Synovitis-Driven Deformity | Tendon Rupture | Surgical Sequencing
DEFORMITY PATTERNS
Critical Must-Knows
- RA synovitis destroys ligaments, tendons and cartilage producing characteristic zig-zag deformities
- Caput ulnae = dorsal DRUJ subluxation; attrition ruptures extensor tendons (Vaughan-Jackson, Mannerfelt)
- Nalebuff classification guides thumb reconstruction: Type I (MCP), Type II (MCP+CMC), Type III (CMC), Type IV (IP)
- Surgical sequence = DIP/PIP first, then MCP, then wrist, then elbow/shoulder (distal-to-proximal)
- Medical optimisation with DMARDs is prerequisite before elective surgical intervention
Clinical Pearls
- "Vaughan-Jackson = EDM rupture from attrition over caput ulnae
- "Mannerfelt-Norman = FPL rupture over scaphoid osteophyte
- "Ulnar drift worsened by radial deviation of wrist (zig-zag collapse)
- "Surgical sequence is distal-to-proximal; wrist before MCP if both needed
Critical RA Hand and Wrist Exam Points
Pathogenesis
Synovial hypertrophy destroys stabilising ligaments and tendons. Pannus erodes articular cartilage and bone. The resulting imbalance produces the classic deformities. Medical control of synovitis is the foundation of management.
Caput Ulnae
Dorsal subluxation of the ulnar head at the DRUJ. Creates a sharp bony prominence that attritions extensor tendons, especially EDM and EDC to small and ring fingers (Vaughan-Jackson sequence). Caput ulnae sign = prominent ulnar head visible and palpable dorsally.
Tendon Ruptures
Vaughan-Jackson: Extensor ruptures from ulnar to radial (EDM, then EDC small, ring, middle) due to attrition over caput ulnae. Mannerfelt-Norman: FPL rupture from attrition over a scaphoid osteophyte or rough bone in the carpal tunnel.
Surgical Sequence
Distal-to-proximal rule: Address DIP/PIP deformities first, then MCP joints, then wrist. Exception: significant wrist disease drives MCP deformity and should be stabilised before or concurrently with MCP surgery. Proximal procedures (elbow, shoulder) are performed last.
Quick Decision Guide
| Deformity | Pathoanatomy | Non-operative | Surgical Options |
|---|---|---|---|
| MCP volar subluxation + ulnar drift | Synovitis destroys collateral ligaments and dorsal capsule; extensor tendons slip ulnarly | DMARDs, MCP splinting, intrinsic stretching | Synovectomy, crossed intrinsic transfer, silicone arthroplasty |
| Swan-neck deformity | PIP hyperextension from FDS rupture, volar plate attenuation, or intrinsic tightness | PIP extension-block splint, exercise | FDS tenodesis, lateral band relocation, PIP arthrodesis |
| Boutonniere deformity | Central slip attenuation from synovitis, lateral bands migrate volar | PIP extension splint, DMARDs | Central slip reconstruction, PIP arthrodesis |
| Extensor tendon rupture | Attrition over caput ulnae (Vaughan-Jackson) or scaphoid (Mannerfelt) | DMARDs, wrist splint to reduce attrition | Tendon transfer (EIP to EDM, side-to-side), Darrach/sauve-kapandji |
DRIFTRheumatoid Hand Deformity Sequence
| D | Dorsal synovitis Starts at wrist and MCP joints, pannus formation |
| R | Rupture risk Tendons attrite over sharp bone edges |
| I | Intrinsic contracture Intrinsic tightness drives swan-neck and MCP deformity |
| F | Flexor/extensor imbalance Ligament destruction creates zig-zag deformities |
| T | Treat medical first DMARD control of synovitis is prerequisite to surgery |
| D | Dorsal synovitis Starts at wrist and MCP joints, pannus formation | F | Flexor/extensor imbalance Ligament destruction creates zig-zag deformities |
| R | Rupture risk Tendons attrite over sharp bone edges | T | Treat medical first DMARD control of synovitis is prerequisite to surgery |
| I | Intrinsic contracture Intrinsic tightness drives swan-neck and MCP deformity |
Hook:DRIFT describes the cascade from synovitis to deformity: treat the inflammation first!
