今日の臨床サポート

リウマチ手

著者: 石川肇 新潟県立リウマチセンター

監修: 竹下克志 自治医科大学整形外科

著者校正/監修レビュー済:2022/03/16
参考ガイドライン:
  1. 一般社団法人 日本リウマチ学会:関節リウマチ診療ガイドライン2020 初版
患者向け説明資料

概要・推奨   

  1. 生物学的製剤やヤヌスキナーゼ(Janus kinase: JAK)阻害薬の時代において、患者のアンメットニーズ応えるための補完治療として、リウマチ手に対する手術治療介入は有用であり必要である[1][2][3]
  1. 関節リウマチ(rheumatoid arthritis: RA)患者に対する関節手術は、患者主観的評価を改善させるため、推奨する。慎重な身体機能評価により、適正なタイミングで行うことが望ましい[4](推奨度2)
  1. RA患者の手関節障害に対する橈骨手根関節の部分関節固定術およびSauvé-Kapandji手術を推奨する[4](推奨度2)
アカウントをお持ちの方はログイン
  1. RA患者の中手指節(MP)関節障害に対してシリコンインプラントによる人工指関節置換術を推奨する[4](推奨度2)
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
石川肇 : 特に申告事項無し[2022年]
監修:竹下克志 : 講演料(第一三共,イーライリリー,ファイザー,エーザイ,塩野義)[2022年]

改訂のポイント:
  1. 新規に図6点、文献16点を追加し、1文献差し替え、本文の加筆・修正を行いました。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. RAは、原因不明の慢性の全身性炎症疾患で特徴的な関節病変を示す。
  1. 有病率は全人口の約0.3~0.8%と推計され、女性は男性の約4倍多く、好発年齢は30~50歳代である。2016年の国民生活基礎調査では、本邦において82.2万人がRAに罹患し有病率は0.75%とされている[5]
  1. 関節外症状として、貧血、リウマトイド結節、血管炎、心、肺、眼症状、アミロイドーシス、骨粗鬆症などがある。
  1. RA患者の手部は発症早期から罹患し、関節炎による疼痛や腱鞘炎による手指屈曲障害、ばね指などが生じる。
  1. 病期の進行とともに関節破壊を伴う関節の変形、不安定性、亜脱臼さらに腱断裂などが原因でさまざまな障害を生じてくる。
 
リウマチ手の症候と重症度

手の症候を重症度で分類した。

 
リウマチ手にみられる病態

滑膜炎によって様々な病態が混在してくる。

問診・診察のポイント  
問診:
  1. 手で困っていることは何か?

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

Hajime Ishikawa, Asami Abe, Toshihisa Kojima, Masayo Kojima, Naoki Ishiguro, Yumi Nomura, Hiroshi Otani, Eriko Hasegawa, Daisuke Kobayashi, Satoshi Ito, Kiyoshi Nakazono, Akira Murasawa
Overall benefits provided by orthopedic surgical intervention in patients with rheumatoid arthritis.
Mod Rheumatol. 2019 Mar;29(2):335-343. doi: 10.1080/14397595.2018.1457468. Epub 2018 Apr 16.
Abstract/Text OBJECTIVES: To clarify systemic effects of orthopedic surgical intervention in patients with rheumatoid arthritis (RA).
METHODS: A prospective observational cohort study was performed in RA patients who were scheduled to have primary elective orthopedic surgeries. Assessments were performed at baseline, 6 and 12 months after surgery using J-HAQ, General Health, EQ-5D, BDI-II, DAS28-CRP(4) and CRP for all registered patients, DASH and grip power for patients with upper-extremity surgeries, TUG for patients with lower-extremity surgeries, and JSSF for patients with ankle and forefoot surgeries.
RESULTS: There were 294 sites in 276 patients whose average age was 64 (19-89) years and average disease duration was 16 (1-60) years. Surgical site was shoulder in six patients, elbow in 26, wrist in 74, hand in 63, hip in 13, knee in 50, ankle in 12, and forefoot in 50. In total, physical function (J-HAQ, grip power, DASH, TUG, JSSF), quality of life (J-HAQ, General Health, EQ-5D) and depression (BDI-II) improved and disease activity (CRP, DAS28-CRP(4)) decreased significantly 6 and 12 months after surgery (p<.01), despite some differences in their outcomes by the preoperative disease activity and the surgical site.
CONCLUSION: Overall benefits were provided by orthopedic surgical intervention generally in patients with RA.

PMID 29575958
Hajime Ishikawa
The latest treatment strategy for the rheumatoid hand deformity.
J Orthop Sci. 2017 Jul;22(4):583-592. doi: 10.1016/j.jos.2017.02.007. Epub 2017 Mar 22.
Abstract/Text With a remarkable improvement in the pharmacotherapy of rheumatoid arthritis (RA), severely handicapped patients are very rare to see. Healing, repair and drug-free, and toward radical cure are coming to be possible. In the clinical practice, more than 50% of the patients are in remission. However, some patients are still difficult to reach remission due to comorbidities and economic burden. In the patient with clinical remission, smoldering synovitis so called "silent destructor" is often detected by ultrasonograpy or by synovial histology in the small joints of the hand. In recent years, over use with "no pain" increases the risk of deformity, osteoarthrosis, tendon rupture and entrapment neuropathy. Highly motivated patients, who concern about the appearance of the hand, hope to get a higher level of activities of daily living and quality of life (QOL). A prospective cohort study was performed for the purpose of knowing whether rheumatoid hand surgery affects the patient's QOL and mental health as well as upper extremity function. A primary hand surgery was scheduled in 119 patients with RA. Synovectomy and Darrach procedure, radiolunate arthrodesis, reconstruction of the extensor tendons, arthroplasty at the metacarpophalangeal (MP) using Swanson implant, fusion at the proximal interphalangeal (PIP) joint, suspensionplasty at the carpometacarpal (CM) joint of the thumb (Thompson method) et al. were performed. As a result, Japanese version of the Stanford Health Assessment Questionnaire (J-HAQ:physical function,QOL), EuroQOL-5 dimension (EQ-5D:QOL), Beck Depression Inventory-II (BDI-II:depression, mentality) at 6 months and at 12 months after surgery improved significantly compared to those just before surgery (p < 0.01). Disease activity score 28- C reactive protein 4 (DAS28-CRP (4)) decreased significantly (p < 0.01). Latest hand surgery with tight medical control is possible to raise QOL and to provide mental wellness for the patient with RA.

Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
PMID 28341088
Chisa Okura, Hajime Ishikawa, Asami Abe, Yukio Yonemoto, Koichi Okamura, Takahito Suto, Tomo Oyakawa, Yusuke Miyagawa, Hiroshi Otani, Satoshi Ito, Daisuke Kobayashi, Kiyoshi Nakazono, Akira Murasawa, Kenji Takagishi, Hirotaka Chikuda
Long-term patient reported outcomes of elbow, wrist and hand surgery for rheumatoid arthritis.
Int J Rheum Dis. 2018 Sep;21(9):1701-1708. doi: 10.1111/1756-185X.13340. Epub 2018 Sep 5.
Abstract/Text AIM: A retrospective questionnaire survey was conducted to investigate the long-term outcomes of elbow, wrist and hand surgery for rheumatoid arthritis (RA).
METHODS: One hundred and thirteen RA patients underwent primary elective elbow, wrist or hand surgery at our hospital between January 2002 and December 2003. To evaluate the outcomes at 10 years after surgery, the patient-reported outcomes were assessed using an original questionnaire that inquired about the site of treatment; the modified Stanford Health Assessment Questionnaire (mHAQ) was also used.
RESULTS: Responses were obtained from 67 patients (98 sites). In the 10 years after surgery, the Disease Activity Score of 28 joint - erythrocyte sedimentation rate (4) and the modified Health Assessment Questionnaire scores of the patients showed significant improvement. Nearly 85% of patients were satisfied with the outcome at the surgical site. The most frequent reason for perceived improvement was 'pain relief' (all surgical sites). An 'improved appearance' was frequently reported after finger surgery and 'increased power' was frequently reported after wrist and thumb surgeries. With regard to elbow surgery, 30% of the patients were satisfied with the increase in motion and power. In contrast, approximately 20% of patients complained of decreased power around the surgical site after elbow and thumb surgeries.
CONCLUSIONS: Our original patient-reported outcome assessment tool revealed that elbow, wrist and hand surgery provided long-lasting benefits in RA patients. While the efficacy differed in some of the surgical sites, pain relief was the most favorable effect. Altered medical therapy may also have impacted the patient-perceived outcomes of surgery at 10 years.

