Pain and deformation of the joints of the fingers are the first symptoms of rheumatoid arthritis. Treatment of polyarthritis of the joints: possible methods Middle phalanx of the triphalangeal fingers

Axiom: Negative examination results of a patient with suspected tendon damage should always be re-evaluated to clarify the diagnosis, especially in an uncontacted patient.

Hammertoe deformity without associated fracture

Primary restoration a suture placed within the first 72 hours from the moment of injury should be considered. A delayed suture is applied in the first week from the moment of injury, and a secondary suture is applied after the complete disappearance of swelling and softening of the scar, usually 4-10 weeks from the moment of injury. It should be emphasized that primary tendon suture is the method of choice whenever possible.

Deformation like a boutonniere

Delayed seam Apply if there is concomitant injury and restoration of hand function must be delayed, or if the condition of the wound due to infection or swelling does not allow the application of a primary suture. A secondary suture is indicated in the presence of severe concomitant injuries or the likelihood of complications from the wound. Partial tendon damage is treated with splinting without surgery.

Extensor splint used for rupture of the extensor tendon at its insertion on the distal phalanx

Extensor tendon injuries are usually closed. If there is a separation of the tendon from its insertion at the distal interphalangeal joint, treatment consists of splinting the joint in extension. Overextension, as already emphasized, should be avoided. In addition, movement at the proximal interphalangeal joint should remain uninhibited.
Longueta should remain in place for 6 weeks. For patients who use their hands and fingertips a lot, plaster immobilization can be recommended.

Hammer finger deformity is a flexion deformity of the distal interphalangeal joint, in which complete passive, but incomplete active extension in the distal interphalangeal joint is possible. This type of injury usually occurs when there is a sudden blow to the tip of an extended finger.

Separation may occur tendons from its insertion site, or there may be an avulsion fracture of the distal phalanx, in which the tendon remains attached to the bone fragment. Rupture of the tendon at the proximal interphalangeal joint can result in a boutonniere deformity; All patients with this type of injury should be referred to a surgeon for repair.

Deformation by type boutonnieres consists of flexing the finger at the proximal interphalangeal joint and hyperextending the distal interphalangeal joint. It usually occurs when the extensor tendon is injured from its insertion on the dorsal surface of the middle phalanx. The lateral bundles are steadily stretched, slide volarly along the axis of the proximal interphalangeal joint and become flexors of the proximal interphalangeal joint. This deformation usually does not immediately appear after injury, but develops as the lateral fascicles slide in the volar direction.
Tendon ruptures above the proximal interphalangeal joint are treated in the same way as ruptures in the area of ​​the middle phalanges (within 3-4 weeks). Referral to a specialist is strongly recommended.

Introduction.

Rheumatoid arthritis can cause various types of deformities of the fingers and hand in general. In its development, the disease follows a path that begins with damage to the synovial membrane of the joints and ultimately ends with bone destruction and the formation of persistent deformities.

Pain is the determining factor in limiting the professional activity of patients. Most patients with severe finger deformity without pain adapt well and can perform their usual work. Deformation of the joint does not mean loss of its function and, in itself, is not an indication for surgical treatment. Each joint of the hand must be considered as part of a complex organ. Correction of metacarpophalangeal joint deformity should precede correction of the proximal interphalangeal joints, while boutonniere deformity should be corrected before or simultaneously with metacarpophalangeal joint surgery.

One of the most difficult issues in rheumatoid hand surgery is the formulation of a comprehensive reconstruction plan. The most important goals of hand surgery in patients with rheumatoid arthritis are: eliminating pain, restoring function and slowing the progression of the disease.

Tenosynovitis.

Rheumatoid arthritis is a disease of the synovial membranes. Tenosynovitis occurs in 60% of patients with rheumatoid arthritis. Not only the synovial membranes of the joints are affected, but also the tendon sheaths. There are three main localizations of the pathological process: the dorsum of the wrist and the palmar surfaces of the wrist and fingers. Rheumatoid tenosynovitis can cause pain, tendon dysfunction, and, after invasion of the tendon by the proliferating synovium, tendon rupture. Treatment can relieve pain and, if undertaken before secondary tendon changes occur, prevent strain and loss of function. Therefore, tenosynovectomy is the first surgical intervention indicated for patients with rheumatoid arthritis.

Dorsal tenosynovitis of the wrist area.

Tenosynovitis of the dorsum of the wrist causes swelling and may involve one or more extensor tendons. Rice. 001. Due to the mobility of the skin on the dorsal surface of the wrist and hand, the pain syndrome is mild and, often, tendon rupture is the first symptom of the disease.

Rice. 1. Tenosynovitis of the dorsum of the wrist

Indications for dorsal tenosynovectomy are: tenosynovitis that does not respond to conservative treatment for 4-6 months and tendon rupture.

Operation technique (Fig. 2) :

1. Longitudinal midline incision on the dorsum of the hand and wrist (a).
2. Transverse sections proximal and distal to the extensor retinaculum (b).
3. Cutting off the retinaculum on the radial side of the wrist (c).
4. Excision of synovium from each tendon
5. Excision of the synovial membrane of the wrist joint if necessary (d,e).
6. Transposition of the extensor retinaculum under the tendons (e).
7. Stabilization of the extensor carpi ulnaris tendon in a dorsal position.
8. Drainage of the wound and sutures to the skin.

Postoperative management.

The palmar splint is applied in the extension position of the metacarpophalangeal joints and the neutral position of the wrist joint for 2 weeks. Movements in the free interphalangeal joints begin 24 hours after surgery. If the patient experiences difficulty in actively extending the metacarpophalangeal joints, then it is necessary to fix the interphalangeal joints in the flexion position. In this case, all the extensor force will be concentrated at the level of the metacarpophalangeal joints.

Fig. 2. Technique for tenosynovectomy of the dorsum of the wrist (a-f).

Palmar tenosynovitis of the wrist area.

Swelling on the palmar surface of the hand is often not pronounced, and tenosynovitis most often leads to carpal tunnel syndrome, as well as dysfunction of the tendons, which is manifested by a decrease in active flexion relative to passive. Early tenosynovectomy with median nerve decompression prevents pain, hallucis atrophy, and spontaneous tendon rupture.

