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Effects of Extensor Synovectomy and Excision of the Distal Ulna in Rheumatoid Arthritis on Long-Term Function
SCIENTIFIC ARTICLE
Effects of Extensor Synovectomy and Excision of the Distal Ulna in Rheumatoid Arthritis on Long-Term Function Abhilash Jain, PhD, Cathy Ball, MSc, Andrew J. Freidin, MBBS, Jagdeep Nanchahal, PhD
Purpose Objective outcomes data after excision of the distal ulna in rheumatoid arthritis are lacking. The aim of this study was to evaluate the functional results of this surgery in the long term. Methods We prospectively collected data on range of motion (22 wrists), visual analog pain scores (14 wrists), and grip strength measured using a Jamar dynamometer (20 hands) in a group of 23 patients (26 wrists) preoperatively and at 3 months, 12 months, and a minimum of 5 years postoperatively (range, 5.3–10.4 y). The Jebsen-Taylor hand function test was administered to 9 patients at the same time points. A subgroup of patients also underwent extensor carpi radialis longus to extensor carpi ulnaris tendon transfer (11 wrists). Results At one year, there were improvements in wrist pronation and supination, which were maintained at final follow-up. Active radial deviation decreased significantly at 3 months (p ⫽ .01) and one year (p ⫽ .02); this remained reduced at final follow-up (not significant). Wrist extension and active ulnar deviation showed slight improvements by one year, but reduced to levels below that measured preoperatively by final follow-up. Wrist flexion was significantly reduced at all time points postoperatively. Grip strength showed improvement from 10.0 kg (standard deviation [SD] 4.1 kg) preoperatively to 12.5 kg (SD 4.6 kg) 1 year after surgery and returned to preoperative levels (9.5 kg, SD 5.6 kg) by final follow-up. Wrist pain was significantly reduced from a mean score of 5 (SD 4) preoperatively to 2 (SD 2) postoperatively (p ⫽ .01). The Jebsen-Taylor hand function test showed improvements in writing and card turning. Conclusions In the long term, excision of the distal ulna in rheumatoid patients results in an improvement in some aspects of hand function. There is a significant (p ⫽ .01) reduction in wrist pain but a reduction of wrist flexion. (J Hand Surg 2010;35A:1442–1448. Copyright © 2010 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Excision, distal, ulna, Jebsen hand function, rheumatoid. (RA) is a chronic, systemic autoimmune disease often affecting the hand and wrist.1 At the wrist, the distal radioulnar joint (DRUJ) is most commonly involved.2 Re-
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HEUMATOID ARTHRITIS
From the Kennedy Institute of Rheumatology, Imperial College, London, United Kingdom. Received for publication November 11, 2009; accepted in revised form April 30, 2010. The authors are grateful for support from the NIHR Biomedical Research Centre funding scheme. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
1442 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
section of the distal ulna, in combination with extensor tenosynovectomy, is a recognized method of addressing the DRUJ involvement in this disease.2 The procedure aims to reduce pain, improve function, prevent tendon Correspondingauthor: AbhilashJain,PhD,KennedyInstituteofRheumatology,ImperialCollege, 1 Aspenlea Road, London, W6 8LH UK; e-mail: [email protected]. 0363-5023/10/35A09-0007$36.00/0 doi:10.1016/j.jhsa.2010.04.034
LONG-TERM FUNCTION AFTER DISTAL ULNA EXCISION
damage, and correct deformity.3 However, there is no consensus as to the efficacy of this surgery.4 – 6 Therefore, there is a need to assess the long-term functional outcomes of patients with RA undergoing hand surgery. Only a few studies have looked at functional outcome after resection of the distal ulna.7–11 We previously reported our prospective results at 1-year follow-up with regard to improvements in pain, hand function, and range of motion.8 In this study, we extended our observations by prospectively measuring functional outcome using the Jebsen-Taylor hand function test, visual analog pain scale, grip strength, and range of motion at a minimum follow-up of 5 years to assess the efficacy of the procedure in the long term. PATIENTS AND METHODS We undertook a prospective study looking at 34 patients with RA undergoing excision of the distal ulna on 39 wrists between May 1997 and April 2002. All patients had well-controlled disease at the time of surgery and gave informed consent. Approval was obtained from the local ethics committee. Over the 10-year follow-up period, we lost 10 patients (11 wrists) to followup. Three patients (3 wrists) died, 2 patients (3 wrists) were hospitalized long-term, 1 patient (1 wrist) moved out of the area, and 4 patients (4 wrists) withdrew from the study. Two further wrists in 2 patients were excluded as they went on to have a wrist arthrodesis. One patient, who had bilateral excision of the distal ulna, remained in the study for range of motion, pain, and grip strength evaluation in the nonfused wrist. This left us with 23 patients (26 wrists) in whom measurements were undertaken preoperatively and at a minimum of 5 years of follow-up (range, 5.3–10.4 y). It was not possible to collect every measurement in all patients. Range of motion data were collected in 22 of these wrists, pain was scored in 14 wrists, grip strength was measured in 20 hands, and Jebsen-Taylor hand function was administered in both the operated and unoperated hands of 9 patients. The mean age of the patients was 58.6 years (range, 38 – 87 y). All but one of these patients was female. A subgroup of patients underwent extensor carpi radialis longus (ECRL) to extensor carpi ulnaris (ECU) transfer. Data for this subgroup were analyzed separately. Surgical technique The senior author carried out all procedures as described previously.8 Briefly, under general anesthesia and tourniquet control, a straight dorsal incision was made. The extensor retinaculum was reflected along the sixth dorsal compartment, an extensor tenosynovec-
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tomy was undertaken, a segment of the terminal branch of the posterior interosseous nerve was resected, and the distal ulna was excised just proximal to the DRUJ. Synovectomy of the radiocarpal joint was performed, Lister’s tubercle was excised, and the capsule was closed. We relocated the palmarly subluxed ECU tendon to its dorsal position with a radially based sling of the extensor retinaculum. The remaining retinaculum was divided, with one segment sutured deep to the tendons and the other sutured over the tendons to prevent bowstringing. A subgroup of patients who had a tendency to radially rotate the wrist on active extension preoperatively underwent an ECRL to ECU tendon transfer (11 wrists). A closed suction drain was inserted if there was excessive bleeding from the cut bone end and a plaster of Paris volar wrist splint was applied. If a drain was used, it was removed the next day and the patients began active pronation and supination exercises the following day. The plaster splint was replaced with a thermoplastic splint at 3 weeks postoperatively and active wrist flexion and extension exercises commenced, except when an ECRL to ECU transfer had been performed, in which case the wrist was statically splinted for 6 weeks. Measures of pain, power, and range of motion All measurements were performed on the operated hand preoperatively and at 3 months, 1 year, and a minimum of 5 years postoperatively (range, 5.3–10.4 y) by the same hand therapist. Owing to the difficulty associated with collecting data over an extended period, some patients were not available for assessment at all intermediate time points. We made all range of motion measurements with a goniometer using a standardized protocol. Flexion, extension, pronation, supination, and active ulnar and radial deviation were measured in 22 wrists (21 patients). Pain was measured using a visual analog scale (1– 10) preoperatively and postoperatively. Complete data at final follow-up were available for 14 wrists in 12 patients. Grip strength was measured using a Jamar dynamometer (Bolingbrook, IL) in 20 operated wrists (19 patients). Jebsen-Taylor hand function The Jebsen-Taylor hand function test12 is a timed, objective, standardized test that has been shown to be reliable in assessing hand function in RA patients.8,13–15 It consists of 7 tests carried out in both the operated and unoperated hands. The tests include (1) writing a short sentence, (2) turning over cards,
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TABLE 1.
