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Surgery for rupture of extensor tendons in rheumatoid arthritis
Surgery /or Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
S U R G E R Y FOR R U P T U R E OF E X T E N S O R T E N D O N S IN R H E U M A T O I D ARTHRITIS
F. T. SHANNON and N. J. BARTON, Nottingham SUMMARY • Forty-two patients underwent fifty-four operations for rupture of extensor tendg~ns in rheumatoid disease. The results are analysed and factors affecting the results discussed. INTRODUCTION There have been many accounts of the methods of repair of ruptured extensor tendons in rheumatoid disease, but only a few studies have provided figures of 10ng-term follow-up (Vainio 1964, Clayton 1965, Harrison 1972). Prevention is better than cure and this may be achieved by early tenosynovectomy and excision of the lower end of the ulna (Clayton 1965, Flatt 1974, Jackson 1974, Kessler 1966, Linscheid 1968), but rupture can occur even after this. :~ For established rupture, there _~.s no place for direct suture of the tendon ends. Flatt (1974) recommends tendon transfers, mentioning in order of preference as the donor muscle, extensor indicis proprius, extensor carpi radialis longus, extensor carpi ulnaris and brachioradialis. Clayton (1965) suggests that "the simplest procedure is probably the best". In rupture of extensor pollicis longus, Midgley (1971) considers extensor indicis proprius the ideal motor, outlining its advantages as being expendable, straight, synergistic and subcutaneous, while Harrison (1972) provides evidence for recommending extensor pollicis brevis. Vainio (1969)states that tendon transfer should be accompanied by local synovectomy; results in fifty-six cases of extensor pollicis longus rupture were good, the best range of movement being restored when extensor indicis proprius was transferred. He also refers to twenty-five cases of combined rupture of ring and little finger tendons (for which he advocated transfer of extensor carpi ulnaris) saying that their results depended on the condition of the metacarpophalangeal joints. Vaughan-Jackson (1969) suggested treating the ruptured little finger tendon by splitting the ring finger tendon, detaching the ulnar half of it and suturing this end-to-end to the distal end of the ruptured little finger tendon. He feels that adjacent end-to-side anastomosis of distal little to intact ring is unsatisfactory. Nalebuff (1969) outlined his preferences: for isolated rupture of the extensors to the little finger, he anastomoses the communis tendon to the adjacent ring tendon, and transfers extensor indicts proprius to extensor digiti minimi to reinforce the power of extension. For the combined ring and little finger ruptures he advises adjacent anastomosis of ring to middle and an extensor indicts proprius transfer to the little finger. For the triple ruptures of middle, ring and little finger tendons he transfers a flexor digitorum superficialis to middle and ring while attaching the extensor indicts proprius tendon to the little finger. Results depend on the activity of disease in the synovium, joints, muscles and tendons and on the particular requirements of the patient. Function is more important than the objective range of movement and subjective opinion must be
F. T. Shannon, F.R.C.S., Ed., Senior Registrar in Orthopaedics, Bradford Royal Infirmary, N. J. Barton, F.R.C.S., Consultant Orthopaedic Surgeon, Harlow Wood Orthopaedic Hospital, Notts. , The H a n d - - V o l . 8
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Surgery for Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
correlated with the clinical assessment. Extension is more important in the index and middle fingers while flexion is the prime need of the ring and little fingers. Evaluation is difficult because of the complexity and multiplicity of lesions and the cyclical nature of the disease. MATERIAL
Case notes over the years 1962 to 1973 at Harlow Wood Orthopaedic Hospital, Nottinghamshire, were searched for records of surgical procedures performed for spontaneous rupture of extensor tendons in rheumatoid hands. Forty-two patients (fifty-four hands) were available for follow-up. Thirty-one were female, eleven male. The average age was forty-seven years. Rheumatoid disease was present for an average of nine years before operation and the duration of follow-up averaged five and a half years (Table 1). Of the fifty-four operations, twenty-nine were for r u p t u r e of extensor pollicis longus, and twenty-five for ruptures of the finger extensor tendons (Table 2). TABLE 1
42 patients:
Age 38 to 73 years RA duration 2 to 27 years Follow-up 1 to 13 years
(av. 47 years) (av. 9 years) (av. 5½ years)
TABLE 2 Extensor Tendons Ruptured
54 operations:
29 E.P.L 12 ring and little combined 6 middle, ring and little (triple) 4 little alone 3 ring alone
TABLE 3
E.P.L (29)
Supplementary Procedures
Synovectomy Ulnar end excision Retinacular transposition Wrist fusion
Fingers (25)
14 1 6 3
16 19 2 5
METHOD