Indications for palmar tenosynovectomy include symptoms of median nerve compression, tenosynovitis refractory to injection therapy, and flexor tendon ruptures.

Operation technique (Fig. 3):

1. A skin incision along the proximal palmar groove distally, extending 4-5 cm proximal to the carpal groove (a).
2. Isolation at the level of the forearm and holding of the median nerve (b).
3. Dissection of the palmar aponeurosis and flexor retinaculum longitudinally
4. Excision of the synovial membrane (c).
5. Revision of the carpal tunnel and, if necessary, resection of the scaphoid osteophyte

Fig. 3. Technique for tenosynovectomy of the palmar area of ​​the wrist.

Tenosynovitis of the flexor tendons at the level of the fingers.

The osteofibrous canals of the flexor tendons are lined with synovium. The canals are not stretchable, and therefore any hypertrophy of the synovium causes tendon dysfunction. It is possible to form rheumatoid nodules on either one or both tendons, which can lead to the formation of the so-called “snapping finger”. Tenosynovectomy (Fig. 4) is made from a zigzag incision (a) on the palmar surface of the finger, the synovium of the tendon canals and rheumatoid nodules are excised (b, c).

Rice. 4. Technique for tenosynovectomy of the flexor tendons at the level of the fingers

Tendon ruptures.

Tendon ruptures can be caused either by invasion of the proliferating synovium or by thinning of the tendon due to friction against an eroded bone surface. The latter type of rupture most often occurs at the level of the ulnar head and scaphoid. In rare cases, ischemic necrosis of the tendon occurs due to a decrease in blood pressure in the blood vessels of the fingers, caused by the pressure of the hypertrophied synovium in the area of ​​the extensor retinaculum, the transverse carpal ligament and the osteofibrous canals of the digital flexor tendons.

The most common sign of a tendon rupture is a sudden loss of the ability to bend or straighten a finger, with little or no trauma and no pain.

Extensor tendon ruptures.

The extensor tendon of any finger can rupture in isolation, but the extensor tendon of the little finger is most often affected. For isolated tendon ruptures, a primary tendon suture is performed, suturing the distal end of the tendon to the adjacent one, or tendon repair. Double tears most often involve the extensor tendons of the 2nd and 4th fingers. In this situation, it is possible to suture the distal ends of the tendons to the adjacent ones. When three or more tendons are torn, it is much more difficult to restore extension function. In this situation, tendon plastic surgery is performed using grafts from the tendons of the superficial digital flexors. In patients with wrist arthrodesis, wrist extensor and flexor tendons can be used to reconstruct finger extension.

Rice. 5. Impaired extension of the fourth finger, due to rupture of the extensor tendon.

Flexor tendon ruptures.

Injuries to one or more of the deep digital flexor tendons are rare and, if the superficial flexor tendons are spared, are not associated with significant loss of function. For ruptures at the level of the palm and wrist, the distal ends of the tendons are sutured to the adjacent intact ones. If the rupture is localized within the osteofibrous canals, the tendon suture is not performed. In case of hyperextension of the nail phalanx, arthrodesis of the distal interphalangeal joint is performed. When the superficial finger flexor tendons are torn, they are not restored. In case of ruptures of both tendons, flexion is restored by bridging tendon plasty, the donors for which are the superficial digital flexor tendons.

Rice. 6. Impaired flexion of the fifth finger, due to rupture of the flexor tendons.

Ruptures of the tendons of the first finger.

Dorsal tenosynovitis is more common than palmar tenosynovitis and involves the extensor pollicis longus tendon. The flexor pollicis longus tendon can be affected either alone or in combination with carpal tunnel syndrome. Its rupture is common and can occur both proximal and distal to the level of the metacarpophalangeal joint. With preserved movements in the joints of the finger, patients complain of a sudden loss of the ability to extend the first finger with minimal trauma, and moderate pain. The patient can straighten the nail phalanx, but hyperextension is impossible. The most reliable test for diagnosing a rupture of the extensor pollicis longus tendon: with the hand pressed to the surface of the table, the patient should raise the extended first finger. If the tendon is damaged, this movement is impossible (Fig. 007). In the presence of fixed finger deformities, diagnosing tendon rupture is difficult.

Rice. 007. Clinic of rupture of the long extensor tendon of the 1st finger of the left hand.

The choice of treatment for a rupture of the extensor pollicis longus tendon depends on the degree of damage to the finger joints. In severe deformities, loss of function from tendon damage is minimal and does not require special treatment. If motion is maintained, it is necessary to restore the tendon by suture, tendon grafting, or transposition. An end-to-end tendon suture is rarely possible due to severe thinning of the tendon. In this case, the tendon is moved from its canal under the skin of the radial surface of the dorsum of the hand. Tendon grafting is the most effective. Donors can be: tendons of the extensor of the second finger or extensor carpi longus.

Rupture of the flexor pollicis longus tendon is less common. Most of these injuries are located at the level of the wrist and result from minimal or no trauma due to thinning of the tendon caused by friction against the eroded surface of the scaphoid bone. If there are significant changes in the interphalangeal joint of the finger, arthrodesis is performed. If movements are maintained, tendon restoration is necessary. In all cases, a revision of the carpal tunnel, synovectomy and resection of the distal portion of the scaphoid bone are performed to prevent recurrent ruptures. After this, tendon bridging or grafting is indicated.

Rheumatoid lesion of the wrist joint.

The wrist joint (Fig. 008) is the cornerstone of the functioning of the hand. A painful, unstable, deformed wrist joint interferes with the function of the fingers and causes their secondary deformation.

