Authors’ Preferred Method of Treatment

We have attempted to restore MP alignment and function by soft tissue surgery, including extensor tendon relocation and tenodesis. In patients with full passive correction, we approach the joint dorsally. A central defect in the joint capsule is repaired, and the extensor tendon is relocated to the dorsum of the joint directly on the bone, as described by Wood and associates. As part of the soft tissue rebalancing, the contracted ulnar sagittal fibers are released and the radial sagittal fibers are reefed in an attempt to rebalance support of the extensor tendon directly over the joint. The aim is to restore full MP extension when direct traction is applied to the extensor tendon.

Although the ulnar intrinsic was released completely in many patients, there have been complications later. In a few fingers, we noted late radial deviation with tightness of the radial intrinsic. For this reason, we now believe that complete ulnar intrinsic release is not without risk and prefer, instead, to step-cut and lengthen the ulnar intrinsic. We believe that the intrinsic transfers that are useful in correcting severe ulnar deviation in rheumatoid arthritis are particularly dangerous in SLE. All the soft tissue surgery that we perform is designed to restore alignment and balance to the joint. It may be foolhardy to think that restoration of local anatomy can withstand the tissue changes in SLE. We believe, however, that the deformities can be corrected and the need for joint replacement thereby delayed or avoided. These same soft tissue repairs are indicated for patients with fixed-MP joint deformities requiring prosthetic replacement.

Prolonged postoperative splinting is required after MP surgery regardless of whether implants are used. The joints are held in good alignment for 6 weeks before motion is initiated. Once MP motion is begun, the fingers are splinted together as a unit to maintain alignment and concentrate flexion at the MP level. Dynamic splinting is also used to support extension and maintain digital alignment during the early healing stage.

Occasionally, we have treated SLE patients who also demonstrate excessive finger MP joint hyperextension. In this situation, the “lasso procedure” described by Zancolli for ulnar nerve palsy is combined with dorsal soft tissue balancing. In this procedure, the sublimis tendon is detached from its insertion and passed around the A1 pulley to restrain MP joint hyperextension.

Authors’ Preferred Method of Treatment

If passive MP joint extension is possible, there are two surgical approaches that we have found useful: EPL rerouting and MP joint arthrodesis. EPL rerouting is preferred if the thumb IP joint requires fusion to provide stability. This procedure restores active MP extension while maintaining mobility, thereby relieving some strain on the CMC joint. However, certain modifications are in order, including reefing the collateral ligaments for lateral support and postoperative splinting for 6 weeks. Temporary Kirschner wire fixation is important to maintain the corrected position. Joints in SLE patients ordinarily do not get stiff after immobilization. The typical range of postoperative flexion is about 40 degrees and is usually achieved even with 6 weeks of immobilization.

When the flexed MP joint cannot be passively corrected or is hyperextended or if the CMC and IP joints are good, arthro­desis is the procedure of choice. The joint should be fixed in 15 to 20 degrees of flexion. Arthroplasty of the MP joint with a flexible implant might be considered, but experience with this approach in SLE patients has not been as successful as in those with rheumatoid arthritis. SLE patients tend to regain excessive motion and fracture the prosthesis, with recurrent deformity. If both the MP and IP joints are fused, it is imperative that motion at the thumb CMC joint be maintained.

Primary subluxation or dislocation of the thumb CMC joint also occurs in lupus. If the MP and IP joints are well aligned and stable, fusion of the CMC joint can be performed to provide general improvement in thumb alignment and function. It is important to stabilize the CMC joint with the metacarpal in a slightly abducted position. However, excessive metacarpal abduction must be avoided because it may lead to excessive MP joint flexion and dislocation, with a further reduction in thumb function. A prosthetic replacement is not indicated.

An alternative to CMC fusion is soft tissue stabilization, which is essential if the MP and IP joints are fused. Realignment of the metacarpal with the flexor carpi radialis (FCR) tendon is effective in maintaining stability with or without resection arthroplasty. Temporary Kirschner wire fixation can be used.

Authors’ Preferred Method of Treatment

Increasing deformity with loss of function, the development of skin breakdown, and extrusion of calcific material are frequent indications for surgical consultation. The most common indications for surgery are vascular insufficiency with digital ulceration, calcinosis, and finger and thumb deformities.

