Rheumatoid Hand and Wrist Surgery

Review Article Rheumatoid Hand and Wrist Surgery: Soft Tissue Principles and Management of Digital Pathology Abstract Philip E. Blazar, MD Stephanie M. Gancarczyk, MD Barry P. Simmons, MD Downloaded from http://journals.lww.com/jaaos by BhDMf5ePHKbH4TTImqenVCyN9N7ltPfEAbvREDUsdrAN0UhZHwNJYUkEOa//Uwp1oIXiBkbSWhQ= on 12/08/2019 Since the advent of disease-modifying antirheumatic drugs for rheumatoid arthritis, orthopedic surgeons see fewer patients in the office who require hand surgery. However, a significant number of patients still seek surgical intervention to improve pain and function. These patients often present with isolated soft tissue pathologies, but even bone and joint pathology require meticulous soft tissue handling in this cohort. This review highlights the principles and techniques relevant to the management of soft tissue deformity in rheumatoid hand and wrist surgery, as exposure in training and practice continues to decrease. M anagement of rheumatoid arthritis (RA) has evolved dramatically since the advent of disease-modifying antirheumatic drugs (DMARDs). As a result, orthopedic surgeons see fewer patients with inflammatory arthritis in whom hand and wrist surgery is indicated. Despite these advances, the prevalence of RA in the United States is approximately 1.3 million people, and many still seek surgical intervention.1 From the Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Blazar, Dr. Gancarczyk, and Dr. Simmons. J Am Acad Orthop Surg 2019;27: 785-793 DOI: 10.5435/JAAOS-D-17-00608 Copyright 2019 by the American Academy of Orthopaedic Surgeons. November 1, 2019, Vol 27, No 21 General Principles and Perceptions The treatment of patients with RA requires a multidisciplinary team including rheumatologists, upper extremity surgeons, and occupational therapists. The success of surgical intervention is controversial and depends on who is asked. Alderman et al2 surveyed over 400 hand surgeons and rheumatologists on various operative reconstructions. Ninetythree percent of hand surgeons versus 50% of rheumatologists perceived extensor tenosynovectomy as effec- tive for the prevention of tendon rupture when diffuse tenosynovitis was present. Sixty-six percent of hand surgeons versus 25% of rheumatologists viewed soft tissue reconstruction for swan neck and boutonniere deformity as successful at increasing function; this discrepancy narrowed with regard to improving aesthetics. To determine patient drivers, Bogoch et al3 studied pre-operative motivations. Over 75% of the patients ranked function, pain, or appearance as the motivator for surgery, and appearance was one of two highest ranked motivators in approximately 50% of the patients. Initial Presentation The soft tissue and bony pathologies that lead to deformity in patients with RA can be multifactorial. A thorough physical examination is integral to deciding appropriate management. Observation and appearance, such as watching the patient perform a task and looking for the appropriate wrist and digit skin creases, provide 785 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Rheumatoid Hand and Wrist Surgery Figure 1 Figure 2 A and B, The Bunnell test evaluates for intrinsic tightness. Passive PIP joint flexion is compared in MCP joint flexion and extension. If the intrinsics are tight, PIP joint flexion will be limited in MCP joint extension, as the intrinsic tendons are on stretch. MCP = metacarpophalangeal, PIP = Passive proximal interphalangeal important information. When skin creases are absent or the skin is taut, the joint has likely had chronic limitations in range of motion. Swelling may be due to synovitis or tenosynovitis of the dorsal and/or volar tendon compartments. Crepitus may be present with finger or thumb range of motion and suggests tenosynovitis. In this scenario, patients may complain of crackling or popping in the wrist or hand with motion. A prominent ulna should be recognized, and distal radial ulnar joint (DRUJ) stability should be evaluated in neutral, pronation, and supination. Next, an evaluation of tendon competency and contracture should be performed. Intrinsic tendon tightness is evaluated with the Bunnell test. Passive proximal interphalangeal (PIP) joint flexion is compared in metacarpophalangeal (MCP) joint flexion and extension. With intrinsic tightness, PIP joint flexion will be limited in MCP joint extension (Figure 1). Each flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), and terminal extensor tendon 786 must be tested. The Elson test assesses the integrity of the central slip (Figure 2). The PIP joint