Range of Wrist Motion From Neutral, Measured in 22 Wrists Mean (SD) of Wrist Motion From Neutral (Degrees)
Wrist Movement
Preoperative
3 mo Postoperative
1 y Postoperative
Minimum 5 y Postoperative
Flexion
48 (15)
32 (16)*
35 (17)*
32 (17)*
Extension
43 (18)
40 (14)
44 (13)
38 (20)
Pronation
80 (12)
86 (7)
86 (6)
84 (6)
Supination
76 (16)
75 (19)
78 (17)
78 (13)
Ulnar deviation
17 (11)
17 (8)
19 (10)
16 (11)
Radial deviation
13 (10)
10 (8)*
10 (11)
7 (8)*
*Statistically significant difference compared with preoperative measurement (p ⬍ .05) by paired Student’s t-test.
(3) picking up small objects and placing them in a container, (4) stacking checkers, (5) simulated eating, (6) moving large empty cans, and (7) moving large weighted cans. The tests are performed separately with each hand, and the total time to perform each test recorded in seconds. The same hand therapist measured hand function preoperatively in a group of 29 RA patients who were scheduled for excision of the distal ulna. Complete final follow-up data were available for 9 of these patients. The remaining 20 patients were excluded because they had either undergone further surgery on the operated hand or had undergone surgery on the other hand during the follow-up period. These additional procedures, which included wrist arthrodesis and Swanson’s metacarpophalangeal joint arthroplasty, would also have influenced hand function. Statistical analysis We assessed the mean changes in Jebsen-Taylor hand function at final follow-up, compared with preoperative values, for both the operated and nonoperated hand using the paired Student’s t-test. Pain scores, grip strength, and range of motion measurements at follow-up time points were compared with preoperative values using the paired Student’s t-test for parametric data and the Wilcoxon signed-rank test for nonparametric data. RESULTS Range of motion Table 1 presents data for range of motion at varying time points. Not all patients were available for measurement at the 3- and 12-month follow-up, so data are presented for 18 and 12 wrists, respectively, for these time points. For all movements
assessed, with the exception of wrist flexion, no statistically significant difference was found at final follow-up compared with preoperative measurements. However, there were slight improvements in wrist pronation and supination. Wrist extension remained relatively stable over the follow-up period, whereas active ulnar deviation initially increased up to one year, followed by a reduction by final review. There was an initial marked reduction in radial deviation, which reached statistical significance at the 3-month and 1-year follow-up; this remained reduced at a minimum of 5 years of follow-up (not significant). Wrist flexion was significantly reduced at all follow-up measurements, with a mean reduction of 16° at a minimum of 5 years (p ⬍ .001) (Fig. 1). On average, for all other measurements, the difference in preoperative and final postoperative results ranged from ⫺5° to 4°. The changes in individual hands ranged widely, over 20° either way, for all movements. ECRL to ECU transfer A subgroup of patients underwent ECRL to ECU transfer. Data for this subgroup were analyzed separately. Mean wrist extension decreased from 53° (standard deviation [SD] 14°) to 46° (SD 24°) at final follow-up. Mean flexion decreased from 51° (SD 12°) to 33° (SD 22°) (p ⫽ .03), active ulna deviation decreased from 20° (SD 7°) to 13° (SD 13°), active radial deviation decreased from 18° (SD 8°) to 9° (SD 10°) (p ⫽ .008), wrist pronation decreased from 89° (SD 2°) to 86° (SD 6°), and wrist supination decreased from 87° (SD 7°) to 81° (SD 10°). These results were similar to the group as a whole, with the exception that active radial deviation was markedly reduced.
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FIGURE 1: Active ranges of motion preoperatively and at 3 months, 12 months, and a minimum of 5 years postoperatively. Bars represent mean values. Statistical results are as compared with preoperative values (paired Student’s t-test). A Extension. B Flexion. C Pronation. D Supination. E Active ulnar deviation. F Active radial deviation.
Pain and grip strength Using a visual analog scale (0 –10), the mean preoperative pain score was 5 (SD 4). This reduced significantly to a mean of 2 (SD 2) at final postoperative follow-up (p ⬍ .01). Four wrists were initially pain-free and remained so at long-term follow-up. In 5 other wrists, patients had complete absence of pain at final follow-up. In the remaining 5 wrists, 3 showed improvement, one was unchanged, and one had increased pain. In the ECRL to ECU subgroup, pain scores reduced from a mean of 3 (SD 4) preoperatively to 1 (SD 1) at final follow-up. Preoperative grip strength for 20 wrists in 16 patients was on average 10.0 kg (SD 4.1 kg). At 3-month follow-up, there was a slight reduction in grip strength
at 9.2 kg (SD 4.9 kg), which improved at 1-year follow-up to a mean of 12.5 kg (SD 4.6 kg); however, neither of these changes reached statistical significance. At final follow-up, the mean grip strength was only marginally reduced to 9.5 kg (SD 5.6 kg) compared with preoperative values. This slight decrease was not statistically significant and indicates that grip strength has been maintained. In the ECRL to ECU transfer subgroup, grip strength decreased from a mean of 8.4 kg (SD 4.5 kg) preoperatively to 6.4 kg (SD 2.2 kg) at final follow-up. Jebsen-Taylor hand function test Table 2 lists the results. The mean time taken and percentage change of the average times from the pre-
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TABLE 2. Jebsen-Taylor Hand Function Test (Seconds) in the Operated and Nonoperated Hand of 9 Patients During >5 Years of Follow-Up Final Postoperative [% Change Compared With Preoperative Time]
Preoperative Jebsen Test
Operated Hand (s)
Nonoperated Hand (s)
Operated Hand (s)
Nonoperated Hand (s)
25.7 (16.9)
24.5 (11.0)
26.4 (19.6)
29.0 (11.7)
[3%]
[18%]
Card turning
7.9 (3.4)
6.6 (2.5)
5.6 (2.0)*
5.2 (1.8)
Picking small objects
9.3 (2.8)
9.1 (2.6)
[20%]
[14%]
11.8 (4.4)
10.5 (1.9)
9.9 (3.0)*
9.2 (1.7)*
[⫺15%]
[⫺12%]
Checkers
6.0 (1.8)
5.4 (1.0)
6.8 (3.1)
5.5 (1.6)
[13%]
[3%]
Lift empty can
6.6 (2.7)
5.9 (3.1)
6.0 (3.1)
5.4 (1.8)
[⫺10%]
[⫺9%]
Lift full can
6.7 (2.4)
5.7 (1.4)
6.6 (3.9)
5.4 (1.0)
[⫺3%]
[⫺5%]
74.9 (30.4)
64.5 (10.3)
71.2 (35.7)
66.5 (14.5)
Writing
Simulated feeding
Total time for all 7 activities
[⫺30%]
[⫺20%]
11.1 (3.7)
10.4 (2.8)
[⫺5%]
[3%]
Data represent mean (SD) in seconds [mean percentage improvement compared with preoperative time]. *Statistically significant improvement compared with preoperative times (p ⬍ .05), by paired Student’s t-test. A negative percentage value indicates an improvement in time to perform the test compared with preoperative measurements.