© 2018 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.
PMID 30187667
Masayo Kojima, Takeo Nakayama, Kiichiro Tsutani, Ataru Igarashi, Toshihisa Kojima, Sadao Suzuki, Nobuyuki Miyasaka, Hisashi Yamanaka
Epidemiological characteristics of rheumatoid arthritis in Japan: Prevalence estimates using a nationwide population-based questionnaire survey.
Mod Rheumatol. 2020 Nov;30(6):941-947. doi: 10.1080/14397595.2019.1682776. Epub 2019 Nov 14.
Abstract/Text Objectives: To elucidate the epidemiological characteristics of patients with rheumatoid arthritis (RA) in Japan using data from the Comprehensive Survey of Living Conditions, a nationwide questionnaire survey conducted in 2016.Methods: In total, 222,365 men and 245,251 women aged ≥16 years were included in the study. RA patients were defined as those who reported 'currently receiving treatment for RA at hospitals, clinics, or a facility for Japanese traditional massage, acupuncture, moxibustion, or judo-orthopedics.' The number of RA patients was estimated from the age-specific prevalence and total Japanese population in 2016. Further, the prevalence of individuals experiencing difficulties in activities of daily living due to health problems and those with mental distress as evaluated by K6 Scale was examined.Results: The estimated number and prevalence of RA in Japan with 95% confidence interval was 822 (768-880) thousand and 0.75% (0.70-0.80%). The population peaked in the late 60s, and the prevalence continued increasing until the early 80s, regardless of sex. Compared with non-RA participants, RA patients were more likely to experience difficulties in activities and to be distressed.Conclusion: High prevalence of RA in older age and mental and physical burden among RA patients were confirmed.

PMID 31625435
Asami Abe, Hajime Ishikawa, Kiyoshi Nakazono, Akira Murasawa, Kunihiko Wakaki
A comparison of the ultrasonography images of the joints of patients with rheumatoid arthritis and the corresponding synovial histological findings.
Mod Rheumatol. 2015 Nov 20;:1-6. doi: 10.3109/14397595.2015.1106680. Epub 2015 Nov 20.
Abstract/Text OBJECTIVES: The objective of this study is to investigate whether ultrasonography (US) images of joints that underwent surgery reflected the synovial histological findings or clinical indicators and to compare the results of the findings related to large joints (LJs) with those of small joints (SJs).
METHODS: The operations were performed on 215 joints in 177 patients with rheumatoid arthritis (RA). The 215 joints included 64 LJs and 151 SJs. The joints with the power Doppler (PD) signal grades 0 and 1 were assigned to group L, while those with grades 2 and 3 were assigned to group H. The Rooney score, Disease Activity Score-erythrocyte sedimentation rate (DAS28), serum matrix metallopeptidase 3 (MMP-3), and C-reactive protein (CRP) levels were determined.
RESULTS: The Rooney score, DAS28, MMP-3, and CRP levels of the LJs were significantly lower in group L than in group H. In group H, similar results were found in the LJs and SJs, with a significant increase in the disease activity, CRP and MMP-3 levels and the histological findings in comparison to group L.
CONCLUSIONS: The PD signal grade was one of the indicators that reflected the degree of synovitis in the histological findings of the active joints of RA patients.

PMID 26457587
Daniel Aletaha, Tuhina Neogi, Alan J Silman, Julia Funovits, David T Felson, Clifton O Bingham, Neal S Birnbaum, Gerd R Burmester, Vivian P Bykerk, Marc D Cohen, Bernard Combe, Karen H Costenbader, Maxime Dougados, Paul Emery, Gianfranco Ferraccioli, Johanna M W Hazes, Kathryn Hobbs, Tom W J Huizinga, Arthur Kavanaugh, Jonathan Kay, Tore K Kvien, Timothy Laing, Philip Mease, Henri A Ménard, Larry W Moreland, Raymond L Naden, Theodore Pincus, Josef S Smolen, Ewa Stanislawska-Biernat, Deborah Symmons, Paul P Tak, Katherine S Upchurch, Jirí Vencovsky, Frederick Wolfe, Gillian Hawker
2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.
Ann Rheum Dis. 2010 Sep;69(9):1580-8. doi: 10.1136/ard.2010.138461.
Abstract/Text OBJECTIVE: The 1987 American College of Rheumatology (ACR; formerly the American Rheumatism Association) classification criteria for rheumatoid arthritis (RA) have been criticised for their lack of sensitivity in early disease. This work was undertaken to develop new classification criteria for RA.
METHODS: A joint working group from the ACR and the European League Against Rheumatism developed, in three phases, a new approach to classifying RA. The work focused on identifying, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/or erosive disease--this being the appropriate current paradigm underlying the disease construct 'RA'.
RESULTS: In the new criteria set, classification as 'definite RA' is based on the confirmed presence of synovitis in at least one joint, absence of an alternative diagnosis better explaining the synovitis, and achievement of a total score of 6 or greater (of a possible 10) from the individual scores in four domains: number and site of involved joints (range 0-5), serological abnormality (range 0-3), elevated acute-phase response (range 0-1) and symptom duration (two levels; range 0-1).
CONCLUSION: This new classification system redefines the current paradigm of RA by focusing on features at earlier stages of disease that are associated with persistent and/or erosive disease, rather than defining the disease by its late-stage features. This will refocus attention on the important need for earlier diagnosis and institution of effective disease-suppressing therapy to prevent or minimise the occurrence of the undesirable sequelae that currently comprise the paradigm underlying the disease construct 'RA'.

PMID 20699241
Daniel Aletaha, Tuhina Neogi, Alan J Silman, Julia Funovits, David T Felson, Clifton O Bingham, Neal S Birnbaum, Gerd R Burmester, Vivian P Bykerk, Marc D Cohen, Bernard Combe, Karen H Costenbader, Maxime Dougados, Paul Emery, Gianfranco Ferraccioli, Johanna M W Hazes, Kathryn Hobbs, Tom W J Huizinga, Arthur Kavanaugh, Jonathan Kay, Tore K Kvien, Timothy Laing, Philip Mease, Henri A Ménard, Larry W Moreland, Raymond L Naden, Theodore Pincus, Josef S Smolen, Ewa Stanislawska-Biernat, Deborah Symmons, Paul P Tak, Katherine S Upchurch, Jirí Vencovský, Frederick Wolfe, Gillian Hawker
2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.
Arthritis Rheum. 2010 Sep;62(9):2569-81. doi: 10.1002/art.27584.
Abstract/Text OBJECTIVE: The 1987 American College of Rheumatology (ACR; formerly, the American Rheumatism Association) classification criteria for rheumatoid arthritis (RA) have been criticized for their lack of sensitivity in early disease. This work was undertaken to develop new classification criteria for RA.
METHODS: A joint working group from the ACR and the European League Against Rheumatism developed, in 3 phases, a new approach to classifying RA. The work focused on identifying, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/or erosive disease--this being the appropriate current paradigm underlying the disease construct "rheumatoid arthritis."
RESULTS: In the new criteria set, classification as "definite RA" is based on the confirmed presence of synovitis in at least 1 joint, absence of an alternative diagnosis that better explains the synovitis, and achievement of a total score of 6 or greater (of a possible 10) from the individual scores in 4 domains: number and site of involved joints (score range 0-5), serologic abnormality (score range 0-3), elevated acute-phase response (score range 0-1), and symptom duration (2 levels; range 0-1).
CONCLUSION: This new classification system redefines the current paradigm of RA by focusing on features at earlier stages of disease that are associated with persistent and/or erosive disease, rather than defining the disease by its late-stage features. This will refocus attention on the important need for earlier diagnosis and institution of effective disease-suppressing therapy to prevent or minimize the occurrence of the undesirable sequelae that currently comprise the paradigm underlying the disease construct "rheumatoid arthritis."

PMID 20872595
Abstract/Text Radiographs of rheumatoid arthritis in longterm multicenter trials vary in quality and precision, making the uniform evaluation of soft tissue swelling, osteoporosis and the size of erosions difficult. A modification of Larsen Score is presented in which only major differences in osseous and joint space changes are determined.

