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Rheumatoid flexor tendon surgery
RHEUMATOID FLEXOR TENDON SURGERY A. GEORGE DASS, MD, and ANDREW L. TERRONO, MD
Tenosynovitis in the hand and wrist is a common finding in patients who have rheumatoid arthritis. In contrast to the more easily treated and diagnosed dorsal tenosynovitis, flexor tenosynovitis may be more problematic. If flexor tendon rupture occurs, this is usually more disabling than extensor tendon ruptures. Therefore, early recognition is important and early tenosynovectomy will prevent flexor tendon ruptures in patients with rheumatoid arthritis. KEY WORDS: flexor tendon, rheumatoid arthritis
Proliferative flexor tenosynovitis is common in patients who have rheumatoid arthritis. Locations include the wrist, palm, and digits. Patient's symptoms and physical examination will identify the areas of involvement. Once the tenosynovitis is identified, specific therapeutic modalities can be instituted. Patients are initially managed by their rheumatologists/internists with nonsteroidal anti-inflammatory medications, oral steroids, and/or chemotherapeutic agents. Many patients respond to these medications with resolution of the tenosynovitis. Others may experience periods of remission and flareups. If ongoing flexor tenosynovitis fails to respond to medical management, then tenosynovectomy is warrantedJ Steroid injections may be administered early in the course of tenosynovitis. If any symptoms or signs of weakness are noted, then steroid injections are contraindicated. Tenosynovectomy is an effective procedure for prevention of tendon rupture as,well as for long-term resolution of the tenosynovitis. 2-4 Recurrent synovitis is uncommon. If tendon rupture occurs, tenosynovectomy is performed along with tendon reconstruction and evaluation and treatment of the causes of attrition to prevent further tendon ruptures.
AREAS OF INVOLVEMENTmTENOSYNOVITIS
ing the disease flexor tendon excursion may be normal but with increased duration, flexor tendon adhesions develop limiting tendon excursion. The hallmark in the diagnosis of flexor tenosynovitis at the wrist is reduced active finger flexion in the presence of preserved passive motion. 2'7"9 Neurolysis may be needed at the time of carpal tunnel release and tenosynovectomy.
Palmar Level Flexor tendon involvement at the level of the palm may present as painful swelling, snapping or locking of the digits, or loss of motion. Nodular formation of the tenosy'novium may involve the tendon from the distal edge of the carpal tunnel to the A1 pulley. Examination demonstrates palmar fullness and tenderness. With involvement near the A1 pulley, snapping or locking of the digit in flexion occurs. Active extension of the digit may be impeded w h e n the nodule presses against the proximal edge of the A1 pulley but locking is usually passively correctable. As with flexor tenosynovitis at more proximal levels, tendon excursion may be limited. Therefore, examination must include the discrepancy between active and passive flexion.
Wrist Level
Digital Level
Carpal tunnel syndrome may be the first symptom of flexor tenosynovitis at the wrist level in patients with rheumatoid arthritis. 5"6 The tenosynovitis increases the volume in a fixed space, the carpal tunnel, producing compression on the median nerve. The tenosynovitis may extend into the proximal portion of the forearm. The diagnosis may be difficult to establish because bulging of the flexor tenosynovitis is limited by the transverse carpal ligament and the antebrachial fascia. Early dur-
Flexor tenosynovitis at the level of the digits may also cause pain, triggering, or limitation of motion. Pain occurs with flexion of the digit producing crepitus or grating. Triggering or locking occurs with increasing nodularity. The area of involvement can extend to the distal interphalangeal (DIP) joint. 1~ Less commonly, flexor tenosynovitis may cause stiffness of the proximal interphalangeal joint (PIP). 11'12 Active motion is limited initially, then passive motion. Stiffness occurs secondarily to the contracted capsule and collateral ligaments. The diagnosis must be differentiated from PIP joint synovitis and/or metacarpal phalangeal (MP) joint involvement associated with intrinsic tightness. Absence of deformity and normal radiographs of the MP and PIP joints excludes these diagnoses. A prior history of locking or triggering is usually found in digital flexor tenosynovitis.
From the Department of Orthopaedics, Tufts University School of Medicine, MA. Address reprint requests to Andrew L. Terrono, MD, Hand Surgical Associates, New England Baptist Hospital, 125 Parker Hill Ave, Suite 540R, Boston, MA 02120. Copyright 9 1993 by W. B. Saunders Company 1048-6666/93/0304-0011505.00/0
31 8
Operative Techniquesin Orthopaedics, Vol 3, No 4 (October), 1993: pp 318-323
SURGICAL INDICATIONS--TENOSYNOVECTOMY Flexor tenosynovectomy is r e c o m m e n d e d in patients who have significant tenosynovitis despite at least a 6-month course of conservative treatment including splinting, steroid injections, a n d systemic medications. 3A3 Persistent symptoms of median nerve compression and triggering or locking of the digits are included in these indications. Other indications include documented tendon rupture or impending tendon rupture. A progressive increase in the loss of active flexion of the digits should be treated by tenosynovectomy. Contraindications to flexor tenosynovectomy are few but include any acute infection or open wounds. Relative contraindications include failure to provide adequate nonoperative management.
