Review Article

Rheumatoid Hand and Wrist

Surgery: Soft Tissue Principles and
Management of Digital Pathology
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Abstract
Philip E. Blazar, MD Since the advent of disease-modifying antirheumatic drugs for
Stephanie M. Gancarczyk, MD rheumatoid arthritis, orthopedic surgeons see fewer patients in the
office who require hand surgery. However, a significant number of
Barry P. Simmons, MD
patients still seek surgical intervention to improve pain and function.
These patients often present with isolated soft tissue pathologies, but
even bone and joint pathology require meticulous soft tissue handling
in this cohort. This review highlights the principles and techniques
relevant to the management of soft tissue deformity in rheumatoid
hand and wrist surgery, as exposure in training and practice continues
to decrease.

From the Department of Orthopedic
Surgery, Brigham and Women’s
Hospital, Boston, MA.
None of the following authors or any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Blazar,
Dr. Gancarczyk, and Dr. Simmons.
J Am Acad Orthop Surg 2019;00:1-9
DOI: 10.5435/JAAOS-D-17-00608
Copyright 2019 by the American
Academy of Orthopaedic Surgeons.
M anagement of rheumatoid
arthritis (RA) has evolved
dramatically since the advent of
disease-modifying antirheumatic drugs
(DMARDs). As a result, orthopedic
surgeons see fewer patients with
inflammatory arthritis in whom hand
and wrist surgery is indicated. Despite
these advances, the prevalence of RA
in the United States is approximately
1.3 million people, and many still seek
surgical intervention.1
General Principles and
Perceptions
The treatment of patients with RA
requires a multidisciplinary team in-
cluding rheumatologists, upper ex-
tremity surgeons, and occupational
therapists. The success of surgical
intervention is controversial and de-
pends on who is asked. Alderman
et al2 surveyed over 400 hand sur-
geons and rheumatologists on various
operative reconstructions. Ninety-
three percent of hand surgeons versus
50% of rheumatologists perceived
extensor tenosynovectomy as effec-
tive for the prevention of tendon
rupture when diffuse tenosynovitis
was present. Sixty-six percent of
hand surgeons versus 25% of rheu-
matologists viewed soft tissue re-
construction for swan neck and
boutonniere deformity as successful
at increasing function; this discrep-
ancy narrowed with regard to im-
proving aesthetics. To determine
patient drivers, Bogoch et al3 studied
pre-operative motivations. Over 75%
of the patients ranked function, pain,
or appearance as the motivator for
surgery, and appearance was one of
two highest ranked motivators in
approximately 50% of the patients.
Initial Presentation
The soft tissue and bony pathologies
that lead to deformity in patients with
RA can be multifactorial. A thorough
physical examination is integral to
deciding appropriate management.
Observation and appearance, such
as watching the patient perform a
task and looking for the appropriate
wrist and digit skin creases, provide

Month 2019, Vol 00, No 00 1

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Rheumatoid Hand and Wrist Surgery

