Surgery in patients with systemic sclerosis of the hand

Microangiopathy in Inflammatory Diseases-Strategies in Surgery of the Lower Extremity

BACKGROUND

Patients with an inflammatory disease frequently develop chronic angiopathy of the capillaries. Due to this pathology, there is an increased rate of complications in lower extremity surgical procedures. It is not uncommon for microangiopathic wound healing disorders to cause deep infections and fistulas, which lead to prolonged courses and hospitalizations. In addition, adhesions and ossifications of the contractile elements occur regularly. This sometimes results in serious limitations of the mobility of the patients. The study aims to present the results of a combination of vacuum and physical therapy.

PATIENT AND METHODS

A retrospective study of six patients with systemic sclerosis undergoing joint-related procedures of the lower extremity between 2015 and 2020 was performed. In addition to characterization of the patients and therapy, special attention was paid to cutaneous wound healing, affection of the fascia and displacement layers, and sclerosis of the muscle and tendon insertion.

RESULTS

The characterized structures (skin, tendon, fascia) show pathological changes at the microangiopathic level, which are associated with delayed healing and less physical capacity. Early suture removal regularly results in secondary scar dehiscence. With a stage-adapted vacuum therapy with sanitation of the deep structures and later on a dermal vacuum system, healing with simultaneous mobilization of the patients could be achieved in our patient cohort.

CONCLUSION

In the case of necessary interventions on the lower extremity, such as trauma surgery, additional decongestive measures in the sense of regular and sustained lymphatic therapy and adapted physiotherapy are indispensable.

Scleroderma of the Hand: Evaluation and Treatment

Scleroderma is derived from Latin meaning hard skin. It is an uncommon, noninflammatory connective tissue disorder characterized by increased fibrosis of the skin and in certain variants, multiple other organ systems. Scleroderma involves a spectrum of pathologic changes and anatomic involvement. It can be divided into localized and systemic scleroderma. Hand involvement is common and can include calcium deposits within the soft tissues, digital ischemia, and joint contracture. Nonsurgical management consists of lifestyle modifications, biofeedback, therapy for digital stiffness/contracture, and various pharmacologic medications. When nonsurgical measures are unsuccessful, certain surgical options may be indicated, each with their inherent advantages and pitfalls. Patients with scleroderma who are undergoing surgical intervention pose unique difficulties because of their poorly vascularized tissue and deficient soft-tissue envelopes, thus increasing their susceptibility to wound healing complications and infection. Some subgroups of patients are frequently systemically ill, and specific perioperative measures should be considered to reduce their surgical risk. The spectrum of hand manifestations seen in patients with scleroderma will be reviewed with the focus on evaluation and management.

Articular Surgery of the Ischemic Hand in Systemic Scleroderma: A Vascular Basis for Arthrodesis and Arthroplasty

Hallmark deformities of systemic scleroderma are early onset and progressively disabling flexion contractures of the proximal interphalangeal (PIP) joints often in conjunction with extension or, less frequently, flexion contractures of the metacarpophalangeal (MCP) joints. Although surgical correction is generally recommended, a prevailing reluctance for operative treatment exists owing to the inherent ischemia of the disease with its potentially compromised healing capacity. Nonetheless, with recognition and preservation of the tenuous but well-defined and constant periarticular vascular networks of the PIP and MCP joints, articular reconstruction with uncomplicated wound healing can prove consistently successful for patients with scleroderma. This article describes the authors' preferred methods of PIP arthrodesis vascularized by the dorsal cutaneous arterial network and MCP silicone implant arthroplasty perfused by the dorsal metacarpal arterial plexus.