is flexed against a flat surface, and the patient is asked to gently extend the finger. In the setting of a central slip injury, the extensor tone at the distal interphalangeal (DIP) joint will increase as a result of tension transmitted through the lateral bands to the terminal tendon. In addition, the MCP joint should be checked for a centralized extensor tendon throughout range of motion and associated early volar subluxation, especially in swan neck deformity. Before finishing the examination, the tenodesis effect can be helpful in diagnosing tendon ruptures or subtler abnormalities, such as sheath scarring (Figure 3). With wrist flexion, the fingers should extend, and, with extension, the fingers should flex. The two hands should be symmetrical; deviations are clues to tendon pathology. In addition to a complete physical examination, we obtain plain radiographs of the hand and wrist to The Elson test assesses the integrity of the central slip. The PIP joint is flexed against a table, and the patient is asked to gently extend the middle phalanx against resistance. In the setting of a central slip injury, the extensor tone at the DIP joint will increase as a result of increased tension in the lateral bands. DIP = distal interphalangeal, PIP = Passive proximal interphalangeal evaluate for joint congruity, joint space narrowing, cyst formation, osteopenia, and marginal erosions. The “scallop sign” is erosive concavity seen in the sigmoid notch. Individual finger and/or thumb radiographs may be indicated. Typically, advanced imaging, such as ultrasonography, CT, and MRI, provides little information beyond that gathered in a thorough a physical and radiographic examination. Extensor Pathology Tenosynovitis and Tendon Rupture Extensor tenosynovitis is a frequent manifestation of RA and often the presenting report.4 Initially it can be treated non-operatively with antirheumatic medication, rest, immobilization, and possible local injection of steroid. Patients that are refractory to at least 6 months of conservative Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Philip E. Blazar, MD, et al Figure 3 Figure 4 A and B, Wrist tenodesis testing can identify tendon rupture and/or subtle abnormalities in the tendon complex. In wrist flexion, the fingers should extend, and, with wrist extension, the fingers should flex. As seen in these images, the digits lie in a smooth cascade. management are candidates for surgical intervention due to concern for tendon rupture.5 Our preferred technique is a midline, longitudinal incision (Figure 4). The extensor retinaculum is opened in line with the third or fourth compartment, then reflected. The tenosynovium is sharply débrided. An oblique or Z-cut in the retinaculum allows it to be sutured in a lengthened position, though this may be unnecessary after excision of the pathologic tenosynovium (Figure 5). Alternatively, the retinacular flaps can be split transversely with a segment sutured volar to the extensor tendons, as an interposition between the tendons and bone.4,6 However, we often find the extensor retinaculum to be thin and tenuous, making it difficult to divide and manipulate for dual functions. Recurrence rates are approximately 10%, and the risk of extensor tendon rupture is minimized to 3% to 7% depending on tendon quality at the time of surgery.4,6,7 This further reinforces the importance of early November 1, 2019, Vol 27, No 21 intervention when medical management has failed or in patients not taking DMARDs. While there are no long-term follow-up studies on chronic, untreated dorsal tenosynovitis, the low recurrence after tenosynovectomy and the challenge of treating tendon rupture make early intervention appealing. Extensor tendons rupture as a result of attrition due to osseous irregularity or direct infiltration from tenosynovitis.8 Most extensor tendon ruptures occur over the DRUJ. If arthritis or instability is noted, as is seen in caput-ulnae syndrome, soft tissue reconstructions should be performed in conjunction with a distal ulna resection, Sauve-Kapandji (pseudarthrosis of the ulna with DRUJ arthrodesis) or distal ulnar replacement.4,9 The most common tendons to rupture are the extensor digiti minimi (EDM) and extensor digitorum communis (EDC) of the fifth, followed by the EDC of the fourth.8 However, many patterns of rupture can occur. A midline, longitudinal incision is used to perform a dorsal tenosynovectomy. Note the dorsal wrist swelling evident on clinical examination. Figure 5 The retinacular tissue is repaired in a lengthened position dorsal to the tendons. A significant amount of tenosynovitis and rice bodies have been removed. 