PMID 8992003
Josef S Smolen, Daniel Aletaha, Johannes W J Bijlsma, Ferdinand C Breedveld, Dimitrios Boumpas, Gerd Burmester, Bernard Combe, Maurizio Cutolo, Maarten de Wit, Maxime Dougados, Paul Emery, Alan Gibofsky, Juan Jesus Gomez-Reino, Boulos Haraoui, Joachim Kalden, Edward C Keystone, Tore K Kvien, Iain McInnes, Emilio Martin-Mola, Carlomaurizio Montecucco, Monika Schoels, Désirée van der Heijde, Desirée van der Heijde, T2T Expert Committee
Treating rheumatoid arthritis to target: recommendations of an international task force.
Ann Rheum Dis. 2010 Apr;69(4):631-7. doi: 10.1136/ard.2009.123919. Epub 2010 Mar 9.
Abstract/Text BACKGROUND: Aiming at therapeutic targets has reduced the risk of organ failure in many diseases such as diabetes or hypertension. Such targets have not been defined for rheumatoid arthritis (RA).
OBJECTIVE: /st> To develop recommendations for achieving optimal therapeutic outcomes in RA.
METHODS: A task force of rheumatologists and a patient developed a set of recommendations on the basis of evidence derived from a systematic literature review and expert opinion; these were subsequently discussed, amended and voted upon by >60 experts from various regions of the world in a Delphi-like procedure. Levels of evidence, strength of recommendations and levels of agreement were derived.
RESULTS: The treat-to-target activity resulted in 10 recommendations. The treatment aim was defined as remission with low disease activity being an alternative goal in patients with long-standing disease. Regular follow-up (every 1-3 months during active disease) with appropriate therapeutic adaptation to reach the desired state within 3 to a maximum of 6 months was recommended. Follow-up examinations ought to employ composite measures of disease activity which include joint counts. Additional items provide further details for particular aspects of the disease. Levels of agreement were very high for many of these recommendations (> or =9/10).
CONCLUSION: The 10 recommendations are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA based on evidence and expert opinion.

PMID 20215140
H Ishikawa, A Murasawa, T Hanyu
The effect of activity and type of rheumatoid arthritis on the flexible implant arthroplasty of the metacarpophalangeal joint.
J Hand Surg Br. 2002 Apr;27(2):180-3. doi: 10.1054/jhsb.2001.0704.
Abstract/Text A retrospective study was performed on 184 Swanson flexible implant arthroplasties of the metacarpophalangeal joint in 75 hands of 64 patients with rheumatoid arthritis, to investigate the influence of systemic factors on the clinical and radiological results. The mean follow-up period was 6 years. The postoperative serum C-reactive protein level was found to affect postoperative pain, and there was a larger extension lag and more subsidence of the implant in those with the mutilating type of the disease.

Copyright 2002 The British Society for Surgery of the Hand.
PMID 12027497
Hajime Ishikawa, Akira Murasawa, Kiyoshi Nakazono, Asami Abe, Hiroshi Otani, Tahahiro Netsu, Takehito Sakai, Hiroe Sato
The patient-based outcome of upper-extremity surgeries using the DASH questionnaire and the effect of disease activity of the patients with rheumatoid arthritis.
Clin Rheumatol. 2008 Aug;27(8):967-73. doi: 10.1007/s10067-007-0830-8. Epub 2008 Jan 24.
Abstract/Text The Disabilities of the Arm, Shoulder and Hand (DASH) is a standardized patient-based outcome measure, which assesses integrated upper-extremity disorders. The objectives of this study were to investigate subjective outcome after upper-extremity surgeries for the patients with rheumatoid arthritis (RA) using the DASH questionnaire (Japanese version) and to investigate the influence of disease activity on the surgical outcome using the Disease Activity Score (DAS) 28-CRP(4). Approximately 127 surgical procedures for the upper extremities in 127 patients with RA were recruited in this study. Surgeries were performed in 4 shoulders, 35 elbows, 60 wrists and 28 hands. The DASH score (disability/symptom score) was investigated just before surgery and at follow-up. The mean follow-up period after the surgery was 15 months on average (range, 6 to 24 months). The preoperative DASH score (disability/symptom score) 50 +/- 23 (mean +/- SD) decreased significantly to 38 +/- 23 at the follow-up (n = 127, p < 0.01). Standardized response mean and effect size revealed a medium effect of -0.6 and -0.5. Patients with various degrees of disease activity improved and the improvements per se were comparable of preoperative disease activity and postoperative response to medical treatment. A favorable subjective outcome of rheumatoid upper-extremity surgeries can be anticipated under the good control of disease activity.

PMID 18214571
D C Ferlic, M L Clayton
Flexor tenosynovectomy in the rheumatoid finger.
J Hand Surg Am. 1978 Jul;3(4):364-7.
Abstract/Text The usual operation fo stenosing flexor tenosynovitis is resection of the proximal pulley. In the rheumatoid hand this operation may not be proper because motion still may be limited by the thickened synovium more distally, and also because there is a greater chance for the production of ulnar drift later on if the proximal pulley system is obliterated. The operation we recommend for the finger with rheumatoid tenosynovitis is a tenosynovectomy, but with maintainence of the pulley system and resection of one slip of the superficialis in order to decompress the digital theca. We have performed this operation on 54 fingers with satisfactory results.

PMID 681721
J R Moore, A J Weiland, L Valdata
Tendon ruptures in the rheumatoid hand: analysis of treatment and functional results in 60 patients.
J Hand Surg Am. 1987 Jan;12(1):9-14.
Abstract/Text Seventy-six reconstructive procedures were performed to treat tendon rupture in 60 patients with rheumatoid arthritis. Tendon rupture commonly occurred in the extensors to the ring and small fingers. However, ruptures of extensors and several flexor tendons were also encountered. Single or double tendon ruptures responded successfully to a variety of tendon transfers. Reconstruction for multiple tendon ruptures is a salvage procedure that is often associated with extensor lag and impairment of overall function. Early aggressive treatment of distal radioulnar joint derangements in the rheumatoid wrist is recommended to forestall many cases of tendon rupture.

PMID 3805649
G Lister
Intraosseous wiring of the digital skeleton.
J Hand Surg Am. 1978 Sep;3(5):427-35. doi: 10.1016/s0363-5023(78)80135-x.
Abstract/Text One hundred cases of osteosynthesis done by the use of intraosseous wiring are presented. Two techniques of wiring are described, one used in transverse fractures and arthrodeses in which an additional Kirschner wire is employed, the other in which No. 0 monofilament wire can be placed perpendicular to the line of osteosynthesis. Forty-seven fractures were treated and there was union in all cases; 53 arthrodeses were performed, with failure in five, due, it is believed, to a failure to observe the essential elements of the technique, namely the need to obtain congruous bone ends and to maintain all internal fixation until there is clinical evidence of union. Overall, 83.2% of the maximum attainable total active range of motion was achieved in the 100 cases.

PMID 701766
Yumi Nomura, Hajime Ishikawa, Asami Abe, Hiroshi Otani, Satoshi Ito, Kiyoshi Nakazono, Akira Murasawa
Arthrodesis of the digital joint using intraosseous wiring in patients with rheumatoid arthritis.
Mod Rheumatol. 2021 Jan;31(1):114-118. doi: 10.1080/14397595.2020.1726607. Epub 2020 Mar 30.
Abstract/Text OBJECTIVE: Digital joints affected by rheumatoid arthritis often have severe deformity and/or dislocation, and arthrodesis in a functional position is required.
METHODS: Arthrodesis was performed using intraosseous wiring (modified Lister's method) from January 2011 to December 2015, and we investigated the union rate, postoperative complications, and patient satisfaction with the operation at the final follow-up. The DASH score, grip power, and pinch power were also investigated before the operation and at the final follow-up.
RESULTS: Arthrodesis was performed for 90 digital joints in 56 patients. Bone union was obtained in 85 of 89 joints (96%). Wire removal was needed due to subcutaneous protrusion in 20 joints and superficial infection in five joints. The mean preoperative DASH score of 50.5 improved to 45.2 at the final follow-up. The pulp pinch power of the index fingers through the little fingers changed significantly. In the questionnaire regarding the operated digit using a visual analogue scale (VAS, 0 [worst] to 100 [best]), the overall satisfaction was 70.
CONCLUSION: With this approach, we achieved painless stability as well as deformity correction. A restored prehensile pattern and improvement in the activities of daily life can thus be expected after surgery.

