Hand and Wrist Surgery - part 9 pptx

73 Rheumatoid Arthritis: Metacarpophalangeal Joint Reconstruction Arthroplasty R. John Naranja, Jr. and Kevin D. Plancher History and Clinical Presentation A 53-year-old right hand dominant woman was originally diagnosed with rheumatoid arthritis 14 years ago. Medical management of her disease process has included chronic oral prednisone. Her primary complaint includes pain and deformity of her hands and decreased function secondary to lack of mobility and strength. Physical Examination The patient has ~25 degrees of ulnar drift at the index through small finger metacarpophalangeal (MP) joints. An extension deficit at the MP measures ~50 degrees (Fig. 73–1). The arc of motion of the digits at the MP joint is 20 degrees. Key pinch strength is 30 N and grip strength is 70 N at position II using the Jamar dynamo- meter. There is relative preservation of joint motion at the proximal interphalangeal (PIP) joint and wrist articulations without significant collapse or deformity. Diagnostic Studies Radiographs of the hand to include posteroanterior (PA) (Fig. 73–2), lateral, and oblique views demonstrate subluxation and joint destruction of the MP joints in the index through small fingers of the right hand. Though there is relative dif- fuse osteopenia present, adequate bone stock appears present for potential implant arthroplasty. A R T H R I T I S O F T H E H A N D A N D W R I S T 462 PEARLS • Meticulous detail is necessary when reaming the proximal phalanx of the little finger when there is poor bone stock and especially in patients with juvenile rheumatoid arthritis. • When silicone synovitis and loss of bone stock occur, a resection arthroplasty should be considered. PITFALLS • Inadequate soft tissue balancing and poor hand therapy can lead to recurrence of the deformities and subluxation of these joints. • Use of silicone implants can lead to an inflammatory response with subsequent erosive changes. Figure 73–1. A classic ulnar drift and extension deficit in a rheumatoid hand seen at the metacarpophalangeal joints. (Illustration courtesy of The Indiana Hand Center and Gary Schnitz.) Differential Diagnosis Degenerative joint disease Rheumatoid arthritis Septic joints Diagnosis Rheumatoid Destruction and Deformi ty of the Index through Smal l Finger Metacarpalphal angeal Joints The MP joint in the rheumatoid hand is commonly affected by joint destruction and deformity. Typically, the disease process involves bony articular destruction, and ulnar and volar capsular contracture with concordant radial capsular attenuation. This subsequently results in subluxation of the flexor sheath in an ulnar and volar direction in addition to ulnar displacement of the common extensor tendon. Intrinsic tightness contributes to overall dysfunction. Indications for arthroplasty reflect the disease process and include pain and disability with radiographic evi- dence of joint destruction, limited MP range of motion secondary to contracted myotendinous and ligamentous supports, ulnar drift that has failed other soft tissue procedures, and stiff distal interphalangeal (DIP) or PIP joints. Arthroplasty of the MP joint predictably addresses these processes and maintains function better than arthrodesis or simple resectional arthroplasty in patients with adequate bone stock, soft tissue coverage, and absence of preexisting infection. R H E U M A T O I D A R T H R I T I S : M E T A C A R P O P H A L A N G E A L J O I N T R E C O N S T R U C T I O N A R T H R O P L A S T Y 463 Figure 73–2. Posteroanterior (PA) radiograph of metacarpophalangeal (MP) subluxation and joint destruction. Metacarpophalangeal destruction and deformity are often accompanied by PIP joint deformity and wrist collapse. Timing of surgical interventions as well as consid- eration of other joint involvement (e.g., hip and knee involvement/shoulder and elbow involvement) requiring further load bearing on the diseased upper extremity following surgery must be noted. With associated wrist involvement, reconstruction of the wrist followed by the MP joint is appropriate. The exception is in the face of an extensor tendon rupture with