SURGICAL TECHNIQUE--TENOSYNOVECTOMY Preparation The patient is placed in the supine position and a hand table is used for support of the arm. The procedure is performed while the patient is under regional or general anesthesia with tourniquet control. The extent of the disease usually precludes the use of local anesthesia, which is preferred in cases of stenosing tenosynovitis in patients without rheumatoid arthritis. Preoperative intravenous antibiotics are routinely administered before the tourniquet is inflated. The extremity is prepared and draped to the midhumeral level. Loupe magnification is recommended to avoid soft tissue injury.
Exposure Adequate exposure is needed for flexor tenosynovectomy. The surgical technique is usually more difficult than dorsal tenosynovectomy because of the diffuse nature of the disease, the close relationship of the neurovascular structures to the flexor tendons and the need to retain the flexor tendon sheath. Skin incisions are based on the areas of involvement. A complete tenosynovectomy must be performed in each area to remove the disease. This is usually accomplished as one stage.
WRIST LEVEL We prefer to do wrist flexor tenosynovectomy through an extended carpal tunnel incision. The incision begins between the palmaris longus and the flexor carpi ulnaris tendons approximately 5 cm proximal to the wrist flexion crease. The incision is extended distally to the ulnar side of the proximal wrist flexion crease and then in line with the intereminence crease. The incision ends at the transverse palmar crease. This incision allows complete exposure of the flexor tendons proximal to the carpal tunnel as well as the contents of the carpal tunnel to the superficial palmar arch. This incision also avoids injury RHEUMATOID FLEXOR TENDON SURGERY
to the palmar cutaneous branch of the median nerve. After the skin is incised, the palmar fascia is split longitudinally. The antebrachial fascia and the transverse ligament are then incised longitudinally. Care is taken to protect and free up both the main median nerve and its motor branch to the thenar musculature, which is always retracted radially. The superficial flexor tendons are individually exposed and the proliferative tenosynovium is removed by sharp dissection. A penrose drain is used to retract the superficial flexors to expose the deep flexors. Tenosynovectomy of the profundus tendons as a group is then performed without separating each tendon from one another. The fingers should be flexed and extended during the tenosynovectomy to facilitate delivery of the tendons into the w o u n d . If the tendons are frayed they are repaired. If unsuspected multiple ruptures are found but finger function is adequate, they are left alone. Function is often maintained through scar or tenosynovitis a n d extensive t e n o s y n o v e c t o m y can worsen the patient's condition. It is important to palpate the floor of the carpal tunnel for any bony spurs that may cause tendon rupture. These spurs must be removed and the adjacent joint debrided of synovitis. Rotation of a capsular flap allows the exposed bone to be covered and creates a smooth bed for tendon gliding. If median nerve compression is noted preoperatively, this carpal tunnel exposure will decompress the median nerve as well. However, if long standing compression of the median nerve is present, neurolysis may be required to decompress fully the nerve.
PALM LEVEL/DIGIT Flexor tenosynovectomy in the palm and digit is usually approached by a zigzag incision. The transverse palmar incision commonly used in nonrheumatoid stenosing tenosynovitis is not usually recommended. The location and length of the incision are dependent on the location and amount of involvement. The skin is incised and the soft tissue is bluntly dissected with scissors d o w n to the center of the flexor tendon sheath. Skin retraction sutures are used to gently retract the skin. The neurovascular bundles are protected on either side of the tendon sheath (Fig 1). A portion of the tendon sheath is incised to facilitate exposure. Annular pulleys are preserved if possible. Complete transection of the A1 pulley is contraindicated in the rheumatoid patient for the fear of increasing the ulnar drift. 1~ The A2 and A4 pulleys should be preserved to prevent bowstringing of the tendons. Flexor tenosynovitis may extend beyond the PIP joint and exposure of the profundus tendon distal to the superficialis insertion must be undertaken. 1~ The flexor tendons are delivered into the wound by flexing the digits. A complete tenosynovectomy of the superficialis and profundus tendons is then performed. If nodularity is found within the tendon substance, the nodules are sharply debrided and the defect closed with a 6-0 nylon running inverted stitch. Completeness of the tenosynovectomy is checked by pulling on each tendon individually. If further adhesions/tenosynovitis limiting excursion are present, then 319
Fig 1. This patient has significant digital and palmar rheumatoid tenosynovitis. Exploration is conducted through a palmar and digital zigzag incision. Extensive tenosynovium is encountered and removed with careful preservation of annular pulleys.
the tenosynovectomy should be extended and the ulnar slip of the flexor digitorum superficialis (FDS) may be resected to decrease the contents of the flexor sheath. Excision of the FDS slip is contraindicated if advanced infiltration of the tendons is found because of the weakened tendons. Complete resection of the FDS is contraindicated for fear of developing a swan-neck deformity.
Closure All wounds are closed with interrupted 5-0 nylon sutures. The soft tissues may be infiltrated with longacting local anesthesia for postoperative pain control. A bulky compression dressing is applied with a volar plaster splint leaving the digits free.
Postoperative Care After wrist, palmar, and digital flexor tenosynovectomy, the patients are instructed in digital active assisted range of motion exercises immediately following surgery. This will limit the amount of adhesions that develop among the flexor tendons. The sutures are removed at 10 to 14 days. The volar splint is discontinued at 3 to 4 weeks. Most patients are able to perform therapy on their own. Individual joint motion using blocking exercises is prescribed. Supervised hand therapy may be needed if range of motion remains poor. Intermittent extension splint of the PIP joint may be needed if there is a developing flexion contracture.
