Number of Ruptured Tendons and Surgical Delay as Prognostic Factors for the Surgical Repair of Extensor Tendon Ruptures in the Rheumatoid Wrist

Treatment for complete extensor tendon rupture: A case report on extensor pollicis longus tendon transfer and tenodesis procedure to radius for a patient with rheumatoid arthritis

The complete loss of finger extension leads to significant inconvenience in daily life and often requires surgical treatment. Despite some disadvantages, the Boyes method, which uses the flexor digitorum superficialis tendon, is commonly performed for complete extensor rupture. We report the case of a 73-year-old woman living alone diagnosed with a subcutaneous rupture of all extensor tendons from the index to the little finger. The favourable range of motion of her wrist allowed us to perform extensor tenodesis. Additionally, the patient had a dislocated thumb interphalangeal (IP) joint, enabling us to use the extensor pollicis longus tendon for tendon transfer in combination with thumb IP joint fusion. The patient demonstrated favourable finger range-of-motion outcomes at the 6-month postoperative assessment. The case shows that extensor pollicis longus tendon transfer and tenodesis may be a viable treatment option for patients with complete extensor rupture accompanied by thumb IP joint deformity and normal wrist range of motion.

Radiographic study of the distal ulna in rheumatoid arthritis with extensor digitorum communis ruptures

OBJECTIVES

Extensor digitorum communis (EDC) rupture of the wrist often occurs in patients with rheumatoid arthritis (RA). Early operation is desirable for patients with a high risk of rupture; therefore, rheumatologists should diagnose it during daily examinations. This study aimed to clarify radiographic changes in the distal ulna and related factors associated with EDC rupture in patients with RA.

METHODS

We analysed plain radiographs of 40 patients with RA associated with EDC rupture and 62 healthy controls. We investigated the deformation of the distal ulna, Larsen grades, and radiological parameters such as ulnar variance (UV), ulnar bowing angle, dorsal protrusion (DP), and dorsal bowing angle.

RESULTS

The ratios of the ulna head deformation, Larsen grades, UV, DP, and dorsal bowing angle were significantly larger in the ruptured group than in the control group. Multiple logistic regression analysis revealed that DP and Larsen grades were significantly associated with EDC rupture.

CONCLUSIONS

Deformity of the distal ulna is evident in patients with an EDC rupture. Ulnar head deformation, high Larsen grades, and large DP are the potential risk factors for EDC rupture.

Modified Boyes' procedure for the multiple finger extensor tendon ruptures in patients with rheumatoid arthritis: A report of two cases

Multiple subcutaneous extensor tendon ruptures in more than the ulnar three fingers sometimes occur in patients with rheumatoid arthritis accompanied by wrist deformity. In these situations, the flexor digitorum superficialis tendon of the middle finger (the FDS3 tendon) and that of the ring finger (the FDS4 tendon) are used for the transferred tendon (modified Boyes' procedure). Here, we treated two patients with rheumatoid arthritis, whose extensor tendons of more than three fingers were ruptured, using the modified Boyes' procedure. Case 1 had ruptures in four fingers (index through little), and Case 2 had ruptures in three fingers (middle through little). The FDS3 and FDS4 tendons were passed subcutaneously around the radial side of the wrist to the extensor sides and interlaced with the distal stump of the ruptured tendons. Switching of the finger movement was achieved smoothly in both cases. The post-operative evaluation showed an extension lag of -15° for the index finger 0° for the middle through the little fingers in Case 1, and 0° for the middle finger and -5° for the ring and little fingers in Case 2. The average post-operative extension lag was -3.5°. However, median nerve palsy occurred in both cases, and it gradually recovered. Stretching of the nerve by the correction of the wrist deformity and increased pressure in the carpal tunnel were supposed to be causes of this palsy. Modified Boyes' procedure is a useful method for more than three ulnar finger extensor tendon ruptures; however, post-operative median nerve palsy should be considered.

Long-term clinical outcome of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands

Purpose

To evaluate the objective and subjective long-term clinical outcomes of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands.

Methods

We evaluated the long-term clinical outcomes of tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands of 37 patients (43 hands) followed up for a mean of 14 years (range, 10–21 years).

