- Email: [email protected]
Clinical update: surgical management of rheumatoid hand
Comment
Clinical update: surgical management of rheumatoid hand Rheumatoid arthritis is often first identified in the upper extremity, with inflammation to the wrist, metacarpophalangeal joints, and proximal interphalangeal joints—this pattern is defined as rheumatoid hand disease. Chronic synovial proliferation damages ligaments, impairs tendon gliding, destroys joints, and causes compressive neuropathy and muscular disuse atrophy. Functional and cosmetic changes in the hand could affect a patient’s employment prospects, lead to loss of independence, and cause social isolation. Preservation of hand function requires the use of medical, physical, and surgical means. Although improved medical treatment has reduced the need for surgery, such surgery is not yet obsolete. There are substantial differences about surgical indications between rheumatologists and hand surgeons.1 The lack of randomised trials makes any treatment plan a matter of debate, and thus collaborative relationships between specialists, including implementation of appropriate clinical studies, are important to provide the best care. The goals of surgery are four-fold: relief of pain, restoration of function, prevention of future deformity (usually considered in early disease), and improvement of hand cosmesis. The improvement in the hand’s appearance after surgery is by no means trivial and is often regarded as important for patients’ satisfaction because of the pain-relieving benefits provided by the surgical procedures.2 Deformity does not always need surgery, but cannot be entirely disregarded. Waiting for severe or end-stage disease will restrict treatment options and reduce final functional outcome. Active rheumatoid disease does not preclude surgical intervention, but lack of response to an adequate medical programme is a prerequisite. Continuing medical management in conjunction with prophylactic surgery could even increase the chance of disease remission.3 Many drugs, including methotrexate and prednisone, can be continued perioperatively without substantial risk of postoperative surgical complications.4 Early in the disease process, the focus of both medical and surgical management should emphasise maintenance of normal structure and function in the hand. Early decompression of the median nerve and flexor tenosynovectomy is recommended when carpal tunnel syndrome impairs grasp, feeling, and proprioception 372
within the hand, which can occur in as many as 80% of patients with rheumatoid arthritis.5 Compressive neuropathies are often overlooked, because sensory disturbances might be regarded as a minor annoyance compared with other problems. 90% of patients show improvements in median nerve function after surgery, even in those who have had rheumatoid arthritis for longer than 15 years.5 Tenosynovitis that limits tendon motion could affect extrinsic extensors and flexors, and intrinsic tendons. Proliferative tenosynovium is characterised by pain, swelling, palpable crepitus, and impaired active movement, and contains increased concentrations of metalloproteinases, collagenases, and cytokines. It may invade and weaken tendons, occasionally causing rupture.6 Tenosynovectomy prevents rupture in patients at risk.7 Such procedures are most common dorsally at the wrist, in finger flexor sheaths, and in the carpal tunnel. In one study,5 84% of patients were satisfied with the outcome of flexor tenosynovectomy, with recurrent inflammation seen in only 10% of patients over 5 years. In chronically inflamed joints, the same destructive process distends and damages capsuloligamentous structures, and causes bony erosions and cartilage destruction. When medical management fails to control inflammation, synovectomy reduces joint pain and swelling, and could delay deformity and articular destruction when used in early disease.8,9 This process could also obviate the need for more complex surgical intervention and even circumvent the need for other treatments.10 At surgery, mild joint-deformity can be corrected without joint replacement. In a multicentre study,11 synovectomy did not prevent recurrence or produce radiographic improvement beyond 5 years. However, a subsequent randomised study10 of 48 patients showed a positive effect of synovectomy in patients refractory to medical management. As a primary endpoint of the study, patients in the surgical treatment group showed a significant reduction in the number of swollen and painful joints. This improvement in pain was also accompanied by a significant improvement in erythrocyte sedimentation rate and concentration of C-reactive protein. More than 40% of surgically treated patients remained in remission in 3-year follow-up, during which articular damage did not progress. www.thelancet.com Vol 370 August 4, 2007
Comment
Figure 1: Dorsal subluxation of ulna and signs of early caput ulnae syndrome Recurrent synovitis at distal radial-ulnar joint has resulted in dorsal migration of ulnar, in reference to radius producing dorsal prominence over back of wrist. Rupture of extensor tendons might be due to persistent synovitis and attritional wear over arthritic ulnar head.
