Treatment of Phalangeal Joint Stiffness Related to Proximal Phalangeal Bone Fractures: Therapeutic Effects on the Range of Motion and Finger Pain

Purpose: Proximal phalangeal bone fractures with displacement are treated using operative procedures. These fractures can cause stiffness of the interphalangeal or metacarpophalangeal joints, which can be relieved using various operative and nonoperative techniques. This study analyzed the range of motion (ROM) and pain after a combination therapy to treat finger stiffness following proximal phalangeal fractures.Methods: Fifty-two patients who underwent operative procedures for proximal phalangeal fractures and showed finger stiffness from March 2015 to January 2021 were included in this retrospective study. The patients in group 1 (n=24) performed elastic resistance exercises, while those in group 2 (n=28) underwent conventional exercise. ROM and pain score were measured at 5, 8, and 12 weeks postoperatively. Furthermore, a patient with a swan-neck deformity and intractable stiffness was treated using partial translocation of the extensor apparatus, and the postoperative outcome is presented.Results: Group 1 showed a larger ROM and less pain than group 2 at 12 weeks postoperatively (p<0.05). Patients in both groups exhibited notable improvements with regard to ROM and pain during the study period (p<0.05). In addition, the swan-neck deformity accompanying hyperextension of the proximal interphalangeal joint was significantly relieved.Conclusion: Proximal phalangeal bone fractures can lead to stiffness of the interphalangeal and metacarpophalangeal joints. Joint stiffness was relieved using an elastic resistance exercise protocol in the early postoperative period. Intractable stiffness showing a fixed joint angle can be treated with thorough tenolysis and corrective surgery.

Correction of rheumatoid swan-neck deformity of the finger using the modified Thompson–Littler method

ABSTRACT Objectives To investigate the outcomes of the modified Thompson–Littler (m-TL) method, a corrective surgical method utilising a dynamic tenodesis, in patients with rheumatoid swan-neck deformity. Methods Twenty-seven fingers in 10 patients with rheumatoid arthritis (RA) underwent surgical correction. The mean age at the time of surgery was 60.3 (45–77) years, the mean duration of RA was 19.3 (4–34) years, and the mean postoperative follow-up period was 2.4 (0.5–6) years. Results The deformity was corrected and the proximal interphalangeal (PIP) joint pain disappeared in all operated fingers. The mean pinch power between the thumb and the operated finger increased. The active extension decreased, the active flexion increased, and the total arc of motion decreased. Comparing the range of motion by Nalebuff’s type classification, the postoperative arc of motion decreased as the type advanced. Conclusions The m-TL method provided a favourable outcome in cases of Type ≤III rheumatoid swan-neck deformity without severe joint deterioration at the PIP joint. Aesthetic and functional improvements were observed and the patients were satisfied with the operation.

Comprehensive assessment of alterations in hand deformities over 11 years in patients with rheumatoid arthritis using cluster analysis and analysis of covariance

Background Although drug therapy for rheumatoid arthritis (RA) has recently improved, treating patients with established disease, whose hands have three major deformities (thumb deformity, finger deformities, and ulnar drift), remains a challenge. The underlying complex pathophysiology makes understanding these deformities difficult, and comprehensive assessment methods require accumulated skill with long learning curves. We aimed to establish a simpler composite method to understand the pathophysiology of and alterations in the hand deformities of patients with RA. Methods We established a rheumatoid hand cohort in 2004 and clinically evaluated 134 hands (67 patients). We repeated the evaluations in 2009 (100 hands of 52 patients) and 2015 (63 hands of 37 patients) after case exclusion. Thumb deformities, finger deformities (swan-neck and boutonnière deformity), and ulnar drift were semi-quantitated and entered as parameters into a two-step cross-sectional cluster analysis for the data in 2004. The parameters in each cluster were plotted at each evaluation point. Two-way analysis of covariance was used to examine whether differences existed between evaluation points and clusters of deformity parameters. Results Five clusters most appropriately described hand deformity: (i) cluster 1, minimal deformity; (ii) cluster 2, type 1 thumb deformity; (iii) cluster 3, thumb deformity and severe boutonnière deformity; (iv) cluster 4, type 2 or 3 thumb deformity and severe ulnar drift; and (v) cluster 5, thumb deformity and severe swan-neck deformity. Clusters 1 and 2 had higher function than cluster 5, and cluster 3 had moderate function. Clusters 1–4 had similar disease duration but showed different paths of deformity progression from disease onset. Clusters 1 and 2 represented conservative deformity parameters and clusters 3, 4, and 5 represented progressive deformity parameters. Over time, thumb deformity evolved into other types of deformities and swan-neck deformity worsened significantly. Conclusions Our comprehensive analysis identified five deformity patterns and a progressive course in the rheumatoid hand. Knowledge of the characteristics of progressive deformity parameters may allow rheumatologists to more easily implement practical interventions and determine functional prognosis.