Authors’ Preferred Method of Treatment: Dorsal Tenosynovectomy

A straight (preferred) or gently curved longitudinal incision is made over the dorsal aspect of the wrist just to the ulnar side of the midline ( Figure 55.7 ). Full-thickness skin flaps, including the subcutaneous tissue, are reflected to expose the underlying extensor retinaculum and deep fascia. The superficial branches of the ulnar and radial nerves remain in the subcutaneous tissue of the flaps and thus are protected. Longitudinal veins are preserved if possible, but transverse communicating veins are divided. The fourth compartment is opened in a “Z” manner. The terminal branch of the posterior interosseous nerve on the radial side of the floor of the fourth compartment can be resected to partially denervate the wrist joint. The septum between the third and fourth compartments is opened and the EPL tendon is identified and protected. The vertical septum between each compartment is divided. The radial flap of retinaculum is hinged on the septum between either the second and third compartments or the first and second compartments (if the second compartment requires tenosynovectomy). The ulnar flap of retinaculum is hinged on the septum between the fourth and fifth compartments.

Surgical technique of dorsal tenosynovectomy. A, A straight dorsal incision has been made. The extensor retinaculum and the bulging dorsal tenosynovitis are seen. B, The retinaculum has been incised in the midline and reflected radially and ulnarward. Tenosynovitis is seen surrounding the extensor tendons. Dorsal tenosynovectomy and retinacular relocation have been completed. The dorsal retinaculum has been placed deep to the extensor tendons. C, Capsular closure is completed and tendon transfer is performed. Note the extensor carpi ulnaris relocation using a portion of the dorsal retinaculum. D, Exposure for dorsal tenosynovectomy. We prefer a straight rather than a slightly curved incision (as shown). Note the superficial branches of the radial and ulnar nerves protected in skin flaps.

( A-C, From Millender LH, Nalebuff EA: Preventative surgery: tenosynovectomy and synovectomy. Orthop Clin North Am 6:765–792, 1975, with permission; D, copyright © Elizabeth Martin.)

The first dorsal compartment is not opened unless it is involved significantly. Hypertrophic synovium is removed from each extensor tendon sheath in a systematic manner. A limited dorsal tenosynovectomy can be done through a single compartment incision (e.g., the fourth) if indicated. In this case, the fourth compartment is opened in the same Z manner, but not extended radially or ulnarly. The posterior interosseous nerve is resected as just described. The tenosynovium is dissected from the extensor tendons with small scissors or with a rongeur.

As much of the diseased tenosynovium is removed as possible, although it is sometimes necessary to leave material that is densely adhered to the extensor tendon’s surface. Frayed areas of the tendons are repaired with absorbable suture. If an area of tendon appears so attenuated or frayed so that tendon rupture seems imminent, the tendon at risk can be sutured to an adjacent extensor tendon above and below the area of damage, or the frayed and attenuated areas can be imbricated. If extensive tendon infiltration is found, similar infiltration may be present in other areas or on the contralateral side, and early surgery in these areas should be considered to prevent rupture.

After complete tenosynovectomy has been performed, the wrist joint is evaluated. If synovitis is present, the joint is opened and wrist synovectomy is performed with a small curved rongeur. The dorsal aspects of the ulna and radius are examined, and any bone spicules, which might cause attrition ruptures, are removed with a rongeur. The distal ulna is resected if it is dislocated and prominent dorsally. This is discussed in greater detail in the section on the distal radioulnar joint (DRUJ).

The dorsal retinaculum is passed deep into the extensor tendons and sutured in place to provide a smooth gliding surface beneath them. If bowstringing is anticipated as a potential problem (e.g., in a patient with good wrist extension), half of the retinaculum may be retained over the tendons ( Figure 55.8 ). The ECU tendon may be stabilized in a dorsal position with a narrow segment of the retinaculum.

Illustration of the basic operative technique. A, The retinaculum is opened in a “Z” fashion. B, Usually, the radial-based retinacular flap is hinged on the 1-2 septum and the ulnar flap on the 4-5 septum. The fifth compartment is opened as needed. C, The retinaculum is usually closed in a lengthened position. If needed, one flap can be placed under the tendons. D, Also if needed, the ulnar flap, which is hinged on the 4-5 septum, can be looped under the extensor carpi ulnaris (ECU). The synovial side of the retinaculum is placed against the ECU.

( A-C, From Slutsky DJ: The principles and practice of wrist surgery , Philadelphia, 2010, Elsevier. D, copyright Elizabeth Martin.)