FLEXOR TENDON RUPTURE Flexor tendon rupture may occur as a sequela of flexor tenosynovitis. It is much less common than extensor tendon rupture, but when it occurs it is more problem320
atic. The two causes of flexor tendon rupture are attrition and invasion of proliferative tenosynovium. 1s17 Attrition ruptures are caused by abrasion of the flexor tendon usually by a bony spur in the carpal tunnel. Erosions of the carpal bones are caused by synovitis, which ultimately leads to spur formation. As the ligamentous supports erode, carpal subluxation occurs. The bony spurs then project into the carpal canal leading to abrasion of the flexor tendons. The most common site of this bony erosion is the volar pole of the scaphoid as described by Mannerfelt and N o r m a n 16 (Fig 2A). Other sites of rupture include the distal radius and ulna, hook of hamate, and t r a p e z i u m J 5'16"~s Proliferative tenosynovitis can invade the flexor tendon anywhere along its length causing rupture. The most common site of rupture is within the carpal canal as with the attrition ruptures. The flexor pollicis longus is the most commonly ruptured flexor tendon. The profundus and superficialis to the index finger are the next most frequently involvedJ 5 The relationship of these tendons to the volar aspect of the scaphoid makes them vulnerable to abrasion and wear. The flexor tendons to the ulnar three digits are less involved.
DIAGNOSIS The diagnosis of flexor tendon rupture may not be readily apparent. If patients have an abundance of proliferative tenosynovitis or poor digital motion, tendon ruptures may go unnoticed. Rupture may be masked by pain, stiffness, or prior weakness. However, attrition ruptures are usually nonpainful because proliferative tenosynovitis is absent. Most patients will present with a sudden inability to flex the involved digit or digits if rupture occurs. Some people will still have some motion secondary to continuity through tenosynovitis or scar. This can be deceiving; therefore, flexion against resistance should be assessed for decreased strength. Two thirds of all ruptures are attrition related and most ruptures, whether caused by attrition or invasion, occur in the carpal canalJ s Radiographs of the hand and wrist must be obtained to look for bony spurs or erosions at the wrist level. Confusion in diagnosis can be encountered if flexor tenosynovitis blocking motion is suspected. In this case there is usually a palpable nodule and the more extended posture seen with a rupture is absent.
SURGICAL INDICATIONS Prevention of flexor tendon ruptures is the key to treatment. If patients have long-standing flexor tenosynovitis or complain of progressive weakness, then the diagnosis of impending flexor tendon rupture should be made. Tenosynovectomy should be performed as described above. If flexor tendon rupture has occurred, then tenosynovectomy of the intact tendons and repair or reconstruction of ruptured tendons is warranted. If attrition is the cause, then spur excision and synovectomy is needed. Some patients will have variable functional DASS AND TERRONO
~, ~1P
Fig 2. This is a 70-year-old woman with rheumatoid arthritis who had a sudden inability to actively flex the IP joint of her thumb. She had good passive IP motion. (A) Radiographs show a scaphoid spur consistent with an attrition rupture. (B) Incision as for an extensive tenosynovectomy is used. Prominent tenosynovitis was found with multiple tendon ruptures that were not disturbed because of excellent active finger motion. The proximal FPL stump is found (arrow). (C) The distal FPL stump is found and tagged (long arrow). The scaphoid spur (short arrow) is found and debrided and covered with capsular rotation flap. (D) A significant gap (arrows) is present between the tendon ends even with traction. Therefore, a palmaris Iongus graft as shown is harvested and used as a bridge graft. (E) Functional IP joint motion is restored.
deficit. For example, if the thumb MP joint is very arthritic with little motion, then maintenance of interphalangeal (IP) joint motion is important and reconstruction of the tendon should be attempted. However, if there is little passive motion at the IP joint of the thumb, then flexor pollicis rupture is not a great functional loss and fusion of the unstable distal joint should be considered. Exploration of the carpal canal floor should also be performed to debride spurs and joint synovitis to prevent further ruptures. If the profundus tendon ruptures, then protection of the sublimis is important. If the profundus has ruptured in the fibro-osseous canal, then tenosynovectomy RHEUMATOID FLEXOR TENDON SURGERY
of the sublimis and possibly tenodesis or arthrodesis of the DIP joint is performed. If the rupture occurs in the palm or carpal tunnel, then primary repair or reconstruction is appropriate. Tendon grafting in the digits should be avoided for single ruptures. Remember, arthritic involvement of the PIP and/or DIP in a patient with or needing MP arthroplasties will influence the choice of reconstruction. Fusion with attachment of the proximal tendon to the proximal phalanx or A2 pulley would be the best option. The problem arises w h e n both profundus and superficialis tendons are ruptured in the same finger. If the cause of the ruptures is attrition in the palm or carpal 321
canal, then repair or reconstruction i s ' a viable option. However, if both have r u p t u r e d in the fibro-osseous canal because of either proliferative tenosynovitis or attrition, then reconstruction is less predictable and should be approached with caution. A two-stage flexor t e n d o n reconstruction m a y be chosen, but the results are very poor. 3 Arthrodesis of the PIP and DIP joints is our treatment of choice with two ruptures at the digital level.
