DEFINITION

Rheumatoid arthritis is a progressive disease that, if uncontrolled, leads to joint destruction, secondary to progressive synovitis, ligament instability, joint dislocation or subluxation, and attrition of adjacent tendons either by bony erosion or direct tenosynovial infiltration.

When tendon rupture occurs on the dorsum of the hand or wrist, patients cannot extend their fingers and have difficulty grasping objects.

The most common tendon ruptures on the dorsum of the hand begin on the ulnar side and usually are a result of subluxation of the distal radioulnar joint (DRUJ), the so-called Vaughan-Jackson or caput ulnae

syndrome.13

On the volar side of the wrist, the most common tendons to rupture are the flexor pollicis longus and the adjacent flexor digitorum profundus (FDP) tendon to the index finger or possibly the long finger. This is

referred to as Mannerfelt syndrome.9

 

 

ANATOMY

 

The extensor tendons of the hand and forearm pass beneath the extensor retinaculum at the wrist. The retinaculum is divided into six separate compartments lined by tenosynovium, which can become involved in the pathology of rheumatoid arthritis.

 

 

The first compartment contains the tendons of the abductor pollicis longus and the extensor pollicis brevis. The former tendon often contains multiple slips, which can contribute to limited space in its respective compartment and secondary de Quervain tenosynovitis.

 

The second compartment consists of the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB), the former tendon inserting at the base of the index metacarpal and the latter at the base of the long finger.

 

The third compartment contains only the tendon of the extensor pollicis longus (EPL), which passes around the tubercle of Lister at a fairly sharp angle. Although frequently involved in tendon ruptures in rheumatoid arthritis, the EPL may also present as an isolated tendon rupture after nondisplaced fractures of the distal radius.

 

The fourth compartment contains the extensor indicis proprius (EIP) and the extensor digitorum communis (EDC), sending tendons from the common extensor muscle in the forearm to each of the fingers. The EIP is a separate muscle tendon unit located within the fourth compartment. It can be differentiated by its distal muscle belly.

 

The fifth extensor compartment contains the extensor digiti quinti (EDQ), often consisting of two slips and passing almost directly over the DRUJ.

 

The sixth compartment contains only the extensor carpi ulnaris (ECU).

 

On the palmar side of the wrist, the flexor pollicis longus is located most radially and passes over the radiocarpal joint adjacent to the trapeziometacarpal joint of the thumb. The flexor pollicis, along with the median nerve and the profundus and sublimis tendons to each digit, passes beneath the deep transverse carpal ligament and represents the contents of the carpal canal.

 

 

Tenosynovial proliferation can exist within the carpal tunnel, arising from the undersurface of the ligament but more commonly proliferating along the tendons themselves.

 

PATHOGENESIS

 

Tendon rupture on the dorsum of the wrist is usually the result of instability in the DRUJ, leading to secondary subluxation and bony erosion through the capsule of the joint and then the tendon.

 

 

The tendon initially affected is the EDQ. As the carpus supinates and subluxates volarly, causing the distal ulna to be more dorsal, tendons typically rupture sequentially in an ulnar to radial direction.

 

The tendons may also be compromised by direct infiltration from the tenosynovium.

 

Although the ulnar tendons are involved most commonly, it is possible for all of the tendons crossing the dorsum of the wrist to rupture, making reconstruction more difficult.

 

On the volar side of the wrist, the flexor pollicis longus may become compromised through erosion by osteophytes and rough bony surfaces at the level of the trapeziometacarpal joint of the thumb or the scaphotrapezial articulation. The adjacent profundus tendon to the index and, occasionally, the long finger can rupture as well.

 

Tendons of the flexor surface of the wrist and forearm are also subject to rupture via direct tenosynovial infiltration, but this is less common.

 

 

In addition to tendon attrition and eventual rupture, tenosynovitis in the carpal tunnel may cause median nerve compression that leads to weakness of the median nerve innervated intrinsics. These include the opponens pollicis and abductor pollicis brevis (APB), the flexor pollicis brevis (usually only the deep head), and the radial two lumbricals. Weakness of these muscles is uncommon but should be checked in all patients with carpal tunnel syndrome (CTS).

 

NATURAL HISTORY

 

Before the advent of treatment for rheumatoid arthritis, the natural history was one of relentless progression. The disease would occasionally “burn itself out,” however, with the radiocarpal joint subluxating in a volar and radial direction, leading to instability and loss of function.

 

 

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FIG 1 • Exposure of the extensor tendons of the wrist shows proliferative tenosynovitis originating from the tenosynovial lining of the extensor retinaculum. If left unchecked, such proliferative tenosynovitis can contribute to extensor tendon rupture at the level of the wrist.

 

 

Also, before the development and routine use of antitumor necrosis factor drugs, patients were occasionally refractory to nonsteroidal medication, corticosteroids, and stronger anti-inflammatory drugs such as methotrexate. When these drug combinations failed, proliferative tenosynovitis occasionally occurred on the dorsum of the wrist, secondary to a “pannus” of diseased, thickened synovium growing directly into the tendons causing collagen destruction and rupture (FIG 1).

 

The worst-case scenario is secondary rupture of all of the finger extensors, with subluxation of the ECU volar to the axis of wrist motion such that it becomes more of a wrist flexor and ulnar deviator than a wrist extensor. The radial wrist extensors may also rupture; however, in part as a result of the more robust nature of the tendons themselves, they tend to remain intact even with progressive disease.

 

The French impressionist painter Pierre Auguste Renoir was said to have had such severe rheumatoid arthritis that in his later years, he would tape a brush to his hand to paint.

 

 

 

 

FIG 2 • A. Passive wrist extension results in passive finger flexion with intact finger flexors. B. Passive wrist flexion should result in passive finger extension when the finger extensor tendons are intact. In this situation, however, those tendons are not intact and passive wrist flexion results in the long, ring, and small extensor fingers remaining in a flexed position. C. In a patient with Mannerfelt syndrome, attempted active flexion of the

thumb and fingers results in absent flexion of the interphalangeal joint of the thumb and, in this situation, the distal interphalangeal joint of the index finger. Clinically, this is similar to anterior interosseous nerve syndrome and must be distinguished clinically and often by electromyography.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients often note a spontaneous loss of finger motion, but there may be minimal swelling and discomfort. Patients occasionally report a snap or twinge of discomfort as the tendon ruptures.

