1. Donald Dewar Consultant Plastic Surgeon Leeds General Infirmary
RA and the hand
Donald Dewar
Consultant Plastic Surgeon
Leeds General Infirmary

2. Introduction rheumatoid arthritis is a systemic auto-immune disorder
characterised by joint inflammation
primarily an enthesopathy
synovitis a prominent feature
secondary destruction of soft tissue and joints
systemic effects
anaemia
interstitial lung disease

3. Pathophysiology earliest signs are at tendon and ligament insertions
inflammation and bone marrow oedema
detectable ~2 years pre-diagnosis
early treatment may abort disease (see Prof Emery)

4. Treatment NSAIDs steroids DMARDs biological therapies
and their side effects
steroids
DMARDs
biological therapies

5. Pathophysiology
NSAIDs
and their side effects
steroids

6. DMARDs methotrexate others sulphasalazine gold D-penicillamine
hydroxychloroquine

7. Biological therapies anti TNF-α anti IL-6 anti B lymphocyte anti IL-1
infliximab, adalimumab, etanercept
anti IL-6
sarilumab, tocilizumab
anti B lymphocyte
rituximab
anti IL-1
anikinra
Janus kinase inhibitor
tofacitinib

8. Early therapy once deformity develops, damage is established
early, more aggressive therapy prevents damage
less loss of function
more likely to be remain in/return to work
may be able to “reset” the disease process
 much less surgery

9. Assessment systemic disorder function is key general health
other limbs
proximal joints
function is key
what can’t you do?
can I do an operation that will make it possible?

10. X-rays generalised osteopaenia soft tissue swelling
loss of joint space
juxta-articular erosions
secondary deformity

11. Other tests MRI USS blood tests bone oedema inflammation
joint effusion
blood tests
rheumatoid factor
anti-CCP

12. Typical deformities wrist MCPJs radio-carpal translocation
ulnar head subluxation
MCPJs
synovitis
ulnar/volar subluxation

13. Typical deformities fingers teno-synovitis swan-neck boutonniere
mallet
teno-synovitis
triggering
pain/stiffness
tendon rupture

14. Typical deformities
rheumatoid nodules

15. Treatment optimal medical therapy surgery for established deformity
resistant disease (synovectomy)
(can’t tolerate the medication)

16. Treatment synovectomy tendon repair/reconstruction surgery to joints
a “prophylactic” operation
tendon repair/reconstruction
Vaughan-Jackson, Mannerfelt, EPL at Lister’s
surgery to joints

17. Treatment Appliance soft tissue Alignment Arthroplasty Arthrodesis
Amputation

18. Treatment - wrist total wrist fusion for radio-carpal subluxation
wrist replacement
ulnar head excision (Darrach’s) for instability
Sauve-Kapandji procedure
ulnar head replacement

19. Treatment – MCPJs (fingers)
need to see an X-ray
if joint preserved, soft tissue procedure will work
if joint damaged, need arthroplasty

20. Treatment – MCPJs (fingers)
contributors to ulnar subluxation
radial pinch
ulnar-facing MC head
radial deviation of wrist (everything is a Z)

21. Treatment – MCPJs (fingers)
Swanson’s
excision arthroplasty
implant prevents ankylosis and heals by encapsulation

22. Treatment – MCPJs (fingers)
transverse or longitudinal incision
access via sagittal band (radial)
synovectomy
radial-facing osteotomy
tighten radial sagittal band on way out
?crossed intrinsic transfer (evidence says no benefit)
ROM often not much improved, but more useful
improved appearance important to patients

23. Treatment – thumb MCPJ instability treated with fusion
good operation
IPJ instability may need fusion
but beware compensatory hyperextension
option for FPL rupture

24. Treatment – tendon ruptures
EPL
EIP transfer
synovectomy
address ulnar head
put retinacular flap under tendons
EDM/EDC (Vaughan-Jackson)
EI transfer
multiple transfer combinations

25. Treatment – tendon ruptures
FPL (Mannerfelt)
interposition graft
transfer from index, or “piggy-backing”

26. Treatment – swan neck loss of “balance” in the finger
is it passively correctable?
correct the cause
mallet  DIPJ fusion
MCPJ subluxation  Swanson’s arthroplasty
volar plate attenuation/rupture  repair or FRD tenodesis
intrinsic tightness  intrinsic release

27. Treatment - boutonniere
secondary to central slip failure
lateral bands slip volarly
DIPJ hyperextends
is it passively correctable?
repair/reconstruct central slip
lateral band centralisation
lateral band transfer (reduces DIPJ hyperextension)
not a great operation (Nalebuff)