Introduction
This chapter discusses the current status and presents updates for several commonly seen connective tissue diseases. Treatment of rheumatoid arthritis has greatly changed, with fewer patients needing surgical treatment compared with decades ago. However, tendinopathies are seen frequently, and their incidence has not changed. Tendinopathies, especially trigger fingers (including trigger thumbs) and entrapment of tendons in the first dorsal compartment, remain the most commonly seen disorders in hand surgery.
Rheumatoid arthritis (Ilse Degreef)
Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily affects the joints. It is a systemic disease, involving the hands in up to 90% of patients, with a common onset of arthralgia and subclinical synovitis before RA diagnosis. , It is an autoimmune disorder that causes synovial inflammation, leading to arthritis with pain, stiffness, damage, and deformities in the affected joints.
RA often affects the wrist, tendons, and small joints in the hands, causing marked impairment of hand function. If disease control with disease-modifying antirheumatic drugs (DMARDs) is insufficient, which is less likely today compared to 20 years ago, surgical treatment can be effective in managing the hand deformities. , It is crucial to realize that RA is a systemic disease, and treatment, decision-making, and rehabilitation must be addressed in a multidisciplinary setting. Today, the need for hand surgery has diminished significantly due to the increased efficacy of medical treatment.
Typical deformities of the hands in RA
RA typically causes complex deformities in the hands. The most commonly involved joints are the metacarpophalangeal and proximal interphalangeal joints, often with a typical wind-swept deformity with ulnar drift of the fingers. However, thumb and wrist deformities are also common and seriously compromise hand function ( Fig. 30.1 ).
Often, wrist problems in RA start at the ulnar side, often with tenosynovitis of the extensor carpi ulnaris. Once this tendon weakens, dislocates, or ruptures, distal radioulnar joint (DRUJ) stability is lost. The radius deviates volarly and radially, and this may initiate or increase the zigzag deformity associated with ulnar swept fingers. The dorsally prominent distal ulna and arthritic DRUJ may cause extensor tendon ruptures (Vaughan-Jackson lesion). Radiocarpal and midcarpal arthritis are also commonly seen.
In the fingers, arthritis and tendon imbalance are encountered, typically with ulnar extensor hood dislocations at the metacarpophalangeal (MCP) joints causing a flexed posture and swan-neck deformities at the interphalangeal joints. Flexor tendon tenosynovitis may persist, and pain, stiffness, and risk for rupture with function loss may also necessitate surgery.
The thumb may collapse with first carpometacarpal arthritis, subluxation, and secondary swan-neck or boutonniere deformity. The MCP and interphalangeal joint are also often involved in degeneration and instability.
Surgical goals
The basic treatment of RA patients is systemic treatment by the rheumatologist and general practitioner. Since the efficacy of medical treatment has increased markedly over the last decades, the need for hand surgery has decreased enormously. However, hand surgery can be considered in select cases to improve the quality of life. Some of the benefits of surgery may include:
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Reduced pain and inflammation and improved overall quality of life
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Improved hand function, allowing patients to perform activities of daily living more easily and to maintain maximal independence
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Preventing further joint damage and deformities
Surgical methods
Synovectomy.
The inflamed synovial tissue surrounding the joint is removed to reduce pain, inflammation, and further soft-tissue damage (tendon and ligamentous ruptures, secondary nerve compression) and/or joint degeneration due to joint instability and chondrolysis. Articular synovectomy can also be performed for diagnostic reasons (biopsy) if the diagnosis is not clear, but these are seldom specific and diagnosis is usually made clinically. In some patients, disabling rheumatoid nodules can be removed ( Fig. 30.2 ).
Tendon repair.
If tendon ruptures occur and function is lost, repairing or, more often, transferring tendons is performed to recover lost motion.
Joint replacement.
If articular damage is severe, function is impaired, and pain is significant, joint arthroplasty may be indicated. Either artificial joints can be implanted or joint interposition, partial fusions, and resection can be considered.
Arthrodesis.
Fusion of any affected joint in the most acceptable position can be considered to maintain as much function as possible. This procedure is typically reserved for patients with severe RA who have significant joint deformities, pain, and severe instability.