Rice. 8. Normal relationship of the elements of the wrist joint (a - triangular fibrocartilaginous complex)

Synovitis in the area of ​​the ulnar head leads to stretching and destruction of the triangular fibrocartilaginous complex and the emergence of the so-called “ulnar head” syndrome. This syndrome is observed in a third of patients requiring surgical treatment and is manifested by dorsal subluxation of the ulnar head, wrist supination and palmar displacement of the extensor carpi ulnaris tendon, leading to radial deviation of the hand. Involvement of the wrist joint begins in the region of the scaphoid and capitate ligaments, as well as the deep palmar radiocarpal ligament. Destruction of these formations leads to rotatory instability of the scaphoid and loss of carpal height. The combination of rotatory subluxation of the scaphoid, volar subluxation of the ulnar body, and dorsal subluxation of the ulnar head results in supination of the wrist relative to the distal forearm. All of the above lead to extensor tendon imbalance, radial deviation of the metacarpals, and ulnar deviation of the fingers. Without treatment, in advanced cases of the disease, destruction of the carpal bones occurs (Fig. 009, 010.).

Rice. 009. Destruction of the wrist bones, ulnar deviation of both hands (x-ray).

Rice. 010. Ulnar deviation of the hand.

Surgical operations on the wrist and radioulnar joints are aimed at preventing bone destruction or reconstructing the affected joints. Preventive measures include synovectomy, tenosynovectomy and restoration of extensor balance.

Synovectomy of the wrist and radioulnar joints.

To date, there are no studies to definitively demonstrate that wrist synovectomy alters the natural history of rheumatoid arthritis. The indication for synovectomy is long-term synovitis without pronounced bone changes on radiographs. In some cases, synovectomy relieves pain in advanced cases of the disease.

Operation technique (Fig.002).

1. Longitudinal midline incision on the dorsum of the hand and wrist
2. The extensor retinaculum is incised over the sixth or fourth extensor canal.
3. The wrist joint capsule is opened with a transverse or U-shaped incision.
4. To facilitate synovectomy, traction is applied to the fingers.
5. If the triangular cartilage is intact, a synovectomy is performed between the triquetral bone and the cartilage. If there are bone erosions, they are curetted
6. The distal radioulnar joint is visualized from a longitudinal section proximal to the triangular cartilage, and the forearm is rotated for synovectomy.
7. The suture on the capsule is made in a state of supination of the forearm to reduce the tendency of the ulna to subluxate.
8. Drainage and suture to the skin

In the postoperative period, the hand is immobilized in a neutral position, and the forearm is in a position of complete supination for 3 weeks; from the 4th to the 6th week it is necessary to wear a removable splint.

Resection of the head of the ulna and reconstruction of the radioulnar joint.

Removal of the distal ulna in patients with rheumatoid arthritis was first described by Smith-Petersen. The main principles of the operation are: minimal resection of the distal portion of the ulna (2 cm or less) to reduce instability of the ulna, synovectomy of the radioulnar joint, correction of wrist supination by suturing a triangular fibrocartilaginous complex to the dorsal ulnar aspect of the radius, and refixation of a displaced extensor carpi ulnaris. on the back of the hand.

Indications for surgery are: synovitis, painful, limited movements in the distal radioulnar joint, rupture of the extensor tendons.

Operation technique (Fig. 011).

1. Longitudinal section on the dorsum of the hand (a, b)
2. Resection of the distal portion of the ulna from a longitudinal section of the capsule (c, d).
3. Synovectomy
4. Correction of wrist supination by suturing a triangular fibrocartilaginous complex to the dorsum of the radius or the palmar portion of the capsule to the dorsum of the ulna (e,f). To correct wrist supination, a flap cut from the extensor carpi ulnaris tendon can also be used (g, h).
5. Stabilize the ulna with the pronator quadratus tendon if necessary.
6. Suture of non-absorbable material on the joint capsule
7. Wound drainage and skin suture

In the postoperative period, the wrist joint is immobilized with a palmar splint up to the heads of the metacarpal bones for 2-3 weeks, after which careful rotational movements begin.

Rice. 011. Surgical technique for resection of the head of the ulna (a - h).

An alternative to resection arthroplasty of the distal radioulnar joint is endoprosthetics of the ulnar head.

Operation technique (Fig. 012):

1. Longitudinal incision along the dorsum of the ulna.
2. Dissection of the extensor retinaculum along the ulnar edge of the ulna between the extensor ulnaris and flexor carpi tendons. It is necessary to remember the passage of the dorsal cutaneous branch of the ulnar nerve in this area!
3. Visualization of the ulna by subperiosteal dissection of the extensor carpi ulnaris tunnel, triangular fibrocartilaginous complex (a), and distal ulnar collateral ligament.
4. Resection of the head of the ulna, osteophytes of the radius. (see Fig. 011 a-d)
5. Treatment of the bone marrow canal (b)
6. Setting up fitting components of the endoprosthesis (c)
7. Installation of endoprosthesis components, suturing the previously isolated fibrous canal of the extensor carpi ulnaris, triangular fibrocartilaginous complex and ulnar collateral ligament to the head of the endoprosthesis with non-absorbable suture material. (d-h)
8. Restoration of the extensor retinaculum.
9. Skin suture

Rice. 012. Surgical technique for endoprosthesis replacement of the head of the ulna (a - h).

In the postoperative period, the hand is immobilized in a neutral position for 3 weeks using a plaster splint, after which the development of active movements begins. Wearing a plaster splint is continued for up to 6 weeks in the intervals between exercise therapy.

Reconstruction of the wrist joint.

Indications for surgery on the wrist joint, whether arthrodesis or arthroplasty, are pain resistant to conservative therapy, deformation and instability of the joint leading to limited function, and progressive destruction of the joint according to radiography.

Partial and total arthrodesis of the wrist joint.

Partial arthrodesis of the wrist joint is indicated for intact bones of the distal row of the wrist. Involvement of the ligamentous apparatus of the proximal row of carpal bones in the process in the early stages of the disease leads to rotation of the scaphoid relative to the vertical axis, dorsal or palmar flexion, and ulnar subluxation of the lunate. In this situation, partial scapholunate-radial arthrodesis in combination with synovectomy of less involved joints relieves pain and prevents further collapse of the carpal bones.

Partial arthrodesis is performed from an incision similar to the incision for synovectomy using bone autografts, which are fixed with Kirschner wires or screws. After partial arthrodesis, patients retain from 25 to 50%

normal range of motion in the wrist joint.