787 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Rheumatoid Hand and Wrist Surgery With rupture of the small finger extensors, we prefer extensor indicis proprius (EIP) transfer to both the EDM and EDC, as EDC reconstruction alone may be inadequate. The distal EDM stump is usually found more distal than the EDC stump. The EIP is identified by the following: (1) the ulnar tendon at the index MCP joint, (2) the most distal muscle belly of the finger extensors, and (3) the lack of junctural connections.10,11 We harvest it just proximal to the sagittal bands via a small transverse incision. Next, via the same incision used for tenosynovectomy, the EIP is delivered proximal to the retinaculum, transferred to the recipient extensor tendon stump distally, and left superficial to the retinaculum. While we have had more experience with the Pulvertaft weave, other surgeons use a side-to-side repair. This technique has been shown to have a higher load to failure and repair stiffness when compared with the Pulvertaft weave.12,13 As the number of extensor tendon ruptures increases, it often becomes necessary to combine techniques, including tendon transfer, tenodesis, and interposition grafting. More recent data suggests that clinical outcomes are similar when comparing tendon transfer and tendon grafting.14 The most commonly used tendon grafts include palmaris longus and fourth toe extensor. Bora et al15 describe using free looped tendon graft to reconstruct multiple extensors with an average extensor lag of 30° at approximately 43 months follow-up. More recent studies have reported an average extensor lag of approximately 16° at 54 months follow-up.16 The most common tendon transfer donors include EIP, FDS to the ring or long finger, and extensor carpi radialis longus or brevis.17,18 When using wrist extensors, an intercalary graft is required for length. In addition, given the relatively limited excursion 788 of the wrist extensors, good outcomes require preserved wrist motion.17 For tendon ruptures involving both the ring and small fingers, our preferred technique is EIP transfer to the small finger and tenodesis of the ring to the long finger EDC. In the case of three or four finger involvement, the FDS to the ring and/or long fingers is harvested proximal to the A1 pulley and identified through a longitudinal incision just proximal to the carpal tunnel. The tendon(s) are directed through the interosseous membrane or around the ulnar aspect of the wrist, and a single tendon can be attached supra-retinacular to two extensor tendons. If the EIP donor is available, it can be transferred in a three-tendon rupture to the stumps of the ring and small fingers, and the long finger stump can be sutured endto-side to the remaining index finger EDC tendon. Using a similar algorithm, Millender et al17 found that of 31 patients studied, most recovered full pre-operative range of motion. When an extensor lag developed, the range was 10 to 30° with a notable correlation between increasing number of tendons ruptured and worse extension. Digital Ulnar Drift Ulnar drift of the fingers is a multifaceted problem involving the extensor tendon complex, capsule, collateral ligaments, and the MCP joint. If the joint is preserved, soft tissue only procedures can be performed. However, even in the setting of MCP arthroplasty, the soft tissues must be rebalanced. Many soft tissue procedures have been described, including crossed intrinsic transfer, radial sagittal band reconstruction, and radial sagittal band imbrication.19–21 Much technical variability lies in the details of sagittal band reconstruction. Multiple grafts have been described, including radial, ulnar, or central slips of extensor tendon, extensor retinaculum, juncturae, or autograft.22,23 In addition, the pulley choices include the radial intrinsic tendon, radial collateral ligament, and transverse metacarpal ligament.22 The goal of each procedure is to rebalance ulnar and radial deviating forces. We follow a similar algorithm when performing a soft tissue only or soft tissue plus arthroplasty reconstruction. A transverse incision is made just proximal to the MCP joints. For each finger, the ulnar sagittal band is longitudinally incised and the ulnar intrinsic tendon is released, as these are deforming forces. If no arthroplasty is performed, the radial sagittal band tissue is subsequently imbricated or reconstructed. We use an ulnar slip of the extensor tendon, approximately 40% the width of the tendon, from as proximal as the incision allows. The distal tendon at the level