The tourniquet can be released and bleeding controlled before final closure. If the tourniquet is released and bleeding is minimal, no drain is necessary. However, a small Penrose or suction drain prevents hematoma formation if the tourniquet is not released. The hand and wrist are immobilized in a bulky conforming dressing and a volar plaster splint. The wrist is held in neutral with the MP joints in extension. The IP joints are left free. The drain is removed 24 to 36 h after surgery. Dorsal tenosynovectomy can be performed in conjunction with other procedures such as thumb fusion, volar synovectomy, or finger tenosynovectomy.

Postoperative Management.

Hand motion is started 24 to 48 h after surgery. Active extension and flexion exercises are emphasized. Motion usually returns rapidly, but in a patient with a low pain threshold, formal hand therapy may be required. The MP joint should be splinted in extension to prevent extensor lag until active extension is possible. The wrist is supported with a volar splint for 2 weeks after the procedure.

When patients have difficulty regaining active MP joint extension, taping the fingers with the PIP and DIP joints in flexion during active extension exercise is helpful in improving joint movement. All the extensor power is concentrated at the MP joint level, and extensor tendon excursion is increased over the areas of surgery ( Figure 55.9 ).

Postoperative metacarpophalangeal (MP) joint exercises can be done with the proximal interphalangeal and dorsal interphalangeal joints taped in flexion. This maximizes extensor tendon excursion as the MP joint moves from flexion (A) to extension (B) .

Complications.

Complications after dorsal tenosynovectomy are infrequent. The most serious complication is skin necrosis or sloughing. When this occurs, the extensor tendons are exposed and are at risk for rupture or scarring. Hematoma formation under the thin dorsal flaps of rheumatoid patients (especially those taking corticosteroids) is the most frequent cause of delayed skin healing. Special care must be taken to prevent hematoma formation. The skin is closed without tension, and a drain should be used routinely. The proximal and distal ends of the wound can be left open if necessary to avoid hematoma formation. A layered closure to cover the tendons with subcutaneous tissue can sometimes be done. Occasionally, it is useful to put the extensor retinaculum over the tendons to protect them if skin breakdown occurs. Sutures should not be removed prematurely. If skin sloughing occurs, the wound can be treated by debridement and skin coverage. The MP joints are splinted in extension until the wound has healed by secondary intention in 2 to 3 weeks.

Occasionally, postoperative adhesions may result in either an extensor lag of the MP joints or loss of active finger flexion. Hand therapy is adjusted to emphasize flexion or extension as necessary. If pain or flexor weakness prevents flexion, passive flexion exercises and dynamic flexion splints can be added. If a significant extensor lag develops, a dynamic dorsal extension splint is used. Loss of motion after dorsal tenosynovectomy occurs more often in patients whose tendons are found to be in poor condition at the time of surgery, in patients with multiple joint involvement, and in those with low pain tolerance. Tenolysis after dorsal tenosynovectomy is rarely necessary. However, if significant impairment of function persists after 6 months of therapy, tenolysis should be considered.

Authors’ Preferred Method of Treatment: Flexor Tenosynovectomy

An incision is made in the midpalm, parallel to the thenar crease, and extended proximally while curving ulnarward at the wrist ( Figure 55.10 ). The incision is extended 4 to 5 cm above the wrist in a zigzag manner. Care should be taken to protect the palmar cutaneous branch of the median nerve at the level of the wrist flexion crease. The deep fascia is divided to expose the median nerve. The palmar fascia is incised and separated from the superficial surface of the transverse carpal ligament, which is divided to open the carpal canal.

A-C, Surgical technique of wrist flexor tenosynovectomy; incisions for wrist, palm, and digital flexor are shown. The flexor tendons are exposed at the wrist and elevated into the wound. The median nerve is retracted with a Penrose drain. The flexor tenosynovium is excised from the flexor tendons. FDP , Flexor digitorum profundus; FDS , flexor digitorum superficialis.

(Copyright Elizabeth Martin.)

The median nerve is freed from adherent synovial tissue. The motor branch of the median nerve is identified and traced into the thenar musculature. If compression of this branch by the fascia of the thenar muscles has occurred, the fascia is divided. The hypertrophic tenosynovium surrounding the flexor tendons is excised, and areas of tendon fraying are repaired as described for the extensor tendons. Occasionally, unsuspected ruptures of the deep flexor tendons may be discovered at this time. Therefore, it is critical that the function of the flexor tendons be known before surgery. If the flexor tendons are functioning by pulling through scar tissue, complete removal of all diseased tissue is not done. Careful dissection is required when performing an extensive flexor tenosynovectomy, and thought must be given to the consequences of separating each of the deep flexor tendons out of the mass of tenosynovium binding them together. It may be more prudent to separate the superficial flexor tendons and leave the deep flexor ones in situ; that is, do not separate the flexor digitorum profundus (FDP) into its four component tendons but merely separate them en masse from their scarred bed.