When the middle carpal joint is involved in the pathological process and the radiocarpal joint is intact, partial arthrodesis is performed using specially designed plates. For example, a diamond-shaped plate for wrist arthrodesis (Diamond Carpal Fusion Plate) (Fig. 15).

Rice. 015. Plate for partial arthrodesis of wrist joints

The plate has a diamond shape with a hole in the central part, allowing manipulation of the wrist bones and, if necessary, bone grafting. The holes for screws inserted into the capitate, hamate and triquetral bones of the wrist are oval, which provides compression when tightening the screws. The hole for the screw inserted into the lunate bone has a rounded shape.

Operation technique: (Fig. 16).

1. S-shaped or longitudinal skin incision along the dorsum of the hand (a).
2. The extensor retinaculum is incised between the 1st and 2nd extensor canals and retracted to the ulnar side (b).
3. The capsule is dissected with an H-shaped incision or a triangular flap is cut out with the base facing the radial side (according to Mayo) (c).
4. Removal of cartilage from the area of ​​the middle joint of the wrist (in some cases, the proximal third of the scaphoid bone is resected) (d, e, f).
5. Bone autoplasty with cancellous grafts taken from the distal part of the radius, wing of the ilium, etc.
6. Fixation of the carpal bones using Kirschner wires. During this manipulation, first of all, the lunate bone is fixed to the capitate bone, and then the remaining bones of the wrist are fixed. (g, h)
7. resection of the cortical layer from the dorsal surface of the capitate, lunate, triquetral and hamate bones using a special hand rasp. (i, j, l)
8. The plate is placed so that its edge, located on the lunate bone, is located at least 1 mm. distal to the articular surface of the lunate. This position avoids the pressure of the plate on the radius during wrist extension.(m)
9. Insertion of screws. The first screw is inserted into the foramen rotundum of the lunate. Then the screws are inserted into the most distant edge of the oval holes of the plate in the following sequence: hook-shaped, triangular, capitate.
10. As long as the screws are not tightened, it is possible to perform additional bone grafting through the central hole of the plate.(n)
11. Tighten the screws in the following sequence: Lunar. hook-shaped, triangular, capitate. (o)
12. Removing the fixing spokes.
13. Checking the range of motion in the wrist joint and the stability of the arthrodesis.(p)
14. Suture on the capsule. (p) The distal third of the extensor retinaculum is sutured over the capsule to avoid injury to the extensor tendons on the plate.
15. Suture on the proximal 2/3 of the extensor retinaculum.
16. Hemostasis, sutures on the skin.

Rice. 016. Technique for partial arthrodesis of the wrist joints using a diamond-shaped plate (Diamond Carpal Fusion Plate) (a-p)

Rice. 017. X-ray of the hand after partial arthrodesis of the wrist joints using a diamond-shaped plate

IN postoperative period The wrist joint is immobilized for 4-6 weeks, after which the Kirschner wires are removed (with osteosynthesis with wires). When using plates, 4 weeks of immobilization is usually sufficient. If necessary, immobilization is continued for 2-3 weeks until bone fusion is achieved according to radiography.

Total arthrodesis The carpal joint is performed using one or two Steinman nails, which are passed through the medullary canal of the radius and carpal bones and are brought out into the spaces between the 2nd and 3rd and between the 3rd and 4th metacarpal bones. (Fig. 18, 19) You can also use thin Bogdanov pins for this. With arthrodesis, the hand is placed in a neutral position, which facilitates the functioning of the fingers in patients with rheumatoid arthritis. The pins are removed 4-6 months after surgery, during which time the wrist is immobilized in a short volar splint.

Rice. 018. X-ray of the hand after total arthrodesis of the wrist joint using a Steinmann nail

Rice. 019. X-ray of the hand after total arthrodesis of the wrist joint

An alternative to arthrodesis of the wrist joint is its total endoprosthetics. Endoprosthesis replacement is indicated for patients with preserved extensor function and moderate osteoporosis.

Operation technique (Fig. 18):

1. Longitudinal dorsal skin incision
2. The extensor retinaculum is incised at level 1 of the extensor fibrous canal and retracted to the ulnar side
3. if necessary, perform synovectomy of the extensor tendons
4. A rectangular access with a distal base is cut out on the wrist joint capsule (a)
5. Resection of the wrist bones is performed using a special guide. The curved flange of the guide is placed in the lunate fossa of the radius to determine the level of resection. The lunate, triquetrum, proximal parts of the scaphoid and capitate bones are subject to resection. The resection plane should be perpendicular to the longitudinal axis of the forearm (b, c, d)
6. Excision of osteophytes of the radius using a stencil (e)
7. Reaming the radius by 20-30 mm.(f)
8. Treatment of the medullary canal of the radius. First, using a reamer inserted into a previously drilled hole, the medullary canal of the radial bone is opened, then using rasps, the canal is prepared for the introduction of the radial component of the prosthesis. (g, h)
9. Installation of the try-in beam component(s)
10. Drilling holes for installing the wrist component using a guide. The middle hole should be in the capitate bone, the radial hole in the scaphoid, the ulnar hole in the hamate, but not intra-articularly. You can check the correct position of the holes by immersing Kirschner wires in them and taking an x-ray. With the correct position of the knitting needle, I will form the letter V, and the knitting needle in the central hole will be a bisector. (k, l, m, n)
11. Preparation by reaming the canal in the capitate bone(s)
12. Installation of the fitting wrist component(p)
13. Installation of the fitting beam component(r)
14. Installation of a spherical polyethylene liner (c)

Both components of the endoprosthesis are fixed using the press fit type.

1. Checking the range of passive movements and stability of the joint(s)
2. Placement of the carpal component. When the screws are correctly placed in the scaphoid and hamate bones, on the control radiograph they form the letter W. (y, f, x) with the stem located in the capitate bone.
3. Setting up the beam component.(ts)
4. Placement of a spherical liner using an impactor.(w)
5. Restoring the integrity of the capsule. The capsule is sutured with tension in the position of extension in the wrist joint of 20 degrees.
6. Transposition of the distal third of the extensor retinaculum under the tendons.
7. Layer-by-layer suture of the wound, leaving vacuum drainage for 24-48 hours.