operative measurements are shown. There was a greater overall percentage improvement in card turning for the operated compared with the unoperated hand at a minimum of 5 years of follow-up. Furthermore, despite showing a slight increase in time taken to complete the writing task in both hands, the percentage reduction in time was much less in the operated hand (3%) compared with the unoperated hand (18%), which suggests that the operated hand had deteriorated less. Simulated feeding showed significant (p ⬍ .05) and similar improvements in both hands, and although this reached statistical significance, it did so in both hands, which suggests that the change was probably not due to the surgery. Stacking checkers and picking up small objects showed a relatively greater percentage increase in time taken to perform the tests in the operated hand compared with the unoperated hand at final review. However, subanalysis of the results showed that 2 patients performed poorly on the operated hand on both of these tests. If these 2 patients are removed from the analysis, the remaining 7 patients show an overall improvement in times taken to stack checkers in both the operated
(⫺12%) and nonoperated (⫺10%) hands. Furthermore, the percent changes in time for picking up small objects remained virtually the same in the operated (4%) and nonoperated hand (1%) at final review. Lifting both light and heavy cans showed an almost identical percent improvement in times in both the operated and unoperated hands over the follow-up period. DISCUSSION The assessment of hand function is complex and especially difficult in RA patients. Previous studies have relied on ranges of motion and grip strength, but function is probably best assessed by a combination of anatomical measures (range of motion and grip strength), functional ability (Jebsen-Taylor hand function test), and questionnaires.16 In this study, we only asked about pain scores. We have previously reported our 1-year postoperative results after excision of the distal ulna and extensor synovectomy and showed improvements in forearm pronation, supination, and wrist extension, but a reduction in wrist flexion.8 Furthermore, we showed significant improvements in grip strength (p ⫽ .05) and a
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reduction in pain (p ⬍ .0001). Using the Jebsen-Taylor hand function test, we also demonstrated improvements in simulated feeding, stacking checkers, and lifting large empty cans. In the current study, we assessed patients at a minimum follow-up of 5 years to determine whether our earlier results were maintained in the longer term. Rheumatoid arthritis is progressive; therefore, patients tend to undergo numerous procedures on their hands over time. This makes collecting longitudinal outcomes data difficult; many patients who were initially entered into our study had to be excluded because additional procedures had been performed that would have influenced hand function. These included Swanson arthroplasty at the metacarpophalangeal joints and wrist arthrodesis. Furthermore, there were fewer patients included in the pain scores and grip strength measurements compared with the range of motion measurements. However, data are complete for each subsection preoperatively and postoperatively; thus, a reasonable cohort of patients in each of these groups allowed statistical analysis and conclusions to be drawn. Nevertheless, since starting our study in 1997, we have managed to collect prospective data on a group of 23 patients (26 wrists) at a minimum follow-up of 5 years (range, 5.3–10.4 y). Range of motion measurements showed an almost identical trend at one year compared with our previous published results,8 with initial improvements in pronation and supination, decreases in active radial deviation and wrist flexion, and increases in active ulnar deviation and wrist extension. However, our longer-term follow-up shows that whereas measurements of pronation, supination, and active radial deviation remain relatively stable, wrist flexion continues to decrease in the longer term. This decrease in wrist flexion in the long term is unlikely to be due to the ongoing disease process, because it was seen at 3 months postoperatively and was consistently decreased at all time points, which suggests it was probably due to the surgery. Wrist extension and active ulnar deviation showed slight improvements by one year, but by final review, both reduced to levels below those measured preoperatively. This decrease may be attributable to the ongoing disease process. However, it is likely that surgery contributed to these outcomes, as not all range of motion measurements deteriorated with time. Reduced radial deviation is advantageous because the aim is to reduce the tendency of the wrist to rotate radially to reduce the tendency to ulnar drift at the metacarpophalangeal joints of the fingers.