After tenosynovectomy is performed, the floor of the carpal canal is inspected and palpated. Any exposed bone spicules, particularly over the volar surface of the scaphoid bone, are removed with a rongeur because they can result in tendon rupture by attrition. Exposed bone surfaces are covered by mobilizing and suturing local soft tissue. Ertel and colleagues described a volar rotation flap to close the defect if primary closure is not possible ( Figure 55.11 ).

A scaphoid osteophyte can erode through the volar wrist capsule (A) and result in the “Mannerfelt lesion.” B, Attrition rupture of the flexor pollicis longus (FPL) tendon. During volar tenosynovectomy, the osteophyte is resected and the defect in the capsule is closed either primarily (C) or with local rotation flaps of the wrist capsule (D, E) . C, Capitate; FCR , flexor carpi radialis; FDP , flexor digitorum profundus; FDS , flexor digitorum superficialis; L, lunate; S, scaphoid.

(Copyright Elizabeth Martin.)

Traction is applied to the flexor tendons to check finger motion. Smooth motion of the fingers and thumb should be present. Catching signals the presence of tendon nodules in the palm or digits. If smooth motion of the tendons is not present, the involved tendon must be explored as far distally as necessary to remove the nodules. After removal of the nodules, the defect in the tendon is repaired with interrupted fine sutures.

Authors’ Preferred Method of Treatment: Digital Tenosynovectomy

We explore the flexor tendon sheaths of rheumatoid patients with digital tenosynovitis through zigzag incisions on the volar aspect of the digits ( Figure 55.12 ). Such incisions can be extended proximally or distally to provide additional exposure if necessary. If multiple fingers are involved, a single transverse incision across the distal part of the palm can be used to expose the proximal portions of the flexor tendon sheaths. The diseased tenosynovium surrounding the tendon is excised. However, the annular pulleys are preserved to prevent bowstringing of the flexor tendons. The pulleys can be narrowed if necessary, but as much pulley as possible needs to be preserved.

Digital flexor tenosynovectomy. A, The tendon sheath is approached through an extensile zigzag incision. B, Note the annular pulleys; the synovium usually bulges through the thin cruciate pulleys. As much annular pulley as possible is preserved when tenosynovectomy is performed. C, Half the superficialis tendon can be excised to allow free excursion of the remaining tendons without compromising annular pulley function.

(Copyright Elizabeth Martin.)

Nodules within the flexor tendons are excised and the defects are closed with fine sutures. After complete tenosynovectomy and nodule excision have been performed, traction is applied to the flexor tendons to confirm smooth gliding. Occasionally, another nodule is present at a different level within the fibroosseous canal and is revealed only after the obvious nodule is excised and flexor tendon excursion is tested. If passive flexion of the finger is greater than the flexion obtained by traction applied to the tendon, additional tenosynovectomy is necessary. The objective of flexor tenosynovectomy is to make active and passive finger flexion equal. Gentle manipulation of stiff joints can be performed to restore passive joint motion at this time.

One surgical solution is to excise one slip of the flexor digitorum superficialis (FDS) tendon to decompress the fibroosseous canal. Although we do not use this method routinely, we prefer it to resecting excessive amounts of annular pulley to allow free excursion of the tendons. The entire FDS tendon may be excised if it is severely diseased and prevents complete “pull-through” of the FDP tendon.

Postoperatively, finger motion is started early, usually the day after surgery. The patient is taught to stabilize each joint of the operated on finger in sequence to exercise the superficial and deep flexor tendons independently; this thereby avoids adhesions between the two tendons.

Extensor Tendon Ruptures.

Although the correct diagnosis of tendon rupture is not usually difficult to make, it requires both an observant patient and an informed physician. The sine qua non of tendon rupture is the sudden loss of finger extension or flexion . Tendon ruptures are generally painless and commonly follow trivial hand use or activity. Rheumatoid patients who become accustomed to frequent variations and limitations of hand function are likely to delay medical attention unless the functional loss after rupture of a tendon is obvious to them or is quite significant. Isolated ruptures of the EDQ or EPL may cause only limited functional loss and therefore go unrecognized or be overshadowed by more significant deformities.