DISTALSurgical Sequencing Rule
| D | DIP/PIP first Address digital deformities before proximal joints |
| I | Intrinsics next Release or transfer intrinsic muscles as needed |
| S | Stabilise wrist Wrist drives MCP position; stabilise before or with MCP surgery |
| T | Tendon transfers Reconstruct ruptured tendons after skeleton is stabilised |
| A | Arthroplasty MCP MCP joint replacement after wrist is addressed |
| L | Last: elbow/shoulder Most proximal joints are addressed last |
| D | DIP/PIP first Address digital deformities before proximal joints | S | Stabilise wrist Wrist drives MCP position; stabilise before or with MCP surgery | A | Arthroplasty MCP MCP joint replacement after wrist is addressed |
| I | Intrinsics next Release or transfer intrinsic muscles as needed | T | Tendon transfers Reconstruct ruptured tendons after skeleton is stabilised | L | Last: elbow/shoulder Most proximal joints are addressed last |
Hook:DISTAL = the surgical sequence goes from fingers back toward the shoulder!
EXTRAVaughan-Jackson Attrition Ruptures
| E | EDM ruptures first Extensor digiti minimi is the most ulnar tendon at DRUJ |
| X | Extensors fail sequentially Small finger EDC, then ring, then middle - ulnar to radial |
| T | Tubercle is the cause Caput ulnae = dorsally subluxed ulnar head acts as a sharp fulcrum |
| R | Restore with EIP transfer Extensor indicis proprius is the workhorse donor for EDM reconstruction |
| A | Address the bone Must smooth or excise the ulnar head (Darrach) or it will re-rupture |
| E | EDM ruptures first Extensor digiti minimi is the most ulnar tendon at DRUJ | R | Restore with EIP transfer Extensor indicis proprius is the workhorse donor for EDM reconstruction |
| X | Extensors fail sequentially Small finger EDC, then ring, then middle - ulnar to radial | A | Address the bone Must smooth or excise the ulnar head (Darrach) or it will re-rupture |
| T | Tubercle is the cause Caput ulnae = dorsally subluxed ulnar head acts as a sharp fulcrum |
Hook:EXTRA tendons rupture from EXTRA bone - smooth the ulnar head before any tendon transfer!
Overview and Epidemiology
Why This Matters
Rheumatoid arthritis affects the hand and wrist in approximately 90 percent of patients, making it the most commonly involved region. The hand deformities are the visible hallmark of RA and are a high-yield exam topic. Understanding the pathomechanics of each deformity, the eponymous tendon rupture patterns, and the correct sequence of surgical reconstruction is essential for fellowship-level knowledge.
Epidemiology
- Prevalence: RA affects approximately 0.5-1 percent of the global population
- Hand involvement: Up to 90 percent of RA patients develop hand/wrist manifestations
- Female-to-male ratio: 3:1
- Peak onset: 30-50 years, though all ages affected
- Bilateral and symmetrical: Characteristic distribution pattern
Impact on Hand Function
- Grip strength: Reduced by up to 70 percent in advanced disease
- Pinch weakness: Especially key pinch (thumb involvement)
- ADL limitation: Buttoning, writing, opening jars affected early
- Deformity progression: Predictable pattern from synovitis to ligament destruction to joint subluxation
Pathophysiology
Synovitis-Driven Destruction in the RA Hand
Rheumatoid synovitis produces hypertrophied pannus tissue that invades and destroys periarticular structures through enzymatic digestion and mechanical pressure. In the hand and wrist, this process targets:
- Joint capsules and ligaments: Leading to instability, subluxation, and ulnar drift
- Extensor tendons: Attrition ruptures over bony prominences (caput ulnae, scaphoid)
- Flexor tendons: Especially FPL in the carpal tunnel (Mannerfelt lesion)
- Articular cartilage and bone: Marginal erosions, cartilage loss, osteopenia
- Intrinsic muscles: Fibrosis and contracture drive swan-neck deformity and contribute to MCP subluxation The resultant imbalance between flexors and extensors produces the classic zig-zag deformity patterns.