Systemic scleroderma: An approach from plastic surgery

Introducción. La esclerosis sistémica (ES) es una enfermedad autoinmune del tejido conectivo que se caracteriza clínicamente por un engrosamiento cutáneo, el cual se da debido a la acumulación de tejido conectivo y puede afectar a otros órganos y a las extremidades. La etiología multifactorial de esta enfermedad corresponde a la interacción de alteraciones en el remodelamiento de la matriz extracelular, función inmunitaria y presencia de vasculopatía proliferativa bajo influencia genética y medioambiental.Objetivo. Realizar una revisión sobre el manejo médico y quirúrgico desde el punto de vista de la cirugía plástica de las lesiones en piel y manos y las alteraciones faciales de los pacientes con ES.Materiales y métodos. Se realizó una búsqueda bibliográfica en las bases de datos Medline, LILACS, PubMed, EMBASE y Current contents con las palabras claves esclerodermia sistémica, cirugía plástica, mano y ulceras.Resultados. La ES requiere manejo multidisciplinario; se presentan casos en los que se indica terapia farmacológica y otros en los que el manejo es quirúrgico complementario.Conclusión. Esta patología afecta de manera importante la piel al provocar lesiones que van desde ulceras digitales hasta atrofia facial, las cuales son susceptibles de manejo por el área de cirugía plástica.

Surgery of the Hand in Severe Systemic Sclerosis

Ten patients with scleroderma and severe hand problems required surgery, and seven were available for follow-up (two died from scleroderma-related complications and one was lost to follow-up). The mean duration of follow-up was 4 (range 1.5–9) years. Thirty-three procedures were carried out, including five metacarpophalangeal joint exisional arthroplasties, 13 proximal interphalangeal joint fusions, ten distal interphalangeal joint fusions, and one thumb interphalangeal joint fusion. The metacarpophalangeal joint excision arthroplasties and proximal interphalangeal joint fusions were performed for the correction of severe fixed “finger-in-palm” deformities. Lesions of cutaneous calcinosis were removed in four patients.

Fixation was satisfactory in all cases of interphalangeal joint fusion, with no cases of non-union. Wound healing was satisfactory in six of seven patients. A second surgical procedure was required in three patients for the removal of tension band wires following interphalangeal fusion. Calcinosis was effectively removed using a high-speed dental burr. The results of hand surgery for systemic sclerosis are reliable, but goals must be limited and patient expectations should be modest.

The short-term effect of gloving in combination with Traditional Thai Massage, heat, and stretching exercise to improve hand mobility in scleroderma patients

BACKGROUND

Systemic sclerosis (SSc) is a chronic, multisystem connective tissue disorder characterized by autoimmune activation, microvascular endothelium damage, and excessive collagen proliferation. The most affected hand presents claw hand deformity and microvascular disease. Deformed hands can cause functional disability and decrease the quality of life. A daily home program can improve mobility of scleroderma patients.

OBJECTIVE

We sought to determine the effect of a daily home exercise program on hand mobility among scleroderma patients.

MATERIALS AND METHODS

This was a randomized control trial. Twenty-eight participants were divided into two groups, both of which received the same daily home treatment: Group 1 with gloves (n = 14) and Group 2 without gloves (n = 14). The 2-week daily home program combined traditional Thai massage (TTM) with stretching exercises and heat. Hand mobility was assessed using hand mobility in scleroderma (HAMIS). The study was conducted in patients who were already on vasodilator drugs.

RESULTS

Both groups showed a significant improvement in hand mobility after 2 weeks of daily home exercise program (P < 0.05). Wearing the glove, however, resulted in better thumb mobility.

CONCLUSIONS

A daily home exercise program improved hand mobility among patients with scleroderma and wearing gloves may improve thumb mobility.

Surgical management of digital calcinosis in CREST syndrome

As a limited form of sclerodermy, CREST syndrome is characterized by calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia, which determine the acronym CREST. Calcinosis is a particularly difficult entity to treat given the paucity of effective options described in the literature. Treatment of finger calcinosis has a wide range of possibilities depending on the extent of calcifications and the involvement of deep structures. From a surgical point of view, whereas simple removal is adequate in minor outpatient cases, a radical debridement in the major and more painful cases seems required. A cover flap is needed particularly in the thumb due to its great functional importance, also if the fingertip is not involved. The authors recommend the kite flap for the dimensions, the tissue quality, and the possibility of giving sensation to the reconstructed area. With this surgical option, the transferred skin is soft, sensate, and the right fit. Usually, no further operations are needed for flap remodeling. The time required for sensory integration is about 2 years, often related to the age of the patient. Debridement and flap reconstruction usually give total resolution of pain, with complete recovery of thumb motion and the thumb-index finger grip.

