Boutonniere rheumatoid arthritis. Treatment of polyarthritis of joints: possible methods

Moscow, st. Berzarina 17 bldg. 2, metro station "Oktyabrskoye Pole"

In 2009 he graduated from the Yaroslavl State Medical Academy with a degree in general medicine.

From 2009 to 2011, he completed a clinical residency in traumatology and orthopedics at the Clinical Emergency Hospital named after. N.V. Solovyov in Yaroslavl.

From 2011 to 2012, he worked as an orthopedic traumatologist at Emergency Hospital No. 2 in Rostov-on-Don.

Currently working in a clinic in Moscow.

2012 – training course in Foot Surgery, Paris (France). Correction of forefoot deformities, minimally invasive surgeries for plantar fasciitis (heel spurs).

February 2014 Moscow – II Congress of Traumatologists and Orthopedists. “Traumatology and orthopedics of the capital. Present and future."

November 2014 - Advanced training “Application of arthroscopy in traumatology and orthopedics”

May 14-15, 2015 Moscow - Scientific and practical conference with international participation. "Modern traumatology, orthopedics and disaster surgeons."

2015 Moscow – Annual international conference “Artromost”.

Damage to the extensor tendons of the hand

The extensor tendons are located just under the skin on the back of the hand and fingers. Due to their superficial location, even a minor wound can easily damage them.

Anatomy of the extensor tendon apparatus of the hand

The extensor tendons are located on the back of the hand and fingers and allow us to straighten our fingers. They start from the nail phalanges and attach to the muscles in the forearm. On the fingers they have a flat shape, but as soon as they move into the area of ​​​​the metacarpal bones they acquire a rounded shape (like a cable).

What happens as a result of an extensor tendon injury?

With a rupture of the extensor tendon, there are much fewer consequences and impairments in hand function than with damage to the finger flexor tendons. If the damage is localized at the level of the fingers, then the upper end of the tendon does not “run away” (thanks to the jumpers between the tendons just above the heads of the metacarpal bones), but remains in place and grows into the surrounding tissues in 3 weeks. Such damage slightly impairs the extension of the finger, approximately to the extent of the award. The function of the hand is almost unaffected. Surgery is required to achieve full extension. If the damage to the extensor tendon is localized at the level of the metacarpal bones, wrist or forearm, then due to reflexive contraction of the muscles they pull the tendons and a significant divergence of the ends of the tendon occurs. Many factors can influence the severity of an injury, including fractures, infections, medical illnesses, and individual differences.

Hammer finger

Hammer finger deformity is shown in the figure. It is a bent nail phalanx at the proximal interphalangeal joint. As a rule, the cause of such damage is a wound with a sharp object or a fall on a straightened finger or a direct blow. If this damage is not treated, then the nail phalanx will not unbend on its own. But the finger will not completely lose its function, because the central bundle of the extensor tendon is attached to the middle phalanx of the finger.

This deformity is caused by the fact that the flexor tendons are constantly in good shape and tend to flex the finger without the opposition of the extensor.

It is not uncommon for the injury to involve separation of part of the distal phalanx.

Deformation boutonniere

It is a bent finger at the proximal interphalangeal joint. As a rule, the cause of such damage is a wound with a sharp object, a circular saw. If this injury is not treated, the finger will not fully straighten on its own. But it will not completely lose its function, because... On the sides of the central bundle of the extensor tendon there are lateral ones and they will take on part of the extensor function. The flexor tendons will tend to bend it without the extensor counteracting it.

It is a fully bent finger in all joints. The cause of such damage to the extensor tendon of the digitorum is usually an injury with a sharp object, a circular saw, at the level of the metacarpal bones, wrist or forearm. If this injury is left untreated, there will be significant loss of extensor function in one or more fingers. Minor extension movements (20-30 degrees) will remain due to the bridges between the extensor tendons at the level of the heads of the metacarpal bones.

First aid for tendon injuries

If you seriously injure your hand, apply a pressure bandage and ice immediately. This will stop or dramatically slow down the bleeding. Raise your arm above your head to slow down the blood flow. Contact a traumatologist as soon as possible.

The doctor must perform primary surgical treatment of the wound, which includes washing the wound with antiseptic solutions, stopping bleeding and suturing. This is followed by a tetanus shot and antibiotics to prevent infection.

Further, if the doctor has diagnosed an injury to the extensor tendon of the hand, then he will refer you to a specialist in hand surgery to treat the injury to the tendon, i.e. it is necessary to perform a “tendon suture” operation, otherwise the extensor function of the finger will be lost.

Treatment of damage to the extensor tendons of the fingers

In the treatment of injuries to the extensor tendons of the fingers, not only a surgical method is used, but also a conservative one, in contrast to injuries to the flexor tendons. Damage at the level of the fingers can be cured without surgery, but with long-term wearing of a plaster or plastic splint. Damage to the tendon at the level of the metacarpal bones, wrist and forearm, unfortunately, can only be treated surgically. Because the ends of a torn or cut tendon need to be stitched. Your doctor will explain the need and benefits of various treatments for extensor tendon injuries.

Treatment methods for various extensor tendon injuries

Hammer finger

If the tendon injury at the level of the distal interphalangeal joint is closed, conservative treatment is possible, namely splinting for 5 weeks. Sometimes, for a faster recovery, the “extensor tendon suture” operation is performed at the level of the fingers. A splint is used after surgery to maintain the finger in an extended position until the tendon heals (approximately 3 weeks). The splint must remain on the finger at all times. Removing the splint prematurely can lead to rupture of the unformed tendon scar and the tip of the finger (nail phalanx) will return to the flexion position. In this case, the splinting is performed again. The doctor should monitor you during treatment to determine whether the splint is secure enough, whether it has broken, and will remove it at the appropriate time.

Deformation boutonniere

Treatment involves splinting the middle joint in a straight position until the tendon injury is completely healed. Sometimes, stitches are needed when the tendons have been cut and even if the tendon ruptures. If the injury is not treated, or if the splint is not worn correctly, the finger can quickly become even more crooked and finally freeze in that position. Be sure to follow your doctor's instructions and wear the splint for at least four to eight weeks. Your doctor will tell you when you can stop wearing the splint.

Wounds on the back of the hand and wrist with damage to the extensor tendons

Injury (damage) to the extensor tendons at the level of the metacarpal bones, wrist or forearm in any case requires surgical treatment, because Due to the reflex contraction of the muscles, they pull the tendons along with them and a significant divergence of the damaged ends occurs.

The operation is performed under conduction or local anesthesia. The damaged ends of the tendon are sutured. Careful hemostasis (stopping bleeding) is performed and the wound is sutured. A plaster splint or plastic splint is applied as mandatory postoperative immobilization to avoid rupture of the sutured tendon. The operation is performed on an outpatient basis and the patient will be able to go home.

Rehabilitation

After any method of treating extensor tendon injuries, both conservative and surgical, rehabilitation (physical therapy, movement development) is necessary. The tendons grow together quite firmly in 3-5 weeks (depending on the location), after which the plaster or splint can be removed. But it is very important to start developing movements in the early stages, otherwise the place where the tendon is sutured can become soldered (grow) to the surrounding tissues and a limitation in extension will arise. And all the work of the surgeon and the patient is in vain. Rehabilitation must begin under the supervision of the attending physician or rehabilitation specialist, then the chances of full restoration of extension will be very high.

When limiting finger movements, also read the article about Dupuytren's contracture

Don't self-medicate!

Only a doctor can determine the diagnosis and prescribe the correct treatment. If you have any questions, you can call or ask a question by email.

ONE PHALANX IS BENT AND DOES NOT STRAIGHTEN

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There is no doubt that a separation (rupture) of the superficial extensor muscle has occurred. None

Conservative measures cannot correct this situation. The only thing is

could have been done - immediately after the injury, apply plaster immobilization in

hyperextension position. Don't waste time - go to the trauma department

brushes as soon as possible.

Clinic address - Moscow, Troitskaya st., 5 (metro station Tsvetnoy Boulevard)

QUESTIONS IN PERSONAL MESSAGES ARE PAID! All clarifications on the answer are only in the “Audience Opinion” window

Moscow Region, Dmitrov, st. Professionalnaya, 26, bldg. 1

Repair of the extensor tendon of the finger

Recovery of injured extensor tendons depends on the area and type of injury.

Hammer finger

Loss of integrity of the connected lateral bundles at the level of attachment to the base of the distal phalanx leads to the absence of its extension, and is known as "hammer finger".

Passive extension is usually completely preserved.

Function of the central bundle without resistance to the middle phalanx +/- relaxation at the level of the proximal interphalangeal joint can cause hyperextension of the proximal interphalangeal joint.

Mechanism of hammertooth deformation formation

Closed injury (most often)

• Sudden forced flexion of an extended finger
• Sports, occupation or homework
• Causes a rupture of the extensor apparatus at the level of attachment to the rear of the distal phalanx with or without detachment of the bone fragment.

Classification of hammer fingers

• Closed injury, +/- avulsion fracture
• Most common damage

• Open tendon injury at the level

• Combined skin and tendon defect

• Damage from hyperextension
• Palmar subluxation of the distal phalanx

Prevalence (occurrence)

• Prevalence by sex and age varies greatly among countries
  • More common in adolescents/young men
  • More often in middle-aged women
• Regardless of gender, the ulnar fingers are more often damaged.

Conservative treatment of closed (type 1) hammertoe

• Most type I cases are treated conservatively with splinting.
• Without bone fragment:
  • eight weeks of continuous splinting
  • four more weeks at night
• With bone fragment:
  • Six weeks of continuous immobilization
• It is recommended to remove the tire only for washing.

• Promote tendon fusion
• Maximize the function
• Restore range of motion to the maximum extent
• Maintain full range of uninjured joints
• Prevent the development of “swan neck” deformity.

• Aluminum with a soft finish that can be cut to size. There should be no sharp edges
• Stamped plastic (Stack)
• Custom made from thermoplastic.

• The dorsal splint allows freedom of the proximal interphalangeal joint and provides sensation to the fingertip. When using a palmar splint, both conditions are violated
• Severe hyperextension can lead to poor circulation. Slight flexion may result in extension deficit.
• Regular monitoring of the position of the splint and the integrity of the skin is necessary.
• The tire must not be loose.

After six weeks (with fracture) and after eight weeks (without fracture)

• Begin gentle flexion exercises
• In the first week, no more than 20-25° of active flexion of the distal interphalangeal joint.
• In the second week, if there is no lack of extension, the joint can be flexed to 35°.
• If the interphalangeal joint is stiff in extension, it may be necessary to stretch the oblique suspensory ligaments.
• If there is insufficient extension, additional splinting may be indicated (and exercises are postponed)
• Splinting is recommended between physical therapy sessions for the first two weeks of mobilization, with a splint at night for four weeks.
• Desensitization of the painful fingertip may be necessary.
• The exercises are intensified gradually to active gripping and pinching.
• Flexion is increased while extension is maintained.

Complications of immobilization in a splint

• Maceration/necrosis of skin
• Maceration/necrosis of the nail bed.
• Allergy to the patch
• Extension deficiency at the distal interphalangeal joint.

Surgical treatment of closed (type 1) hammertoe

An open repair technique has been described, but the results are no better than with conservative treatment. The rate of complications is very high.

