Surgical treatment of rheumatic tenosynovitis

Surgical Treatment of Rheumatic Tenosynovitis LOT D . HOWARD, JR ., M .D .,

Presented before the Section on Industrial Medicine and Surgery at the 83rd Annual Session of the California Medical Association, Los Angeles, California, May 9 - 13, 19.54 .

tenosynovitis has been recognized for many years but should be brought to attention anew because of existing confusion as to etiology and its relationship to industrial injury . Tenosynovitis is the response of a tendon sheath to irritation . The cause of the irritation may be specific, such as bacterial invasion or trauma of some kind . The disease may be acute or chronic . When the exact cause of the irritation is not evident, even after bacteriologic and pathologic study, the term "nonspecif c tenosynovitis" is generally used . Cases of this classification are chronic in nature and resistant to the usual forms of conservative therapy . Remissions and exacerbations are common, and in all such cases symptoms become more pronounced when the involved tendons are activated as in work . That this form of tenosynovitis is a rheumatic disorder and therefore a manifestation of a systemic disease seems highly probable in the light of existing information . ON-SPECIFIC

REVIEW OF THE LITERATURE

Vischerl' reported on seven cases, all previously diagnosed as tuberculosis . Positive evidence of tuberculosis could not be found in a careful study, but in all cases rheumatic nodules were present in material microscopically examined . An analogy was drawn between these nodules and the Ashoff bodies found in acute rheumatic fever . KanaveI' reported on fourteen cases of tuberculous tenosynovitis of the hand . However, in only one case was there associated pulmonary tuberculosis ; in the remainder there was no evidence of tuberculosis elsewhere . It was not stated whether or not tubercle bacilli were found locally . Cordes' likewise was unable I

San Francisco, California

to identify the tubercle bacillus in this disease and he expressed the opinion that the condition is related to rheumatism . Albertinil used the term "fungose" to describe this form of tenosynovitis . He stated the condition is non-tuberculous but did not agree with Vischer and Cordes that the disease is rheumatic . Giinther 6 used the term "hygromatous rheumatica" in a discussion of the problem and remarked that fluid may or may not be present in the involved tendon sheath . He also commented that although the histologic features resembled those of tuberculosis, the tubercle bacillus was not found in smear or animal inoculation in any of the reviewed cases . Klinge,1 1 reporting a careful histologic study, said that the microscopic appearance of the involved tendon sheath is practically identical with the changes noted in polyarthritis . He was unable to find any evidence of tuberculosis . Continuing the work of Kanavel, Mason" reported thirty-three cases of chronic tenosynovitis of the hand and said that in twentythree there was histologic proof of tuberculosis ; but here again no mention was made of whether or not the tubercle bacillus was isolated . Six of the entire series of cases were classed as rheumatic tenosynovitis, with the mention that these cases were hardly distinguishable from the others which were termed tuberculous . Edstrom, 5 reporting upon examination of all chronic rheumatic patients for the year 1943 at the Lund Hospital in Sweden, said that 48 per cent showed tendinous involvement, and in 42 per cent there was upper extremity involvement . The most common location of the tendon involvement was the flexors of the fingers (35 per cent), and Edstrom ventured to say that such involvement may be the first symptom of polyarthritis . In a report of two cases of tenosynovitis in patients with chronic polyarthritis . Baumgartner 2 noted the presence of rheumatic 163 American Journal of Surgery, Volume 89, June, 1955

Rheumatic Tenosynovitis nodules in the microscopic study of the involved tendon sheath . Kellgren and Ball' noted that tendon lesions were present in forty-two of i oo cases of rheumatism . Pathologic description was made from material obtained by thirty-eight biopsies

tenosynovitis, selected as representative on the basis of similarity of complaints, physical findings and conditions observed at operation . Of the eleven patients, five were women and six were men . As three of the patients, a man and two women, had bilateral disease, the total

e

r

4 CASES

I CASE

3 CASES

EXTENSOR SURFACE

11

2 CASES

3 CASES

ICASE

FLEXOR SURFACE Fin . i . Location of fourteen areas of involvement in eleven cases .