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Grip strength initially increased by one year postoperatively but then reduced to that seen preoperatively. It is well recognized that grip strength decreases with age17,18 and that patients with RA have reduced grip strength compared with both normal controls and patients with osteoarthritis.19 Normal values for grip strength show an average decrease of between 5% and 10% per decade of life,17,20 with a rapid decrease seen after 60 years of age.17 Furthermore, women show a relatively earlier loss of strength17 and 22 of the 23 patients in our study were female. Our patients had a mean age of 58.6 years at the time of surgery and would on average be over 60 years old at the final follow-up. The grip strength of our patients decreased by a mean of 5% over the study period, which is in keeping with that expected in this age group. This suggests that surgery does not result in deterioration in grip strength in the longer term. A subgroup of our patients with a tendency to radial rotation of the wrist also underwent ECRL to ECU transfer. Our previous study had shown that at 1-year follow-up, this subgroup showed an almost identical trend as the group that did not have this tendon transfer.8 It was not the aim of the current study to look specifically at this tendon transfer. Subanalysis of this group at a minimum of 5 years of follow-up showed similar trends to the group as a whole. At 1-year followup, we had previously shown a slight decrease in active wrist radial deviation and no change in active ulna deviation.8 However, in this study, at final follow-up active radial deviation was significantly reduced from a mean of 18° preoperatively to 9° postoperatively (p ⫽ .008). This would be expected given that ECRL is one of the main radial deviators of the wrist, and our data suggest that the tendon transfer is an efficacious procedure. The Jebsen-Taylor hand function test is useful in assessing the rheumatoid hand.8,14 It takes into account variations in disease activity and changes due to surgery by allowing assessment of both the operated and contralateral nonoperated hand individually. RA is progressive and symmetrical in nature, and patients commonly undergo sequential and multiple procedures. In the current study, 20 patients were excluded from the final Jebsen-Taylor analysis because they had either undergone further surgery on the operated hand or had undergone surgery to the other hand, which would have influenced the hand function results. However, we analyzed the remaining 9 patients preoperatively and postoperatively and have no reason to suppose the results are not representative. Furthermore, we were able to compare operated and unoperated wrists. This high-
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lights the difficulty in collecting prospective outcomes data in this group of patients. Our previous study showed improvements in simulated feeding, stacking checkers, and lifting large empty cans at 1-year followup.8 In the current study, simulated feeding showed a statistically significant improvement in the time taken to complete the test at a minimum of 5 years of follow-up compared with preoperatively; however, this change was seen in both hands. This suggests that in the long term, the improvement is unlikely to be due to the surgery. The ability to stack checkers appeared to deteriorate over time. However, 2 of the 9 patients assessed performed poorly on this test, as well as that of picking up small objects. These 2 tests assess predominantly fine finger movements. There is no clear reason why these 2 patients should have performed badly on these 2 particular tests given that their results for the other 5 tests were in keeping with the overall trend. One of these 2 patients underwent further tests of sensation, shoulder function, and self-reported disease activity, but the results of these additional tests did not explain the Jebsen-Taylor hand function results. The second of the 2 patients declined these further tests. Nevertheless, if these 2 patients are removed from the analysis, the results for the remaining 7 patients suggest that the times for these tests are no worse than in the nonoperated hand. Furthermore, there was no noticeable improvement in times for lifting both empty and full cans. The 2 tests that showed relative improvements in the operated hand compared with the nonoperated hand at long-term follow-up were those of writing and card turning. These results suggest that in the long term, surgery has less influence on certain aspects of hand function, but certainly does not detract from it. The most consistent finding in our study was that pain was significantly (p ⫽ .01) reduced in the long term, with visual analog pain scores reduced from a mean of 5 preoperatively to 2 postoperatively. Despite recent reports confirming a reduction in rates of rheumatoid surgery in both Europe21 and North America,22 our data suggest that excision of the distal ulna and extensor synovectomy is still an effective option in the management of the rheumatoid wrist. Results of this and our previous study8 confirm that in the medium term, there are improvements in wrist motion and aspects of hand function that appear to be maintained in the long term up to 5 years. In the long term, there is also a significant (p ⫽ .01) reduction in pain but at the expense of reduction in wrist flexion.
REFERENCES 1. Trieb K. Treatment of the wrist in rheumatoid arthritis. J Hand Surg 2008;33A:113–123. 2. Lee SK, Hausman MR. Management of the distal radioulnar joint in rheumatoid arthritis. Hand Clin 2005;21:577–589. 3. Burge P. The principles of surgery in the rheumatoid hand. Curr Orthop 2003;17:17–27. 4. Alderman AK, Chung KC, Kim HM, Fox DA, Ubel PA. Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists. J Hand Surg 2003;28A:3–11; discussion 12–13. 5. Ghattas L, Mascella F, Pomponio G. Hand surgery in rheumatoid arthritis: state of the art and suggestions for research. Rheumatology (Oxford) 2005;44:834 – 845. 6. Alderman AK, Chung KC, Demonner S, Spilson SV, Hayward RA. The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns. Arthritis Rheum 2002;47:537–542. 7. Jackson IT, Milward TM, Lee P, Webb J. Ulnar head resection in rheumatoid arthritis. Hand 1974;6:172–180. 8. Jain A, Ball C, Nanchahal J. Functional outcome following extensor synovectomy and excision of the distal ulna in patients with rheumatoid arthritis. J Hand Surg 2003;28B:531–536. 9. Newman RJ. Excision of the distal ulna in patients with rheumatoid arthritis. J Bone Joint Surg 1987;69B:203–206. 10. Rana NA, Taylor AR. Excision of the distal end of the ulna in rheumatoid arthritis. J Bone Joint Surg 1973;55B:96 –105. 11. Rasker JJ, Veldhuis EF, Huffstadt AJ, Nienhuis RL. Excision of the ulnar head in patients with rheumatoid arthritis. Ann Rheum Dis 1980;39:270 –274. 12. Jebsen RH, Taylor N, Trieschmann RB, Trotter MJ, Howard LA. An objective and standardized test of hand function. Arch Phys Med Rehabil 1969;50:311–319. 13. Jones E, Hanly JG, Mooney R, Rand LL, Spurway PM, Eastwood BJ, et al. Strength and function in the normal and rheumatoid hand. J Rheumatol 1991;18:1313–1318. 14. Sharma S, Schumacher HR Jr, McLellan AT. Evaluation of the Jebsen hand function test for use in patients with rheumatoid arthritis [corrected]. Arthritis Care Res 1994;7:16 –19. 15. Vliet Vlieland TP, van der Wijk TP, Jolie IM, Zwinderman AH, Hazes JM. Determinants of hand function in patients with rheumatoid arthritis. J Rheumatol 1996;23:835– 840. 16. Pap G, Angst F, Herren D, Schwyzer HK, Simmen BR. Evaluation of wrist and hand handicap and postoperative outcome in rheumatoid arthritis. Hand Clin 2003;19:471– 481. 17. Doherty TJ. The influence of aging and sex on skeletal muscle mass and strength. Curr Opin Clin Nutr Metab Care 2001;4:503–508. 18. MacLennan WJ, Hall MR, Timothy JI, Robinson M. Is weakness in old age due to muscle wasting? Age Ageing 1980;9:188 –192. 19. Slatkowsky-Christensen B, Mowinckel P, Loge JH, Kvien TK. Health-related quality of life in women with symptomatic hand osteoarthritis: a comparison with rheumatoid arthritis patients, healthy controls, and normative data. Arthritis Rheum 2007;57: 1404 –1409. 20. Bohannon RW, Peolsson A, Massy-Westropp N, Desrosiers J, BearLehman J. Reference values for adult grip strength measured with a Jamar dynamometer: a descriptive meta-analysis. Physiotherapy 2006; 92:11–15. 21. Sokka T, Kautiainen H, Hannonen P. Stable occurrence of knee and hip total joint replacement in Central Finland between 1986 and 2003: an indication of improved long-term outcomes of rheumatoid arthritis. Ann Rheum Dis 2007;66:341–344. 22. Louie GH, Ward MM. Changes in the rates of joint surgery among patients with Rheumatoid Arthritis in California, 1983–2007. Ann Rheum Dis 2010;69:868 – 871.