 

With an extensor tendon rupture, patients cannot actively extend the metacarpophalangeal (MCP) joints of the involved digit.

 

 

In the case of isolated rupture of the EDQ, an intact EDC to the small finger may make it difficult to confirm the diagnosis.

 

The proximal and distal interphalangeal joints of the finger may be extended through the intrinsics even when the extensors are ruptured.

 

Wrist flexion should result in MCP joint extension through tenodesis if the extensor tendons are intact. When the finger extensors are ruptured, this tenodesis effect is absent (FIG 2A,B).

 

The patient should also be examined for subluxation of the extensor tendons, which may mimic tendon rupture. In this case, the tendon will subluxate ulnarly to lie between the MCP joints. Patients with subluxation rather than rupture should be able to maintain extended position if the MCP joints are passively extended.

 

On the volar side of the wrist, the examiner should check closely for the possibility of associated tenosynovial proliferation proximal and deep to the transverse carpal ligament.

 

 

Active digital motion may cause palpable crepitus at this level.

 

Such proliferation may result in coexisting CTS. The examiner should question the patient regarding symptoms of CTS and should assess for signs of CTS.

 

 

Examination findings suggestive of CTS include decreased sensation or paresthesias in the thumb, index, middle, and radial ring finger; thenar pain; Phalen compression test; and APB weakness.

 

 

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The patient should also be examined carefully for active flexion at the distal interphalangeal joints of the index and long fingers as well as the interphalangeal joint of the thumb.

 

 

Absence of flexion should alert the surgeon to the possibility of rupture of the flexor pollicis longus and the FDP to the index and occasionally the long finger.

 

These tendons are particularly vulnerable when subluxation and spur formation are present at the trapeziometacarpal or scaphotrapezial joints as well as the volar radiocarpal joint.

 

Tendon rupture at this level is referred to as Mannerfelt syndrome (FIG 2C) and needs to be differentiated from anterior interosseous nerve palsy.

 

 

Direct pressure on the flexor pollicis longus muscle in the forearm should lead to passive flexion in the interphalangeal joint of the thumb if the tendon is intact.

 

The tenodesis test also is effective for the flexor pollicis longus and profundus and sublimis tendons to the fingers; however, in patients with progressive rheumatoid arthritis, the radiocarpal joint and the interphalangeal joints may become arthritic, making passive motion of the wrist and fingers somewhat

more difficult and therefore the test more unreliable.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Anteroposterior (AP) and lateral radiographs of the hand and wrist should be obtained to look for subtle changes of the DRUJ, such as subluxation or a small osteophyte (FIG 3), which may be consistent with the physical findings of tendon rupture (FIG 4).

 

Similar attention should be paid to the volar surface of the radiocarpal joint and the trapeziometacarpal joint of the thumb as well as the scaphotrapezial and trapezoidal joints.

 

Radiographs should be examined for arthrosis and deformity, which may mimic tendon rupture by causing motion loss.

 

Radiographs of the cervical spine may reveal subluxation, possibly causing nerve compression and secondary sensory loss or weakness.

 

Computed tomography (CT) and magnetic resonance imaging (MRI) are not routinely needed.

 

 

 

FIG 3 • AP radiograph of the wrist of the patient in FIG 4 shows osteophyte formation in the DRUJ ( arrow). (From Lubahn JD, Wolfe TL. Surgical treatment and rehabilitation and tendon ruptures in the rheumatoid hand. In: Mackin EJ, Callahan AD, Skirven TM, et al, eds. Rehabilitation of the Hand and Upper Extremity, ed

5. St. Louis: Mosby, 2002:1598-1607.)

 

 

 

FIG 4 • The clinical consequences of a spur in the DRUJ: rupture of the EDQ and EDC to the ring and small fingers. When the patient attempts to actively extend the fingers, the ring and small fingers remain flexed. (From Lubahn JD, Wolfe TL. Surgical treatment and rehabilitation and tendon ruptures in the rheumatoid hand. In: Mackin EJ, Callahan AD, Skirven TM, et al, eds. Rehabilitation of the Hand and Upper Extremity, ed

5. St. Louis: Mosby, 2002:1598-1607.)

 

 

Electromyography and nerve conduction studies may be helpful in the evaluation of the patient with potential tendon ruptures, particularly if tenodesis testing is normal in the face of a loss of active finger extension or flexion.

 

 

Compression of both the anterior interosseous and posterior interosseous nerves can occur in rheumatoid arthritis, usually secondary to ganglion cyst formation at the level of the elbow joint.

 

 

DIFFERENTIAL DIAGNOSIS

In the case of tendon ruptures on the dorsum of the hand and wrist, the differential diagnosis is primarily that of posterior interosseous nerve compression or posterior interosseous nerve syndrome.

Compression of the posterior interosseous branch of the radial nerve, or the radial nerve itself more proximally, needs to be considered as the cause of the patient's inability to extend the fingers. Careful physical examination of the proximal forearm and elbow is therefore important to include a large cyst, lipoma, radiocapitellar effusion, or other elbow abnormality that may be causing compression of the radial nerve more proximally and leading to muscle paralysis. Electrophysiologic testing may also prove helpful.

With respect to Mannerfelt syndrome, absence of flexion at the interphalangeal joint of the thumb and the distal interphalangeal joints in the index and long fingers should be differentiated from the anterior interosseous nerve syndrome, which when present in rheumatoid arthritis is usually due to a large ganglion originating on the volar surface of the elbow.

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative management probably is more feasible with respect to Mannerfelt syndrome than with the Vaughn-Jackson or caput ulnae syndrome. Although the functional deficit is generally greater with loss of finger extensors than loss of active flexion of the interphalangeal joint of the thumb and distal interphalangeal

joints of the index and long fingers, some patients may still function remarkably well.

 

Supportive measures in patients who for one reason or another are not deemed suitable surgical candidates may be provided by a certified hand therapist or occupational therapist able to assist the patient with his or her activities of daily living.