Pathomechanics of Major RA Hand Deformities
| Deformity | Primary Structure Damaged | Mechanism | Resulting Posture |
|---|---|---|---|
| MCP volar subluxation | Dorsal capsule, collateral ligaments, volar plate | Synovitis stretches dorsal capsule; flexor tendons pull proximal phalanx volarly | Proximal phalanx subluxes volarly on metacarpal head |
| Ulnar drift | Radial collateral ligament, radial sagittal band | Radial-sided structures attenuate; intrinsic muscles pull ulnarly; extensor tendons slip ulnar to MCP axis | Fingers deviate ulnarly at MCP joints |
| Swan-neck | Volar plate, FDS insertion, intrinsic muscles | Volar plate laxity + intrinsic tightness + FDS rupture/attenuation allows PIP hyperextension | PIP hyperextension + DIP flexion |
| Boutonniere | Central slip (extensor mechanism) | Synovitis at PIP attenuates central slip; lateral bands migrate volar | PIP flexion + DIP hyperextension |
| Caput ulnae | DRUJ capsule, TFCC, ECU tendon sheath | DRUJ synovitis leads to dorsal ulnar head subluxation and supination of carpus | Prominent dorsally subluxed ulnar head |
Zig-Zag Collapse Concept
Wrist radial deviation drives MCP ulnar deviation (zig-zag collapse). When the carpus supinates and deviates radially due to RA destruction, the metacarpals point more ulnarly. This biomechanical linkage means wrist position governs MCP alignment. Correcting wrist alignment is critical before or during MCP surgery.
Why Ulnar-Sided Structures Fail First
The DRUJ and ulnar-sided wrist structures are the first to be affected in RA because:
- Ulnar styloid and head have thin overlying soft tissue
- ECU tendon sheath is a common site of early synovitis
- The TFCC is vulnerable to pannus invasion
- Extensor tendons (especially EDM) lie directly over the subluxing ulnar head
Classification and Types
Nalebuff Classification of RA Thumb Deformity
| Type | Joint Affected | Pathoanatomy | Deformity | Surgical Treatment |
|---|---|---|---|---|
| Type I (most common) | MCP joint | MCP synovitis stretches dorsal capsule and collateral ligaments; IP hyperextends to compensate | MCP flexion + IP hyperextension (boutonniere-type) | MCP arthrodesis or synovectomy + extensor reconstruction |
| Type II | MCP + CMC | Combined MCP boutonniere and CMC subluxation | MCP flexion + CMC dorsal subluxation + IP hyperextension | CMC arthroplasty + MCP arthrodesis |
| Type III | CMC joint | CMC synovitis leads to dorsal subluxation; MCP hyperextends and adducts (swan-neck type) | CMC subluxation + MCP hyperextension + IP flexion | CMC arthroplasty or arthrodesis + MCP flexion release |
| Type IV | IP joint | IP joint destruction from synovitis; rare isolated pattern | IP joint destruction, often fibrous or bony ankylosis | IP arthrodesis |
The Nalebuff classification is the most commonly examined system for RA thumb deformity. Type I is by far the most common. Key principle: the thumb is classified by which joint is the primary site of destruction, which then dictates the surgical plan.
Clinical Assessment
History
- Disease duration and treatment: DMARDs, biologics, steroid history
- Hand function: Grip, pinch, ADLs (buttoning, key turning, writing)
- Deformity progression: Rate of change, which fingers affected first
- Pain: Localise to specific joints (wrist, MCP, PIP)
- Tendon function: Sudden loss of extension (rupture), triggering
Examination
- Inspect: Zig-zag deformity pattern, MCP ulnar drift, wrist supination, thumb posture
- Palpate: Synovitis (boggy swelling), caput ulnae, tendon fraying (crepitus)
- Active ROM: Finger extension (test each tendon individually), flexion cascade
- Tendon integrity: Test EDM independently (extend small finger while holding others flexed)
- Passive correctability: Can MCP joints be reduced? PIP deformity flexible or fixed?
Caput Ulnae Assessment and Tendon Integrity Check
Caput ulnae sign: Prominent ulnar head palpable dorsally, especially with forearm pronation. The "piano key" test demonstrates dorsal subluxation: press the ulnar head - it depresses like a piano key and rebounds when released.