With disease progression, synovitis eventually leads to joint instability and destructive arthritis. The wrist rests in radial deviation, with ulnar translocation and supination of the carpus. These changes are seen in 70% of patients 3 years after disease onset.12–14 Dorsal subluxation of the ulnar head also occurs, affecting forearm rotation and causing many ruptures of the digital extensor tendon, which is called the caput ulnae syndrome (figure 1).14 Wrist deformity can be corrected and extensor rupture prevented with early intervention, including ulnar head resection, wrist extensor tendon rebalancing, and tenosynovectomy.12 When radiocarpal arthritis is present, early intervention remains possible. Preservation of the midcarpal joint enables radiolunate arthrodesis to realign the carpus, while maintaining a functional arc of wrist motion. In advanced cases, surgical options might need to be restricted to wrist arthrodesis and tendon transfers. A study of 25 patients3 followed up for 13 years after limited wrist fusion, resection of the distal ulna, and extensor tenosynovectomy showed resolution of symptoms in 22 patients. Grip strength and forearm rotation were greatly improved. The midcarpal joint space remained preserved in 16 of the 25 wrists. Overall, carpal arthrodesis is one of the few surgical procedures that consistently reduces pain and improves hand function in patients with rheumatoid arthritis. Chronic synovitis in metacarpophalangeal joints can damage the restraining collateral ligaments and the sagittal band, which balances extrinsic extensor and intrinsic tendon forces. The result is metacarpophalangeal ulnar deviation and palmar subluxation, with ulnar subluxation of the extensor mechanism. Loss of the joint extension www.thelancet.com Vol 370 August 4, 2007
takes place, causing a functional problem with grasp and release. More extensive destruction and irreducible deformity to the joint requires joint replacement. Silicone implants function as spacers after resection arthroplasty (figure 2). When enveloped in capsule and scar tissue, these implants provide stability and reliable pain relief.15 Active metacarpophalangeal motion and digit alignment improve initially. Over time, implants can fracture, in association with recurrent deformity and loss of motion. Of 381 patients with metacarpophalangeal arthroplasty, 83% and 63% still have their implanted joints intact at 10 and 17 years, respectively.16 Crossed intrinsic transfer, soft-tissue rebalancing, and wrist realignment with partial or total wrist-fusion have all been associated with improved implant survival.16,17 Patients’ satisfaction with metacarpophalangeal arthroplasty has been linked to functional improvements and to cosmetic improvements of the hand.2,18 New metacarpophalangeal-implant designs with improved fixation methods, new materials, and unconstrained anatomical articular-surface components could improve long-term results of arthroplasty. A recent review19 of these newer joint designs used in patients with osteoarthritis noted a 40% improvement in grip strength and pinch strength, with only two of 19 patients noting joint pain at 1 year postoperatively. Joint stability in these designs depends on soft tissues, including functioning collateral ligaments, which means that implantation must occur before advanced deformity occurs. The early results with this new generation of implants are encouraging. Randomised trials will be needed to study acceptance over established silicone-implant designs.20
Figure 2: Late rheumatoid arthritis in 62-year-old patient Right hand shows evidence of metacarpophalangeal subluxation and angular deformities of all fingers. Surgical correction of left hand consisted of metacarpophalangeal silicone arthroplasty, proximal and distal interphalangeal fusions, and partial thumb fusion, and resulted in improved function, pain, and cosmesis.