Rice. 020. Technique of total wrist joint replacement.

Postoperative management.

Preventive antibacterial therapy is carried out intraoperatively and for 5 days after surgery.

Wearing a plaster splint in a position of extension in the wrist joint of 25-30 degrees and the absence of radio-ulnar deviation of the hand for 2 weeks, after which they begin to develop movements in the joint. In some cases, immobilization is continued for up to 6 weeks in the intervals between physical education classes. Patients with synovitis require a longer period of immobilization. Hand grip strength usually returns 8 to 9 weeks after surgery. The restored range of motion is 80 percent of that required to perform daily work (about 40 degrees of flexion and extension, 40 degrees - total radio-ulnar deviation). A control radiographic examination is performed 6 weeks, 3, 6, 12 months after surgery, then annually.

It is necessary to exclude sports such as golf, tennis, bowling and lifting weights of more than 8 kilograms.

Deformations of the metacarpophalangeal joints.

The metacarpophalangeal joints are key to the function of the fingers. Rheumatoid joint damage leads to various deformities of the fingers and loss of function.

The metacarpophalangeal joints are condylar joints with two axes of motion. Due to this structure, the metacarpophalangeal joints are less stable than the interphalangeal joints and are more susceptible to deforming effects.

Proliferative synovitis promotes stretching of the joint capsule and damage to the collateral ligaments. The loss of the stabilizing influence of the collateral ligaments is one of the leading reasons for the progression of the deformity. Normally, the metacarpophalangeal joints are stable in a position of maximum flexion, with minimal possibility of abduction. In patients with rheumatoid arthritis, abduction within 45 degrees is possible at maximum flexion. The combination of deformation of the wrist joint, imbalance of the interosseous, lumbrical muscles and extensor tendons of the fingers, pressure of the first finger during a pinch grip with stretching of the joint capsule leads to palmar subluxation of the main phalanx and ulnar deviation of the fingers.

Surgical operations on the metacarpophalangeal joints can be divided into preventive and reconstructive. The only potentially preventative procedure is metacarpophalangeal joint synovectomy. Reconstructive surgeries include soft tissue surgeries and various types of arthroplasty.

Synovectomy.

Synovectomy is indicated for patients with persistent synovitis that does not respond to conservative therapy for 6-9 months, with minimal bone changes as determined by radiography and minimal joint deformity.

Synovectomy of several joints is made from a transverse incision along the dorsal surface of the joints; synovectomy of an isolated joint can be made from a longitudinal incision along the ulnar surface of the joint. The dorsal veins are preserved whenever possible to avoid massive edema in the postoperative period. Access to the joint is carried out through the ulnar part of the lateral fibers of the tendon-aponeurotic stretch, the extensor tendon is retracted to the radial side, the capsule is opened with a transverse incision. To effectively remove the synovial membrane, traction is applied using the finger. At the end of the procedure, it is necessary to restore the extensor apparatus. Active movements can begin 1-2 days after surgery.

Operations on soft tissues.

Soft tissue operations are usually performed in combination with synovectomy or joint replacement, but can also be used individually.

Centralization of the extensor tendon displaced to the ulnar side is necessary to correct the deformity, restore extension and prevent the progression of finger deviation. The degree of tendon dislocation varies from minimal to complete displacement when the tendon is in the space between the metacarpal bones.

Once the tendon is identified, the transverse and sagittal fibers of the tendon-aponeurotic extension are crossed on the ulnar side. The tendon is released and transferred to the dorsum of the metacarpophalangeal joint. The simplest method of tendon centralization is to crimp the stretched radial fibers of the tendon-aponeurotic sprain using absorbable suture material. This type of centralization can be used if the tendon does not tend to slip. Otherwise, the extensor tendon can be secured to the joint capsule or main phalanx with sutures passed through holes in the bone or with anchor screws.

In the postoperative period, the fingers are immobilized in the extension position. Active movements begin 4-5 days after surgery, exercises are performed 3-4 times a day. In the intervals between classes, the fingers are immobilized. From the 7th day, a plaster splint is used at night, and during the day it is replaced with dynamic elastic splinting. This immobilization is continued for 4-6 weeks, which is important to prevent recurrence of the deformity.

Endoprosthetics of metacarpophalangeal joints.

In the late 50s and early 60s, Vainio, Riordan, and Flower reported on a method for correcting deformity of the metacarpophalangeal joints, which involved resection of the affected joint and interposition of soft tissue between the bone ends. The results of resection arthroplasty were unsatisfactory, which resulted in recurrence of the deformity. In the mid-60s, Swanson reported positive results in metacarpophalangeal joint replacement using silicone implants. Currently, endoprosthesis replacement is the most common and effective procedure for correcting deformities of the metacarpophalangeal joints in patients with rheumatoid arthritis.

The endoprosthesis must meet the following criteria, formulated by Flatt and Fisher in 1969: provide sufficient range of motion, stability and be resistant to lateral and rotational forces.

As a rule, rheumatoid disease combines ulnar deviation and palmar subluxation of the metacarpophalangeal joint with deformation and stiffness of the remaining finger joints. Endoprosthesis replacement is indicated for patients with severe deformity and limited function. Contraindications to endoprosthetics are: an infectious process in the joint area, defective skin in the area of ​​the intended operation, damage to the musculotendinous system that cannot be corrected, and severe osteoporosis. Correction of wrist joint deformity should precede reconstruction of the metacarpophalangeal joints.

Operation technique.

1. Longitudinal skin incision for endoprosthetics of one joint and transverse for several joints
2. It is necessary to preserve the superficial veins and nerves.
3. Access to the joint through the ulnar bundles of the tendon-aponeurotic stretch.
4. Synovectomy (joint capsule and radial collateral ligament are preserved)
5. Resection of the metacarpal head
6. Preparation of the bone marrow canals, starting from the proximal phalanges
7. Implant size determination
8. Installation of endoprosthesis
9. Reconstruction of the joint capsule and radial collateral ligament.
10. Centralization of the extensor tendon
11. Drainage and suture to the skin. Removal of drainage for 1-2 days.

