Rheumatoid arthritis (RA) is a chronic autoimmune disease, the essence of which is inflammation that begins within the synovial membrane of the joints and tendon sheaths. In the course of RA, secondary damage to the joints and periarticular tissues occurs, leading to deformations most strongly expressed in the area of the hands and feet, although the changes often also affect the knee or hip joint. The term "rheumatoid hand" refers to a set of deformities resulting from subluxation of the wrist and finger joints, post-inflammatory soft tissue fibrosis, and muscle atrophy. Despite the development of pharmacological therapies, the only effective solution for many patients is surgery, which allows to alleviate pain and improve the function of the hand.
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What is rheumatoid arthritis?
The presence of the so-called rheumatoid factor, which is an antibody directed against its own immunoglobulin G. The inflammatory process begins in the synovial membrane of the joint that builds the inner layer of the joint capsule. In the capsular-ligamentous apparatus, inflammatory infiltrates are formed, consisting of lymphocytes, macrophages and granulocytes, which form the so-called rheumatoid granulation tissue. The granulation tissue gradually penetrates into the joint, leading to the destruction of the joint cartilage. The mechanism of cartilage destruction is the production of the so-called pannus, which disrupts the nutrition of cartilage from the synovial fluid, and is also a source of proteolytic enzymes leading to tissue degradation. The articular surfaces and the subcartilage layer of the bones deteriorate, and vascular damage causes the accumulation of exudate in the joint. At the same time, the ongoing repair processes lead to the formation of fibrous and then bone adhesions limiting the mobility of the joint. Inflammatory and fibrotic changes also affect the sheaths in which the tendons run, leading to disturbances in tendon displacement, muscle atrophy and imbalance of muscle tension, which aggravates the degree of deformation.
RA symptoms
The first symptoms of rheumatoid arthritis develop slowly. Periodic low-grade fever appears, accompanied by pain in joints and muscles. There is morning stiffness, tactile pain and symmetrical swelling of the joints of the hands, as well as the presence of the so-called. rheumatoid nodules on the dorsal surface of the skin of the fingers. X-rays can show local osteoporosis and rheumatoid factor is found in the blood. RA occurs in periods of exacerbation (when symptoms worsen) and reemission (when the inflammation processes are suppressed and symptoms are alleviated). The diagnosis of rheumatoid arthritis is based on specific diagnostic criteria. A rheumatologist or an orthopedic surgeon may order the required RA examinations, and then, taking into account the nature of the reported symptoms, he or she determines the diagnosis as "certain", "probable" or decides about a suspected rheumatoid disease requiring further observation. Early diagnosis enables quick implementation of appropriate treatment - it is worth noting that rheumatoid arthritis is a progressive disease, which means that various measures can only slow down the progression of deformity.
Treatment of rheumatoid arthritis
The goals of rheumatoid arthritis treatment are to inhibit inflammation, relieve pain, reduce the degree of deformity and prevent loss of hand function. Treatment of RA should be comprehensive and include:
painkillers and anti-inflammatory drugs, including immunosuppressants, biological treatment,
rehabilitations,
orthopedic equipment (e.g. wrist and hand orthoses, aids facilitating the grip),
psychotherapy,
surgery.
Hand deformities in the course of rheumatoid arthritis
Subluxation at the wrist joints
Inflammation of the wrist joint in RA leads to the destruction of the ligaments connecting the bones of the forearm with the proximal row of the bones of the wrist. The radial bone forms a direct joint with the wrist, while the head of the ulna is delimited by an articular disc. Joint destruction can lead to subluxation of the ulna head, which is manifested by the dorsal ankle protruding below the wrist from the side of the little finger. A subluxation of the ulna head can irritate the tendons of the wrist extension muscles, increasing the risk of rupture.
In a healthy hand, the wrist bones are arranged in an arc across the palm of the hand. In the rheumatoid hand, the wrist bone becomes unstable and its arched structure collapses, increasing the risk of pressure on the structures running in the wrist canal.
Distortions in the metacarpophalangeal joints
The metacarpophalangeal joints are located at the base of the fingers and connect the metacarpal bones to the phalanges of the fingers. In RA, the fingers are subluxated and abnormal elbow deviation (ulnarisation), tilting towards the little finger. Ulnarization is caused by the asymmetry in the shape of the damaged heads of the metacarpal bones, the presence of exudate in the joints, and the natural tendency of the flexors and extensors to pull the fingers elbow.
Buttonhole finger
The deformity of the buttonhole toe consists in permanent flexion in the proximal interphalangeal joint and hyperextension in the distal interphalangeal joint. The buttonhole toe results from damage to the central band of the tendon that extends the finger at the level of the proximal interphalangeal joint.
Swan neck finger
The swan neck deformity is the inverse of the buttonhole toe deformation. There is unnatural hyperextension in the PIP joints, while in the PIP joints excessive flexion is observed. The main cause of deformation is the destruction of the proximal interphalangeal joint and the disturbed balance between the forces that extend and flex the finger.
Hammer finger
The hammer finger is bent in the distal interphalangeal joint due to the tendon extending the finger from the attachment on the distal phalanx.