373
Comment
We declare that we have no conflict of interest. 1
2
3
4
5 6 Figure 3: Recurrent synovitis Condition seen in imbalances of intrinsic and extrinsic extensor tendon function, leading to development of swan-neck deformities. 7
At the interphalangeal joints, swan-neck and boutonnière deformities often develop, and become rigid over time (figure 3). Angular deformities also occur, especially in the thumb. Wrist deviation and metacarpophalangeal ulnar-drift affect proximal interphalangeal position, and could need correction before proximal interphalangeal surgery. The swan neck deformity is particularly disabling. Timely intervention is desirable to correct early swan-neck deformities, because rigid deformities usually need arthrodesis in a compromised position to provide the best function. Early correction of swan-neck deformities often consists of tenodesis procedures that restrict proximal interphalangeal hyperextension. Arthroplasty of rheumatoid proximal interphalangeal joints has provided poor results and is not often indicated. Successful management of the rheumatoid hand needs a collaborative effort from rheumatologists, surgeons, therapists, and patients. Such working relationships should allow optimum preservation of function over time. Future advances benefiting patients will be facilitated by surgeons and medical specialists working together. *Steven L Moran, Allen T Bishop Divisions of Plastic Surgery (SLM) and Hand Surgery (SLM, ATB), Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905, USA [email protected]
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Alderman AK, Ubel PA, Kim HM, Fox DA, Chung KC. Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists and hand surgeons. J Rheumatol 2003; 30: 1464–72. Mandl LA, Galvin DH, Bosch JP, et al. Metacarpophalangeal arthroplasty in rheumatoid arthritis: what determines satisfaction with surgery? J Rheumatol 2002; 29: 2488–91. Ishikawa H, Murasawa A, Nakazono K. Long-term follow-up study of radiocarpal arthrodesis for the rheumatoid wrist. J Hand Surg 2005; 30: 658–66. Jain A, Witbreuk M, Ball C, Nanchahal J. Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery. J Hand Surg [Am] 2002; 27: 449–55. Tolat AR, Stanley JK, Evans RA. Flexor tenosynovectomy and tenolysis in longstanding rheumatoid arthritis. J Hand Surg [Br] 1996; 21: 538–43. Jain A, Nanchahal J, Troeberg L, Green P, Brennan F. Production of cytokines, vascular endothelial growth factor, metalloproteinases, and tissue inhibitor of metalloproteinases 1 in tenosynovium demonstrates its potential for tendon destruction in rheumatoid arthritis. Arthitis Rheum 2001; 44: 1754–60. Ryu J, Saito S, Honda T, Yamamoto K. Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. J Hand Surg [Br] 1998; 23: 658–61. Nicolle FV, Holt PJL, Calnan JS. Prophylactic synovectomy of the joints of the rheumatoid hand. Ann Rheum Dis 1971; 30: 476–80. Wilde AH. Synovectomy of the proximal interphalangeal joint of the finger in rheumatoid arthritis. J Bone Joint Surg 1974; 56: 71–78. Nakamura H, Nagashima M, Ishigami S, Wauke K, Yoshino S. The anti-rheumatic effect of multiple synovectomy in patients with refractory arthritis. Int Orthop 2000; 24: 242–45. McEwen C. Multicenter evaluation of synovectomy in the treatment of rheumatoid arthritis: report of results at the end of five years. J Rheumatol 1988; 15: 765–69. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrah procedure. J Hand Surg 1992; 17: 1109–17. Hindley CJ, Stanely JK. The rheumatoid wrist: patterns of disease progression. A review of 50 cases. J Hand Surg 1991; 16B: 275–79. Vaughan-Jackson OJ. Attrition ruptures of tendons as a factor in production of deformities in the rheumatoid hand. Proc R Soc Med 1959; 52: 132–34. Swanson AB. Flexible implant arthroplasty for arthritic finger joints: rationale, technique, and results of treatment. J Bone Joint Surg 1972; 54: 435–55. Trail IA, Martin JA, Nuttall D, Stanely JK. Seventeen-year survivorship analysis of silastic metacarpophalangeal joint replacement. J Bone Joint Surg [Br] 2004; 86-B: 1002–06. Pereira JA, Belcher HJCR. A comparison of metacarpophalangeal joint silastic arthroplasty with or without crossed intrinsic transfer. J Hand Surg 2001; 26B: 229–34. Chung KC, Kotsis SV, Kim HM, Burke FD, Wilgis EF. Reasons why rheumatoid arthritis patients seek surgical treatment for hand deformities. J Hand Surg 2006; 31: 289–94. Parker W, Moran SL, Hormel KB, Rizzo M, Beckenbaugh RD. Nonrheumatoid metacarpophalangeal joint arthritis. Unconstrained pyrolytic carbon implants: indications, technique and outcomes. Hand Clin 2006; 22: 183–93. Cook SD, Beckenbaugh RD, Redondo J, et al. Long-term follow-up of pyrolytic carbon metacarpophalangeal implants. J Bone Joint Surg 1999; 81: 635–48.