Extensor tendon assessment in RA:
- Test each finger's active extension independently
- EDM rupture: Inability to extend small finger independently (Vaughan-Jackson)
- EDC rupture cascade: Progressive loss of extension from ulnar to radial digits
- FPL rupture (Mannerfelt): Loss of thumb IP flexion against resistance
- Sudden loss of extension is a rupture until proven otherwise - do not attribute to disease flare without ultrasound or MRI confirmation
Tendon Rupture Patterns in RA
| Eponym | Tendon(s) Involved | Mechanism | Site of Attrition | Reconstruction |
|---|---|---|---|---|
| Vaughan-Jackson | EDM first, then EDC (small, ring, middle sequentially) | Attrition over dorsally subluxed ulnar head | Dorsal DRUJ (caput ulnae) | EIP transfer to EDM; side-to-side for EDC; address ulnar head |
| Mannerfelt-Norman | Flexor pollicis longus (FPL) | Attrition over scaphoid osteophyte or rough bone in carpal tunnel | Volar wrist / carpal tunnel (scaphoid ridge) | FDS ring finger transfer to distal FPL; carpal tunnel release |
| Extensor carpi ulnaris | ECU rupture or subluxation | Synovitis of ECU sheath, tendon attenuation | Dorsal ulnar wrist | ECU reconstruction or transfer; stabilise DRUJ |
Do Not Miss the Mannerfelt Lesion
FPL rupture in RA is often painless and may present as an incidental finding. The patient reports inability to flex the thumb IP joint. Unlike extensor ruptures, this is a flexor-side attrition in the carpal tunnel. Always examine FPL function in RA patients - loss of thumb IP flexion against resistance is diagnostic. Carpal tunnel release alone may prevent further ruptures if caught early.
Investigations
Imaging Protocol
Views: PA, lateral, oblique of both hands and wrists; Norgard (ball-catcher) view for early erosions
Look for: Periarticular osteopenia, joint space narrowing, marginal erosions, carpal collapse, ulnar translocation, scapholunate dissociation, MCP volar subluxation, ulnar drift
Larsen grading: Standardised scoring system for RA radiographic progression
Ultrasound: Dynamic assessment of tendon integrity, synovitis (power Doppler), tenosynovitis
MRI: Gold standard for early erosions, pannus, bone marrow oedema; assesses tendon quality
Key finding: Tendon discontinuity, surrounding synovitis, bony spurs causing attrition
Indication: Assess bone stock for arthroplasty or arthrodesis, carpal bone erosion severity
Helpful for: Planning wrist arthrodesis fixation, evaluating distal radius and ulnar head architecture
Imaging Pearl
The Norgard (ball-catcher) view is the most sensitive plain radiograph for early RA erosions in the hands. It profiles the MCP joints and wrist in slight oblique and ulnar-deviated position, revealing erosions that may be missed on standard PA views. Always request bilateral hand and wrist radiographs for comparison and to document the symmetrical pattern typical of RA.
Management Algorithm
Medical Optimisation (Prerequisite to Surgery)
DMARD Therapy Timeline
Methotrexate: First-line conventional synthetic DMARD (csDMARD) Adjuncts: Hydroxychloroquine, sulfasalazine, leflunomide (combination therapy common) Bridging: Short-term low-dose prednisone while awaiting DMARD effect (6-12 weeks)
Biologic DMARDs (bDMARDs): TNF inhibitors (adalimumab, etanercept), IL-6 inhibitors (tocilizumab), B-cell therapy (rituximab) JAK inhibitors: Tofacitinib, baricitinib, upadacitinib (targeted synthetic DMARDs) Treat-to-target: Aim for remission or low disease activity
Methotrexate: Generally continue through surgery (evidence supports safety) Biologics: Withhold 2-5 half-lives before surgery; restart once wound healed (usually 2 weeks) Prednisone: Stress dose coverage if on chronic steroids Coordinate with rheumatology: Perioperative DMARD management is a joint decision
Medical-Surgical Coordination Pearl
The rheumatologist and hand surgeon must work as a team. Surgery on an actively inflamed joint has higher complication rates. The general principle is: optimise medical management first, then operate on the structural consequences. Exceptions include acute tendon ruptures (urgent surgery to prevent further attrition) and severe nerve compression.