decreased passive MP range of motion. Metacarpopha- langeal arthroplasty should be performed first to gain passive motion in association with the extensor tendon repairs at the level of the wrist. Surgical Management A transverse or longitudinal skin incision is created dorsally over the region of the metacarpal necks. The dorsal veins are preserved and the extensor hoods to each digit are exposed with care to protect the neurovascular structures radially and ulnarly. The extensor tendon is identified and is usually subluxed ulnarly with attenuation of the extensor tendon at its radial aspect (Fig. 73–3). The extensor hood is longitudi- nally incised ulnar to the common extensor tendon in the middle and ring fingers, and between the common extensor and the ulnar capsular ligament of each digit. As- sociated capsular tissue is released distally to adequately allow the base of the proximal phalanx to be dislocated dorsal to the metacarpal. The radial collateral ligament of each digit is preserved if possible. With the MP joint placed into flexion, the metacarpal neck is exposed subperiosteally and transversely osteotomized using a microair saw (Fig. 73–4). Care is taken to leave part of the metaphyseal flare for support of the prosthesis. Proliferative synovium along with the transected metacarpal head is completely removed (Fig. 73–5). Attention is then directed toward the base of the proximal phalanx where all cartilaginous surfaces are removed in addition to any marginal osteophytes. The volar plate is identified and released from its attachment at the base of the proximal phalanx. In all but the index finger it is then completely resected. In the index finger it will be used in conjunction with the radial collateral ligament for later capsular reconstruction. Release and resection of the volar plate allow further identification of the underlying flexor sheath. An incision is made into the flexor sheath with subsequent delivery of the flexor tendon into the wound using a blunt hook. Hypertrophic tenosynovium is then removed. Evaluation of appropriate tendon excursion following the tenosynovectomy will determine whether flexor tendon exploration on the palmar aspect of the hand over the A1 and A2 pulleys is A R T H R I T I S O F T H E H A N D A N D W R I S T 464 Figure 73–3. Synovial reaction with pannus and subluxation of the extensor tendon at the MP joint. necessary. This is typically done using a palmar/digital zigzag-type of incision with care to preserve the A1 and A2 pulleys in the index and long fingers to avoid further ulnar subluxation of these tendons. The ulnar intrinsic tendon in all but the index finger is also delivered into the wound and incised at its myotendinous junction typically at the level of the MP joint. In the index finger, preservation of the ulnar intrinsic tendon is recommended to help maintain supination in this digit for pinching function. This pinching function is further reinforced by reconstructing the radial collateral ligament of the index and long finger by using the collateral ligaments and capsule. The ulnar collateral ligament, which has previously been divided at its insertion at the proximal phalanx, is now further mobilized by dissection proximally on the metacarpal, with care taken to maintain its attachment. Similarly, the previously preserved radial collateral ligament is dissected as a unit with the overlying capsule from its distal insertion. These capsular tissues may be tagged and retracted for later reconstruction using a 2–0 Dacron suture. With regard to the small digit MP joint, the abductor digits minimi tendon is iso- lated and sectioned with care to protect the ulnar neurovascular structures. The proximal end of the abductor digiti minimi tendon is then attached to the flexor digiti minimi tendon immediately volar in position to the abductor digiti minimi. The intramedullary canal of the metacarpal and proximal phalanx is then reamed in a rectangular fashion centrally in the canal using a combination of R H E U M A T O I D A R T H R I T I S : M E T A C A R P O P H A L A N G E A L J O I N T R E C O N S T R U C T I O N A R T H R O P L A S T Y 465 A B Figure 