Results

The mean time from rupture to surgery was 13.1 weeks (range, 3–48 weeks). The mean extension lag of the metacarpophalangeal joint was 8.7° (range, 0–40°), the mean pulp-to-palm distance was 0.4 cm (range, 0–3 cm), and the mean overall satisfaction rate was 86.5 (range, 70–100). There were no significant differences in clinical outcomes between tendon transfers and tendon grafts. There was a significant correlation between extension lag of the metacarpophalangeal joint and overall satisfaction rate (R² = 0.155; p = 0.009). Time to surgery was significantly correlated with extension lag of the metacarpophalangeal joint (R² = 0.437; p = 0.001) in the tendon graft group.

Conclusions

Both tendon transfer and tendon graft for extensor tendon ruptures in rheumatoid hands achieve satisfactory results that are maintained for an average of 14 years. In cases of tendon graft, the time to surgery should be considered, and there is concern over extension lag of MP joint.

Level of Evidence

IV

Changes in tendon length and excursion following extensor tendon grafting at the distal radioulnar joint

IV.

Risk factors for rupture of extensor tendons in the rheumatoid wrist

This study assessed the risk factors for spontaneous extensor tendon rupture in the rheumatoid wrist. The rupture group consisted of 25 wrists that had rupture of the extensor tendons and later received tendon reconstruction. The non-rupture group included 77 rheumatoid wrists without extensor tendon rupture. We assessed patients' pain at the distal radioulnar joint and swelling in the extensor tendon compartments clinically, matrix metalloproteinase-3 level in blood samples, and radiographic findings. We found that swelling in the extensor tendon compartments, the scallop sign, and severe dorsal subluxation are significantly associated with spontaneous extensor tendon rupture, but serum matrix metalloproteinase-3 level is not.Level of evidence: IV.

Extensor tendon ruptures in rheumatoid wrists

Background and aims

Rheumatoid arthritis is a chronic inflammatory disease. The associated involvement of hands and tendons is over 90% and impairs overall function. In the course of the disease, the joints are often operated on. During this operation, ruptures of the extensor tendons are found by chance without the patients noticing them. The aim of this retrospective study is the prevalence of extensor tendon rupture. Which tendon is destroyed most frequently? How can the functional outcome be measured after reconstruction?

Materials and methods

From 1572 operations on rheumatoid wrists, 61 extensor tendon ruptures were identified in 41 patients. The average time between the first rheumatic symptoms of the hand and surgery was 6.4 years. The average duration of RA was 7.8 years. 26 patients with 27 tendon reconstructions were included in the follow-up with an average postoperative duration of 4.6 years (3 to 14.2 years).

Results

Extensor tendons ruptures typically occurred at mechanically stressed sites. The most frequent rupture was found in the extensor pollicis longus tendon (21 tendons), followed by the small finger extensor tendon (14 tendons). A transfer was performed on 7 tendons. Fifty-five tendon lesions were sutured at other intact tendons. Free grafts were not used. The results in Clayton and QuickDASH scores were significantly different. Functional improvement was consistent with the results of tendon reconstructions in healthy control groups.

Conclusion

In rheumatoid patients, a rupture of an extensor tendon must be expected at 4%. Patients tolerate and compensate this damage for a long time. The function of the hand including the tendon function is the most important factor in assessing the success of the operation. The subjective patient acceptance depends on the progress of the underlying disease, postoperative care (ergotherapy, physiotherapy, orthosis) and the patients' demands.

Electronic supplementary material

The online version of this article (10.1007/s00590-020-02731-1) contains supplementary material, which is available to authorized users.

