· relief of pain
· improvement of function
· correction of deformity
· control of local disease activity
· synovectomy and capsulorrhaphy
· tendon repair and reconstruction
Synovectomy
· role controversial
· decreases pain
· probably retards progression of disease
· esp. in small joints (? also in carpus)
· indicated if no response of synovitis to 6 mths of medical treatment
· arthrodesis
· arthroplasty
· preventative
· prevent joint destruction and deformity by control of disease
· maintenance
· sustain function and relieve pain
· reconstructive
· restore function in joints destroyed by disease
· is a systemic disease
· anaemia
· corticosteroids
· osteoporosis
· optimally control disease medically prior to surgery
· multiple small procedures better than major procedure
· tailor treatment programme for each patient
· function most important - do not compromise for correction of deformity
· mechanical block from synovial proliferation
· adhesions from inflammation
· palpable hypertrophied synovium in palm and fingers
· palpable palmar crepitus on finger movement
· greater passive than active flexion
· by synovectomy
Palm
· palmar sheaths exposed through distal transvserse incision
· tendons cleared proximally to lumbrical origin
· cleared distally by traction on tendon
Fingers
· digital sheaths exposed through Brunner incision
· A2 and A4 pulleys preserved
Postoperative
· early mobilisation
· inability to extend digit from flexed position
· due to trapping of nodule proximal to A1 pulley
· reproduction of triggering
· palpable nodule
· transverse incision at distal palmar crease
· A1 pulley opened longitudinally
· ? opening of pulley may predispose to ulnar drift
· tendon pared
· adequacy of decompression confirmed
· uncommon
· most common is FPL
· invasion by synovium
· avascularity of tendon
· attrition from spike on carpal bone
· FPL from scaphoid spike
· Mannerfelt lesion
· inability to flex finger
· exposure of carpal tunnel and distal palm
· division of TCL
· synovectomy performed
· bony spicule removed
FPL
· direct repair usually not possible
· options are
1. bridge graft
· palmaris longus
· slip of FCR
2. tendon transfer
· sublimus transfer
FDP
· in palm and wrist
· suture to adjacent intact tendon
· in finger
· fuse DIP jt
FDS
· no functional loss
FDP and FDS
· options depend on state of hand
· staged graft of FDP
· fusion of PIP and DIP jts
Postoperative
· immobilisation for 3 weeks in position of function
· gradual ROM for 3 weeks
· compression of median nerve secondary to synovitis of flexor tendons
· pain and parasthesiae from median nerve compression
· thenar weakness and wasting from recurrent branch compression
· carpal tunnel release
· flexor synovectomy
· extensor tendon synovitis
· diffuse boggy swelling on dorsum of wrist
· often associated with wrist joint disease
· synovectomy
· straight dorsal incision
· dorsal veins preserved if possible
· extensor retinaculum detached
· commenced ulnarly over tendon of ECU
· reflected radially as compartments sequentially opened
· 1st compartment does not need to be exposed
· synovectomy of tendons
· distal 3/4 of detached extensor retinaculum passed under tendons
· leaves them decompressed
· protects them from subsequent wrist joint synovitis
· proximal 1/4 of extensor retinaculum passed over tendons
· to prevent bowstringing
· sutured medially
· attrition from spike on distal ulna
· little and ring extensors
· attrition from Lister’s tubercle
· EPL
· synovial invasion
· most common in little finger
· attrition on bony spicule of distal ulna
· called Vaughn-Jackson lesion
· usually radial progression of rupture (ring then middle)
· presents as dropped finger
· may not be obvious due to other deformities
· other causes of dropped finger
1. extensor tendon dislocation
· tendons lie in interMC furrows
· lie volar to axis of motion and become flexors
2. MCP joint dislocation
· fingers flexed and ulnarly deviated
· tendon visible / palpable