of the MCP joint is left intact. This tendon slip is passed around the deep transverse metacarpal ligament or the radial collateral ligament, if available, and sutured back to itself. Adjacent juncturae tendinum can be used as an alternative donor. Once the reconstruction is complete, the extensor tendon should be tested to ensure it remains centralized through range of motion. Occasionally, the ulnar sagittal band will need to be repaired in a lengthened position to act as a check against radial subluxation. When an arthroplasty is indicated, the capsule is incised longitudinally, a thorough synovectomy is performed, and the ulnar collateral ligament is released. The radial collateral ligament is sharply released off its origin on the metacarpal head and a tagging suture is placed to test the mechanical properties of the identified tissue. By pulling proximal tension, the deformity should correct and, preferably, overcorrect (Figure 6). A Kirschner wire is used to make two holes in the dorsal, radial metacarpal approximately Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Philip E. Blazar, MD, et al Figure 6 A–C, Note the ulnar drift of all four fingers. A transverse incision just proximal to the MCP joints is used to perform multiple arthroplasties or isolated sagittal band reconstructions and EDC centralizations. Even in the setting of joint arthroplasty, attention must be paid to the soft tissues. Here the radial collateral ligament is identified, released, and tagged with a suture before placing the MCP implant. Pulling on the tagging sutures should correct the ulnar drift deformity. EDC = extensor digitorum communis, MCP = metacarpophalangeal 7 to 8 mm from the joint surface, leaving at least a 3 to 5 mm bone bridge. Using these tunnels, a stitch is placed into and out of the bone, and the local tissue is re-tensioned. If local tissue is unable to reconstruct the radial collateral ligament, a portion of the volar plate can be used. Evidence for or against collateral ligament reconstruction is limited.24 However, we have found that this practice, in combination with a post-operative casting and splinting regimen, leads to greater correction of ulnar deviation deformity when compared with leaving the collateral ligaments. Finally, the finger should be tested through range of motion and sagittal band rebalancing is performed as previously described. The post-operative dressing is crucial. The MCP joints should be immobilized in full extension, and soft dressings are used to reinforce radial deviation in the splint. At 10 days, a November 1, 2019, Vol 27, No 21 hand-based cast, which immobilizes the MCP joints and leaves the PIP joints free, is applied. Similarly, the MCP joints should be held in full extension and radial deviation. Three weeks later, the cast is removed and occupational therapy is started. This is augmented by a night-time splint that holds the fingers in the corrected position. An outrigger splint is designed for this purpose; it is a dynamic, dorsal hand splint with finger slings that hold the MCP joints in an extended and radially deviated position. Isolated soft tissue reconstruction is rarely indicated, but with appropriate patient selection, the outcomes are successful. Dell et al25 reported their results using a distally based central portion of extensor tendon. Recurrent ulnar drift at an average of 9 years follow-up was approximately 10° and MCP joint motion significantly improved. In our expe- rience, MCP stiffness is a frequent complication. However, if PIP joint range of motion is maintained, patients are satisfied with the functional outcome. Swan Neck and Boutonnière Deformity Swan Neck Deformity In RA, swan neck deformity can be from pathology at the DIP, PIP, or MCP joint. Regardless of etiology, it is characterized by attenuation of the volar plate at the PIP joint and elongation or rupture of the terminal extensor tendon at the distal phalanx (Figure 7). Treatment is based on identifying and correcting the deforming anatomic structures. The success of non-operative management and soft tissue only reconstruction depends on pre-operative range of motion and the status of the various joints. This discussion will 789 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Rheumatoid Hand and Wrist Surgery Figure 7 Swan neck deformity is characterized by PIP joint hyperextension and DIP joint flexion due to attenuation of the volar plate at the PIP joint and elongation or rupture of the terminal extensor tendon at the distal phalanx. DIP = distal interphalangeal, PIP = Passive proximal interphalangeal focus on the correction