JHS 䉬 Vol A, September
Effects of Extensor Synovectomy and Excision of the Distal Ulna in Rheumatoid Arthritis on Long-Term Function Abhilash Jain, PhD, Cathy Ball, MSc, Andrew J. Freidin, MBBS, Jagdeep Nanchahal, PhD
Purpose Objective outcomes data after excision of the distal ulna in rheumatoid arthritis are lacking. The aim of this study was to evaluate the functional results of this surgery in the long term. Methods We prospectively collected data on range of motion (22 wrists), visual analog pain scores (14 wrists), and grip strength measured using a Jamar dynamometer (20 hands) in a group of 23 patients (26 wrists) preoperatively and at 3 months, 12 months, and a minimum of 5 years postoperatively (range, 5.3–10.4 y). The Jebsen-Taylor hand function test was administered to 9 patients at the same time points. A subgroup of patients also underwent extensor carpi radialis longus to extensor carpi ulnaris tendon transfer (11 wrists). Results At one year, there were improvements in wrist pronation and supination, which were maintained at final follow-up. Active radial deviation decreased significantly at 3 months (p ⫽ .01) and one year (p ⫽ .02); this remained reduced at final follow-up (not significant). Wrist extension and active ulnar deviation showed slight improvements by one year, but reduced to levels below that measured preoperatively by final follow-up. Wrist flexion was significantly reduced at all time points postoperatively. Grip strength showed improvement from 10.0 kg (standard deviation [SD] 4.1 kg) preoperatively to 12.5 kg (SD 4.6 kg) 1 year after surgery and returned to preoperative levels (9.5 kg, SD 5.6 kg) by final follow-up. Wrist pain was significantly reduced from a mean score of 5 (SD 4) preoperatively to 2 (SD 2) postoperatively (p ⫽ .01). The Jebsen-Taylor hand function test showed improvements in writing and card turning. Conclusions In the long term, excision of the distal ulna in rheumatoid patients results in an improvement in some aspects of hand function. There is a significant (p ⫽ .01) reduction in wrist pain but a reduction of wrist flexion. (J Hand Surg 2010;35A:1442–1448. Copyright © 2010 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Excision, distal, ulna, Jebsen hand function, rheumatoid. (RA) is a chronic, systemic autoimmune disease often affecting the hand and wrist.1 At the wrist, the distal radioulnar joint (DRUJ) is most commonly involved.2 Re-
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From the Kennedy Institute of Rheumatology, Imperial College, London, United Kingdom. Received for publication November 11, 2009; accepted in revised form April 30, 2010. The authors are grateful for support from the NIHR Biomedical Research Centre funding scheme. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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section of the distal ulna, in combination with extensor tenosynovectomy, is a recognized method of addressing the DRUJ involvement in this disease.2 The procedure aims to reduce pain, improve function, prevent tendon Correspondingauthor: AbhilashJain,PhD,KennedyInstituteofRheumatology,ImperialCollege, 1 Aspenlea Road, London, W6 8LH UK; e-mail: [email protected]. 0363-5023/10/35A09-0007$36.00/0 doi:10.1016/j.jhsa.2010.04.034
LONG-TERM FUNCTION AFTER DISTAL ULNA EXCISION
damage, and correct deformity.3 However, there is no consensus as to the efficacy of this surgery.4 – 6 Therefore, there is a need to assess the long-term functional outcomes of patients with RA undergoing hand surgery. Only a few studies have looked at functional outcome after resection of the distal ulna.7–11 We previously reported our prospective results at 1-year follow-up with regard to improvements in pain, hand function, and range of motion.8 In this study, we extended our observations by prospectively measuring functional outcome using the Jebsen-Taylor hand function test, visual analog pain scale, grip strength, and range of motion at a minimum follow-up of 5 years to assess the efficacy of the procedure in the long term. PATIENTS AND METHODS We undertook a prospective study looking at 34 patients with RA undergoing excision of the distal ulna on 39 wrists between May 1997 and April 2002. All patients had well-controlled disease at the time of surgery and gave informed consent. Approval was obtained from the local ethics committee. Over the 10-year follow-up period, we lost 10 patients (11 wrists) to followup. Three patients (3 wrists) died, 2 patients (3 wrists) were hospitalized long-term, 1 patient (1 wrist) moved out of the area, and 4 patients (4 wrists) withdrew from the study. Two further wrists in 2 patients were excluded as they went on to have a wrist arthrodesis. One patient, who had bilateral excision of the distal ulna, remained in the study for range of motion, pain, and grip strength evaluation in the nonfused wrist. This left us with 23 patients (26 wrists) in whom measurements were undertaken preoperatively and at a minimum of 5 years of follow-up (range, 5.3–10.4 y). It was not possible to collect every measurement in all patients. Range of motion data were collected in 22 of these wrists, pain was scored in 14 wrists, grip strength was measured in 20 hands, and Jebsen-Taylor hand function was administered in both the operated and unoperated hands of 9 patients. The mean age of the patients was 58.6 years (range, 38 – 87 y). All but one of these patients was female. A subgroup of patients underwent extensor carpi radialis longus (ECRL) to extensor carpi ulnaris (ECU) transfer. Data for this subgroup were analyzed separately. Surgical technique The senior author carried out all procedures as described previously.8 Briefly, under general anesthesia and tourniquet control, a straight dorsal incision was made. The extensor retinaculum was reflected along the sixth dorsal compartment, an extensor tenosynovec-
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tomy was undertaken, a segment of the terminal branch of the posterior interosseous nerve was resected, and the distal ulna was excised just proximal to the DRUJ. Synovectomy of the radiocarpal joint was performed, Lister’s tubercle was excised, and the capsule was closed. We relocated the palmarly subluxed ECU tendon to its dorsal position with a radially based sling of the extensor retinaculum. The remaining retinaculum was divided, with one segment sutured deep to the tendons and the other sutured over the tendons to prevent bowstringing. A subgroup of patients who had a tendency to radially rotate the wrist on active extension preoperatively underwent an ECRL to ECU tendon transfer (11 wrists). A closed suction drain was inserted if there was excessive bleeding from the cut bone end and a plaster of Paris volar wrist splint was applied. If a drain was used, it was removed the next day and the patients began active pronation and supination exercises the following day. The plaster splint was replaced with a thermoplastic splint at 3 weeks postoperatively and active wrist flexion and extension exercises commenced, except when an ECRL to ECU transfer had been performed, in which case the wrist was statically splinted for 6 weeks. Measures of pain, power, and range of motion All measurements were performed on the operated hand preoperatively and at 3 months, 1 year, and a minimum of 5 years postoperatively (range, 5.3–10.4 y) by the same hand therapist. Owing to the difficulty associated with collecting data over an extended period, some patients were not available for assessment at all intermediate time points. We made all range of motion measurements with a goniometer using a standardized protocol. Flexion, extension, pronation, supination, and active ulnar and radial deviation were measured in 22 wrists (21 patients). Pain was measured using a visual analog scale (1– 10) preoperatively and postoperatively. Complete data at final follow-up were available for 14 wrists in 12 patients. Grip strength was measured using a Jamar dynamometer (Bolingbrook, IL) in 20 operated wrists (19 patients). Jebsen-Taylor hand function The Jebsen-Taylor hand function test12 is a timed, objective, standardized test that has been shown to be reliable in assessing hand function in RA patients.8,13–15 It consists of 7 tests carried out in both the operated and unoperated hands. The tests include (1) writing a short sentence, (2) turning over cards,
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TABLE 1.