PMID 32017657
A N Ertel, L H Millender, E Nalebuff, D McKay, B Leslie
Flexor tendon ruptures in patients with rheumatoid arthritis.
J Hand Surg Am. 1988 Nov;13(6):860-6.
Abstract/Text One hundred fifteen flexor tendon ruptures were reviewed in 43 hands with rheumatoid arthritis, one hand with psoriatic arthritis, and one hand with lupus erythematosis. Ninety-one tendons were ruptured at the wrist, four ruptures occurred at the palm, and 20 ruptures occurred within the digits. At the wrist level, 61 ruptures were caused by attrition on a bone spur and 30 were caused by direct invasion of the tendon by tenosynovium. All ruptures distal to the wrist were caused by invasion of the tendon by tenosynovium. Patients whose ruptures were caused by attrition regained better motion than those whose ruptures were caused by invasion by tenosynovitis; however, motion overall was poor. Patients with isolated ruptures in the palm or at the wrist had the best functional results. Those patients with multiple ruptures within the carpal canal had a worse prognosis. Ruptures of both tendons within the fibro-osseous canal had the worst prognosis. The severity of the patient's disease and the degree of articular involvement had a great effect on the outcome of surgery. Prevention of tendon ruptures by early tenosynovectomy and removal of bone spurs should be the cornerstone of treatment.

PMID 3225411
Hajime Ishikawa, Asami Abe, Akira Murasawa, Kiyoshi Nakazono, Hidehiro Horizono, Katsushi Ishii, Eiko Seki
Rheumatoid wrist deformity and risk of extensor tendon rupture evaluated by 3DCT imaging.
Skeletal Radiol. 2010 May;39(5):467-72. doi: 10.1007/s00256-009-0867-7. Epub 2010 Feb 7.
Abstract/Text OBJECTIVE: Extensor tendon rupture on the dorsum of the wrist is commonly seen in patients with rheumatoid arthritis (RA). It causes immediate dysfunction of the hand and surgical reconstruction is usually required. The purpose of this study was to clarify the risk of extensor tendon rupture by quantifying wrist deformity on three-dimensional computed tomography (3DCT) images.
MATERIALS AND METHODS: Three-dimensional CT images of 108 wrists in 102 patients with RA and 38 wrists in 38 healthy volunteers were analyzed retrospectively. All of the rheumatoid wrists had caused persistent pain for more than 6 months despite ongoing medical treatment. Extensor tendon rupture was noted in 49 wrists in 47 patients, and no rupture was noted in 59 wrists in 56 patients. The dorsal subluxation ratio (DSR) of the ulnar head and the carpal supination angle (CSA) were measured utilizing a new technique.
RESULTS: The average DSR and CSA in the rupture group (n = 49), the non-rupture group (n = 59), and the normal wrist group (n = 38) were 37%, 19%, and 26%, and 15 degrees , 11 degrees , and 6 degrees respectively. The cut-off values for extensor tendon rupture in the wrists of patients with RA were 32% (sensitivity; 70%, specificity; 75%) in the DSR, and 14 degrees (71%, 68%) in the CSA.
CONCLUSION: By utilizing 3DCT imaging of the rheumatoid wrist, these parameters can help improve our ability to predict extensor tendon rupture.

PMID 20140732
S C Williamson, P Feldon
Extensor tendon ruptures in rheumatoid arthritis.
Hand Clin. 1995 Aug;11(3):449-59.
Abstract/Text The best treatment for extensor tendon rupture is prevention, either by medical management or surgical tenosynovectomy before tendon ruptures occur. Once a rupture has occurred, tendon transfer or free tendon grafting can provide acceptable restoration of extensor function. Communication with the rheumatologist is necessary to provide timely treatment for chronic dorsal tenosynovitis (and impending tendon rupture) or for single finger extension loss before the disease progresses to multiple finger extension loss. Consideration always must be given to associated joint involvement when planning surgical treatment.

PMID 7559823
Asami Abe, Hajime Ishikawa, Akira Murasawa, Kiyoshi Nakazono
Extensor tendon rupture and three-dimensional computed tomography imaging of the rheumatoid wrist.
Skeletal Radiol. 2010 Apr;39(4):325-31. doi: 10.1007/s00256-009-0763-1. Epub 2009 Aug 7.
Abstract/Text PURPOSE: Extensor tendon rupture on the dorsum of the wrist is commonly seen in patients with rheumatoid arthritis (RA). The diagnosis of tendon rupture is usually straightforward, but it is sometimes difficult in the hand with complex deformity. The purposes of this study were to investigate the reliability of three-dimensional computed tomography (3DCT) imaging of extensor tendons in the rheumatoid wrist and in the normal wrist and to clarify the validity of its clinical application to the diagnosis of tendon rupture in the rheumatoid wrist.
METHODS: Preoperative 3DCT images of 48 wrists of 45 patients with RA and 3DCT images of 38 wrists of 38 healthy volunteers were reviewed retrospectively by six orthopaedic surgeons who were unaware of all other study data. Extensor tendon rupture was verified by operation on 20 rheumatoid wrists.
RESULTS: Regarding interobserver and intra-observer reliabilities of 3DCT imaging of the extensor tendons, agreement with respect to tendon rupture in this study group was high, and Cohen's kappa (kappa) coefficient was variable, depending on the individual tendon. Positive predictive value (PPV) of tendon rupture in the extensor digiti minimi (EDM), extensor digitorum communis (EDC) V and IV and extensor pollicis longs (EPL) tendons was more than 60%, but those for the other extensor tendons were less than 50%. Negative predictive value (NPV) was more than 96% in all extensor tendons, in both rheumatoid and normal wrists.
CONCLUSIONS: Extensor tendons in normal and rheumatoid wrists were well depicted by 3DCT imaging. In the rheumatoid wrists, extensors of the ring and little fingers and the thumb were depicted more accurately than those to the other fingers. 3DCT imaging was clinically applicable to wrists for which it was difficult to diagnose by physical examination a definite cause for the loss of extension of the fingers.

PMID 19662401
Yu Sakuma, Kensuke Ochi, Takuji Iwamoto, Asami Saito, Koichiro Yano, Yurino Naito, Shinji Yoshida, Katsunori Ikari, Shigeki Momohara
Number of ruptured tendons and surgical delay as prognostic factors for the surgical repair of extensor tendon ruptures in the rheumatoid wrist.
J Rheumatol. 2014 Feb;41(2):265-9. doi: 10.3899/jrheum.130861. Epub 2014 Jan 15.
Abstract/Text OBJECTIVE: Extensor tendon ruptures in the rheumatoid wrist are usually restored by extensor tendon reconstruction surgery. However, the factors significantly correlated with the outcomes of extensor tendon reconstruction have not been defined. We examined factors showing a statistically significant correlation with postoperative active motion after tendon reconstruction.
METHODS: Spontaneous extensor tendon ruptures of 66 wrists in patients (mean age, 52.6 yrs) with rheumatoid arthritis (RA) were evaluated. All patients underwent tendon reconstruction surgery with wrist arthroplasty or arthrodesis. Active ranges of motion of the affected fingers were evaluated at 12 weeks postsurgery. Statistical significance was determined using multiple and single regression analyses.
RESULTS: Forty-six (69.6%) wrists had "good" results, while 13 (19.7%) and 7 (10.6%) wrists had "fair" and "poor" results, respectively. In multiple regression analysis, an increased number of ruptured tendons and the age at operation were independent variables significantly correlated with the postoperative active motion of reconstructed tendons (p = 0.009). Single regression analysis also showed a significant association between the number of ruptured tendons and surgical delay (p = 0.02).
CONCLUSION: The number of ruptured extensor tendons was significantly correlated with the results of tendon reconstruction, and the number of ruptured tendons was significantly correlated with preoperative surgical delay. Our results indicate that, in patients presenting with possible finger extensor tendon rupture, rheumatologists should consult with hand surgeons promptly to preserve hand function.

