Tendon Grafting for Multiple Extensor Tendon Ruptures of Fingers in Rheumatoid Hands

Abstract

We assessed the outcome of tendon grafting of multiple finger extensor tendon ruptures in 14 patients with rheumatoid arthritis. Extensor lags improved from a preoperative mean of 33 degrees (range, 20 degrees-65 degrees) to a postoperative mean of 18 degrees (range, 0-60 degrees). However, loss of finger flexion was observed, with a mean postoperative fingertip to palm distance of 1.6 (range: 0-7.5) cm. Patient satisfaction correlated with the fingertip to palm distance, though not with the postoperative extensor lag. Because of the loss of finger flexion which was probably due to muscle contracture, we conclude that the results of tendon grafts in this situation are unsatisfactory.

The prevalence of the extensor indicis tendon and its variants: a systematic review and meta-analysis

“…It is also the commonest tendon transfer to restore thumb extension after loss of EPL function [30]. In addition, the EIP tendon offers surgical possibilities to treat ulnar deviation of the fingers and tendon ruptures in patients with rheumatoid arthritis [9,11,27]. During an EI transfer to EPL, a careful identification of an existing EPI is crucial otherwise a separate extension of the thumb will be impossible [14].…”

Tendon Transfers in the Rheumatoid Hand for Reconstruction

“…If the proximal unit shows less than 2 cm of tendon excursion intraoperatively or the rupture is more chronic in nature, irreversible contracture and adhesion formation should be assumed and grafting should be avoided. 10,11 However, this study included only 2 patients with rheumatoid arthritis and it may not be possible to generalize the results to the rheumatoid population. 10 Transfer of the abductor pollicis longus (APL) has been described for EPL ruptures in rheumatoid patients.…”

“…8,20 IP joints can be kept free to allow for gentle range of motion immediately after surgery. 8,11,25 Typically, after a period of 3 to 4 weeks, a passive motion protocol is initiated, which is advanced to active motion and eventually slight resistance exercises by 6 weeks. 5,8,11,20 Dynamic extension splinting is another option applied at 3 weeks, used to slowly increase thumb flexion while protecting the transfer for 3 to 4 weeks.…”

Options in extensor tendon reconstruction in rheumatoid arthritis

“…If muscle fibrosis with limited contractility is already present and tension is too high but the extensibility of the fingers is good, functional deficit may result due to loss of finger flexion. Nakamura [19] therefore recommends that tendon grafting should not be performed if there is a contractile proximal muscletendon unit and reduced passive excursion of less than 2 cm becomes apparent intraoperatively.…”

“…Since atrophy and muscle fibrosis sets in after retraction due to the temporary disuse of the muscle, the time to graft reconstruction should not exceed 12-20 weeks after rupture has occurred [18,19]. Nakamura and Katsuki [19] therefore recommends that contractility be assessed intraoperatively prior to reconstruction and that the idea of tendon grafting should be abandoned if there is a passive excursion of less than 2 cm. If a decision is taken to graft despite inadequate excursion and the patient's reduced functional requirements, the graft should not be woven into the ulnar finger rays under too much tension because this may lead to loss of fist closure.…”