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Funamura K, Ishikawa H, Abe A, Ito S, Otani H, Takamura S, Sudo M, Nakazono K, Murasawa A. More than 10 years' follow-up of the Swanson metacarpophalangeal joint arthroplasty for the rheumatoid hand. J Orthop Sci 2024; 29:788-794. [PMID: 37012139 DOI: 10.1016/j.jos.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/21/2023] [Accepted: 03/15/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND In recent years, advances in pharmacotherapy for rheumatoid arthritis have dramatically improved the control of disease activity. However, a significant number of patients still develop hand deformity and require surgical reconstruction. The objective of this study was to evaluate the long-term efficacy and drawbacks of the Swanson metacarpophalangeal joint arthroplasty for patients with rheumatoid arthritis over 10 years. METHODS Clinical and radiological evaluations were performed for 87 joints of 29 hands in 27 patients who underwent metacarpophalangeal joint arthroplasty using the Swanson implant, and who were followed up for an average of 11.4 (10-14) years. RESULTS The number of operated tender and swollen metacarpophalangeal joints decreased from 24 (27.6%) and 28 (32.2%) to 1 (1.1%) and 2 (2.3%), respectively. The patients' general health and disease activity score 28-erythrocyte sedimentation rate improved at the last survey. Mild recurrence of ulnar drift was observed, but the deformity was generally well-corrected. Implant fracture was noted in eight joints (9.2%), and revision surgery was performed in two joints (2.3%). The average active range of extension/flexion changed from -46.3°/65.9° to -32.3°/56.6°. While a significant change was not noted in grip or pinch strength, patients were satisfied with the operation especially in terms of pain relief and improved hand appearance. CONCLUSIONS The long-term results of Swanson metacarpophalangeal joint arthroplasty were good in pain relief and correction of deformity, but some problems remain with regard to implant durability and mobility.
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Affiliation(s)
- Kei Funamura
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
| | - Hajime Ishikawa
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan.
| | - Asami Abe
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
| | - Hiroshi Otani
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
| | - Sayuri Takamura
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
| | - Masanori Sudo
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
| | - Kiyoshi Nakazono
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
| | - Akira Murasawa
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Shibata City, Niigata 957-0054, Japan
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Herren DB, Ishikawa H, Rizzo M, Ross M, Solomons M. Arthroplasty in the hand: what works and what doesn't? J Hand Surg Eur Vol 2022; 47:4-11. [PMID: 34018871 DOI: 10.1177/17531934211017703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Daniel B Herren
- Department of Hand Surgery, Schulthess Klinik, Zurich, Switzerland
| | | | - Marco Rizzo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark Ross
- Brisbane Hand and Upper Limb Research Institute, Brisbane Private Hospital, Brisbane, Queensland, Australia
| | - Michael Solomons
- Department of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
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Notermans BJW, Lans J, Arnold D, Jupiter JB, Chen NC. Factors Associated With Reoperation After Silicone Metacarpophalangeal Joint Arthroplasty in Patients With Inflammatory Arthritis. Hand (N Y) 2020; 15:805-811. [PMID: 32122171 PMCID: PMC7850254 DOI: 10.1177/1558944719831236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Silicone metacarpophalangeal (MCP) joint arthroplasty has a high revision rate. It has been suggested that the preoperative degree of ulnar drift and radial wrist deviation influences the durability of MCP silicone arthroplasties. The goal of this study was to evaluate what factors are associated with reoperation after silicone MCP arthroplasty. Materials and Methods: We retrospectively evaluated all adult patients who underwent MCP silicone arthroplasty between 2002 and 2016 at one institutional system for inflammatory arthritis. After manual chart review, we included 73 patients who underwent 252 arthroplasties. Fingers treated included 66 index, 67 long, 60 ring, and 59 small fingers. Results: The overall reoperation rate was 9.1% (N = 23). Indications for reoperation were implant breakage (n = 11), instability (n = 4), soft tissue complications (n = 4), infections (n = 3), and stiffness (n = 1). There was a trend that patients who underwent single-digit arthroplasty had higher rates of revision (19% vs 3.5%, P = .067). Radiographic follow-up demonstrated joint incongruency in 50% of cases, bone erosion in 58% of cases, and implant breakage in 19% of cases. There was a trend toward higher rates of revision in patients without preoperative MCP joint subluxation (19% vs 6.7%, P = .065) The 1-, 5-, and 10-year implant survival rates were 96%, 92%, and 70%, respectively. Revision surgery occurred at <14 months in 15 patients (65%) and after 5 years in 8 (35%) patients. Conclusions: Revision surgery after silicone MCP arthroplasty appears to be bimodal. Patients with greater hand function preoperatively may be at higher risk of revision surgery.
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Affiliation(s)
- Bo J. W. Notermans
- Massachusetts General Hospital, Boston, USA,Bo J. W. Notermans, Kaatstraat 47, Utrecht, 3513 BV, The Netherlands.