Immobilization using a Kirschner wire (immersing the wire and passing it obliquely [not longitudinally] to avoid pain at the tip of the finger) is sometimes indicated in patients who are unable to wear a splint due to occupational or other social or psychological reasons.

Type 2 hammertoe (open tendon injury at or proximal to the distal interphalangeal joint)

Acute injury is treated with surgical repair of the extensor apparatus followed by immobilization for eight weeks using a splint or submerged Kirschner wire.

Type 3 hammertoe (combined skin or tendon defect)

Requires soft tissue restoration

Type 4 hammer finger

Type 4A growth plate injury

• The extensor apparatus is attached to the basal epiphysis.
• Correction possible by closed reduction
• A splint in extension for four weeks, then a control x-ray to assess the healing of the fracture and the position of the fragments.

• Overflexion injury
• 20-50% fractures of the articular surface
• Can be treated with a splint, pin fixation, or open reduction and internal fixation. Be careful not to split the small bone fragment with a pin or screw.

• Damage from hyperextension
• >50% articular surface fractures
• Palmar subluxation of the distal phalanx in relation to the proximal fragment (which remains in the correct anatomical position, held by the extensor tendon insertion and joint capsule). The distal fragment is displaced towards the palmar side.
• Can be treated in a splint, Kirschner wire fixation, or by open reduction and internal fixation.
• For palmar subluxation of the main fragment of the distal phalanx, the method of fixation with Kirschner wires according to Ishiguro is effective.
  • Flex the distal interphalangeal joint.
  • Pass the Kirschner wire through the dorsal surface of the middle phalanx 1-2 mm to the rear and proximal to the bone fragment.
  • Pull the nail phalanx distally and straighten it to reposition it.
  • Pass the axial pin through the nail phalanx through the distal interphalangeal joint.
  • Put on a protective bar.
  • Remove the wire after 4-6 weeks.

Hammertoe (TI area, interphalangeal joint)

• Closed hammertoe is treated with splinting for 6-8 weeks.
• If the injury is open, hammertoe can be treated by suturing the tendon.
• The mobilization protocol is the same as for the treatment of type 1 hammertoe deformities of the three-phalangeal fingers.

Triphalangeal fingers - middle phalanx (zone II) and main phalanx of the first finger (zone TII)

Middle phalanx of triphalangeal fingers

Usually occurs with open cut wounds or crushing (more often than with closed injuries as in zone I).

Often incomplete damage to the tendon due to its width at the level of the middle flank.

If the damage is less than 50%, the tendon may not be sutured.

When restoring, a braided seam or a seam with cross stitches according to Silversklold is performed. The tendon is usually too thin (0.5 mm) to use an axial suture.

• The distal interphalangeal joint is splinted in full extension for six weeks.
• Active flexion of the proximal interphalangeal joint is allowed during immobilization.

Proximal phalanx of the first finger

If the flexor longus tendon is damaged at the level of the main phalanx, it can be sutured as described above, or an axial suture with crossing stitches can be used according to Silversklold.

• The interphalangeal joint is splinted in full extension for six weeks.
• Active flexion of the metacarpophalangeal joint is allowed.

Boutonniere-type injury to the extensor tendon of the triphalangeal fingers

Deformation like a boutonniere (button loop)

• The proximal interphalangeal joint of the finger is held in flexion, and the distal interphalangeal joint is hyperextended.
• If left untreated, permanent deformity may develop.

Causes

• Closed damage to the central bundle.
• Closed injury to the central bundle with avulsion fracture.
• Open damage to the central beam.
• Palmar dislocation in the proximal interphalangeal joint with separation of the central fascicle from its attachment to the base of the middle phalanx.

Pseudo-boutonniere deformation

• Typically due to hyperextension injury at the proximal interphalangeal joint.
• Flexion contracture of the proximal interphalangeal joint leads to contraction of the oblique retinaculum ligaments and, accordingly, to loss of flexion in the distal interphalangeal joint.

Treatment of acute open boutonniere-type injury

• The tendon may be sutured.
• In contaminated wounds with loss of tendon tissue, an alternative method is needed to restore the central fascicle.

• An adequate stump of the central bundle is a straight suture with the imposition of an axial suture and a twisting suture crossing along the dorsal surface of the tendon.
• Inadequate stump of the central bundle - transosseous fixation through the canal at the base of the middle phalanx or anchor fixation.

Plastic surgery with a free tendon graft

It can be performed on an emergency basis or with delayed intervention.

A fragment of the split palmaris longus tendon is passed through the canal at the base of the middle phalanx and the ends are crossed over the joint in a figure of eight.

The free ends of the graft are wrapped around the lateral bundles of the extensor apparatus.

The proximal interphalangeal joint is fixed in extension for approximately 2 weeks, then careful active mobilization is begun in a small volume, gradually increasing the amplitude to full flexion within 6 weeks.

Distally based central bundle flap

To replace a defect in the central bundle, a part of the proximal part of the central bundle, deployed in the distal direction, is used.

The defect in the proximal part of the central bundle is sutured.

Restoration with a side bundle flake

• The lateral bundles are separated from their lateral attachment to the oblique retaining ligaments.
• Split the side bundles lengthwise by 2 cm.
• The medial part is sutured to the midline, leaving the lateral parts in place to perform the function of the lateral bundles.

Damage to the first finger

The extensors are usually large enough to allow for axial and crisscross sutures along the dorsal side.

Injuries at the level of the main phalanx of the triphalangeal fingers

Care must be taken not to disturb the ratio of the length of the central and lateral components of the extensor apparatus.

To prevent adhesions, movements should begin early with a small amplitude.

Partial damage

For restoration, a twisting crossing suture or an epithenon suture is used.

Early mobilization to prevent adhesions.

Complete damage

For restoration, an axial suture and a criss-crossing or epitenon suture are used.

Damage to the first finger (zone TIV, metacarpal bone)

The extensor longus and brevis tendons are distinct oval tendons.

Injury from snowcock (fist on teeth)

When struck with a fist, the metacarpophalangeal joint is damaged. Patients may be reluctant to describe the mechanism of injury.

When hitting the teeth, the extensor tendon and joint capsule are damaged and become infected with oral microflora.

This damage is often diagnosed late only after infection has developed.

Suppurative arthritis can develop as early as 48 hours after injury.

The wound channel passes through the skin, extensor tendon, joint capsule and synovium into the joint.

There may be an articular cartilage defect, a fracture, or a foreign body in the joint (such as a tooth fragment) in the metacarpal head.

• X-ray to identify a fracture or foreign body.
• Blood tests.
• Culture of wound discharge.
• Control of white blood cells and C-reactive protein, especially in the presence of infection.

Surgical treatment of impact damage in zone V

• Monitor tetanus immunization status
• Start intravenous antibiotics.
• Examine the wound in the operating room. When examining a hand with extended metacarpal-flank joints, the relative position of the skin, tendon and joint capsule changes (as they overlap each other). It is easy to miss damage to the joint capsule.
• Excise the edges of the skin wound within 1-2 mm.
• Expand the wound proximally and distally.
• There is usually visible damage to the extensor tendon, the ends of which can be parted. Otherwise, it is necessary to split the tendon longitudinally to examine the metacarpophalangeal joint.
• Visible damage to the joint capsule may occur. If it is known for sure that the damage was caused by a blow to the teeth, it is necessary to open the joint longitudinally and wash it (even if there are no visible puncture wounds).
• Primary suturing of the wound is not performed.
• If the joint is infected, repeated rinsing of the joint in the operating room is necessary until the wound is clean. Repeat sowing.
• Significant tendon damage is repaired in a delayed manner after cleansing the wound.
• Minor extensor injuries can be left without suturing to heal on their own.

Damage to the extensor hood

The thick tendon at the level of the extensor hood can be repaired with an axial suture with a criss-crossing suture.

Open damage to the sagittal bundles

Damage to the sagittal bundles is not common, since they are protected from injury by their location.

The sagittal fascicles must be restored, otherwise the extensor tendon will move laterally, causing discomfort and loss of extension.

Closed damage to the sagittal bundles

Subcutaneous rupture of the radial sagittal bundles with subluxation of the extensor tendon to the ulnar side is possible in non-rheumatoid patients due to trauma (forced flexion or extension).

This results in discomfort, displacement of the extensor tendon with a clicking sound when the metacarpophalangeal joint is flexed, and an extension deficit.

Treatment of closed damage to the sagittal fascicles in the acute period

Up to two weeks after injury.

Splinting of the metacarpophalangeal joint in a position of flexion at an angle of 10-20° of flexion for six weeks.

Leave the interphalangeal joints free.

Treatment of closed damage to the sagittal bundles in the delayed period

One of the repair techniques is required to stabilize and centralize the extensor tendon. These include:

• Direct reconstruction of radial sagittal bundles.
• Reconstruction using a tendon bridge.
• Restoration using a common extensor digitorum flake, passed under the intermetacarpal ligament and sutured onto itself.
• Use of a free tendon graft.
• Fifth finger - transposition of the extensor tendon of the little finger with subluxation of the extensor with abduction of the fifth finger at the metacarpophalangeal joint.

Limited mobilization of the ulnar sagittal fascicle may be required to restore balance.

Injuries of the first finger (zone TV, carpometacarpal joint)

The extensor pollicis brevis and abductor pollicis longus muscles (2-4 tendon bundles) can be damaged in zone V.

These tendons can be repaired using axial and wraparound sutures as described above.

The superficial branch of the radial nerve may be damaged. It should be restored, since the neuroma and neuropathic pain limit the ability to work.

Triphalangeal injuries (zone VI, metacarpal)

For injuries to the extensor tendons in zone VI, the prognosis is better than for injuries in zones II-V. They can be repaired with axial and twist sutures as described above.

Injuries at the level of the wrist (zone VII)

Open damage

The tendon suture in this zone is performed in the same way as described for zones V and VI. Proper placement of the ends of injured tendons in multiple injuries (common) can be difficult. You should act methodically, if necessary, apply marking seams.

Restoration of the extensor ligament

When the extensors at the wrist level are damaged, the integrity of the suspensory ligament is compromised.

Sometimes the ligament must be further dissected for access in the proximal and distal directions.

To eliminate the possibility of tension on the tendons like a bowstring, you need to try to preserve part of the ligament in each channel.

Subcutaneous tear

The flexor carpi ulnaris may be displaced ulnarly with supination, palmar flexion, and ulnar deviation after a Collis fracture.

Injuries at the level of the distal forearm (zone VIII)

• The tendons are repaired as described above.
• If there is damage at the level of the tendon-muscular part, a suture is possible if part of the tendon tissue at the proximal end is preserved.
• A side-to-side suture or tendon transposition (primary or delayed) is performed if it is impossible to securely fixate it to the muscle belly.

Injuries at the level of the proximal third of the forearm (zone IX)

• Extensor carpi, extensor digitorum communis, and extensor digiti minimi originate from the lateral epicondyle.
• The extensor pollicis pollicis, abductor pollicis longus, and extensor pollicis propria muscles arise from the proximal forearm.
• Loss of function after injury may be due to:
  • Crossing muscles
  • Nerve damage
• Combinations of both
• Internal damage can be much more serious than the skin damage initially suggests.

