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Correction of Swan-Neck Deformity in Rheumatoid Arthritis
Correction of Swan-Neck Deformity in Rheumatoid Arthritis ROBERT E. LEACH, M.D. STUART H. BAUMGARD, M.D.
Although surgery is not the ultimate answer in rheumatoid arthritis, until our medical colleagues discover and eradicate the causative agent, the orthopedic surgeon will playa role in the management of this disease. Ascertaining the precise time for surgical intervention in the rheumatoid patient is difficult. Most procedures are performed on joints after partial destruction, deformity, and some loss of function of the involved joint. It has been hoped that the early synovectomies, advocated by a few authors,.·4 will preserve the integrity and function of involved joints. However, there has been no report of a good comparative series that proves the efficacy of early operation. In the hand, in particular, synovitis, deformity, and joint destruction may be progressing while the patient maintains reasonable function. It is difficult to persuade internist, patient, or sometimes even the surgeon that surgical intervention should be undertaken at this point. Yet this may be the best time to perform such surgical procedures as tenosynovectomy or synovectomy. Time and further studies will provide the answer to this hypothesis. Rheumatoid arthritis may cause anyone of three conditions at the proximal interphalangeal (PIP) joint. The joint may be destroyed by synovial pannus with resulting partial fibrous ankylosis or gross joint instability. If the joint synovium invades the overlying central slip of the extensor tendon causing it to rupture or attenuate, a boutonniere deformity characterized by hyperflexion at the PIP joint and hyperextension at the distal interphalangeal (DIP) joint is produced. A third deformity, the swan-neck, is caused by contracture of the intrinsic lateral bands that migrate dorsally and pull the PIP joint into hyperextension. This hyperextension increases tension on the flexor profundus tendon, and the stronger flexor tendon stretches the extensor at the DIP joint, producing a flexion deformity at this joint. The swan-neck deformity thus becomes apparent with hyperextension at the PIP joint and flexion at the DIP joint. Surgical Clinics of North America- Vol. 48, No.3, June, 1968
661
662
ROBERT
E.
LEACH, STUART
H.
BAUMGARD
With a simple synovitis of the PIP joint, synovectomy may preserve the joint and prevent the boutonniere deformity from developing. Once the joint has been destroyed the choice is between arthrodesis or the insertion of a metallic prosthesis. Until these prostheses can be evaluated more thoroughly, their use should be restricted to those surgeons who have been instrumental in developing the techniques. In the presence of a boutonniere deformity, Fowler 3 and Dolphin2 have advocated cutting the distal extensor tendon proximal to the DIP joint but distal to the joining of the lateral bands. This allows the distal joint to be flexed actively. Arthrodesis of the PIP joint in the position of function is an alternative procedure. Tightness of the intrinsic bands may be tested by hyperextending the metacarpophalangeal (MP) joint and passively flexing the PIP and DIP joints. The joints of normalpersons may be flexed completely. Those with intrinsic band tightness will have some or complete lack of flexion of the two distal joints. The Littler 5 release for intrinsic contractures is excellent for many patients. It is particularly valuable in those instances in which PIP flexion is restricted with the MP joint in extension. Some rheumatoid patients, however, have restriction of PIP joint flexion even with the MP joint in flexion. For these patients the Littler release may not be effective. In the patient who has an intrinsic contracture secondary to rheumatoid arthritis and who has a good PIP joint space roentgenographically, we employ the lateral band mobilization technique developed by Nalebuff6 et al. This is effective in allowing flexion of the PIP joint, regardless of the position of the MP joint. It is more effective if performed in the earlier stages of the disease when some active flexion at the PIP joint is still possible. Nalebuff believes that when the PIP joint is hyperextended and cannot be actively flexed by the patient, even lateral band mobilization may not be enough. This procedure may have to be combined with a capsular reefing on the volar surface or the sublimis tenodesis of Swanson. 7 In our experience if roentgenograms show a good joint space, even in those patients in whom flexion is not possible at the PIP joint before operation, lateral band mobilization will provide some flexion at the PIP joint after operation. When joint changes are present with the swan-neck deformity, arthrodesis of the PIP joint is more effective. OPERATIVE PROCEDURE The incision found to be most useful starts on the dorsal aspect of the middle phalanx proximal to the DIP joint, swings to the midlateral line at the PIP joint, and then dorsally over the proximal phalanx (Fig. 1). The skin and subcutaneous tissues are separated from the dorsal extensor mechanism, and the middle slip of the extensor is inspected. This middle slip over the PIP joint must be intact for lateral band mobilization to be performed. The lateral bands are traced from the transverse fibers of the extensor hood at the MP joint out to where they join over the middle phalanx. An incision is made separating the lateral
CORRECTION OF SWAN-NECK DEFORMITY IN RHEUMATOID ARTHRITIS
Figure 1.