Complications
| Complication | Incidence / Risk | Risk Factors | Management |
|---|---|---|---|
| Progressive deformity despite surgery | Common in poorly controlled disease | Inadequate DMARD therapy, poor soft tissue quality | Optimise medical management, revision surgery if functional |
| Silicone implant fracture (MCP) | 10-30 percent at 10 years | High demand, poor bone stock, inadequate soft tissue balance | Often asymptomatic; revision if painful or deformity recurs |
| Ulnar translocation after Darrach | Reported in 10-25 percent long-term | Aggressive distal ulnar resection, insufficient ligament repair | Sauve-Kapandji preferred if possible; partial repair if identified |
| Tendon re-rupture after transfer | 5-15 percent | Persistent bony spurs, ongoing synovitis | Ensure attrition source addressed at index surgery |
| Wound healing problems | Higher than non-RA population | Chronic steroids, poor nutrition, vasculitis | Pre-operative skin assessment; steroid management; meticulous technique |
| Infection | Elevated with DMARDs / biologics | Immunosuppression, steroids, poor glycaemic control | Perioperative antibiotic; withhold biologics; coordinate with rheumatology |
Prevention of Complications
The key to preventing complications in RA hand surgery is:
- Medical optimisation: Control synovitis before elective surgery
- Meticulous soft tissue handling: RA tissues are fragile and prone to failure
- Address the underlying cause: Remove bony attrition sources, tenosynovectomy
- Realistic expectations: RA surgery improves function and reduces pain but rarely restores normal hand mechanics
- Coordinate perioperative DMARD management with rheumatology to balance infection risk against flare
Outcomes and Prognosis
Outcomes by Procedure
| Procedure | Pain Relief | Functional Outcome | Survival / Durability |
|---|---|---|---|
| Total wrist arthrodesis | Over 90 percent good-excellent pain relief | Stable platform for hand function; improved grip | Fusion rate over 95 percent; durable long-term |
| Silicone MCP arthroplasty | Good pain relief in 80-90 percent | Improved alignment and appearance; modest grip improvement | 10-year implant survival approximately 70-80 percent |
| EIP to EDM transfer | Reliable restoration of small finger extension | Depends on quality of donor and recipient tissue | Good durability if ulnar head addressed |
| Darrach procedure | Good relief of DRUJ pain | Improved forearm rotation, eliminates attrition | Risk of ulnar translocation long-term (10-25 percent) |
| Thumb MCP arthrodesis | Excellent pain relief | Reliable pinch restoration, stable thumb column | High fusion rate, durable |
Prognostic Factors
Best outcomes: Well-controlled disease (DMARDs), early intervention before fixed deformity, good bone stock, patient compliance with therapy, non-smoker
Poor outcomes: Active synovitis at time of surgery, steroid dependence, multiple previous surgeries, poor bone quality, vasculitis
Key message: RA hand surgery is reconstructive, not curative. The goal is pain relief, improved function, and prevention of further deformity. Patients who understand this have better satisfaction.
Evidence Base and Key Trials
Rupture of extensor tendons by attrition at the inferior radio-ulnar joint: report of two cases
- Original description of sequential extensor tendon rupture by attrition at the distal radio-ulnar joint in rheumatoid disease
- Rupture begins with extensor digiti minimi (EDM) due to attrition over the dorsally subluxed ulnar head (caput ulnae)
- Progresses radially: EDM, then extensor digitorum communis to small, ring, and middle fingers in sequence
- Identified dorsal subluxation of the ulnar head as the mechanical cause of attrition
Scaphoid exostosis causing rupture of the flexor pollicis longus
- Describes attrition rupture of flexor pollicis longus over a scaphoid exostosis (osteophyte) within the carpal tunnel in rheumatoid disease
- Mechanism parallels the Mannerfelt-Norman lesion: rough bone on the volar scaphoid ridge abrades the FPL during flexion
- Often associated with carpal tunnel syndrome, requiring concurrent release and spur excision
- FPL reconstruction by tendon transfer or graft can restore thumb IP flexion
Metacarpophalangeal joint arthroplasty in rheumatoid arthritis: a long-term assessment
- Retrospective review of Swanson silicone MCP arthroplasty in rheumatoid patients with mean follow-up over 10 years
- Significant improvement in pain scores and MCP joint alignment persisted at long-term review
- Implant fracture rate approximately 10-30 percent at long-term follow-up
- Many fractured implants remained asymptomatic and functionally acceptable
Arthrodesis of the wrist for rheumatoid arthritis
- Total wrist arthrodesis via intramedullary pin fixation combined with iliac crest bone graft provided reliable pain relief in rheumatoid arthritis
- Stable fusion provided a platform that improved hand function distally and enabled subsequent MCP and tendon reconstruction
- Position of fusion (slight extension, neutral deviation) was critical for optimal grip strength and key pinch
- Established wrist arthrodesis as a durable surgical option for end-stage RA wrist disease
Boutonniere rheumatoid thumb deformity
- Describes Nalebuff Type I boutonniere rheumatoid thumb deformity: MCP flexion with IP hyperextension
- MCP joint is the primary site of deformity, requiring MCP stabilisation (arthrodesis preferred) for a stable thumb column
- Soft-tissue rebalancing alone is rarely sufficient; bony stabilisation at MCP is the workhorse
- Pain relief, restored pinch, and durable correction with MCP arthrodesis in appropriate patients
Exam Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Vaughan-Jackson Rupture
"A 58-year-old woman with long-standing seropositive RA presents with sudden inability to extend her small and ring fingers of the right hand over the past 2 weeks. She reports no pain. On examination, she has a prominent dorsally subluxed ulnar head, active extension of index and middle fingers is preserved, but she cannot actively extend the small and ring fingers. Passive extension is full. Wrist radiographs show advanced RA changes with dorsal subluxation of the ulnar head and carpal collapse. What is the diagnosis and management?"
