rheumatoid arthritis
DESCRIPTION
RA OF HANDTRANSCRIPT
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Rheumatoid Arthritis
R. Hill
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Rheumatoid Arthritis
• Auto-immune process of unknown aetiology causing a chronic inflammatory process
• Primarily affects the synovium in the Hand
• Epidemiology
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Surgical Aims
• Decrease pain
• Prevent worsening deformity/function
• Improve appearance/ function
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Stages of Rheumatic joint involvement
Stage Description
I Synovitis no deformity
II Synovitis, passively correctable deformity
III Fixed deformity, no joint changes
IV Articular destruction
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Surgical Procedures
• Synovectomy
• Tenosynovectomy
• Tendon Surgery
• Arthroplasty
• Arthrodesis
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Thumb Deformities
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Type 1 Boutonniere
• Usually due to MCP joint synovitis
• Exclude FPL rupture
• Treatment– early Synovectomy + tendon
reconstruction– Intermediate Arthrodesis or Arthroplasty– late ST repair, arthroplasty or
arthrodesis
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Type III Swan-Neck Deformity• Result of CMC disease
• Treatment– Early Resection arthroplasty with
tendon interposition (RATI)– Intermediate RATI + volar tenodesis or
arthrodesis of MCPJ– Late RATI and MCPJ arthrodesis
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Type IV Gamekeepers Thumb
• Due to synovitis of the MCPJ– NB no CMCJ disease
• Treatment– Early Synovectomy, adductor fascia release
and repair UCL– Late Arthrodesis/ arthroplasty + adductor
fascia release.
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Type II
• Combination of Type I and II
• Treatment– CMCJ RATI– MCPJ Tendon reconstruction
arthroplasty/arthrodesis– IPJ Nil - arthrodesis
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Type V
• Due to stretching of the volar plate
• Treatment Arthrodesis, volar capsulodesis or sesamoidesis
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Arthritis Mutilans
• Instability and joint destruction
• Treatment– Early Early arthrodesis– Late Arthrodesis with bone grafting
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Boutonniere deformity
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Boutonniere
• Stage I PIPJ lag 10-15 degrees
• Stage II PIPJ lag 30-40 Degrees
• Stage III PIPJ Fixed
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Treatment
• Stage I Ext. tendon tenotomy
• Stage II Repair central slip and bands.
Ext Tendon tenotomy
• Stage III Arthrodesis / arthroplasty
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Swan-Neck Deformity
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Types of Swan-Neck Deformity
• Type I Passive Motion at PIPJ possible
• Type II Related to MCPJ and intrinsic tightness
• Type III Fixed PIPJ preserved joint
• Type IV Fixed PIPJ and degenerate joint
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Treatment of Swan-Neck deformity
• Type I DIPJ Fusion
Volar Tenodesis
Retinacular ligament reconstruction
Dermadesis
• Type II Intrinsic Release (IR) + type I
or
Correct MCPJ disorder
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Treatment Swan-Neck deformity
• Type III Restore passive motion
Correct deformity later
• Type IV Salvage procedure.
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Evidence
• No randomised control trials
• Papers often retrospective over long periods
• Poor numbers with no controls
• No validated scoring systems to evaluate outcome
• Results poor yet conclusion’s often positive