Reconstruction and repair of atraumatic extensor tendon ruptures in rheumatoid wrists: Less extension lag after direct repair than interposition tendon grafting

The purpose of this study was to investigate the outcomes of extensor tendon repair involving the original stump in atraumatic extensor tendon rupture of rheumatoid wrists. For this study, 16 cases were reviewed involving 14 patients with rheumatoid arthritis. A total of 52 ruptured tendons impacted 36 fingers; 51 tendons were repaired in 35 fingers. The ruptured tendon stumps were repaired either directly by end-to-end suture or by free interposition tendon graft. The 8- to 10-strand core suture method was used for direct repair with a looped 4-0 nylon suture. In all patients, the extensor retinaculum was released and repaired under the tendons. Postoperatively, a volar splint with the wrist and fingers extended was applied for 3 to 4 weeks, followed by a removable splint and gentle active flexion until 6 weeks. The mean follow-up period was 32 months. All fingers recovered active metacarpophalangeal (MCP) joint extension, including independent and active extension of the little finger. Overall, the mean extension lag at the MCP joint was 1.7°. The mean fingertip-to-palm distance with the MCP joint flexed was 0.24mm. The mean extension lag at the MCP joint was significantly greater after interposition tendon grafting (3.2°) than after direct repair (0°). There was no significant difference in the mean fingertip-to-palm distance between direct repair (0.38mm) and interposition tendon grafting (0.13mm). No re-rupture or additional extensor tendon rupture was observed. Repair of the original extensor tendon stump yields satisfactory outcomes and appears to be a viable alternative to tendon transfers in patients with rheumatoid wrists with atraumatic extensor tendon ruptures. Direct repair reduces postoperative extension lag without a significant difference in flexion deficit when compared with interposition tendon grafting.

Clinical Results of Autogenous Palmaris Longus Tendon Graft for Ruptures of Multiple Extensors in Rheumatoid Hands

PURPOSE

The purpose of this study was to evaluate the clinical outcome of autogenous palmaris longus grafting for extensor tendon ruptures of 2 or more fingers in rheumatoid hands and to identify the factors related to the clinical outcome.

METHODS

Between 2000 and 2013, a total 41 patients with advanced rheumatoid arthritis and multiple extensor tendon ruptures reconstructed with autogenous palmaris longus tendon grafts were reviewed. Extension lag at the metacarpophalangeal (MCP) joint, total active motion (TAM), and fingertip-to-palm (TTP) distance were evaluated at final follow-up. Simple regression analysis was done to determine the factors predictive of clinical outcome.

RESULTS

The mean extension lag at the MCP joint of the reconstructed finger was 9° (range, 0°-90°; median, 0°). The mean TAM was 239° (range, 85°-280°; median, 260°), and the mean TTP distance was 5 mm (range, 0-50 mm; median, 0 mm). Simple regression analysis showed that only age was related to extension lag at the MCP joint and only arthritis of the MCP joint was related to TAM.

CONCLUSIONS

In rheumatoid arthritis, extensor tendon reconstruction of multiple extensor tendon ruptures using autogenous palmaris longus tendon graft is a viable option to achieve a favorable clinical result.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Tendon Transfers in the Rheumatoid Hand for Reconstruction

Long-standing rheumatoid arthritis can result in spontaneous tendon rupture caused by attrition of the tendons. Ruptures of the ulnar-sided extensor tendons, flexor pollicis longus, and the flexor digitorum profundus can be seen. Primary repair of these tendon ruptures is frequently not possible because of delayed presentation and tendon damage by the disease process. Tendon transfers are the preferred method of treatment in patients with rheumatoid arthritis. At surgery, it is critical to address the underlying cause of rupture to prevent future tendon ruptures. Rates of tendon rupture may decrease due to improved medications for rheumatoid arthritis.

Subcutaneous flexor tendon rupture in patients with rheumatoid arthritis

OBJECTIVE

We examined the clinical features and functional outcomes of surgically repaired subcutaneous flexor tendon ruptures in patients with rheumatoid arthritis (RA).

METHODS

This retrospective study included 41 fingers of 24 RA patients who underwent surgical treatment for flexor tendon ruptures. Evaluations performed at the time of presentation following rupture were C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and disease activity score in 28 joints (DAS28)-ESR, as well as Larsen grading for carpal bone destruction. The ruptured tendon and postoperative active range of motion (ROM) of digits were also examined.

RESULTS

The mean CRP was 2.4 mg/dl, ESR was 52 mm/h, and the DAS28-ESR was 4.5. Carpal bone destruction according to Larsen grade IV-V was observed in 18/24 patients. Affected digits were most commonly the thumb (12) and the ring and little fingers (9 each). Tendon ruptures were most common in the carpal tunnel in zone IV. The mean postoperative finger ROM (flexion/extension) was 38°/2° for the interphalangeal (IP) joint of the thumb and 23°/-2° for the distal interphalangeal joint of the other four fingers.