In the postoperative period, immobilization is performed in a palmar plaster splint with a side on the ulnar side in the position of extension and radial deviation in the metacarpophalangeal joints for 4-6 weeks. The interphalangeal joints remain free. The splint is removed during physical therapy sessions. After 6 weeks, a dynamic splint and a removable plaster splint are used at night for 3 months.

Finger deformities.

The most common types of finger deformities are the boutonniere type and the “swan neck” type.

Swan neck deformity

The “swan neck” deformity is manifested by hyperextension of the middle phalanx and flexion of the distal one. There are four types of deformation.

I type of deformation .

In type I deformity, the full range of passive movements in the proximal interphalangeal joint is preserved, and functional losses are caused to a greater extent by limited extension of the nail phalanx. Treatment of this group of patients should be aimed at limiting hyperextension of the middle phalanx and restoring extension of the distal phalanx. Correction of hyperextension of the middle phalanx is performed using a ring-shaped splint (the so-called “Silver ring” splint), which does not limit movements. Flexor tenodesis, palmar dermadesis, and arthrodesis of the distal interphalangeal joint are also performed.

Arthrodesis of the distal interphalangeal joint.

Arthrodesis is made from a curved incision on the dorsum of the joint, the extensor tendon is cut transversely, and the articular cartilage is removed. For fixation, a thin Kirschner wire is used, inserted into the medullary canal of the middle phalanx. If necessary, to prevent rotation, a second wire inserted in an oblique direction is additionally used. The nail phalanx is fixed in a position of full extension. In the postoperative period, a short aluminum splint is used for immobilization for 4-6 weeks.

For arthrodesis, mini-screws (Herbert, Herbert-Whipple, etc.) can be used. This type of fixation has a number of advantages: stability, no need for additional immobilization, and the ability not to remove the metal structure.

Dermadesis.

Dermadesis can be used only for type I deformity and is aimed at preventing hyperextension of the middle phalanx. An ellipsoidal fragment of skin measuring 4-5 mm at its widest point is removed from the palmar surface of the proximal interphalangeal joint. In this case, it is necessary to keep the saphenous veins and tendon sheaths intact. A suture is placed on the skin in the position of flexion of the proximal interphalangeal joint.

Tenodesis of the flexor tendons.

Patients with the first type of deformity, while maintaining the full range of motion in the proximal interphalangeal joint, experience difficulty in the initial stages of flexion. For tenodesis, the superficial digital flexor tendon is used. The tendon sheath is accessed through a zigzag incision on the palmar surface of the finger. The vagina is opened through two longitudinal incisions on either side of the tendons. The pedicles of the superficial flexor tendon are cut off and sutured to the walls of the osteofibrous canal in a position of 20-30 degrees of flexion in the proximal interphalangeal joint. Refixation of the tendon pedicles can also be performed directly to the bone, but this technique is associated with additional technical difficulties. In the postoperative period, the finger is immobilized in a flexion position of about 30 degrees for 3 weeks, after which active flexion begins, extension is limited for 6 weeks.

II type of deformation.

Type II deformity is characterized by the dependence of the degree of passive flexion in the proximal interphalangeal joint on the position of the metacarpophalangeal joints: with extended and radially deviated main phalanges, flexion is limited, and with bent and ulnarly deviated, flexion is preserved. This proves that the deformity is secondary to damage to the metacarpophalangeal joints. The deformity develops due to an imbalance of the hand's own muscles, the tension of the tendons of which is stronger when the metacarpophalangeal joints are extended. Thus, to correct the “swan neck” it is necessary to eliminate the traction of the tendons of the hand’s own muscles and, if necessary, perform endoprosthesis replacement of the metacarpophalangeal joints.

III type of deformation.

In patients with type III deformity, the limitation of movements in the proximal interphalangeal joint is constant and does not depend on the position of adjacent joints. In this case, no radiological changes are observed. In this group of patients, retraction of periarticular tissues is observed. In this situation, the joint can be redressed with fixation in a flexion position of about 80 degrees for 10 days, then active flexion of the finger begins. Extension is limited using a dorsal splint.

Flexion can also be limited by lateral portions of the tendon-aponeurotic stretch shifted to the dorsal side, which can be separated from the central portion by two parallel longitudinal incisions in the position of flexion of the finger.

IV type of deformation.

It is characterized by limited flexion in the proximal interphalangeal joint in combination with pronounced intra-articular radiological changes.

When choosing a correction method, it is necessary to take into account the condition of adjacent joints. For treatment, both arthrodesis of the proximal interphalangeal joint in a flexion position of 25-45 degrees, with the degree of flexion increasing from the second to the fifth fingers, and endoprosthetics can be used.

“Boutonniere” type deformation.

The deformity consists of three main components: flexion at the proximal interphalangeal joints, hyperextension at the distal interphalangeal joints, and hyperextension at the metacarpophalangeal joints. The development of deformity begins with the proximal interphalangeal joints; changes in adjacent joints are secondary. There are three stages of deformation.

I(initial) stage of deformation.

It is characterized by flexion of the proximal interphalangeal joints of about 10-15 degrees and the absence of hyperextension of the distal ones (or slight hyperextension). At this stage, an extensor tenotomy is performed to restore the possibility of joint flexion in the distal interphalangeal joint. The operation is performed from a longitudinal incision on the dorsal surface of the middle phalanx, the extensor tendon is isolated and crossed in an oblique or transverse direction (the first is preferable). In the postoperative period, dynamic splinting is performed, aimed at straightening the proximal interphalangeal joint and, at the same time, not limiting flexion.

II(moderate) stage of deformation.

