Frontiers in Upper Extremity Surgery Reconstructive S urgery in the Hand a nd Wrist in Rheumatoid Arthritis
Reconstructive Surgery in the Hand and Wrist in Rheumatoid Arthritis • • • • •
Barry P. Simmons, MD Chief Hand/Upper E xtremity Service Department o f Orthopedic S urgery Brigham and Women’s Hospital Harvard Medical School
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Philosophical Overview • What does the p atient want? – Pain relief – Functional I mprovement – Self I mage
• What can the p atient e xpect? – Outcomes – Manage patient expectations
Philosophical overview
• What is the p rocedure, immobilization and rehabilitation • Engage p atients in the d ecision
The Most I mportant Factor in Predicting Results is the Status of the Hand and Wrist Pre-Operatively
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MCP dislocations, boutonniere and swan neck deformity, Z thumb deformity
• Severe d eformity;; can h ave d ifferent deformities in one o r b oth h ands • What can the p atient e xpect? Cannot make this hand “normal”. 7
Prioritizing surgery if multiple joints involved • Wrist: fusion/arthroplasty • Thumb: CMC, MCP, IP • Wrist and Thumb can o ften h ave surgery at the same sitting • Digits: – MCP’s – PI P/DI P
Prioritizing surgery if multiple joints involved • Patients u sually most satisfied from wrist and thumb surgery: pain relief and function • Wrist and thumb surgery require less post- operative rehab • Digital surgery more complex, more rehab, less satisfying • If start with digits, may not want a ny further surgery
Tenosynovectomy • Effective way to p revent e xtensor tendon ruptures • Tendon transfers e ffective if ruptures h ave occurred;; more complex surgery, immobilization, rehab • “Always” rupture o ver distal ulna
Tenosynovectomy
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Rupture extensors to ring/little
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Extensor tendon transfers: EIP->EDQ/EDC 5, adjacent junctures EDC 4 and 3
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Rupture ulnar 3 extensors
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Rupture extensor digitorum communis
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Flexor tendon ruptures FPL, Index flexors Differential Dx: AIN palsy
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Distal radioulnar joint
Dislocated Silastic prosthesis
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Distal radioulnar joint • Darrach procedure (resection distal u lna) • Distal radioulnar arthrodesis with proximal ulna o stectomy (Suave-Kapandji) • Baldwin procedure • Hemi-interposition arthroplasty;; less instability of d istal ulna • Avoid implants 21
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Hemi-interposition arthroplasty
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Reconstructive Alternatives at the Radiocarpal Joint • Wrist arthrodesis – Gold s tandard – High success rate
• Wrist arthroplasty – Multiple f ailed implants – Patients prefer arthroplasty t o arthrodesis if have bilateral s urgery 23
Wrist Arthrodesis
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Total Wrist Arthroplasty • Silastic spacer • Metal-to-plastic – Meuli – Arizona Medical Center – Tri-axial – Biaxial – Universal (KMI );; Universal 2 (I ntegra)
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Universal • Metal to P lastic
Prosthesis Placement
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Final Radiographs
• • • • •
How do I decide how to guide patient in their decision
Bilateral disease Adequate b one stock 50*-60* o f motion Non crutch walker Arthroplasty n on-dominant, a rthrodesis dominant wrist • If you d o the a rthroplasty first they will request the same on the contralateral wrist
Is wrist arthrodesis still the gold standard?
Maybe n ot
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Intracarpal/Radiocarpal disease • Multiple options d epending o n involved joints • Ulnar translocation o f carpus most common instability pattern in RA;; radiolunate a rthrodesis (Chamay procedure) • Can be creative;; rarely an o ption
Thumb ray Boutonniere thumb: • MCP flexion • IP hyperextension • CMC usually spared
• Surgical options
• MCP arthroplasty • IP arthrodesis • Try to avoid fusing both joints;; never fuse all 3
Boutonniere T humb
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Thumb ray • Swan neck deformity • CMC usually involved • MCP hyperextension • I P flexion
– Surgical options • CMC resection arthroplasty • MCP fusion • I P spared
MCP Arthroplasty
Silastic Implants • Soft t issue procedures rarely indicated;; poor results • Don’t f orget t he thumb • Advantages of t humb arthroplasty v s arthrodesis: don’t worry about f usion and don’t have t o remove hardware
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Rehabilitation • Early ROM with dynamic extension orthosis • Wide spectrum of results;; ROM varied from 10° to 50°
Rehabilitation (1 ½ -2 hours to fit/instruct)
Hand-Based Cast for 3-4 Weeks Leave PI P’s free
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Post-op 3 months 41
Objective and Subjective (Outcome Study) results for MCP arthroplasty • 80% P atients S atisfied with Surgery • Hand Appearance and P ain Relief
– Most highly c orrelated with s atisfaction
• Ability to h old large, light o bjects – Only f unctional ability t hat is associated with patient s atisfaction 42
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Proximal Interphalangeal Joints • Boutonniere d eformity – arthrodesis most c ommonly
• Swan-neck d eformity – The MCP joints have t o be c orrected as well – Manipulation and pins f or 3 weeks – FDS tenodesis f or s upple s wan necks, rare in RA, most c ommon in SLE