of flexible swan neck deformity in the setting of preserved articular surfaces and joint alignment. When this does not exist, arthrodesis or arthroplasty may be required. Treatment starts at the PIP joint, as volar PIP laxity must be addressed, and PIP joint correction may lead to secondary improvement of DIP deformity. Initially, non-operative management with a PIP ring-splint, preventing joint hyperextension, should be attempted. If this fails, many surgical techniques have been developed, including volar dermadesis, central slip tenotomy, volar plate advancement, flexor tenodesis, and spiral oblique retinacular ligament (SORL) reconstruction. A recent biomechanical study showed no significant difference in the stiffness of volar plate repair, FDS tenodesis, single lateral band transfer, double lateral band transfer, and dual split lateral band 790 transfer to stabilize a hyperextended PIP joint.26 Isolated dermadesis or central slip tenotomy do not typically provide lasting correction.27 Dermadesis involves excising an ellipse of skin and subcutaneous tissue on the volar aspect of the PIP joint, typically about 5 mm in width, taking care not to penetrate the flexor sheath or injure the digital neurovascular bundles. SORL reconstruction is achieved using either free tendon graft or lateral band re-routing.27,28 The goal is to create a tether that lies volar to the axis of PIP joint and dorsal to the axis of the DIP joint. This attempts to restore the link between PIP and DIP motion. In a comparative study by Oh et al,29 neither free tendon graft nor lateral band re-routing was shown to be superior. In the rheumatoid cohort, we rarely consider SORL reconstruction. Surgery on the dorsal apparatus can lead to significant stiffness and necessitate a complex rehabilitation program that is prone to poor compliance. Our preferred technique in rheumatoid patients with flexible swan neck deformity and preserved joints is FDS tenodesis. Unlike the original technique described by Swanson, we harvest one slip of FDS.27,30 A Brunner incision is used to access between the A1 and A3 pulleys. The FDS tendon is identified, but left within the tendon sheath. One slip is cut at the proximal extent of the A1 pulley. To limit effect on MCP range of motion, the FDS slip is pulled through a small slit in the flexor sheath between the A1 and A2 pulleys. This tendon can be sutured back to itself and/or to the adjacent flexor tendon sheath. At completion, the FDP is assessed to ensure it is not tethered by the reconstruction. Typically, we attempt to achieve a PIP joint flexion angle that matches with the natural cascade of the hand, starting with approximately 20° in the index finger and progressing to 40° in the small finger. Inevitably, soft tissue procedures attenuate over time, especially in the rheumatoid cohort. To help combat the loss of correction, PIP joint capsulotomy or pinning can be considered, though we do not routinely use either. The outcomes of FDS tenodesis have not been studied extensively in the rheumatoid cohort, but the available data are promising. According to the literature, PIP hyperextension deformity is improved by approximately 30°, resulting in overcorrection with residual flexion contracture of approximately 5°.31 In addition, the DIP joint extension lag was shown to correct in approximately 70% of the cases. Boutonnière Deformity Boutonnière deformity occurs when the lateral bands slip volarly, transforming them into PIP joint flexors.32 This results in contracted oblique retinacular ligaments and, eventually, changes in the PIP joint volar plate and collateral ligaments. In addition, the DIP joint is pulled into hyperextension. In RA, the cause is often PIP joint synovitis, which leads to attenuation of the central slip. Many treatment options have been described, including terminal tendon tenotomy, central slip re-insertion or reconstruction using dorsal PIP capsule, a slip of FDS, or the lateral bands.32–36 Though most studies are case reports or small case series, the outcomes are unpredictable with loss of correction over time.37 In a study by Kiefhaber et al,37 close to 10% of the patients developed a recurrent PIP flexion deformity of greater than 70° an average of 22 months postoperatively. As a result, the indications for soft tissue only boutonnière reconstruction are limited in the rheumatoid cohort. If the joint is preserved, we prefer dynamic PIP joint extension splinting for at least 8 weeks. If limited DIP flexion Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Philip E. Blazar, MD, et al Figure 8 Figure 9 Digital flexor