SURGICAL TREATMENTmRECONSTRUCTION OF THE FLEXOR POLLICIS LONGUS The technique of flexor pollicis longus (FLP) reconstruction we describe can also apply to most other flexor tendon ruptures in the proximal palm or carpal tunnel t9 (Fig 2). The carpal tunnel is approached t h r o u g h a curved incision parallel a n d just \ , ulnar to the thenar crease, extending from the transverse palmar crease distally to 3 to 4 cm proximal to the wrist flexion crease. The carpal tunnel is exposed and a t e n o s y n o v e c t o m y performed. The proximal a n d distal s t u m p s of the FPL are identified. The proximal s t u m p should be the most radial a n d volar tendon within the carpal canal and m a y be more proximal than expected. If the proximal stump is difficult to find, then the incision should be extended proximally, because it can ahvays be found. The t e n d o n excursion is t h e n evaluated. Gentle constant traction is then applied and often the excursion will increase a n d be satisfactory (Fig 2B). The distal stump can often be found with flexion of the IP joint a n d gentle attempts at grasping it in the fibroosseous canal. The volar surface of the scaphoid is identified and a s y n o v e c t o m y and spur debridement is performed (Fig 2C). Capsular tissue is mobilized to cover the defect. A bridge graft using the palmaris longus approximates the two stumps using a weave technique and 3-0 or 4-0 nonabsorbable suture (Fig 2D). The distal anastomosis is usually the first performed and t h e n the proximal. Tension is set with the wrist in neutral position a n d the IP joint fully flexed. The IP joint should fully extent with the wrist fully flexed. W h e n the distal stump cannot be retrieved in the carpal canal there are several options. A full-length t e n d o n graft or sublimis transfer can be performed or an incision can be m a d e at the IP joint, the distal stump found, a n d a bridge graft performed. If a graft is chosen, the distal juncture is performed a n d then the proximal portion of the graft can be passed into the carpal canal by attachment to it by a silicone feeding tube. The proximal juncture is t h e n performed as described above. If the palmaris longus is absent, then a portion of the flexor carpi radialis or abductor pollicis longus tendons m a y be u s e d or a sublimus transfer performed. If the muscle excursion is poor, a sublimus transfer m u s t be performed.
OUTCOME The results of flexor t e n o s y n o v e c t o m y for long-term resolution of tenosynovitis and prevention of flexor t e n d o n rupture are well d o c u m e n t e d . 2-4 Flexor t e n d o n rupture
322
Fig 3. A palmaris Iongus bridge graft Inserted for a ruptured FDP in the palm.
has more variable results. Ertel et al's review of flexor t e n d o n ruptures shows a n u m b e r of prognostic factors. 15 Patients did better if they had attrition ruptures or isolated ruptures in the wrist or palm. Average IP joint motion was 23 ~ with a range of 0 ~ to 45 ~ after FPL repairs or reconstruction (Fig 2E). PIP motion averaged 55 ~ after FDP repairs at the palm or wrist with a range of 20 ~ to 80 ~ (Fig 3). Patients fared poorly if multiple t e n d o n ruptures were evident, r u p t u r e occurred in the digits, rupture was caused in infiltrative tenosynovitis, or significant articular involvement in the h a n d and digits were present. By p e r f o r m i n g early t e n o s y n o v e c t o m y , the complications of tendon ruptures can be avoided.
REFERENCES 1. Nalebuff EA: Rheumatoid hand surgery--Update. J Hand Surg 8: 848-856, 1982 2. Flatt AE: The Care of the Rheumatoid Hand (ed 3). St Louis, MO, Mosby, 1974 3. Brown FE, Brown ML: Long term results after tenosynovectomy to treat the rheumatoid hand. J ttand Surg [Am] 13:704-708, 1988 4. Straub RL, Ranawat CS: The wrist in rheumatoid arthritis---Surgical treatment and results. J Bone Joint Surg [Am] 57:1-20,1969 5. Herbison GJ, Jeng C, Martin JL, et al: Carpal tunnel syndrome in rheumatoid arthritis. Am J Phys Med Rehabil 52:68-74, 1973 6. }tenderson ED, LipscombPR: Surgical treatment of the rheumatoid hand. JAMA 5:431-436, 1961 7. Millender LH, Nalebuff EA: Preventive surgery--Tenosynovectomy and synovectomy (symposium on rheumatoid arthritis). Orthop Clin North Am 6:765-792, 1975 8. Marmor L: Surgery of Rheumatoid Arthritis. Philadelphia, PA, Lea & Febiger, 1967 9. Wissenger HA: Digital flexor lag in rheumatoid arthritis--Clinical significance and treatment. Plast Reconstr Surg 47:465-468, 1971 10. FeriicDC, Clayton ML: Flexor tenosynovectomy on the rheumatoid finger. J Hand Surg [Am] 4:364-367, 1978 11. Millis MB, Millender LH, Nalebuff EA: Stiffness of the proximal interphalangeal joints in rheumatoid arthritis. J Bone Joint Surg [Am] 58:801-805, 1976
DASS AND TERRONO
12. Helel BH: Extraarticular causes of proximal inte~phalangeal joint stiffness in rheumatoid arthritis. Hand 7:37-40, 1975 13. Clayton ML: Surgical treatment of the wrist in rheumatoid arthritis---A review of thirty-seven patients. J Bone Joint Surg [Am] 47: 741-750, 1965 14. Flatt AE: Some pathomechanics of ulnar drift. Plast Reconstr Surg 37:295, 1966 15. Ertel AN, Millender LH, Nalebuff EA, et al: Flexor tendon ruptures in rheumatoid arthritis. J Hand Surg [Am] 13:860-863, 1988 16. Mannerfelt N, Norman O: Attrition ruptures of flexor tendons in
