1. Spontaneous extensor tendon rupture in RA wrist: Risk factor & Prevention
Jung-Hua Hsueh, Lee-Wei Chen, M.D., Ph.D
Department of Plastic Surgery,
Kaohsiung Veterans General Hospital, Taiwan
~10.14
Relevant Financial Interests: nothing to disclose

2. Clinical scenario
64 y/o RA (20yrs) woman: Sudden inability of extension of RRF & RLF

3. Tenosynovitis & Tendon rupture
Common in RA patients.
Tenosynovectomy : for no response to medical Tx.
Painless, Sudden inability to extend fingers.
Untreated: progress to rupture of adjacent extensor tendons.
Early recognition: decrease the rate of unsuspected extensor tendon ruptures in RA.
Moore JRJ Hand Surg Am 1987; 12(1):9-14.
Ryu J, Saito S, J Hand Surg Br 1998; 23(5):
The purpose of our study
Williamson SC, Hand Clin 1995; 11(3):
Risk Factor of spontaneous extensor tendon rupture in rheumatoid wrist, and Prevention.

4. MATERIALS: 27 RA pts during 1997-2013

5. Methods Image evaluation
Retrospectively chart review
Relative factor record
Outcome: telephone inquiry
Larsen Grading Scale©
Grade 0: Intact bony outlines, normal joint space.
Grade 1: Erosion <1 mm in diameter or joint space narrowing.
Grade 2: One or several small erosions (diameter > 1 mm).
Grade 3: Marked erosions.
Grade 4: Severe erosions: no joint space left; the original bony outlines partly preserved.
Grade 5: Mutilating changes: The original bony outlines destroyed.
Statistical analysis
Larsen A J Rheumatol 1995; 22(10):
Stata 9.1 software
Two-sided P values <0.05 conventional threshold as significant

6. Result: Tendon rupture group data

8. Result: Group 1 V.S Group 2
Group 1
Tendon rupture
Group 2
Tenosynovitis P
Sex
15 (100)♀
11 (92)♀; 1 (8)♂ NS
Involved episode 17 14
Operation age
46 [28–65]
51 [34–74]
Time lag to operation (months)
1 [1–2]
6.4 [1–18]
0.02
Disease duration (years)
12.2 [3–30]
6 [1–22]
Tenosynovitis >1 year
14 (93)
6 (50)
0.03
Follow up time (years)
4.7 [1-1]
4.5 [1-18]
Larsen grade of wrist
IV(9),V(8)
I(4), II(2), III(5),IV(2),V(1)
0.01
None of the hypothesized variables had any significant correlation

9. Result: clinical & X-ray finding in 3 groups
Persistent Tenosynovitis
Larsen grade>4
Ulna distal end dislocation
Carpal collapse
Scallop sign
Ankylosis 1
N=17 N 15 8 12 11 % 88
100 47 71 65 OR
13.1
3.01
9.33
3.73
4.19
2.2
95 CI
2.36–72.72
0.14–4.042
1.64–52.94
0.97–14.22
1.10–15.9
0.58–8.28
P*1
0.003
0.03
0.01
0.05
0.24 2
N=14 14 5 4 3 6 36 28 21 42
14.4
1.75
0.62
0.68
0.30–71.42
0.89–3.411
0.21–14.06
0.14–2.60
0.13–2.95
0.18–2.61
P *2
0.002
0.04
0.59
0.51
0.55
0.58
N=23 9 7 39 30 52
Group 1: spontaneous extensor tendon rupture
Group 2: tenosynovitis episodes
Group 3: Unaffected hands in Group 1 & 2
*1 P: Group 1 v 3; *2 P: Group 2 v 3

10. Extended tenosynovectomy group
Mean age :51 years (34–74).
Mean disease duration: 6 yrs (1–22).
Pain relief : 79% pts.
Extended tenosynovectomy : decreased deterioration in X–ray (P:0.01).
No serious complication.
No spontaneous extensor tendon rupture during follow-up.
Group A: s/p extended tenosynovectmy
Group B:: without tenosynovectomy
Unpaired Student T test between Group A & B: OR-11.6, 95% CI-1.81~74.7, P-0.01.

11. Extended tenosynovectomy
Extended tenosynovectomy decrease inflammation, pain relif & delay X-ray Larsen’s grade deterioration
Longer disease duration
Persistent tenosynovitis
Bone erosion : scallop sign, carpal collapse, ulna dislocation
Wrist Larsen grade
Extensor rupture
Extended tenosynovectomy

12. Conclusion Risk factor recognition Longer disease duration
Persistent tenosynovitis >1 year with poor medical control
Image reference
Larsen‘s grade >4
Ulna distal end dislocation
Carpal collapse
Scallop sign
Patient information
Risk of extensor tendon rupture
Recommend prophylactic tenosynovectomy
Local sym. control & decrease X-ray change
Prevent more severe damage of extensor tendons
The scallop sign is characterized by a sclerotic border with deepening and widening of the sigmoid
notch(articular surface for the ulna is called the ulnar notch of the radius). Beyond incidental interest, attention is called to the
scallop sign because it seems diagnostic of existing or impending extensor tendon rupture
Leonel Daza, Rheumatol 2001;28;