deformity

– Preserved PIP Joint Surface

– Intact FDS!!!

• FDS Tendodesis

– 1 slip transected proximally

and sutured to tendon

sheath or proximal phalanx

SWAN NECK DEFORMITY:

SOFT TISSUE

RECONSTRUCTION • FDS Tenodesis

• Indications:

– Supple Swan Neck, any

degree of deformity

– Preserved PIP Joint Surface

– Intact FDS!!!

• FDS Tendodesis

– 1 slip transected proximally

and sutured to tendon

sheath or proximal phalanx

SWAN NECK DEFORMITY:

SOFT TISSUE

RECONSTRUCTION

• ORL Ligament Tenodesis

• Indications:

– Supple Swan Neck, any

degree of deformity

– Preserved PIP Joint Surface

– No available FDS

SWAN NECK DEFORMITY:

SOFT TISSUE

RECONSTRUCTION

• ORL Ligament Tenodesis

• Indications:

– Supple Swan Neck, any

degree of deformity

– Preserved PIP Joint Surface

– No available FDS

CONCLUSIONS

• Rheumatoid arthritis affects the hand, both the articular surfaces and

ligamentous support structures, via progressive synovial inflammation,

pannus formation and erosion

• Rheumatoid hand deformity is characterized by deformity at the level of the

wrist, MCP, PIP and DIP with distal mobile components displacing to

counteract proximal deformity (ie wrist deformity leads to compensatory

MCP deformity leads to compensatory PIP deformity….)

• Surgical treatment relies of identifying the principle actor causing

imbalance and working proximal to distal to correct the deforming forces

THANK YOU