Skin incision.
Figure 2. Hemostat under lateral band which has been partially mobilized. Dotted line indicates extension of inci ion.
Figure 3. Black line indicates incision for lateral band mobilization; eparation of the lateral bands is performed on the radial and ulnar aspects of the finger.
FINGER EXTENDED DORSAL VIEW INCISION
LATERAL VIEW
663
664
ROBERT
E.
LEACH, STUART
H. BAUMGARD
Figure 4. After mobilization, complete flexion of PIP and DIP joints should be possible with MP joint in extension. Arrow points to lateral band.
bands from the middle slip of the extensor, starting at the junction of the lateral bands over the middle phalanx, and going proximally to the transverse fibers of the hood of the MP joint (Fig. 2). This separation of the lateral bands from the middle slip of the extensor is performed on both sides of the finger (Fig. 3). Easy access is provided to the PIP joint where a complete synovectomy may be accomplished if needed. In the late stages of intrinsic contracture, there is often little synovium in this jOint. If synovectomy is performed, care must be taken not to injure the fibers of the middle slip of the extensor tendon. Stretching or rupturing these fibers will produce a boutonniere deformity. However, following lateral band mobilization, as long as the central slip is intact, a boutonniere deformity will not be produced and good extension of the middle and distal phalanges will still be possible. The lateral bands are dissected volarly so that they fall below the axis of flexion of the PIP joint. The effectiveness of this release should be tested by hyperextending the MP joint and flexing the distal two phalanges (Fig. 4). The distal phalanges should be able to be completely flexed and, if this is not possible, it should be determined if the lateral bands have been mobilized all the way back to the MP joint. If complete flexion is not still possible, the collateral ligaments of the PIP joint may have to be partially incised. The PIP joint is positioned at approximately 70 to 90 degrees of flexion and the skin is closed. The closure is often tight, and it may be necessary to suture the skin distally leaving a small defect over the proximal phalanx to be filled with a skin graft. The skin closure may be the limiting factor in how much flexion it is possible to gain.
POSTOPERATIVE CARE Postoperative care is as important as the operative technique. Fluffed sponges in the hand and between the fingers are covered by a Kerlix and an elastic bandage. The MP joints are flexed to 70 degrees and the PIP joints between 70 and 90 degrees. Adhesive tape is run from the dorsum of the hand over the MP, PIP, and DIP joints and
CORRECTION OF SWAN-NECK DEFORMITY IN RHEUMATOID ARTHRITIS
665
fastened to the bandages at the wrist to keep the fingers flexed. Usually this bandage is changed on the fourth to sixth postoperative day and new dressings applied. Suture removal is delayed until three weeks after operation because the wounds heal more slowly with attempted early finger motion. During this three-week period the fingers are kept taped down, but the patient is encouraged to try to flex the joints further to make a completely closed fist. Following suture removal, the patient does active assistive exercises. In patients with severe hyperextension of the PIP joint, it is our intention to create a flexion contracture of approximately 15 to 20 degrees at the PIP joint. Once the finger starts drifting back into neutral, it will inevitably go into hyperextension. The patient should tape down his fingers in 90 degrees of flexion at the PIP joint every night for a few months. Even in patients who preoperatively had little or no active flexion at the PIP joint, most patients postoperatively have had flexion for approximately 15 to 70 degrees. Active and active assistive exercises must be continued by the patient. Several have been seen in whom lateral band mobilizations were performed, and early results were excellent. After several years the patients had stopped exercising and the fingers have gone back to a neutral or partially hyperextended position. Although they retained some ability to overcome this, it was becoming increasingly more difficult. In those patients who kept exercising, this did not tend to occur (Fig. 5). The results of this operative technique have generally been good, and the procedure has been found satisfactory to both surgeons and patients.