PMID 24429172
Abstract/Text Existing classifications of rheumatoid wrist involvement are based on the degree or stage of destruction of the wrist. We suggest to classify rheumatoid wrist involvement according to the type rather than the extent of destruction. In order to recognize the nature of wrist destruction at an early stage of the disease as well as in late stages, a continuous series of 63 patients with definitive rheumatoid arthritis for over 20 years and wrist involvement of more than ten years were analysed both clinically and radiologically. Based on radiological appearance of the late stage, three different types of wrist involvement can be recognized: Group I--Type I: rheumatoid arthritis--ankylosis Group II--Type II: rheumatoid arthritis--(secondary) osteoarthrosis Group III--Type III: rheumatoid arthritis--destabilization Spontaneous ankylosis is characteristic for patients with a juvenile onset of rheumatoid arthritis, however, it also occurs in patients with a later consent of the disease. Patients in group II (type II) demonstrate a tendency to develop secondary arthrosis. Articular surface cartilage loss progresses at a rate which remains in relative equilibrium with processes typical of arthrosis, stabilizing the carpal architecture. In group III (type III), all wrists develop an unstable radiocarpal joint as evidenced by ulnar and palmar subluxation of the carpus relative to the radius and progressive loss of carpal height. When early surgical treatment is considered, it is crucial to recognize patients with type III wrist destruction. For these patients, an osseous stabilizing procedure is essential for long-term stabilization of the wrist. It is important that any evidence of progressive loss of carpal height or of ulnar radiocarpal translocation not be ignored.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 7926987
H Ishikawa, A Murasawa, A Suzuki, M Mizukoshi, A Yamazaki, M Abe
The Senami Wrist Supporter for patients with rheumatoid arthritis.
Mod Rheumatol. 2000 Sep;10(3):155-9. doi: 10.3109/s101650070023.
Abstract/Text Abstract One of the wrist orthoses, the Senami Wrist Supporter (SWS), was applied to 203 rheumatoid wrists in 112 patients who had persistent wrist pain and restricted forearm rotation due to synovitis and instability at the distal radioulnar joint (DRUJ). The study was performed by sending out a questionnaire to the patients about the use of the SWS at home, and examining grip strength and forearm rotation with and without the use of the SWS. The average age of the patients was 61 years, and the average follow-up period was 18 months. The rate of compliance of wearing the SWS at home was 73% on average. It was higher in wrists of Larsen-Dale-Eek (LDE) grades 0, I, and II (normal, slight, and definite early abnormality) than in those of grades III, and IV (medium and severe destructive abnormality). Decreased pain was noted in 52% of the wrists at the time of applying the SWS. The SWS was not used in 10% of the wrists because of remission of pain at follow-up. Grip strength increased significantly (P < 0.01) and so did forearm rotation (P < 0.05) by the stabilizing effect of the SWS on the unstable DRUJ. The use of the SWS was confirmed to be an efficient measure to treat painful rheumatoid wrists with early stages of disease at the DRUJ.

PMID 24383593
C Chantelot, C Fontaine, R M Flipo, H Migaud, F Le Coustumer, A Duquennoy
Synovectomy combined with the Sauvé-Kapandji procedure for the rheumatoid wrist.
J Hand Surg Br. 1999 Aug;24(4):405-9.
Abstract/Text The aim of synovectomy-stabilization (synovectomy combined with the Sauvé-Kapandji procedure) of the rheumatoid wrist is to obtain a stable painless wrist, retaining enough mobility for function. Thirty-nine wrists were retrospectively examined, at a mean follow up of 64.8 months. The improvement in pain was very significant. We noticed a decrease in wrist motion affecting both flexion and radial deviation. The arthritic change in the wrist continued to increase. We noticed a mean ulnar shift of 2.2 mm and a mean increase in the radial deviation of the wrist of 7 degrees. Only transfer of the extensor carpi radialis longus tendon to the extensor carpi radialis brevis tendon was effective in correcting radial deviation of the carpus. Ninety-seven per cent of patients were very satisfied or satisfied. These encouraging results, even at advanced stages of wrist arthritis, have prompted us to lessen the indications for wrist arthrodesis.

PMID 10473145
Abstract/Text Forty-three rheumatoid wrists in 43 patients with bilateral wrist involvement were treated with synovectomy of the extensor tendons and wrist joint combined with a Darrach procedure in the period from 1966 to 1986. Clinical and radiologic assessment of the wrists was carried out after an average follow-up period of 11 years, with comparison of the treated and the opposite untreated wrists. The authors confirmed what others have concluded regarding the operation: pain was generally decreased, forearm rotation increased, and wrist extension and palmar flexion changed little. Radiologically, carpal collapse and palmar carpal subluxation progressed nearly parallel to the opposite wrists, but ulnar carpal shift was much greater in the surgically treated wrists. Therefore it is suggested that some measure to prevent ulnar carpal shift, such as Clayton's tendon transfer or radiolunate arthrodesis, should be included in this operation.

PMID 1430952
A Chamay, D Della Santa, A Vilaseca
Radiolunate arthrodesis. Factor of stability for the rheumatoid wrist.
Ann Chir Main. 1983;2(1):5-17.
Abstract/Text Spontaneous radiolunate arthrodesis found in nearly 13% of rheumatoid wrists confer on this joint a durable physiologic orientation with reduced but sufficient mobility. Twelve cases of this type of fusion were studied radiologically and clinically with an average follow-up of 5 years. The authors advise surgical arthrodesis as a supplementary procedure with synovectomy every time there is instability of the carpal articulation with ulnar disalignment. Seven cases are reported, 4 of which are presented in detail. The operative technic and indications are discussed briefly.

PMID 9336625
Hajime Ishikawa, Akira Murasawa, Kiyoshi Nakazono
Long-term follow-up study of radiocarpal arthrodesis for the rheumatoid wrist.
J Hand Surg Am. 2005 Jul;30(4):658-66. doi: 10.1016/j.jhsa.2005.02.005.
Abstract/Text PURPOSE: Pain-free stability of the wrist is a prerequisite for the rheumatoid hand to maintain power and perform various tasks. The purpose of this study was to investigate whether a radiocarpal (radiolunate, radioscapholunate, or radiolunotriquetral) arthrodesis produces a stable wrist and whether the results remain satisfactory for more than 10 years.
METHODS: A retrospective review was performed on 25 wrists of 25 patients with rheumatoid arthritis who had radiocarpal arthrodesis. All patients had a synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. The indications for radiocarpal arthrodesis included radiographic changes in Larsen-Dale-Eek grades II to IV, midcarpal joint space of greater than 1 mm, and ulnar shift or palmar subluxation of the carpus. The presence of scapholunate dissociation was an optional indication. The mean follow-up period was 13 years (range, 10-18 y) and radiographs taken just before the surgery and 0 to 2 years, 2 to 5 years, 5 to 10 years, and more than 10 years after the surgery were evaluated as were pain relief, swelling, grip power, range of motion, and complications.
RESULTS: Pain was resolved for 22 of the patients and 3 experienced occasional mild pain. Swelling generally decreased, grip power increased significantly, flexion decreased, and forearm rotation increased significantly. The complication rate was low. Radiographically ulnar shift and palmar subluxation improved initially and were maintained at the time of the 10-year follow-up evaluation; carpal collapse improved initially but returned to the preoperative level by the time of the 5-year follow-up evaluation. The midcarpal joint space was preserved in 16 wrists, and all but 1 wrist (in a patient with mutilating type of the disease) remained stable.
CONCLUSIONS: Radiocarpal arthrodesis for treatment of the rheumatoid wrist results in good stability with preservation of motion despite radiographic progression of the disease. We therefore recommend this treatment for the unstable wrist with moderate deterioration.

PMID 16039354
Ryo Okabayashi, Hajime Ishikawa, Asami Abe, Hiroshi Otani, Kei Funamura, Rika Kakutani, Satoshi Ito, Youichi Kurosawa, Shunsuke Sakai, Kiyoshi Nakazono, Motohiro Suzuki, Yukihiro Matsuyama, Akira Murasawa
Twenty years' follow-up of radiocarpal arthrodesis for rheumatoid wrists.
Mod Rheumatol. 2021 Mar;31(2):312-318. doi: 10.1080/14397595.2020.1782565. Epub 2020 Jul 10.
Abstract/Text OBJECTIVES: A pain-free stable wrist is a prerequisite for patients with rheumatoid arthritis to improve their activity of daily life. The present study investigated whether or not radiocarpal arthrodesis yielded good results for more than 20 years.
METHODS: A retrospective study was performed on 20 unstable wrists in 17 patients with rheumatoid arthritis. Radiocarpal arthrodesis combined with synovectomy and the Darrach procedure was performed. Wrist pain, grip power, the range of motion, pharmacotherapy, ESR, CRP, and serial radiographs were investigated at the baseline and 20 years after the operation. Patient-reported outcomes using the mHAQ, DASH and patient's satisfaction level were investigated at the final follow-up.
RESULTS: Pain had disappeared completely in all patients at 20 years after the operation. The average grip power increased in 16 wrists (80%) and decreased in 4 wrists (20%). Wrist extension and flexion significantly decreased, and supination and pronation remained within the functional range. Radiographically, ulnar shift and palmar subluxation initially improved and remained unchanged for a long time. Fourteen patients (82.4%) with 17 wrists were satisfied with this operation.
CONCLUSION: Radiocarpal arthrodesis for rheumatoid wrists provided painless stability for a long period for 20 years or more.