73–4. Clinical photo (A) and drawing (B) demonstrating transversely osteotomized metacarpal neck of the index finger. (Illustration courtesy of The Indiana Hand Center and Gary Schnitz.) Figure 73–5. Synovium removed from transected metacarpal head. (Illustra- tion courtesy of The Indiana Hand Center and Gary Schnitz.) curette, broach, and microair drill with a smooth leader point bur (Fig. 73–6). In the index finger, the medullary canal of the proximal phalanx requires the rectangular reaming to be performed in an orientation of slight rotation such that the dorsal ulnar corner is more dorsal than the dorsal radial corner, and the radial palmar corner is volar to the ulnar palmar corner of the rectangle when viewed axially. This will favor slight supination to help the index finger function in supination. In the small finger proximal phalanx, the reverse is true and the rectangular reaming should place the dorsal radial corner more dorsal than the dorsal ulnar corner and the ulnar palmar corner is volar to the radial palmar corner. This will favor the slight pronation required for the small digit. Care must be taken to avoid perforation of the cortex. Rough edges are flattened carefully and trial implants are placed for sizing. Evaluation of proper fit should include placing the MP joint into full extension with no demonstrable impingement or instability. Tension may be further modified with soft tissue releases or bony resection. The largest possible implant should be used with good fit of the stem into the canal and appropriate apposition of the midsection with bone (Fig. 73–7). With good bone stock, a grommet may also be used and press-fit into the intramedullary canals with the midsection of the implant resting on the grommet. Following placement of the implant, residual laxity of the index and occa- sionally the long finger joint can be addressed by imbricating the radial collateral A R T H R I T I S O F T H E H A N D A N D W R I S T 466 A C B Figure 73–6. (A,B) Clinical photos showing reaming with appropriate alignments performed in the metacarpal of the index finger. Note identification and tagging with a suture of the radial/collateral ligament. (C) Reaming of the proximal phalanx to prepare the canal. (Illustration courtesy of The Indiana Hand Center and Gary Schnitz.) ligament and capsule over the dorsal aspect of the base of the proximal phalanx at the dorsoradial border through a 1-mm drill hole (Fig. 73–8). Proximal reat- tachment to the metacarpal may also be necessary. If the radial collateral ligament has become too attenuated for the reconstruction, a proximally based flap using the radial half of the volar plate may be incorporated and similarly sutured to the dorsoradial aspect of the proximal phalanx. The distally released ulnar collateral ligament is then sutured to the ulnar edge of the radial collateral ligament and capsule. The extensor hood is repaired using 4–0 Dexon sutures and invert- ing the knots. The radial portion of the extensor hood is reefed to centralize the extensor tendon with care to bury the knots. In the index and long fingers, over- correction of the extensor tendons radially assists in avoiding a pronation force. In some cases, if the extensor tendon does not have adequate longitudinal tension, it requires imbrication. The juncturae tendinum are repaired and the skin is closed with interrupted 5–0 nylon sutures, followed by application of a volumi- nous hand-conforming dressing. R H E U M A T O I D A R T H R I T I S : M E T A C A R P O P H A L A N G E A L J O I N T R E C O N S T R U C T I O N A R T H R O P L A S T Y 467 Figure 73–7. Implant is placed in the canal with the best fit and appropriate position with bone. (Illustra- tion courtesy of The Indiana Hand Center and Gary Schnitz.) Figure 73–8. Implant in place with imbrication of the radial/collateral ligament added for stability. (Illustration courtesy of The Indiana Hand Center and Gary Schnitz.) Postoperative Management Dressings are changed 2 days postoperatively and the patient is fitted for a dynamic extension splint to be worn during the day and a resting splint to be used at night. An occupational therapist