 

 

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With median nerve entrapment and compression from the proliferative tenosynovitis at the level of the

radiocarpal joint, disability becomes more progressive and nonsurgical treatment more difficult. There may be a role for corticosteroid injection at the level of the radiocarpal joint, and certainly, referral to a rheumatologist is crucial for the control and management of the disease before any surgical intervention.

 

In the case of wrist or finger extensor tendon rupture, nonsurgical treatment may be beneficial in terms of resting the radiocarpal joint and interphalangeal joints of the fingers to prevent further tendon rupture by attrition. Splinting the wrist or hand may prove beneficial for pain control and to prevent further damage to the joints and soft tissues.

 

Nonoperative management of thenar atrophy may be justified if there is an ulnar innervated deep muscle head of the flexor pollicis brevis to serve as a strong palmar flexor of the thumb. Lack of opposition may be of minimal functional significance, especially in the nondominant hand. If there is lack of sensation, the benefits of opposition transfer will be even smaller. Careful patient selection is critical.

 

SURGICAL MANAGEMENT

Basic Principles of Tendon Transfer

 

A large variety of donor options exist. Considerations for donor selection include (1) expendability, (2) synergistic function between original and new function, (3) independent function, (4) good voluntary control,

(5) straight line of pull or requirement of minimal (no more than one) pulleys, (6) avoidance of scarred or skin grafted areas, (7) sufficient muscle excursion, and (8) sufficient muscle power. Transferred muscles can be

expected to lose one grade of strength.6

 

 

 

Use of a Pulvertaft weave rather than end-to-end repair will greatly decrease the risk of rupture. Restore full range of motion prior to tendon transfer. Transfers will not be able to move stiff joints. Avoid surgery in patients with open wounds or uncontrolled disease.

 

 

 

FIG 5 • A. When extensor tendon rupture leads to loss of extension in only one digit, such as the small finger, end-to-side transfer of the distal ruptured tendon to the more proximal adjacent EDC tendon of the ring finger can be performed. B. If the ruptured end is distal to the midmetacarpal region, this transfer may lead to abduction of the small finger metacarpal, and under these circumstances, tendon transfer of the EIP to the distal stump of the EDQ is undertaken (depicted here as an end-to-end transfer). C. EIP to EDQ, depicted here as a Pulvertaft weave between the distal tendon and the proximal transferred EIP.

 

 

Insensate areas are less likely to benefit from transfer.

 

 

If diagnosed early, an interposition graft may be used to reconstruct the ruptured tendon.7 The palmaris tendon, a strip of the flexor carpi radialis (FCR), and a slip of the EDQ are suitable choices.

 

 

Outcomes are similar between tendon transfer and tendon reconstruction with graft. Results correlate inversely with number of fingers involved or chronicity of injury.5

Extensor Tendon Rupture

 

 

A variety of tendon transfers are available for reconstruction of single and multiple extensor tendon ruptures. It is important for the surgeon to locate the site of tendon rupture and identify as well as treat the cause.

 

Usually, rupture is secondary to the distal ulna subluxating dorsally through the attenuated fibers of the DRUJ. When subluxation occurs at this level, it erodes through the floor of the fourth and fifth extensor compartments.

 

Tendon reconstruction is therefore not complete unless it involves removal of the dorsal osteophyte by a modified Darrach procedure and coverage of the distal ulna with a flap of extensor retinaculum.

 

When the distal ulna is unstable, the pronator quadratus may be brought dorsal to stabilize the bone. The ECU or flexor carpi ulnaris (FCU) combined with ECU2 may also be considered.

 

Small finger extension loss

 

 

Single tendon rupture of the EDQ may go unnoticed, particularly if there is a strong EDC to the small finger. Often, however, EDC contribution to the small finger is hypoplastic or absent and all that is present is a junctura tendinae from the small finger to the adjacent ring finger. Isolated loss of function in the EDQ is manifest by weakness or lack of extension of the small finger.

 

The distal stump of the ruptured tendon is sewn end to side to the intact ring finger EDC tendon. The risk of this transfer, however, is excessive abduction of the small finger when the distal tendon is short (FIG 5A). In general,

 

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the transfer should be performed to the tendon of the adjacent EDC of the ring finger with the weave as far proximal as the distal stump of the EDQ will allow.

 

Alternatively, an EIP transfer may be performed (FIG 5B,C).

 

Ring and small fingers extension loss

 

 

 

In addition to the EDC tendons to the ring and small fingers, the EDQ usually will have ruptured. The EIP is transferred to the EDQ.

 

The distal ring finger EDC tendon is transferred end to side to the adjacent intact long finger EDC tendon (FIG 6). Alternately, the distal stumps of the EDC ring and small and EDQ may each be woven to the EIP.

 

Another alternative is transferring the FCR to EDC of ring and small with EDQ. This allows maintenance of powerful independent index finger extension. This can be helpful with a concomitant partial or total wrist fusion (FIG 7A-F).

 

Long and ring fingers extension loss (FIG 8A)

 

 

Although two fingers are seemingly involved, the EDC tendon to the small finger is usually ruptured as well. The EDQ remains intact.

 

If the index finger EDC tendon is intact, EIP transfer to the long and ring finger EDC tendons is performed (FIG 8B).

 

 

 

 

FIG 6 • In cases of double rupture in the ring and small fingers, transfer of the EIP to the distal EDQ, with end-to-side transfer of the distal EDC of the ring finger to the adjacent EDC to the long finger, is a standard transfer.

 

 

 

FIG 7 • Preoperative radiograph (A) and (B) clinical picture of a patient with mixed rheumatoid and gouty arthropathies resulting in ring and small EDC ruptures. C. EDC ruptures are verified (digits to the left). D. FCR is harvested with insufficient length for transfer. (continued)

 

 

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FIG 7 • (continued) E. A suture is first placed at the distal most portion of the FCR before splitting the

tendon proximally and flipping of one slip of FCR distally to extend the tendon transfer. F. The transfer is completed with lengthened the FCR to EDQ, EDC ring and EDC small (digits to the left).