The factors leading to rupture of a single tendon, unless corrected, are often responsible for subsequent ruptures with more significant functional loss. Frequently, after a rupture of the extensor tendon of the little finger, the ring finger extensor ruptures, followed by the long finger extensor, and so on ( Figure 55.13 ). This occurs as the remaining intact tendons shift ulnarward and become abraded over the roughened edges of the distal ulna. Thus, the usual progression of extensor tendon ruptures is in a radial direction, with the index finger being the last one affected. In our experience, multiple extensor tendon ruptures (especially those that occur in rapid succession) are the result of attrition as the tendons wear against a bone spicule on the ulnar aspect of the wrist.

Examples of extensor tendon ruptures. A, Dorsal tenosynovitis and single rupture of the extensor digitorum communis (EDC) tendon to the ring finger. Note the minimal lag associated with a single rupture. B, Double rupture of the EDC to the ring and little fingers. When two tendons rupture, there is an appreciable extension lag and the disability becomes obvious. C, Triple rupture involving the long, ring, and little fingers.

(From Millender LH, Nalebuff EA: Preventative surgery: tenosynovectomy and synovectomy. Orthop Clin North Am 6:765–792, 1975, with permission.)

Although sudden loss of extension of the little, ring, and middle fingers is most likely the result of multiple extensor tendon ruptures, three other conditions occur in rheumatoid arthritis that can mimic tendon rupture and should be excluded before surgery is performed to restore extensor power to the fingers. The most common of these conditions is MP joint dislocation, which results in a flexed and ulnar-deviated position of the finger. The lack of passive MP joint extension and the presence of palpable or visible extensor tendons on the dorsal aspect of the hand make the differential diagnosis between MP joint dislocation and extensor tendon rupture straightforward. The second condition to be excluded is displacement of the extensor tendons into the valleys between the metacarpal heads. When such displacement occurs, extensor force is lost because the tendons now lie volar to the axes of motion of the MP joints. With this condition, the posture of the fingers is similar to the posture that occurs in patients with multiple extensor tendon ruptures.

Differentiation between extensor tendon rupture and displacement of the tendons between the metacarpal heads can sometimes be made if the patient is able to maintain MP joint extension actively after the joints are extended passively. This is not always the case, however, and occasionally it is necessary to explore the tendons at the level of the wrist at the time of MP arthroplasty to verify their continuity. Treatment of subluxation of the extensor tendons consists of relocation over the MP joints with or without MP joint arthroplasty.

The least common but most difficult condition to diagnose among those simulating multiple extensor tendon rupture is paralysis of the common extensor muscle secondary to posterior interosseous nerve compression as a result of elbow synovitis. Several subtle differences allow tendon rupture to be differentiated from muscle paralysis. Patients with posterior interosseous nerve compression usually demonstrate some radial deviation of the wrist because of paralysis of the ECU muscle, in addition to the absence of active finger extension. Soft tissue fullness around the elbow signals proliferative synovitis of the radiohumeral and ulnohumeral joints, which can result in compression of the posterior interosseous nerve. In patients with posterior interosseous nerve compression, the extensors of the middle and ring fingers may be weaker than those of the index and small fingers. Thus, there is a greater extensor lag of the middle and ring fingers than of the index and little fingers.

In contrast, in rheumatoid attrition ruptures, the ring and little finger extensors are involved first. The best diagnostic test is the presence or absence of MP joint extension as the wrist is flexed. A positive “tenodesis effect” is found in the paralytic condition because the extensor tendons are in continuity. With tendon rupture, flexion of the wrist generally has no effect on finger extension because the extensor tendons are not in continuity. In addition, patients with multiple extensor tendon ruptures usually have dorsal tenosynovitis or a prominent distal ulna, which predisposes them to extensor tendon rupture, whereas patients with posterior interosseous nerve compression may have no such findings about the wrist.

Flexor Tendon Ruptures.

Flexor tenosynovitis is not uncommon in rheumatoid arthritis. Although carpal tunnel syndrome is the most common manifestation of flexor tenosynovitis at the wrist, weakness, loss of dexterity of the hand, local or radiating pain, and discomfort with hand use can occur. Tendon gliding becomes restricted, and progressive loss of active finger flexion ensues. A discrepancy between active and passive finger flexion is characteristic of rheumatoid flexor tenosynovitis. Triggering, locking, loss of the normal finger cascade, and loss of active flexion can occur, particularly with tenosynovitis in the palm or in the fibroosseous canals. Joint stiffness makes concomitant flexor tenosynovitis more difficult to detect. Flexor tendon ruptures occur but are much less common than extensor tendon ruptures.

