Current Concepts in the Surgical Management of Rheumatoid and Osteoarthritic Hands and Wrists

Abstract

Rheumatoid arthritis (RA) is a progressively destructive disease. Gradual loss of hand function in RA patients affects their ability for self-care and interferes with their productivity in society. The continuing improvement in the medical management of RA has markedly decreased the incidence of RA hand surgery. In contrast to RA, osteoarthritis (OA) has less inflammatory reaction in the joints and is characterized by degradation of cartilage, resulting in joint destruction and osteophyte formation. The initial treatment of OA is medication and therapy. Steroid injection into affected joints can provide short-term relief, though repeat injections carry a cumulative risk of weakening the soft tissue. In this article the authors share their extensive experience in RA and OA hand surgery to provide a clear discussion of the indications and outcomes of its practice.

Concepts in Ulnar Drift Deformity

“…Pannus, a membrane of fi brovascular tissue, develops at the site of synovial bony attachments and advances over the articular surface [ 4 ]. This highly vascularized tissue releases infl ammatory cytokines, lysosomal enzymes, and free radicals that lead to degeneration of the hyaline cartilage [ 23 ]. Proliferation of pannus leads to erosion and softening of the metacarpal and proximal phalanx [ 4 ].…”

“…Unfortunately, there is a lack of robust evidence on the effectiveness of surgical interventions to address ulnar drift [ 23 ]. Furthermore, there are differing opinions between hand surgeons and rheumatologists regarding the appropriateness and timing of surgery [ 28 -30 ].…”

“…Intrinsic muscle contracture is clinically apparent when there is restricted fl exion at the proximal interphalangeal joint while the MCP is passively held in extension. The abductor digiti minimi may be divided to remove the ulnar force on the small fi nger [ 23 ].…”

Terapia ocupacional na artrite reumatoide: o que o reumatologista precisa saber?

“…36,37 Essa abordagem foi primeiramente descrita em 1965, 38 por meio da análise dos acometimentos motores motivados pelo processo inflamatório comum à AR e sua combinação com princípios biomecânicos, voltados para minimizar a atuação de forças que favoreciam o desenvolvimento de desvios e deformidades articulares durante a feitura de tarefas cotidianas, 39 como a hiperextensão da articulação metacarpofalangeanas do I dedo, o desvio ulnar das articulaç ões metacarpofalangeanas do II ao V dedo e instalação de padrões de deformidades, como pescoço de cisne, dedo em martelo ou botoeira, pelo acometimento das articulaç ões interfalangeanas distais. 40 Devido à importância e à constância necessárias para o desempenho das AVDs, modificaç ões na forma de feitura dessas permitem importante redução do estresse articular e do gasto energético, facilitam ou viabilizam a participação do paciente em ocupaç ões significativas. 36,37 A tabela 2 ilustra as principais orientaç ões dos conceitos de proteção articular e conservação de energia.…”

Applying Evidence in the Care of Patients with Rheumatoid Hand and Wrist Deformities

“…It is worth noting that the presence of a deformity is not an absolute indication for surgery, as many patients with hand deformities may still retain reasonable hand function. 14 …”