RHEUMATOID FLEXOR TENDON SURGERY
rheumatoid arthritis cause by bony spurs in the carpal tunnel. J Bone Joint Surg [Br] 51:270-277, 1969 17. Nalebuff EA: Surgical treatment of tendon ruptures in the rheumatoid hand. Surg Clin North Am 49:811-822, 1969 18. Craig EV, House JH: Dorsal carpal dislocation and flexor tendon rupture in rheumatoid arthritis---A case report. J Hand Surg [Am] 9:261-264, 1984 19. Toledano B, Terrono AL, Millender LH: Reconstruction of the rheumatoid thumb. Hand Clin 8:121-129, 1992
323
Tenosynovitis in the hand and wrist is a common finding in patients who have rheumatoid arthritis. In contrast to the more easily treated and diagnosed dorsal tenosynovitis, flexor tenosynovitis may be more problematic. If flexor tendon rupture occurs, this is usually more disabling than extensor tendon ruptures. Therefore, early recognition is important and early tenosynovectomy will prevent flexor tendon ruptures in patients with rheumatoid arthritis. KEY WORDS: flexor tendon, rheumatoid arthritis
Proliferative flexor tenosynovitis is common in patients who have rheumatoid arthritis. Locations include the wrist, palm, and digits. Patient's symptoms and physical examination will identify the areas of involvement. Once the tenosynovitis is identified, specific therapeutic modalities can be instituted. Patients are initially managed by their rheumatologists/internists with nonsteroidal anti-inflammatory medications, oral steroids, and/or chemotherapeutic agents. Many patients respond to these medications with resolution of the tenosynovitis. Others may experience periods of remission and flareups. If ongoing flexor tenosynovitis fails to respond to medical management, then tenosynovectomy is warrantedJ Steroid injections may be administered early in the course of tenosynovitis. If any symptoms or signs of weakness are noted, then steroid injections are contraindicated. Tenosynovectomy is an effective procedure for prevention of tendon rupture as,well as for long-term resolution of the tenosynovitis. 2-4 Recurrent synovitis is uncommon. If tendon rupture occurs, tenosynovectomy is performed along with tendon reconstruction and evaluation and treatment of the causes of attrition to prevent further tendon ruptures.
AREAS OF INVOLVEMENTmTENOSYNOVITIS
ing the disease flexor tendon excursion may be normal but with increased duration, flexor tendon adhesions develop limiting tendon excursion. The hallmark in the diagnosis of flexor tenosynovitis at the wrist is reduced active finger flexion in the presence of preserved passive motion. 2'7"9 Neurolysis may be needed at the time of carpal tunnel release and tenosynovectomy.
Palmar Level Flexor tendon involvement at the level of the palm may present as painful swelling, snapping or locking of the digits, or loss of motion. Nodular formation of the tenosy'novium may involve the tendon from the distal edge of the carpal tunnel to the A1 pulley. Examination demonstrates palmar fullness and tenderness. With involvement near the A1 pulley, snapping or locking of the digit in flexion occurs. Active extension of the digit may be impeded w h e n the nodule presses against the proximal edge of the A1 pulley but locking is usually passively correctable. As with flexor tenosynovitis at more proximal levels, tendon excursion may be limited. Therefore, examination must include the discrepancy between active and passive flexion.
Wrist Level
Digital Level
Carpal tunnel syndrome may be the first symptom of flexor tenosynovitis at the wrist level in patients with rheumatoid arthritis. 5"6 The tenosynovitis increases the volume in a fixed space, the carpal tunnel, producing compression on the median nerve. The tenosynovitis may extend into the proximal portion of the forearm. The diagnosis may be difficult to establish because bulging of the flexor tenosynovitis is limited by the transverse carpal ligament and the antebrachial fascia. Early dur-
Flexor tenosynovitis at the level of the digits may also cause pain, triggering, or limitation of motion. Pain occurs with flexion of the digit producing crepitus or grating. Triggering or locking occurs with increasing nodularity. The area of involvement can extend to the distal interphalangeal (DIP) joint. 1~ Less commonly, flexor tenosynovitis may cause stiffness of the proximal interphalangeal joint (PIP). 11'12 Active motion is limited initially, then passive motion. Stiffness occurs secondarily to the contracted capsule and collateral ligaments. The diagnosis must be differentiated from PIP joint synovitis and/or metacarpal phalangeal (MP) joint involvement associated with intrinsic tightness. Absence of deformity and normal radiographs of the MP and PIP joints excludes these diagnoses. A prior history of locking or triggering is usually found in digital flexor tenosynovitis.