PMID 32530346
Daniel B Herren, Hajime Ishikawa
Partial arthrodesis for the rheumatoid wrist.
Hand Clin. 2005 Nov;21(4):545-52. doi: 10.1016/j.hcl.2005.08.005.
Abstract/Text The correct treatment of wrist deformation in the patient who has rheumatoid arthritis has a major impact on the preservation of function of the hand. Surgical decisions should be individualized, based on the patient's needs and the future development of deformation. Partial wrist arthrodesis in rheumatoid wrists is an excellent tool to preserve stability and functional mobility in the long term. In cases of severe destruction complete wrist fusion should be considered alternatively.

PMID 16274864
M L Clayton, D C Ferlic
Tendon transfer for radial rotation of the wrist in rheumatoid arthritis.
Clin Orthop Relat Res. 1974 May;(100):176-85.
Abstract/Text
PMID 4838397
Abstract/Text
PMID 4543376
S L Jolly, D C Ferlic, M L Clayton, D A Dennis, E A Stringer
Swanson silicone arthroplasty of the wrist in rheumatoid arthritis: a long-term follow-up.
J Hand Surg Am. 1992 Jan;17(1):142-9.
Abstract/Text Twenty-three Swanson silicone rubber implants in patients with stage III or stage IV rheumatoid arthritis were reviewed at an average of 72 months after surgery. Minimum follow-up in patients with unrevised implants was 44 months. Results were rated good or excellent in 48%, fair in 4%, and poor in 48%. Pain was the primary indication for surgery. Patient satisfaction and pain relief were achieved in 63%. Implant fracture occurred in 52%. Revision rate was 30%, including one recommended revision. Radiographic changes consistent with particulate synovitis were seen in 30%. Prosthesis settling and bony resorption were seen in more than 75% of the patients. Survivorship analysis demonstrated 42% survival at 77 months. Progressive clinical and radiologic deterioration was seen. Swanson silicone rubber implant is recommended only in the very low demand patient with stage III or stage IV rheumatoid arthritis and in those with insufficient bone stock to allow total wrist arthroplasty with a metal-on-plastic design.

PMID 1538096
Daniel B Herren, Hajime Ishikawa, Marco Rizzo, Mark Ross, Michael Solomons
Arthroplasty in the hand: what works and what doesn't?
J Hand Surg Eur Vol. 2022 Jan;47(1):4-11. doi: 10.1177/17531934211017703. Epub 2021 May 21.
Abstract/Text This review describes the different possibilities for arthroplasties at the proximal interphalangeal joint, thumb carpometacarpal joint, distal radioulnar joint, metacarpophalangeal joint and the wrist. For each joint, the indication for arthroplasty is explained, the surgical technique with the suitable implant is described and a brief summary of the outcomes reported in the literature is given.

PMID 34018871
Yuichiro Matsui, Akio Minami, Makoto Kondo, Jyunichi Ishikawa, Makoto Motomiya, Norimasa Iwasaki
A Minimum 5-Year Longitudinal Study of a New Total Wrist Arthroplasty in Patients With Rheumatoid Arthritis.
J Hand Surg Am. 2020 Mar;45(3):255.e1-255.e7. doi: 10.1016/j.jhsa.2019.06.011. Epub 2019 Aug 14.
Abstract/Text PURPOSE: To evaluate the longitudinal clinical outcomes using a new semiconstrained wrist prosthesis for the treatment of severe rheumatoid arthritis of the wrist.
METHODS: Twenty patients with rheumatoid arthritis (20 wrists) underwent total wrist arthroplasty with the prosthesis in a clinical trial. The preoperative Larsen classification was grade IV in 16 wrists and grade V in 4 wrists. Assessments were performed before surgery, 1.5 years after surgery, and at final follow-up (≥ 5 years after surgery) using the visual analog scale for pain, Figgie wrist score, Japanese version of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and plain radiographs.
RESULTS: At final follow-up, no patient had wrist pain. The preoperative flexion-extension arc at final follow-up was similar to the preoperative range. The mean 1.5-year postoperative Figgie score was significantly improved and was unchanged at final follow-up. The DASH score significantly improved from before surgery to 1.5 years after surgery; the DASH score was improved further at final follow-up, but not significantly. Five of the 19 wrists evaluated had radiographic findings indicating carpal component loosening at final follow-up; however, all patients with the loosening were asymptomatic and had not undergone revision surgery.
CONCLUSIONS: Total wrist arthroplasty using this wrist prosthesis leads to favorable clinical outcomes regarding pain relief and retained range of wrist motion.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
PMID 31421936
E A Nalebuff
Diagnosis, classification and management of rheumatoid thumb deformities.
Bull Hosp Joint Dis. 1968 Oct;29(2):119-37.
Abstract/Text
PMID 5729736
E A Nalebuff
The rheumatoid thumb.
Clin Rheum Dis. 1984 Dec;10(3):589-607.
Abstract/Text Although the thumb is frequently involved in rheumatoid arthritis, causing significant functional loss as well as pain and deformity, much can be done surgically to alleviate the condition and restore function to the patient. It is important to understand the factors leading to the various thumb deformities. With this understanding it is possible to formulate a rational treatment programme which will benefit the patient and satisfy the surgeon.

PMID 6532645
A Terrono, L Millender, E Nalebuff
Boutonniere rheumatoid thumb deformity.
J Hand Surg Am. 1990 Nov;15(6):999-1003.
Abstract/Text The boutonniere deformity is the most common rheumatoid thumb deformity. It can be classified into early, moderate, and advanced types, depending on whether the deformity is passively correctable. Fifty-three patients with 74 procedures form the basis of these recommendations. The early type treated with metacarpophalangeal joint synovectomy and extensor pollicis longus rerouting have a high recurrence rate of 64%. Metacarpophalangeal joint fusion is the procedure of choice for the moderate type with isolated metacarpophalangeal joint involvement. Metacarpophalangeal joint arthroplasty is best suited for the low-demand, older patients with borderline proximal and distal joints. Interphalangeal joint releases done with metacarpophalangeal joint fusions have a high recurrence rate and are not recommended. In advanced cases metacarpophalangeal joint arthroplasty and interphalangeal joint fusion is our procedure of choice.

PMID 2269799
Tetsuya Nemoto, Hajime Ishikawa, Asami Abe, Kiyoshi Nakazono, Hiroshi Otani, Hyunho Lee, Akira Murasawa, Yoichi Toyoshima, Katsunori Inagaki
Metacarpophalangeal Joint Arthroplasty Using Flexible Hinge Toe Implant with Grommets for Boutonnière Deformity of Rheumatoid Thumb.
J Hand Surg Asian Pac Vol. 2018 Mar;23(1):66-70. doi: 10.1142/S242483551850008X.
Abstract/Text BACKGROUND: MP joint arthroplasty is one of the treatment options for the rheumatoid thumb with boutonniere deformity. The use of flexible hinge toe implant for MP joint reconstruction was introduced; however, the outcome of flexible toe implantation for the reconstruction of the MP joint has not as yet been reported in detail. Therefore, in this study, we retrospectively investigated the clinical outcome and radiological findings.
METHODS: We assessed 56 Swanson implant arthroplasties that used flexible hinge toe implants with grommets to address boutonnière deformity of the thumb MP joint. The minimum follow-up period was 6 months. Pain, the range of motion, grip strength, pinch strength, General health Visual analogue scale and DASH (Disabilities of Hand, Shoulder and Hand) were assessed.
RESULTS: For most of the patients, the procedure provided painless motion and stability to the thumb. In the radiological assessments, the preoperative flexion angles at the MP joint were 45° improved to 17°. The origin of arc was shifted toward the extended position and the average arc of motion was 21°, with a flexion arc from 23° to 44°. The severity of boutonniere deformity was improved in most cases. The average grip strength changed from 110 to 121 mmHg and the average side pinch power changed from 1.5 to 2.2 kgf. General health VAS improved from 40 to 29 (p = 0.019), and the DAS28-CRP decreased from 3.3 to 2.4 (p < 0.001). Infection occurred in one case, and there were no implant fractures.
CONCLUSIONS: Swanson flexible hinge toe implant arthroplasty with grommets applied to the MP joint of the thumb was one of the recommended procedures for the reconstruction of boutonnière deformity of the thumb.