Typical hand surgical procedures in RA
Early surgery to prevent devastating function loss and collapse of wrist and hand is focused on disease control if DMARDS are insufficient. A biopsy may help in diagnosis, synovectomy for treating joint affections, and tenosynovectomy to prevent complications such as tendon ruptures and nerve compressions (e.g., compression of the posterior interosseus nerve with dropped fingers, which mimics extensor tendon ruptures). Nerve decompression surgery may be needed, most commonly carpal tunnel release, which is highly prevalent in RA. In tendon inflammation, it is advised to wait for synovectomy no more than 6 months in extensor tendons and 3 months in flexor tendons to avoid tendon ruptures.
Unstable, painful, and arthritic joints are often fused. Partial or total wrist arthrodesis (with plates or central pinning) in a neutral position may preserve hand function. The oldest technique is a Clayton-Mannerfelt single Steinmann pin arthrodesis. In selected cases, implant arthroplasty may be considered. The distal ulna may be removed (Darrach procedure), fused with ulnar resection (Sauvé-Kapandji procedure), or replaced by semiconstrained linked implant arthroplasty of the DRUJ ( Fig. 30.3 ). , Tendon ruptures, often caused by DRUJ arthritis (Vaughan-Jackson lesion), are commonly treated by transferring the extensor digitorum communis or flexor digitorum superficialis of the fourth finger ( Fig. 30.4 ).
In the typical ulnarly deviated MCP joint deformities, the MCP joints can be rebalanced by extensor repositioning, interosseus muscle transfers from ulnar to radial insertions (Flatt’s intrinsic transfer), and silicone spacer implantation ( Fig. 30.5 ). Often, reconstruction of the thumb at the same time allows for improved pinch. Swan-neck deformities can be addressed by reconstruction of the joints, soft-tissue rebalancing, or fusion in the best position, depending on the presentation and individual needs of the patient.
Complications and surgical risks
The risks associated with rheumatoid arthritis hand surgery are higher than in the general population due to the underlying systemic disease and the medications needed to treat it, which compromise immunity and healing capacity. The most common complications are:
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Infection: particularly if implants are used.
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Bleeding: especially in patients on drugs that increase bleeding such as anticoagulant and antiplatelet agents. Severe hematoma formation can delay wound healing and result in secondary infection.
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Nerve damage: due to severe synovitis and disturbance of normal anatomy, nerves are more at risk in RA surgery.
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Stiffness: Tendon surgery, joint synovectomy, and arthroplasty can lead to stiffness and limit hand function.
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Implant failure: In joint replacement surgery, there is a risk of implant failure due to implant loosening, instability, or periprosthetic factures, any of which may require additional surgery.
Medication policy in perioperative period
Although most medications for treating RA increase infection risk and slow down wound healing, most medications are not interrupted for surgery, since the interruption will increase systemic problems, and the risks may not outweigh possible benefits. If possible, the date for surgery is scheduled as far away as possible from periodic dosages of medications to reduce their influence on surgical risks.
Tendinopathies in the flexor and extensor tendons (Jin Bo Tang)
Tenosynovitis in the hand is usually a trigger digit , caused by a constricting A1 pulley in the distal palm, or de Quervain’s disease at the wrist, which is tenosynovitis of the first extensor tendon compartment. Tenosynovitis is the inflammation of the fluid-filled sheath that surrounds a tendon, typically leading to pain, mild swelling, and stiffness, often after repetitive use of the hand. The disease can often be relieved with rest or conservative treatment.
Trigger fingers (including trigger thumbs)
Anatomy.
The digital flexor tendons are within closed synovial sheaths covered by segmental rigid pulleys. The tendon sheaths are firmly attached to the metacarpals and phalanges. The pulley at the base of each digit where the digit meets the palm is the A1 pulley. The pulleys serve to hold the flexor tendons close to the bone while the digits are actively flexed. The movement of the tendons against the pulleys can create friction and degeneration and fibrosis in the tendon, with development of nodules on the volar aspect of the tendons ( Fig. 30.6 ). These nodules preclude smooth tendon gliding and finger flexion, i.e., trigger fingers. As long as the other pulleys are intact, the A1 pulley can be incised completely to release the mechanical mismatch.
Risk factors.