From the Department of Orthopaedics, Tufts University School of Medicine, MA. Address reprint requests to Andrew L. Terrono, MD, Hand Surgical Associates, New England Baptist Hospital, 125 Parker Hill Ave, Suite 540R, Boston, MA 02120. Copyright 9 1993 by W. B. Saunders Company 1048-6666/93/0304-0011505.00/0
31 8
Operative Techniquesin Orthopaedics, Vol 3, No 4 (October), 1993: pp 318-323
SURGICAL INDICATIONS--TENOSYNOVECTOMY Flexor tenosynovectomy is r e c o m m e n d e d in patients who have significant tenosynovitis despite at least a 6-month course of conservative treatment including splinting, steroid injections, a n d systemic medications. 3A3 Persistent symptoms of median nerve compression and triggering or locking of the digits are included in these indications. Other indications include documented tendon rupture or impending tendon rupture. A progressive increase in the loss of active flexion of the digits should be treated by tenosynovectomy. Contraindications to flexor tenosynovectomy are few but include any acute infection or open wounds. Relative contraindications include failure to provide adequate nonoperative management.
SURGICAL TECHNIQUE--TENOSYNOVECTOMY Preparation The patient is placed in the supine position and a hand table is used for support of the arm. The procedure is performed while the patient is under regional or general anesthesia with tourniquet control. The extent of the disease usually precludes the use of local anesthesia, which is preferred in cases of stenosing tenosynovitis in patients without rheumatoid arthritis. Preoperative intravenous antibiotics are routinely administered before the tourniquet is inflated. The extremity is prepared and draped to the midhumeral level. Loupe magnification is recommended to avoid soft tissue injury.
Exposure Adequate exposure is needed for flexor tenosynovectomy. The surgical technique is usually more difficult than dorsal tenosynovectomy because of the diffuse nature of the disease, the close relationship of the neurovascular structures to the flexor tendons and the need to retain the flexor tendon sheath. Skin incisions are based on the areas of involvement. A complete tenosynovectomy must be performed in each area to remove the disease. This is usually accomplished as one stage.
WRIST LEVEL We prefer to do wrist flexor tenosynovectomy through an extended carpal tunnel incision. The incision begins between the palmaris longus and the flexor carpi ulnaris tendons approximately 5 cm proximal to the wrist flexion crease. The incision is extended distally to the ulnar side of the proximal wrist flexion crease and then in line with the intereminence crease. The incision ends at the transverse palmar crease. This incision allows complete exposure of the flexor tendons proximal to the carpal tunnel as well as the contents of the carpal tunnel to the superficial palmar arch. This incision also avoids injury RHEUMATOID FLEXOR TENDON SURGERY
to the palmar cutaneous branch of the median nerve. After the skin is incised, the palmar fascia is split longitudinally. The antebrachial fascia and the transverse ligament are then incised longitudinally. Care is taken to protect and free up both the main median nerve and its motor branch to the thenar musculature, which is always retracted radially. The superficial flexor tendons are individually exposed and the proliferative tenosynovium is removed by sharp dissection. A penrose drain is used to retract the superficial flexors to expose the deep flexors. Tenosynovectomy of the profundus tendons as a group is then performed without separating each tendon from one another. The fingers should be flexed and extended during the tenosynovectomy to facilitate delivery of the tendons into the w o u n d . If the tendons are frayed they are repaired. If unsuspected multiple ruptures are found but finger function is adequate, they are left alone. Function is often maintained through scar or tenosynovitis a n d extensive t e n o s y n o v e c t o m y can worsen the patient's condition. It is important to palpate the floor of the carpal tunnel for any bony spurs that may cause tendon rupture. These spurs must be removed and the adjacent joint debrided of synovitis. Rotation of a capsular flap allows the exposed bone to be covered and creates a smooth bed for tendon gliding. If median nerve compression is noted preoperatively, this carpal tunnel exposure will decompress the median nerve as well. However, if long standing compression of the median nerve is present, neurolysis may be required to decompress fully the nerve.
PALM LEVEL/DIGIT Flexor tenosynovectomy in the palm and digit is usually approached by a zigzag incision. The transverse palmar incision commonly used in nonrheumatoid stenosing tenosynovitis is not usually recommended. The location and length of the incision are dependent on the location and amount of involvement. The skin is incised and the soft tissue is bluntly dissected with scissors d o w n to the center of the flexor tendon sheath. Skin retraction sutures are used to gently retract the skin. The neurovascular bundles are protected on either side of the tendon sheath (Fig 1). A portion of the tendon sheath is incised to facilitate exposure. Annular pulleys are preserved if possible. Complete transection of the A1 pulley is contraindicated in the rheumatoid patient for the fear of increasing the ulnar drift. 1~ The A2 and A4 pulleys should be preserved to prevent bowstringing of the tendons. Flexor tenosynovitis may extend beyond the PIP joint and exposure of the profundus tendon distal to the superficialis insertion must be undertaken. 1~ The flexor tendons are delivered into the wound by flexing the digits. A complete tenosynovectomy of the superficialis and profundus tendons is then performed. If nodularity is found within the tendon substance, the nodules are sharply debrided and the defect closed with a 6-0 nylon running inverted stitch. Completeness of the tenosynovectomy is checked by pulling on each tendon individually. If further adhesions/tenosynovitis limiting excursion are present, then 319
Fig 1. This patient has significant digital and palmar rheumatoid tenosynovitis. Exploration is conducted through a palmar and digital zigzag incision. Extensive tenosynovium is encountered and removed with careful preservation of annular pulleys.
the tenosynovectomy should be extended and the ulnar slip of the flexor digitorum superficialis (FDS) may be resected to decrease the contents of the flexor sheath. Excision of the FDS slip is contraindicated if advanced infiltration of the tendons is found because of the weakened tendons. Complete resection of the FDS is contraindicated for fear of developing a swan-neck deformity.