PMID 29409412
R L Wilson
Rheumatoid arthritis of the hand.
Orthop Clin North Am. 1986 Apr;17(2):313-43.
Abstract/Text Rheumatoid arthritis often begins in the hand, and upper extremity function can be seriously impaired with progression of the disease. When numerous areas are involved, a multitude of deformities can arise. Before initiating treatment of an arthritic patient, the surgeon must understand the natural course of the disease process, the response to medical treatment, and the functional limitations the disease has imposed. This article describes the examination for and treatment of this disease.

PMID 3520431
E A Nalebuff, J Garrett
Opera-glass hand in rheumatoid arthritis.
J Hand Surg Am. 1976 Nov;1(3):210-20.
Abstract/Text Characteristic deformities occur in the fingers, thumb, and wrist in the opera-glass hand in rheumatoid arthritis. Shortening and instability are the result of bone resorption and dislocation and can be severely disabling. Early spontaneous fusion of the proximal interphalangeal joint preserves digital length. Functional improvement can be obtained in the fingers by interphalangeal joint arthrodesis and metacarpophalangeal prosthetic arthroplasty and in the thumb with metacarpophalangeal and/or interphalangeal arthrodesis. With interphalangeal arthrodesis, interposition grafts often are required in order to restore length and secure fusion. "Prophylactic" arthrodesis of interphalangeal joints should be considered when resorption seems imminent.

PMID 1018089
V E Wood, D R Ichtertz, H Yahiku
Soft tissue metacarpophalangeal reconstruction for treatment of rheumatoid hand deformity.
J Hand Surg Am. 1989 Mar;14(2 Pt 1):163-74.
Abstract/Text The long-term results of soft tissue metacarpophalangeal reconstruction without articular resection were reviewed in 16 hands of 12 patients with painful ulnar deviation-subluxation deformity. No splinting was used beyond 3 weeks. Patients had either lupus or rheumatoid arthritis. The mean age at operation was 66 years, with mean disease duration of 15.9 years before operation. At follow-up (mean, 81 months), complete pain relief occurred in 88% of patients and 56 degrees and 64 degrees mean active metacarpophalangeal and proximal interphalangeal range of motion was present, respectively. Ulnar drift was corrected to 6 degrees on the average. The first semiobjective grading scale for metacarpophalangeal reconstruction was introduced. There were 82% good or excellent results.

PMID 2649543
Charles A Goldfarb, Peter J Stern
Metacarpophalangeal joint arthroplasty in rheumatoid arthritis. A long-term assessment.
J Bone Joint Surg Am. 2003 Oct;85-A(10):1869-78.
Abstract/Text BACKGROUND: The long-term results of silicone metacarpophalangeal arthroplasty in patients with rheumatoid arthritis are uncertain. The purpose of this investigation was to evaluate the subjective, objective, and radiographic outcomes at the time of long-term follow-up.
METHODS: Patients with rheumatoid arthritis who underwent simultaneous silicone metacarpophalangeal joint arthroplasties of all four fingers by one surgeon were eligible for inclusion in the study. The results of a total of 208 arthroplasties in fifty-two hands of thirty-six patients were evaluated at an average of fourteen years postoperatively. Active metacarpophalangeal joint motion, ulnar drift, and radiographs were assessed. The radiographs were reviewed for changes in bone length, erosions, and implant fractures. The Michigan Hand Outcomes Questionnaire (MHQ) was administered to the patients.
RESULTS: The mean arc of motion of the metacarpophalangeal joints improved from 30 degrees preoperatively to 46 degrees immediately after the surgery but decreased to 36 degrees at the time of final follow-up. The mean extension deficit of the metacarpophalangeal joints improved from 57 degrees preoperatively to 11 degrees immediately after the surgery but worsened to 23 degrees at the time of final follow-up. The mean ulnar drift improved from 26 degrees preoperatively to <5 degrees in the immediate postoperative period and then recurred to an average of 16 degrees at the time of final follow-up. Implant fractures were associated with increased ulnar drift (p < 0.001). Bone reaction adjacent to the implant was demonstrated by bone-shortening in most patients and by erosions in 29% of the patients. One hundred and thirty implants (63%) were broken and forty-five (22%) more were deformed at the time of final follow-up. The MHQ score averaged 48 of 100 points. The patients expressed satisfaction with the function of only 38% of the hands, and only 27% of the hands were pain-free at the time of final follow-up. A greater degree of ulnar drift was associated with decreased patient satisfaction and a decreased score for the cosmetic appearance (p CONCLUSIONS: The outcome after silicone metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis worsens with long-term follow-up. Given these findings, the indications for and long-term expectations of silicone metacarpophalangeal arthroplasty must be carefully examined in light of the improvements in the medical management of rheumatoid disease.

PMID 14563791
Koei Oh, Hajime Ishikawa, Asami Abe, Yoichi Toyoshima, Katsunori Inagaki, Akira Murasawa
Assessment of malalignment at the metacarpophalangeal joint of the rheumatoid hand using three-dimensional computed tomogram.
Mod Rheumatol. 2016;26(1):62-7. doi: 10.3109/14397595.2015.1056992. Epub 2015 Jul 20.
Abstract/Text OBJECTIVE: For the assessment of rheumatoid hand, three-dimensional (3D) malalignment including flexed or rotational deformities and dislocation at the finger joint is one of the important findings. The objective of this study is to prove usefulness of 3D computed tomography (3DCT) for the accurate measurement of palmoulnar flexion deformity at the metacarpophalangeal (MP) joint of the rheumatoid hand.
METHODS: Swanson implant arthroplasty at the 2nd through the 5th MP joints was performed at 179 joints in 46 hands of 40 patients with rheumatoid arthritis. Pre-and postoperatively, evaluations included Larsen grade and ulnar flexion angle by an x-ray; and ulnar flexion angle, palmar flexion angle, and resected bone length by a 3DCT.
RESULTS: With progression of Larsen grade and the joint dislocation, ulnar flexion angle increased. Average ulnar flexion angle was 18.7 ± 16.0° (mean ± SD) in grade III, 38.4 ± 21.2° in grade IV, and 40.1 ± 21.1° in grade V, 29.6 ± 16.0°in "subluxation," 24.8 ± 21.2° in "dislocation," and 41.1 ± 22.2° in "severe dislocation." There was no significant difference between grade of the MP joint dislocation and palmar flexion angle. With progression of the MP joint dislocation, resected bone length increased.
CONCLUSION: A 3DCT gives accurate information about deformity of the rheumatoid hand. Also, an appropriate length of bone resection can be determined in the preoperative planning.

PMID 26025433
A B Swanson, G de Groot Swanson, H Ishikawa
Use of grommets for flexible implant resection arthroplasty of the metacarpophalangeal joint.
Clin Orthop Relat Res. 1997 Sep;(342):22-33.
Abstract/Text In 1987, after 11 years of research, press fit titanium circumferential grommets were introduced for arthroplasty of the metacarpophalangeal joint to protect the flexible hinge implant midsection from sharp bony edges and shearing forces that can initiate implant abrasions and tears leading to implant fracture and formation of silicone wear particles. The effectiveness of the titanium circumferential grommets was assessed by comparing the results of 170 metacarpophalangeal joint implant (high performance) arthroplasties performed with (139 joints) and without (31 joints) grommets in 38 patients presenting an average 5.8 years followup. Both groups obtained pain relief, functional motion, stability, and correction of deformity. There was no evidence of particulate synovitis or infection. There were four implant fractures (12.9%) in the nongrommet group, and one (0.7%), because of implant rotation, in the grommet group. Although favorable bone remodeling was observed in both groups, the grommet group showed greater bone preservation at the metaphyseal and midshaft levels and increased intramedullary bone production around the implant stems. The results depend on appropriate surgical staging, meticulous operative and postoperative techniques, severity and progression of disease, and implant durability. The circumferential grommets safely and effectively protect the implant to bone interface to further the durability of implant arthroplasty of the metacarpophalangeal joint.