Comprehensive assessment of alterations in hand deformities over 11 years in patients with rheumatoid arthritis using cluster analysis and analysis of covariance

BackgroundAlthough drug therapy for rheumatoid arthritis (RA) has recently improved, treating patients with established disease, whose hands have three major deformities (thumb deformity, finger deformities, and ulnar drift), remains a challenge. The underlying complex pathophysiology makes understanding these deformities difficult, and comprehensive assessment methods require accumulated skill with long learning curves. We aimed to establish a simpler composite method to understand the pathophysiology of and alterations in the hand deformities of patients with RA.MethodsWe established a rheumatoid hand cohort in 2004 and clinically evaluated 134 hands (67 patients). We repeated the evaluations in 2009 (100 hands of 52 patients) and 2015 (63 hands of 37 patients) after case exclusion. Thumb deformities, finger deformities (swan-neck and boutonnière deformity), and ulnar drift were semi-quantitated and entered as parameters into a two-step cross-sectional cluster analysis for the data in 2004. The parameters in each cluster were plotted at each evaluation point. Two-way analysis of covariance was used to examine whether differences existed between evaluation points and clusters of deformity parameters.ResultsFive clusters most appropriately described hand deformity: (i) cluster 1, minimal deformity; (ii) cluster 2, type 1 thumb deformity; (iii) cluster 3, thumb deformity and severe boutonnière deformity; (iv) cluster 4, type 2 or 3 thumb deformity and severe ulnar drift; and (v) cluster 5, thumb deformity and severe swan-neck deformity. Clusters 1 and 2 had higher function than cluster 5, and cluster 3 had moderate function. Clusters 1–4 had similar disease duration but showed different paths of deformity progression from disease onset. Clusters 1 and 2 represented conservative deformity parameters and clusters 3, 4, and 5 represented progressive deformity parameters. Over time, thumb deformity evolved into other types of deformities and swan-neck deformity worsened significantly.ConclusionsOur comprehensive analysis identified five deformity patterns and a progressive course in the rheumatoid hand. Knowledge of the characteristics of progressive deformity parameters may allow rheumatologists to more easily implement practical interventions and determine functional prognosis.

Eleven-year alterations in hand deformities in rheumatoid arthritis by comprehensive assessment using cluster analysis and analysis of covariance

BackgroundAlthough drug therapy in rheumatoid arthritis has recently improved, treating established rheumatoid hand, consisting of three major deformities—thumb deformity, finger deformities, and ulnar drift— remains a challenge. Underlying complex pathophysiology makes it difficult to comprehensively understand these deformities, and comprehensive assessment methods require accumulated skill and long learning curves. We aimed to establish an easier composite method of understanding the pathophysiology and to elucidate alterations in deformities.MethodsWe established a rheumatoid hand cohort in 2004 and clinically evaluated 134 hands (67 patients). We repeated the evaluations in 2009 (100 hands in 52 patients) and 2015 (63 hands in 37 patients) after case exclusion. Thumb deformities, finger deformities (swan-neck and boutonnière deformity), and ulnar drift were semi-quantified and entered as parameters into a two-step cluster (cross-sectional) analysis for the data in 2004. The parameters in each cluster were plotted at each evaluation point. Two-way analysis of covariance was performed to examine whether differences existed between evaluation points and clusters for the deformity parameters.ResultsFive clusters were most appropriate to clarify each deformity: cluster 1: minimal deformity; cluster 2: type 1 thumb deformity; cluster 3: thumb deformity and severe boutonnière deformity; cluster 4: type 2 or 3 thumb deformity and severe ulnar drift; cluster 5: thumb deformity and severe swan-neck deformity. Clusters 1 and 2 had higher function than cluster 5, and cluster 3 had moderate function. Clusters 1–4 had similar disease duration, and showed different paths of deformity progression from disease onset. We considered clusters 1 and 2 as a conservative subset and clusters 3, 4, and 5 as a progressive subset. Over time, thumb deformity type altered to other types, and swan-neck deformity worsened significantly.ConclusionsOur comprehensive assessment indicated five deformity patterns and a progressive course in rheumatoid hand. Knowledge of the characteristics of the progressive subset may allow rheumatologists to more easily determine practical interventions and functional prognosis.