Closure All wounds are closed with interrupted 5-0 nylon sutures. The soft tissues may be infiltrated with longacting local anesthesia for postoperative pain control. A bulky compression dressing is applied with a volar plaster splint leaving the digits free.
Postoperative Care After wrist, palmar, and digital flexor tenosynovectomy, the patients are instructed in digital active assisted range of motion exercises immediately following surgery. This will limit the amount of adhesions that develop among the flexor tendons. The sutures are removed at 10 to 14 days. The volar splint is discontinued at 3 to 4 weeks. Most patients are able to perform therapy on their own. Individual joint motion using blocking exercises is prescribed. Supervised hand therapy may be needed if range of motion remains poor. Intermittent extension splint of the PIP joint may be needed if there is a developing flexion contracture.
FLEXOR TENDON RUPTURE Flexor tendon rupture may occur as a sequela of flexor tenosynovitis. It is much less common than extensor tendon rupture, but when it occurs it is more problem320
atic. The two causes of flexor tendon rupture are attrition and invasion of proliferative tenosynovium. 1s17 Attrition ruptures are caused by abrasion of the flexor tendon usually by a bony spur in the carpal tunnel. Erosions of the carpal bones are caused by synovitis, which ultimately leads to spur formation. As the ligamentous supports erode, carpal subluxation occurs. The bony spurs then project into the carpal canal leading to abrasion of the flexor tendons. The most common site of this bony erosion is the volar pole of the scaphoid as described by Mannerfelt and N o r m a n 16 (Fig 2A). Other sites of rupture include the distal radius and ulna, hook of hamate, and t r a p e z i u m J 5'16"~s Proliferative tenosynovitis can invade the flexor tendon anywhere along its length causing rupture. The most common site of rupture is within the carpal canal as with the attrition ruptures. The flexor pollicis longus is the most commonly ruptured flexor tendon. The profundus and superficialis to the index finger are the next most frequently involvedJ 5 The relationship of these tendons to the volar aspect of the scaphoid makes them vulnerable to abrasion and wear. The flexor tendons to the ulnar three digits are less involved.
DIAGNOSIS The diagnosis of flexor tendon rupture may not be readily apparent. If patients have an abundance of proliferative tenosynovitis or poor digital motion, tendon ruptures may go unnoticed. Rupture may be masked by pain, stiffness, or prior weakness. However, attrition ruptures are usually nonpainful because proliferative tenosynovitis is absent. Most patients will present with a sudden inability to flex the involved digit or digits if rupture occurs. Some people will still have some motion secondary to continuity through tenosynovitis or scar. This can be deceiving; therefore, flexion against resistance should be assessed for decreased strength. Two thirds of all ruptures are attrition related and most ruptures, whether caused by attrition or invasion, occur in the carpal canalJ s Radiographs of the hand and wrist must be obtained to look for bony spurs or erosions at the wrist level. Confusion in diagnosis can be encountered if flexor tenosynovitis blocking motion is suspected. In this case there is usually a palpable nodule and the more extended posture seen with a rupture is absent.
SURGICAL INDICATIONS Prevention of flexor tendon ruptures is the key to treatment. If patients have long-standing flexor tenosynovitis or complain of progressive weakness, then the diagnosis of impending flexor tendon rupture should be made. Tenosynovectomy should be performed as described above. If flexor tendon rupture has occurred, then tenosynovectomy of the intact tendons and repair or reconstruction of ruptured tendons is warranted. If attrition is the cause, then spur excision and synovectomy is needed. Some patients will have variable functional DASS AND TERRONO
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Fig 2. This is a 70-year-old woman with rheumatoid arthritis who had a sudden inability to actively flex the IP joint of her thumb. She had good passive IP motion. (A) Radiographs show a scaphoid spur consistent with an attrition rupture. (B) Incision as for an extensive tenosynovectomy is used. Prominent tenosynovitis was found with multiple tendon ruptures that were not disturbed because of excellent active finger motion. The proximal FPL stump is found (arrow). (C) The distal FPL stump is found and tagged (long arrow). The scaphoid spur (short arrow) is found and debrided and covered with capsular rotation flap. (D) A significant gap (arrows) is present between the tendon ends even with traction. Therefore, a palmaris Iongus graft as shown is harvested and used as a bridge graft. (E) Functional IP joint motion is restored.
deficit. For example, if the thumb MP joint is very arthritic with little motion, then maintenance of interphalangeal (IP) joint motion is important and reconstruction of the tendon should be attempted. However, if there is little passive motion at the IP joint of the thumb, then flexor pollicis rupture is not a great functional loss and fusion of the unstable distal joint should be considered. Exploration of the carpal canal floor should also be performed to debride spurs and joint synovitis to prevent further ruptures. If the profundus tendon ruptures, then protection of the sublimis is important. If the profundus has ruptured in the fibro-osseous canal, then tenosynovectomy RHEUMATOID FLEXOR TENDON SURGERY
of the sublimis and possibly tenodesis or arthrodesis of the DIP joint is performed. If the rupture occurs in the palm or carpal tunnel, then primary repair or reconstruction is appropriate. Tendon grafting in the digits should be avoided for single ruptures. Remember, arthritic involvement of the PIP and/or DIP in a patient with or needing MP arthroplasties will influence the choice of reconstruction. Fusion with attachment of the proximal tendon to the proximal phalanx or A2 pulley would be the best option. The problem arises w h e n both profundus and superficialis tendons are ruptured in the same finger. If the cause of the ruptures is attrition in the palm or carpal 321
canal, then repair or reconstruction i s ' a viable option. However, if both have r u p t u r e d in the fibro-osseous canal because of either proliferative tenosynovitis or attrition, then reconstruction is less predictable and should be approached with caution. A two-stage flexor t e n d o n reconstruction m a y be chosen, but the results are very poor. 3 Arthrodesis of the PIP and DIP joints is our treatment of choice with two ruptures at the digital level.