3. posterior interosseous nerve palsy
· due to compression from synovitis at elbow
· other fingers can extend
· tenodesis effect of MCP extension on wrist flexion preserved
Fingers
· synovectomy as above
· removal of bony spicules from end of ulna
· end-to-end repair seldom feasible
· tendon transfer performed
1. one tendon (V)
· side-to-side anastomosis to ring extensor tendon
2. two tendons (V, IV)
· tendon transfer of EIP
3. three tendons (V, IV, III)
· tendon transfer of FDS IV
· passed through interosseous membrane
Thumb
· treated with transfer of EIP
Postoperative
· protect for 6 weeks in extensor assist splint
· ulnar displacement of tendon
· moves tendon volar to axis of MCP jt
· become flexors
· occurs with ulnar drift of MCP jts in association with MCP synovitis
· dorsal hood of extensor weakened
· usually ring and little
· causes dropped fingers
· is treatment of MCP disease
· deformity is
· dorsal subluxation of distal ulna
· volar subluxation of ulnar carpus
· supination of carpus on wrist
· radial deviation of carpus
· synovitis leads to destruction of
· ulnar carpal ligamentous complex
· TFCC
· results in caput ulna syndrome
· dorsal dislocation of distal ulna
· volar subluxation of ulnar carpus
· supination of carpus on wrist
· volar subluxation of ECU
· subluxation of ECU leads to radial deviation
· radial extensors overpower ECU
· begins beneath radioscaphocapitate ligament
· leads to rotatory instability of scaphoid
· results in
· volarflexion of scaphoid
· scapholunate dislocation
· loss of radial carpal height
· radial rotation of carpus
Indications
· painful synovitis not responding to medical treatment
· minimal radiographic changes
Technique
· approach as for extensor synovectomy
· tendons retracted
· distally based capsular flap raised
· radiocarpal and intercarpal joints exposed
· DRUJ exposed through longitudinal incision
Indications
· caput ulna syndrome
· radiocarpal joint functional and stable
Technique
· may consider reconstruction (Sauve-Kapandji) for younger patients
· usually resect distal ulna
· silastic implants no longer used
Darrach resection
· distal ulna exposed through longitudinal capsular incision
· capsule and TFCC reflected and preserved
· 2 cm of distal ulna resected
· synovectomy of DRUJ
· distal ulna stabilised with remaining capsule
· may use strip of ECU
Sauve-Kapandji reconstruction
· syn. Lauenstein procedure
· principles
· arthrodesis of DRUJ
· proximal pseudarthrosis to maintain reduction
· dorsoulnar approach to DRUJ
· hole for transverse screw predrilled in ulna
· proximal pseudarthrosis created
· transverse osteotomy 1 cm proximal to ulnar styloid
· 1 cm ulnar segment excised
· synovectomy and excision of DRUJ
· radius drilled with ulna in desired position
· transverse lag screw inserted
· pseudarthrosis filled with adjacent muscle
Indications
· wrist deformity or instability
· significant pain or loss of function
· functional ROM
· adequate bone stock
· functioning wrist extensors
· low to moderate demands
Advantages
· over arthrodesis
· preservation of motion (albeit small)
Disadvantages
· failure of implant
Postoperative
· active wrist extension splint
Indications
· stiff wrist
· poor bone stock
· no functioning wrist extensors
· high demands (eg walking aids)
Technique
· Mannerfelt fusion
· Steinmann pin along 3rd MC
· dorsal approach as for synovectomy
· remaining bone denuded
· medullary canal of radius perforated
· dorsal longitudinal incision over 3rd MT
· extensor expansion split
· medullary canal of MC head perforated
· Steinmann pin driven down 3rd MC shaft across carpus and into radius
· end countersunk
Position
· wrist fused in neutral with this technique
· aim for slight dorsiflexion (position of function)
· if bilateral
· dominant hand in slight dorsiflexion
· nondominant hand in slight palmarflexion (for hygiene)
· consider arthroplasty in less affected side
Postoperative
· short arm cast for 6 weeks