Rheumatoid Arthritis

R. Hill

Rheumatoid Arthritis

• Auto-immune process of unknown aetiology causing a chronic inflammatory process

• Primarily affects the synovium in the Hand

• Epidemiology

Surgical Aims

• Decrease pain

• Prevent worsening deformity/function

• Improve appearance/ function

Stages of Rheumatic joint involvement

Stage Description

I Synovitis no deformity

II Synovitis, passively correctable deformity

III Fixed deformity, no joint changes

IV Articular destruction

Surgical Procedures

• Synovectomy

• Tenosynovectomy

• Tendon Surgery

• Arthroplasty

• Arthrodesis

Thumb Deformities

Type 1 Boutonniere

• Usually due to MCP joint synovitis

• Exclude FPL rupture

• Treatment– early Synovectomy + tendon

reconstruction– Intermediate Arthrodesis or Arthroplasty– late ST repair, arthroplasty or

arthrodesis

Type III Swan-Neck Deformity• Result of CMC disease

• Treatment– Early Resection arthroplasty with

tendon interposition (RATI)– Intermediate RATI + volar tenodesis or

arthrodesis of MCPJ– Late RATI and MCPJ arthrodesis

Type IV Gamekeepers Thumb

• Due to synovitis of the MCPJ– NB no CMCJ disease

• Treatment– Early Synovectomy, adductor fascia release

and repair UCL– Late Arthrodesis/ arthroplasty + adductor

fascia release.

Type II

• Combination of Type I and II

• Treatment– CMCJ RATI– MCPJ Tendon reconstruction

arthroplasty/arthrodesis– IPJ Nil - arthrodesis

Type V

• Due to stretching of the volar plate

• Treatment Arthrodesis, volar capsulodesis or sesamoidesis

Arthritis Mutilans

• Instability and joint destruction

• Treatment– Early Early arthrodesis– Late Arthrodesis with bone grafting

Boutonniere deformity

Boutonniere

• Stage I PIPJ lag 10-15 degrees

• Stage II PIPJ lag 30-40 Degrees

• Stage III PIPJ Fixed

Treatment

• Stage I Ext. tendon tenotomy

• Stage II Repair central slip and bands.

Ext Tendon tenotomy

• Stage III Arthrodesis / arthroplasty

Swan-Neck Deformity

Types of Swan-Neck Deformity

• Type I Passive Motion at PIPJ possible

• Type II Related to MCPJ and intrinsic tightness

• Type III Fixed PIPJ preserved joint

• Type IV Fixed PIPJ and degenerate joint

Treatment of Swan-Neck deformity

• Type I DIPJ Fusion

Volar Tenodesis

Retinacular ligament reconstruction

Dermadesis

• Type II Intrinsic Release (IR) + type I

or

Correct MCPJ disorder

Treatment Swan-Neck deformity

• Type III Restore passive motion

Correct deformity later

• Type IV Salvage procedure.

Evidence

• No randomised control trials

• Papers often retrospective over long periods

• Poor numbers with no controls

• No validated scoring systems to evaluate outcome

• Results poor yet conclusion’s often positive

Doctors.net.uk would like to thank Dr R Hill for contributing this

presentation