Figure 5. Left hand postoperatively after lateral band mobilization. Preoperatively, patient had flexion of only 10 degrees at PIP joint. Right hand not operated on because function is still good.
666
ROBERT
E. LEACH, STUART H. BAUMGARD
SUMMARY An operative method for overcoming the swan-neck deformity secondary to an intrinsic contracture in rheumatoid arthritis has been presented. This involves mobilization of the lateral bands in a manner previously described by N alebuff which allows them to fall below the axis of flexion of the PIP joint. A rigid postoperative routine has been presented that is thought to be essential to the success of the operation.
REFERENCES 1. Clayton, M. L.: Surgical treatment at the wrist in rheumatoid arthritis: A review of thirtyseven patients. J. Bone Joint Surg. 47-A:741-750 (June) 1965.
2. Dolphin, J. A.: Extensor tenotomy for chronic boutonniere deformity of the finger; report of two cases. J. Bone Joint Surg. 47-A:161-164 (Jan.) 1965. 3. Fowler, S. B.: Quoted by Littler, J. W., and Eaton, R G.: Redistribution of forces in the correction of the boutonniere deformity. J. Bone Joint Surg. 49-A:1267-1274 (Oct.) 1967. 4. Leach, R E.: Surgery in the conservative treatment of rheumatoid arthritis of the hand. Lahey Clin. Found. Bull. 13:281-286 (Oct.-Dec.) 1964. 5. Littler, J. W.: Quoted by Harris, C., Jr., and Riordan, D. C.: Intrinsic contracture in hand and its surgical treatment. J. Bone Joint Surg. 36-A:10-18 (Jan.) 1954. 6. Nalebuff, E. A., Potter, T. A., and Tomaselli, R: Surgery of swan neck deformity of the rheumatoid hand: A new approach (Abstract). Arthritis & Rheumatism 6:289 (June) 1963. 7. Swanson, A. B.: Surgery of the hand in cerebral palsy and the swan-neck deformity. J. Bone Joint Surg. 42-A:951-964 (Sept.) 1960.
Although surgery is not the ultimate answer in rheumatoid arthritis, until our medical colleagues discover and eradicate the causative agent, the orthopedic surgeon will playa role in the management of this disease. Ascertaining the precise time for surgical intervention in the rheumatoid patient is difficult. Most procedures are performed on joints after partial destruction, deformity, and some loss of function of the involved joint. It has been hoped that the early synovectomies, advocated by a few authors,.·4 will preserve the integrity and function of involved joints. However, there has been no report of a good comparative series that proves the efficacy of early operation. In the hand, in particular, synovitis, deformity, and joint destruction may be progressing while the patient maintains reasonable function. It is difficult to persuade internist, patient, or sometimes even the surgeon that surgical intervention should be undertaken at this point. Yet this may be the best time to perform such surgical procedures as tenosynovectomy or synovectomy. Time and further studies will provide the answer to this hypothesis. Rheumatoid arthritis may cause anyone of three conditions at the proximal interphalangeal (PIP) joint. The joint may be destroyed by synovial pannus with resulting partial fibrous ankylosis or gross joint instability. If the joint synovium invades the overlying central slip of the extensor tendon causing it to rupture or attenuate, a boutonniere deformity characterized by hyperflexion at the PIP joint and hyperextension at the distal interphalangeal (DIP) joint is produced. A third deformity, the swan-neck, is caused by contracture of the intrinsic lateral bands that migrate dorsally and pull the PIP joint into hyperextension. This hyperextension increases tension on the flexor profundus tendon, and the stronger flexor tendon stretches the extensor at the DIP joint, producing a flexion deformity at this joint. The swan-neck deformity thus becomes apparent with hyperextension at the PIP joint and flexion at the DIP joint. Surgical Clinics of North America- Vol. 48, No.3, June, 1968
661
662
ROBERT
E.
LEACH, STUART
H.