Figure 1 Figure 2

The Elson test assesses the integrity

of the central slip. The PIP joint is
flexed against a table, and the
patient is asked to gently extend the
A and B, The Bunnell test evaluates for intrinsic tightness. Passive PIP joint middle phalanx against resistance.
flexion is compared in MCP joint flexion and extension. If the intrinsics are tight, In the setting of a central slip injury,
PIP joint flexion will be limited in MCP joint extension, as the intrinsic tendons are the extensor tone at the DIP joint will
on stretch. MCP = metacarpophalangeal, PIP = Passive proximal increase as a result of increased
interphalangeal tension in the lateral bands. DIP =
distal interphalangeal, PIP = Passive
proximal interphalangeal
important information. When skin must be tested. The Elson test as-
creases are absent or the skin is taut, the sesses the integrity of the central slip
joint has likely had chronic limitations (Figure 2). The PIP joint is flexed evaluate for joint congruity, joint
in range of motion. Swelling may be against a flat surface, and the patient space narrowing, cyst formation, os-
due to synovitis or tenosynovitis of the is asked to gently extend the finger. teopenia, and marginal erosions. The
dorsal and/or volar tendon compart- In the setting of a central slip injury, “scallop sign” is erosive concavity
ments. Crepitus may be present with the extensor tone at the distal inter- seen in the sigmoid notch. Individual
finger or thumb range of motion and phalangeal (DIP) joint will increase finger and/or thumb radiographs
suggests tenosynovitis. In this scenario, as a result of tension transmitted may be indicated. Typically, ad-
patients may complain of crackling or through the lateral bands to the vanced imaging, such as ultraso-
popping in the wrist or hand with terminal tendon. In addition, the nography, CT, and MRI, provides
motion. A prominent ulna should be MCP joint should be checked for a little information beyond that gath-
recognized, and distal radial ulnar joint centralized extensor tendon through- ered in a thorough a physical and
(DRUJ) stability should be evaluated out range of motion and associated radiographic examination.
in neutral, pronation, and supination. early volar subluxation, especially in
Next, an evaluation of tendon swan neck deformity. Before finishing
competency and contracture should the examination, the tenodesis effect
Extensor Pathology
be performed. Intrinsic tendon tight- can be helpful in diagnosing tendon
ness is evaluated with the Bunnell ruptures or subtler abnormalities, Tenosynovitis and Tendon
test. Passive proximal interphalan- such as sheath scarring (Figure 3). Rupture
geal (PIP) joint flexion is compared in With wrist flexion, the fingers should Extensor tenosynovitis is a frequent
metacarpophalangeal (MCP) joint extend, and, with extension, the manifestation of RA and often the
flexion and extension. With intrinsic fingers should flex. The two hands presenting report.4 Initially it can be
tightness, PIP joint flexion will be lim- should be symmetrical; deviations treated non-operatively with anti-
ited in MCP joint extension (Figure 1). are clues to tendon pathology. rheumatic medication, rest, immobi-
Each flexor digitorum superficialis In addition to a complete physical lization, and possible local injection
(FDS), flexor digitorum profundus examination, we obtain plain radio- of steroid. Patients that are refractory
(FDP), and terminal extensor tendon graphs of the hand and wrist to to at least 6 months of conservative

2 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Philip E. Blazar, MD, et al

Figure 3 Figure 4

A and B, Wrist tenodesis testing can identify tendon rupture and/or subtle A midline, longitudinal incision is
abnormalities in the tendon complex. In wrist flexion, the fingers should extend, used to perform a dorsal
and, with wrist extension, the fingers should flex. As seen in these images, the tenosynovectomy. Note the dorsal
digits lie in a smooth cascade. wrist swelling evident on clinical
examination.

management are candidates for sur- intervention when medical manage-

gical intervention due to concern
for tendon rupture.5 Our preferred
technique is a midline, longitudinal
incision (Figure 4). The extensor reti-
naculum is opened in line with the
third or fourth compartment, then
reflected. The tenosynovium is sharply
débrided. An oblique or Z-cut in the
retinaculum allows it to be sutured
in a lengthened position, though this
may be unnecessary after excision of
the pathologic tenosynovium (Figure
5). Alternatively, the retinacular flaps
can be split transversely with a seg-
ment sutured volar to the extensor
tendons, as an interposition between
the tendons and bone.4,6 However, we
often find the extensor retinaculum to
be thin and tenuous, making it diffi-
cult to divide and manipulate for dual
functions.
Recurrence rates are approximately
10%, and the risk of extensor tendon
rupture is minimized to 3% to 7%
depending on tendon quality at the
time of surgery.4,6,7 This further re-
inforces the importance of early
ment has failed or in patients not
taking DMARDs. While there are no Figure 5
long-term follow-up studies on
chronic, untreated dorsal tenosyno-
vitis, the low recurrence after teno-
synovectomy and the challenge of
treating tendon rupture make early
intervention appealing.
Extensor tendons rupture as a
result of attrition due to osseous
irregularity or direct infiltration from
tenosynovitis.8 Most extensor ten-
don ruptures occur over the DRUJ.
If arthritis or instability is noted,
as is seen in caput-ulnae syndrome,
soft tissue reconstructions should
be performed in conjunction with a
distal ulna resection, Sauve-Kapandji
(pseudarthrosis of the ulna with
DRUJ arthrodesis) or distal ulnar
replacement.4,9 The most common
tendons to rupture are the extensor
digiti minimi (EDM) and extensor The retinacular tissue is repaired in a
digitorum communis (EDC) of the lengthened position dorsal to the
fifth, followed by the EDC of the tendons. A significant amount of
fourth.8 However, many patterns of tenosynovitis and rice bodies have
been removed.
rupture can occur.