Information obtained from the records included age, sex, occupation, the indication for operation and the type of tendon repair performed, together with details of simultaneous supplementary procedures (Table 3). All patients were interviewed by one of us (F.T.S.), who recorded the subjective opinion of the patients as well as the findings on examination of both joint and tendon function. In studying the objective results three simple measurements were considered the most informative:
(1) The extension deficit. This is a reasonably objective estimate of the function restored to a repaired extensor tendon. It was measured in centimetres from the metacarpal plane to the edge of the fingernail. 280
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Surgery /or Rupture o/ Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
(2) The flexion deficit. The distance by which the tip of the fully flexed digit fell short of the distal palmar crease was recorded to determine whether the extensor repair might have limited flexion. This was consider particularly important for the ring and little fingers. (3) Measurement of both pinch and patmar grip were recorded using a sphygmomanometer cuff inflated to 50 mm of mercury and measuring how much more the patient could squeeze this. When there was joint involvement, the above measurements were affected by that as well as by the state of the tendons. It is in the nature o f the disease that there may be several different types of pathological process in one finger. RESULTS
Ruptured Extensor Pollieis Longus (29 hands) The operations performed and their results are shown in Table 4. The average extension deficit was 1.3 cm, whether extensor indicis or extensor carpi radialis longus was used. The deficit in flexion measured from the distal palmar crease averaged 1.7 cm, the distance being significantly greater when extensor carpi radialis longus was transferred. For the twenty-nine repairs of extensor pollicis longus the objective assessment agreed with subjective satisfaction in twentyseven cases, even in the presence of joint changes such as the " Z " deformity. Two patients were dissatisfied, both from the group of extensor indicis proprius transfer, examined at ten and eleven years follow-up respectively: both had evidence of re-rupture (see discussion). Isolated Rupture o / L i t t l e Finger Tendons (4 hands) Anastomosis to the extensor digitorum communis tendon of another finger had been performed four times; to the ring finger tendon in three and to the middle finger in one instance. One might expect that these would have done better than the average figures indicate (Table 5). Three patients were satisfied. There was one who was not satisfied and she had a particularly poor outcome (Table 6): at five and a half years follow-up there was a 12 cm extension deficit, the repair had failed, the dislocated metacarpophalangeal joints were painful and she had a poor grip. TABLE 4
E.P.L. Ruptures (29) Operation
E.I.P. Transfer (20) E.C.R.L. Transfer (8) E.P.B. Tenodesis (1) OVERALL AV.
Extension Deficit (cms) 1.5 (0~) 1.0 (0-3) 0.0
Flexion Deficit (cms) 1.3 (0-3) 2.7 (0--7) 2.0
Grip (ram H g ~ 50) 50 (20-100) 55 (30-140) 40
1.3
1.7
50
Isolated Rupture of Ring Finger Tendons (3 hands) Extensor carpi radialis longus had been transferred in one, while anastomosis to the adjacent middle finger tendon had been performed in two cases. The results were worse than one might expect (Table 5). There were two failures (Table 6): one, the carpi radialis transfer, at four and a half years follow-up, had a 7 cm extension deficit as well as progressive joint disease (Fig. 1). The other patient, at three years follow-up, had a 3 cm extension deficit, a 6 cm flexion deficit; she complained more of the extension loss. The Hand~Vol. 8
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Surgery for Rupture o/ Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton TABLE 5 Total Finger Tendou Ruptures (25)
Group . Averages
Extension Deficit (cms)
Isolated Little (4) Isolated Ring (3~ Combined L i t t l e and R i n g (12) Combined Little, Ring and Middle (6) O V E R A L L A V E R A G E (25) S A T I S F I E D A V E R A G E (15) D I S S A T I S F I E D A V E R A G E (10)
Flexion Deficit (cms)
Grip (ram Hg ~ 50)
2 2.7
50 45 65 75 60 70 50
4.5 3.3 4 6 4.5 2.0 8.0
1 2
1.5 0.5 3.0
TABLE 6 Adverse Factors in Dissatisfied Patients with Finger Extensor Tendon Ruptures
.~ ~
Rupture Group
~
~
Little alone ( 4 )
31
Adjacent
"~ ~ t ~ "~ ~
. ~
~
~'
~ ,
~ ~ ~~ ~ Symptoms
~
-
*
. . . .
* Loss grip, pain joints
* *
* -
* *
* - . . . .
Loss e x t n / p a i n middle, ring, little Loss extn/loss grip
*
*
*
*
-
-
Loss of grip
*
*
*
-
-
-
Pain ring/little M.C.P. joints
-
* *
* Loss grip/loss extn ring/little Pain finger joints * Loss extension Loss extension 3 0
Rir~ Ring alone (3) Ring and Little c o m b i n e d (12)
24 47
E:C.R.L. trans. Adj. Midd.
1
Adjacent Middle 9 Adjacent Middle ' ! 4 b F.C,U. trans.
*
*
Middle, Ring and Little c o m b i n e d (6) '
10b E.D.C. Index trans. 15 E.I.P. trans. 34 E.I.P. trans. 48 E.C.R.L. trans.
*
*
Loss of grip
* -
-
*
~
*
*
-
* * -
DISSATISFIED SATISFIED
10 pts. 15 pts
7 5
7 3
6 4
3 1
3 0
Fig. la. Extension Deficit 7cm. Fig. lb. Flexion Deficit 2cm. Isolated r u p t u r e of ring finger tendon, treated by E.C.R.L. transfer. Dissatisfied at 4½ years follow-up, loss of extension, painful subluxation. M.C.P. joints, intrinsic contraeture, r u p t u r e d superficialis tendons. 282
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Surgery for Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. :Shannon and N.: .L Bartot~
Fig. 2a. Extension Deficit lcm. Fig. 2b. Flexion Deficit 0cm. Combined little and ring tendon rupture, treated by adjacent anastomosis to middle finger tendon. Satisfied at 6½ years follow-up, uneven pull evident. Ruptures of both Little and Ring Finger tendons combined (12 hands) Six hands had an adjacent anastomosis performed to the middle finger tendon, indicis was transferred in three and in three others the tendon of flexor carpi ulnaris was used. In all but one the little and ring finger tendons were sutured together,: a n d joined thus to the proximal motor (one exception being the individual suture of each rupture t o a longitudinally split extensor indicis proprius tendon). There was no significant difference whichever operation had been performed. The cumulative results of the little and ring fingers combined (Table 5), included nine satisfied patients, who accepted 2.5 cm extension deficit but achieved full flexion, so important for the ulnar two fingers (Fig. 2). Three dissatisfied patients were objective failures; at seven years follow-up, their average extension deficit was 9 cm, flexion deficit was 3 c m , the extensor tendons were intact but dislocated (Table 6). Triple Ruptures (6 hands) The ruptured extensor tendons of little, ring and middle fingers combined were sutured en masse to an indicis transfer in two cases, and "attached to the index tendons" in two, while extensor carpi radialis longus was used in two further cases. At follow-up only one of the six could fully extend. The majority (Table 5) had appreciable limitation of flexion. The good grip may be due to the fact that four of the six were males. Subjectively only two of the six were satisfied. Of the four dissatisfied, three patients had post-operative wound complications (Table 6), the fourth had an 11 cm extension deficit, a 4 cm flexion deficit and severe joint deformity.
COMPLICATIONS There were three complications; one haematoma and two wound infections. All three occurred in operations performed for triple rupture. All three patients were dissatisfied. DISCUSSION
T h e results showed that surgical management in twenty-nine ruptures of extensor pollicis longus was generally satisfactory, u s e of extensor carpi radialis provided extension equal to that achieved by an extensor indicis proprius transfer (Table 4). There was a greater flexion deficit using extensor carpi radialis longus but this was not considered a handicap by the patients concerned. This transfer was quite adequate and had the advantage of-sparing extensor indicis The Hand--Vol. 8
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Surgery for Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
proprius for other finger tendon repairs. There were two failures, both extensor indicis proprius transfers which had ruptured again; they also had an extensor lag at the metacarpophalangeal joint because of extensor pollicis brevis involvement. Two others who had similar evidence of failure of the extensor pollicis longus repair were satisfied--intact extensor pollicis brevis tendons providing useful extension at their metacarpophalangeal joints. Extensor pollicis longus was ruptured in association with other extensors in two patients, the extensor pollicis results being satisfactory. In patient No. 14b, extensor carpi radialis longus was used for the thumb; flexor carpi ulnaris was transferred to a combined little and ring rupture--at eight years follow-up this patient was dissatisfied because of his poor grip (Table 6), the extensor tendons were intact but dislocated. In patient No. 10b, indicis proprius was used for the thumb; an associated triple rupture was sutured en masse to the index communis tendon--this failed because of a number of factors (Table 6). In twenty-five procedures for ruptures of finger extensors, operation was seldom successful in achieving full extension (Table 5). There was also an overall average flexion deficit of 1.5 cm: only the group of combined little and ring finger ruptures appeared to gain reasonably full flexion. There was no significant difference in the palmar grip between any of the groups examined. There was a close correlation between the objective assessment and the subjective results. Only fifteen out of the twenty-five patients were satisfied; these clearly had the best results. Of those satisfied, any who had an extension deficit had an extensor lag, that is to say a loss of extension was due to tendon dysfunction, not to joint disorder. These patients could flex quite close to the palm and they had strong grips. In the dissatisfied patients a number of contributory adverse factors were identifiable (Table 6). These were systemic steroid therapy around the time of operation, post-operative wound complications, metacarpophalangeal joint dislocation, intrinsic muscle contracture, rupture of a flexor superficialis tendon and, of course, rupture of the extensor tendon repair. At least two of these factors were present in those patients who had unsatisfactory results. CONCLUSIONS
On the basis of this study some comments can be made on the value of certain tendon transfers. It is assumed that simultaneous dorsal synovectomy, retinacular transposition and excision of the lower end of ulna where appropriate will usually supplement the tendon repair. Extensor pollicis longus ruptures can be satisfactorily treated by extensor carpi radialis longus transfer, thus saving extensor indicis proprius for other possible repairs. For the fingeLtendon ruptures it is suggested that attention first to metacarpophalangeal folnt dislocation, intrinsic muscle contractures, and flexor tenosynovitis should improve the final functional results. The type of surgical procedure to be recommended depends on the pattern of rupture: (a) isolated rupture of the little or the ring finger tendons should probably be treated by extensor indicis proprius or flexor carpi ulnaris transfers, rather than using adjacent anastomoses; 284
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Surgery [or Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
(b) the combined ruptures of little and ring finger tendons might have gained more extension if a separate transfer was done to each, rather than joining both to a common motor tendon--e.g, an adjacent anastomosis of ring to middle together with an extensor indicis proprius transfer to little (Nalebuff 1969); (c) the triple ruptures of little, ring and middle finger tendons clearly require more than a single motor transfer; a possible selection may b e - transfers of flexor carpi ulnaris to the little finger tendon, of extensor indicis proprius to the ring finger tendon and an adjacent anastomosis of the middle tendon to the index communis tendon. In this difficult situation Nalebuff (1969) suggests using a flexor digitorum superficialis tendon; we have no experience of this transfer. Post-operative plaster splintage should immobilise the wrist and the metacarpophalangeal joints in extension, the interphalangeal joints can be left free. Some of the patients in this series who lost flexion may have done so because of the whole finger being immobilised for several weeks. Since the outcome of surgery for finger extensor tendon ruptures is often poor, perhaps conservative management using dynamic bracing as practised by Savill (1969) would give equal or better functional results. ACKNOWLEDGEMENTS The authors are grateful to the Consultant Orthopaedic Surgeons and Rheumatologists at Nottingham and at Harlow Wood Orthopaedic Hospital for permission to study their patients. They also thank Miss Briggs and Mrs. Blythe for secretarial assistance, and Mr. Harrison (Bradford) for the illustrations. REFERENCES
CLAYTON, M. L. (1965) Surgical Treatment at the Wrist in Rheumatoid Arthritis. A Review of Thirty-Seven Patients. Journal of Bone and Joint Surgery. 47A: 741-750. FLATT, A. E. (1974) The care of the rheumatoid hand. 3rd Edition. Saint Louis. C. V. Mosby Company: 113-120. JACKSON, I. T., MILWARD, T. M., LEE, P., and WEBB, J. (1974) Ulnar Head Resection in Rheumatoid Arthritis. The Hand 6: 172-180. HARRISON, S., SWANNELL, A. J., and ANSELL, B. M. (1972) Repair of extensor pollicis longus using extensor poUicis brevis in rheumatoid arthritis. Annals of the Rheumatic Diseases 31: 490492. KESSLER, I., and VAINIO, K. (1966) Posterior (Dorsal) Synovectomy for Rheumatoid Involvement of the Hand and Wrist. A Follow-up Study of Sixty-six Procedures. Journal of Borle and Joint Surgery. 48A: 1085-1094. LAINE, V. A. L, and VAINIO, K. J. (1955) Spontaneous Ruptures Of Tendons In Rheumatoid Arthritis. Acta Orthopaedica Scandinavica 24: 250-257, LINSCHEID, R. I. (1968) Surgery for Rheumatoid Arthritis--Timing and Techniques: The Upper Extremity. Journal of Bone and Joint Surgery. 50A: 605-613. MIDGLEY, R. D. (1971) Surgery of Rheumatoid Arthritis (Eds. CREUSS, R. L. and MITCHELL, N. S,) Philadelphia. J. B. Lippincott Company 159-163. NALEBUFF, E. A. (1969) Surgical Treatment of Tendon Rupture in the Rheumatoid Hand. The Surgical Clinics of North America 49: 811-822. PULVERTAFT, R. G. (1956) Tendon Grafts for Flexor Tendon Injuries in the Fingers and Thumb. A Study of Technique and Results. Journal of Bone and Joint Surgery 38B: 175-194. RIDDELL, D. M. (1963) Spontaneous Rupture of the Extensor Pollicis Longus. The Results of Tendon Transfer. Journal of Bone and Joint Surgery 45B: 506-510. SAVILL, D. L. (1969) The Use of Splints in Management of the Rheumatoid Hand. La Main Rheumatoide (Ed. TUBIANA, R.) Group d'Etude de la Main. Monograph No. 3 Paris. L'Expansion Scientifique Francais: 219-228. The H a n d - - V o l . 8
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Surgery for Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
SAVILL, D. L. (1972) Surgery of the rheumatoid hand. Journal of Bone and Joint Surgery 54B: 559-560. STRAUB, L. R. and WILSON, E. H. (1956) Spontaneous Rupture of the Extensor Tendons in the Hand Associated with Rheumatoid Arthritis. Journal of Bone and Joint Surgery 38A: 1208-1217. VAINIO, K. J. (1964) Hand. In Surgery of Arthritis (Ed. MILCH, R. A.) Baltimore. The Williams and Wilkins Co.: 130-157. VAINIO, K. (1967) Surgery of the Rheumatoid Hand. In Modern Trends in Orthopaedics Vot. 5 (Ed. GRAHAM, W. D.) London. Butterworths. 219-236. VAUGHAN-JACKSON, O. J. (1962) Rheumatoid Hand Deformities as Considered in the Light of Tendon Imbalance. Journal of Bone and Joint Surgery 44B: 764-775. VAUGHAN-JACKSON, O. J. (1969) Tendon Ruptures in the Hand. The Hand 1: 122-124.
286
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S U R G E R Y FOR R U P T U R E OF E X T E N S O R T E N D O N S IN R H E U M A T O I D ARTHRITIS
F. T. SHANNON and N. J. BARTON, Nottingham SUMMARY • Forty-two patients underwent fifty-four operations for rupture of extensor tendg~ns in rheumatoid disease. The results are analysed and factors affecting the results discussed. INTRODUCTION There have been many accounts of the methods of repair of ruptured extensor tendons in rheumatoid disease, but only a few studies have provided figures of 10ng-term follow-up (Vainio 1964, Clayton 1965, Harrison 1972). Prevention is better than cure and this may be achieved by early tenosynovectomy and excision of the lower end of the ulna (Clayton 1965, Flatt 1974, Jackson 1974, Kessler 1966, Linscheid 1968), but rupture can occur even after this. :~ For established rupture, there _~.s no place for direct suture of the tendon ends. Flatt (1974) recommends tendon transfers, mentioning in order of preference as the donor muscle, extensor indicis proprius, extensor carpi radialis longus, extensor carpi ulnaris and brachioradialis. Clayton (1965) suggests that "the simplest procedure is probably the best". In rupture of extensor pollicis longus, Midgley (1971) considers extensor indicis proprius the ideal motor, outlining its advantages as being expendable, straight, synergistic and subcutaneous, while Harrison (1972) provides evidence for recommending extensor pollicis brevis. Vainio (1969)states that tendon transfer should be accompanied by local synovectomy; results in fifty-six cases of extensor pollicis longus rupture were good, the best range of movement being restored when extensor indicis proprius was transferred. He also refers to twenty-five cases of combined rupture of ring and little finger tendons (for which he advocated transfer of extensor carpi ulnaris) saying that their results depended on the condition of the metacarpophalangeal joints. Vaughan-Jackson (1969) suggested treating the ruptured little finger tendon by splitting the ring finger tendon, detaching the ulnar half of it and suturing this end-to-end to the distal end of the ruptured little finger tendon. He feels that adjacent end-to-side anastomosis of distal little to intact ring is unsatisfactory. Nalebuff (1969) outlined his preferences: for isolated rupture of the extensors to the little finger, he anastomoses the communis tendon to the adjacent ring tendon, and transfers extensor indicts proprius to extensor digiti minimi to reinforce the power of extension. For the combined ring and little finger ruptures he advises adjacent anastomosis of ring to middle and an extensor indicts proprius transfer to the little finger. For the triple ruptures of middle, ring and little finger tendons he transfers a flexor digitorum superficialis to middle and ring while attaching the extensor indicts proprius tendon to the little finger. Results depend on the activity of disease in the synovium, joints, muscles and tendons and on the particular requirements of the patient. Function is more important than the objective range of movement and subjective opinion must be
F. T. Shannon, F.R.C.S., Ed., Senior Registrar in Orthopaedics, Bradford Royal Infirmary, N. J. Barton, F.R.C.S., Consultant Orthopaedic Surgeon, Harlow Wood Orthopaedic Hospital, Notts. , The H a n d - - V o l . 8
No. 3
1976
279
Surgery for Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
correlated with the clinical assessment. Extension is more important in the index and middle fingers while flexion is the prime need of the ring and little fingers. Evaluation is difficult because of the complexity and multiplicity of lesions and the cyclical nature of the disease. MATERIAL
Case notes over the years 1962 to 1973 at Harlow Wood Orthopaedic Hospital, Nottinghamshire, were searched for records of surgical procedures performed for spontaneous rupture of extensor tendons in rheumatoid hands. Forty-two patients (fifty-four hands) were available for follow-up. Thirty-one were female, eleven male. The average age was forty-seven years. Rheumatoid disease was present for an average of nine years before operation and the duration of follow-up averaged five and a half years (Table 1). Of the fifty-four operations, twenty-nine were for r u p t u r e of extensor pollicis longus, and twenty-five for ruptures of the finger extensor tendons (Table 2). TABLE 1
42 patients:
Age 38 to 73 years RA duration 2 to 27 years Follow-up 1 to 13 years
(av. 47 years) (av. 9 years) (av. 5½ years)
TABLE 2 Extensor Tendons Ruptured
54 operations:
29 E.P.L 12 ring and little combined 6 middle, ring and little (triple) 4 little alone 3 ring alone
TABLE 3
E.P.L (29)
Supplementary Procedures
Synovectomy Ulnar end excision Retinacular transposition Wrist fusion
Fingers (25)
14 1 6 3
16 19 2 5
METHOD
Information obtained from the records included age, sex, occupation, the indication for operation and the type of tendon repair performed, together with details of simultaneous supplementary procedures (Table 3). All patients were interviewed by one of us (F.T.S.), who recorded the subjective opinion of the patients as well as the findings on examination of both joint and tendon function. In studying the objective results three simple measurements were considered the most informative:
(1) The extension deficit. This is a reasonably objective estimate of the function restored to a repaired extensor tendon. It was measured in centimetres from the metacarpal plane to the edge of the fingernail. 280
The Hand--Vol. 8
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1976
Surgery /or Rupture o/ Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
(2) The flexion deficit. The distance by which the tip of the fully flexed digit fell short of the distal palmar crease was recorded to determine whether the extensor repair might have limited flexion. This was consider particularly important for the ring and little fingers. (3) Measurement of both pinch and patmar grip were recorded using a sphygmomanometer cuff inflated to 50 mm of mercury and measuring how much more the patient could squeeze this. When there was joint involvement, the above measurements were affected by that as well as by the state of the tendons. It is in the nature o f the disease that there may be several different types of pathological process in one finger. RESULTS
Ruptured Extensor Pollieis Longus (29 hands) The operations performed and their results are shown in Table 4. The average extension deficit was 1.3 cm, whether extensor indicis or extensor carpi radialis longus was used. The deficit in flexion measured from the distal palmar crease averaged 1.7 cm, the distance being significantly greater when extensor carpi radialis longus was transferred. For the twenty-nine repairs of extensor pollicis longus the objective assessment agreed with subjective satisfaction in twentyseven cases, even in the presence of joint changes such as the " Z " deformity. Two patients were dissatisfied, both from the group of extensor indicis proprius transfer, examined at ten and eleven years follow-up respectively: both had evidence of re-rupture (see discussion). Isolated Rupture o / L i t t l e Finger Tendons (4 hands) Anastomosis to the extensor digitorum communis tendon of another finger had been performed four times; to the ring finger tendon in three and to the middle finger in one instance. One might expect that these would have done better than the average figures indicate (Table 5). Three patients were satisfied. There was one who was not satisfied and she had a particularly poor outcome (Table 6): at five and a half years follow-up there was a 12 cm extension deficit, the repair had failed, the dislocated metacarpophalangeal joints were painful and she had a poor grip. TABLE 4
E.P.L. Ruptures (29) Operation
E.I.P. Transfer (20) E.C.R.L. Transfer (8) E.P.B. Tenodesis (1) OVERALL AV.
Extension Deficit (cms) 1.5 (0~) 1.0 (0-3) 0.0
Flexion Deficit (cms) 1.3 (0-3) 2.7 (0--7) 2.0
Grip (ram H g ~ 50) 50 (20-100) 55 (30-140) 40
1.3
1.7
50
Isolated Rupture of Ring Finger Tendons (3 hands) Extensor carpi radialis longus had been transferred in one, while anastomosis to the adjacent middle finger tendon had been performed in two cases. The results were worse than one might expect (Table 5). There were two failures (Table 6): one, the carpi radialis transfer, at four and a half years follow-up, had a 7 cm extension deficit as well as progressive joint disease (Fig. 1). The other patient, at three years follow-up, had a 3 cm extension deficit, a 6 cm flexion deficit; she complained more of the extension loss. The Hand~Vol. 8
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281
Surgery for Rupture o/ Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton TABLE 5 Total Finger Tendou Ruptures (25)
Group . Averages
Extension Deficit (cms)
Isolated Little (4) Isolated Ring (3~ Combined L i t t l e and R i n g (12) Combined Little, Ring and Middle (6) O V E R A L L A V E R A G E (25) S A T I S F I E D A V E R A G E (15) D I S S A T I S F I E D A V E R A G E (10)
Flexion Deficit (cms)
Grip (ram Hg ~ 50)
2 2.7
50 45 65 75 60 70 50
4.5 3.3 4 6 4.5 2.0 8.0
1 2
1.5 0.5 3.0
TABLE 6 Adverse Factors in Dissatisfied Patients with Finger Extensor Tendon Ruptures
.~ ~
Rupture Group
~
~
Little alone ( 4 )
31
Adjacent
"~ ~ t ~ "~ ~
. ~
~
~'
~ ,
~ ~ ~~ ~ Symptoms
~
-
*
. . . .
* Loss grip, pain joints
* *
* -
* *
* - . . . .
Loss e x t n / p a i n middle, ring, little Loss extn/loss grip
*
*
*
*
-
-
Loss of grip
*
*
*
-
-
-
Pain ring/little M.C.P. joints
-
* *
* Loss grip/loss extn ring/little Pain finger joints * Loss extension Loss extension 3 0
Rir~ Ring alone (3) Ring and Little c o m b i n e d (12)
24 47
E:C.R.L. trans. Adj. Midd.
1
Adjacent Middle 9 Adjacent Middle ' ! 4 b F.C,U. trans.
*
*
Middle, Ring and Little c o m b i n e d (6) '
10b E.D.C. Index trans. 15 E.I.P. trans. 34 E.I.P. trans. 48 E.C.R.L. trans.
*
*
Loss of grip
* -
-
*
~
*
*
-
* * -
DISSATISFIED SATISFIED
10 pts. 15 pts
7 5
7 3
6 4
3 1
3 0
Fig. la. Extension Deficit 7cm. Fig. lb. Flexion Deficit 2cm. Isolated r u p t u r e of ring finger tendon, treated by E.C.R.L. transfer. Dissatisfied at 4½ years follow-up, loss of extension, painful subluxation. M.C.P. joints, intrinsic contraeture, r u p t u r e d superficialis tendons. 282
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Surgery for Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. :Shannon and N.: .L Bartot~
Fig. 2a. Extension Deficit lcm. Fig. 2b. Flexion Deficit 0cm. Combined little and ring tendon rupture, treated by adjacent anastomosis to middle finger tendon. Satisfied at 6½ years follow-up, uneven pull evident. Ruptures of both Little and Ring Finger tendons combined (12 hands) Six hands had an adjacent anastomosis performed to the middle finger tendon, indicis was transferred in three and in three others the tendon of flexor carpi ulnaris was used. In all but one the little and ring finger tendons were sutured together,: a n d joined thus to the proximal motor (one exception being the individual suture of each rupture t o a longitudinally split extensor indicis proprius tendon). There was no significant difference whichever operation had been performed. The cumulative results of the little and ring fingers combined (Table 5), included nine satisfied patients, who accepted 2.5 cm extension deficit but achieved full flexion, so important for the ulnar two fingers (Fig. 2). Three dissatisfied patients were objective failures; at seven years follow-up, their average extension deficit was 9 cm, flexion deficit was 3 c m , the extensor tendons were intact but dislocated (Table 6). Triple Ruptures (6 hands) The ruptured extensor tendons of little, ring and middle fingers combined were sutured en masse to an indicis transfer in two cases, and "attached to the index tendons" in two, while extensor carpi radialis longus was used in two further cases. At follow-up only one of the six could fully extend. The majority (Table 5) had appreciable limitation of flexion. The good grip may be due to the fact that four of the six were males. Subjectively only two of the six were satisfied. Of the four dissatisfied, three patients had post-operative wound complications (Table 6), the fourth had an 11 cm extension deficit, a 4 cm flexion deficit and severe joint deformity.
COMPLICATIONS There were three complications; one haematoma and two wound infections. All three occurred in operations performed for triple rupture. All three patients were dissatisfied. DISCUSSION
T h e results showed that surgical management in twenty-nine ruptures of extensor pollicis longus was generally satisfactory, u s e of extensor carpi radialis provided extension equal to that achieved by an extensor indicis proprius transfer (Table 4). There was a greater flexion deficit using extensor carpi radialis longus but this was not considered a handicap by the patients concerned. This transfer was quite adequate and had the advantage of-sparing extensor indicis The Hand--Vol. 8
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1976
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Surgery for Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
proprius for other finger tendon repairs. There were two failures, both extensor indicis proprius transfers which had ruptured again; they also had an extensor lag at the metacarpophalangeal joint because of extensor pollicis brevis involvement. Two others who had similar evidence of failure of the extensor pollicis longus repair were satisfied--intact extensor pollicis brevis tendons providing useful extension at their metacarpophalangeal joints. Extensor pollicis longus was ruptured in association with other extensors in two patients, the extensor pollicis results being satisfactory. In patient No. 14b, extensor carpi radialis longus was used for the thumb; flexor carpi ulnaris was transferred to a combined little and ring rupture--at eight years follow-up this patient was dissatisfied because of his poor grip (Table 6), the extensor tendons were intact but dislocated. In patient No. 10b, indicis proprius was used for the thumb; an associated triple rupture was sutured en masse to the index communis tendon--this failed because of a number of factors (Table 6). In twenty-five procedures for ruptures of finger extensors, operation was seldom successful in achieving full extension (Table 5). There was also an overall average flexion deficit of 1.5 cm: only the group of combined little and ring finger ruptures appeared to gain reasonably full flexion. There was no significant difference in the palmar grip between any of the groups examined. There was a close correlation between the objective assessment and the subjective results. Only fifteen out of the twenty-five patients were satisfied; these clearly had the best results. Of those satisfied, any who had an extension deficit had an extensor lag, that is to say a loss of extension was due to tendon dysfunction, not to joint disorder. These patients could flex quite close to the palm and they had strong grips. In the dissatisfied patients a number of contributory adverse factors were identifiable (Table 6). These were systemic steroid therapy around the time of operation, post-operative wound complications, metacarpophalangeal joint dislocation, intrinsic muscle contracture, rupture of a flexor superficialis tendon and, of course, rupture of the extensor tendon repair. At least two of these factors were present in those patients who had unsatisfactory results. CONCLUSIONS
On the basis of this study some comments can be made on the value of certain tendon transfers. It is assumed that simultaneous dorsal synovectomy, retinacular transposition and excision of the lower end of ulna where appropriate will usually supplement the tendon repair. Extensor pollicis longus ruptures can be satisfactorily treated by extensor carpi radialis longus transfer, thus saving extensor indicis proprius for other possible repairs. For the fingeLtendon ruptures it is suggested that attention first to metacarpophalangeal folnt dislocation, intrinsic muscle contractures, and flexor tenosynovitis should improve the final functional results. The type of surgical procedure to be recommended depends on the pattern of rupture: (a) isolated rupture of the little or the ring finger tendons should probably be treated by extensor indicis proprius or flexor carpi ulnaris transfers, rather than using adjacent anastomoses; 284
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Surgery [or Rupture of Extensor Tendons in Rheumatoid Arthritis--F. T. Shannon and N. J. Barton
(b) the combined ruptures of little and ring finger tendons might have gained more extension if a separate transfer was done to each, rather than joining both to a common motor tendon--e.g, an adjacent anastomosis of ring to middle together with an extensor indicis proprius transfer to little (Nalebuff 1969); (c) the triple ruptures of little, ring and middle finger tendons clearly require more than a single motor transfer; a possible selection may b e - transfers of flexor carpi ulnaris to the little finger tendon, of extensor indicis proprius to the ring finger tendon and an adjacent anastomosis of the middle tendon to the index communis tendon. In this difficult situation Nalebuff (1969) suggests using a flexor digitorum superficialis tendon; we have no experience of this transfer. Post-operative plaster splintage should immobilise the wrist and the metacarpophalangeal joints in extension, the interphalangeal joints can be left free. Some of the patients in this series who lost flexion may have done so because of the whole finger being immobilised for several weeks. Since the outcome of surgery for finger extensor tendon ruptures is often poor, perhaps conservative management using dynamic bracing as practised by Savill (1969) would give equal or better functional results. ACKNOWLEDGEMENTS The authors are grateful to the Consultant Orthopaedic Surgeons and Rheumatologists at Nottingham and at Harlow Wood Orthopaedic Hospital for permission to study their patients. They also thank Miss Briggs and Mrs. Blythe for secretarial assistance, and Mr. Harrison (Bradford) for the illustrations. REFERENCES
CLAYTON, M. L. (1965) Surgical Treatment at the Wrist in Rheumatoid Arthritis. A Review of Thirty-Seven Patients. Journal of Bone and Joint Surgery. 47A: 741-750. FLATT, A. E. (1974) The care of the rheumatoid hand. 3rd Edition. Saint Louis. C. V. Mosby Company: 113-120. JACKSON, I. T., MILWARD, T. M., LEE, P., and WEBB, J. (1974) Ulnar Head Resection in Rheumatoid Arthritis. The Hand 6: 172-180. HARRISON, S., SWANNELL, A. J., and ANSELL, B. M. (1972) Repair of extensor pollicis longus using extensor poUicis brevis in rheumatoid arthritis. Annals of the Rheumatic Diseases 31: 490492. KESSLER, I., and VAINIO, K. (1966) Posterior (Dorsal) Synovectomy for Rheumatoid Involvement of the Hand and Wrist. A Follow-up Study of Sixty-six Procedures. Journal of Borle and Joint Surgery. 48A: 1085-1094. LAINE, V. A. L, and VAINIO, K. J. (1955) Spontaneous Ruptures Of Tendons In Rheumatoid Arthritis. Acta Orthopaedica Scandinavica 24: 250-257, LINSCHEID, R. I. (1968) Surgery for Rheumatoid Arthritis--Timing and Techniques: The Upper Extremity. Journal of Bone and Joint Surgery. 50A: 605-613. MIDGLEY, R. D. (1971) Surgery of Rheumatoid Arthritis (Eds. CREUSS, R. L. and MITCHELL, N. S,) Philadelphia. J. B. Lippincott Company 159-163. NALEBUFF, E. A. (1969) Surgical Treatment of Tendon Rupture in the Rheumatoid Hand. The Surgical Clinics of North America 49: 811-822. PULVERTAFT, R. G. (1956) Tendon Grafts for Flexor Tendon Injuries in the Fingers and Thumb. A Study of Technique and Results. Journal of Bone and Joint Surgery 38B: 175-194. RIDDELL, D. M. (1963) Spontaneous Rupture of the Extensor Pollicis Longus. The Results of Tendon Transfer. Journal of Bone and Joint Surgery 45B: 506-510. SAVILL, D. L. (1969) The Use of Splints in Management of the Rheumatoid Hand. La Main Rheumatoide (Ed. TUBIANA, R.) Group d'Etude de la Main. Monograph No. 3 Paris. L'Expansion Scientifique Francais: 219-228. The H a n d - - V o l . 8
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SAVILL, D. L. (1972) Surgery of the rheumatoid hand. Journal of Bone and Joint Surgery 54B: 559-560. STRAUB, L. R. and WILSON, E. H. (1956) Spontaneous Rupture of the Extensor Tendons in the Hand Associated with Rheumatoid Arthritis. Journal of Bone and Joint Surgery 38A: 1208-1217. VAINIO, K. J. (1964) Hand. In Surgery of Arthritis (Ed. MILCH, R. A.) Baltimore. The Williams and Wilkins Co.: 130-157. VAINIO, K. (1967) Surgery of the Rheumatoid Hand. In Modern Trends in Orthopaedics Vot. 5 (Ed. GRAHAM, W. D.) London. Butterworths. 219-236. VAUGHAN-JACKSON, O. J. (1962) Rheumatoid Hand Deformities as Considered in the Light of Tendon Imbalance. Journal of Bone and Joint Surgery 44B: 764-775. VAUGHAN-JACKSON, O. J. (1969) Tendon Ruptures in the Hand. The Hand 1: 122-124.
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