BAUMGARD
With a simple synovitis of the PIP joint, synovectomy may preserve the joint and prevent the boutonniere deformity from developing. Once the joint has been destroyed the choice is between arthrodesis or the insertion of a metallic prosthesis. Until these prostheses can be evaluated more thoroughly, their use should be restricted to those surgeons who have been instrumental in developing the techniques. In the presence of a boutonniere deformity, Fowler 3 and Dolphin2 have advocated cutting the distal extensor tendon proximal to the DIP joint but distal to the joining of the lateral bands. This allows the distal joint to be flexed actively. Arthrodesis of the PIP joint in the position of function is an alternative procedure. Tightness of the intrinsic bands may be tested by hyperextending the metacarpophalangeal (MP) joint and passively flexing the PIP and DIP joints. The joints of normalpersons may be flexed completely. Those with intrinsic band tightness will have some or complete lack of flexion of the two distal joints. The Littler 5 release for intrinsic contractures is excellent for many patients. It is particularly valuable in those instances in which PIP flexion is restricted with the MP joint in extension. Some rheumatoid patients, however, have restriction of PIP joint flexion even with the MP joint in flexion. For these patients the Littler release may not be effective. In the patient who has an intrinsic contracture secondary to rheumatoid arthritis and who has a good PIP joint space roentgenographically, we employ the lateral band mobilization technique developed by Nalebuff6 et al. This is effective in allowing flexion of the PIP joint, regardless of the position of the MP joint. It is more effective if performed in the earlier stages of the disease when some active flexion at the PIP joint is still possible. Nalebuff believes that when the PIP joint is hyperextended and cannot be actively flexed by the patient, even lateral band mobilization may not be enough. This procedure may have to be combined with a capsular reefing on the volar surface or the sublimis tenodesis of Swanson. 7 In our experience if roentgenograms show a good joint space, even in those patients in whom flexion is not possible at the PIP joint before operation, lateral band mobilization will provide some flexion at the PIP joint after operation. When joint changes are present with the swan-neck deformity, arthrodesis of the PIP joint is more effective. OPERATIVE PROCEDURE The incision found to be most useful starts on the dorsal aspect of the middle phalanx proximal to the DIP joint, swings to the midlateral line at the PIP joint, and then dorsally over the proximal phalanx (Fig. 1). The skin and subcutaneous tissues are separated from the dorsal extensor mechanism, and the middle slip of the extensor is inspected. This middle slip over the PIP joint must be intact for lateral band mobilization to be performed. The lateral bands are traced from the transverse fibers of the extensor hood at the MP joint out to where they join over the middle phalanx. An incision is made separating the lateral
CORRECTION OF SWAN-NECK DEFORMITY IN RHEUMATOID ARTHRITIS
Figure 1.
Skin incision.
Figure 2. Hemostat under lateral band which has been partially mobilized. Dotted line indicates extension of inci ion.
Figure 3. Black line indicates incision for lateral band mobilization; eparation of the lateral bands is performed on the radial and ulnar aspects of the finger.
FINGER EXTENDED DORSAL VIEW INCISION
LATERAL VIEW
663
664
ROBERT
E.
LEACH, STUART
H. BAUMGARD
Figure 4. After mobilization, complete flexion of PIP and DIP joints should be possible with MP joint in extension. Arrow points to lateral band.
bands from the middle slip of the extensor, starting at the junction of the lateral bands over the middle phalanx, and going proximally to the transverse fibers of the hood of the MP joint (Fig. 2). This separation of the lateral bands from the middle slip of the extensor is performed on both sides of the finger (Fig. 3). Easy access is provided to the PIP joint where a complete synovectomy may be accomplished if needed. In the late stages of intrinsic contracture, there is often little synovium in this jOint. If synovectomy is performed, care must be taken not to injure the fibers of the middle slip of the extensor tendon. Stretching or rupturing these fibers will produce a boutonniere deformity. However, following lateral band mobilization, as long as the central slip is intact, a boutonniere deformity will not be produced and good extension of the middle and distal phalanges will still be possible. The lateral bands are dissected volarly so that they fall below the axis of flexion of the PIP joint. The effectiveness of this release should be tested by hyperextending the MP joint and flexing the distal two phalanges (Fig. 4). The distal phalanges should be able to be completely flexed and, if this is not possible, it should be determined if the lateral bands have been mobilized all the way back to the MP joint. If complete flexion is not still possible, the collateral ligaments of the PIP joint may have to be partially incised. The PIP joint is positioned at approximately 70 to 90 degrees of flexion and the skin is closed. The closure is often tight, and it may be necessary to suture the skin distally leaving a small defect over the proximal phalanx to be filled with a skin graft. The skin closure may be the limiting factor in how much flexion it is possible to gain.