Hemiarthroplasty in a patient with severe systemic sclerosis

Systemic sclerosis (scleroderma) is a connective tissue disorder of unknown etiology. This rare, chronic, multisystem disorder encompasses a number of variations leading to focal and systemic classifications, which includes features such as skin thickening. The changes within the skin microstructure have led to numerous surgical complications. In a review of the orthopedic literature, we found no reports describing surgical outcomes or the success of skin closures in procedures related to the hip for patients with scleroderma. We present a case of a 74-year-old man with a history of scleroderma who underwent a bipolar hemiarthroplasty to repair a right transcervical femoral neck fracture. The risk factors associated with wound healing and effects of skin contractures in systemic sclerosis patients are reviewed.

Reconstructive hand surgery for scleroderma joint contractures

Systemic scleroderma can cause significant hand deformity and functional impairment. Surgery is often avoided due to the perceived risks of wound healing. The most common surgical procedures have been digital sympathectomy, arthrodesis or arthroplasty of the proximal interphalangeal (PIP) or both, and metacarpophalangeal (MCP) joints. We describe herein successful soft tissue hand surgery in 2 patients for treatment of scleroderma claw deformities without the use of arthrodesis or arthroplasty. At the MCP joint, the tight capsules were excised, and the collateral ligaments and volar plates were released. At the PIP joints, the volar plates were released and the tight palmar skin was released, resulting in marked improvement of joint position. Intensive hand therapy was used to maximize function. In these 2 patients with claw deformity, we found that tight volar skin was the main contributor to flexion contracture at the PIP level. In contrast, joint capsule contracture was the main contributor to hyperextension deformity at the MCP level.

Wound healing after hand surgery in patients with systemic sclerosis--a retrospective analysis of 41 operations in 19 patients

This retrospective study evaluates the results of 41 consecutive hand and forearm operations in 19 patients with systemic sclerosis performed between 1985 and 2000. The mean age of the patients was 50 (14-84) years. Twenty-seven operations were elective and 14 were acute, carried out for skin breakdown and/or skin necrosis. One minor wound healing problem occurred in the elective group. In the acute group, seven of 14 operations healed uneventfully. Four patients had necrosis/infections after surgery, which required further surgery. Two patients had repeated wound infections. Another patient only healed after he stopped smoking. In systemic sclerosis, surgery performed electively does not seem to have increased difficulty with wound healing. Even larger operations, such as wrist arthrodesis or wrist replacement, can be performed safely. In acute cases with spontaneous skin breakdown and/or necrosis and/or critically ischaemic fingers, wound healing is more precarious and several procedures may be necessary to achieve skin healing.

Current treatment options in systemic Sclerosis (Scleroderma)

Systemic Sclerosis (SSc) or Scleroderma is a generalized autoimmune disease with variable involvement of the skin and major organs. Etiology and pathogenesis are still largely unknown, but a variety of humoral and cellular autoimmune phenomena can be observed, and a pivotal role of T lymphocytes in SSc pathogenesis is postulated. The rarity of the disease, the wide spectrum of clinical manifestations and severity as well as a variable course render therapy in SSc a major challenge. In view of the immunopathogenesis of SSc, many (presumed) immunomodulatory agents have been used, but no single agent has been proven to be convincingly effective. Trials with extracorporeal therapies (such as photopheresis, plasmapheresis) or even stem cell transplantation are in progress. In contrast to the hitherto unsuccessful therapeutic approaches for the overall disease course, some life-threatening organ manifestations can often be treated successfully, e.g. interstitial pneumonitis with i.v. cyclophosphamide and scleroderma renal crisis with ACE inhibitors and haemodialysis, respectively. Furthermore, pharmacological and supportive treatment of Raynaud's phenomenon and gastrointestinal involvement can alleviate the burden of the disease. Current therapeutic options as well as hitherto investigated immunomodulators are reviewed in this article.