is helpful in maintaining proper alignment of the digits during active and active-assisted range of motion. A passive range-of-motion goal of 0 to 70 degrees in the ring and small finger and 0 to 45 degrees in the index and long finger is achievable by approximately 2 weeks. Further aggressive range of motion, articularly in the index and long fingers, is not necessary to promote stability and durability of the implant in these digits. Care must be taken to avoid contracture in other joints, specif- ically the PIP, elbow, and shoulder. This can be avoided by dorsal extension splints of the PIP to be used during exercise, and concomitant range-of-motion exercises directed at the elbow and shoulder. Therapy is required for a minimum of 3 months. Complications Rheumatoid patients with a history of being treated with steroids are at risk for the de- velopment of infection, wound healing difficulties, and complications related to poor bone stock such as fractures. Recurrence of deformity with subluxation of the joint or extensor tendons can usually be traced back to insufficient soft tissue balancing and/or inadequate postoperative bracing and therapy. Further complications related to implant wear can result in silicone particles inciting an inflammatory response and subsequent erosive changes. Salvage procedures for complications related to MP joint arthroplasty typically involve revision capsuloligamentous reconstruction in cases of instability, or implant replacement in the event of implant failure or fracture. With more serious complications such as deep infection or bony erosion and loss of bone stock secondary to silicone synovitis, simple resection arthroplasty is a reasonable option. Acknowledgments This chapter is dedicated to James W. Strickland who is always willing to share his wisdom through years of experience. Suggested Readings Beckenbaugh RD, Dobyns JH, Linscheid RL, Bryan RS. Review and analysis of silicone- rubber metacarpophalangeal implants. J Bone Joint Surg [Am] 1976;58A: 483–487. Bieber EJ, Weiland AJ, Volenec-Dowling S. Silicone-rubber implant arthroplasty of the metacarpophalangeal joints for rheumatoid arthritis. J Bone Joint Surg [Am] 1986;68A:206–209. Kirschenbaum D, Schneider LH, Adams DC, Cody RP. Arthroplasty of the metacarpophalangeal joints with use of silicone-rubber implants in patients who have rheumatoid arthritis: long-term results. J Bone Joint Surg [Am] 1993;75A:3–12. Millender LH, Nalebuff EA. Metacarpophalangeal joint arthroplasty utilizing the silicone rubber prosthesis. Orthop Clin North Am 1973;4:349–371. Nalebuff EA. Surgical treatment of finger deformities in the rheumatoid hand. Surg Clin North Am 1969;49:833–846. Swanson AB. Flexible implant arthroplasty for arthritic finger joints. Rationale, technique, and results of treatment. J Bone Joint Surg [Am] 1972;54A:435–455. 468 Section XII Congenital Anomalies of the Hand A. Failure of F orm ation Short Below-Elbow Amputation Robert T. Ciocco and Scott H. Kozin Transverse Deficiency of the Digits Scott H. Kozin Radial Deficiency (Radial Clubhand) Alexander D. Mih Ulnar Deficiency (Ulnar Clubhand) Scott H. Kozin B. Undergrowth Brachydactyly Scott H. Kozin Hypoplastic Digits and Hands Scott H. Kozin Reconstruction of a Type II Hypoplastic Thumb Allan E. Peljovich and Peter M. Waters C. Failure of Differentiation Congenital Radioulnar Synostosis Allan E. Peljovich and Peter M. Waters D. D uplication of Parts Polydactyly and Bifid Thumb Kevin D. Plancher E. Overgrowth Macrodactyly Ann E. Van Heest and James House [...]