tenosynovectomy is performed via a transverse incision at the distal palmar crease. Each flexor tendon is delivered into the wound and a meticulous tenosynovectomy is performed. remains, splinting can be combined with a terminal tendon tenotomy. However, these patients often have degenerative joint changes on close inspection. Therefore, PIP arthrodesis is performed more commonly in patients with functional limitations and pain due to a boutonnière deformity. Flexor Pathology Tenosynovitis and Tendon Rupture Flexor tenosynovitis often presents as loss of active finger flexion with or without joint stiffness.4 In addition, crepitus can develop in the presence of flexor tendon nodules or carpal osteophytes. When compared with the superficialis, the FDP is predisposed to nodule formation, especially in zone II.38 If uncontrolled, flexor tenosynovitis can lead to tendon rupture. Other causes of flexor tendon rupture in the rheumatoid patient include progressive volar MCP joint deformity, chronic carpal instability, and osteophytes, most commonly in the carpal tunnel.39 Since flexor tendon rupture in the November 1, 2019, Vol 27, No 21 A and B, After the transverse carpal ligament and the volar forearm fascia are released, dense tenosynovitis is encountered encompassing the flexor tendons. The flexor tendons are individually assessed and a thorough tenosynovectomy is performed. The median nerve (*) is identified and protected throughout this procedure. sheath is catastrophic, we avoid steroid injections in those with clear evidence of infiltrative tenosynovitis, in favor of early surgical intervention. Approaches for flexor tenosynovectomy include exposure of the digits via Brunner incisions, a transverse palmar incision, and/or a carpal tunnel incision extended into the forearm. Our usual approach is a transverse incision at the distal palmar crease. Each flexor tendon is delivered into the wound and a tenosynovectomy is performed (Figure 8). This limits the need for separate digital incisions. However, if a nodule is large enough to prevent full flexion and, therefore, access to the tendons, digital incisions are made. Pulleys should be preserved when able. We prefer to remove the ulnar slip of the FDS, especially in the setting of attenuated tissue or significant nodularity, as the postoperative range of motion is superior.38 We choose the ulnar slip to avoid creating an ulnar-deviating force; however, there is no direct evidence to support this theory. In the setting of isolated stenosing tenosynovitis with no associated flexor tendon nodules or infiltrative synovitis, a standard A1 pulley release may be performed. If flexor tendon rupture occurs, correction of osseous deformity, followed by tendon grafting, is our preferred method of treatment, though tendon transfer is an alternative. We start with an extended carpal tunnel approach. The transverse carpal ligament and the volar forearm fascia are released. The median nerve is mobilized and protected. The flexor tendons are individually assessed for abrasion and a meticulous tenosynovectomy is performed (Figure 9). If less than 50% of the tendon width is involved, a débridement is sufficient. If greater than 50% is involved, repair versus reconstruction should be considered.40 In the setting of tendon rupture, the proximal end is found and débrided back to healthy 791 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Rheumatoid Hand and Wrist Surgery Figure 10 Via a side-to-side technique, the intercalary graft is sewn to the ruptured FPL tendon. Next, a prolene suture is used to shuttle the graft into the proximal incision. FPL = flexor pollicis longus tissue. The carpus is examined for bony projections. When present, these are removed and covered with an adjacent capsule flap. If a tendon requires reconstruction, a Brunner incision is made over the associated MCP joint. While preserving as much of the pulley system as possible, any tenosynovitis within the digital sheath is débrided and the distal tendon stump is identified. A suture shuttle is positioned in its place. Our preferred tendon graft is palmaris longus, though half of the flexor carpi radialis can be used. Alternatively, if both flexor tendons to a finger are involved, the FDS can be used as intercalary or turnover graft. The graft is sewn to the ruptured tendon in the distal incision, then brought through the canal using the suture shuttle (Figure 10). The graft is tensioned using tenodesis, and the proximal junction is com- 792 pleted to the débrided stump of affected tendon. Outcomes for flexor tenosynovectomy are not as favorable when compared