Scenario 2: RA Hand Surgical Sequencing
"A 52-year-old woman with seropositive RA presents with bilateral hand deformities. The right hand shows: fixed MCP volar subluxation of all four fingers with 30 degrees ulnar drift, extensor tendon rupture of the small finger, caput ulnae with carpal collapse, and a Type I Nalebuff thumb deformity. Her disease is well-controlled on methotrexate and adalimumab. She requests surgical reconstruction. Describe your surgical plan and the order of procedures."
Guidelines, Registries & Global Practice
Global Epidemiology
- RA prevalence: 0.5-1 percent worldwide; higher in Northern European and North American populations
- Hand involvement: The most common site of RA manifestation across all ethnicities
- Declining surgery rates: Biologic DMARDs have dramatically reduced the need for reconstructive RA hand surgery in well-resourced settings
- Delayed presentation: In resource-limited settings, patients often present with established deformities
Practice Variation by Resource Setting
- High-resource: Early biologic therapy, hand therapy teams, silicone arthroplasty, total wrist arthroplasty as an option
- Limited-resource: Conventional DMARDs, arthrodesis preferred over arthroplasty (no implant costs, no need for long-term follow-up of implants)
- Universal principle: Tendon attrition must be addressed surgically regardless of resource setting - delay leads to further ruptures
- Surgical training: RA hand reconstruction is increasingly concentrated in specialist centres as caseloads decline
Society and Reference Guidance (Side by Side)
| Source | Medical Management Emphasis | Surgical Indications | Implant Preference |
|---|---|---|---|
| BSR / NICE (UK) | Treat-to-target with DMARDs; biologics for inadequate response at 6 months | Surgery for structural damage unresponsive to medical therapy; urgent for tendon rupture | Silicone MCP arthroplasty well-established; wrist arthrodesis preferred over arthroplasty |
| ACR / AF (US) | Methotrexate first-line; early biologic escalation; JAK inhibitors as option | Functional impairment and pain despite optimal medical therapy | Silicone MCP arthroplasty; wrist arthroplasty gaining acceptance in select patients |
| EULAR (European) | Treat-to-target within 6 months; combination csDMARDs before biologics | Multidisciplinary decision; surgery for irreversible structural damage | No specific implant guidance; arthrodesis vs arthroplasty by surgeon preference |
| ASSH / IFSSH | Coordinate perioperative DMARD management with rheumatology | Tendon rupture is semi-urgent; electives when disease quiescent | Silicone MCP standard; pyrolytic carbon an alternative in some centres |
Registry and Evidence Note
Joint replacement registries (NJR UK, AOANJRR Australia, AJRR US) now track wrist and small joint arthroplasty. Data consistently show that silicone MCP implants have 10-year survival of approximately 70-80 percent, with fracture being the primary mode of failure. Total wrist arthrodesis remains the benchmark against which wrist arthroplasty is measured. The overall volume of RA hand surgery has declined dramatically in countries with early biologic access, making surgical training and maintenance of expertise an ongoing concern.