Functional deficiency is caused by flexion at the proximal interphalangeal joints, reaching 30-40 degrees. This position is compensated by hyperextension of the nail phalanx. Measures to correct the deformity are aimed at restoring active extension in the proximal interphalangeal joint by shortening the central portion of the extensor tendon and fixing the displaced lateral portions on the dorsum of the finger. This operation is possible if the following conditions are met: good condition of the skin on the dorsum of the finger, normal functioning of the flexor tendons, absence of radiological changes in the joint and the possibility of passive correction of the deformity. To prevent recurrence of the deformity, the operation is combined with extensor tenotomy at the level of the distal interphalangeal joint. In the postoperative period, the proximal interphalangeal joint is fixed in the extension position with two intersecting Kirschner wires, which are removed after 3-4 weeks. After the start of active movements, immobilization is continued with a splint at night for several weeks.

III(severe) stage of deformation.

Characterized by the inability to passively extend the proximal interphalangeal joint. In this case, correction of the deformity is possible by applying staged plaster casts or dynamic splinting. In case of ineffectiveness or radiographic changes in the joint, arthrodesis of the proximal interphalangeal joint is indicated. Fixation of the proximal interphalangeal joint of the second finger is carried out at an angle of 25 degrees, the third - fifth fingers in increasing order to an angle of 45 degrees at the fifth finger. An alternative to arthrodesis may be endoprosthetics of the proximal interphalangeal joint. Endoprosthesis replacement is indicated if the function of the metacarpophalangeal joints is preserved; otherwise, it is preferable to perform endoprosthesis replacement of the latter.

Deformations of the first finger of the hand.

Deformities of the first finger occur in 60-81% of patients suffering from rheumatoid arthritis, and play a leading role in limiting daily activity and the ability of self-care for this group of patients. Impaired function of the first toe can be caused by damage to the joints, muscles, tendons and nerves. Therefore, to select a surgical correction method, it is necessary to evaluate the contribution of each of these structures to the development of deformity.

Classification of deformities of the first finger.

Rheumatoid arthritis can involve all joints of the first toe. The classification of deformities of the first finger of the hand was proposed in 1968 by Nalebuff.

DeformationItype or deformation like a “boutonniere”.

Occurs in 50-74% of cases of rheumatoid arthritis requiring treatment. The formation of deformity begins with synovitis of the metacarpophalangeal joint, then the extensor apparatus is involved in the process. The extensor longus tendon is displaced ulnarly and palmarly relative to the center of rotation of the joint. This causes the joint to flex. Secondary hyperextension of the nail phalanx occurs, the first metacarpal bone assumes an abducted position, which ultimately leads to palmar subluxation of the main phalanx and erosion of the dorsal portion of the base of the phalanx and the head of the metacarpal bone. (rice).

In the initial stage of the disease, when passive movements in the joints are preserved, surgical measures are limited to synovectomy of the metacarpophalangeal joint and reconstruction of the extensor apparatus. In the second stage of the disease, with destruction of the metacarpophalangeal joint and subject to minimal changes in adjacent joints, arthrodesis of the metacarpophalangeal joint is performed. If there are changes in the interphalangeal or trapezio-metacarpal joints, then it is more advisable to perform endoprosthetics of the metacarpophalangeal joint. In the third stage, destruction affects both the interphalangeal and metacarpophalangeal joints. In this situation, the operation of choice may be arthrodesis of the interphalangeal joint and endoprosthetics of the metacarpophalangeal joint.

IItype of deformation.

This is the most rare type.

In type II deformity, subluxation occurs in the trapezio-metacarpal joint, which is the main substrate of the deformity, adduction of the metacarpal bone, flexion in the metacarpophalangeal joint and extension in the interphalangeal joint. Types I and II of deformity are clinically similar.

IIIswan neck type or deformation.

In type III or “swan neck” deformity, the pathological focus is initially localized in the metacarpophalangeal joint. Synovitis results in capsule weakness and dorsoradial subluxation of the base of the metacarpal bone. Subluxation of more than 4 mm leads to mandatory progression of the deformity. Secondary imbalance of the extensor apparatus, weakness of the palmar plate of the metacarpophalangeal joint leads to hyperextension of the main phalanx and flexion of the nail. At the first and second stages of deformity development, resection arthroplasty of the trapezio-metacarpal joint is indicated. In the third stage of the disease, arthrodesis of the metacarpophalangeal joint and resection arthroplasty of the trapezio-metacarpal joint are performed.

Types IV and V of deformity begin at the metacarpophalangeal joint. Synovitis results in weakness of the ulnar collateral ligament or volar plate. With these types of deformities, the carpometacarpal joint remains intact.

IVtype or deformation of the “goalkeeper”.

Type IV is called “goalie” deformity and is more common. Sprain of the ulnar collateral ligament results in radial deviation of the main phalanx and subsequent adduction of the metacarpal. At an early stage of deformity, synovectomy of the metacarpophalangeal joint and restoration of the collateral ligament are performed. In advanced cases, arthrodesis or endoprosthetics of the metacarpophalangeal joint is performed.

Vtype of deformation.

Type V deformity is the result of thinning of the palmar plate of the metacarpophalangeal joint, which leads to hyperextension of the main phalanx and secondary flexion of the nail phalanx. For correction, the metacarpophalangeal joint is stabilized in the flexion position by palmar capsulodesis, sesamodesis or arthrodesis.

VItype of deformation.

Type VI deformity is the result of gross bone destruction leading to significant instability and subsequent shortening of the finger. This deformity, called disfiguring arthritis, can lead to various changes in the joints of the finger.

Zagorodniy N.V., Seidov I.I., Hadzhiharalambus K., Belenkaya O.I., Elkin D.V., Makinyan L.G., Zakharyan...

Zagorodniy N.V., Seidov I.I., Khadzhiharalambus K., Belenkaya O.I., Elkin D.V., Makinyan L.G., Zakharyan N.G., Arutyunyan O.G., Petrosyan A.S. .

The content of the article

Rheumatoid arthritis (RA)- a chronic (or subacute) disease characterized by progressive symmetrical inflammatory damage to the joints (polyarthritis) and a number of systemic extra-articular manifestations (which justifies the use of the term “rheumatoid disease”). The incidence of RA is 1-2% in women and occurs 3-4 times more often than in men; this difference is less pronounced in childhood and old age. It can begin at any age, the peak incidence in women is 35-55 years, in men - 40-60 years.