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Rheumatoid Hand and Wrist Surgery
With rupture of the small finger
extensors, we prefer extensor indicis
proprius (EIP) transfer to both the
EDM and EDC, as EDC reconstruc-
tion alone may be inadequate. The
distal EDM stump is usually found
more distal than the EDC stump. The
EIP is identified by the following: (1)
the ulnar tendon at the index MCP
joint, (2) the most distal muscle belly
of the finger extensors, and (3) the
lack of junctural connections.10,11
We harvest it just proximal to the
sagittal bands via a small transverse
incision. Next, via the same incision
used for tenosynovectomy, the EIP is
delivered proximal to the retinacu-
lum, transferred to the recipient
extensor tendon stump distally, and
left superficial to the retinaculum.
While we have had more experience
with the Pulvertaft weave, other
surgeons use a side-to-side repair.
This technique has been shown to
have a higher load to failure and
repair stiffness when compared with
the Pulvertaft weave.12,13
As the number of extensor tendon
ruptures increases, it often becomes
necessary to combine techniques,
including tendon transfer, tenodesis,
and interposition grafting. More
recent data suggests that clinical
outcomes are similar when compar-
ing tendon transfer and tendon
grafting.14 The most commonly used
tendon grafts include palmaris lon-
gus and fourth toe extensor. Bora
et al15 describe using free looped
tendon graft to reconstruct multiple
extensors with an average exten-
sor lag of 30° at approximately
43 months follow-up. More recent
studies have reported an average
extensor lag of approximately 16° at
54 months follow-up.16 The most
common tendon transfer donors
include EIP, FDS to the ring or long
finger, and extensor carpi radialis
longus or brevis.17,18 When using
wrist extensors, an intercalary graft
is required for length. In addition,
given the relatively limited excursion
4 Journal of the American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
of the wrist extensors, good outcomes
require preserved wrist motion.17
For tendon ruptures involving both
the ring and small fingers, our pre-
ferred technique is EIP transfer to the
small finger and tenodesis of the ring
to the long finger EDC. In the case of
three or four finger involvement, the
FDS to the ring and/or long fingers is
harvested proximal to the A1 pulley
and identified through a longitudinal
incision just proximal to the carpal
tunnel. The tendon(s) are directed
through the interosseous membrane
or around the ulnar aspect of the
wrist, and a single tendon can be
attached supra-retinacular to two
extensor tendons. If the EIP donor is
available, it can be transferred in a
three-tendon rupture to the stumps of
the ring and small fingers, and the
long finger stump can be sutured end-
to-side to the remaining index finger
EDC tendon. Using a similar algo-
rithm, Millender et al17 found that of
31 patients studied, most recovered
full pre-operative range of motion.
When an extensor lag developed,
the range was 10 to 30° with a notable
correlation between increasing num-
ber of tendons ruptured and worse
extension.
Digital Ulnar Drift
Ulnar drift of the fingers is a multi-
faceted problem involving the exten-
sor tendon complex, capsule, collateral
ligaments, and the MCP joint. If the
joint is preserved, soft tissue only pro-
cedures can be performed. However,
even in the setting of MCP arthro-
plasty, the soft tissues must be re-
balanced.
Many soft tissue procedures have
been described, including crossed
intrinsic transfer, radial sagittal band
reconstruction, and radial sagittal
band imbrication.19–21 Much tech-
nical variability lies in the details of
sagittal band reconstruction. Multi-
ple grafts have been described,
including radial, ulnar, or central
slips of extensor tendon, extensor
retinaculum, juncturae, or autograft.22,23
In addition, the pulley choices
include the radial intrinsic tendon,
radial collateral ligament, and trans-
verse metacarpal ligament.22 The goal
of each procedure is to rebalance
ulnar and radial deviating forces.
We follow a similar algorithm
when performing a soft tissue only
or soft tissue plus arthroplasty
reconstruction. A transverse incision
is made just proximal to the MCP
joints. For each finger, the ulnar sag-
ittal band is longitudinally incised
and the ulnar intrinsic tendon is re-
leased, as these are deforming forces.
If no arthroplasty is performed, the
radial sagittal band tissue is subse-
quently imbricated or reconstructed.
We use an ulnar slip of the exten-
sor tendon, approximately 40% the
width of the tendon, from as proxi-
mal as the incision allows. The distal
tendon at the level of the MCP joint
is left intact. This tendon slip is passed
around the deep transverse meta-
carpal ligament or the radial collat-
eral ligament, if available, and
sutured back to itself. Adjacent junc-
turae tendinum can be used as an
alternative donor. Once the recon-
struction is complete, the extensor
tendon should be tested to ensure it
remains centralized through range of
motion. Occasionally, the ulnar sag-
ittal band will need to be repaired in a
lengthened position to act as a check
against radial subluxation.
When an arthroplasty is indicated,
the capsule is incised longitudinally, a
thorough synovectomy is performed,
and the ulnar collateral ligament is
released. The radial collateral liga-
ment is sharply released off its origin
on the metacarpal head and a tagging
suture is placed to test the mechanical
properties of the identified tissue. By
pulling proximal tension, the defor-
mity should correct and, preferably,
overcorrect (Figure 6). A Kirschner
wire is used to make two holes in the
dorsal, radial metacarpal approximately
 Philip E. Blazar, MD, et al