Development of an In Vitro Swan Neck Deformity Biomechanical Model

Background: Injury to the finger’s extensor mechanism is a common cause of swan neck deformity (SND). Progression of extensor and flexor tendon imbalance negatively affects laxity of the volar plate, resulting in the inhibition of proper finger motion. The complexity of finger anatomy, however, makes understanding the pathomechanics of these deformities challenging. Therefore, development of an SND model is imperative to understand its influence on finger biomechanics and to provide an in vitro model to evaluate the various treatment options. Methods: The index, middle, and ring fingers from 8 cadaveric specimens were used in an in vitro active motion simulator to replicate finger flexion/extension. An SND model was developed through sectioning of the terminal extensor tendon at the distal insertion (creating a mallet finger) and transverse retinacular ligament (TRL). A strain gauge inserted under the volar plate measured laxity of the plate, and electromagnetic trackers recorded proximal interphalangeal joint (PIPJ) angles. Results: Strain in the volar plate increased progressively with creation of the mallet and SND conditions ( P = .015). Although not statistically significant, the mallet finger condition accounted for 26% of the increase, whereas sectioning of the TRL accounted for 74% ( P = .031). As predicted, PIPJ hyperextension was not detectable by joint angle measurement; however, the PIPJ angle had a strong positive correlation with volar plate strain ( R2 = 1.0, P < .001). Conclusion: Volar plate strain measurement, in an in vitro model, can detect an induced SND. Moreover, as a surrogate for PIPJ hyperextension, volar plate strain may be useful to evaluate the time-zero effectiveness of various surgical interventions.

AB0228 COMPREHENSIVE RHEUMATOID HAND ASSESSMENT THROUGH PATTERN OF DEFORMITIES USING CLUSTER ANALYSIS

Background:The treatment of rheumatoid hand, which is characterized by thumb deformity, finger deformities, and ulnar drift (UD), is challenging. Its pathophysiology is complex, and a comprehensive understanding of the optimal intervention for this condition requires high technical skill and extensive clinical experience. Moreover, the natural course of rheumatoid hand itself remains unclear.Objectives:This study was performed to comprehensively evaluate rheumatoid hand through the specific parameters of each deformity.Methods:A rheumatoid hand cohort was established in 2004. In total, 134 hands of 67 patients were registered and underwent clinical evaluations. All hands surgically treated during follow-up were excluded from the study, but the contralateral hands were assessed. Evaluations were repeated in 2009 (100 hands of 52 patients) and in 2015 (63 hands of 37 patients) among all available patients. Therefore, among the data obtained from the 3 study endpoints, 297 hands were available for the cross-sectional analysis and 43 hands were available for the longitudinal analysis.Thumb deformities and finger deformities (swan-neck and boutonnière) were semi-quantitated by the Nalebuff classification score, and UD was quantified using a metacarpophalangeal joint condition scoring method1). A two-step cluster analysis was performed with entered parameters, and the distribution of each parameter was considered to clarify the characteristics of each cluster. The hands with different clusters at each endpoint were recruited for the following longitudinal analysis. The natural course of rheumatoid hand was considered based on the cluster change.Results:Seven clusters were used in this study to emphasize the impact of thumb deformity on function. The characteristics of each cluster were as follows. Cluster 1: mild finger deformities and various severities of UD; Cluster 2: type 1 thumb deformity and various severities of UD; Cluster 3: type 2 thumb deformity and severe UD; Cluster 4: type 3 or 4 thumb deformity, low or moderate level of swan-neck deformity, and various severities of UD; Cluster 5: various types of thumb deformity, severe boutonnière deformity, and various severities of UD; Cluster 6: type 1 thumb deformity, severe swan-neck deformity, and various severities of UD; and Cluster 7: type 6 thumb deformity.The longitudinal analysis showed that Cluster 1 mainly changed to Cluster 2 or 4, indicating progression of thumb deformity. Cluster 2 changed to Cluster 3, indicating that thumb type 1 progressed to type 2 (Figure 1). When the affected period was shorter than 10 years, the incidence of severe hand deformity (including two or more affected joint areas and low hand function) was <10%. In contrast, when the affected period was longer than 10 years, the incidence of severe hand deformity was >30% (Figure 2).Figure 1.Figure 2.Conclusion:This study suggests the presence of seven patterns of deformity enabling a comprehensive understanding of rheumatoid hand. Furthermore, the results of the longitudinal analysis suggest a natural course of rheumatoid hand progression. Therefore, from the distribution of parameters of each deformity and its severity, rheumatologists can easily classify rheumatoid hand and determine its pathophysiology to choose the most effective intervention.References:[1]Toyama S, Oda R, Tokunaga D et al. A new assessment tool for ulnar drift in patients with rheumatoid arthritis using pathophysiological parameters of the metacarpophalangeal joint. Modern rheumatology 2019, 29: 113-8.Acknowledgments:This work was supported by JSPS KAKENHI Grant Numbers JP19K19914.Disclosure of Interests:None declared