with extensor tenosynovectomy. Studies report recurrence rates of approximately 30%.38 Despite this percentage, patients often have significant improvement in pain and range of motion.38,41 Long-term outcomes have not been published since the advent of DMARDs, which may assist in further decreasing recurrence rates. Ertel et al42 looked at 115 flexor tendon ruptures to identify patterns and prognostic variables. More proximal ruptures tended to result from a bony spur, most commonly on the scaphoid. Ruptures within the digital sheath were typically due to infiltrative tenosynovitis. The flexor pollicis longus is the most commonly affected at the wrist, while the index finger FDP is the most commonly affected within the palm and digit. Opposite to extensor tendons, flexor tendons tend to rupture in a radial to ulnar direction. Multiple tendon ruptures and ruptures of both tendons within the flexor sheath of one digit had a worse prognosis. One or two flexor tendon ruptures proximal to the pulley system had the best prognosis. As flexor tendon reconstruction results do not match with those of the extensor tendon, prevention with early tenosynovectomy and removal of osteophytes is key. In addition, given the variable outcomes, DIP joint fusion is a reliable salvage that should be considered in the setting of intra-sheath FDP rupture. Summary While the medical management of RA has vastly improved, it is still a relatively common disease affecting over 1 million people in the United States. Gross abnormalities are now less common, and more patients present with subtle and flexible deformity. As a result, it is important to have an understanding of isolated soft tissue reconstruction and soft tissue handling in conjunction with salvage procedures. While studies suggest most pathologies can be treated to meet the patient goals of improved function and appearance, a substantial portion of our data is based on small case series and retrospective analyses before the use of DMARDs. These medications not only decrease the number of patients that need surgery but also may decrease recurrence and improve outcomes. Further biomechanical comparisons and prospective longterm studies are needed to truly understand the best treatments and confirm our perception of improved clinical outcomes. References References printed in bold type are those published within the past 5 years. 1. 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. 2. Alderman AK, Chung KC, Kim HM, Fox DA, Ubel PA: Effectiveness of rheumatoid hand surgery: Contrasting perceptions of hand surgeons and rheumatologists. J Hand Surg Am 2003;28:3-11. 3. Bogoch ER, Escott BG, Ronald K: Hand appearance as a patient motivation for surgery and a determinant of satisfaction with metacarpophalangeal joint arthroplasty for rheumatoid arthritis. J Hand Surg Am 2011;36:1007-1014.e1. 4. Simmons BP, Smith GR: “Reconstructive Surgery for Rheumatic Disease: The Hand and Wrist.” Textbook of Rheumatoloogy. Sledge CB, Ruddy S, Harris ED Jr, Kellely WN, eds. Philadelphia, PA, WB Saunders, 1997, pp 1647-1674. 5. Hsueh JH, Liu WC, Yang KC, Hsu KC, Lin CT, Chen LW: Spontaneous extensor tendon rupture in the rheumatoid wrist: Risk factors and preventive role of extended tenosynovectomy. Ann Plast Surg 2016; 76(suppl 1):S41-S47. 6. Brown FE, Brown ML: Long-term results after tenosynovectomy to treat the rheumatoid hand. J Hand Surg Am 1988; 13:704-708. Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Philip E. Blazar, MD, et al 7. Thirupathi RG, Ferlic DC, Clayton ML: Dorsal wrist synovectomy in rheumatoid arthritis—A long-term study. J Hand Surg Am 1983;8:848-856. 8. Vaughan-Jackson OJ: Rupture of extensor tendons by attrition at the inferior radioulnar joint; report of two cases. J Bone Joint Surg Br 1948;30B:528-530. 9. Brumfield R, Kuschner SH, Gellman H, Liles DN, Van Winckle G: Results of dorsal wrist synovectomies in the rheumatoid hand. J Hand Surg Am 1990;15:733-735. 10. Mestdagh H, Bailleul JP, Vilette B, Bocquet F, Depreux R: Organization of the extensor complex of the digits. Anat Clin 1985;7: 49-53. 11. von Schroeder HP, Botte MJ: Anatomy of the extensor tendons of the fingers: Variations and multiplicity. J Hand Surg Am 1995;20:27-34. 12. Rivlin M, Eberlin KR, Kachooei AR, et al: Side-to-side versus pulvertaft extensor tenorrhaphy-a biomechanical study. J Hand Surg Am 2016;41:e393-e397. 13. Brown SH, Hentzen ER, Kwan A, Ward SR, Fridén J, Lieber RL: Mechanical strength of the side-to-side versus Pulvertaft weave tendon repair. J Hand Surg Am 2010;35:540-545. 