Figure 6

A–C, Note the ulnar drift of all four fingers. A transverse incision just proximal to the MCP joints is used to perform multiple
arthroplasties or isolated sagittal band reconstructions and EDC centralizations. Even in the setting of joint arthroplasty,
attention must be paid to the soft tissues. Here the radial collateral ligament is identified, released, and tagged with a suture
before placing the MCP implant. Pulling on the tagging sutures should correct the ulnar drift deformity. EDC = extensor
digitorum communis, MCP = metacarpophalangeal

7 to 8 mm from the joint surface,
leaving at least a 3 to 5 mm bone
bridge. Using these tunnels, a stitch is
placed into and out of the bone, and
the local tissue is re-tensioned. If
local tissue is unable to reconstruct
the radial collateral ligament, a
portion of the volar plate can be
used. Evidence for or against collat-
eral ligament reconstruction is lim-
ited.24 However, we have found that
this practice, in combination with a
post-operative casting and splinting
regimen, leads to greater correction
of ulnar deviation deformity when
compared with leaving the collateral
ligaments. Finally, the finger should
be tested through range of motion
and sagittal band rebalancing is
performed as previously described.
The post-operative dressing is cru-
cial. The MCP joints should be im-
mobilized in full extension, and soft
dressings are used to reinforce radial
deviation in the splint. At 10 days, a
hand-based cast, which immobilizes
the MCP joints and leaves the PIP
joints free, is applied. Similarly, the
MCP joints should be held in full
extension and radial deviation.
Three weeks later, the cast is removed
and occupational therapy is started.
This is augmented by a night-time
splint that holds the fingers in the
corrected position. An outrigger
splint is designed for this purpose; it
is a dynamic, dorsal hand splint with
finger slings that hold the MCP joints
in an extended and radially deviated
position.
Isolated soft tissue reconstruction is
rarely indicated, but with appropri-
ate patient selection, the outcomes
are successful. Dell et al25 reported
their results using a distally based
central portion of extensor tendon.
Recurrent ulnar drift at an average of
9 years follow-up was approxi-
mately 10° and MCP joint motion
significantly improved. In our expe-
rience, MCP stiffness is a frequent
complication. However, if PIP joint
range of motion is maintained, pa-
tients are satisfied with the func-
tional outcome.
Swan Neck and Boutonnière
Deformity
Swan Neck Deformity
In RA, swan neck deformity can be
from pathology at the DIP, PIP, or
MCP joint. Regardless of etiology, it
is characterized by attenuation of the
volar plate at the PIP joint and elon-
gation or rupture of the terminal
extensor tendon at the distal phalanx
(Figure 7). Treatment is based on
identifying and correcting the de-
forming anatomic structures. The
success of non-operative manage-
ment and soft tissue only recon-
struction depends on pre-operative
range of motion and the status of the
various joints. This discussion will