The presence of inflammatory flexor tenosynovitis adversely affects the outcome of reconstructive surgery. That is, there is less restoration of function after a tendon transfer done for a rupture caused by inflammatory synovitis than after one performed for an attrition rupture. The most common flexor tendon to rupture is the FPL. Patients with this rupture lose active flexion of the IP joint of the thumb. It occurs when the tendon is eroded by a volar osteophyte on the scaphoid that penetrates the volar wrist capsule and is known as the “Mannerfelt lesion.” The diagnosis of FPL rupture is not difficult unless there is a fixed-hyperextension deformity or stiffness of the IP joint.

An isolated rupture of the FDP tendon results in an inability to flex the DIP joint actively. A condition that mimics FDP tendon rupture and in fact is a precursor to such a rupture is a rheumatoid nodule in the tendon within the fibroosseous canal of the finger. The nodule restricts profundus excursion, and there is loss of active flexion of the DIP joint. This condition was discussed earlier.

Rupture of both the superficial and deep flexor tendons causes such obvious functional loss that the diagnosis is straightforward. The patient lacks active PIP and DIP joint motion and can flex the finger only at the MP joint. Of course, passive finger motion must be present to conclude that both tendons are ruptured.

After a flexor tendon rupture is recognized, the site of rupture must be determined. Flexor tendon ruptures can occur at the wrist, in the palm, and within the finger. Palpation for fullness (or lack thereof) within the finger can be useful in this regard. Ultimately, surgical exploration is often necessary to determine the exact site of a rupture.

Rupture of the Extensor Pollicis Longus.

Rupture of the EPL is common in rheumatoid arthritis ( Figure 55.14 ). Functional loss varies, depending on the functional capacity of the EPB and the status of the thumb joints. Although spontaneous rupture of the EPL can cause a “droop” or incomplete extension of the IP joint of the thumb, more commonly the patient maintains the ability to extend this joint despite the rupture. IP joint extension is a shared function of the EPL and the intrinsic muscles of the thumb. The intrinsics alone can extend this joint to neutral; the EPL is necessary for IP joint hyperextension. A patient with rupture of the EPL loses extension of the MP joint because the EPB is not strong enough to extend this joint by itself. Occasionally, no deformity occurs at either the MP or IP joint level, and the diagnosis is often missed unless a specific test for tendon function is done by asking the patient to extend the thumb with the palm resting on a flat surface while the examiner palpates the tendon of the EPL at the wrist.

Extensor pollicis longus tendon rupture. Note that the major deformity is loss of metacarpophalangeal joint extension. The interphalangeal joint can be extended by intact intrinsic tendons, as seen in this patient.

If the tendon is ruptured and functional loss or deformity is significant, EPL function should be restored. The options available include end-to-end repair, tendon grafting, or tendon transfer. Although a tendon rupture can occasionally be repaired by an end-to-end technique, this is an exception and should not be expected. In general, tendon grafts through areas of rheumatoid tissue tend to become adherent. However, a graft used to repair an EPL rupture can function satisfactorily. The power and long excursion of the thumb flexor overcome the adhesions that form on the dorsum. The proximal motor must not be scarred or contracted for this to be effective, and for this reason, we prefer tendon transfers for the treatment of EPL rupture. The two most commonly used tendons for transfer are the EIP and ECRL. We prefer to use the EIP because (1) it can be taken from the index finger at the MP joint level without interfering with index finger’s function and (2) in our experience the patient does not lose independent extension of the index finger as a result of this transfer.

Rupture of the Flexor Pollicis Longus.

The most common flexor tendon to rupture in patients with rheumatoid arthritis is the FPL. It is usually secondary to attrition at the level of the carpal scaphoid bone and has been referred to as the Mannerfelt lesion. The functional loss is variable. If the patient has a good IP joint, the loss is apparent. If the MP joint has significant involvement or is fused, the loss of any IP joint motion results in substantial functional loss. Either terminal joint stability or restoration of active motion must be provided. Even if the IP joint is fused to provide stable pinch, the volar aspect of the wrist still must be explored. The bone spicule that has disrupted the FPL affects the tendons of the index finger next and must be removed. One of our patients was found to have ruptures of both the superficial and deep flexor tendons of the index and middle fingers, in addition to the thumb flexor.

Operative Technique.