POSTOPERATIVE CARE Postoperative care is as important as the operative technique. Fluffed sponges in the hand and between the fingers are covered by a Kerlix and an elastic bandage. The MP joints are flexed to 70 degrees and the PIP joints between 70 and 90 degrees. Adhesive tape is run from the dorsum of the hand over the MP, PIP, and DIP joints and
CORRECTION OF SWAN-NECK DEFORMITY IN RHEUMATOID ARTHRITIS
665
fastened to the bandages at the wrist to keep the fingers flexed. Usually this bandage is changed on the fourth to sixth postoperative day and new dressings applied. Suture removal is delayed until three weeks after operation because the wounds heal more slowly with attempted early finger motion. During this three-week period the fingers are kept taped down, but the patient is encouraged to try to flex the joints further to make a completely closed fist. Following suture removal, the patient does active assistive exercises. In patients with severe hyperextension of the PIP joint, it is our intention to create a flexion contracture of approximately 15 to 20 degrees at the PIP joint. Once the finger starts drifting back into neutral, it will inevitably go into hyperextension. The patient should tape down his fingers in 90 degrees of flexion at the PIP joint every night for a few months. Even in patients who preoperatively had little or no active flexion at the PIP joint, most patients postoperatively have had flexion for approximately 15 to 70 degrees. Active and active assistive exercises must be continued by the patient. Several have been seen in whom lateral band mobilizations were performed, and early results were excellent. After several years the patients had stopped exercising and the fingers have gone back to a neutral or partially hyperextended position. Although they retained some ability to overcome this, it was becoming increasingly more difficult. In those patients who kept exercising, this did not tend to occur (Fig. 5). The results of this operative technique have generally been good, and the procedure has been found satisfactory to both surgeons and patients.
Figure 5. Left hand postoperatively after lateral band mobilization. Preoperatively, patient had flexion of only 10 degrees at PIP joint. Right hand not operated on because function is still good.
666
ROBERT
E. LEACH, STUART H. BAUMGARD
SUMMARY An operative method for overcoming the swan-neck deformity secondary to an intrinsic contracture in rheumatoid arthritis has been presented. This involves mobilization of the lateral bands in a manner previously described by N alebuff which allows them to fall below the axis of flexion of the PIP joint. A rigid postoperative routine has been presented that is thought to be essential to the success of the operation.
REFERENCES 1. Clayton, M. L.: Surgical treatment at the wrist in rheumatoid arthritis: A review of thirtyseven patients. J. Bone Joint Surg. 47-A:741-750 (June) 1965.
2. Dolphin, J. A.: Extensor tenotomy for chronic boutonniere deformity of the finger; report of two cases. J. Bone Joint Surg. 47-A:161-164 (Jan.) 1965. 3. Fowler, S. B.: Quoted by Littler, J. W., and Eaton, R G.: Redistribution of forces in the correction of the boutonniere deformity. J. Bone Joint Surg. 49-A:1267-1274 (Oct.) 1967. 4. Leach, R E.: Surgery in the conservative treatment of rheumatoid arthritis of the hand. Lahey Clin. Found. Bull. 13:281-286 (Oct.-Dec.) 1964. 5. Littler, J. W.: Quoted by Harris, C., Jr., and Riordan, D. C.: Intrinsic contracture in hand and its surgical treatment. J. Bone Joint Surg. 36-A:10-18 (Jan.) 1954. 6. Nalebuff, E. A., Potter, T. A., and Tomaselli, R: Surgery of swan neck deformity of the rheumatoid hand: A new approach (Abstract). Arthritis & Rheumatism 6:289 (June) 1963. 7. Swanson, A. B.: Surgery of the hand in cerebral palsy and the swan-neck deformity. J. Bone Joint Surg. 42-A:951-964 (Sept.) 1960.