 

 

 

 

FIG 8 • A. Clinical appearance of a hand with rupture of the EDC to the long and ring fingers. B. Optional tendon transfer when the EDC to the index finger is intact is transfer of the EIP to the distal stumps of the long and ring fingers. C. When the EDC to the index finger has been ruptured and EIP transfer is not an option, transfer of the distal EDC of the long finger to the adjacent EIP of the index and transfer of the distal ring EDC to the adjacent small finger extensor, is shown here. (A: From Lubahn JD, Wolfe TL. Surgical treatment and rehabilitation and tendon ruptures in the rheumatoid hand. In: Mackin EJ, Callahan AD, Skirven TM, et al, eds. Rehabilitation of the Hand and Upper Extremity, ed 5. St. Louis: Mosby, 2002:1598-1607; B,C: From Williams DP, Lubahn JD. Reconstruction of extensor tendons. Atlas Hand Clin 2005;10:209-222.)

 

 

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If the EDC tendon to the index finger has ruptured, end-to-side transfer of the distal tendon of the long finger EDC to the adjacent intact EIP and transfer of the distal tendon of the ring finger EDC to the adjacent

 

intact EDQ may be considered (FIG 8C). Long, ring, and small fingers extension loss

 

If the EIP and EDC tendons to the index finger are intact, the EIP can be transferred to the distal stumps of the ring and small fingers EDC tendons using end-to-end or end-to-side techniques, depending on the length of the distal stumps.

 

The EDC to the long finger is transferred end to side to the adjacent intact index EDC tendon (FIG 9).

 

If only the EIP is intact and all remaining tendons on the dorsum of the wrist have ruptured, transfer of the flexor digitorum sublimis (FDS) of the ring finger around the radial or ulnar border of the forearm is the next logical choice.

 

In patients with partial or complete wrist fusion, or in patients with limited wrist motion, transfer of the ECRL may be considered. Although not “in phase” with the finger extension, the line of pull matches reasonably well.

 

Index, long, ring, and small fingers extension loss

 

 

The two most common transfers are the FDS around the radial and ulnar sides of the forearm or through the interosseous membrane (FIG 10A,B).

 

Transfer of one of the radial wrist extensors is a suitable alternative (FIG 10C).

 

Loss of thumb extension

 

 

EPL rupture is common and often results in minimal loss of function.

 

Late or chronic ruptures require transfer of the EIP to the distal end of the EPL. The proximal muscle will usually begin to atrophy and become nonfunctional by 6 months after the injury.

 

 

 

 

FIG 9 • Rupture of the common extensors to the long, ring, and small fingers with extensor digiti quinti

(EDQ) rupture can be treated, as shown here, with transfer of the extensor indicis proprius (EIP) to the distal stumps of the ring and small fingers with distal end-to-side transfer from the extensor digitorum communis (EDC) to the long finger to the adjacent index EDC.

 

 

 

 

 

FIG 10 • A. Rupture of all four finger extensors may be treated alternatively with transfer of the flexor digitorum superficialis (FDS) to the long and ring fingers, harvested in the distal palm and transferred around the radius and ulna, with the two forearm bones serving as pulleys for the transferred tendon. B. Alternatively, both FDS tendons may be transferred around the radial side of the forearm and sutured to the distal stumps of the EDC tendons. C. With rupture of all common extensor tendons to the fingers as well as the EIP and the EDQ, extension may be restored through transfer of one of the radial wrist extensors. This is ideal when a partial wrist fusion is being planned, as shown.

 

 

If the EIP is not available, transfer of the FDS from the long or ring finger can be considered. The FDS can be routed through the interosseous membrane or around the radial side of the forearm as described for transfer to restore finger extension.14

 

A recent transfer that has been described is a partial ECRL turnover tendon. It may be useful when the EIP is not available, as it allows reconstruction of even very distal ruptures without need for graft.4

 

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FIG 11 • Extensor pollicis brevis rupture. Boutonnière deformity of the thumb (Nalebuff type I).

 

 

Chronic synovitis at the thumb MCP joint may lead to attritional rupture of the dorsal capsule and the extensor

pollicis brevis.

 

 

This boutonnière deformity of the thumb is a type I as described by Nalebuff10 and Nalebuff and Millender11 (FIG 11).

 

The deformity usually progresses after extensor pollicis brevis rupture. The EPL shifts ulnarly, the collateral ligaments weaken, and the thumb metacarpal becomes abducted radially. The interphalangeal joint hyperextends as a reciprocal response to the MCP joint flexion.

 

Transfer of the EPL to the extensor pollicis brevis insertion in the base of the proximal phalanx and the dorsal capsule of the MCP joint of the thumb is performed. Local anesthesia is typically adequate.

 

Flexor Tendon Rupture

 

Tendon transfer for the treatment of flexor tendon disruption in the rheumatoid patient is much less common than for extensor tendon rupture.

 

Mannerfelt syndrome should be treated by transfer of the brachioradialis tendon to the flexor pollicis longus.

 

 

Associated disruption of a FDP tendon is usually treated by transferring the distal stump end to side to the adjacent digit's FDP tendon.

 

Lack of Opposition

 

Lack of opposition function may cause minimal functional deficit in patients with advanced rheumatoid arthritis. Many patients may be managed conservatively.

 

If chronic CTS is the underlying cause, division of the transverse carpal ligament in combination with tenosynovectomy (as in open carpal tunnel release) will alleviate median nerve compression.

 

If intrinsic wasting is already present, however, decompression of the median nerve may not restore thenar function.

 

 

Consideration should thus be given to simultaneous tendon transfer to restore opposition at the time of carpal tunnel decompression in the setting of intrinsic weakness

 

Recovery of opposition after carpal tunnel release will be delayed in the best of cases. Tendon transfer provides rapid return of function and so should be considered in most patients.

 

 

A variety of tendon transfers may be used to restore opposition. These include the palmaris longus,3 EIP, FDS, and abductor digiti minimi.8

 

If performed at the same time as carpal tunnel release, the palmaris longus transfer is preferred, as it is done through the same incision and has minimal extra morbidity.

 

Otherwise, transfer of the extensor indicis is reliable, has minimal morbidity, and has the most reliable pulley (ulnar border of the wrist).

 

FDS transfer is also very reliable. It has two main drawbacks. Sacrifice of a FDS tendon may decrease grip strength. Donor site morbidity including swan-neck deformity or flexion contracture of the proximal interphalangeal joint may occur. Women tend to be more at risk for the former and men the latter. Donor site morbidity may be minimized by not removing the tendon portion distal to the A1 pulley.