Month 2019, Vol 00, No 00 5

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Rheumatoid Hand and Wrist Surgery
Figure 7
Swan neck deformity is characterized
by PIP joint hyperextension and
DIP joint flexion due to attenuation
of the volar plate at the PIP joint
and elongation or rupture of the
terminal extensor tendon at the
distal phalanx. DIP = distal
interphalangeal, PIP = Passive
proximal interphalangeal
focus on the correction of flexible
swan neck deformity in the setting of
preserved articular surfaces and joint
alignment. When this does not exist,
arthrodesis or arthroplasty may be
required.
Treatment starts at the PIP joint, as
volar PIP laxity must be addressed,
and PIP joint correction may lead
to secondary improvement of DIP
deformity. Initially, non-operative
management with a PIP ring-splint,
preventing joint hyperextension, should
be attempted. If this fails, many sur-
gical techniques have been developed,
including volar dermadesis, central
slip tenotomy, volar plate advance-
ment, flexor tenodesis, and spiral ob-
lique retinacular ligament (SORL)
reconstruction. A recent biomechani-
cal study showed no significant dif-
ference in the stiffness of volar plate
repair, FDS tenodesis, single lateral
band transfer, double lateral band
transfer, and dual split lateral band
6 Journal of the American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
transfer to stabilize a hyperextended
PIP joint.26
Isolated dermadesis or central slip
tenotomy do not typically provide
lasting correction.27 Dermadesis in-
volves excising an ellipse of skin and
subcutaneous tissue on the volar
aspect of the PIP joint, typically
about 5 mm in width, taking care
not to penetrate the flexor sheath
or injure the digital neurovascular
bundles. SORL reconstruction is
achieved using either free tendon
graft or lateral band re-routing.27,28
The goal is to create a tether that lies
volar to the axis of PIP joint and
dorsal to the axis of the DIP joint.
This attempts to restore the link
between PIP and DIP motion. In a
comparative study by Oh et al,29
neither free tendon graft nor lateral
band re-routing was shown to be
superior. In the rheumatoid cohort,
we rarely consider SORL reconstruc-
tion. Surgery on the dorsal apparatus
can lead to significant stiffness and
necessitate a complex rehabilitation
program that is prone to poor com-
pliance. Our preferred technique in
rheumatoid patients with flexible
swan neck deformity and preserved
joints is FDS tenodesis.
Unlike the original technique de-
scribed by Swanson, we harvest one
slip of FDS.27,30 A Brunner incision is
used to access between the A1 and
A3 pulleys. The FDS tendon is
identified, but left within the tendon
sheath. One slip is cut at the proxi-
mal extent of the A1 pulley. To limit
effect on MCP range of motion, the
FDS slip is pulled through a small slit
in the flexor sheath between the A1
and A2 pulleys. This tendon can be
sutured back to itself and/or to the
adjacent flexor tendon sheath. At
completion, the FDP is assessed to
ensure it is not tethered by the
reconstruction. Typically, we attempt
to achieve a PIP joint flexion angle that
matches with the natural cascade of
the hand, starting with approximately
20° in the index finger and progressing
to 40° in the small finger. Inevitably,
soft tissue procedures attenuate over
time, especially in the rheumatoid
cohort. To help combat the loss of
correction, PIP joint capsulotomy or
pinning can be considered, though we
do not routinely use either.
The outcomes of FDS tenodesis
have not been studied extensively in
the rheumatoid cohort, but the
available data are promising. Ac-
cording to the literature, PIP hyper-
extension deformity is improved by
approximately 30°, resulting in over-
correction with residual flexion con-
tracture of approximately 5°.31 In
addition, the DIP joint extension lag
was shown to correct in approxi-
mately 70% of the cases.
Boutonnière Deformity
Boutonnière deformity occurs when
the lateral bands slip volarly, trans-
forming them into PIP joint flex-
ors.32 This results in contracted
oblique retinacular ligaments and,
eventually, changes in the PIP joint
volar plate and collateral ligaments.
In addition, the DIP joint is pulled
into hyperextension. In RA, the
cause is often PIP joint synovitis,
which leads to attenuation of the
central slip. Many treatment options
have been described, including ter-
minal tendon tenotomy, central slip
re-insertion or reconstruction using
dorsal PIP capsule, a slip of FDS, or
the lateral bands.32–36 Though most
studies are case reports or small case
series, the outcomes are unpredict-
able with loss of correction over
time.37 In a study by Kiefhaber
et al,37 close to 10% of the patients
developed a recurrent PIP flexion
deformity of greater than 70° an
average of 22 months post-
operatively. As a result, the indications
for soft tissue only boutonnière
reconstruction are limited in the
rheumatoid cohort. If the joint is
preserved, we prefer dynamic PIP
joint extension splinting for at least
8 weeks. If limited DIP flexion