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Okura C, Ishikawa H, Abe A, Yonemoto Y, Okamura K, Suto T, Oyakawa T, Miyagawa Y, Otani H, Ito S, Kobayashi D, Nakazono K, Murasawa A, Takagishi K, Chikuda H. Long-term patient reported outcomes of elbow, wrist and hand surgery for rheumatoid arthritis. Int J Rheum Dis 2018; 21:1701-1708. [PMID: 30187667 DOI: 10.1111/1756-185x.13340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Chisa Okura
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan.,Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hajime Ishikawa
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Asami Abe
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Yukio Yonemoto
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Koichi Okamura
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takahito Suto
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tomo Oyakawa
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Yusuke Miyagawa
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Hiroshi Otani
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Daisuke Kobayashi
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Kiyoshi Nakazono
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Akira Murasawa
- Department of Rheumatology, Niigata Rheumatic Center, Niigata, Japan
| | - Kenji Takagishi
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.,Department of Orthopaedic Surgery, Saint-Pierre Hospital, Takasaki, Gunma, Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Nemoto T, Ishikawa H, Abe A, Nakazono K, Otani H, Lee H, Murasawa A, Toyoshima Y, Inagaki K. Metacarpophalangeal Joint Arthroplasty Using Flexible Hinge Toe Implant with Grommets for Boutonnière Deformity of Rheumatoid Thumb. J Hand Surg Asian Pac Vol 2018; 23:66-70. [PMID: 29409412 DOI: 10.1142/s242483551850008x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Tetsuya Nemoto
- * Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan.,† Department of Orthopaedic Surgery, Showa University, Tokyo, Japan
| | - Hajime Ishikawa
- * Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan
| | - Asami Abe
- * Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan
| | - Kiyoshi Nakazono
- * Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan
| | - Hiroshi Otani
- * Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan
| | - Hyunho Lee
- * Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan
| | - Akira Murasawa
- * Department of Rheumatology, Niigata Rheumatic Center, Shibata, Japan
| | - Yoichi Toyoshima
- † Department of Orthopaedic Surgery, Showa University, Tokyo, Japan
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Möller K, Sollerman C, Geijer M, Kopylov P, Tägil M. Avanta Versus Swanson Silicone Implants in the MCP Joint—A Prospective, Randomized Comparison of 30 Patients Followed for 2 Years. ACTA ACUST UNITED AC 2016; 30:8-13. [PMID: 15620485 DOI: 10.1016/j.jhsb.2004.09.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2004] [Accepted: 09/16/2004] [Indexed: 11/26/2022]
Abstract
The results of Swanson and Avanta metacarpophalangeal joint arthroplasties in rheumatoid patients were compared in a prospective, randomized study of 30 patients (120 implants). At 2-year follow-up, grip strength was measured, hand function was assessed with the Sollerman test and the subjective outcome was determined with visual analogue scores. With both implants ulnar deviation and flexion deformities decreased, and there was no difference between the groups. The increase in range of motion was 7° greater with Avanta implants than with Swanson implants. Grip strength and hand function were unaltered but the visual analogue scales showed decreased pain levels and subjective improvements in hand function, grip strength and cosmesis. Twenty-four of 30 patients were satisfied. Fracture of the silicone spacer occurred with 12 Avanta (20%) and eight Swanson implants (13%), with a higher fracture frequency in men.
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Affiliation(s)
- K Möller
- Department of Hand Surgery, Sahlgrenska University Hospital/Sahlgrenska, Göteborg, Sweden.
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Ochi K, Sakuma Y, Ishida O, Yano K, Yoshida S, Koyama T, Ishibashi M, Ikari K, Momohara S. Modified metacarpal shortening osteotomy of the midcarpal bone for preserving metacarpophalangeal joints in patients with rheumatoid arthritis. Mod Rheumatol 2015; 26:313-4. [PMID: 26382579 DOI: 10.3109/14397595.2015.1081338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Recent advances in medication choices have strikingly improved the management of rheumatoid arthritis. However, medication alone cannot place back already deformed joints. Thus, to prevent metacarpophalangeal (MP) joint destruction, joint deformity correction should be considered since mechanical stress induced by finger motions will eventually destruct the undestructed joint, with a possibility of recurrence and future implant arthroplasty in mind since RA still remains as a progressive disease. We report a modified metacarpal shortening osteotomy for correcting MP joint deformity. The advantage of our technique over previous osteotomies is that it easily allows for subsequent implant arthroplasty even after the recurrence of joint deformity/destruction. Major modifications include that the metacarpal is shortened at its mid-shaft and the osteotomy is performed vertical to the shaft and fixed with surgical wiring. We believe that combination therapy consisting of medication and surgery is preferable to prevent joint destruction, even in this age of biological agents.