 

A variety of insertion sites may be used. Typically, the tendon is sutured to the APB tendon using a Pulvertaft weave. Suture anchors or a bone tunnel may also be used.

 

Additional insertions have been described including the proximal phalanx, the extensor mechanism, or dorsal capsule. A portion of the tendon may also be used to reconstruct the collateral ligament. This allows the tendon transfer to restore additional functions including thumb MCP extension or stability. In these cases, a dual insertion is generally performed, with the tendon being attached to the APB tendon as well as a second location. This second insertion may weaken tendon transfer function and is generally unnecessary unless there is additional deficit of the thumb (eg, extensor pollicis brevis dysfunction or collateral ligament insufficiency).

 

Preoperative Planning

 

All patients with rheumatoid arthritis require a thorough general physical examination as well as careful evaluation of their cervical spine, including posteroanterior and lateral radiographs, often with flexion and extension views to evaluate cervical spine instability.

 

Limited joint mobility is a contraindication to tendon transfer.

 

 

Directed therapy may be used to improve contracture.

 

For example, brachioradialis tendon transfer to the flexor pollicis longus is an ideal transfer and is likely to yield an excellent result but only if there is adequate passive motion at the interphalangeal joint and MCP joint as well as the basal joint and the thumb. If these joints are stiff, the brachioradialis might be better saved for other needs as the patient's arthritis progresses.

 

With lack of opposition, the thumb metacarpal will be adducted and supinated. Contracture of the first web space may also be present. Intraoperatively, web space contracture may be treated by release of the fascia of adductor pollicis and first dorsal interosseous. The skin may be lengthened by skin graft, flap, or Z-plasty. Severe contractures may require metacarpal base osteotomy or trapeziectomy.

 

The carpus should be examined for stability. In particular, the DRUJ on the ulnar side of the wrist should be checked for dorsal instability and subluxation and the volar radial side of the wrist for palmar subluxation.

 

Planning needs to take into consideration the results of preoperative radiographs of the wrist, hand, and cervical spine as well as electromyographic tests.

 

 

If the findings on electromyography are negative and the surgeon is certain that tendon rupture is responsible for the lack of active finger motion, plans should be made to transfer expendable existing tendons to those that

 

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have ruptured. In the case of multiple extensor tendon ruptures to the fingers, the ECRL and the FDS from the long and ring fingers are two of the most common donor tendons.

 

If radiographs reveal significant joint destruction and instability, appropriate arthrodesis or arthroplasty should be considered rather than tendon transfer.

 

Instruments designed for tendon weaves are extremely valuable.

 

 

Sharp tendon passers facilitate a Pulvertaft weave. When sharp, pointed tendon passers are not available, a no. 11 blade can be passed through the tendon followed by a hemostat to grasp the knife and guide the hemostat through the tendon. The hemostat then grasps the transferred tendon, weaving it through the recipient tendon.

 

3-0 and 4-0 braided nonabsorbable sutures on appropriate needles are recommended for tendon repairs.

Positioning

 

Most tendon transfers are done with the patient in the supine position on the operating table.

 

The contralateral arm or lower extremity may be sterilely draped in the event that a tendon graft is needed.

 

Anesthesia may be either general or an axillary block, depending on the patient's preference and the stability of the cervical spine.

 

 

Although isolated carpal tunnel release may be performed under local anesthesia, carpal tunnel release combined with palmaris longus opponensplasty requires block or general anesthesia.

 

TECHNIQUES

• Extensor Indicis Proprius Tendon Transfer

   

  Isolate the EIP through a 1-cm longitudinal or curvilinear incision on the dorsoulnar aspect of the index MCP joint.

   

  The EIP is usually the ulnar tendon of the two located dorsal to the MCP joint of the index finger.

   

  Make a second 2- to 3-cm incision over the mid-dorsal wrist (unless a dorsal wrist incision has already been made for another procedure).

   

  Incise the retinaculum overlying the fourth extensor compartment and locate the EIP tendon ulnar and deep to the EDC tendons.

   

  The EIP is identified by its muscle belly, which is the most distal in the fourth extensor compartment.

   

  Once the identity of the EIP is confirmed proximally and distally, suture the index EIP and EDC tendons together as far distal as possible using 4-0 nonabsorbable braided suture. This will allow the EDC to index finger to pull on the EIP distal remnant.

   

  Invert or bury the knot to void prominence under thin rheumatoid skin.

   

  Incise the EIP just proximal to the stitch, and then free any tendinous interconnections over the dorsum of the hand.

   

  Some authors advocate to take a segment of extensor hood with the EIP tendon. This should only be done if the additional length is needed for the transfer. If performed, repair the extensor hood using small nonabsorbable suture to prevent EDC subluxation.

   

   

  Use a blunt instrument or Penrose drain to pull the EIP tendon into the wrist wound. Transfer the EIP to the exposed recipient tendon using a Pulvertaft weave.

   

  A single weave, although usually sufficient for smaller tendons, should be supplemented with an additional one or two weaves if possible. This will significantly strengthen the repair site.

   

  If insufficient distal tendon is present for a weave, either an end-to-end repair or a weave in which the transferred tendon is brought through a transverse incision in the distal recipient stump from volar to dorsal is an effective option. As many as three distal tendons may be sewn to the proximal EIP using single weaves. Usually, the EDQ would be most proximal followed by the EDC ring and long.

   

  Skin incisions are closed and a splint is applied for 3 to 4 weeks after which time therapy is begun under the supervision of a hand therapist.

• Flexor Carpi Radialis Tendon Transfer for Finger Extension

   

  Works best when combined with partial or total wrist fusion

   

  Primary skin incision for wrist fusion is made over the fourth dorsal compartment. The wrist fusion is performed before tendon transfer as to have a fixed tension for the transfer.

   

  The FCR may be harvested with a single longitudinal incision on the volar wrist, taken with a portion of the palmar aponeurosis, or, alternatively, it may be harvested through a series of incisions volarly. It is important to free the proximal muscle from its fascial attachments.

   

   

  The FCR is then passed subcutaneously around the radius and delivered into the primary skin incision. The FCR may then be woven into the EDC of ring and small with EDQ.