Figure 8
Digital flexor tenosynovectomy is
performed via a transverse incision
at the distal palmar crease. Each
flexor tendon is delivered into the
wound and a meticulous
tenosynovectomy is performed.
remains, splinting can be combined
with a terminal tendon tenotomy.
However, these patients often have
degenerative joint changes on close
inspection. Therefore, PIP arthrodesis
is performed more commonly in pa-
tients with functional limitations and
pain due to a boutonnière deformity.
Flexor Pathology
Tenosynovitis and Tendon
Rupture
Flexor tenosynovitis often presents as
loss of active finger flexion with or
without joint stiffness.4 In addition,
crepitus can develop in the presence
of flexor tendon nodules or carpal
osteophytes. When compared with
the superficialis, the FDP is predis-
posed to nodule formation, espe-
cially in zone II.38 If uncontrolled,
flexor tenosynovitis can lead to ten-
don rupture. Other causes of flexor
tendon rupture in the rheumatoid
patient include progressive volar
MCP joint deformity, chronic carpal
instability, and osteophytes, most
commonly in the carpal tunnel.39
Since flexor tendon rupture in the
Month 2019, Vol 00, No 00
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Philip E. Blazar, MD, et al
Figure 9
A and B, After the transverse carpal ligament and the volar forearm fascia are
released, dense tenosynovitis is encountered encompassing the flexor tendons.
The flexor tendons are individually assessed and a thorough tenosynovectomy
is performed. The median nerve (*) is identified and protected throughout this
procedure.
sheath is catastrophic, we avoid force; however, there is no direct
steroid injections in those with clear evidence to support this theory. In
evidence of infiltrative tenosynovitis, the setting of isolated stenosing
in favor of early surgical intervention. tenosynovitis with no associated
Approaches for flexor tenosyno- flexor tendon nodules or infiltrative
vectomy include exposure of the synovitis, a standard A1 pulley
digits via Brunner incisions, a trans- release may be performed.
verse palmar incision, and/or a car- If flexor tendon rupture occurs,
pal tunnel incision extended into the correction of osseous deformity, fol-
forearm. Our usual approach is a lowed by tendon grafting, is our pre-
transverse incision at the distal pal- ferred method of treatment, though
mar crease. Each flexor tendon is tendon transfer is an alternative. We
delivered into the wound and a te- start with an extended carpal tunnel
nosynovectomy is performed (Figure approach. The transverse carpal lig-
8). This limits the need for separate ament and the volar forearm fascia
digital incisions. However, if a nod- are released. The median nerve is
ule is large enough to prevent full mobilized and protected. The flexor
flexion and, therefore, access to the tendons are individually assessed for
tendons, digital incisions are made. abrasion and a meticulous tenosy-
Pulleys should be preserved when novectomy is performed (Figure 9). If
able. We prefer to remove the less than 50% of the tendon width is
ulnar slip of the FDS, especially in involved, a débridement is sufficient.
the setting of attenuated tissue or If greater than 50% is involved,
significant nodularity, as the post- repair versus reconstruction should
operative range of motion is supe- be considered.40 In the setting of
rior.38 We choose the ulnar slip to tendon rupture, the proximal end is
avoid creating an ulnar-deviating found and débrided back to healthy
7
Rheumatoid Hand and Wrist Surgery
Figure 10
Via a side-to-side technique, the
intercalary graft is sewn to the