14. Chung US, Kim JH, Seo WS, Lee KH: Tendon transfer or tendon graft for ruptured finger extensor tendons in rheumatoid hands. J Hand Surg Eur Vol 2010;35:279-282. 15. Bora FW, Osterman AL, Thomas VJ, Maitin EC, Polineni S: The treatment of ruptures of multiple extensor tendons at wrist level by a free tendon graft in the rheumatoid patient. J Hand Surg Am 1987; 12:1038-1040. 16. Chu PJ, Lee HM, Hou YT, Hung ST, Chen JK, Shih JT: Extensor-tendons reconstruction using autogenous palmaris longus tendon grafting for rheumatoid arthritis patients. J Orthop Surg Res 2008; 3:16. 19. Oster LH, Blair WF, Steyers CM, Flatt AE: Crossed intrinsic transfer. J Hand Surg Am 1989;14:963-971. 20. Wood VE, Ichtertz DR, Yahiku H: Soft tissue metacarpophalangeal reconstruction for treatment of rheumatoid hand deformity. J Hand Surg Am 1989;14: 163-174. 21. Lee JH, Baek JH, Lee JS: A reconstructive stabilization technique for nontraumatic or chronic traumatic extensor tendon subluxation. J Hand Surg Am 2017;42: e61-e65. 22. Watson HK, Weinzweig J, Guidera PM: Sagittal band reconstruction. J Hand Surg Am 1997;22:452-456. 23. Nagaoka M, Satoh T, Nagao S, Matsuzaki H: Extensor retinaculum graft for chronic boxer’s knuckle. J Hand Surg Am 2006;31: 947-951. 24. Burezq H, Polyhronopoulos GN, Beaulieu S, Brown HC, Williams B: The value of radial collateral ligament reconstruction and abductor digiti minimi release in metacarpophalangeal joint arthroplasty. Ann Plast Surg 2005;54:397-401. 25. Dell PC, Renfree KJ, Below Dell R: Surgical correction of extensor tendon subluxation and ulnar drift in the rheumatoid hand: Long-term results. J Hand Surg Br 2001;26: 560-564. 26. Micev AJ, Saucedo JM, Kalainov DM, Wang L, Ma M, Yaffe MA: Surgical techniques for correction of traumatic hyperextension instability of the proximal interphalangeal joint: A biomechanical study. J Hand Surg Am 2015;40: 1631-1637. 27. Nalebuff EA, Millender LH: Surgical treatment of the swan-neck deformity in rheumatoid arthritis. Orthop Clin North Am 1975;6:733-752. 28. Thompson JS, Littler JW, Upton J: The spiral oblique retinacular ligament (Sorl). J Hand Surg Am 1978;3:482-487. 31. Brulard C, Sauvage A, Mares O, Wavreille G, Fontaine C: Treatment of rheumatoid swan neck deformity by tenodesis of proximal interphalangeal joint with a half flexor digitorum superficialis tendon. About 23 fingers at 61 Months follow-up. Chir Main 2012;31:118-127. 32. Littler JW, Eaton RG: Redistribution of forces in the correction of boutonniere deformity. J Bone Joint Surg Am 1967;49: 1267-1274. 33. Ahmad F, Pickford M: Reconstruction of the extensor central slip using a distally based flexor digitorum superficialis slip. J Hand Surg Am 2009;34:930-932. 34. Urbaniak JR, Hayes MG: Chronic boutonniere deformity—An anatomic reconstruction. J Hand Surg Am 1981;6: 379-383. 35. Slesarenko YA, Hurst LC, Mai K: Suture anchor technique for anatomic reconstruction in chronic boutonnière deformity. Tech Hand Up Extrem Surg 2005;9:172-174. 36. Dolphin JA: Extensor tenotomy for chronic Boutonni’Ere deformity of the finger; report of two cases. J Bone Joint Surg Am 1965; 47:161-164. 37. Kiefhaber TR, Strickland JW: Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: Long-term results. J Hand Surg Am 1993;18:984-989. 38. Wheen DJ, Tonkin MA, Green J, Bronkhorst M: Long-term results following digital flexor tenosynovectomy in rheumatoid arthritis. J Hand Surg Am 1995;20:790-794. 39. 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. 40. Chow SP, Yu OD: An experimental study on incompletely cut chicken tendons—A comparison of two methods of management. J Hand Surg Br 1984;9: 121-125. 17. Millender LH, Nalebuff EA, Albin R, Ream JR, Gordon M: Dorsal tenosynovectomy and tendon transfer in the rheumatoid hand. J Bone Joint Surg Am 1974;56: 601-610. 29. Oh JY, Kim JS, Lee DC, et al: Comparative study of spiral oblique retinacular ligament reconstruction techniques using either a lateral band or a tendon graft. Arch Plast Surg 2013;40:773-778. 41. Tolat AR, Stanley JK, Evans RA: Flexor tenosynovectomy and tenolysis in longstanding rheumatoid arthritis. J Hand Surg Br 1996;21:538-543. 18. Nalebuff EA, Patel MR: Flexor digitorum sublimis transfer for multiple extensor tendon ruptures in rheumatoid arthritis. Plast Reconstr Surg 1973;52:530-533. 30. Swanson AB: Surgery of the hand in cerebral palsy and the swan-neck deformity. J Bone Joint Surg Am 1960;42A: 951-964. 42. Ertel AN, Millender LH, Nalebuff E, McKay D, Leslie B: Flexor tendon ruptures in patients with rheumatoid arthritis. J Hand Surg Am 1988;13:860-866. November 1, 2019, Vol 27, No 21 793 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.