Fractional Flexor Tendon Lengthening for Advanced Metacarpophalangeal Flexion Contracture in Rheumatoid Hands

Written By: Sam Savage

Published Date: January 10, 2007 Last Edited: January 10, 2007

By Al-Ahaideb, Abdulaziz; Drosdowech, Darren S; Pichora, David R

This technical report discusses a subgroup of rheumatoid patients who have minimal ulnar drift but a severe fixed metacarpophalangeal joint flexion contracture for whom conventional metacarpophalangeal joint arthroplasty alone was insufficient to correct the deformity. We describe a surgical technique to deal with this clinical problem that uses fractional flexor tendon lengthening in the forearm to correct the severe flexion deformity at the metacarpophalangeal joint. (J Hand Surg 2006;31 A:1690-1693. Copyright 2006 by the American Society for Surgery of the Hand.)

Key words: Rheumatoid arthritis, hand, metacarpophalangeal joint, flexion contracture, fractional lengthening.

Rheumatoid arthritis often produces the characteristic metacarpophalangeal (MCP) joint deformities of volar dislocation and ulnar deviation. Surgical reconstruction for MCP disease typically comprises replacement arthroplasty and soft-tissue rebalancing. Associated MCP flexion contracture is usually mild and is easily corrected by metacarpal head excision. We report on a subgroup of rheumatoid patients with minimal ulnar drift but severe fixed MCP flexion contracture for whom conventional MCP arthroplasty alone was insufficient to correct the deformity. Associated contracture of the proximal interphalangeal joints was variable.

Hastings and Evans1 reported on very similar deformities in 6 hands of 3 patients from a population of 125 having systematic lupus erythematosus (SLE). The articular surface is spared in SLE; thus they were able to correct the deformity by combined MCP volar capsulotomy, intrinsic release, and metacarpal shortening. Our rheumatoid group differed in that the MCP joints were dislocated and the articular surface was damaged or destroyed.2 Therefore, MCP arthroplasty was required as part of the procedure to correct the deformity. Rather than using metacarpal shortening, we wished to determine whether fractional flexor tendon lengthening (FFTL) could be successfully applied to patients with severe rheumatoid MCP flexion contracture.

For severe wrist and finger contracture in cerebral palsy, Zancolli et al3 advocate lengthening multiple flexor tendons via circumferential release of the muscle fascia. Le Viet4 broadened the application to include Volkmann’s contracture and recommended intramuscular transverse tenotomy at the musculotendinous junction.

Materials and Methods

Thirty-seven patients had MCP arthroplasty over a 30month period. A retrospective analysis identified 8 of these patients as having severe fixed MCP flexion contractures of 90 to -120. Associated proximal interphalangeal contracture was seen in some. There were 7 women and 1 man, with a mean age of 68 years (Table 1). Three patients were rheumatoid factor positive and 2 were negative, 1 of whom was anti-nuclear antibody (ANA) positive. The rheumatoid factor status of the others was not documented. There were 5 left hands and 3 right hands; all patients were right-hand dominant. Skin maceration and intertrigo were present in 3 patients with more severely contracted hands, and all patients complained of disabling loss of hand function.

The initial evaluation before surgery included assessment of function, radiographs, and measurement of active and passive ranges of MCP motion. Preoperative grip strength testing was not performed because no patient could grasp the dynamometer.

Table 1. Patient Demographics

The average postoperative follow-up period was 17 months (range, 6-31 mo). Evaluation included subjective assessment, active and passive ranges of motion, and grip strength testing with comparison with the contralateral hand.

The surgical procedure included all of the standard features of silicone MCP replacement arthroplasty including metacarpal head resection, ulnar intrinsic tenotomy, volar plate release, capsulotomy, collateral ligament release, and flexor tendon check. If after metacarpal head excision there still was considerable MCP flexion deformity, an FFTL was performed through a separate volar forearm incision. The sublimi were individually lengthened by intramuscular transverse tenotomy and circumferential fasciotomy as described by Zancolli et al3 and Le Viet.4 In some severe contractures, some or all of the profundi were also lengthened. A successful contracture release was defined as allowing for full, unresisted passive digital extension with the MCP prosthesis in place. No additional procedure was required to correct the proximal interphalangeal contractures when present. All patients had rehabilitation with dynamic extension splinting.

Results

Table 1 shows the long flexor tendons that needed to be released at the forearm. The release was performed when the tendon was believed to be tight and notably contributing to the lack of extension. There was no correlation between the extent of FFTL required and the degree of preoperative flexion contracture.

The mean preoperative MCP contracture measured 90 to 120. The postoperative mean active and passive arcs of motion were 60 and 80, respectively. The mean active range of motion was from 4 to 63 (Table 2).

Grip-strength values ranged from 8 to 18 kg and were higher at longer postoperative intervals (Table 1). There was no difference between surgically treated and non-surgically treated hands. There was no correlation between the number of tendons lengthened and grip strength. No postoperative complications were recorded. Wound healing and skin hygiene were satisfactory.