The volar aspect of the palm and wrist is exposed through a curved incision along the thenar crease and is extended proximally in a zigzag manner ( Figure 55.20 ). The bone spicule on the ulnar aspect of the scaphoid bone, which protrudes into the radial side of the carpal canal, is removed, and the exposed bone is covered by mobilizing adjacent soft tissue. Attention is then directed toward restoration of tendon function. Surgical choices include the use of a bridge graft, a standard tendon graft, or a tendon transfer. If both tendon ends can be identified at the wrist level, we prefer to insert a short bridge graft. The palmaris longus is suitable for this, but if it is not present, a slip of the FCR or one of the multiple slips of the APL can be used. If suturing at the level of the rupture is difficult because of its location in the carpal tunnel, incisions can be made at the level of the MP joint and distal forearm and the graft passed across the tunnel and sutured distal and proximal to it. If the distal tendon stump cannot be brought into the wrist incision, we either use a full-length tendon graft or transfer a superficial flexor tendon. The preference is to use the superficial flexor of the long finger as the motor because it is longer and avoids compromising the grip function of the ring and little fingers.

A, Radiograph of a patient with a ruptured flexor pollicis longus (FPL) tendon. Note the osteophyte of the scaphoid, which caused an attrition rupture of the FPL. B, Another patient with a ruptured FPL tendon. The flexor tendons are exposed, and the ruptured one is held with forceps. Synovium from the scaphotrapezial joint can be seen ( arrow ). A sharp spur on the scaphoid can be palpated adjacent to this capsular tear. Note the ruptured proximal tendon and intact finger flexors. C, Range of motion of the interphalangeal joint of the thumb 4 months postoperatively.

(From Nalebuff EA: Reconstructive surgery and rehabilitation of the hand. In Kelly WN, Harris ED, Ruddy S, et al., editors: Textbook of rheumatology , ed 2, Philadelphia, 1985, WB Saunders, pp 1818–1826, with permission.)

The superficial flexor is detached in the distal part of the palm and sutured to the volar aspect of the distal phalanx of the thumb with a suture passed through the distal phalanx and tied over a button on the dorsal aspect of the nail plate. A soft rubber catheter or a tendon passer is used to bring the tendon through the sheath and pulley mechanism. The stump of the FPL is elevated, and the underlying cortex is roughened before final attachment of the graft or transfer. Carpal tunnel release and flexor tenosynovectomy are usually performed at the same time. The thumb and wrist are immobilized in moderate flexion for 3 weeks, after which active motion is started. If the carpal tunnel was opened to perform tendon reconstruction, the wrist is positioned in neutral for 3 weeks to prevent flexor tendon bowstringing.

Rupture of the Flexor Digitorum Profundus.

Rupture of one or more of the deep flexor tendons is not uncommon. If a patient with these ruptures can maintain superficial flexor function (both range of motion and strength), functional loss is minimal. The treatment should match the degree of functional loss. If the distal tendon stump becomes adherent, the patient may lose active flexion but may maintain enough stability of the DIP joint to preclude the need for surgical stabilization.

The most important factor determining the type of treatment is the level of tendon rupture. Flexor tendon ruptures can occur within the finger, at the palm, or at the wrist. The palm is the easiest level at which function can be restored. Ruptures in the palm may be less obvious if the ruptured tendon adheres to the adjacent flexors. This obscures the diagnosis inasmuch as DIP joint flexion is possible with the finger extended and the flexor mass pulls on the distal tendon end through scar tissue; however, this is not so when the finger is flexed actively or passively at the PIP joint. This situation can be confused with a flexor tendon nodule that blocks active excursion of the profundus tendon. Clues to the proper diagnosis include the lack of a palpable nodule and an alteration in resting finger posture, with the finger assuming a more extended position than the adjacent fingers.

Flexor tendon ruptures at the palm and wrist levels are best treated by suturing the distal tendon ends to the adjacent intact tendon, although small bridge grafts can be used at the wrist level. Suturing to adjacent tendon cannot be done if the rupture occurs within the fibroosseous canal. In this case, surgery is performed only to remove diseased synovium from the intact superficial flexor, which is now vital to finger function. Caution should be used when considering staged flexor tendon reconstruction of the FDP through an intact FDS. The results with this technique have not been good. If the DIP joint hyperextends, we prefer to stabilize the DIP joint rather than consider a flexor tendon graft through an intact FDS tendon.

Rupture of the Flexor Digitorum Superficialis.