CONCLUSIONS

Patients with flexor tendon ruptures present with high disease activity and advanced bone destruction. It is important to reduce the risk of progressive bone destruction and subsequent tendon rupture via tight control of disease activity.

Association between position of the fixed ulnar head and carpal translocation after the Sauvé-Kapandji procedure in patients with rheumatoid arthritis

OBJECTIVE

The Sauvé-Kapandji procedure is a common surgical procedure for rheumatoid wrist, which involves fixing dissected ulnar head to the distal radius in order to provide "bony support" to the carpus. The purpose of this study was to investigate whether the position of the fixed ulnar head was associated with postsurgical carpus translocation.

METHODS

We retrospectively reviewed radiographs of 40 patients who underwent the Sauvé-Kapandji procedure and were subsequently followed up for over two years. The association between the fixed ulnar head position and postsurgical carpus translocation was statistically analysed with a confidence interval of 95% (p < 0.05).

RESULTS

Multiple regression analysis suggested that the radial inclination of the fixed ulnar head, the absence of increases in ulnar variance, and wide "bony support" were significantly associated with less postsurgical carpal translocation.

CONCLUSION

Our study indicated that good concordance between the "bony support" and the carpus might be important in reducing postsurgical carpus translocation.

Factors affecting extension lag after tendon reconstruction for finger extensor tendon rupture due to distal radioulnar lesion

BACKGROUND

Although extensor tendon rupture associated with distal radioulnar joint disorder is often encountered, its treatment has not yet been established. We report the postoperative results for reconstruction of finger extensor tendon rupture due to distal radioulnar lesion and analyse the factors affecting postoperative extension lag.

METHODS

We examined 74 index, middle, ring, or little fingers with extensor tendon rupture of 34 hands. Primary diseases were rheumatoid arthritis in 24 hands and osteoarthritis in 10. Reconstruction methods included tendon graft in 45 fingers, extensor indicis proprius tendon transfer in 15, and end-to-side adjacent tendon suture in 14. At final postoperative follow-up ranging from 12 to 40 (mean: 18) months, we measured metacarpophalangeal (MCP) joint range of motion and extension lag and statistically evaluated the relationship between postoperative extension lag and several clinical factors.

RESULTS

We encountered no cases of re-rupture or worsening of finger flexion range after reconstruction. Mean postoperative active flexion of the MCP joint was 78.1 (range: 45-95) degrees. Mean postoperative extension lag was 10.3 (range: 0-50) degrees. We observed that postoperative extension lag was significantly larger in fingers associated with extensor tendon rupture in two or three additional fingers in the affected hand or in fingers of patients aged 80 years or over. The interval from rupture to reconstruction, reconstruction method, or arthritis type did not remarkably affect outcome.

CONCLUSIONS

This study uncovered that surgical intervention for extensor tendon rupture should be performed before three fingers become affected.

Comparison of surgical treatments for triple extensor tendon ruptures in rheumatoid hands: A retrospective study of 48 cases

OBJECTIVE

This retrospective study was designed to evaluate the outcomes of four different surgical reconstructions for extensor tendon ruptures in ulnar three fingers in 48 patients with rheumatoid arthritis.

METHODS

The following four techniques were performed; palmaris longus tendon grafting (PL group; n = 9), extensor indicis proprius (EIP) tendon transfers (EIP group; n = 8), end-to-side transfers with tension-reduced early mobilization (End-to-side group; n = 16), and a combination of end-to-side and EIP transfers (Combination group; n = 15). Loss of extension was evaluated to determine the mean postoperative range of motion of the metacarpophalangeal (MP) joint and clinical outcomes were categorized using modified Geldmacher criteria.

RESULTS

Combination group demonstrated the best mean MP joint extension (-3°), followed by End-to-side group (-12°), EIP group (-16°), and PL group (-21°). Combination group yielded the best clinical outcomes with all cases showing good results.

CONCLUSIONS

The combination of end-to-side and EIP transfer was an effective surgical reconstruction procedure for triple fingers extension loss.