... year of age and may be combined with internal fixation removal Suggested Readings Bayne LG, Klug MS Long-term review of the surgical treatment of radial deficiencies J Hand Surg [Am] 198 7;12A:1 69 1 79 Buck-Gramcko D Radialization as a new treatment for radial club hand J Hand Surg [Am] 198 5;10A :96 4 96 8 Kessler I Centralization of the radial club hand by gradual distraction J Hand Surg [Br] 198 9;14B:37–42... club hand A continuing study of sixty-eight patients with one hundred and seventeen club hands J Bone Joint Surg [Am] 197 7;59A:1–13 Lamb DW, Scott H, Lam WL, Gillespie WJ, Hooper G Operative correction of radial club hand A long-term follow-up centralization of the hand on the ulna J Hand Surg 199 7;22B:533–536 Riordan DC Congenital absence of the radius, a 15-year follow up J Bone Joint Surg [Am] 196 3;45A:1783... F Toe to hand transfer in children Part 2: Functional and psychological aspects J Hand Surg [Br] 199 6;21B:735–745 Kozin SH, Thoder JJ Congenital anomalies of the upper extremity In: Baratz ME, Watson AD, Imbriglia JE, eds Orthopaedic Surgery: The Essentials New York: Thieme; 199 9:657–673 Pennsler JM, Carroll NC, Cheng LF Distraction osteogenesis in the hand Plast Reconstr Surg 199 8;102 :92 95 Seitz... aphalangic hand J Hand Surg [Am] 198 2;7:454–4 59 Ireland DC, Takayama N, Flatt AE Poland’s syndrome A review of forty-three cases J Bone Joint Surg [Am] 197 6;58A:52–58 James MA, Durkin RC Nonvascularized toe proximal phalanx transfers in the treatment of aphalangia Hand Clin 199 8;14:1–15 Kay SP, Wiberg M Toe to hand transfer in children Part 1: technical aspects J Hand Surg [Br] 199 6;21B:723–734 Kay SP, Wiberg... Surg [Br] 199 7;22B:607–611 Bora FW Jr, Nicholson JT, Cheema HM Radial meromelia The deformity and its treatment J Bone Joint Surg [Am] 197 0;52A :96 6 97 9 Brenner C Electronic limbs for infants and pre-school children J Prosthet Orthotics 199 1;4:184– 190 Clark S, Patton J Occupational therapy for the limb deficient child Clin Orthop 198 0;148 :93 –100 Crone N A comparison of myo-electric and standard prostheses—a... growth and the possibility of normal sensation The disadvantages include the technical demands of the procedure and the potential loss of the transferred toe Suggested Readings Flatt AE The Care of Congenital Hand Anomalies, 2nd ed St Louis: Quality Medical Publishing; 199 4:1 49 1 79 Goldberg NH, Watson HK Composite toe (phalanx and epiphysis) transfers in the reconstruction of the aphalangic hand J Hand. .. Orthopedics 199 5;18:1 29 138 Vilkki SK Advances in microsurgical reconstruction of the congenitally adactylous hand Clin Orthop 199 5;314:45–58 483 C O N G E N I TA L A N O M A L I E S O F T H E H A N D 76 Radial Deficiency (Radial Clubhand) Alexander D Mih History and Clinical Presentation A 4-month-old girl was seen for evaluation of right upper extremity deformity She was the product of a full-term delivery... Surg [Br] 198 3;65B:346–3 49 Vilkki SK Advances in microsurgical reconstruction of the congenitally adactylous hand Clin Orthop 199 5;314:45–58 477 C O N G E N I TA L A N O M A L I E S O F T H E H A N D 75 Transverse Deficiency of the Digits Scott H Kozin History and Clinical Presentation A 10-month-old boy presented with a congenital anomaly of the right hand (Fig 75–1) He is the product of a full-term normal... frequent monitoring to avoid potential complications • Toe-to -hand transfer is difficult in adactyly and may require multiple toe transfers 478 Figure 75–1 A 10-monthold with congenital anomaly of the right hand TRANSVERSE DEFICIENCY OF THE DIGITS Figure 75–2 Anomalous right hand with absent thumb, index, long, ring, and small digits index, long, ring, and small digits (Fig 75–2) There are palpable metacarpals,... resemble hand 15 mos and older Voluntary opening TD that was designed for toddlers and preschool children; shaped like a lobster claw; closing force achieved by spring mechanism Cable-driven hand can be either voluntary opening or closing and has a cosmetic glove; currently research in progress to develop a more efficient pediatric mechanical hand 15 mos to 5 years Myoelectric Single-site or dual-site . the upper limb. J Hand Surg [Br] 199 7;22B:607–611. Bora FW Jr, Nicholson JT, Cheema HM. Radial meromelia. The deformity and its treatment. J Bone Joint Surg [Am] 197 0;52A :96 6 97 9. Brenner C. Electronic. spring mechanism Cable-driven hand can be either voluntary opening or closing and has a cosmetic glove; currently research in progress to develop a more efficient pediatric mechanical hand Single-site or dual-site. infants and pre-school children. J Prosthet Orthotics 199 1;4:184– 190 . Clark S, Patton J. Occupational therapy for the limb deficient child. Clin Orthop 198 0;148 :93 –100. Crone N. A comparison of myo-electric