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: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2017/01/26
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. リウマチ手とは、関節リウマチ(Rheumatoid Arthritis、RA)に罹患した手をいう。
  1. RAの発症時から高頻度に手は罹患し、朝のこわばりとともに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。
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関連論文:
著者:
雑誌名: Mod Rheumatol. 2009;19(1):47-52. doi: 10.1007/s10165-008-0118-0. Epub 2008 Aug 30.
Abstract/Text
PMID 18758892  Mod Rheumatol. 2009;19(1):47-52. doi: 10.1007/s10165-00・・・
著者:
雑誌名: Mod Rheumatol. 2015 Nov 20:1-6. [Epub ahead of print]
Abstract/Text
PMID 26457587  Mod Rheumatol. 2015 Nov 20:1-6. [Epub ahead of print]
著者: A Larsen
雑誌名: J Rheumatol. 1995 Oct;22(10):1974-5.
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  J Rheumatol. 1995 Oct;22(10):1974-5.
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。
※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、実際の保険適用の査定において保険適用及び保険適用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用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 : 講演料(中外製薬株式会社,ブリストル・マイヤーズスクイブ株式会社),研究費・助成金など(IQVIAサービシーズジャパン,エーザイ,ギリアド・サイエンシズ株式会社,Corronal LCC)[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 関節リウマチ(rheumatoid arthritis: 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。
  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。<図表><図表>
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」。
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文献 

著者: 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
雑誌名: 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  Ann Rheum Dis. 2010 Sep;69(9):1580-8. doi: 10.1136/ard.・・・
著者: 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
雑誌名: 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  Arthritis Rheum. 2010 Sep;62(9):2569-81. doi: 10.1002/a・・・
著者: 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
雑誌名: 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  Ann Rheum Dis. 2010 Apr;69(4):631-7. doi: 10.1136/ard.2・・・
著者: A Larsen
雑誌名: J Rheumatol. 1995 Oct;22(10):1974-5.
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  J Rheumatol. 1995 Oct;22(10):1974-5.
著者: Hajime Ishikawa, Akira Murasawa, Kiyoshi Nakazono, Asami Abe, Hiroshi Otani, Tahahiro Netsu, Takehito Sakai, Hiroe Sato
雑誌名: 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  Clin Rheumatol. 2008 Aug;27(8):967-73. doi: 10.1007/s10・・・
著者: D C Ferlic, M L Clayton
雑誌名: 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 Hand Surg Am. 1978 Jul;3(4):364-7.
著者: A N Ertel, L H Millender, E Nalebuff, D McKay, B Leslie
雑誌名: 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  J Hand Surg Am. 1988 Nov;13(6):860-6.
著者: J R Moore, A J Weiland, L Valdata
雑誌名: 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  J Hand Surg Am. 1987 Jan;12(1):9-14.
著者: S C Williamson, P Feldon
雑誌名: 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  Hand Clin. 1995 Aug;11(3):449-59.
著者: B R Simmen, H Huber
雑誌名: Handchir Mikrochir Plast Chir. 1994 Jul;26(4):182-9.
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  Handchir Mikrochir Plast Chir. 1994 Jul;26(4):182-9.
著者: C Chantelot, C Fontaine, R M Flipo, H Migaud, F Le Coustumer, A Duquennoy
雑誌名: 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  J Hand Surg Br. 1999 Aug;24(4):405-9.
著者: H Ishikawa, T Hanyu, T Tajima
雑誌名: J Hand Surg Am. 1992 Nov;17(6):1109-17.
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  J Hand Surg Am. 1992 Nov;17(6):1109-17.
著者: A Chamay, D Della Santa, A Vilaseca
雑誌名: 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  Ann Chir Main. 1983;2(1):5-17.
著者: Hajime Ishikawa, Akira Murasawa, Kiyoshi Nakazono
雑誌名: 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  J Hand Surg Am. 2005 Jul;30(4):658-66. doi: 10.1016/j.j・・・
著者: M L Clayton, D C Ferlic
雑誌名: Clin Orthop Relat Res. 1974 May;(100):176-85.
Abstract/Text
PMID 4838397  Clin Orthop Relat Res. 1974 May;(100):176-85.
著者: L H Millender, E A Nalebuff
雑誌名: J Bone Joint Surg Am. 1973 Jul;55(5):1026-34.
Abstract/Text
PMID 4543376  J Bone Joint Surg Am. 1973 Jul;55(5):1026-34.
著者: S L Jolly, D C Ferlic, M L Clayton, D A Dennis, E A Stringer
雑誌名: 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  J Hand Surg Am. 1992 Jan;17(1):142-9.
著者: E A Nalebuff
雑誌名: Bull Hosp Joint Dis. 1968 Oct;29(2):119-37.
Abstract/Text
PMID 5729736  Bull Hosp Joint Dis. 1968 Oct;29(2):119-37.
著者: E A Nalebuff
雑誌名: 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  Clin Rheum Dis. 1984 Dec;10(3):589-607.
著者: A Terrono, L Millender, E Nalebuff
雑誌名: 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  J Hand Surg Am. 1990 Nov;15(6):999-1003.
著者: G Ferro, M Chiariello, B Trimarco, F Perticone, B Ricciardelli, F Rengo, M Condorelli
雑誌名: G Ital Cardiol. 1978;8(9):962-7.
Abstract/Text In 49 patients suffering of heart diseases we have studied the changes of radiologic cardiac measurements and systolic time intervals (STI) in the four functional classes of the New York Heart Association (NYHA) classification, investigating also the existence of any relationship between these different parameters. Only the patients in functional classes 3rd and 4th showed significant changes in STI and radiologic measurements as compared to the control group. Moreover, a significant negative correlation has been observed between relative heart volume and left ventricular ejection time (LVET) (r = 0.69, P less than 0.001) and LVETc (r = 0.82, P less than 0.001) and a positive correlation between relative heart volume and pre-ejection period (PEP) (r = 0.59, P less than 0.01) and PEP/LVET ratio (r = 0.75, P less than 0.001). These results seem to demonstrate that relative heart volumetry is a fairly accurate index of the cardiac conditions in non valvular heart diseases.

PMID 710766  G Ital Cardiol. 1978;8(9):962-7.
著者: R L Wilson
雑誌名: 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  Orthop Clin North Am. 1986 Apr;17(2):313-43.
著者: E A Nalebuff, J Garrett
雑誌名: 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  J Hand Surg Am. 1976 Nov;1(3):210-20.
著者: V E Wood, D R Ichtertz, H Yahiku
雑誌名: 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  J Hand Surg Am. 1989 Mar;14(2 Pt 1):163-74.
著者: Charles A Goldfarb, Peter J Stern
雑誌名: 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  J Bone Joint Surg Am. 2003 Oct;85-A(10):1869-78.
著者: H Ishikawa, A Murasawa, T Hanyu
雑誌名: 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  J Hand Surg Br. 2002 Apr;27(2):180-3. doi: 10.1054/jhsb・・・
著者: A B Swanson, G de Groot Swanson, H Ishikawa
雑誌名: 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  Clin Orthop Relat Res. 1997 Sep;(342):22-33.
著者: Louis W Catalano, Andreas C Skarparis, Steven Z Glickel, O Alton Barron, Debra Mulley, Lewis B Lane, Debby Malley, Louis B Lane
雑誌名: 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  J Hand Surg Am. 2003 May;28(3):448-52. doi: 10.1053/jhs・・・
著者: J A Chow, S Dovelle, L J Thomes, P K Ho, J Saldana
雑誌名: 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  J Hand Surg Br. 1989 Feb;14(1):18-20.

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