Risk factors for trigger fingers include repeated powerful gripping. Trigger finger is more common in people with certain medical conditions, such as diabetes and RA. Trigger finger is seen in elderly individuals and is rare in children, more common in women, often over the age of 50. Women during pregnancy or after delivery more often have trigger fingers. Pediatric trigger thumb can result in locked flexion of the infant’s thumb, which usually resolves as the child grows. Surgical decisions are made in the preschool ages if the thumb remains locked; only in severe pediatric trigger thumb where function is affected by the extreme flexion of the interphalangeal joint, early surgery is necessary.
Clinical presentations.
Trigger finger may progress over weeks or months, initially with discomfort or pain during active digital flexion, decrease in grip strength, and dropping objects. Symptoms include finger stiffness, particularly in the morning, a popping or clicking sensation as the finger moves, and in severe cases, a finger catching or locking in a flexed position, which suddenly pops straight.
Upon examination, it is often found that tenderness or a bump in the palm at the base of the affected finger. Swelling of the finger is not often found. Typically, there is no history of acute trauma, but the patient often has one of these risk factors as described earlier. The diagnosis is clinical, without routine need of using ultrasound or other diagnostic tools.
Nonsurgical treatment.
Nonsurgical treatment is indicated for the patient who has short duration and relatively mild presentations. Even with a lump noted in the palm, nonsurgical treatment can still be used if the patient does not wish to proceed to surgical release immediately. The treatment includes rest, avoiding activities that cause or worsen the trigger, and injection of steroid into the tendon sheath. Splinting does not have definite effectiveness, and we do not recommend it unless for some reason a steroid injection is contraindicated. Gentle stretching exercises can help decrease stiffness and improve motion in the involved digit.
Over-the-counter medications, such as acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs), can help relieve pain, and the NSAIDs also have antiinflammatory properties, but they do not seem to effectively tackle the underlying mechanical mismatch.
Steroid injections are more often used. Cortisone, an antiinflammatory agent, can be injected into the tendon sheath at the base of the affected digit ( Fig. 30.7 ). A steroid injection often resolves the condition. If symptoms do not improve with one injection or improve but then come back weeks or months later, a second injection may be given. If two or three injections do not help the problem, surgical release is often recommended.
Surgical treatment.
Trigger finger surgery is an outpatient procedure under local anesthetic. Through a small incision at the distal palm crease or at the thumb proximal flexion crease, a 1 to 1.5 cm transverse incision cm is made to expose the A1 pulley. The A1 pulley is about 1 cm long and rigid. The pulley is longitudinally cut with surgical scissors under direct visualization. After release, the flexor tendon can glide more easily through the tendon sheath, making the clicking/catching sensation go away. The patient can then be asked to move the digit to see whether motion is smooth. If necessary, a part of the proximal A2 pulley can also be released, which does not cause tendon bowstringing. , If the tendons move smoothly, the skin is closed. Digital nerve damage is possible and needs to be avoided. In releasing the A1 pulley in the thumb, the radial digital nerve can course obliquely in the area of the A1 pulley ( Fig. 30.8 ); in dissecting the subcutaneous tissues, one should identify the nerve or stay away from it and avoid cutting it.
The patient can use the hand normally one or two days after surgery if there is minimal pain. Outcomes of surgical release are generally good and reliable. Complications are uncommon but include digital nerve injury, digital stiffness, temporary soreness at the site of surgery, and infection. Partial release of the A1 pulley or release of multiple pulleys are inappropriate surgeries. Trigger finger occurs in other pulleys occasionally. If the symptoms have not resolved after releasing the A1 pulley of a finger, another pulley—such as the proximal A2 pulley—may be involved. Then, the proximal part of the A2 pulley can be released. Further release of the pulleys may lead to bowstringing, so it is best to remove one slip of the FDS tendon to eliminate the mechanical mismatch when the proximal A2 pulley has already released.
de Quervain’s disease
Anatomy and causes.
There are two named tendons in the first extensor compartment (also called the first dorsal compartment): abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). The extensor retinaculum is a rigid and narrow constrictive band, which prevents bowstringing of the tendons during wrist extension and thumb abduction ( Fig. 30.9 ). Repetitive motion of the tendons against the extensor retinaculum causes local pathologic changes such as swelling, fibrosis, and degenerative changes, which present as pain and limitation of wrist and thumb motions.
