Effects of extensor synovectomy and excision of the distal ulna in rheumatoid arthritis on long-term function

Rheumatoid Hand Surgery in the Era of Biologic Therapy: A Rheumatologist-oriented Overview

Rheumatoid arthritis (RA) can cause significant hand and wrist damage and dysfunction. The aim of medical treatment is to eradicate inflammation and prevent damage to joints and soft tissues. Advances in newer biological therapies over the last two decades have resulted in greater remission rates and lower disease activity status. Despite these improvements, surgical intervention is still indicated in cases of disability, irreversible deformities, and severe pain. However, there are large variations in the surgical rates of common rheumatoid hand procedures, which may indicate clinical uncertainty or disagreement between treating rheumatologists and hand surgeons. In this review, we provide a basic overview of common problems of the hand and wrist in RA patients. The target audience is rheumatologists for their better understanding of surgical options and for better informed patient consultation before referring to hand surgeons.

Long-term results of simple hemiresection arthroplasty in the rheumatoid distal radio-ulnar joint

We retrospectively studied the radiological and clinical results of a simple hemiresection arthroplasty, a modification of previous oblique distal ulnar resections, in 62 patients with rheumatoid arthritis (68 wrists) over a mean follow-up of 103 (range 60-173) months. Fourteen wrists (20%) became fused at the radiocarpal joint and 28 wrists fused (41%) at the midcarpal joints during follow-up. Severe ulnar translocation of the carpus was observed in two wrists (3%), radio-ulnar convergence in five wrists (7%), as well as a significant decrease of carpal height ratio, without any radiological findings of stylocarpal impingement. Improvements in forearm pronation and supination, and reduction in pain were maintained at the last follow-up. Grip strength was not significantly improved. The Jebsen-Taylor hand function test showed improvements in writing, card turning, and simulated feeding. Fifty-two patients (58 wrists, 85%) were satisfied with the results at the last follow-up. Simple hemiresection arthroplasty showed good long-term results with few complications.

Efficacy of inpatient burn rehabilitation: a prospective pilot study examining range of motion, hand function and balance

PURPOSE

To examine the effect of inpatient rehabilitation therapy on range of motion, hand function and balance in the burn population.

METHODS

This study utilizes a prospective longitudinal design. Inclusion criteria are adults admitted to a regional inpatient rehabilitation hospital with a primary diagnosis of burn injury. Demographic and medical data are collected. Primary outcomes include range of motion at four joints (shoulder, elbow, hip, knee), hand function (Jebsen Taylor Hand Test) and balance (Berg Balance Scale). Outcomes are measured at admission and discharge. Students't-test is used to determine significant differences in outcomes from admission to discharge.

RESULTS

Eleven subjects meet inclusion criteria. The mean age is 50 years, rehabilitation length of stay is 35 days and total body surface area burned is 41%. Subjects demonstrate significant improvements in range of motion, hand function and balance from admission to discharge (p<0.05).

CONCLUSIONS

Specific functional measures, range of motion, hand function and balance, demonstrate significant improvement during inpatient rehabilitation. Future work is needed to investigate other functional benefits of rehabilitation and to compare the impact of inpatient rehabilitation to other therapeutic interventions.

[Hand and wrist surgery]

Despite improved medical treatment of rheumatoid arthritis, carpal tunnel compression, caput ulnae syndrome and palmar and dorsal tenosynovitis with potential tendon rupture represent urgent surgical indications. While diagnostic and therapeutic synovectomy may guide medical treatment, it should be performed before joint instability and destructive arthritis are established. Swan-neck and Boutonniere deformities as well as ulnar or radial drift of metacarpophalangeal (MCP) joints or the wrist can only be corrected when the involved joints are supple and intact. In the presence of destructive arthritis, partial and total wrist fusion, arthroplasties of the MCP joints and arthrodeses of the distal interphalangeal joints are recommended.