SURGICAL TREATMENTmRECONSTRUCTION OF THE FLEXOR POLLICIS LONGUS The technique of flexor pollicis longus (FLP) reconstruction we describe can also apply to most other flexor tendon ruptures in the proximal palm or carpal tunnel t9 (Fig 2). The carpal tunnel is approached t h r o u g h a curved incision parallel a n d just \ , ulnar to the thenar crease, extending from the transverse palmar crease distally to 3 to 4 cm proximal to the wrist flexion crease. The carpal tunnel is exposed and a t e n o s y n o v e c t o m y performed. The proximal a n d distal s t u m p s of the FPL are identified. The proximal s t u m p should be the most radial a n d volar tendon within the carpal canal and m a y be more proximal than expected. If the proximal stump is difficult to find, then the incision should be extended proximally, because it can ahvays be found. The t e n d o n excursion is t h e n evaluated. Gentle constant traction is then applied and often the excursion will increase a n d be satisfactory (Fig 2B). The distal stump can often be found with flexion of the IP joint a n d gentle attempts at grasping it in the fibroosseous canal. The volar surface of the scaphoid is identified and a s y n o v e c t o m y and spur debridement is performed (Fig 2C). Capsular tissue is mobilized to cover the defect. A bridge graft using the palmaris longus approximates the two stumps using a weave technique and 3-0 or 4-0 nonabsorbable suture (Fig 2D). The distal anastomosis is usually the first performed and t h e n the proximal. Tension is set with the wrist in neutral position a n d the IP joint fully flexed. The IP joint should fully extent with the wrist fully flexed. W h e n the distal stump cannot be retrieved in the carpal canal there are several options. A full-length t e n d o n graft or sublimis transfer can be performed or an incision can be m a d e at the IP joint, the distal stump found, a n d a bridge graft performed. If a graft is chosen, the distal juncture is performed a n d then the proximal portion of the graft can be passed into the carpal canal by attachment to it by a silicone feeding tube. The proximal juncture is t h e n performed as described above. If the palmaris longus is absent, then a portion of the flexor carpi radialis or abductor pollicis longus tendons m a y be u s e d or a sublimus transfer performed. If the muscle excursion is poor, a sublimus transfer m u s t be performed.
OUTCOME The results of flexor t e n o s y n o v e c t o m y for long-term resolution of tenosynovitis and prevention of flexor t e n d o n rupture are well d o c u m e n t e d . 2-4 Flexor t e n d o n rupture
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Fig 3. A palmaris Iongus bridge graft Inserted for a ruptured FDP in the palm.
has more variable results. Ertel et al's review of flexor t e n d o n ruptures shows a n u m b e r of prognostic factors. 15 Patients did better if they had attrition ruptures or isolated ruptures in the wrist or palm. Average IP joint motion was 23 ~ with a range of 0 ~ to 45 ~ after FPL repairs or reconstruction (Fig 2E). PIP motion averaged 55 ~ after FDP repairs at the palm or wrist with a range of 20 ~ to 80 ~ (Fig 3). Patients fared poorly if multiple t e n d o n ruptures were evident, r u p t u r e occurred in the digits, rupture was caused in infiltrative tenosynovitis, or significant articular involvement in the h a n d and digits were present. By p e r f o r m i n g early t e n o s y n o v e c t o m y , the complications of tendon ruptures can be avoided.
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12. Helel BH: Extraarticular causes of proximal inte~phalangeal joint stiffness in rheumatoid arthritis. Hand 7:37-40, 1975 13. Clayton ML: Surgical treatment of the wrist in rheumatoid arthritis---A review of thirty-seven patients. J Bone Joint Surg [Am] 47: 741-750, 1965 14. Flatt AE: Some pathomechanics of ulnar drift. Plast Reconstr Surg 37:295, 1966 15. Ertel AN, Millender LH, Nalebuff EA, et al: Flexor tendon ruptures in rheumatoid arthritis. J Hand Surg [Am] 13:860-863, 1988 16. Mannerfelt N, Norman O: Attrition ruptures of flexor tendons in
RHEUMATOID FLEXOR TENDON SURGERY
rheumatoid arthritis cause by bony spurs in the carpal tunnel. J Bone Joint Surg [Br] 51:270-277, 1969 17. Nalebuff EA: Surgical treatment of tendon ruptures in the rheumatoid hand. Surg Clin North Am 49:811-822, 1969 18. Craig EV, House JH: Dorsal carpal dislocation and flexor tendon rupture in rheumatoid arthritis---A case report. J Hand Surg [Am] 9:261-264, 1984 19. Toledano B, Terrono AL, Millender LH: Reconstruction of the rheumatoid thumb. Hand Clin 8:121-129, 1992
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