Range of Wrist Motion From Neutral, Measured in 22 Wrists Mean (SD) of Wrist Motion From Neutral (Degrees)
Wrist Movement
Preoperative
3 mo Postoperative
1 y Postoperative
Minimum 5 y Postoperative
Flexion
48 (15)
32 (16)*
35 (17)*
32 (17)*
Extension
43 (18)
40 (14)
44 (13)
38 (20)
Pronation
80 (12)
86 (7)
86 (6)
84 (6)
Supination
76 (16)
75 (19)
78 (17)
78 (13)
Ulnar deviation
17 (11)
17 (8)
19 (10)
16 (11)
Radial deviation
13 (10)
10 (8)*
10 (11)
7 (8)*
*Statistically significant difference compared with preoperative measurement (p ⬍ .05) by paired Student’s t-test.
(3) picking up small objects and placing them in a container, (4) stacking checkers, (5) simulated eating, (6) moving large empty cans, and (7) moving large weighted cans. The tests are performed separately with each hand, and the total time to perform each test recorded in seconds. The same hand therapist measured hand function preoperatively in a group of 29 RA patients who were scheduled for excision of the distal ulna. Complete final follow-up data were available for 9 of these patients. The remaining 20 patients were excluded because they had either undergone further surgery on the operated hand or had undergone surgery on the other hand during the follow-up period. These additional procedures, which included wrist arthrodesis and Swanson’s metacarpophalangeal joint arthroplasty, would also have influenced hand function. Statistical analysis We assessed the mean changes in Jebsen-Taylor hand function at final follow-up, compared with preoperative values, for both the operated and nonoperated hand using the paired Student’s t-test. Pain scores, grip strength, and range of motion measurements at follow-up time points were compared with preoperative values using the paired Student’s t-test for parametric data and the Wilcoxon signed-rank test for nonparametric data. RESULTS Range of motion Table 1 presents data for range of motion at varying time points. Not all patients were available for measurement at the 3- and 12-month follow-up, so data are presented for 18 and 12 wrists, respectively, for these time points. For all movements
assessed, with the exception of wrist flexion, no statistically significant difference was found at final follow-up compared with preoperative measurements. However, there were slight improvements in wrist pronation and supination. Wrist extension remained relatively stable over the follow-up period, whereas active ulnar deviation initially increased up to one year, followed by a reduction by final review. There was an initial marked reduction in radial deviation, which reached statistical significance at the 3-month and 1-year follow-up; this remained reduced at a minimum of 5 years of follow-up (not significant). Wrist flexion was significantly reduced at all follow-up measurements, with a mean reduction of 16° at a minimum of 5 years (p ⬍ .001) (Fig. 1). On average, for all other measurements, the difference in preoperative and final postoperative results ranged from ⫺5° to 4°. The changes in individual hands ranged widely, over 20° either way, for all movements. ECRL to ECU transfer A subgroup of patients underwent ECRL to ECU transfer. Data for this subgroup were analyzed separately. Mean wrist extension decreased from 53° (standard deviation [SD] 14°) to 46° (SD 24°) at final follow-up. Mean flexion decreased from 51° (SD 12°) to 33° (SD 22°) (p ⫽ .03), active ulna deviation decreased from 20° (SD 7°) to 13° (SD 13°), active radial deviation decreased from 18° (SD 8°) to 9° (SD 10°) (p ⫽ .008), wrist pronation decreased from 89° (SD 2°) to 86° (SD 6°), and wrist supination decreased from 87° (SD 7°) to 81° (SD 10°). These results were similar to the group as a whole, with the exception that active radial deviation was markedly reduced.
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FIGURE 1: Active ranges of motion preoperatively and at 3 months, 12 months, and a minimum of 5 years postoperatively. Bars represent mean values. Statistical results are as compared with preoperative values (paired Student’s t-test). A Extension. B Flexion. C Pronation. D Supination. E Active ulnar deviation. F Active radial deviation.
Pain and grip strength Using a visual analog scale (0 –10), the mean preoperative pain score was 5 (SD 4). This reduced significantly to a mean of 2 (SD 2) at final postoperative follow-up (p ⬍ .01). Four wrists were initially pain-free and remained so at long-term follow-up. In 5 other wrists, patients had complete absence of pain at final follow-up. In the remaining 5 wrists, 3 showed improvement, one was unchanged, and one had increased pain. In the ECRL to ECU subgroup, pain scores reduced from a mean of 3 (SD 4) preoperatively to 1 (SD 1) at final follow-up. Preoperative grip strength for 20 wrists in 16 patients was on average 10.0 kg (SD 4.1 kg). At 3-month follow-up, there was a slight reduction in grip strength
at 9.2 kg (SD 4.9 kg), which improved at 1-year follow-up to a mean of 12.5 kg (SD 4.6 kg); however, neither of these changes reached statistical significance. At final follow-up, the mean grip strength was only marginally reduced to 9.5 kg (SD 5.6 kg) compared with preoperative values. This slight decrease was not statistically significant and indicates that grip strength has been maintained. In the ECRL to ECU transfer subgroup, grip strength decreased from a mean of 8.4 kg (SD 4.5 kg) preoperatively to 6.4 kg (SD 2.2 kg) at final follow-up. Jebsen-Taylor hand function test Table 2 lists the results. The mean time taken and percentage change of the average times from the pre-
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TABLE 2. Jebsen-Taylor Hand Function Test (Seconds) in the Operated and Nonoperated Hand of 9 Patients During >5 Years of Follow-Up Final Postoperative [% Change Compared With Preoperative Time]
Preoperative Jebsen Test
Operated Hand (s)
Nonoperated Hand (s)
Operated Hand (s)
Nonoperated Hand (s)
25.7 (16.9)
24.5 (11.0)
26.4 (19.6)
29.0 (11.7)
[3%]
[18%]
Card turning
7.9 (3.4)
6.6 (2.5)
5.6 (2.0)*
5.2 (1.8)
Picking small objects
9.3 (2.8)
9.1 (2.6)
[20%]
[14%]
11.8 (4.4)
10.5 (1.9)
9.9 (3.0)*
9.2 (1.7)*
[⫺15%]
[⫺12%]
Checkers
6.0 (1.8)
5.4 (1.0)
6.8 (3.1)
5.5 (1.6)
[13%]
[3%]
Lift empty can
6.6 (2.7)
5.9 (3.1)
6.0 (3.1)
5.4 (1.8)
[⫺10%]
[⫺9%]
Lift full can
6.7 (2.4)
5.7 (1.4)
6.6 (3.9)
5.4 (1.0)
[⫺3%]
[⫺5%]
74.9 (30.4)
64.5 (10.3)
71.2 (35.7)
66.5 (14.5)
Writing
Simulated feeding
Total time for all 7 activities
[⫺30%]
[⫺20%]
11.1 (3.7)
10.4 (2.8)
[⫺5%]
[3%]
Data represent mean (SD) in seconds [mean percentage improvement compared with preoperative time]. *Statistically significant improvement compared with preoperative times (p ⬍ .05), by paired Student’s t-test. A negative percentage value indicates an improvement in time to perform the test compared with preoperative measurements.
