Rheumatoid Arthritis

R. Hill

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

Surgical Aims
Decrease pain Prevent worsening deformity/function

Improve appearance/ function

Stages of Rheumatic joint involvement

Stage I II III IV Description Synovitis no deformity Synovitis, passively correctable deformity Fixed deformity, no joint changes Articular destruction

Surgical Procedures
Synovectomy Tenosynovectomy Tendon Surgery Arthroplasty Arthrodesis

Thumb Deformities

Type 1 Boutonniere
Usually due to MCP joint synovitis Exclude FPL rupture

Treatment
early Synovectomy + tendon reconstruction Arthrodesis or Arthroplasty ST repair, arthroplasty or arthrodesis

Intermediate late

Type III

Swan-Neck Deformity

Result of CMC disease Treatment

Early Intermediate Late Resection arthroplasty with tendon interposition (RATI) RATI + volar tenodesis or arthrodesis of MCPJ RATI and MCPJ arthrodesis

Type IV

Gamekeepers Thumb

Due to synovitis of the MCPJ

NB no CMCJ disease

Treatment
Early Late Synovectomy, adductor fascia release and repair UCL Arthrodesis/ arthroplasty + adductor fascia release.

Type II
Combination of Type I and II
Treatment
CMCJ MCPJ IPJ RATI Tendon reconstruction arthroplasty/arthrodesis Nil - arthrodesis

Type V
Due to stretching of the volar plate
Treatment Arthrodesis, volar capsulodesis or sesamoidesis

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

Boutonniere deformity

Boutonniere
Stage I
Stage II Stage III

PIPJ lag 10-15 degrees

PIPJ lag 30-40 Degrees PIPJ Fixed

Treatment
Stage I
Stage II

Ext. tendon tenotomy

Repair central slip and bands. Ext Tendon tenotomy

Stage III

Arthrodesis / arthroplasty

Swan-Neck Deformity

Types of Swan-Neck Deformity

Type I
Type II Type III Type IV

Passive Motion at PIPJ possible

Related to MCPJ and intrinsic tightness Fixed PIPJ preserved joint Fixed PIPJ and degenerate joint

Treatment of Swan-Neck deformity

Type I
DIPJ Fusion Volar Tenodesis Retinacular ligament reconstruction Dermadesis

Type II

Intrinsic Release (IR) + type I or Correct MCPJ disorder

Treatment Swan-Neck deformity

Type III Restore passive motion Correct deformity later Salvage procedure.

Type IV

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 conclusions often positive