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Affiliation(s)
- Kensuke Ochi
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and.,b Department of Orthopaedic Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Yu Sakuma
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Osamu Ishida
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Koichiro Yano
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Shinji Yoshida
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Takuma Koyama
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Mina Ishibashi
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Katsunori Ikari
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
| | - Shigeki Momohara
- a Department of Orthopaedic Surgery , Institute of Rheumatology, Tokyo Women's Medical University , Tokyo , Japan and
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Matsubara S, Motomiya M, Iwasaki N. Extensor tendon dislocation after end-to-side transfer in a rheumatoid patient. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2014; 19:119-22. [PMID: 24641754 DOI: 10.1142/s0218810414720083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a case of extensor tendon dislocation at the metacarpophalangeal joint of the middle finger in which it appeared that an ulnar translation force created by an end-to-side transfer contributed to the dislocation. We recommend alterations in technique or alternative method of extensor tendon reconstruction to avoid this complication if unfavorable factors for end-to-side transfer exist.
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Affiliation(s)
- Shinji Matsubara
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo 060-8638, Japan
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Joyce TJ. Currently available metacarpophalangeal prostheses: their designs and prospective considerations. Expert Rev Med Devices 2014; 1:193-204. [PMID: 16293040 DOI: 10.1586/17434440.1.2.193] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although implanted for over 40 years, finger prostheses have failed to match the success achieved by artificial hip and knee prostheses, despite a myriad of designs having been proposed and implanted. This article looks at the currently available designs of metacarpophalangeal prosthesis, both single-piece and multicomponent implants. An appraisal of their designs and the clinical results, where available, are provided. The review also considers the challenges that are still faced by bioengineers and surgeons concerned with improving the success of metacarpophalangeal prostheses. In addition, key current areas of concern such as in vitro testing and contemporary issues in rheumatology, which may be diminishing the amount of metacarpophalangeal arthroplasty taking place, are discussed.
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Affiliation(s)
- Thomas J Joyce
- National University of Ireland, Department of Mechanical and Biomedical Engineering, Nun's Island, Galway, Ireland.
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Pettersson K, Wagnsjö P, Hulin E. NeuFlex compared with Sutter prostheses: A blind, prospective, randomised comparison of Silastic metacarpophalangeal joint prostheses. ACTA ACUST UNITED AC 2009; 40:284-90. [PMID: 17065118 DOI: 10.1080/02844310600940612] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Forty patients (156 metacarpophalangeal joints) with mutilating rheumatoid arthritis were randomly allocated in a blinded manner to have either NeuFlex or Sutter implants. Indications for operation were pain and severe deformity. Thirty-nine patients were followed up postoperatively for one year. An independent physiotherapist and occupational therapist examined each one. Grip strength, range of motion, and pain during activity and at rest were measured. The Canadian Occupational Performance Measure (COPM) assessed the patients' evaluation of their occupational performance. Both groups had overall good results, but it seems that though patients' mobility and grip strength improve considerably, pain seems to do so only relatively. Most patients seem to be satisfied with the operation and their functional gain. Five out of 78 Sutter and two out of 78 NeuFlex implants broke. We found no major differences between the two designs, but the patients in the NeuFlex group seemed to be more satisfied with their occupational performance (COPM performance) (p=0.05).
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Affiliation(s)
- Kurt Pettersson
- Department of Hand Surgery, Orebro University Hospital, Orebro, Sweden.
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Ghattas L, Mascella F, Pomponio G. Hand surgery in rheumatoid arthritis: state of the art and suggestions for research. Rheumatology (Oxford) 2005; 44:834-45. [PMID: 15797979 DOI: 10.1093/rheumatology/keh608] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The role of surgery in the clinical management of patients with rheumatoid arthritis (RA)-associated hand dysfunction is still a subject of controversy. The efficacy of surgery in RA-associated hand dysfunction is assessed through an exhaustive review of published studies. METHODS A high-sensitivity search strategy was used to identify in MedLine and CENTRAL original studies related to hand and wrist surgery in RA patients. We selected articles including at least two adult RA patients which evaluated clinical outcomes through an observational or experimental design. Eligible studies were evaluated by standardized criteria. Two investigators independently used a pre-defined form to extract data about patient population, intervention, follow-up and clinical outcomes. Disagreements were discussed and resolved. RESULTS One hundred and ninety-six papers met inclusion criteria. Only five were randomized trials, while most studies followed an observational design, often of poor quality. As such, we could not pool data for statistical analysis; however, we were still able to provide a best evidence synthesis. A positive trend suggesting the efficacy of total carpal arthrodesis and metacarpophalangeal arthroplasty in reducing pain and improving function seemed to emerge from the published studies. CONCLUSIONS Despite recent advances in medical treatment, surgery still plays a role in the clinical management of RA-associated hand dysfunction. However, the majority of the available studies showed methodological flaws that prevented a clear definition of both surgical indications and criteria for choosing any specific procedure. Suggestions for further investigations are also provided.
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Affiliation(s)
- L Ghattas
- Istituto di Clinica Medica, Ematologia ed Immunologia Clinica, Università di Ancona, Via Conca, 1 60020, Italy.
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