1. Rheumatoid Arthritis R. Hill

2. Rheumatoid Arthritis Auto-immune process of unknown aetiology causing a chronic inflammatory process Primarily affects the synovium in the Hand Epidemiology

3. Surgical Aims Decrease pain Prevent worsening deformity/function Improve appearance/ function

4. Stages of Rheumatic joint involvement

5. Surgical Procedures Synovectomy Tenosynovectomy Tendon Surgery Arthroplasty Arthrodesis

6. Thumb Deformities

7. Type 1 Boutonniere Usually due to MCP joint synovitis Exclude FPL rupture Treatment –early Synovectomy + tendon reconstruction –IntermediateArthrodesis or Arthroplasty –lateST repair, arthroplasty or arthrodesis

8. Type III Swan-Neck Deformity Result of CMC disease Treatment –EarlyResection arthroplasty with tendon interposition (RATI) –IntermediateRATI + volar tenodesis or arthrodesis of MCPJ –LateRATI and MCPJ arthrodesis

9. Type IVGamekeepers Thumb Due to synovitis of the MCPJ –NB no CMCJ disease Treatment –EarlySynovectomy, adductor fascia release and repair UCL –LateArthrodesis/ arthroplasty + adductor fascia release.

10. Type II Combination of Type I and II Treatment –CMCJ RATI –MCPJTendon reconstruction arthroplasty/arthrodesis –IPJNil - arthrodesis

11. Type V Due to stretching of the volar plate TreatmentArthrodesis, volar capsulodesis or sesamoidesis

12. Arthritis Mutilans Instability and joint destruction Treatment –Early Early arthrodesis –Late Arthrodesis with bone grafting

13. Boutonniere deformity

14. Boutonniere Stage IPIPJ lag 10-15 degrees Stage IIPIPJ lag 30-40 Degrees Stage IIIPIPJ Fixed

15. Treatment Stage IExt. tendon tenotomy Stage IIRepair central slip and bands. Ext Tendon tenotomy Stage IIIArthrodesis / arthroplasty

16. Swan-Neck Deformity

17. Types of Swan-Neck Deformity Type IPassive Motion at PIPJ possible Type IIRelated to MCPJ and intrinsic tightness Type IIIFixed PIPJ preserved joint Type IVFixed PIPJ and degenerate joint

18. Treatment of Swan-Neck deformity Type I DIPJ Fusion Volar Tenodesis Retinacular ligament reconstruction Dermadesis Type IIIntrinsic Release (IR) + type I or Correct MCPJ disorder

19. Treatment Swan-Neck deformity Type III Restore passive motion Correct deformity later Type IV Salvage procedure.

20. Evidence No randomised control trials Papers often retrospective over long periods Poor numbers with no controls No validated scoring systems to evaluate outcome Results poor yet conclusion’s often positive

21. Doctors.net.uk would like to thank Dr R Hill for contributing this presentation