Muscle

Muscle bellies are difficult to repair. Sometimes it is possible to adapt the crossed ends with a suture behind the epimysium. Large muscle fragments should not be caught in the suture, as this can cause ischemia and necrosis.

radial nerve

Branches from the radial nerve extend to the brachialis, brachioradialis and extensor carpi radialis longus muscles at the level of the distal third of the shoulder. It then divides into motor and sensory branches. The superficial branch of the radial nerve (sensory) continues distally under the brachioradialis muscle, emerging at the level of the distal third through the anatomical snuffbox. Damage to the motor branch of the radial nerve should be diagnosed during revision, if possible with restoration. If the function of the radial nerve is lost, its restoration in a delayed manner or tendon transposition is indicated.

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The information on this site is provided for educational purposes and is not intended as medical advice or treatment.

Axiom: Negative examination results of a patient with suspected tendon damage should always be re-evaluated to clarify the diagnosis, especially in an uncontacted patient.

Primary restoration a suture placed within the first 72 hours from the moment of injury should be considered. A delayed suture is applied in the first week from the moment of injury, and a secondary suture is applied after the complete disappearance of swelling and softening of the scar, usually 4-10 weeks from the moment of injury. It should be emphasized that primary tendon suture is the method of choice whenever possible.

Delayed seam Apply if there is concomitant injury and restoration of hand function must be delayed, or if the condition of the wound due to infection or swelling does not allow the application of a primary suture. A secondary suture is indicated in the presence of severe concomitant injuries or the likelihood of complications from the wound. Partial tendon damage is treated with splinting without surgery.

Extensor tendon injuries are usually closed. If there is a separation of the tendon from its insertion at the distal interphalangeal joint, treatment consists of splinting the joint in extension. Overextension, as already emphasized, should be avoided. In addition, movement at the proximal interphalangeal joint should remain uninhibited.
Longueta should remain in place for 6 weeks. For patients who use their hands and fingertips a lot, plaster immobilization can be recommended.

Hammer finger deformity is a flexion deformity of the distal interphalangeal joint, in which complete passive, but incomplete active extension in the distal interphalangeal joint is possible. This type of injury usually occurs when there is a sudden blow to the tip of an extended finger.

Separation may occur tendons from its insertion site, or there may be an avulsion fracture of the distal phalanx, in which the tendon remains attached to the bone fragment. Rupture of the tendon at the proximal interphalangeal joint can result in a boutonniere deformity; All patients with this type of injury should be referred to a surgeon for repair.

Deformation by type boutonnieres consists of flexing the finger at the proximal interphalangeal joint and hyperextending the distal interphalangeal joint. It usually occurs when the extensor tendon is injured from its insertion on the dorsal surface of the middle phalanx. The lateral bundles are steadily stretched, slide volarly along the axis of the proximal interphalangeal joint and become flexors of the proximal interphalangeal joint. This deformation usually does not immediately appear after injury, but develops as the lateral fascicles slide in the volar direction.
tendon ruptures above the proximal interphalangeal joint are treated in the same way as ruptures in the area of ​​the middle phalanges (within 3-4 weeks). Referral to a specialist is strongly recommended.

Introduction.

Rheumatoid arthritis can cause various types of deformities of the fingers and hand in general. In its development, the disease follows a path that begins with damage to the synovial membrane of the joints and ultimately ends with bone destruction and the formation of persistent deformities.

Pain is the determining factor in limiting the professional activity of patients. Most patients with severe finger deformity without pain adapt well and can perform their usual work. Deformation of the joint does not mean loss of its function and, in itself, is not an indication for surgical treatment. Each joint of the hand must be considered as part of a complex organ. Correction of metacarpophalangeal joint deformity should precede correction of the proximal interphalangeal joints, while boutonniere deformity should be corrected before or simultaneously with metacarpophalangeal joint surgery.

One of the most difficult issues in rheumatoid hand surgery is the formulation of a comprehensive reconstruction plan. The most important goals of hand surgery in patients with rheumatoid arthritis are: eliminating pain, restoring function and slowing the progression of the disease.

Tenosynovitis.

Rheumatoid arthritis is a disease of the synovial membranes. Tenosynovitis occurs in 60% of patients with rheumatoid arthritis. Not only the synovial membranes of the joints are affected, but also the tendon sheaths. There are three main localizations of the pathological process: the dorsum of the wrist and the palmar surfaces of the wrist and fingers. Rheumatoid tenosynovitis can cause pain, tendon dysfunction, and, after invasion of the tendon by the proliferating synovium, tendon rupture. Treatment can relieve pain and, if undertaken before secondary tendon changes occur, prevent strain and loss of function. Therefore, tenosynovectomy is the first surgical intervention indicated for patients with rheumatoid arthritis.

Dorsal tenosynovitis of the wrist area.

Tenosynovitis of the dorsum of the wrist causes swelling and may involve one or more extensor tendons. Rice. 001. Due to the mobility of the skin on the dorsal surface of the wrist and hand, the pain syndrome is mild and, often, tendon rupture is the first symptom of the disease.

Rice. 1. Tenosynovitis of the dorsum of the wrist

Indications for dorsal tenosynovectomy are: tenosynovitis that does not respond to conservative treatment for 4-6 months and tendon rupture.

Operation technique (Fig. 2) :

1. Longitudinal midline incision on the dorsum of the hand and wrist (a).
2. Transverse sections proximal and distal to the extensor retinaculum (b).
3. Cutting off the retinaculum on the radial side of the wrist (c).
4. Excision of synovium from each tendon
5. Excision of the synovial membrane of the wrist joint if necessary (d,e).
6. Transposition of the extensor retinaculum under the tendons (e).
7. Stabilization of the extensor carpi ulnaris tendon in a dorsal position.
8. Drainage of the wound and sutures to the skin.

Postoperative management.

The palmar splint is applied in the extension position of the metacarpophalangeal joints and the neutral position of the wrist joint for 2 weeks. Movements in the free interphalangeal joints begin 24 hours after surgery. If the patient experiences difficulty in actively extending the metacarpophalangeal joints, then it is necessary to fix the interphalangeal joints in the flexion position. In this case, all the extensor force will be concentrated at the level of the metacarpophalangeal joints.

Fig. 2. Technique for tenosynovectomy of the dorsum of the wrist (a-e).

Palmar tenosynovitis of the wrist area.

Swelling on the palmar surface of the hand is often not pronounced, and tenosynovitis most often leads to carpal tunnel syndrome, as well as dysfunction of the tendons, which is manifested by a decrease in active flexion relative to passive. Early tenosynovectomy with median nerve decompression prevents pain, hallucis atrophy, and spontaneous tendon rupture.

Indications for palmar tenosynovectomy include symptoms of median nerve compression, tenosynovitis refractory to injection therapy, and flexor tendon ruptures.

Operation technique (Fig. 3):

1. A skin incision along the proximal palmar groove distally, extending 4-5 cm proximal to the carpal groove (a).
2. Isolation at the level of the forearm and holding of the median nerve (b).
3. Dissection of the palmar aponeurosis and flexor retinaculum longitudinally
4. Excision of the synovial membrane (c).
5. Revision of the carpal tunnel and, if necessary, resection of the scaphoid osteophyte

Fig. 3. Technique for tenosynovectomy of the palmar area of ​​the wrist.

Tenosynovitis of the flexor tendons at the level of the fingers.

The osteofibrous canals of the flexor tendons are lined with synovium. The canals are not stretchable, and therefore any hypertrophy of the synovium causes tendon dysfunction. It is possible to form rheumatoid nodules on either one or both tendons, which can lead to the formation of the so-called “snapping finger”. Tenosynovectomy (Fig. 4) is made from a zigzag incision (a) on the palmar surface of the finger, the synovium of the tendon canals and rheumatoid nodules are excised (b, c).

Rice. 4. Technique for tenosynovectomy of the flexor tendons at the level of the fingers

Tendon ruptures.

Tendon ruptures can be caused either by invasion of the proliferating synovium or by thinning of the tendon due to friction against an eroded bone surface. The latter type of rupture most often occurs at the level of the ulnar head and scaphoid. In rare cases, ischemic necrosis of the tendon occurs due to a decrease in blood pressure in the blood vessels of the fingers, caused by the pressure of the hypertrophied synovium in the area of ​​the extensor retinaculum, the transverse carpal ligament and the osteofibrous canals of the digital flexor tendons.

The most common sign of a tendon rupture is a sudden loss of the ability to bend or straighten a finger, with little or no trauma and no pain.

Extensor tendon ruptures.

The extensor tendon of any finger can rupture in isolation, but the extensor tendon of the little finger is most often affected. For isolated tendon ruptures, a primary tendon suture is performed, suturing the distal end of the tendon to the adjacent one, or tendon repair. Double tears most often involve the extensor tendons of the 2nd and 4th fingers. In this situation, it is possible to suture the distal ends of the tendons to the adjacent ones. When three or more tendons are torn, it is much more difficult to restore extension function. In this situation, tendon plastic surgery is performed using grafts from the tendons of the superficial digital flexors. In patients with wrist arthrodesis, wrist extensor and flexor tendons can be used to reconstruct finger extension.

Rice. 5. Impaired extension of the fourth finger, due to rupture of the extensor tendon.

Flexor tendon ruptures.

Injuries to one or more of the deep digital flexor tendons are rare and, if the superficial flexor tendons are spared, are not associated with significant loss of function. For ruptures at the level of the palm and wrist, the distal ends of the tendons are sutured to the adjacent intact ones. If the rupture is localized within the osteofibrous canals, the tendon suture is not performed. In case of hyperextension of the nail phalanx, arthrodesis of the distal interphalangeal joint is performed. When the superficial finger flexor tendons are torn, they are not restored. In case of ruptures of both tendons, flexion is restored by bridging tendon plasty, the donors for which are the superficial digital flexor tendons.

Rice. 6. Impaired flexion of the fifth finger, due to rupture of the flexor tendons.

Ruptures of the tendons of the first finger.

Dorsal tenosynovitis is more common than palmar tenosynovitis and involves the extensor pollicis longus tendon. The flexor pollicis longus tendon can be affected either alone or in combination with carpal tunnel syndrome. Its rupture is common and can occur both proximal and distal to the level of the metacarpophalangeal joint. With preserved movements in the joints of the finger, patients complain of a sudden loss of the ability to extend the first finger with minimal trauma, and moderate pain. The patient can straighten the nail phalanx, but its hyperextension is impossible. The most reliable test for diagnosing a rupture of the extensor pollicis longus tendon: with the hand pressed to the surface of the table, the patient should raise the extended first finger. If the tendon is damaged, this movement is impossible (Fig. 007). In the presence of fixed finger deformities, diagnosing tendon rupture is difficult.

Rice. 007. Clinical rupture of the tendon of the long extensor of the 1st finger of the left hand.

The choice of treatment for a rupture of the extensor pollicis longus tendon depends on the degree of damage to the finger joints. In severe deformities, loss of function from tendon damage is minimal and does not require special treatment. If motion is maintained, it is necessary to restore the tendon by suture, tendon grafting, or transposition. An end-to-end tendon suture is rarely possible due to severe thinning of the tendon. In this case, the tendon is moved from its canal under the skin of the radial surface of the dorsum of the hand. The most effective tendon transplant. Donors can be: tendons of the extensor of the second finger or extensor carpi longus.

Rupture of the tendon of the long flexor of the first finger is less common. Most of these injuries are located at the level of the wrist and result from minimal or no trauma due to thinning of the tendon caused by friction against the eroded surface of the scaphoid bone. If there are significant changes in the interphalangeal joint of the finger, arthrodesis is performed. If the movements are saved, the tendon needs to be restored. In all cases, a revision of the carpal tunnel, synovectomy and resection of the distal portion of the scaphoid bone are performed to prevent recurrent ruptures. After that, bridging tendon plasty or transplantation is indicated.