   

  If the FCR transfer is of insufficient length to reach the EDC stumps, the FCR may be split proximally and a portion flipped distally. It is helpful to place a stitch in the distal aspect of the transfer as to not strip the tendon completely.

   

  Similar to other tendon transfers, the tension must be set at the time of transfer. The FCR is sewn into the extensors with the fingers in full extension.

   

   

  The skin incisions are then closed and the hand is splinted with the fingers fully extended.

   

• Flexor Digitorum Superficialis Tendon Transfer for Finger Extension

  P.794

   

  In the case of rupture of all of the extensor tendons on the dorsum of the wrist and when wrist motion is

  still intact, tendon transfer of the FDS, as suggested by Boyes,1 is a reliable method to restore finger extension.

   

  The FDS and FDP to each of the donor fingers must be intact.

   

   

  Preexisting swan-neck deformity in a donor digit may worsen after harvest of the FDS tendon. Long and ring FDS tendons are used most often.

   

  Make a transverse incision in the distal palm and divide the FDS tendon proximal to the bifurcation between the A1 and A2 pulleys. This leaves the chiasm of Camper intact to provide proximal interphalangeal stability and helps prevent development of a swan-neck deformity (TECH FIG 1).

   

  Splinting the proximal interphalangeal joint in flexion postoperatively will also help to minimize the risk of developing a swan-neck deformity.

   

   

   

  TECH FIG 1 • Transfer of the FDS to the long and ring fingers. The distal incision in the palm is used to isolate the sublimis tendon as far distal as possible by flexing the finger so that the chiasm of Camper is visible in the wound. The tendon is divided just proximal to the chiasm, leaving enough distal tendon to contribute to the stability of the proximal interphalangeal joint in extension and thereby avoiding a secondary instability of that joint and possible swan-neck deformity.

   

   

  Isolate the FDS tendon proximally through a Henry-type incision in the distal forearm and atraumatically deliver it into that incision.

   

  Pass the tendon deep to the median nerve, the FDP, the FCR, the flexor pollicis longus, and the radial artery and the nerve at the wrist with a blunt tendon passer, hemostat, or Kelly clamp.

   

  The transferred tendon sits on the radius using the bone as a pulley to enhance the effectiveness of the transfer.

   

  If the FDS to the ring finger is too short to pass around the radial side of the wrist, an alternative route is beneath the FDP, FCU, and ulnar artery and nerve around the ulnar side of the forearm using the ulna as the pulley.

   

  In general, the radial path is preferred to minimize ulnar deviation of the digits.

   

  Alternatively, the FDS tendon is passed volar to dorsal through an incision in the interosseous membrane just proximal to the DRUJ.

   

  The membrane functions as the pulley.

   

  Weave the smaller distal tendon stumps through the larger transferred FDS tendon in the manner described by Pulvertaft.12

   

  Adjust tension such that with slight wrist flexion, the fingers are maintained in full extension.

   

  Immobilize the hand and wrist with the wrist in 40 degrees of extension and the fingers flexed until tension

  is noted at the suture line (TECH FIG 2).

   

  Ideally, this should be close to the “safe position” with slight MCP joint flexion and relative interphalangeal joint extension.

   

   

   

  TECH FIG 2 • The ideal splint for transfer to the extensor tendons of the finger immobilizes the wrist in the so-called safe position. With wrist extension, tension at the site of transfer is usually minimal. Finger flexion at the MCP joint is ideal to prevent scarring of the collateral ligaments and secondary loss of finger flexion. The amount of flexion possible is judged in the operating room by passive flexion of the finger until a minimum amount of tension is seen at the repair site. (From Williams DP, Lubahn JD. Reconstruction of extensor tendons. Atlas Hand Clin 2005;10:209-222.)

• Extensor Carpi Radialis Longus or Brevis Transfer

   

  When all of the finger extensors have ruptured, wrist motion is severely limited (ie, after a partial or complete wrist fusion), and the radiocarpal joint is stable, the wrist extensors become potential muscles for use as transfers.

   

  The ECRL and the ECRB are located in the second dorsal compartment of the wrist adjacent to the fourth compartment and are separated only by the tubercle of Lister and the EPL.

   

  Expose the ECRL or ECRB using a straight dorsal incision or a limited transverse incision over the base of the index and long metacarpals at their respective insertion sites.

   

   

  Divide the tendon selected for transfer, usually the ECRL, at its insertion and transfer it ulnarly to the recipient tendon stump.

   

• Brachioradialis Tendon Transfer (Reconstruction of Mannerfelt Syndrome)

  P.795

   

  Expose the forearm muscles and the brachioradialis tendon insertion on the distal radial aspect of the radius through a Henry-type incision. The brachioradialis is detached from its insertion and carefully released proximally to increase its excursion.

   

  Confirm the tendon rupture by direct exposure of the slightly more distal and radial tendon of the flexor pollicis longus.

   

  Mobilize the distal tendon stump and perform a tenolysis to remove adhesions.

   

   

   

  TECH FIG 3 • A,B. Pulvertaft weave shown sequentially as a sharp tendon passer is used to puncture the tendon through and through and then grasp the tendon being transferred and weave it through the recipient tendon. C. The transfer is secured at each weave with one or two nonabsorbable braided nylon sutures. (From Lubahn JD, Wolfe TL. Surgical treatment and rehabilitation and tendon ruptures in the rheumatoid hand. In: Mackin EJ, Callahan AD, Skirven TM, et al, eds. Rehabilitation of the Hand and Upper Extremity, ed 5. St. Louis: Mosby, 2002:1598-1607.)

   

   

  Weave the distal flexor pollicis longus through the brachioradialis in a Pulvertaft fashion. Sharp tendon passers facilitate this technique (TECH FIG 3).

   

  Adjust tension such that with wrist flexion, the MCP and interphalangeal joints of the thumb extend fully and with wrist extension, they flex 30 to 40 degrees.

   

  Secure the weaves with 3-0 or 4-0 braided nonabsorbable sutures.

   

  If the index or long FDP tendons also are ruptured, isolate the distal tendon stumps and repair them end to side.

• Extensor Pollicis Longus Tendon Transfer (Reconstruction of Thumb Boutonnière Deformity)

   

  Make a longitudinal incision to expose and identify the EPL tendon at its insertion onto the base of the distal phalanx.

   

  Incise the tendon at that level and mobilize it proximally (TECH FIG 4A).

   

  Carefully protect the intrinsic tendon, which will now be the sole extensor for the thumb interphalangeal joint.

   

  Expose the dorsal base of the proximal phalanx and weave the EPL tendon through the dorsal capsule, securing it using a 3-0 or 4-0 nonabsorbable braided suture (TECH FIG 4B).

   

  Alternatively, secure the EPL tendon in place using drill holes or a suture anchor in the proximal phalanx (TECH FIG 4C,D).

   

  The thumb is splinted or casted for 4 weeks, and a protective splint is worn for strenuous activities for 6 to 8 weeks.

   

  P.796

   

   

   

  TECH FIG 4 • Extensor pollicis brevis rupture. A,B. Tendon transfer of the EPL proximally to the site of insertion of the extensor pollicis brevis, allowing the hyperextended interphalangeal joint to drop into a more flexed position and allowing active extension at the level of the MCP joint. C,D. EPL is anchored through drill holes to the base of the proximal phalanx. (From Lubahn JD, Wolfe TL. Surgical treatment and rehabilitation and tendon ruptures in the rheumatoid hand. In: Mackin EJ, Callahan AD, Skirven TM, et al, eds. Rehabilitation of the Hand and Upper Extremity, ed 5. St. Louis: Mosby, 2002:1598-1607.)

• Flexor Digitorum Superficialis Opposition Transfer (TECH FIG 5A-F)

   

  The FDS tendon is harvested as described earlier (see Flexor Digitorum Superficialis Tendon Transfer for Finger Extension).

   

  The forearm incision is made on the ulnar aspect of the wrist to expose the FCU. The incision is curved proximally to allow access to the finger flexors.

   

  The donor tendon is isolated and brought into the forearm.

   

  A pulley is made using the FCU. The FCU is split longitudinally without detaching it from the pisiform. One limb is then divided to create a distally based slip. The cut end is passed back through the intact tendon near the pisiform to create a loop closed by a tendon weave. The weave is sutured with small nonabsorbable suture.

   

  The FDS tendon is passed through the FCU loop.

   

  A subcutaneous tunnel is made between the pulley and a small incision on the radial side of the thumb MCP joint. The tunnel should be superficial to the median nerve. The tendon is passed through this tunnel.

   

  The transverse carpal ligament or Guyon canal may also be used as a pulley.

   

  The tendon is sutured to the APB tendon using a Pulvertaft weave.

   

  The tendon is tensioned with the thumb in opposition and the wrist in neutral.

   

  Because of the large excursion of the FDS tendon, precise tensioning is less crucial in this transfer.

   

  A thumb spica cast is worn for 4 weeks and then transitioned to a removable splint.

   

   

   

  TECH FIG 5 • Flexor digitorum superficialis transfer. A. The skin markings are at the distal palmar crease (middle finger was used in this patient only because the ring finger FDS had been previously used), radial thumb, and ulnar forearm. B. Through the forearm incision, a portion of FCU is used to create a pulley. (continued)

   

   

  P.797

   

   

   

  TECH FIG 5 • (continued) C,D. After dividing the superficialis tendon in the distal palm and drawing it into forearm, a tunnel is made from the thumb to forearm. E. The tendon graft is then passed through the FCU loop and the subcutaneous tunnel to its point of attachment at the thumb. F. Excellent opposition was restored in this patient.

• Palmaris Longus Opposition Transfer

   

  Preoperatively, confirm presence of the palmaris longus by physical examination. Because the tendon is not long enough to reach the thumb, it is augmented by including a strip of the palmar fascia.

   

  A longitudinal incision is made from the proximal palmar crease to the forearm. The palmar cutaneous branch of the median nerve arises radial to the palmaris longus tendon and should be identified and protected. After division of the skin, a 1-cm band of the palmar fascia is removed in continuity with the palmaris longus tendon. This additional tissue provides the length required for the palmaris longus to reach the thumb. This will also accomplish the carpal tunnel release. The tendon is then freed from the forearm to palm.

   

  A second incision is made on the radial aspect of the thumb MCP joint. A subcutaneous tunnel is made between this and the forearm incision.

   

  The tendon with attached fascia is passed from the forearm to second incision. It is inserted into the APB tendon with a weave.

   

  The transfer is tensioned with the thumb in full opposition, MCP joint in full extension, and wrist in neutral.

   

  A thumb spica cast is worn for 4 weeks and then transitioned to a removable splint.

• Extensor Indicis Proprius Transfer for Lack of Opposition

 

The EIP tendon is obtained as in the section Extensor Indicis Proprius Tendon Transfer and passed around the ulnar side of the distal dorsal forearm.

 

A second incision is made along the radial aspect of thumb MCP joint.

 

A subcutaneous tunnel is around the ulnar border of the wrist from the dorsal forearm incision to this second incision. Care should be taken to not entrap or damage the ulnar neurovascular bundle. This can be done by staying superficial to the FCU. This task is made easier by making an additional small incision proximal to the pisiform. The tendon is first passed into this incision, then a second time across the palm.

 

The EIP is passed around the ulnar side of the wrist through the tunnel and inserted into the APB tendon with a weave.

 

The transfer is tensioned with the thumb in full opposition and the wrist in slight flexion.

 

A thumb spica cast is worn for 4 weeks and then transitioned to a removable splint.

 

 

P.798

 

PEARLS AND PITFALLS
		EIP harvest	Obtain the EIP transfer by tracing the ulnar most inserting tendon in the MCP joint region of the index finger proximally at the level of the wrist. In a certain percentage of patients, the ulnar most tendon is in fact the EDC rather than the EIP. The EIP, however, is always the deeper, more volar tendon at the level of the wrist. Tracing this independent muscle tendon unit from the wrist to the index finger MCP joint will help assure the surgeon that the correct tendon is being released for transfer. Distal repair of the dorsal apparatus at the site of EIP harvest is somewhat controversial. Although some experts recommend repair, others feel confident that the

 

EDQ transfers	Sufficient length of the distal segment of the EDQ should be available to allow tendon transfer to the adjacent EDC without abducting the small finger. If this transfer is tight, the side-to-side transfer of EDQ to the EDC of the ring finger should be abandoned and tendon transfer to the EIP or another suitable donor pursued.
Unstable DRUJ	At the time of tendon transfer, inspect the DRUJ to be certain that any osteophytes have been débrided and a localized flap rotated to cover the exposed bone created. If the DRUJ is deemed unstable, transfer of the pronator quadratus dorsally may be used to stabilize the distal ulna.
Suturing	When suturing tendon grafts at the site of tendon weave (ie, where a graft or transfer is passed through another tendon), one or two sutures should be sufficient. Take care that the needle does not pass through the tendon near the thread from another suture. If this occurs, the suture is weakened or possibly cut in two by the needle and the graft or transfer is predisposed to rupture. Cutting needles should never be used, as they place both the suture and the tendon at risk.
Tendon transfer	Ensure adequate size of tunnel for passage of tendon. When passing tendons from one compartment to another, make sure to pull in line with the tendon instead of up and out of the wound, as this may avulse the tendon. This may be accomplished by “winding” the tendon using an Allis retractor placed into the wound. Avoid passing tendon through scarred areas. Avoid surgery in the setting of open wounds. Full range of motion should be obtained prior to transfer.

 

defect can be left with no risk of extensor lag. The surgeon needs to be aware of the

potential risk of extensor lag, and we recommend attention to the defect by suture repair.

 

 

 

 

POSTOPERATIVE CARE

 

Postoperative care for each of these tendon transfers is similar.

 

In the case of tendon transfer to restore loss of finger extensors, the hand and wrist are immobilized with the wrist extended about 40 degrees. More may be desirable in certain instances, but too much extension could damage already fragile joints.

 

 

The MCP joints are brought into flexion until tension is noted at the suture line. Forty degrees or more is ideal to maintain the desired length of the collateral ligaments and prevent MCP joint extension contractures.

 

Immobilization is continued for 3.5 to 4 weeks, and gentle active motion is begun, maintaining the hand in a splint for protection.

 

At 6 weeks, some resistive exercises may be added to the program. By 12 weeks, the patient should be able to resume normal activities.

 

In the case of flexor tendon rupture, the hand and wrist are immobilized with the wrist in 60 degrees of flexion,

the MCP joints in 40 degrees of flexion, and the interphalangeal joints allowed to extend until tension is noted at the suture line. Immobilization is continued for 6 weeks, at which time a gentle active range-of-motion program is begun without resistance.

 

At 12 weeks, resistive exercises are added and the patient is permitted to gradually resume normal activity.

In the case of opposition transfer, the thumb is immobilized in full opposition and the wrist in neutral to slight flexion. A thumb spica cast is worn for 4 weeks and then transitioned to a removable splint.

 

OUTCOMES

Outcomes in tendon transfer surgery in rheumatoid arthritis are highly dependent on the patient's medical condition and ability to cooperate with the postoperative splinting and rehabilitation program. Most patients who are supervised by a therapist achieve a better result than those who try to make it on their own.

With good medical management of rheumatoid arthritis, when the disease is well controlled, and in cooperative patients who are motivated to improve, good results should be expected.

Tendon transfer should always be delayed in patients with active disease, as results will be poor.

The only surgical procedure to be performed in poorly controlled patients is synovectomy and with the caveat that success hinges on eventual good medical control of the disease.

Outcomes correlate inversely with the number of ruptured tendons and chronicity of injury.5

 

 

COMPLICATIONS

Infection

Skin or surgical wound breakdown Attenuation of the transferred tendon Rerupture of the tendons

Loss of motion due to improper tensioning of the transferred tendon Joint stiffness

 

 

P.799

REFERENCES

1. Boyes JH. Bunnell's Surgery of the Hand, ed 5. Philadelphia: JB Lippincott, 1970.

    

2. Breen TF. Jupiter JB. Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna. J Hand Surg Am 2012;14: 612-617.

    

3. Camitz H. Surgical treatment of paralysis of opponens muscle of thumbs. Acta Chir Scand 1929;65:77-81.

    

4. Chetta MD, Ono S, Chung KC. Partial extensor carpi radialis longus turn-over tendon transfer for reconstruction of the extensor pollicis longus tendon in the rheumatoid hand: case report. J Hand Surg Am

    

   2012;37:1217-1220.

    

    

5. Chung US, Kim JH, Seo WS, et al. Tendon transfer or tendon graft for ruptured finger extensor tendons in rheumatoid hands. J Hand Surg Eur Vol 2010;35:279-282.

    

    

6. Davis TR. Median and ulnar nerve palsy. In: Wolfe SW, Hotchkiss RN, Pederson WC, et al, eds. Green's Operative Hand Surgery, vol 2, ed 6. Philadelphia: Elsevier, 2011:1093-1137.

    

    

7. Hamlin C, Littler JW. Restoration of the extensor pollicis longus tendon by an intercalated graft. J Bone Joint Surg Am 1977;59(3):412-414.

    

    

8. Littler JW, Cooley SG. Opposition of the thumb and its restoration by abductor digiti quinti transfer. J Bone Joint Surg Am 1963;45: 1389-1396.

    

    

9. Mannerfelt L, Norman O. Attrition ruptures of flexor tendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel: a clinical and radiological study. J Bone Joint Surg Br 1969;51(2):270-277.

    

    

10. Nalebuff EA. Diagnosis, classification and management of rheumatoid thumb deformities. Bull Hosp Joint Dis 1968;29:119-137.

     

     

11. Nalebuff EA, Millender LH. Surgical treatment of the boutonniere deformity in rheumatoid arthritis. Orthop Clin North Am 1975;6: 753-763.

     

     

12. Pulvertaft RG. Tendon grafts for flexor tendon injuries in the fingers and thumb: a study of technique and results. J Bone Joint Surg 1956;38B:175-194.

     

     

13. Vaughan-Jackson OJ. Rupture of extensor tendons by attrition at the inferior radio-ulnar joint: report of two cases. J Bone Joint Surg Br 1948;30B(3):528-530.

     

     

14. Williamson SC, Feldon P. Extensor tendon ruptures in rheumatoid arthritis. Hand Clin 1995;11:449-459.