www.thelancet.com Vol 370 August 4, 2007
Clinical update: surgical management of rheumatoid hand Rheumatoid arthritis is often first identified in the upper extremity, with inflammation to the wrist, metacarpophalangeal joints, and proximal interphalangeal joints—this pattern is defined as rheumatoid hand disease. Chronic synovial proliferation damages ligaments, impairs tendon gliding, destroys joints, and causes compressive neuropathy and muscular disuse atrophy. Functional and cosmetic changes in the hand could affect a patient’s employment prospects, lead to loss of independence, and cause social isolation. Preservation of hand function requires the use of medical, physical, and surgical means. Although improved medical treatment has reduced the need for surgery, such surgery is not yet obsolete. There are substantial differences about surgical indications between rheumatologists and hand surgeons.1 The lack of randomised trials makes any treatment plan a matter of debate, and thus collaborative relationships between specialists, including implementation of appropriate clinical studies, are important to provide the best care. The goals of surgery are four-fold: relief of pain, restoration of function, prevention of future deformity (usually considered in early disease), and improvement of hand cosmesis. The improvement in the hand’s appearance after surgery is by no means trivial and is often regarded as important for patients’ satisfaction because of the pain-relieving benefits provided by the surgical procedures.2 Deformity does not always need surgery, but cannot be entirely disregarded. Waiting for severe or end-stage disease will restrict treatment options and reduce final functional outcome. Active rheumatoid disease does not preclude surgical intervention, but lack of response to an adequate medical programme is a prerequisite. Continuing medical management in conjunction with prophylactic surgery could even increase the chance of disease remission.3 Many drugs, including methotrexate and prednisone, can be continued perioperatively without substantial risk of postoperative surgical complications.4 Early in the disease process, the focus of both medical and surgical management should emphasise maintenance of normal structure and function in the hand. Early decompression of the median nerve and flexor tenosynovectomy is recommended when carpal tunnel syndrome impairs grasp, feeling, and proprioception 372
within the hand, which can occur in as many as 80% of patients with rheumatoid arthritis.5 Compressive neuropathies are often overlooked, because sensory disturbances might be regarded as a minor annoyance compared with other problems. 90% of patients show improvements in median nerve function after surgery, even in those who have had rheumatoid arthritis for longer than 15 years.5 Tenosynovitis that limits tendon motion could affect extrinsic extensors and flexors, and intrinsic tendons. Proliferative tenosynovium is characterised by pain, swelling, palpable crepitus, and impaired active movement, and contains increased concentrations of metalloproteinases, collagenases, and cytokines. It may invade and weaken tendons, occasionally causing rupture.6 Tenosynovectomy prevents rupture in patients at risk.7 Such procedures are most common dorsally at the wrist, in finger flexor sheaths, and in the carpal tunnel. In one study,5 84% of patients were satisfied with the outcome of flexor tenosynovectomy, with recurrent inflammation seen in only 10% of patients over 5 years. In chronically inflamed joints, the same destructive process distends and damages capsuloligamentous structures, and causes bony erosions and cartilage destruction. When medical management fails to control inflammation, synovectomy reduces joint pain and swelling, and could delay deformity and articular destruction when used in early disease.8,9 This process could also obviate the need for more complex surgical intervention and even circumvent the need for other treatments.10 At surgery, mild joint-deformity can be corrected without joint replacement. In a multicentre study,11 synovectomy did not prevent recurrence or produce radiographic improvement beyond 5 years. However, a subsequent randomised study10 of 48 patients showed a positive effect of synovectomy in patients refractory to medical management. As a primary endpoint of the study, patients in the surgical treatment group showed a significant reduction in the number of swollen and painful joints. This improvement in pain was also accompanied by a significant improvement in erythrocyte sedimentation rate and concentration of C-reactive protein. More than 40% of surgically treated patients remained in remission in 3-year follow-up, during which articular damage did not progress. www.thelancet.com Vol 370 August 4, 2007
Comment
Figure 1: Dorsal subluxation of ulna and signs of early caput ulnae syndrome Recurrent synovitis at distal radial-ulnar joint has resulted in dorsal migration of ulnar, in reference to radius producing dorsal prominence over back of wrist. Rupture of extensor tendons might be due to persistent synovitis and attritional wear over arthritic ulnar head.
