Extensor Tendon Rupture in Rheumatoid Arthritis-Surgical Strategies and Results

Background: Rupture of extensor tendons in rheumatoid arthritic hands results in extension lag of fingers and weakens grip power that affects the function of the involved hands. Surgical reconstruction of ruptured tendons should be aimed at both restoration of tendon motion and treatment local causative factors. Aim and Objectives: This study reports the results of surgical repair of extensor tendon rupture in rheumatoid hands using tendon graft, tendon transfer or combination of both techniques. The importance of treating wrist pathologies that cause tendon rupture is also emphasized. Patients and Methods: From October 2001 to May 2008, 15 rheumatoid arthritis patients presenting with spontaneous rupture of extensor tendons of the hands were referred from rheumatologist for surgical reconstruction. A total of 52 ruptured extensor tendons underwent surgical intervention in 17 hands of these 15 patients. The surgical techniques for repair of ruptured extensor tendons were categorized into three groups as tendon graft, tendon transfer, or a combination of both procedures. The range of motion at metacarpophalangeal (MCP) joints of involved fingers were recorded preoperatively and postoperatively. The results were graded by average net gain in range of motion of MCP joints at the end of follow-up. An average net gain of more than 30 degrees in MCP range of motion is classified as excellent result. A good indicates gain between 10 and 30 degrees. While a fair result is defined as less than 10 degrees in gain, a poor result indicates no improvement or even worse. Results: In the three groups of surgical interventions, there are 4 excellent and 3 good results in 9 primary tendon graft procedures, one excellent and 3 good results in 6 primary tendon transfer procedures, and one good result in 2 combined tendon graft and transfer procedures, five reconstruction procedures in the whole series were graded with fair to poor results due to re-rupture of tendon, adhesion, and failed medical control of rheumatoid disease. The extension lag at the MCP joint decreased from a preoperative mean of 54 degrees (range, 35 degrees-80 degrees) to a postoperative mean of 19.5 degrees (range, 5 degrees-65 degrees) in primary tendon graft procedures. The extension lag at the MCP joint decreased from a preoperative mean of 40.2 degrees (range, 0 degree-80 degrees) to a postoperative mean of 8.8 degrees (range, 0 degree-25 degrees) in primary tendon transfer procedures. The extension lag at the MCP joint decreased from a preoperative mean of 51.6 degrees (range, 40 degrees-68 degrees) to a postoperative mean of 37 degrees (range, 15 degrees-60 degrees) in combined tendon graft and transfer procedures. Also, a gross perforation on the dorsal capsule of the distal radioulnar joint (DRUJ) that causes attrition of the extensor tendons over the eroded bony surface was observed in all cases underwent simultaneous tendon reconstruction and wrist synovectomy procedures. 16 of 17 primary tendon reconstruction procedures were combined with dorsal wrist and DRUJ synovectomy, ulnar head debridement procedures, and capsule repair with retinacular flap. Conclusion: Extensor tendon reconstruction in the hand with tendon graft or tendon transfer provides a functional benefit for rheumatoid patients. Surgical intervention is aimed not only at restoring extensor function but also eradicating local causative factors and preventing further damage of tendon.