of tendinous lesions . The essential features were local fibrinoid degeneration followed by granulation tissue . Six cases of tumorous lesions on the dorsum of the hand were reported by Kestler . 9 One was proved to be tuberculous . In the other five a diagnosis of rheumatoid disease was made pathologically . In two of the five cases rheumatoid arthritis developed later . Although the description closely fitted that of rheumatic tenosynovitis, Kestler considered the five cases a new entity, which he named collagenous pseudotumors of tendon sheaths . Bickel, Kimbrough and Dahlin 3 remarked on the rarity of tuberculous involvement of tendon sheaths . They reported on fifty-two cases observed at the Mayo Clinic between the years 1915 and 1949 in which tuberculous involvement of tendon sheaths was diagnosed-proved by bacteriologic and histologic examination in thirty-seven cases . The present study is based on eleven cases, from a group of cases of so-called non-specific 1

number of operations was fourteen . The average age of the women was forty-one years and that of the men forty-four years . The youngest patient in the series was a man twenty-three years of age and the oldest a man aged fiftyeight . The average duration of symptoms in the women was 2 .4 years ; in the men, 2 .6 years . In the three cases of shortest duration of symptoms-one month in two cases and two months in another-the patients were men and industrial injury was claimed as the cause . The longest duration of symptoms, fourteen years, was also in a man . Six of the eleven patients had involvement of the extensor surface, four had involvement on the flexor surface and one had involvement on both extensor and flexor surfaces . The specific locations of the fourteen areas of involvement (Fig 1) were as follows : Flexor surface, two involving the sheath of the long flexor tendon of the index finger, three in which the digital flexors were involved in the distal forearm and palm, and one in which the entire ulnar bursa I64



Rheumatic Tenosynovitis

2B 2C 2A FIG . 2 . A, rheumatic tenosynovitis of digital flexor tendon sheath of index finger . Note general swelling of the finger and bulge of cul-de-sac in distal palm . B, rheumatic tenosynovitis of exten-

sor digitorum communis sheath at wrist level, both distal and proximal to transverse dorsal carpal ligament. The contained fluid could be pressed to either side of the ligament . C, an extensive case of rheumatic tenosynovitis involving the digital flexor tendon sheaths in the palm and above the wrist . Note the abnormal stance of the index and little fingers due to direct tendon damage by the process .

was involved ; extensor group, four cases of involvement of the extensor communis tendons of the fingers at the wrist level ; three cases of extensor carpi ulnaris involvement, with additional involvement in two of the three, consisting in one instance of involvement of the sheath of the extensor digiti quinti proprius, the head of the ulna and the distal radioulnar joint, and in the other instance involvement of the sty loid process of the ulna and the wrist joint . In the remaining case there was involvement of the extensor carpi radialis tendons and of the long extensor tendon of the thumb at wrist level . In all cases there was complaint of swelling at the time of first examination . The other symptoms in the order of their frequency were as follows : pain, limited motion, crepitus and weakness . Of particular significance was the fact that in eight of the eleven cases there was a history of previous rheumatic joint disease or of tenosynovitis of a similar type ; and in two cases typical rheumatic joint involvement was noted to be in progress during the period the tenosynovitis was being treated . In only two cases was there previous history of tuberculosis . Both patients were women, one with a history r 1

of minor pulmonary involvement at the age of eighteen years and the other with a history of suppurative cervical adenitis at the age of ten years . Active disease was not present in either case at this time . The diagnosis is based primarily on the history and the presence of a boggy swelling, involving one or more tendon sheaths . (Fig . 2 .) Often if pressure is applied to one area of the sheath, swelling increases at the opposite end owing to a change in location of the fluid . A crepitant sensation may also be present if granulation tissue or rice bodies are abundant . The skin is seldom if ever involved . There are no signs of acute inflammation, either local or systemic . A history of previous rheumatic joint disease or of other stigmas of rheumatic affliction is most likely . Stiffness of a joint may be noted, or active disease within the joint may he present . The presence of knuckle "pads" or palmar fascia thickening may give additional evidence of a general rheumatic diathesis . The differential diagnosis could include such entities as ganglion or tumor of the tendon sheath ; however, the principal one is tuberculous tenosynovitis, which can so closely resemble rheumatic tenosynovitis clinically 65

Rheumatic Tenosynovitis

FIG . 3 . Operative field in distal palm at base of index finger showing removed sublimis tendon and flexor tendon sheath in foreground . Note polypoid granulation tissue filling the sheath and attached to the tendon, which in some areas was actually invaded . The profundus flexor tendon trimmed smooth of granulation tissue may be seen in the background .