With disease progression, synovitis eventually leads to joint instability and destructive arthritis. The wrist rests in radial deviation, with ulnar translocation and supination of the carpus. These changes are seen in 70% of patients 3 years after disease onset.12–14 Dorsal subluxation of the ulnar head also occurs, affecting forearm rotation and causing many ruptures of the digital extensor tendon, which is called the caput ulnae syndrome (figure 1).14 Wrist deformity can be corrected and extensor rupture prevented with early intervention, including ulnar head resection, wrist extensor tendon rebalancing, and tenosynovectomy.12 When radiocarpal arthritis is present, early intervention remains possible. Preservation of the midcarpal joint enables radiolunate arthrodesis to realign the carpus, while maintaining a functional arc of wrist motion. In advanced cases, surgical options might need to be restricted to wrist arthrodesis and tendon transfers. A study of 25 patients3 followed up for 13 years after limited wrist fusion, resection of the distal ulna, and extensor tenosynovectomy showed resolution of symptoms in 22 patients. Grip strength and forearm rotation were greatly improved. The midcarpal joint space remained preserved in 16 of the 25 wrists. Overall, carpal arthrodesis is one of the few surgical procedures that consistently reduces pain and improves hand function in patients with rheumatoid arthritis. Chronic synovitis in metacarpophalangeal joints can damage the restraining collateral ligaments and the sagittal band, which balances extrinsic extensor and intrinsic tendon forces. The result is metacarpophalangeal ulnar deviation and palmar subluxation, with ulnar subluxation of the extensor mechanism. Loss of the joint extension www.thelancet.com Vol 370 August 4, 2007
takes place, causing a functional problem with grasp and release. More extensive destruction and irreducible deformity to the joint requires joint replacement. Silicone implants function as spacers after resection arthroplasty (figure 2). When enveloped in capsule and scar tissue, these implants provide stability and reliable pain relief.15 Active metacarpophalangeal motion and digit alignment improve initially. Over time, implants can fracture, in association with recurrent deformity and loss of motion. Of 381 patients with metacarpophalangeal arthroplasty, 83% and 63% still have their implanted joints intact at 10 and 17 years, respectively.16 Crossed intrinsic transfer, soft-tissue rebalancing, and wrist realignment with partial or total wrist-fusion have all been associated with improved implant survival.16,17 Patients’ satisfaction with metacarpophalangeal arthroplasty has been linked to functional improvements and to cosmetic improvements of the hand.2,18 New metacarpophalangeal-implant designs with improved fixation methods, new materials, and unconstrained anatomical articular-surface components could improve long-term results of arthroplasty. A recent review19 of these newer joint designs used in patients with osteoarthritis noted a 40% improvement in grip strength and pinch strength, with only two of 19 patients noting joint pain at 1 year postoperatively. Joint stability in these designs depends on soft tissues, including functioning collateral ligaments, which means that implantation must occur before advanced deformity occurs. The early results with this new generation of implants are encouraging. Randomised trials will be needed to study acceptance over established silicone-implant designs.20
Figure 2: Late rheumatoid arthritis in 62-year-old patient Right hand shows evidence of metacarpophalangeal subluxation and angular deformities of all fingers. Surgical correction of left hand consisted of metacarpophalangeal silicone arthroplasty, proximal and distal interphalangeal fusions, and partial thumb fusion, and resulted in improved function, pain, and cosmesis.
