[Differential therapy for the rheumatoid thumb]

The thumb frequently is involved in rheumatoid arthritis and often is a source of significant functional loss, pain, and deformity. Surgical intervention in patients with rheumatoid arthritis of the thumb should be based on the degree of radiological destruction according to Larsen, the natural course of the rheumatoid hand, the nature and stage of deformity as well as the status of tendons, ligaments, and adjacent joints. The goals of surgery are to relieve pain, increase motion, and restore thumb function. The timing for shoulder surgery should be early in the course of the disease, since it determines the long-term prognosis and the remaining surgical options. Treatment options, alone or in combination, include synovectomy, arthrodesis, arthroplasty, and tendon repair or transfer. Joint-preserving surgery is indicated in the early stages of radiological destruction according to Larsen classification O-III, whereas the late stages of destruction (Larsen IV-V) require reconstructive surgery. Especially in hand and finger arthritis, the "wait and see" strategy should no longer be followed. Close interdisciplinary cooperation between surgeon and rheumatologist is necessary for early therapeutic strategy, taking into account the functional unit of the whole upper extremity. The ultimate aim is to provide pain relief, improve function, enhance appearance, and slow the progression of disease. When the pathogenesis and pathoanatomy of the impaired rheumatoid thumb are appreciated, and appropriate treatment is selected, surgical intervention is likely to provide a favorable outcome for the patient.