Hand surgery in the course of rheumatoid arthritis
Surgery in RA enables the improvement of the hand function required for daily activities such as preparing and consuming food, personal hygiene and dressing. It is very important to determine the real effect of the operation depending on the degree of deformation, because the nature of distortions in RA most often does not allow the full function of the hand to be restored.
Hand surgery in RA is divided into preventive and reconstructive.
Prophylactic treatments include:
Muscle tendon transfers
The procedure is to alter the course of the tendon in such a way as to change the direction of the force of the tendon acting on a specific joint. As a result, the balance of tensions within the fingers of the hand is improved, preventing the ulnarization of the fingers and deformation of the swan neck or boutonniere,
Removal of inflamed tendon sheaths (tenosynovectomy)
The procedure is performed in patients whose inflammation of the tendon sheaths persists despite undergoing 3-6 months of pharmacological therapy. Tenosynovectomy is a prophylaxis of the secondary weakening of the tendon structure and its rupture.
Removal of the inflamed synovium of the joint (synovectomy)
The synovectomy procedure allows to limit the destruction of the joint and is a prophylaxis of total stiffness of the hand joints.
Excision of the dorsally protruding part of the ulna head
The procedure reduces the mechanical friction between the bones and extensor tendons, reducing the risk of rupture.
Hand treatments or reconstruction include:
Stiffening the joint (arthrodesis),
Endoprosthetics - replacement of a damaged joint with an artificial prosthesis,
Repair of broken muscle tendons,
Median nerve decompression (treatment of carpal tunnel syndrome).
Finger joint arthrodesis or endoprosthesis?
Joint damage may require stiffening (arthrodesis) or arthroplasty. The thumb joints - interphalangeal and metacarpophalangeal - ensure the stability of the grip, therefore it is more advisable to perform arthrodesis within them. Treatment of the carpal-metacarpal joint of the thumb, in which the movements of opposing the thumb take place, requires mobility, which is why in this case the procedure of implanting an endoprosthesis is more often chosen.
The proximal and distal interphalangeal joints of II-V fingers are usually stiffened due to the insufficient mass of ligaments which would protect the finger joint endoprosthesis against dislocation. On the other hand, the metacarpophalangeal joints are successfully replaced with an artificial implant, which allows to maintain mobility in this segment of the hand.
Wrist arthrodesis or endoprosthesis?
Wrist arthrodesis is well tolerated by patients because it relieves pain and at the same time provides a stable basis for manipulation movements in the hand joints. Radiocarpal arthroplasty maintains a low mobility of the wrist, but is associated with a higher risk of complications. On the other hand, the development of biomedical engineering means that newer models of endoprostheses with a higher degree of stability and a lower risk of loosening appear on the market, which gives hope for their effective use in the surgical treatment of rheumatoid hand.
Repair of broken muscle tendons
A torn muscle tendon can be sewn to the attachment site or replaced with a graft taken from elsewhere in the body. Also, transfers are made of adjacent tendons to replace the function of the broken tendons.
If rheumatoid arthritis has damaged multiple joints, it is imperative to determine the correct sequence for reconstructive surgery. The wrist joints are treated first to lead to the initial alignment of the wrist-hand complex. Then, procedures are carried out, such as the operation of the buttonhole finger or the operation of the "swan neck" finger.
Sources:
Rehim, Shady A., and Kevin C. Chung. “Applying Evidence In The Care Of Patients With Rheumatoid Hand And Wrist Deformities.” Plastic and reconstructive surgery 132.4 (2013): 885–897.
Chung, Kevin C., and Sandra V. Kotsis. “Outcomes of Hand Surgery in the Patient with Rheumatoid Arthritis.” Current opinion in rheumatology 22.3 (2010): 336–341.
Zimmerman-Górska Irena. „Choroby reumatyczne” PZWL, Warszawa 2004.
Frequently asked questions about rheumatoid arthritis:
The first symptoms of rheumatoid arthritis develop slowly. Periodic low-grade fever appears, accompanied by pain in joints and muscles. There are morning stiffness, tactile pain and symmetrical swelling of the joints. Rheumatoid arthritis most often affects the small joints of the hands and feet, less often the elbow, knee and hip joints. The diagnostic process of RA should be carried out by a rheumatologist or orthopedist.
Due to the inflammatory nature of RA, drugs to suppress arthritis and immunosuppressants are the main methods of fighting the disease. A form of non-pharmacological treatment in patients who have been taking medications for a minimum period of 3-6 months is a surgical procedure consisting in the removal of the synovial membrane of joint capsules and tendon sheaths. The synovial membrane is the primary focus of inflammation, and its resection prevents the spread of lesions to adjacent tissues and reduces the degree of deformation. Other methods of treatment include rehabilitation, the use of orthoses to stabilize the joints and psychotherapy of the patient (due to the progressive nature of RA).
Corrective boutonniere and swan neck finger deformities can be treated surgically using a tendon transfer procedure. This procedure influences the direction of the tendon forces on the finger joints and reduces the degree of deformation. Persistent deformities require arthrodesis (stiffening the joint) or implantation of an artificial finger joint prosthesis. The surgical method is selected by the surgeon who qualifies for the procedure.