373
Comment
We declare that we have no conflict of interest. 1
2
3
4
5 6 Figure 3: Recurrent synovitis Condition seen in imbalances of intrinsic and extrinsic extensor tendon function, leading to development of swan-neck deformities. 7
At the interphalangeal joints, swan-neck and boutonnière deformities often develop, and become rigid over time (figure 3). Angular deformities also occur, especially in the thumb. Wrist deviation and metacarpophalangeal ulnar-drift affect proximal interphalangeal position, and could need correction before proximal interphalangeal surgery. The swan neck deformity is particularly disabling. Timely intervention is desirable to correct early swan-neck deformities, because rigid deformities usually need arthrodesis in a compromised position to provide the best function. Early correction of swan-neck deformities often consists of tenodesis procedures that restrict proximal interphalangeal hyperextension. Arthroplasty of rheumatoid proximal interphalangeal joints has provided poor results and is not often indicated. Successful management of the rheumatoid hand needs a collaborative effort from rheumatologists, surgeons, therapists, and patients. Such working relationships should allow optimum preservation of function over time. Future advances benefiting patients will be facilitated by surgeons and medical specialists working together. *Steven L Moran, Allen T Bishop Divisions of Plastic Surgery (SLM) and Hand Surgery (SLM, ATB), Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905, USA [email protected]
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Alderman AK, Ubel PA, Kim HM, Fox DA, Chung KC. Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists and hand surgeons. J Rheumatol 2003; 30: 1464–72. Mandl LA, Galvin DH, Bosch JP, et al. Metacarpophalangeal arthroplasty in rheumatoid arthritis: what determines satisfaction with surgery? J Rheumatol 2002; 29: 2488–91. Ishikawa H, Murasawa A, Nakazono K. Long-term follow-up study of radiocarpal arthrodesis for the rheumatoid wrist. J Hand Surg 2005; 30: 658–66. Jain A, Witbreuk M, Ball C, Nanchahal J. Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery. J Hand Surg [Am] 2002; 27: 449–55. Tolat AR, Stanley JK, Evans RA. Flexor tenosynovectomy and tenolysis in longstanding rheumatoid arthritis. J Hand Surg [Br] 1996; 21: 538–43. Jain A, Nanchahal J, Troeberg L, Green P, Brennan F. Production of cytokines, vascular endothelial growth factor, metalloproteinases, and tissue inhibitor of metalloproteinases 1 in tenosynovium demonstrates its potential for tendon destruction in rheumatoid arthritis. Arthitis Rheum 2001; 44: 1754–60. Ryu J, Saito S, Honda T, Yamamoto K. Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. J Hand Surg [Br] 1998; 23: 658–61. Nicolle FV, Holt PJL, Calnan JS. Prophylactic synovectomy of the joints of the rheumatoid hand. Ann Rheum Dis 1971; 30: 476–80. Wilde AH. Synovectomy of the proximal interphalangeal joint of the finger in rheumatoid arthritis. J Bone Joint Surg 1974; 56: 71–78. Nakamura H, Nagashima M, Ishigami S, Wauke K, Yoshino S. The anti-rheumatic effect of multiple synovectomy in patients with refractory arthritis. Int Orthop 2000; 24: 242–45. McEwen C. Multicenter evaluation of synovectomy in the treatment of rheumatoid arthritis: report of results at the end of five years. J Rheumatol 1988; 15: 765–69. Ishikawa H, Hanyu T, Tajima T. Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrah procedure. J Hand Surg 1992; 17: 1109–17. Hindley CJ, Stanely JK. The rheumatoid wrist: patterns of disease progression. A review of 50 cases. J Hand Surg 1991; 16B: 275–79. Vaughan-Jackson OJ. Attrition ruptures of tendons as a factor in production of deformities in the rheumatoid hand. Proc R Soc Med 1959; 52: 132–34. Swanson AB. Flexible implant arthroplasty for arthritic finger joints: rationale, technique, and results of treatment. J Bone Joint Surg 1972; 54: 435–55. Trail IA, Martin JA, Nuttall D, Stanely JK. Seventeen-year survivorship analysis of silastic metacarpophalangeal joint replacement. J Bone Joint Surg [Br] 2004; 86-B: 1002–06. Pereira JA, Belcher HJCR. A comparison of metacarpophalangeal joint silastic arthroplasty with or without crossed intrinsic transfer. J Hand Surg 2001; 26B: 229–34. Chung KC, Kotsis SV, Kim HM, Burke FD, Wilgis EF. Reasons why rheumatoid arthritis patients seek surgical treatment for hand deformities. J Hand Surg 2006; 31: 289–94. Parker W, Moran SL, Hormel KB, Rizzo M, Beckenbaugh RD. Nonrheumatoid metacarpophalangeal joint arthritis. Unconstrained pyrolytic carbon implants: indications, technique and outcomes. Hand Clin 2006; 22: 183–93. Cook SD, Beckenbaugh RD, Redondo J, et al. Long-term follow-up of pyrolytic carbon metacarpophalangeal implants. J Bone Joint Surg 1999; 81: 635–48.
www.thelancet.com Vol 370 August 4, 2007