Current Concepts in the Management of Rheumatoid Hand

Abstract

Rheumatoid arthritis (RA) is a chronic inflammatory disease caused by a T cell-driven autoimmune process, which majorly involves the diarthrodial joints. It affects 1% of the US population, and approximately 70% of patients with RA develop pathologies of the hand, especially of the metacarpophalangeal joints (MCP). Furthermore, also the extensor and flexor tendons of the fingers are frequently involved. The first line of treatment should be conservative. Three general classes of drugs are currently available for RA: nonsteroidal anti-inflammatory agents (NSAIDs), corticosteroids, and disease modifying antirheumatic drugs (DMARDs). Encouraging results have been obtained using DMARDs. However, when severe deformities occur or when patients are unresponsive to medical management and injections therapy, surgical intervention should be performed to relieve pain and restore function. Several surgical options have been described for the management of MCP joint deformities, including soft tissue procedures, arthrodesis, and prosthetic replacement. Tendons ruptures are generally managed with tendon transfer surgery, while different surgical procedures are available to treat fingers deformities. The aim of the present review is to report the current knowledge in the management of MCP joint deformities, as well as tendons damage and fingers deformities, in patients with RA.

A 10-Year Follow-Up of Uncemented Constrained Metacarpophalangeal Joint Arthroplasties Using the RM Prosthesis in a Patient with Rheumatoid Arthritis.

“…Functional flexion postures averaged about 60° at the MCPJ and PIPJ, and 40° at the DIPJ [11,12]. A MCPJ fusion should be avoided as a primary surgical procedure, and it is only considered when other surgical procedures have been failed [2,[11][12][13][14]. Despite the well-known high complication rate (wear-related synovitis and osteolysis, implant loosening and/or breakage), the silicone rubber implants, introduced in 1968 by Swanson [15] and its recent further development NeuFlex, introduced in 1998, are recommended unchanged for low-demand patients with RA ( Figure 1A-B) [4,16,17], and MCPJ resection-interposition arthroplasties with the use of autologous soft tissue structures can be another option for these patients [11,[18][19][20].…”

“…Patients presenting with this deformity often report inability to extend the fingers. Moreover, the deformity limits the ability to cut the fingers around larger objects, and fine pinch is obstructed because the index and middle fingers can no longer oppose the thumb in a tip-to-tip pinch [2].…”

Rheumatoid Hand Surgery: Reconstruction of a Musician’s Hand

“…Some articles contraindicate lesser MP joint fusion because MP joint activity is crucial to the arc of motion of the finger, and despite the aesthetic advantage achieved by the fusion of the MP joint, the loss of motion can impair the patient's activities of daily living. 1) Other articles report that arthrodesis is contraindicated for the lesser MP joints; however, it offers excellent benefits in terms of pain reduction, improved alignment, and stability with substantial functional benefit. 5) In our case, MP fixation worked very well to support the middle and ring fingers not only in terms of playing the erhu, but also in terms of the activities of daily life.…”

“…1) Reconstructive hand surgery is well established for the management of rheumatoid arthritis patients. However, hand reconstruction does not restore normal function to the rheumatoid hand.…”

Case-Based Examples of Management of the Rheumatoid Hand

“…In early cases, ulnar deviation can be addressed with a cross intrinsic transfer in which the ulnar lateral bands are transferred to either the proximal phalanges or the extensor tendons [ 1 ]. For patients demonstrating articular surface damage of the MCP joint or severe volar subluxation, soft tissue reconstruction will not be effective, and MCP joint arthroplasty is [ 2 ]. Several studies have shown encouraging short-term functional and aesthetic outcomes associated with this procedure; however, a high rate of implant breakage has been reported at long-term follow-up [ 3 -6 ].…”