On preoperative radiographs, all but 1 patient had Larsen grade 4 or 5 changes, confirming the advanced state of disease in this group.5 After rehabilitation, patients were able to perform simple independent daily activities such as personal hygiene and preparing meals, which were impossible before surgery.

Figure 1 shows the right hand of one of the study patients. It shows the severe degree of flexion contracture at the MCP joint with very minimal ulnar drift deformity. Figure 2 shows the maceration in the palm as a result of a long-standing flexion deformity.

Figure 3 shows the forearm incision that was used to perform the fractional flexor tendon lengthening. Figure 4 shows the first postoperative visit. It shows clearly the amount of extension we achieved in the MCP joint even before starting the physiotherapy and the extension exercises. It is obvious that the left hand has the same deformity and will have the same procedure once the right hand is rehabilitated.

Discussion

Local soft-tissue and intrinsic muscle release, metacarpal head resection, and replacement arthroplasty are the conventional means of correcting the wellknown deformity of ulnar drift. We report treatment for the severely contracted rheumatoid MCP joint. Our small group of rheumatoid arthritis patients had finger contractures like those of 3 patients with SLE described by Hastings and Evans1; the clinical photograph in their publication shows a deformity identical to that seen in some of our patients. Some of our patients had a form of mixed connective tissue dis ease rather than pure rheumatoid arthritis. Our group required MCP arthroplasty to replace damaged and dislocated joint surfaces. Correction of flexion contracture could be achieved simply by additional re section of the metacarpal neck and shaft, but this may produce relative overlengthening of the extensors and some flexors or intrinsics, with secondary loss of grip strength and function. Therefore, to avoid excessive bone resection, we selectively lengthened those extrinsic flexors that were tight.

Table 2. Surgical Outcomes

Figure 1. The hand in severe flexion deformity.

There is no loss of motion with this procedure compared with conventional arthroplasty. Bieber et al6 reported on 46 postoperative rheumatoid hands with an average flexion contracture of 10 and an average active flexion arc of 51. Our corresponding values of 4 and 60 are slightly better but are unlikely to be statistically significant. The study of Bieber et al6 did not categorize patients by degree of preoperative MCP flexion contracture. It is reassuring that the functional results in our patients are at least as good as those of arthroplasty in rheumatoid arthritis patients who had conventional deformity. No untoward effects occurred as a result of adding FFTL to MCP arthroplasty. Grip strengths were at least maintained if not improved. Most importantly, patients regained basic hand functions that had been lost before surgery.

Figure 2. Skin maceration in the hand.

Thus far, we do not have a good explanation for the pathogenesis of extrinsic MCP flexor contractures seen here. We sent a biopsy of the flexor digitorum superficialis sheath from one of our patients, and it shows evidence of inflammation. This is in keeping with the pathophysiology of rheumatoid disease.

In addition to being a retrospective study, our study has a lack of clinically relevant statistics due to a small patient population size and the absence of a control group. Nevertheless, we conclude that there is a small subgroup of rheumatoid arthritis patients with some features of mixed connective tissue disease who have severe finger flexion contracture. Furthermore, we believe that fractional flexor tendon lengthening is a reasonable adjunctive procedure to m\etacarpophalangeal arthroplasty in treating this condition. Improved arc of motion and functional outcome, maintained grip strength, lack of complications, and simplicity of the procedure help support this observation.

Figure 3. The forearm incision.

Figure 4. The postoperative visit.

References

1. Hastings DE, Evans JA. The lupus hand: a new surgical approach. J Hand Surg 1978;5:179-183.

2. Wilson RL, Carlblom ER. The rheumatoid metacarpophalangeal joint. Hand Clin 1989;5:223-237.

3. Zancolli EA, Goldner LJ, Swanson AB. Surgery of the spastic hand in cerebral palsy: report of the Committee on Spastic Hand Evaluation (International Federation of Societies for Surgery of the Hand). J Hand Surg 1983;8:766-772.

4. Le Viet D. Flexor tendon lengthening by tenotomy at the musculotendinous junction. Ann Plast Surg 1986;17:239-246.

5. Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockholm) 1977;18:481-491.

6. Bieber EJ, Weiland AJ, Volenec-Dowling S. Silicone-rubber implant arthroplasty of the metacarpophalangeal joints for rheumatoid arthritis. J Bone Joint Surg 1986;68A:206-209.

Abdulaziz Al-Ahaideb, MD, Darren S. Drosdowech, MD,

David R. Pichora, MD

From King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; St. Joseph’s Hospital, University of Western Ontario, London, Ontario, Canada; and Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada.

Received for publication January 15, 2006; accepted in revised form August 28, 2006.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Corresponding author: Abdulaziz Al-Ahaideb, MD, Kingston General Hospital, Queen’s University, Kingston, Ontario, K7M 9C3 Canada; e- mail: [email protected].

0363-5023/06/31A10-0018$32.00/0

doi:10.1016/j.jhsa.2006.08.019

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