Clinical presentation.
The symptoms develop gradually. The patient feels pain during wrist extension and thumb extension or abduction and has tenderness along the radial side of the wrist. The pain is exacerbated by gripping and raising objects with the wrist in neutral or when the wrist is deviated ulnarly. Moving the thumb is painful and difficult, and grasping or gripping is sometimes impossible. Lifting is weak, and the patient easily drops objects. Tenderness at the first extensor compartment is always found on examination. Swelling may not be present.
The patient may have a clear recent history of repetitive use of the wrist, including holding a baby with the arm. The Finkelstein test is used for diagnosis. The test is positive when ulnar deviation of the wrist, with the thumb flexed and wrapped by fingers to make a fist, causes pain in the first dorsal compartment area ( Fig. 30.10 ).
Treatment.
Nonsurgical treatment is similar to treating trigger finger, but injection is sometimes not effective, possibly because there is a septum inside the first extensor compartment, which prevents the injected steroid from bathing the entire compartment. The injection also may not produce lasting benefit if the mechanical mismatch is extreme. Local steroid injection ( Fig. 30.11 ) can be repeated 2 to 3 times, which usually is effective. If the injections are not effective, or the symptoms are severe at the first clinic visit, surgical release is warranted.
Surgical release is indicated if conservative treatment is not effective over several months, and the surgical procedure is straightforward with little risk of complications. A longitudinal incision (1–1.5 cm) directly over the first extensor compartment exposes the extensor retinaculum, and the first compartment is released completely ( Fig. 30.12 ). Be careful not to injure the overlying radial sensory nerve. Care is taken to examine and release possible sub-sheath between two tendons inside the compartment. A transverse incision can also be used, which may be better cosmetically, but more care should be taken to avoid the radial sensory nerve.
Complications.
The radial sensory nerve runs obliquely proximal to the first extensor compartment ( Fig. 30.9 ). In most cases, it is about 1 cm proximal to the proximal margin of this compartment. However, there is variation in its the path, and an extended proximal incision should be avoided. Before surgery, the operator may also examine the course of the nerve in nonobese patients as it may be visible or palpable by rolling it side to side. In obese patients, the operator should take care to identify and protect this nerve if a longer surgical incision is made in order to visualize the first dorsal compartment beneath the subcutaneous fat. The recommended incision ( Fig. 30.12 ) sufficiently exposes the tendon sheath and allows for easy release of the sheath and any sub-sheath separating the two tendons inside the first compartment ( Fig. 30.12 ).
Bowstringing and subluxation of the extensor tendons do not happen if the surgical release is confined to the densest portion of the extensor retinaculum. However, if the release is too long, tendon bowstringing may occur. There is also a risk of subluxation when the release is unnecessarily long. The treatment is to reconstruct a part of released sheath by forming a Z-plasty of the extensor retinaculum.
Recurrence of the tenosynovitis of the first dorsal compartment of the wrist usually relates to incomplete release or having not released the intracompartmental septum (sub-sheath) inside the first dorsal compartment. , Sato et al found the prevalence of intracompartmental septum in patients with de Quervain’s disease was 62% (69 of 112 wrists) with ultrasound examination. Ultrasound is considered a conventional part of the surgery to confirm there is no sub-sheath or the sub-sheath is released to expose both tendons.
In-depth advice: Tips to avoid complications of trigger fingers and de Quervain’s disease
Complications after trigger digit release or surgical release for de Quervain’s disease are much less common than complications after flexor or extensor tendon repairs. If the surgical release is properly done, there should be no complications. The complications of nerve injuries or bowstringing of the tendons relate to unnecessarily larger surgical incision and release of the pulleys/sheath. The persistence or recurrence of symptoms relates to failure to completely release the A1 pulley in trigger finger or in not recognizing and releasing the sub-sheath of the first dorsal compartment. If these complications are found, reoperation is indicated.
More recently, some surgeons use percutaneous or ultrasound-guided trigger finger release. There are reports of possible increased risks of complications with percutaneous release of the trigger fingers and similar effectiveness without increasing complications. , It remains a question whether this increases or decreases surgical complications. The release surgery for tenosynovitis is now popularly performed in the office or minor procedure room with field sterility; therefore field sterilization should be sufficient when properly carried out. , The patient who is treated in a wide-awake setting should be asked to actively move digits and wrist during surgery to ascertain complete release of the constricting sheath.