ruptured FPL tendon. Next, a prolene
suture is used to shuttle the graft into
the proximal incision. FPL = flexor
pollicis longus
tissue. The carpus is examined for
bony projections. When present,
these are removed and covered with
an adjacent capsule flap. If a tendon
requires reconstruction, a Brunner
incision is made over the associated
MCP joint. While preserving as
much of the pulley system as possi-
ble, any tenosynovitis within the
digital sheath is débrided and the
distal tendon stump is identified. A
suture shuttle is positioned in its
place. Our preferred tendon graft is
palmaris longus, though half of the
flexor carpi radialis can be used.
Alternatively, if both flexor tendons
to a finger are involved, the FDS can
be used as intercalary or turnover
graft. The graft is sewn to the rup-
tured tendon in the distal incision,
then brought through the canal using
the suture shuttle (Figure 10). The
graft is tensioned using tenodesis,
and the proximal junction is com-
8 Journal of the American Academy of Orthopaedic Surgeons
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
pleted to the débrided stump of
affected tendon.
Outcomes for flexor tenosynovec-
tomy are not as favorable when
compared with extensor tenosyno-
vectomy. Studies report recurrence
rates of approximately 30%.38 Despite
this percentage, patients often have
significant improvement in pain and
range of motion.38,41 Long-term out-
comes have not been published since
the advent of DMARDs, which may
assist in further decreasing recurrence
rates. Ertel et al42 looked at 115 flexor
tendon ruptures to identify patterns
and prognostic variables. More prox-
imal ruptures tended to result from a
bony spur, most commonly on the
scaphoid. Ruptures within the digital
sheath were typically due to infiltrative
tenosynovitis. The flexor pollicis lon-
gus is the most commonly affected at
the wrist, while the index finger FDP is
the most commonly affected within the
palm and digit. Opposite to extensor
tendons, flexor tendons tend to rup-
ture in a radial to ulnar direction.
Multiple tendon ruptures and rup-
tures of both tendons within the
flexor sheath of one digit had a
worse prognosis. One or two flexor
tendon ruptures proximal to the
pulley system had the best prognosis.
As flexor tendon reconstruction re-
sults do not match with those of the
extensor tendon, prevention with
early tenosynovectomy and removal
of osteophytes is key. In addition,
given the variable outcomes, DIP
joint fusion is a reliable salvage that
should be considered in the setting of
intra-sheath FDP rupture.
Summary
While the medical management of
RA has vastly improved, it is still a
relatively common disease affecting
over 1 million people in the United
States. Gross abnormalities are now
less common, and more patients
present with subtle and flexible
deformity. As a result, it is important
to have an understanding of isolated
soft tissue reconstruction and soft
tissue handling in conjunction with
salvage procedures. While studies
suggest most pathologies can be
treated to meet the patient goals of
improved function and appearance, a
substantial portion of our data is
based on small case series and retro-
spective analyses before the use of
DMARDs. These medications not
only decrease the number of patients
that need surgery but also may
decrease recurrence and improve
outcomes. Further biomechanical
comparisons and prospective long-
term studies are needed to truly
understand the best treatments and
confirm our perception of improved
clinical outcomes.
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