Perioperative DMARD Management (Global Best Practice)
Coordinate with rheumatology for every RA surgical case:
- Continue: Methotrexate through surgery (evidence supports safety)
- Withhold biologics: 2-5 half-lives pre-operatively; restart 2 weeks post-op if wound healed
- Prednisone: Stress dose coverage for patients on chronic steroids
- JAK inhibitors: Withhold 3-7 days before surgery (short half-life)
- Postpone elective surgery if active infection or poorly controlled disease
- Document: DMARD plan in the operation note and communicate to the anaesthetic team
Controversies & Areas of Uncertainty
Darrach vs Sauve-Kapandji
The Darrach procedure removes the attrition source but risks ulnar translocation of the carpus over time (10-25 percent). Sauve-Kapandji preserves the ulnar buttress but creates a pseudarthrosis that can be unstable. Choice depends on bone quality, DRUJ congruency, and surgeon preference. No high-quality RCTs compare the two.
Wrist Arthrodesis vs Arthroplasty
Total wrist arthrodesis is reliable and durable but sacrifices all motion. Total wrist arthroplasty preserves some flexion-extension but has higher revision rates and is unsuitable for high-demand patients. In RA (low demand, bilateral disease), arthroplasty is increasingly considered for the non-dominant side while fusing the dominant wrist.
Silicone vs Pyrolytic Carbon MCP Implants
Silicone (Swanson) implants have long track records but fracture over time and may cause particulate synovitis. Pyrolytic carbon implants aim for more anatomical reconstruction but have limited long-term data in RA. Most surgeons still use silicone for RA MCP arthroplasty due to familiarity and published outcomes.
Declining Surgical Volume
With effective biologic DMARDs, the need for RA hand surgery has declined markedly in well-resourced settings. This creates a training challenge: fewer cases mean fewer surgeons gaining expertise. The paradox is that when surgery is needed, it is often more complex (revision-type scenarios) and requires subspecialist skills.
THE RHEUMATOID HAND AND WRIST
Clinical summary
Pathomechanics
- •Synovial pannus destroys ligaments, tendons, and cartilage producing zig-zag deformities
- •Caput ulnae = dorsal DRUJ subluxation; causes attrition ruptures of extensors
- •Wrist radial deviation drives MCP ulnar drift (zig-zag collapse concept)
- •Ulnar-sided structures fail first (ECU sheath synovitis, DRUJ, EDM attrition)
Key Deformities
- •MCP: volar subluxation + ulnar drift from ligament destruction and flexor pull
- •Swan-neck: PIP hyperextension + DIP flexion (intrinsic tightness, volar plate laxity, FDS rupture)
- •Boutonniere: PIP flexion + DIP hyperextension (central slip attenuation, lateral bands volar)
- •Thumb: Nalebuff Type I (MCP boutonniere) most common; Type III (CMC swan-neck) second
Tendon Ruptures
- •Vaughan-Jackson: EDM then EDC small, ring, middle - ulnar to radial attrition over caput ulnae
- •Mannerfelt-Norman: FPL rupture from attrition over scaphoid osteophyte in carpal tunnel
- •Treatment principle: address the bone causing attrition before or during tendon transfer
- •EIP is workhorse donor for EDM; FDS ring finger for FPL reconstruction
Surgical Sequence
- •Distal-to-proximal rule: DIP/PIP first, then MCP, then wrist, then elbow/shoulder
- •Exception: stabilise wrist before or with MCP surgery (wrist drives MCP position)
- •Combine procedures using same approach when possible (dorsal wrist + extensor repair)
- •Medical optimisation (DMARDs) is prerequisite before elective surgery
Key Procedures
- •Total wrist arthrodesis: gold standard for end-stage RA wrist (fusion in 10-20 degrees extension)
- •Darrach: distal ulnar excision for caput ulnae; Sauve-Kapandji preserves ulnar buttress
- •Silicone MCP arthroplasty: for fixed MCP subluxation; 10-year survival approximately 70-80 percent
- •Thumb MCP arthrodesis: for Nalebuff Type I (most common thumb deformity)
Perioperative Management
- •Continue methotrexate through surgery (evidence supports safety)
- •Withhold biologics 2-5 half-lives pre-operatively; restart at 2 weeks post-op
- •Stress dose steroids for patients on chronic prednisone
- •Sudden painless loss of extension = rupture until proven otherwise (do not wait)