Loss of FDS function alone causes no obvious functional loss. In fact, as described previously in the section on tenosynovitis, we occasionally resect half of the FDS to restore proper function of the deep flexor tendon. The diagnosis of FDS rupture can be made only by careful examination. The treatment should not jeopardize existing tendon function; however, suturing to adjacent tendons within the palm or the wrist is feasible. A tenosynovectomy should be performed to protect the FDP tendons.

Rupture of Both Superficial and Deep Finger Flexor Tendons.

The loss of both flexor tendons of a finger results in obvious and significant functional loss: the finger “sticks out” from the other fingers and thereby “gets in the way.” Restoration of active finger flexion is a goal that is not always possible to achieve. For this reason, it is far better to be aware of early nodular tenosynovitis and to perform a prophylactic tenosynovectomy before tendon rupture occurs. If ruptures have occurred at the wrist, function can be restored by suturing to adjacent tendons or by a bridge graft of the FDP tendon with the suture lines placed proximal and distal to the carpal tunnel area. It is not necessary to reconstruct FDS tendon ruptures at the wrist. Therefore, an intact portion of it can be used for bridge grafts to reconstruct ruptured FDP tendons. If the rupture is in the palm and the distal tendon stump is long enough, adjacent suturing to an FDP tendon is the best option. If not, transfer of an FDS to the distal profundus stump can be done.

Within the fibroosseous canal, the same problem encountered in tendon laceration at this level exists, except that the situation is worse. The disease is not localized, and the dissection needed for exposure leaves a very poor bed for tendon grafting. In addition, the adjacent joints may have restricted or painful motion (or both). In our experience, free-flexor tendon grafts have not produced good results in patients with rheumatoid arthritis. Occasionally, if no other alternative is available, we perform a staged-flexor tendon reconstruction using a silicone-rubber tendon rod, particularly for younger patients who have minimal joint involvement. The technique is essentially the same as described for posttraumatic flexor tendon reconstruction.

Finally, because of advanced age, poor status of the IP joints, or generalized disease, the wisest choice for some patients in whom both flexor tendons have ruptured within the finger is to fuse both the PIP and DIP joints in a functional position. In this way, satisfactory function can be restored and pain diminished. Suturing the proximal flexor tendon stumps to the base of the proximal phalanx may augment MP flexor strength if there is free excursion of the flexor tendon proximal to the rupture. Of course, this is a last resort, but it should be considered as a method to handle this complicated problem with selected patients.

Indications.

The indications for wrist joint synovectomy have never been clearly established. No studies have conclusively demonstrated that synovectomy changes the natural course of rheumatoid disease. In addition, because the wrist is a multiarticulated complex joint, total synovectomy is impossible. The indicators used for diagnosing wrist synovectomy vary among hand surgeons. Some have recommended a several-month trial period of conservative therapy before synovectomy. Flatt advocated early synovectomy because of the rapid joint destruction that can occur when active synovitis does not respond to medical therapy. Hindley and Stanley found relative sparing of the midcarpal joint and suggested that early synovectomy may prevent progression. We and others have found that synovectomy can provide significant pain relief, even in patients with advanced disease. Synovectomy in some cases can thus be an alternative to wrist salvage.

We used wrist synovectomy in a small group of patients with persistent, painful wrist synovitis, and minimal-to-moderate radiographic involvement. Many authors, including Brumfield and colleagues, found consistent and dramatic relief for pain and varying loss of wrist motion after wrist synovectomy in long-term follow-up reviews. Grip strength was found to be adequate, not weaker, after synovectomy.

We have found that synovectomy can relieve pain despite moderate destruction of the radiocarpal joint (based on radiographs). Thus, if a patient has clinical evidence of radiocarpal synovitis and other wrist surgery is being done, we include wrist synovectomy combined with denervation even when the radiographs show relatively advanced destructive changes.

Adolfsson and Frisen performed a limited series of arthroscopic dorsal wrist synovectomies with good short-term results. Although we have done only a small series using this technique, early results are encouraging. We have found little morbidity and more rapid recovery after this procedure than after open wrist synovectomy. Synovectomy of the wrist may also be more effective and durable in the era of biologics and disease-modifying agents.

Operative Technique: Dorsal Approach for Synovectomy.

The wrist is exposed with a straight, longitudinal incision as described for dorsal tenosynovectomy ( Figure 55.22 ). The terminal branch of the posterior interosseous nerve can be found consistently on the floor of the fourth dorsal compartment, deep in the extensor tendons. This is an articular branch that innervates the wrist joint. It can be resected to partially denervate the wrist joint for pain relief.

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