operative measurements are shown. There was a greater overall percentage improvement in card turning for the operated compared with the unoperated hand at a minimum of 5 years of follow-up. Furthermore, despite showing a slight increase in time taken to complete the writing task in both hands, the percentage reduction in time was much less in the operated hand (3%) compared with the unoperated hand (18%), which suggests that the operated hand had deteriorated less. Simulated feeding showed significant (p ⬍ .05) and similar improvements in both hands, and although this reached statistical significance, it did so in both hands, which suggests that the change was probably not due to the surgery. Stacking checkers and picking up small objects showed a relatively greater percentage increase in time taken to perform the tests in the operated hand compared with the unoperated hand at final review. However, subanalysis of the results showed that 2 patients performed poorly on the operated hand on both of these tests. If these 2 patients are removed from the analysis, the remaining 7 patients show an overall improvement in times taken to stack checkers in both the operated
(⫺12%) and nonoperated (⫺10%) hands. Furthermore, the percent changes in time for picking up small objects remained virtually the same in the operated (4%) and nonoperated hand (1%) at final review. Lifting both light and heavy cans showed an almost identical percent improvement in times in both the operated and unoperated hands over the follow-up period. DISCUSSION The assessment of hand function is complex and especially difficult in RA patients. Previous studies have relied on ranges of motion and grip strength, but function is probably best assessed by a combination of anatomical measures (range of motion and grip strength), functional ability (Jebsen-Taylor hand function test), and questionnaires.16 In this study, we only asked about pain scores. We have previously reported our 1-year postoperative results after excision of the distal ulna and extensor synovectomy and showed improvements in forearm pronation, supination, and wrist extension, but a reduction in wrist flexion.8 Furthermore, we showed significant improvements in grip strength (p ⫽ .05) and a
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reduction in pain (p ⬍ .0001). Using the Jebsen-Taylor hand function test, we also demonstrated improvements in simulated feeding, stacking checkers, and lifting large empty cans. In the current study, we assessed patients at a minimum follow-up of 5 years to determine whether our earlier results were maintained in the longer term. Rheumatoid arthritis is progressive; therefore, patients tend to undergo numerous procedures on their hands over time. This makes collecting longitudinal outcomes data difficult; many patients who were initially entered into our study had to be excluded because additional procedures had been performed that would have influenced hand function. These included Swanson arthroplasty at the metacarpophalangeal joints and wrist arthrodesis. Furthermore, there were fewer patients included in the pain scores and grip strength measurements compared with the range of motion measurements. However, data are complete for each subsection preoperatively and postoperatively; thus, a reasonable cohort of patients in each of these groups allowed statistical analysis and conclusions to be drawn. Nevertheless, since starting our study in 1997, we have managed to collect prospective data on a group of 23 patients (26 wrists) at a minimum follow-up of 5 years (range, 5.3–10.4 y). Range of motion measurements showed an almost identical trend at one year compared with our previous published results,8 with initial improvements in pronation and supination, decreases in active radial deviation and wrist flexion, and increases in active ulnar deviation and wrist extension. However, our longer-term follow-up shows that whereas measurements of pronation, supination, and active radial deviation remain relatively stable, wrist flexion continues to decrease in the longer term. This decrease in wrist flexion in the long term is unlikely to be due to the ongoing disease process, because it was seen at 3 months postoperatively and was consistently decreased at all time points, which suggests it was probably due to the surgery. Wrist extension and active ulnar deviation showed slight improvements by one year, but by final review, both reduced to levels below those measured preoperatively. This decrease may be attributable to the ongoing disease process. However, it is likely that surgery contributed to these outcomes, as not all range of motion measurements deteriorated with time. Reduced radial deviation is advantageous because the aim is to reduce the tendency of the wrist to rotate radially to reduce the tendency to ulnar drift at the metacarpophalangeal joints of the fingers.