PMID 9308520
I A Trail, J A Martin, D Nuttall, J K Stanley
Seventeen-year survivorship analysis of silastic metacarpophalangeal joint replacement .
J Bone Joint Surg Br. 2004 Sep;86(7):1002-6. doi: 10.1302/0301-620x.86b7.15061.
Abstract/Text We reviewed the records and radiographs of 381 patients with rheumatoid arthritis who had undergone silastic metacarpophalangeal joint replacement during the past 17 years. The number of implants was 1336 in the course of 404 operations. Implant failure was defined as either revision or fracture of the implant as seen on radiography. At 17 years, the survivorship was 63%, although on radiographs two-thirds of the implants were seen to be broken. Factors which improved survival included soft-tissue balancing, crossed intrinsic transfer and realignment of the wrist. Surgery to the thumb and proximal interphalangeal joint had a deleterious effect and the use of grommets did not protect the implant from fracture.

PMID 15446527
Louis W Catalano, Andreas C Skarparis, Steven Z Glickel, O Alton Barron, Debra Mulley, Lewis B Lane, Debby Malley, Louis B Lane
Treatment of chronic, traumatic hyperextension deformities of the proximal interphalangeal joint with flexor digitorum superficialis tenodesis.
J Hand Surg Am. 2003 May;28(3):448-52. doi: 10.1053/jhsu.2003.50084.
Abstract/Text PURPOSE: To our knowledge, there are no reports in the literature regarding treatment of chronic, posttraumatic proximal interphalangeal (PIP) joint hyperextension deformities with flexor digitorum superficialis tenodesis. The purpose of this study was to describe the surgical treatment and results of flexor digitorum superficialis tenodesis for the treatment of chronic, posttraumatic PIP joint hyperextension deformities.
METHODS: Twelve patients were reviewed retrospectively and re-examined at a mean follow-up period of 35 months (range, 6-108 mo). Evaluation included completion of a Disabilities of the Arm, Shoulder, and Hand questionnaire and range of motion (ROM) measurements.
RESULTS: There were 5 excellent, 5 good, and 2 fair results. Five patients had a residual flexion contracture at the PIP joint of 5 degrees to 15 degrees, although this did not create any functional impairment as determined by responses to the Disabilities of the Arm, Shoulder, and Hand questionnaire at follow-up evaluation. The 2 patients with fair results had postoperative PIP flexion contractures of 30 degrees and 60 degrees. All 12 patients returned to their previous occupations and recreational activities.
CONCLUSIONS: Flexor digitorum superficialis tenodesis is an effective method with predictable results for the treatment of chronic, traumatic hyperextension deformities of the PIP joint.

PMID 12772103
Rika Kakutani, Hajime Ishikawa, Asami Abe, Kei Funamura, Masanori Sudo, Shunsuke Sakai, Hiroshi Otani, Satoshi Ito, Kiyoshi Nakazono, Akira Murasawa, Naoki Kondo, Hiroyuki Kawashima
Correction of rheumatoid swan-neck deformity of the finger using the modified Thompson-Littler method.
Mod Rheumatol. 2021 Aug 12;. doi: 10.1093/mr/roab015. Epub 2021 Aug 12.
Abstract/Text OBJECTIVES: To investigate the outcomes of the modified Thompson-Littler (m-TL) method, a corrective surgical method utilising a dynamic tenodesis, in patients with rheumatoid swan-neck deformity.
METHODS: Twenty-seven fingers in 10 patients with rheumatoid arthritis (RA) underwent surgical correction. The mean age at the time of surgery was 60.3 (45-77) years, the mean duration of RA was 19.3 (4-34) years, and the mean postoperative follow-up period was 2.4 (0.5-6) years.
RESULTS: The deformity was corrected and the proximal interphalangeal (PIP) joint pain disappeared in all operated fingers. The mean pinch power between the thumb and the operated finger increased. The active extension decreased, the active flexion increased, and the total arc of motion decreased. Comparing the range of motion by Nalebuff's type classification, the postoperative arc of motion decreased as the type advanced.
CONCLUSIONS: The m-TL method provided a favourable outcome in cases of Type ≤III rheumatoid swan-neck deformity without severe joint deterioration at the PIP joint. Aesthetic and functional improvements were observed and the patients were satisfied with the operation.

© Japan College of Rheumatology 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
PMID 34894255
Souichirou Takigawa, Steve Meletiou, Michael Sauerbier, William P Cooney
Long-term assessment of Swanson implant arthroplasty in the proximal interphalangeal joint of the hand.
J Hand Surg Am. 2004 Sep;29(5):785-95. doi: 10.1016/j.jhsa.2004.03.008.
Abstract/Text PURPOSE: The purpose of this study was to evaluate the clinical results of Swanson silicone implant arthroplasty of the proximal interphalangeal (PIP) joint, specifically evaluating clinical results with long-term assessment.
METHODS: A retrospective review of 70 silicone implants of the PIP joint in 48 patients was performed with an average follow-up period of 6.5 years (range, 3-20 y). Clinical assessment included motion, stability, and alignment. Radiographic assessment included implant fracture, deformity, and cystic bone resorption. The pathology consisted of degenerative joint disease in 14, posttraumatic arthritis (TA) in 11, rheumatoid arthritis (RA) in 13, and idiopathic arthritis (IA) associated with collagen disease in 12 patients. Swan neck and boutonniere deformities were assessed separately. Statistical analysis of preoperative risk factors was compared with the postoperative assessment of pain, motion, and function (return to work).
RESULTS: There was no significant change in the active range of motion (ROM) before and after PIP arthroplasty (26 degrees vs 30 degrees ). Correction of swan neck and boutonniere deformities was difficult, usually leading to poor results. There was improvement in maximum active extension before surgery lacking 32 degrees to after surgery lacking 18 degrees . From a statistical standpoint rheumatoid joint involvement with PIP arthroplasty had poorer results than degenerative or posttraumatic arthritis with respect to pain relief and ROM. Pain relief was present in 70% of replaced PIP joints with residual pain and loss of strength in 30%. Radiographic analysis showed abnormal bone formation (cystic changes) in 45%. There were 11 implant fractures and 9 joints that required revision surgery.
CONCLUSIONS: Silicone replacement of the PIP joint is effective in providing relief of pain from arthritis but does not provide improvement in motion or correction of deformity. It provided a poorer outcome in rheumatoid disease in comparison with degenerative, posttraumatic, or idiopathic arthritis.

PMID 15465226
I Ohshio, T Ogino, A Minami, H Kato
Reconstruction of the central slip by the transverse retinacular ligament for boutonnière deformity.
J Hand Surg Br. 1990 Nov;15(4):407-9. doi: 10.1016/0266-7681(90)90080-n.
Abstract/Text A method of repair of boutonnière deformity is described, using the transverse retinacular ligament. Six fingers in five patients were treated by this procedure. The deformity was improved in all fingers; complete or almost complete correction was obtained in four fingers and incomplete correction in two. However, severe limitation of flexion of the D.I.P. joint appeared in two fingers after surgery. This procedure is not indicated for boutonnière deformities with severe contracture of the lateral band; its best indication is in cases in which the central slip is defective and conservative treatment is not effective.

PMID 2269828
J A Chow, S Dovelle, L J Thomes, P K Ho, J Saldana
A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation.
J Hand Surg Br. 1989 Feb;14(1):18-20.
Abstract/Text To compare the functional results of early controlled mobilisation and static immobilisation following repair of extensor tendons, we conducted a comparative study between two centres. In one, a consecutive series of tenorrhaphy patients was treated post-operatively by the dynamic splinting technique. In the other, a consecutive group was treated by static splinting. All patients treated by dynamic splinting were graded excellent within six weeks following surgery; no tendon ruptures occurred and no secondary corrective tendon surgery was required. After static splinting, 40% were graded excellent, 31% good, 29% fair, and none poor; six fingers treated by static splintage subsequently required tenolysis. Following surgical repair of extensor tendons of the hand, patients treated by early controlled motion regain better flexion function in terms of grip strength and pulp-to-palm distance. Dynamic splinting is a more effective technique than static splinting in the prevention of extensor lag.

PMID 2926213

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから