Surgery in patients with systemic sclerosis of the hand.

Systemic sclerosis of the hand is an uncommon form of arthritis that can cause significant functional loss in the hand. It poses serious problems for the surgeon because of the diminished circulation of the digits. The tightness of the skin and joint stiffness that are characteristic of this condition make restoration of function difficult. Calcinosis, which is common in patients with systemic sclerosis of the hand, can be treated by excision or curettage. Patients with severe deformities of the digits and thumb often require fusions to improve grasp. Joint replacements with implants are not as successful in patients with systemic sclerosis as they are in patients with rheumatoid or degenerative arthritis. There have been recent attempts to improve the circulation to the fingers by sympathectomy or by vein grafts. These techniques, however, provide only temporary improvement and do not prevent or correct the severe digital and thumb deformities associated with this disease.

Surgery of systemic lupus erythematosus arthritis of the hand.

Systemic lupus erythematosus (SLE) is one of a group of three uncommon arthritic diseases, including psoriatic arthritis and scleroderma, that superficially resemble rheumatoid arthritis (RA). These diseases frequently involve the hand and wrist and therefore are significant to the hand surgeon. SLE has certain specific characteristics that separate it from the other two conditions. Each of these diseases has distinct features affecting the nature of the deformities as well as the treatment indicated to adequately care for these patients.

Surgery of psoriatic arthritis of the hand.

Psoriatic arthritis is an uncommon form of arthritis that poses specific problems for the hand surgeon. Although there are similarities between this form of arthritis and the more common rheumatoid or degenerative arthritis, this particular entity is unique, and physicians or surgeons treating these patients should be aware of the differences to advise or carry out appropriate treatment. Before embarking upon specifics, it is fitting to review some of the fundamentals of this condition.

Extradigital glomus tumour.

We report a case of an extradigital glomus tumour found in the forearm. A review of the literature suggests that extradigital glomus lesions in the upper limb may be more common than they are thought to be.

Current recommendations for surgery of the rheumatoid hand and wrist.

Treatment of the hand with rheumatoid arthritis has not changed significantly over the past year. Two studies indicated that methotrexate administration need not be discontinued prior to surgery. Electron microscopy has shown that rheumatoid tendons are morphologically different from normal tendons. Early synovectomy has been reintroduced as a valuable technique, and the need for a team approach in disease management has been emphasized. Several authors emphasized rigid surgical fixation to improve digital and wrist fusions. Three studies reported good long-term results from metacarpophalangeal joint arthroplasty. Derangements of the distal radioulnar joint can benefit from the Sauve-Kapandji procedure. A newer technique to stabilize the distal ulna following the Darrach procedure was introduced, also, the treatment of swan-neck and boutonniere deformities, the results of which were somewhat disappointing, was reviewed.

Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow.

Decompression of the ulnar nerve at the elbow with medial epicondylectomy was done in 43 patients and reviewed with an average follow-up of 2.3 years. Eight were graded as excellent, 23 as good, 9 as fair, and 3 as poor results. A special emphasis was placed on analysis of the potential disadvantages of medial epicondylectomy including bone tenderness at the osteotomy site, vulnerability of the ulnar nerve, ulnar collateral ligament instability, and weakness from disruption of the flexor pronator origin. Clinical assessment of strength including quantitative measurement of pinch strength, grip strength and endurance, and testing of forearm muscles did not show these potential disadvantages to be significant problems.

Delayed diagnosis in non-union of the body of the hamate: a case report.

Fractures of the body of the hamate are uncommon. We report a case with symptomatic non-union in which the diagnosis was not made until oblique pronated radiographs were taken.

The rheumatoid swan-neck deformity.

It is important to evaluate each swan-neck deformity to determine the mobility and radiographic condition of the PIP joint. This information forms a basis for logical treatment. In those fingers with little or no loss of motion, the treatment alternatives include DIP joint fusions, dermadesis, or flexor tenodesis. With significant loss of PIP joint motion, an attempt is made to first restore passive motion by manipulation and lateral band or skin releases. It then becomes essential to restore flexor tendon excursion. In those patients with destroyed joint surfaces the salvage procedures of fusion and arthroplasty are the treatments of choice.

The rheumatoid thumb.

Although the thumb is frequently involved in rheumatoid arthritis, causing significant functional loss as well as pain and deformity, much can be done surgically to alleviate the condition and restore function to the patient. It is important to understand the factors leading to the various thumb deformities. With this understanding it is possible to formulate a rational treatment programme which will benefit the patient and satisfy the surgeon.

Present approach to the severely involved rheumatoid wrist.

The wrist is a common target for rheumatoid arthritis, with the radiocarpal joint being involved more often than the midcarpal joint. The authors discuss the treatment modalities available for patients with advanced disease: total wrist fusion, flexible implant arthroplasty, and partial wrist fusion. The last procedure, utilized only since 1982 and limited to patients with only radiocarpal joint involvement, eliminates pain and corrects deformity while maintaining a significant range of motion. The indications and techniques for each procedure are described.

The rheumatoid hand. Reflections on metacarpophalangeal arthroplasty.

Metacarpophalangeal (MP) implant arthroplasties have been widely used during the past 15 years. It is difficult to evaluate the effectiveness of MP arthroplasty. Patients with rheumatoid arthritis are so varied that meaningful comparisons of results from different series are not possible. However, certain factors influence the results of this operation. Some of these factors are related to the patient's motivation. Others include the condition of the adjacent joints and tendons. Staging of multiple procedures is advisable. The surgical technique is exacting. Postoperative therapy is vital in achieving maximum benefit from MP arthroplasties. Complications of this procedure include infection, prosthetic fracture, recurrent deformity, and limited motion. The concept of the flexible hinged prosthesis acting as a spacer to encourage encapsulation is good and is generally successful in improving hand function while correcting deformity and relieving pain.

Rheumatoid hand surgery--update.

Many varied and bizarre deformities of the hand are encountered in rheumatoid arthritis. The surgical procedures commonly performed generally fall into five groups, including: synovectomy, tenosynovectomy, tendon surgery, arthroplasty, and arthrodesis. Hand surgery plays an important role in the management of patients with rheumatoid arthritis. The surgeon trained in the techniques described should be part of any team managing the patient with arthritis, not a "course of last resort" called upon when all else fails.

Hand involvement in psoriatic arthritis.

From a population of 105 patients with confirmed psoriatic arthritis, 25 patients required hand surgery. These 25 surgical patients were evaluated retrospectively both clinically and radiographically. The patterns of hand and wrist involvement as well as the results of surgery differed from those typically seen in rheumatoid disease. Spontaneous fusion of the wrist in a functional position, severe proximal interphalangeal involvement often with marked flexion contractures, severe erosion of the distal interphalangeal joint with spontaneous fusions, and generalized stiffness characterize these hands. Minimal improvement in motion and a significantly increased incidence of infection following arthroplasty were noted.

The surgical treatment of hand deformities in systemic lupus erythematosis.

Ten patients with systemic lupus erythematosis hand deformities were studied. Wrist involvement included distal ulnar subluxation in 14 wrists (with four requiring excision) and various degrees of carpal instability in 12 wrists (usually asymptomatic). Metacarpophalangeal (MP) joint subluxation treated by soft tissue procedures for passively correctable deformities in 30 joints had a failure rate of 70%. MP joint arthroplasties performed in 33 joints gave fair results in 16 joints with fixed deformities and good results in 17 joints with passively correctable deformities. Thumb deformities always involved all three joints, and maintenance of carpometacarpal (CMC) joint stability was the key to thumb reconstruction. CMC joint stabilization with ligamentous reconstruction gave good results in three of four thumbs. Four CMC joint fusions and two CMC joint implant arthroplasties gave good results. Each was accompanied by appropriate procedures on the MP joint or interphalangeal joint.

Anomalous volar branch of the dorsal cutaneous ulnar nerve: a case report.

A 17-year-old boy, who had complained of pain for many years, had an anomalous branch from the dorsal ulnar cutaneous nerve which passed ulnar to the pisiform bone and was compressed by the flexor carpi ulnaris tendon. The symptoms were relieved completely by decompression of this nerve.