Rheumatoid lesion of the wrist joint.

The wrist joint (Fig. 008) is the cornerstone of the functioning of the hand. A painful, unstable, deformed wrist joint interferes with the function of the fingers and causes their secondary deformation.

Rice. 8. Normal relationship of the elements of the wrist joint (a - triangular fibrocartilaginous complex)

Synovitis in the area of ​​the ulnar head leads to stretching and destruction of the triangular fibrocartilaginous complex and the emergence of the so-called “ulnar head” syndrome. This syndrome is observed in a third of patients requiring surgical treatment and is manifested by dorsal subluxation of the ulnar head, wrist supination and palmar displacement of the extensor carpi ulnaris tendon, leading to radial deviation of the hand. Involvement of the wrist joint begins in the region of the scaphoid and capitate ligaments, as well as the deep palmar radiocarpal ligament. Destruction of these formations leads to rotatory instability of the scaphoid and loss of carpal height. The combination of rotatory subluxation of the scaphoid, volar subluxation of the ulnar body, and dorsal subluxation of the ulnar head results in supination of the wrist relative to the distal forearm. All of the above lead to extensor tendon imbalance, radial deviation of the metacarpals, and ulnar deviation of the fingers. Without treatment, in advanced cases of the disease, destruction of the carpal bones occurs (Fig. 009, 010.).

Rice. 009. Destruction of the wrist bones, ulnar deviation of both hands (x-ray).

Rice. 010. Ulnar deviation of the hand.

Surgical operations on the wrist and radioulnar joints are aimed at preventing bone destruction or reconstructing the affected joints. Preventive measures include synovectomy, tenosynovectomy and restoration of extensor balance.

Synovectomy of the wrist and radioulnar joints.

To date, there are no studies to definitively demonstrate that wrist synovectomy alters the natural history of rheumatoid arthritis. The indication for synovectomy is long-term synovitis without pronounced bone changes on radiographs. In some cases, synovectomy relieves pain in advanced cases of the disease.

Operation technique (Fig.002).

1. Longitudinal median incision on the dorsum of the hand and wrist
2. The extensor retinaculum is incised over the sixth or fourth extensor canal.
3. The wrist joint capsule is opened with a transverse or U-shaped incision.
4. To facilitate synovectomy, traction is applied to the fingers.
5. If the triangular cartilage is intact, a synovectomy is performed between the triquetral bone and the cartilage. If there are bone erosions, they are curetted
6. The distal radioulnar joint is visualized from a longitudinal section proximal to the triangular cartilage, and the forearm is rotated for synovectomy.
7. The suture on the capsule is made in a state of supination of the forearm to reduce the tendency of the ulna to subluxate.
8. Drainage and suture to the skin

In the postoperative period, the hand is immobilized in a neutral position, and the forearm is in a position of complete supination for 3 weeks; from the 4th to the 6th week it is necessary to wear a removable splint.

Resection of the head of the ulna and reconstruction of the radioulnar joint.

Removal of the distal ulna in patients with rheumatoid arthritis was first described by Smith-Petersen. The main principles of the operation are: minimal resection of the distal portion of the ulna (2 cm or less) to reduce instability of the ulna, synovectomy of the radioulnar joint, correction of wrist supination by suturing a triangular fibrocartilaginous complex to the dorsal ulnar aspect of the radius, and refixation of a displaced extensor carpi ulnaris. on the back of the hand.

Indications for surgery are: synovitis, painful, limited movements in the distal radioulnar joint, rupture of the extensor tendons.

Operation technique (Fig. 011).

1. Longitudinal section on the dorsum of the hand (a, b)
2. Resection of the distal portion of the ulna from a longitudinal section of the capsule (c, d).
3. Synovectomy
4. Correction of wrist supination by suturing a triangular fibrocartilaginous complex to the dorsum of the radius or the palmar portion of the capsule to the dorsum of the ulna (e,f). To correct wrist supination, a flap cut from the extensor carpi ulnaris tendon can also be used (g, h).
5. Stabilize the ulna with the pronator quadratus tendon if necessary.
6. Suture of non-absorbable material on the joint capsule
7. Wound drainage and skin suture

In the postoperative period, the wrist joint is immobilized with a palmar splint up to the heads of the metacarpal bones for 2-3 weeks, after which careful rotational movements begin.

Rice. 011. Surgical technique for resection of the head of the ulna (a - h).

An alternative to resection arthroplasty of the distal radioulnar joint is endoprosthetics of the ulnar head.

Operation technique (Fig. 012):

1. Longitudinal incision along the dorsum of the ulna.
2. Dissection of the extensor retinaculum along the ulnar edge of the ulna between the extensor ulnaris and flexor carpi tendons. It is necessary to remember the passage of the dorsal cutaneous branch of the ulnar nerve in this area!
3. Visualization of the ulna by subperiosteal dissection of the extensor carpi ulnaris tunnel, triangular fibrocartilaginous complex (a), and distal ulnar collateral ligament.
4. Resection of the head of the ulna, osteophytes of the radius. (see Fig. 011 a-d)
5. Treatment of the bone marrow canal (b)
6. Setting up fitting components of the endoprosthesis (c)
7. Installation of endoprosthesis components, suturing the previously isolated fibrous canal of the extensor carpi ulnaris, triangular fibrocartilaginous complex and ulnar collateral ligament to the head of the endoprosthesis with non-absorbable suture material. (d-h)
8. Restoration of the extensor retinaculum.
9. Skin suture

Rice. 012. Surgical technique for endoprosthesis replacement of the head of the ulna (a - h).

In the postoperative period, the hand is immobilized in a neutral position for 3 weeks using a plaster splint, after which the development of active movements begins. Wearing a plaster splint is continued for up to 6 weeks in the intervals between exercise therapy.

Reconstruction of the wrist joint.

Indications for surgery on the wrist joint, whether arthrodesis or arthroplasty, are pain resistant to conservative therapy, deformation and instability of the joint leading to limited function, and progressive destruction of the joint according to radiography.

Partial and total arthrodesis of the wrist joint.

Partial arthrodesis of the wrist joint is indicated for intact bones of the distal row of the wrist. Involvement of the ligamentous apparatus of the proximal row of carpal bones in the process in the early stages of the disease leads to rotation of the scaphoid relative to the vertical axis, dorsal or palmar flexion, and ulnar subluxation of the lunate. In this situation, partial scapholunate-radial arthrodesis in combination with synovectomy of less involved joints relieves pain and prevents further collapse of the carpal bones.

Partial arthrodesis is performed from an incision similar to the incision for synovectomy using bone autografts, which are fixed with Kirschner wires or screws. After partial arthrodesis, patients retain from 25 to 50%

normal range of motion in the wrist joint.

When the middle carpal joint is involved in the pathological process and the radiocarpal joint is intact, partial arthrodesis is performed using specially designed plates. For example, a diamond-shaped plate for arthrodesis of the wrist (Diamond Carpal Fusion Plate) (Fig. 15).

Rice. 015. Plate for partial arthrodesis of the wrist joints

The plate has a diamond shape with a hole in the central part, allowing manipulation of the wrist bones and, if necessary, bone grafting. The holes for screws inserted into the capitate, hamate and triquetral bones of the wrist are oval, which provides compression when tightening the screws. The hole for the screw inserted into the lunate bone has a rounded shape.

Operation technique: (Fig. 16).

1. S-shaped or longitudinal skin incision along the dorsum of the hand (a).
2. The extensor retinaculum is incised between the 1st and 2nd extensor canals and retracted to the ulnar side (b).
3. The capsule is dissected with an H-shaped incision or a triangular flap is cut out with the base facing the radial side (according to Mayo) (c).
4. Removal of cartilage from the area of ​​the middle joint of the wrist (in some cases, the proximal third of the scaphoid bone is resected) (d, e, f).
5. Bone autoplasty with cancellous grafts taken from the distal part of the radius, wing of the ilium, etc.
6. Fixation of the carpal bones using Kirschner wires. During this manipulation, first of all, the lunate bone is fixed to the capitate bone, and then the remaining bones of the wrist are fixed. (g, h)
7. resection of the cortical layer from the dorsal surface of the capitate, lunate, triquetral and hamate bones using a special hand rasp. (i, j, l)
8. The plate is placed so that its edge, located on the lunate bone, is located at least 1 mm. distal to the articular surface of the lunate. This position avoids the pressure of the plate on the radius during wrist extension.(m)
9. Insertion of screws. The first screw is inserted into the foramen rotundum of the lunate. Then the screws are inserted into the most distant edge of the oval holes of the plate in the following sequence: hook-shaped, triangular, capitate.
10. As long as the screws are not tightened, it is possible to perform additional bone grafting through the central hole of the plate.(n)
11. Tighten the screws in the following sequence: Lunar. hook-shaped, triangular, capitate. (o)
12. Removing the fixing spokes.
13. Checking the range of motion in the wrist joint and the stability of the arthrodesis.(p)
14. Suture on the capsule. (p) The distal third of the extensor retinaculum is sutured over the capsule to avoid injury to the extensor tendons on the plate.
15. Suture on the proximal 2/3 of the extensor retinaculum.
16. Hemostasis, sutures on the skin.

Rice. 016. Technique for partial arthrodesis of the wrist joints using a diamond-shaped plate (Diamond Carpal Fusion Plate) (a-p)

Rice. 017. X-ray of the hand after partial arthrodesis of the wrist joints using a diamond-shaped plate

IN postoperative period The wrist joint is immobilized for 4-6 weeks, after which the Kirschner wires are removed (with osteosynthesis with wires). When using plates, 4 weeks of immobilization is usually sufficient. If necessary, immobilization is continued for 2-3 weeks until bone fusion is achieved according to radiography.

Total arthrodesis The carpal joint is performed using one or two Steinman nails, which are passed through the medullary canal of the radius and carpal bones and are brought out into the spaces between the 2nd and 3rd and between the 3rd and 4th metacarpal bones. (Fig. 18, 19) You can also use thin Bogdanov pins for this. With arthrodesis, the hand is placed in a neutral position, which facilitates the functioning of the fingers in patients with rheumatoid arthritis. The pins are removed 4-6 months after surgery, during which time the wrist is immobilized in a short volar splint.

Rice. 018. X-ray of the hand after total arthrodesis of the wrist joint using a Steinmann nail

Rice. 019. X-ray of the hand after total arthrodesis of the wrist joint

An alternative to arthrodesis of the wrist joint is its total endoprosthetics. Endoprosthetics is indicated for patients with preserved extensor function and moderate osteoporosis.

Operation technique (Fig. 18):

1. Longitudinal dorsal skin incision
2. The extensor retinaculum is dissected at level 1 of the extensor fibrous canal and retracted to the ulnar side
3. if necessary, perform synovectomy of the extensor tendons
4. A rectangular access with a distal base is cut out on the capsule of the wrist joint (a)
5. Resection of the wrist bones is performed using a special guide. The curved flange of the guide is placed in the lunate fossa of the radius to determine the level of resection. The lunate, triquetrum, proximal parts of the scaphoid and capitate bones are subject to resection. The resection plane should be perpendicular to the longitudinal axis of the forearm (b, c, d)
6. Excision of osteophytes of the radius using a stencil (e)
7. Reaming the radius by 20-30 mm.(f)
8. Treatment of the medullary canal of the radius. First, using a reamer inserted into a previously drilled hole, the medullary canal of the radius is opened, then a canal is prepared with the help of rasps for the introduction of the radial component of the prosthesis. (g,h)
9. Installation of the try-in beam component(s)
10. Reaming the holes for the carpal component using a guide. The middle hole should be in the capitate, the radius in the scaphoid, the ulna in the hamate, but not intraarticular. You can check the correct position of the holes by immersing Kirschner wires in them and taking an x-ray. With the correct position of the knitting needle, I will form the letter V, and the knitting needle in the central hole will be a bisector. (k, l, m, n)
11. Preparation by reaming the canal in the capitate bone(s)
12. Installation of the fitting wrist component(p)
13. Installation of the fitting beam component(r)
14. Installation of a spherical polyethylene liner (c)

Both components of the endoprosthesis are fixed using the press fit type.

1. Checking the range of passive movements and stability of the joint(s)
2. Placement of the carpal component. With the correct setting of the screws in the scaphoid and hamate bones, on the control radiograph they form the letter W with the stem located in the capitate bone. (y, f, x)
3. Setting up the beam component.(ts)
4. Placement of a spherical liner using an impactor.(w)
5. Restoring the integrity of the capsule. The capsule is sutured with tension in the position of extension in the wrist joint of 20 degrees. (u)
6. Transposition of the distal third of the extensor retinaculum under the tendons.
7. Layer-by-layer wound suture with vacuum drainage left for 24-48 hours.

Rice. 020. Technique of total wrist arthroplasty.

Postoperative management.

Intraoperatively and within 5 days after surgery, preventive antibiotic therapy is carried out.

Wearing a plaster splint in a position of extension in the wrist joint of 25-30 degrees and the absence of radio-ulnar deviation of the hand for 2 weeks, after which they begin to develop movements in the joint. In some cases, immobilization is continued for up to 6 weeks in the intervals between physical education classes. Patients with synovitis require a longer period of immobilization. Hand grip strength usually returns 8 to 9 weeks after surgery. The restored range of motion is 80 percent of that required to perform daily work (about 40 degrees of flexion and extension, 40 degrees - total radio-ulnar deviation). A control radiographic examination is performed 6 weeks, 3, 6, 12 months after surgery, then annually.

It is necessary to exclude sports such as golf, tennis, bowling and lifting weights of more than 8 kilograms.

Deformations of the metacarpophalangeal joints.

The metacarpophalangeal joints are key to the function of the fingers. Rheumatoid joint damage leads to various deformities of the fingers and loss of their function.

The metacarpophalangeal joints are condylar joints with two axes of motion. Due to this structure, the metacarpophalangeal joints are less stable than the interphalangeal ones and are more susceptible to deforming effects.

Proliferative synovitis promotes stretching of the joint capsule and damage to the collateral ligaments. Loss of the stabilizing effect of collateral ligaments is one of the leading causes of deformity progression. Normally, the metacarpophalangeal joints are stable in the position of maximum flexion, while the possibility of abduction is minimal. In patients with rheumatoid arthritis, at maximum flexion, abduction within 45 degrees is possible. The combination of deformity of the wrist joint, imbalance of the interosseous, vermiform muscles and extensor tendons of the fingers, pressure of the first finger during a pinch grip with stretching of the joint capsule leads to palmar subluxation of the main phalanx and ulnar deviation of the fingers.

Surgery on the metacarpophalangeal joints can be divided into preventive and reconstructive. The only potentially preventive procedure is metacarpophalangeal synovectomy. Reconstructive surgeries include soft tissue surgeries and various types of arthroplasty.

Synovectomy.

Synovectomy is indicated for patients with persistent synovitis that does not respond to conservative therapy for 6-9 months, with minimal bone changes as determined by radiography and minimal joint deformity.

Synovectomy of several joints is made from a transverse incision along the dorsal surface of the joints; synovectomy of an isolated joint can be made from a longitudinal incision along the ulnar surface of the joint. The dorsal veins are preserved whenever possible to avoid massive edema in the postoperative period. Access to the joint is carried out through the ulnar part of the lateral fibers of the tendon-aponeurotic stretch, the extensor tendon is retracted to the radial side, the capsule is opened with a transverse incision. To effectively remove the synovial membrane, traction is applied using the finger. At the end of the procedure, it is necessary to restore the extensor apparatus. Active movements can begin 1-2 days after surgery.

Operations on soft tissues.

Soft tissue operations are usually performed in combination with synovectomy or joint replacement, but can also be used individually.

Centralization of the extensor tendon displaced to the ulnar side is necessary to correct the deformity, restore extension and prevent the progression of finger deviation. The degree of tendon dislocation varies from minimal to complete displacement when the tendon is in the space between the metacarpal bones.

Once the tendon is identified, the transverse and sagittal fibers of the tendon-aponeurotic extension are crossed on the ulnar side. The tendon is released and transferred to the dorsum of the metacarpophalangeal joint. The simplest method of tendon centralization is to crimp the stretched radial fibers of the tendon-aponeurotic sprain using absorbable suture material. This type of centralization can be used if the tendon does not tend to slip. Otherwise, the extensor tendon can be secured to the joint capsule or main phalanx with sutures passed through holes in the bone or with anchor screws.

In the postoperative period, the fingers are immobilized in the extension position. Active movements begin 4-5 days after surgery, exercises are performed 3-4 times a day. In the intervals between classes, the fingers are immobilized. From the 7th day, a plaster splint is used at night, and during the day it is replaced with dynamic elastic splinting. This immobilization is continued for 4-6 weeks, which is important to prevent recurrence of the deformity.

Endoprosthetics of metacarpophalangeal joints.

In the late 50s and early 60s, Vainio, Riordan, and Flower reported on a method for correcting deformity of the metacarpophalangeal joints, which involved resection of the affected joint and interposition of soft tissue between the bone ends. The results of resection arthroplasty were unsatisfactory, which resulted in recurrence of the deformity. In the mid-60s, Swanson reported positive results in metacarpophalangeal joint replacement using silicone implants. Currently, endoprosthesis replacement is the most common and effective procedure for correcting deformities of the metacarpophalangeal joints in patients with rheumatoid arthritis.

The endoprosthesis must meet the following criteria, formulated by Flatt and Fisher in 1969: provide sufficient range of motion, stability and be resistant to lateral and rotational forces.

As a rule, rheumatoid disease combines ulnar deviation and palmar subluxation of the metacarpophalangeal joint with deformation and stiffness of the remaining finger joints. Endoprosthesis replacement is indicated for patients with severe deformity and limited function. Contraindications to endoprosthetics are: an infectious process in the joint area, defective skin in the area of ​​the intended operation, damage to the musculotendinous system that cannot be corrected, and severe osteoporosis. Correction of wrist joint deformity should precede reconstruction of the metacarpophalangeal joints.

Operation technique.

1. Longitudinal skin incision for endoprosthetics of one joint and transverse for several joints
2. It is necessary to preserve the superficial veins and nerves.
3. Access to the joint through the ulnar bundles of the tendon-aponeurotic stretch.
4. Synovectomy (joint capsule and radial collateral ligament are preserved)
5. Resection of the metacarpal head
6. Preparation of the bone marrow canals, starting from the proximal phalanges
7. Implant size determination
8. Installation of endoprosthesis
9. Reconstruction of the joint capsule and radial collateral ligament.
10. Centralization of the extensor tendon
11. Drainage and suture to the skin. Removal of drainage for 1-2 days.

In the postoperative period, immobilization is performed in a palmar plaster splint with a side on the ulnar side in the position of extension and radial deviation in the metacarpophalangeal joints for 4-6 weeks. The interphalangeal joints remain free. The splint is removed during physical therapy sessions. After 6 weeks, a dynamic splint and a removable plaster splint are used at night for 3 months.

Finger deformities.

The most common types of finger deformities are the boutonniere type and the “swan neck” type.

Swan neck deformity

The “swan neck” deformity is manifested by hyperextension of the middle phalanx and flexion of the distal one. There are four types of deformation.

I type of deformation .

In type I deformity, the full range of passive movements in the proximal interphalangeal joint is preserved, and functional losses are caused to a greater extent by limited extension of the nail phalanx. Treatment of this group of patients should be aimed at limiting hyperextension of the middle phalanx and restoring extension of the distal phalanx. Correction of hyperextension of the middle phalanx is performed using a ring-shaped splint (the so-called “Silver ring” splint), which does not limit movements. Flexor tenodesis, palmar dermadesis, and arthrodesis of the distal interphalangeal joint are also performed.

Arthrodesis of the distal interphalangeal joint.

Arthrodesis is made from a curved incision on the dorsum of the joint, the extensor tendon is cut transversely, and the articular cartilage is removed. For fixation, a thin Kirschner wire is used, inserted into the medullary canal of the middle phalanx. If necessary, to prevent rotation, a second wire inserted in an oblique direction is additionally used. The nail phalanx is fixed in a position of full extension. In the postoperative period, a short aluminum splint is used for immobilization for 4-6 weeks.

For arthrodesis, mini-screws (Herbert, Herbert-Whipple, etc.) can be used. This type of fixation has a number of advantages: stability, no need for additional immobilization, and the ability not to remove the metal structure.

Dermadesis.

Dermadesis can be used only for type I deformity and is aimed at preventing hyperextension of the middle phalanx. An ellipsoidal fragment of skin measuring 4-5 mm at its widest point is removed from the palmar surface of the proximal interphalangeal joint. In this case, it is necessary to keep the saphenous veins and tendon sheaths intact. A suture is placed on the skin in the position of flexion of the proximal interphalangeal joint.

Tenodesis of the flexor tendons.

Patients with the first type of deformity, while maintaining the full range of motion in the proximal interphalangeal joint, experience difficulty in the initial stages of flexion. For tenodesis, the superficial digital flexor tendon is used. The tendon sheath is accessed through a zigzag incision on the palmar surface of the finger. The vagina is opened through two longitudinal incisions on either side of the tendons. The pedicles of the superficial flexor tendon are cut off and sutured to the walls of the osteofibrous canal in a position of 20-30 degrees of flexion in the proximal interphalangeal joint. Refixation of the tendon pedicles can also be performed directly to the bone, but this technique is associated with additional technical difficulties. In the postoperative period, the finger is immobilized in a flexion position of about 30 degrees for 3 weeks, after which active flexion begins, extension is limited for 6 weeks.

II type of deformation.

Type II deformity is characterized by the dependence of the degree of passive flexion in the proximal interphalangeal joint on the position of the metacarpophalangeal joints: with extended and radially deviated main phalanges, flexion is limited, and with bent and ulnarly deviated, flexion is preserved. This proves that the deformity is secondary to damage to the metacarpophalangeal joints. The deformity develops due to an imbalance of the hand's own muscles, the tension of the tendons of which is stronger when the metacarpophalangeal joints are extended. Thus, to correct the “swan neck” it is necessary to eliminate the traction of the tendons of the hand’s own muscles and, if necessary, perform endoprosthesis replacement of the metacarpophalangeal joints.

III type of deformation.

In patients with type III deformity, the limitation of movements in the proximal interphalangeal joint is constant and does not depend on the position of adjacent joints. In this case, no radiological changes are observed. In this group of patients, retraction of periarticular tissues is observed. In this situation, the joint can be redressed with fixation in a flexion position of about 80 degrees for 10 days, then active flexion of the finger begins. Extension is limited using a dorsal splint.

Flexion can also be limited by lateral portions of the tendon-aponeurotic stretch shifted to the dorsal side, which can be separated from the central portion by two parallel longitudinal incisions in the position of flexion of the finger.

IV type of deformation.

It is characterized by limited flexion in the proximal interphalangeal joint in combination with pronounced intra-articular radiological changes.

When choosing a correction method, it is necessary to take into account the condition of adjacent joints. For treatment, both arthrodesis of the proximal interphalangeal joint in a flexion position of 25-45 degrees, with the degree of flexion increasing from the second to the fifth fingers, and endoprosthetics can be used.

"Boutonniere" type deformation.

The deformity consists of three main components: flexion at the proximal interphalangeal joints, hyperextension at the distal interphalangeal joints, and hyperextension at the metacarpophalangeal joints. The development of deformity begins with the proximal interphalangeal joints; changes in adjacent joints are secondary. There are three stages of deformation.

I(initial) stage of deformation.

It is characterized by flexion of the proximal interphalangeal joints of about 10-15 degrees and the absence of hyperextension of the distal ones (or slight hyperextension). At this stage, an extensor tenotomy is performed to restore the possibility of joint flexion in the distal interphalangeal joint. The operation is performed from a longitudinal incision on the dorsal surface of the middle phalanx, the extensor tendon is isolated and crossed in an oblique or transverse direction (the first is preferable). In the postoperative period, dynamic splinting is performed, aimed at straightening the proximal interphalangeal joint and, at the same time, not limiting flexion.

II(moderate) stage of deformation.

Functional deficiency is caused by flexion at the proximal interphalangeal joints, reaching 30-40 degrees. This position is compensated by hyperextension of the nail phalanx. Measures to correct the deformity are aimed at restoring active extension in the proximal interphalangeal joint by shortening the central portion of the extensor tendon and fixing the displaced lateral portions on the dorsum of the finger. This operation is possible if the following conditions are met: good condition of the skin on the dorsum of the finger, normal functioning of the flexor tendons, absence of radiological changes in the joint and the possibility of passive correction of the deformity. To prevent recurrence of the deformity, the operation is combined with extensor tenotomy at the level of the distal interphalangeal joint. In the postoperative period, the proximal interphalangeal joint is fixed in the extension position with two intersecting Kirschner wires, which are removed after 3-4 weeks. After the start of active movements, immobilization is continued with a splint at night for several weeks.

III(severe) stage of deformation.

Characterized by the inability to passively extend the proximal interphalangeal joint. In this case, correction of the deformity is possible by applying staged plaster casts or dynamic splinting. In case of ineffectiveness or radiographic changes in the joint, arthrodesis of the proximal interphalangeal joint is indicated. Fixation of the proximal interphalangeal joint of the second finger is carried out at an angle of 25 degrees, the third - fifth fingers in increasing order to an angle of 45 degrees at the fifth finger. An alternative to arthrodesis may be endoprosthetics of the proximal interphalangeal joint. Endoprosthesis replacement is indicated if the function of the metacarpophalangeal joints is preserved; otherwise, it is preferable to perform endoprosthesis replacement of the latter.

Deformations of the first finger of the hand.

Deformities of the first finger occur in 60-81% of patients suffering from rheumatoid arthritis, and play a leading role in limiting daily activity and the ability of self-care for this group of patients. Impaired function of the first toe can be caused by damage to the joints, muscles, tendons and nerves. Therefore, to select a surgical correction method, it is necessary to evaluate the contribution of each of these structures to the development of deformity.

Classification of deformities of the first finger.

Rheumatoid arthritis can involve all the joints of the thumb. The classification of deformities of the first finger of the hand was proposed in 1968 by Nalebuff.

DeformationItype or deformation of the "boutonniere" type.

It occurs in 50-74% of cases of rheumatoid arthritis requiring treatment. The formation of deformity begins with synovitis of the metacarpophalangeal joint, then the extensor apparatus is involved in the process. The extensor longus tendon is displaced ulnarly and palmarly relative to the center of rotation of the joint. This causes flexion of the joint. Secondary hyperextension of the nail phalanx occurs, the first metacarpal bone assumes an abducted position, which ultimately leads to palmar subluxation of the main phalanx and erosion of the dorsal portion of the base of the phalanx and the head of the metacarpal bone. (rice).

In the initial stage of the disease, when passive movements in the joints are preserved, surgical measures are limited to synovectomy of the metacarpophalangeal joint and reconstruction of the extensor apparatus. In the second stage of the disease, with destruction of the metacarpophalangeal joint and subject to minimal changes in adjacent joints, arthrodesis of the metacarpophalangeal joint is performed. If there are changes in the interphalangeal or trapezio-metacarpal joints, then it is more advisable to perform endoprosthetics of the metacarpophalangeal joint. In the third stage, destruction affects both the interphalangeal and metacarpophalangeal joints. In this situation, the operation of choice may be arthrodesis of the interphalangeal joint and endoprosthetics of the metacarpophalangeal joint.

IItype of deformation.

This is the most rare type.

In type II deformity, subluxation occurs in the trapezio-metacarpal joint, which is the main substrate of the deformity, adduction of the metacarpal bone, flexion in the metacarpophalangeal joint and extension in the interphalangeal joint. Types I and II deformities are similar clinically.

IIItype or deformities of the "swan neck" type.

In type III or “swan neck” deformity, the pathological focus is initially localized in the metacarpophalangeal joint. Synovitis results in capsule weakness and dorsoradial subluxation of the base of the metacarpal bone. Subluxation of more than 4 mm leads to mandatory progression of the deformity. Secondary imbalance of the extensor apparatus, weakness of the palmar plate of the metacarpophalangeal joint leads to hyperextension of the main phalanx and flexion of the nail. At the first and second stages of deformity development, resection arthroplasty of the trapezio-metacarpal joint is indicated. In the third stage of the disease, arthrodesis of the metacarpophalangeal joint and resection arthroplasty of the trapezio-metacarpal joint are performed.

Types IV and V of deformity begin at the metacarpophalangeal joint. Synovitis results in weakness of the ulnar collateral ligament or volar plate. With these types of deformities, the carpometacarpal joint remains intact.

IVtype or deformation of the “goalkeeper”.

Type IV is called “goalie” deformity and is more common. Sprain of the ulnar collateral ligament results in radial deviation of the main phalanx and subsequent adduction of the metacarpal. At an early stage of deformity, synovectomy of the metacarpophalangeal joint and restoration of the collateral ligament are performed. In advanced cases, arthrodesis or endoprosthetics of the metacarpophalangeal joint is performed.

Vtype of deformation.

Type V deformity is the result of thinning of the palmar plate of the metacarpophalangeal joint, which leads to hyperextension of the main phalanx and secondary flexion of the nail phalanx. For correction, the metacarpophalangeal joint is stabilized in the flexion position by palmar capsulodesis, sesamodesis or arthrodesis.

VItype of deformation.

Type VI deformity is the result of gross bone destruction leading to significant instability and subsequent shortening of the finger. This deformity, called disfiguring arthritis, can lead to various changes in the joints of the finger.

Zagorodniy N.V., Seidov I.I., Hadzhiharalambus K., Belenkaya O.I., Elkin D.V., Makinyan L.G., Zakharyan...

Zagorodniy N.V., Seidov I.I., Khadzhiharalambus K., Belenkaya O.I., Elkin D.V., Makinyan L.G., Zakharyan N.G., Arutyunyan O.G., Petrosyan A.S. .

Early phase of rheumatoid arthritis characterized by the appearance of morning stiffness (always! over 30 minutes) in the small joints of the hands (proximal interphalangeal and metacarpophalangeal) and feet (proximal interphalangeal and metatarsophalangeal) with the development of inflammatory edema of the periarticular tissues, the occurrence of pain in the above joints on palpation (positive symptom of transverse compression brushes).

The process is usually symmetrical and covers the joints of both hands (Fig. 1-2) and both feet almost simultaneously.

Fig.1-2. Early RA. Noteworthy are the symmetrical arthritis of the proximal interphalangeal (spindle-shaped finger) and metacarpophalangeal joints.

If the duration of such clinical symptoms is no more than 1 year, then we are talking about a potentially reversible, clinical-pathogenetic stage of the disease - early RA (ERA).

Signs that allow you to suspect RPA (according to R. Emery):

- > 3 swollen joints;

Symmetrical lesion of the metacarpophalangeal and metatarsophalangeal joints;

Positive "lateral compression test" of the metacarpophalangeal and metatarsophalangeal joints;

Morning stiffness > 30 min;

ESR > 25 mm/hour.

RRA is most often accompanied by systemic manifestations such as fever, weight loss, and the appearance of rheumatoid nodules.

Already at an early stage of rheumatoid arthritis, the following changes in laboratory and instrumental parameters will be characteristic:

ESR more than 25 mm/h;

CRP more than 6 mg/ml;

Fibrinogen more than 5 g/l;

The presence of rheumatoid factor, antibodies to cyclic citrullinated peptide (ACCP), antibodies to vimentin in the blood serum.

Note: if such signs are present, the patient should be referred for consultation to a rheumatologist

Clinical picture of RA.

Joint damage.

Morning stiffness is one of the main symptoms of RA; its development is associated with overproduction of synovial fluid containing high concentrations of proinflammatory cytokines (IL-1, IL-6, TNF-α), which contribute to the maintenance of the inflammatory process in the joints and further destruction of cartilage and bone. Morning stiffness is diagnostically significant if it lasts more than one hour.

Over time, patients develop rheumatoid hand: ulnar deviation of the metacarpophalangeal joints, usually developing 1-5 years from the onset of the disease (Fig. 1-3); lesions of the fingers of the hands in the “boutonniere” type (flexion in the proximal interphalangeal joints) or “swan neck” (hyperextension in the proximal interphalangeal joints) (Fig. 1-4); deformity of the hand according to the "button loop" type (Fig. 1-4, 1-5).

Rice. 1-3. Ulnar deviation ("walrus fin")

Rice. 1-4."Neck of a swan."

Rice. 1-5."Button loop"

Foot joints, like the hands, they are involved in the pathological process quite early, which is manifested by both typical clinical symptoms and early changes on radiographs. More typical is damage to the metatarsophalangeal joints of the II-IV fingers with the subsequent development of deformation and deformation of the foot due to multiple subluxations and ankylosis.

Hip joint in RA, it is relatively rarely involved in the pathological process. Its defeat is manifested by pain with irradiation to the groin or lower parts of the gluteal region and limitation of internal rotation of the limb. There is a tendency to fix the hip in the position of semi-flexion. Aseptic necrosis of the femoral head, which develops in some cases, followed by protrusion of the acetabulum, sharply limits movements in the hip joint. Adequate treatment in this case is joint arthroplasty.

Inflammation knee joints characterized by their swelling due to developed synovitis and pain when performing active and passive movements. The defiguration of the joints develops, and upon palpation the protrusion of the patella is determined. Due to high intra-articular pressure, protrusions of the posterior inversion of the articular capsule into the popliteal fossa (Baker's cyst) often form. To relieve pain, patients try to keep their lower limbs in a state of flexion, which leads over time to the appearance of flexion contracture, and then ankylosis of the knee joints. Quite often, valgus (varus) deformity of the knee joints is formed.

Defeat spinal joints, usually accompanied by their ankylosing in the cervical region. Sometimes subluxations of the atlantoaxial joint are observed, and even less often - signs of compression of the spinal cord or vertebral artery.

Temporomandibular joints They are especially often affected in childhood, but can be involved in the pathological process in adults, which leads to significant difficulties in opening the mouth.

Ligamentous apparatus and synovial bursae: tenosynovitis in the area of ​​the wrist and hand; bursitis, most often in the elbow joint; synovial cyst on the back of the knee joint (Baker's cyst).

Extra-articular manifestations of RA.

Constitutional symptoms.

Already from the first weeks of the disease, patients with RA experience weight loss, reaching 10-20 kg in 4-6 months, sometimes up to the development of cachexia. An increase in body temperature is typical, accompanied by increased fatigue, adynamia, and general malaise. Fever, Appearing already in the initial stage of the disease, it worries more often in the afternoon and evening. Its duration ranges from two to three weeks to several months. The severity of the temperature reaction is variable - from low-grade fever to 39-40°C in special forms of RA. An increase in body temperature is associated with the hyperproduction of proinflammatory cytokines (IL-1; IL-3; IL-6; TNF-α) and prostaglandins by monocyte-macrophages. With an increase in body temperature, tachycardia and pulse lability are observed.

RA is typical muscle damage, manifested in the initial stage of the disease with myalgia, then myositis develops with foci of necrosis and generalized amyotrophy. Reasons for the development of muscle atrophy: mobilization of the affected limb segments due to severe pain, the influence of pro-inflammatory cytokines causing myolysis. A direct correlation has been proven between the degree of muscle atrophy, the activity and severity of rheumatoid inflammation. The combination of atrophy of the interspinous muscles, thenar and hypothenar muscles with swelling of the metacarpophalangeal, proximal interphalangeal joints, and wrist joints is characterized as “rheumatoid hand.”

Skin lesions in RA.

Skin lesions in RA develop against the background of high activity of the rheumatoid process and include capillaritis, hemorrhagic vasculitis, digital arteritis, and leg ulcers. The appearance of skin changes in RA is associated with the progressive course of rheumatoid vasculitis and requires active suppressive therapy of the underlying disease.

Rheumatoid nodules - painless rounded dense formations from 2-3 mm to 2-3 cm in diameter, which are detected in 2-30% of cases of the disease. They are located predominantly subcutaneously on the extensor side of the joints of the fingers (Fig. 1-6), elbow joints and forearms, other localization is possible. Rheumatoid nodules are not adjacent to the deep layers of the dermis; they are painless, mobile, sometimes fused to the aponeurosis or bone.

Rice. 1-6. Rheumatoid nodules

They must be differentiated from gouty tophi, osteophytes in osteoarthritis, and xanthomatous nodules.

The presence of rheumatoid nodules is associated with high titers of rheumatoid factor in the blood serum. Their size changes over time, and during remission they may disappear completely. The appearance of rheumatoid nodules in the initial stage of RA is an unfavorable prognostic sign.

Peripheral lymphadenopathy diagnosed in 40-60% of RA patients. The anterior and posterior cervical, submandibular, sub- and supraclavicular, axillary and inguinal lymph nodes are most often affected, while the severity of lymphadenopathy depends on the activity of the immunoinflammatory process. Lymph nodes are of moderate density, painless, not fused to the skin, easily displaceable, their sizes range from 1 to 3 cm. When the nature of lymphadenopathy changes (an increase in the size of the lymph nodes, a change in their density, generalization of the process), it is necessary to carry out a differential diagnosis with systemic blood diseases, which are characterized by enlargement of peripheral lymph nodes (non-Hodgkin lymphoma, lymphogranulomatosis, chronic lymphocytic leukemia, etc.).

Splenomegaly observed in approximately 25-30% of patients with RA, while the most objective data can be obtained by ultrasound examination of the spleen.

The following changes in the general blood test are characteristic: anemia, thrombocytosis, neutropenia.

Anemia in patients with RA occurs quite often (almost 50% of patients), and in most cases we are talking about the so-called “anemia of chronic inflammation” (ACI). Its pathogenesis is polyetiological. One of the reasons for the development of ACV in patients with RA is the inhibition of the functional activity of erythropoiesis precursor cells, as a result of which their proliferative potential is reduced and the processes of differentiation and heme synthesis are disrupted. The second important factor in the development of anemia is a violation of the metabolism and utilization of iron. In patients with RA, a decrease in iron absorption and a decrease in the binding of transferrin by erythroblasts is detected, as well as a disorder of iron metabolism associated with its retention in the organs and cells of the reticuloendothelial system and a slow entry into the bone marrow - the so-called “functional” iron deficiency.

A decrease in the production of endogenous erythropoietin and the insufficient ability of the bone marrow to increase the production of erythrocytes is also one of the pathogenetic factors of ACV in RA. Another cause of anemic syndrome in RA may be a shortening of the life span of erythroid cells.

Lung damage for rheumatoid arthritis:

Diffuse interstitial pulmonary fibrosis;

Pleurisy (dry or exudative, usually with a small amount of fluid, can be successfully relieved with standard therapy);

Alveolitis (can be segmental, lobular and extremely rarely total);

Obliterating bronchiolitis (casuistically rare);

Granuloma (creates difficulties in differential diagnosis).

In the presence of multiple pulmonary nodules, a differential diagnosis should be made among the following nosological forms:

1. Wegener's granulomatosis.

2. Amyloidosis.

3. Sarcoidosis.

4. Tumors (papillomatosis, bronchopulmonary cancer, metastases, non-Hodgkin lymphoma).

5. Infections (tuberculosis, fungal infections, embolism in sepsis).

Lung damage associated with rheumatoid arthritis requires active suppressive therapy using high doses of glucocorticoids (45–60 mg per day peros, 250 mg intravenously) with subsequent correction according to the dynamics of the process.

The cardiovascular system: pericarditis, coronary arteritis, granulomatous heart disease (rare), early development of atherosclerosis.

Myocarditis in patients with RA is characterized by tachycardia, muffled sounds, and systolic murmur at the apex. Echocardiography shows a decrease in ejection fraction, stroke volume, and an increase in cardiac output.

Kidney damage in patients with RA they occur in 10-25% of cases (glomerulonephritis, amyloidosis). In RA, mesangial-proliferative variant is most often diagnosed (about 60% of cases), less often - membranous variant of glomerulonephritis; they are combined with high activity of the immunoinflammatory process and most often manifest themselves as isolated urinary syndrome; in some cases, the development of nephrotic syndrome is possible. Progressive kidney damage can lead to the formation of end-stage renal failure and uremia.

In patients with RA duration of more than 7-10 years, renal amyloidosis may develop, which is characterized by persistent proteinuria (protein loss is up to 2-3 g/day), cylindruria and peripheral edema. The diagnosis is verified based on histological examination of nephrobiopsy material. This is the most prognostically unfavorable variant of kidney damage, since the average life expectancy of such patients is 2-4 years. Death occurs as a result of the formation of terminal renal failure.

Eye damage: iritis, iridocyclitis, episcleritis and scleritis, scleromalacia, peripheral ulcerative keratopathy.

Most often (about 3.5% of cases) iridocyclitis is diagnosed. Iritis is more common in juvenile RA, but can also occur in adults. The onset of the process is usually acute, then it can take a protracted course, often complicated by the development of synechiae. Episcleritis is accompanied by moderate pain, segmental redness of the anterior segment of the eye; With scleritis, severe pain occurs, scleral hyperemia develops, and vision loss is possible. When RA is combined with Sjögren's syndrome, keratoconjunctivitis sicca develops. It should be borne in mind that methotrexate, which is the main basic drug for the treatment of rheumatoid arthritis, can promote the growth of rheumatoid nodules in the eyeball. This situation requires an immediate change in therapy.

Damage to the nervous system: symmetrical sensory-motor neuropathy, cervical myelitis.

The pathogenesis of peripheral polyneuropathy is based on the pathology of the vasanervorum. Patients develop paresthesia, a burning sensation in the lower and upper extremities, tactile and pain sensitivity decreases, and movement disorders appear. With active RA, symptoms of polyneuritis with severe pain in the extremities, sensory or motor impairment, and muscle atrophy are sometimes observed.

Classification criteria for rheumatoid arthritis (ACR/EULAR, 2010)

Rheumatoid arthritis may be suspected if:

There is at least 1 swollen joint;

Other diseases inducing synovitis are excluded;

The total for all sections ranges from 6 to 10 points.

· 1 large joint – 0 points

· 2-10 large joints – 1 point

· 1-3 small joints – 2 points

· 4-10 small joints – 3 points

· >10 joints (at least 1 small joint must be included) - 5 points

Duration of synovitis:

o less than 6 weeks - 0 points

o more than 6 weeks – 1 point

· Changes in one of the laboratory parameters:

o RF neg. and/or ACDC neg. -0 points

o RF + (weakly positive) and/or ACCP + - 2 points

o RF ++ (sharply positive) and/or ACDC ++ - 3 points

· Changes in acute phase parameters:

o ESR and/or CRP are normal – 0 points

ESR and/or CRP are increased – 1 point (Table 1-1). If a patient has had symptoms of rheumatoid arthritis for more than three months, the patient should be immediately sent to a rheumatologist to begin early aggressive therapy, since it is in patients with a short history that there is a “window of opportunity,” that is, a period of time when the treatment can actively suppress immune inflammation and affect on the course and outcome of the disease.

Rheumatoid arthritis (RA) is an autoimmune rheumatic disease of unknown etiology, characterized by chronic erosive arthritis (synovitis) and systemic inflammatory damage to internal organs. RHEUMATOID ARTHRITIS is characterized by a variety of onset and course options.

Classification and stages of rheumatoid arthritis

Main diagnosis:

1. RA seropositive.*
2. RA is seronegative.*
3. Special clinical forms of RA:

• Felty's syndrome;
• Still's disease that develops in adults.

* Seropositivity/seronegativity is determined based on the results of a test for rheumatoid factor (RF)

Clinical stage

1. Very early - disease duration less than 6 months.
2. Early - disease duration is 6-12 months.
3. Advanced - the duration of the disease is more than 1 year in the presence of typical symptoms.
4. Late - the duration of the disease is 2 years or more, pronounced destruction of small and large joints (III-IV X-ray stage), the presence of complications.

Disease activity

• 0 - remission (DAS28< 2,6)
• 1 - low activity (2.6< DAS28 < 3,2)
• 2 - average activity (3.3< DAS28 < 5,1)
• 3 - high activity (DAS28 > 5.1)

Presence of extra-articular (systemic) manifestations

1. Rheumatoid nodules
2. Cutaneous vasculitis (ulcerative necrotizing vasculitis, nail bed infarctions, digital arteritis, livedoangiitis)
3. Vasculitis affecting other organs
4. Neuropathy (mononeuritis, polyneuropathy)
5. Pleurisy (dry, effusion), pericarditis (dry, effusion)
6. Sjögren's syndrome
7. Eye damage (scleritis, episcleritis, retinal vasculitis

Presence of erosions as shown by radiography, MRI, ultrasound

1. Erosive
2. Non-erosive

X-ray stage (no Steinbrocker)

I - Minor periarticular osteoporosis. Single cystic clearings of bone tissue (CPCT). Slight narrowing of the joint spaces in individual joints.

II - Moderate (severe) periarticular osteoporosis. Multiple CPCTs. Narrowing of joint spaces. Single erosions of articular surfaces (1-4). Minor bone deformities.

III - The same as II, but multiple erosions of the articular surfaces (5 or more), multiple severe bone deformations, subluxations and dislocations of the joints.

IV - The same as III, plus single (multiple) bone ankylosis, subchondral osteosclerosis, osteophytes on the edges of the articular surfaces.

Presence of antibodies to cyclic citrullinated peptide (ACCP, aCCP)

1. ACCP-positive;
2. ACCP-negative.

Function class

I - Self-service, non-professional and professional activities are fully preserved.

II - Self-service and professional activities are preserved, non-professional activities are limited.

III-Self-service is preserved, non-professional and professional activities are limited.

IV - Self-service, non-professional and professional activities are limited.

Presence of complications

1. Secondary systemic amyloidosis;
2. Secondary osteoarthritis;
3. Systemic osteoporosis<;/li>
4. Osteonecrosis;
5. Tunnel syndromes (carpal tunnel syndrome, compression syndrome of the ulnar and tibial nerves);
6. Instability of the cervical spine, subluxation in the atlanto-axial joint, including with myelopathy;
7. Atherosclerosis.

INDEX DAS28

DAS28 = 0.56 √NPV + 0.28√NPV + 0.7 In ESR + 0.014 OOSE

First symptoms

Prodromal period (not always): general symptoms (fatigue, weight loss, arthralgia, including changes in atmospheric pressure, sweating, low-grade fever, loss of appetite), increased ESR, moderate anemia.

Variants of onset and first signs of rheumatoid arthritis

1. Symmetrical polyarthritis with a gradual increase in pain and stiffness, mainly in the small joints of the hands (the most common option);
2. Acute polyarthritis with predominant damage to the joints of the hands and feet, severe morning stiffness. Often accompanied by an early rise in titers of IgM RF, ACCP;
3. Mono- or oligoarthritis of the knee or shoulder joints, followed by rapid involvement of the small joints of the hands and feet;
4. Acute monoarthritis of one of the large joints (reminiscent of septic arthritis or microcrystalline arthritis);
5. Acute oligo- or polyarthritis with severe systemic manifestations (febrile fever, lymphadenopathy, hepatosplenomegaly), reminiscent of Still's disease in adults. This variant often develops in young patients;
6. “Palindromic rheumatism” - characterized by the development of multiple recurrent attacks of acute symmetrical polyarthritis with damage to the joints of the hands, less often the knee and elbow joints, lasting from several hours to several days and ending with complete recovery;
7. Recurrent bursitis, tenosynovitis, especially often in the area of ​​the wrist joints;
8. Acute polyarthritis in the elderly with multiple lesions of small and large joints, severe pain, limited mobility and the appearance of diffuse edema (RS3PE syndrome, Remitting seronegative symmetric synovitis with pitting edema - remitting seronegative symmetric synovitis with cushion-shaped edema);
9. Generalized myalgia with the development of the following symptoms: stiffness, depression, bilateral carpal tunnel syndrome, weight loss. The characteristic symptoms of RA develop later.

In a number of patients, RA may debut with undifferentiated arthritis - NA (oligoarthritis of large joints/asymmetric arthritis of the joints of the hands/seronegative oligoarthritis of the joints of the hands/migratory unstable polyarthritis). Moreover, during the first year of observation, 30-50% of patients with RA develop significant RA, 40-55% experience spontaneous remission, and in the remaining patients RA persists or another disease is detected.

Extra-articular manifestations of RA

General symptoms: general weakness, weight loss, low-grade fever.

Rheumatoid nodules: dense, painless, not fused with the underlying tissues. The skin over them is not changed. They are localized in the area of ​​the outer surface of the olecranon, tendons of the hand, Achilles tendons, sacrum, and scalp. They usually appear 3-5 years after the onset of RA.

Vasculitis:

1. Digital arteritis;
2. Cutaneous vasculitis (including pyoderma gangrenosum);
3. Peripheral neuropathy;
4. Vasculitis with damage to internal organs (heart, lungs, intestines, kidneys);
5. Palpable purpura;
6. Microinfarctions of the nail bed;
7. Livedo reticularis.

Damages of the cardiovascular system:

1. Pericarditis;
2. Myocarditis;
3. Endocarditis;
4. Extremely rare - coronary arteritis, granulomatous aortitis;
5. Early and rapid development of atherosclerotic lesions and their complications (myocardial infarction, stroke).

Primary lesions of the respiratory system:

1. Diseases of the pleura: pleurisy, pleural fibrosis;
2. Respiratory tract diseases: crico-arytenoid arthritis, the formation of bronchiectasis, bronchiolitis (follicular, obliterative), diffuse panbronchiolitis;
3. Interstitial lung diseases: interstitial pneumonia, acute eosinophilic pneumonia, diffuse damage to the alveoli, amyloidosis, rheumatoid nodes;
4. Vascular lesions of the lungs: vasculitis, capillaries, pulmonary hypertension.

Secondary lesions of the respiratory system:

1. Opportunistic infections: pulmonary tuberculosis, aspergillosis, cytomegalovirus pneumonitis, atypical mycobacterial infection;
2. Toxic damage due to medications: methotrexate, sulfasalazine.

Kidney damage: most often associated with the development of amyloidosis (characterized by nephrotic syndrome - proteinuria 1-3 g/l, cylindruria, peripheral edema). Sometimes membranous or membranous-proliferative glomerulonephritis develops with trace proteinuria and microhematuria.

Amyloidosis: damage to the kidneys (proteinuria, renal failure), intestines (diarrhea, intestinal perforation), spleen (splenomegaly), heart (heart failure) are observed.

Blood system:

1. Anemia
2. Thrombocytosis
3. Neutropenia
4. Lymphopenia

Variants of the course of RA

1. Long-term spontaneous clinical remission;
2. Intermittent course with alternating periods of complete or partial remission and exacerbations involving previously unaffected joints;
3. Progressive course with increasing destruction of joints, involvement of new joints, development of systemic manifestations;
4. a rapidly progressive course with constantly high disease activity and severe extra-articular manifestations.

Non-drug treatment of rheumatoid arthritis

1. To give up smoking;
2. Maintaining ideal body weight;
3. A balanced diet high in polyunsaturated fatty acids;
4. Changing the stereotype of motor activity;
5. Exercise therapy and physiotherapy;
6. Orthopedic benefit.

Articular lesions in RA:

1. Morning stiffness in the joints, lasting at least an hour (duration depends on the severity of synovitis);
2. Pain on movement and palpation, swelling of the affected joints;
3. Decreased hand grip strength, hand muscle atrophy;

Hand lesions:

1. Ulnar deviation of the metacarpophalangeal joints;
2. Damage to the fingers of the hands in the “boutonniere” type (flexion of the 8 proximal interphalangeal joints) or “swan neck” type (hyperextension of the proximal interphalangeal joints)
3. Lornet type hand deformation

Lesions of the knee joints:

1. Flexion and valgus deformities;
2. Baker's cysts (popliteal cysts.

Foot lesions:

1. Deformity with lowering of the anterior arch
2. Subluxations of the heads of the metatarsophalangeal joints
3. Deformity of the first finger (hallux valgus)

Lesions of the cervical spine: subluxations of the atlantoaxial joint, which can be complicated by compression of the arteries.

Lesions of the ligamentous apparatus, synovial bursae:

1. Tenosynovitis in the area of ​​the wrist joints, hand joints;
2. Bursitis (usually in the elbow joint);
3. Synovial cysts of the knee joint.

Criteria for the diagnosis of RA according to ACR/EULAR

(American college of Rheumathology/European League against rheumatoid arthritis classification criteria)

To verify the diagnosis of PA, 3 conditions must be met:

• The presence of at least one swollen joint according to physical examination;
• Exclusion of other diseases that may be accompanied by inflammatory changes in the joints;
• Having at least 6 points out of 10 possible according to 4 criteria.

Classification criteria RA ACR/EULAR 2010

*ACR/EULAR 2010 criteria distinguish different categories of joints:

• Exception joints - changes in the distal interphalangeal joints, first carpometacarpal joints, first metatarsophalangeal joints are not taken into account;
• Large joints - shoulder, elbow, hip, knee, ankle;
• Small joints - metacarpophalangeal, proximal interphalangeal, II-V metatarsophalangeal, interphalangeal joints of the thumbs, wrist joints;
• Other joints - may be affected by RA, but are not included in any of the groups listed above (temporomandibular, acromioclavicular, sternoclavicular, etc.).

Main groups of drugs for the treatment of rheumatoid arthritis

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Non-selective and selective. NSAIDs have a good analgesic effect, but do not affect the progression of joint destruction and the overall prognosis of the disease. Patients receiving NSAIDs require dynamic monitoring with assessment of CBC, liver tests, creatinine levels, as well as EGD if there are additional risk factors for gastroenterological side effects.

Along with NSAIDs, it is recommended to use paracetamol, weak opioids, tricyclic antidepressants, and neuromodulators to relieve joint pain.

In some situations (for example, in the presence of severe systemic manifestations of RA), it is permissible to carry out pulse therapy with GCs for a quick but short-term suppression of the activity of inflammation. GCs can also be used locally (intra-articular administration).

Before starting therapy, it is necessary to assess the presence of comorbid conditions and the risk of side effects.

The dynamic monitoring program for these patients recommends monitoring blood pressure, lipid profile, glucose levels, and densitometry.

Basic anti-inflammatory drugs (DMARDs)

Drugs with anti-inflammatory and immunosuppressive activity. DMARD therapy should be given to all patients, and treatment should be started as early as possible. DMARDs can be prescribed as monotherapy or as part of combination therapy with other DMARDs or a genetically engineered biological drug. Patient management also requires dynamic monitoring with assessment of general condition and clinical indicators.

Genetically engineered biological products (GEBP)

Preparations based on monoclonal antibodies that bind to cytokines involved in the pathogenesis of RA, their receptors, etc. The use of biologically active drugs requires the mandatory exclusion of tuberculosis before starting treatment and during further observation. It is also necessary to treat concomitant somatic pathologies - anemia, osteoporosis, etc.

In some situations, surgical treatment may be required - joint replacement, synovectomy, arthrodesis.

Timely initiation and correctly selected therapy allows patients with RA to achieve good results in maintaining their ability to work, and in some patients, to bring life expectancy to the population level.

General characteristics of genetically engineered biological drugs for rheumatoid arthritis

Criteria for the effectiveness of therapy according to EULAR (EUROPEAN LEAGUE AGAINST RHEUMATHOID ARTHRITIS) taking into account the index

General characteristics of DMARDs

Criteria for RA remission

ACR (American college of Rheumatology)

• morning stiffness less than 15 minutes.
• no discomfort
• no joint pain when moving
• no joint swelling
• ESR less than 30 mm/h (women); ESR less than 20 mm/h (men)

Clinical remission: 5 out of 6 signs within 2 months. and more

EULAR (European League against rheumatoid arthritis)

FDA (Food and Drug Administration)

Remission - clinical remission no ACR and absence of radiographic progression for 6 months. in the absence of DMARD therapy.

Complete clinical remission - clinical remission according to ACR and absence of radiographic progression for 6 months. during DMARD therapy.

Clinical effect is achievement of ACR response for at least the next 6 months.