Reconstruction of the rheumatoid thumb

Most rheumatoid patients will present with one or more thumb deformities at some stage of their clinical history. The goal of treatment is restoration and maintenance of stable and painless motion. Treatment is based on the type and stage of the deformity. The boutonniere thumb is the most common deformity. Metacarpophalangeal arthrodesis is preferred for isolated metacarpophalangeal involvement. For advanced cases in a low-demand patient, metacarpophalangeal arthroplasty with interphalangeal arthrodesis is performed. In the higher demand hand with an uninvolved carpometacarpal joint, arthrodesis of both metacarpophalangeal and interphalangeal joints may be considered. The less common swan neck is approached by treating the carpometacarpal joint with a hemiarthroplasty or a total resection with capsulodesis or arthrodesis of the metacarpophalangeal joint. Adduction contracture is treated by Z-plasty of the skin of the first web space and release of the adductor aponeurosis. Gamekeeper's deformity is treated with reconstruction of the ulnar collateral ligament. Arthrodesis is recommended for those patients with articular erosion of the metacarpophalangeal joint. Flexor pollicis longus and extensor pollicis longus tendon ruptures are common in rheumatoid patients. Extensor pollicis longus ruptures are usually treated with EIP transfer or observation. Flexor pollicis longus ruptures are more disabling and usually require a tendon transfer, tendon graft, or an interphalangeal joint fusion in patients with radiographic destruction of that joint.