FIG . 4. Low power microscopic view of tendon sheath

showing marked polypoid proliferation of lining .

that only by careful study and detailed examination of the removed tissue can the distinction be made . SURGICAL TREATMENT AND OPERATIVE FINDINGS

In the present series surgical treatment at each involved site consisted of complete, meticulous excision of the tendon sheath. Good visibility of the operative field was brought about by using a tourniquet for ischemia . In each instance the swelling present was due to distention of the involved sheath by clear, straw-colored fluid and an abundance of granulation-like tissue having a polypoid or villous form . (Fig . 3 .) The sheath structures were thickened . In seven instances there was direct involvement of the tendon consisting of an ingrowth of granulation tissue into the tendon with actual destruction of tendon fibers . In several instances this resulted in an attenuated and elongated tendon by virtue of pseudotendon proliferation ; in one instance actual tendon rupture was noted . Free floating rice bodies were noted in five of the fourteen operations . In one case of bilateral involvement rice bodies were present on one side but not on the other . Where the tendons were involved to the extent of functional loss, repair was done at the time of operation . This consisted of tendon shortening or substitution transfers . Tendon grafts were not used . If a bone was involved, the involved portion of bone was removed if 1

feasible . No effort was made to reconstruct the tendon sheath after the sheath was excised . In each instance all the removed material was sent for pathologic examination, and in four cases the material was sent for bacteriologic study and guinea pig inoculation . In each instance the cultures were sterile for ordinary pathogens, and the tubercle bacilli were not isolated by smear, by culture or by guinea pig inoculation . PATHOLOGIC STUDY

The reports on pathologic examination of the excised material show that no fewer than seven pathologists made the diagnosis on one or more cases independent of each other . The variation in the descriptive diagnostic terms included the following : Tenosynovitis, chronic, fibrinoid ; synovitis, subacute, non-specific ; tenosynovitis, villous, proliferative ; tenosynovitis, chronic, proliferative ; tenosynovitis, chronic, rheumatoid nodule . In no case was there microscopic evidence of tuberculosis or tumor . The general histologic descriptions were very similar to each other and included some or all of the following characteristics (Fig . 4) : The tendon sheath lining was thickened ; the surface was thrown into papillary or polypoid folds and was covered with a prominent layer of mesothelial cells ; the stroma showed edema and vascularization with moderate infiltration of lymphocytes and plasma cells . An occasional phagocytic cell was seen, and not infrequently eosinophils were identified . In some areas fibrin with immeshed leukocytes were seen attached to the surface . The deeper layer I66

Rheumatic Tenosynovitis of the sheath was fibrous but showed edema in some cases . In one specimen (Fig . 5) a dense fibrous nodule, 3 mm . in diameter, was seen . This nodule consisted of a central zone of amorphous material bordered by a cellular layer of elongated cells in radial arrangement . This is the characteristic appearance of a rheumatoid nodule . The histologic section of a tendon shows diminution of fibrocollagenous fibers . Histologic section of a piece of muscle shows some atrophy of muscle fibers with focal increase in sarcolemma nuclei . Histologic section of involved bone was described as characteristic of chronic osteomyelitis . COMPOUND F IN TREATMENT

Two patients, both with bilateral involvement, after operative treatment of one side received hydrocortisone (compound F) as an injection into the involved tendon sheaths on the other side . One of the patients had flexor tendon involvement in the distal forearm and palm ; the other had communis extensor tendon involvement at the wrist level. In both instances the swelling and symptoms were abolished within twenty-four to forty-eight hours . Recurrence followed in each instance, however, and the patient with flexor tendon involvement was operated upon shortly thereafter . The patient with involvement of the extensor tendon obtained relief after each injection for periods varying from two to four weeks . Injections were repeated as necessary and the condition was kept under control for eight months before surgical intervention . Compound F was put into the surgical wound immediately after operation in three cases, and postoperative reaction and pain were appreciably reduced . RESULTS