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Grip strength initially increased by one year postoperatively but then reduced to that seen preoperatively. It is well recognized that grip strength decreases with age17,18 and that patients with RA have reduced grip strength compared with both normal controls and patients with osteoarthritis.19 Normal values for grip strength show an average decrease of between 5% and 10% per decade of life,17,20 with a rapid decrease seen after 60 years of age.17 Furthermore, women show a relatively earlier loss of strength17 and 22 of the 23 patients in our study were female. Our patients had a mean age of 58.6 years at the time of surgery and would on average be over 60 years old at the final follow-up. The grip strength of our patients decreased by a mean of 5% over the study period, which is in keeping with that expected in this age group. This suggests that surgery does not result in deterioration in grip strength in the longer term. A subgroup of our patients with a tendency to radial rotation of the wrist also underwent ECRL to ECU transfer. Our previous study had shown that at 1-year follow-up, this subgroup showed an almost identical trend as the group that did not have this tendon transfer.8 It was not the aim of the current study to look specifically at this tendon transfer. Subanalysis of this group at a minimum of 5 years of follow-up showed similar trends to the group as a whole. At 1-year followup, we had previously shown a slight decrease in active wrist radial deviation and no change in active ulna deviation.8 However, in this study, at final follow-up active radial deviation was significantly reduced from a mean of 18° preoperatively to 9° postoperatively (p ⫽ .008). This would be expected given that ECRL is one of the main radial deviators of the wrist, and our data suggest that the tendon transfer is an efficacious procedure. The Jebsen-Taylor hand function test is useful in assessing the rheumatoid hand.8,14 It takes into account variations in disease activity and changes due to surgery by allowing assessment of both the operated and contralateral nonoperated hand individually. RA is progressive and symmetrical in nature, and patients commonly undergo sequential and multiple procedures. In the current study, 20 patients were excluded from the final Jebsen-Taylor analysis because they had either undergone further surgery on the operated hand or had undergone surgery to the other hand, which would have influenced the hand function results. However, we analyzed the remaining 9 patients preoperatively and postoperatively and have no reason to suppose the results are not representative. Furthermore, we were able to compare operated and unoperated wrists. This high-
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lights the difficulty in collecting prospective outcomes data in this group of patients. Our previous study showed improvements in simulated feeding, stacking checkers, and lifting large empty cans at 1-year followup.8 In the current study, simulated feeding showed a statistically significant improvement in the time taken to complete the test at a minimum of 5 years of follow-up compared with preoperatively; however, this change was seen in both hands. This suggests that in the long term, the improvement is unlikely to be due to the surgery. The ability to stack checkers appeared to deteriorate over time. However, 2 of the 9 patients assessed performed poorly on this test, as well as that of picking up small objects. These 2 tests assess predominantly fine finger movements. There is no clear reason why these 2 patients should have performed badly on these 2 particular tests given that their results for the other 5 tests were in keeping with the overall trend. One of these 2 patients underwent further tests of sensation, shoulder function, and self-reported disease activity, but the results of these additional tests did not explain the Jebsen-Taylor hand function results. The second of the 2 patients declined these further tests. Nevertheless, if these 2 patients are removed from the analysis, the results for the remaining 7 patients suggest that the times for these tests are no worse than in the nonoperated hand. Furthermore, there was no noticeable improvement in times for lifting both empty and full cans. The 2 tests that showed relative improvements in the operated hand compared with the nonoperated hand at long-term follow-up were those of writing and card turning. These results suggest that in the long term, surgery has less influence on certain aspects of hand function, but certainly does not detract from it. The most consistent finding in our study was that pain was significantly (p ⫽ .01) reduced in the long term, with visual analog pain scores reduced from a mean of 5 preoperatively to 2 postoperatively. Despite recent reports confirming a reduction in rates of rheumatoid surgery in both Europe21 and North America,22 our data suggest that excision of the distal ulna and extensor synovectomy is still an effective option in the management of the rheumatoid wrist. Results of this and our previous study8 confirm that in the medium term, there are improvements in wrist motion and aspects of hand function that appear to be maintained in the long term up to 5 years. In the long term, there is also a significant (p ⫽ .01) reduction in pain but at the expense of reduction in wrist flexion.
REFERENCES 1. Trieb K. Treatment of the wrist in rheumatoid arthritis. J Hand Surg 2008;33A:113–123. 2. Lee SK, Hausman MR. Management of the distal radioulnar joint in rheumatoid arthritis. Hand Clin 2005;21:577–589. 3. Burge P. The principles of surgery in the rheumatoid hand. Curr Orthop 2003;17:17–27. 4. Alderman AK, Chung KC, Kim HM, Fox DA, Ubel PA. Effectiveness of rheumatoid hand surgery: contrasting perceptions of hand surgeons and rheumatologists. J Hand Surg 2003;28A:3–11; discussion 12–13. 5. Ghattas L, Mascella F, Pomponio G. Hand surgery in rheumatoid arthritis: state of the art and suggestions for research. Rheumatology (Oxford) 2005;44:834 – 845. 6. Alderman AK, Chung KC, Demonner S, Spilson SV, Hayward RA. The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns. Arthritis Rheum 2002;47:537–542. 7. Jackson IT, Milward TM, Lee P, Webb J. Ulnar head resection in rheumatoid arthritis. Hand 1974;6:172–180. 8. Jain A, Ball C, Nanchahal J. Functional outcome following extensor synovectomy and excision of the distal ulna in patients with rheumatoid arthritis. J Hand Surg 2003;28B:531–536. 9. Newman RJ. Excision of the distal ulna in patients with rheumatoid arthritis. J Bone Joint Surg 1987;69B:203–206. 10. Rana NA, Taylor AR. Excision of the distal end of the ulna in rheumatoid arthritis. J Bone Joint Surg 1973;55B:96 –105. 11. Rasker JJ, Veldhuis EF, Huffstadt AJ, Nienhuis RL. Excision of the ulnar head in patients with rheumatoid arthritis. Ann Rheum Dis 1980;39:270 –274. 12. Jebsen RH, Taylor N, Trieschmann RB, Trotter MJ, Howard LA. An objective and standardized test of hand function. Arch Phys Med Rehabil 1969;50:311–319. 13. Jones E, Hanly JG, Mooney R, Rand LL, Spurway PM, Eastwood BJ, et al. Strength and function in the normal and rheumatoid hand. J Rheumatol 1991;18:1313–1318. 14. Sharma S, Schumacher HR Jr, McLellan AT. Evaluation of the Jebsen hand function test for use in patients with rheumatoid arthritis [corrected]. Arthritis Care Res 1994;7:16 –19. 15. Vliet Vlieland TP, van der Wijk TP, Jolie IM, Zwinderman AH, Hazes JM. Determinants of hand function in patients with rheumatoid arthritis. J Rheumatol 1996;23:835– 840. 16. Pap G, Angst F, Herren D, Schwyzer HK, Simmen BR. Evaluation of wrist and hand handicap and postoperative outcome in rheumatoid arthritis. Hand Clin 2003;19:471– 481. 17. Doherty TJ. The influence of aging and sex on skeletal muscle mass and strength. Curr Opin Clin Nutr Metab Care 2001;4:503–508. 18. MacLennan WJ, Hall MR, Timothy JI, Robinson M. Is weakness in old age due to muscle wasting? Age Ageing 1980;9:188 –192. 19. Slatkowsky-Christensen B, Mowinckel P, Loge JH, Kvien TK. Health-related quality of life in women with symptomatic hand osteoarthritis: a comparison with rheumatoid arthritis patients, healthy controls, and normative data. Arthritis Rheum 2007;57: 1404 –1409. 20. Bohannon RW, Peolsson A, Massy-Westropp N, Desrosiers J, BearLehman J. Reference values for adult grip strength measured with a Jamar dynamometer: a descriptive meta-analysis. Physiotherapy 2006; 92:11–15. 21. Sokka T, Kautiainen H, Hannonen P. Stable occurrence of knee and hip total joint replacement in Central Finland between 1986 and 2003: an indication of improved long-term outcomes of rheumatoid arthritis. Ann Rheum Dis 2007;66:341–344. 22. Louie GH, Ward MM. Changes in the rates of joint surgery among patients with Rheumatoid Arthritis in California, 1983–2007. Ann Rheum Dis 2010;69:868 – 871.
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