Reconstructive surgery of the thumb in rheumatoid arthritis

This article presents recommendations for reconstructive thumb surgery based on results obtained by team evaluation of 79 patients who had 186 thumb operations performed by the Arthritis Service at Rancho Los Amigos Hospital from January 1, 1962 through December 31, 1976. The operations included: 11 synovectomies and reconstructions, with synovitis recurring in two; 10 metacarpophalangeal silastic arthroplasties, with no infections or breakage; 11 carpometacarpal silastic arthroplasties, with dislocation in two and superficial infection in one; and 154 arthrodeses, with 139 fusions. If there is inadequate response to nonoperative treatment, and no significant joint changes or instability, we recommend soft tissue surgery. For the boutonniere deformity, we recommend an Inglis or Nalebuff procedure. For the flexible swan neck deformity we recommend a capsulodesis and/or percutaneous pinning. An adduction contracture can be treated with tenotomy and/or arthrodesis. If there is instability and/or roentgenographic changes, we recommend a silastic arthroplasty in the carpometacarpal joint and an arthrodesis in the interphalangeal joint. We also prefer an arthrodesis (15° flexion, 15° internal rotation) in the metacarpophalangeal joint unless there is no carpometacarpal motion, when we recommend a silastic arthroplasty. All involved thumb joints should be operated on at the same time. The Kirschner wires used in arthrodeses should be left buried for 10-12 weeks, as it can be difficult to determine fusion clinically and radiographically.