Excluding one very recent case, the average time of follow-up was thirteen months . In one of the remaining ten cases there was suggestion of recurrence at the operative site five months following operation, but at the time of report recurrence was not certain . In the other nine cases there was no recurrence at the time of their last observation . Functional recovery following complete extirpation of the tendon sheath was complete, or very nearly so, in cases in which the involvement was in the distal forearm or palm or on the extensor surface at wrist level, provided there was no actual

Fic . g Lo power magnification of a rheumatoid nodule seen during microscopic study of excised tendon sheath in a case of rheumatic tenosynovitis .

tendon involvement requiring reconstructive procedures . In cases of digital flexor sheath involvement, approximately one-half of the motion was recovered-enough for most practical purposes . SUMMARY

Rheumatic tenosynovitis can be controlled satisfactorily by operation . The method is to remove the sheath but preserve the tendon . After such a procedure full motion often does not result but there is usually enough motion to be useful . In severe cases the tendon itself may be partially destroyed and may even rupture . I n such cases it is necessary to reconstruct the tendon at the time the sheath is removed . Instilling hydrocortisone in the wound at the time of operation reduces pain considerably . Tuberculous tenosynovitis is relatively rare ; tenosynovitis should not be considered tuberculous unless there is irrefutable pathologic or bacteriologic evidence to support that diagnosis . Acknowledgment : Acknowledgment is hereby made for the contribution of both material and assistance to Drs . Sterling Bunnell, Donald Pratt and William Fielder, San Francisco, Calif. REFERENCES 1 . ALBERTINI, A . V . Spezielle Pathologic der Sehnen, Sehnenscheiden and Schleimbeutel . Handbuch der Speziellen pathologischen Anatomic and Histologie, vol . 9, pp . 5o8-6o9, 1029 . F . flenke & 0 . Lubarsch . 2 . BAUMGARTNER, W . Polytendovaginitis rheumatica . Scbweiz . coned . Wchnscbr ., 76 : 8oo-811, 194.6 .

Rheumatic Tenosynovitis 3 . BICKEL, W . H ., KIMBROUGH, R . F. and DAHLIN, D . C . Tuberculous tenosynovitis . J. A . M. A ., 151 : 31 -35 1953 . 4. CORDES . Unspecifische chronische Tendovaginitis . 7'' Zentralbl . f. Chir ., 54 : 406, 1927 . 5 . GDSTROM, G . The significance of peritendinitis in the clinical picture of chronic rheumatic polyarthritis . Nord. med., 2 5 : 379-385, 1945 . 6 . GUNTHER, H . Uber Hygromatosis rheumatica and verivandte Affektionen der Sehenscheiden and Schleimbeutel . Deutscbe med . Wchnscbr ., 57 : 1362 - 1365,1931 . 7 . KANAVEL, A . B . Tuberculosis tenosynovitis of the hand . Surg ., Gynec . e" Obst ., 37 : 635-647, 1923 .

8 . KELLGREN, J . H . and BALL, J . Lesion in rheumatoid arthritis, a clinical pathological study . Ann . Rbeumat . Dis., 9 : 48 -65, 1 95 0 . 9 . KESTLER, 0 . C . Collagenous pseudotumors of the hand . Ann . Rbeumat . Dis ., 2 : 282-288, 1952 . lo. KLINGE, F . Das Gewelisbild des fieberhoften Rheumatismus . Virchows Arcb . f. path . Anat ., 286 : 333 -388, 1 93 2 1 1 . MASON, M . L . Tuberculous tenosynovitis of the hand . Surg., Gynec . er Obst ., 59 : 363 - 396. 1934 . 12 . VISCHER, A . Beitrage zur Histologie der chronischen, nicht tuberklosen Tendovaginitis, Unbesondere der stenosierenden Form . Karresp . bl . Schiveir . Arzte ., 49 : 103-115, 1919 .

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