Intersection syndrome
Intersection syndrome is a condition that affects the first and second compartments of the wrist extensors. The condition may occur after repetitive friction at the junction where the tendons of the first dorsal compartment cross over those in the second, creating tenosynovitis. The pain is located over the second dorsal compartment area. This disease may occur after certain sport activities. , This disease is rare, and many hand surgeons (including the authors) have not encountered it. Not a few surgeons consider it a misnomer. However, it is useful to know the possibility. Ultrasound examination may provide more support for diagnosis, as the clinical findings are not typical and diagnosis may be doubtful from clinical symptoms. The treatment is similar with those of de Quervain’s disease.
Tennis elbow and other tendinopathies around the elbow (Ilse Degreef)
The elbow is a hinge joint and key to the hand function that is unique to humans. Motion and stability are the basic properties the elbow needs to fulfill its duty. However, most of the upper and forearm muscles are attached with their tendons crossing the joint, and the motion and forces used in daily living put a lot of tension, load, and shear stresses. Therefore the area is prone to pathology: tendinosis, peritendinous bursitis, calcifications, ossifications, traction spurs, and partial and complete tears at their attachments are often encountered in active, working, or sporting individuals. Here, we will discuss the four major tendon attachments that are affected around the elbow: the forearm extensor and flexor muscles (epicondylitis) and the upper arm’s biceps and triceps insertion tendinopathy.
Epicondylitis
The most common and notorious complaint is the one of tennis elbow , also known as lateral epicondylitis. It is a common condition that affects the lateral side of the elbow in 2% to 3% of the people. Its incidence peaks at the age of 50 and occurs equally in men and women. Although it is called tennis elbow, it can affect anyone, and overuse of the muscles and tendons in the forearm that attach to the lateral epicondyle is likely to play a role in its etiology, since repetitive movements and forceful activities are associated with a high incidence of this disease, even up to 23% of people with certain jobs. Medial epicondylitis (also named golfer’s elbow ) is very similar to lateral epicondylitis, but the prevalence is lower (1%–2% up to 5%), and in 1% both complaints are concurrent, more so in women.
Causes.
Activities that involve repetitive gripping, such as using a computer mouse, playing musical instruments, or performing manual labor, can contribute to the development of tennis elbow. Repetitive or excessive use of the forearm muscles and tendons while moving the elbow joint can lead to small tears in the tendons that attach to the lateral epicondyle. This repetitive use can cause strain, shear stress to the tendon attachments, and a chronic fibroblastic response in the tendon insertion with granulating tissue and round cell infiltration. The local free nerve endings convey pain and discomfort. In a strict sense, it is not an inflammation but an angio-fibroblastic hyperplasia. Therefore it should be called epicondylosis or tendinosis, not “-itis.”
Anatomy.
The origins of the wrist and fingers extensor muscle group on the lateral epicondyle of the humerus are involved in tennis elbow, the ones of the wrist flexors on the medial side in golfer’s elbow. Anatomically, the tendinosis and tears are seen mostly in the extensor carpi radialis brevis (ECRB), but the common extensor insertion may also involve the extensor digitorum communis, extensor carpi radialis longus, and the extensor carpi ulnaris muscles. In golfer’s elbow, most commonly the origins of the flexor carpi radialis and pronator teres insertions are involved, but also the flexor carpi ulnaris, flexor digitorum superficialis (FDS), and palmaris longus may be implicated.
Diagnosis.
The diagnosis of tennis/golfer’s elbow is clinical. Tenderness on palpation, painful stretch, and pain on resisted contracture of the involved muscles are diagnostic. In tennis elbow, this means pain on the lateral epicondyle, increasing with resisted isometric extension of the wrist (chair test) and pain with passive wrist flexion with increasing elbow extension ( Fig. 30.13 ). On examination, tenderness is found on the lateral epicondyle commonly at the site of origin of the extensor tendons or in the musculotendinous junction of the extensors just distal to the insertion ( Fig. 30.14 ). In most patients, the tenderness is very localized within an area of 1 to 2 cm.