Etiology and pathogenesis of rheumatoid arthritis

The role of the following factors in the origin of RA is discussed:
1) immune disorders with the development of autoimmune reactions to collagen or IgG;
2) genetic factors;
3) infectious agents - bacteria, mycoplasmas, viruses.
In RA, numerous autoantibodies are detected, including rheumatoid factors - antibodies, often of the IgM class, directed against one's own IgG (epitopes of its Fc fragment), antinuclear antibodies, antibodies to cytoplasmic cytoskeletal antigens - vimentin and keratin. There is a defect in cellular immunity (reduced number of T-suppressors). The synovial membrane is infiltrated with lymphocytes (mainly T-helper cells) and plasma cells, the synovial fluid contains locally synthesized immunoglobulins (including rheumatoid factors), immune complexes, and lymphokines. The role of T-lymphocytes in the pathogenesis of RA is confirmed by a decrease in the activity of the rheumatoid process after drainage of the thoracic lymphatic duct and leukapheresis with the removal of T-lymphocytes. The listed disorders suggest the mechanism of tissue damage. An unknown foreign antigen, localized in the synovial membrane, is processed by antigen-presenting cells (synovial membrane cells, macrophages, etc.) and causes local antibody formation, which occurs intensively under conditions of T-suppressor deficiency and T-helper excess. Antibodies combine with the antigen, forming immune complexes, attract neutrophils to the synovial fluid and activate the complement system. Neutrophils and macrophages phagocytose immune complexes and release chemical mediators of inflammation - lymphokines, lysosomal enzymes, prostaglandins, leukotrienes, free oxygen radicals. Continued inflammation stimulates proliferation of the synovium, proteolytic enzymes and free radicals destroy cartilage and bone. The pathogenesis of most extra-articular lesions is associated with the development of immune complex vasculitis.
Genetic factors are of great importance, which was proven by studying the frequency of RA in families and in identical twins. Some major histocompatibility complex antigens (HLA DR4 and HLA DW4) are detected in patients with RA much more often than in the population, others (HLA DRW2) - less often.
The role of infectious agents - bacteria, viruses and other microorganisms - is quite possible, but not proven and needs further study. In various experimental models, the development of arthritis is closely associated with infection, and rheumatoid factors are observed in several diseases with proven persistence of the immune stimulus.
In RA, inflammation and proliferation of the synovium primarily develop. First, infiltration with mononuclear cells is noted, then synovial cells proliferate, the villi hypertrophy, and a tumor-like aggressive granulation tissue called pannus is formed along the edge of the articular cartilage. Pannus gradually penetrates the cartilage, destroys it and fills the joint cavity, subsequently developing fibrous and bony ankylosis of the joint.
Changes in the blood vessels (vasculitis) are detected, as well as characteristic subcutaneous (rheumatoid) nodules with an area of ​​necrosis surrounded by macrophages and fibroblasts. Similar formations are also observed in the pleura, pericardium and lungs. Lymph node hyperplasia is often observed. Changes in internal organs can be detected - the heart (carditis), lungs and pleura (chronic interstitial pneumonia, pleurisy), kidneys (nephritis, amyloidosis), etc.

Rheumatoid Arthritis Clinic

The onset of the disease can vary, but the most typical is the gradual onset of pain and stiffness in the joints of the hands and feet, followed by the development of symmetrical peripheral polyarthritis. The proximal interphalangeal, metacarpophalangeal, metatarsophalangeal, and wrist joints are most often affected. Less common is damage to one joint, such as the knee, or recurrence of arthritis. In 15-20% of patients, the disease begins acutely - sometimes after mental trauma or a cold - with severe pain in the joints and fever. Sometimes the first symptoms are weakness, malaise or morning stiffness. Sometimes articular syndrome is preceded by fever with chills, accompanied by lymphadenopathy, serositis, etc.
RA affects all joints except the thoracic and lumbar spine. In 50% of patients, the hip joints are affected (rarely at the beginning of the disease, but usually in the first years). The pain in the joints is worse in the morning when waking up, then decreases and gets worse again.
It pours out at night, leading to sleep disturbances. Characterized by morning stiffness of movement in all joints; With active RA, stiffness may persist for many hours after waking up. The affected joints are swollen, often warm, and the skin color usually does not change. The swelling is mild, caused by effusion and proliferation of the synovium. Movement in inflammatory joints is painful and limited in scope. Muscle atrophy is characteristic.
The most commonly affected joints are the metacarpophalangeal, proximal interphalangeal and wrist joints. Damage to the distal interphalangeal joints is not typical. The fingers become spindle-shaped early on, and the metacarpophalangeal joints and wrist swell. Tenosynovitis in the wrists can cause carpal tunnel syndrome due to compression of the median nerve. Later, as the disease progresses, weakening of the joint capsule, tendon ruptures, and muscle atrophy are observed. These changes can cause characteristic deformities, ulnar deviation (lateral deviation of the fingers), “swan neck” (flexion contracture of the distal and hyperextension of the proximal interphalangeal joints), the “boutonniere” or “button loop” symptom (flexion contracture of the proximal and hyperextension of the distal interphalangeal joints). These deformities, combined with atrophy of the interosseous muscles on the dorsum of the hand, form the characteristic picture of a “rheumatoid hand.”
The joints of the feet and ankles are deformed in the same way as the joints of the hands - lateral deviation of the fingers and subluxation of the metatarsophalangeal joints are noted, so that the heads of the bones can be palpated from the side of the sole.
The appearance of rheumatoid nodules in the tendons of the flexor muscles of the fingers and toes can cause sharply painful snapping of the finger.
In the knee joints there is effusion, frequent subluxations due to weakening of the joint capsule and atrophy of the quadriceps femoris muscle, valgus or varus deformities. The synovial space may extend to form a Baker's cyst in the popliteal fossa; if the joint is ruptured from behind, then synovial fluid penetrates into the intermuscular spaces of the leg, causing swelling and pain, which should be differentiated from that of deep vein thrombosis. Deformation of the knee joint may also be associated with thickening of the periarticular tissues. Difficulty in extension develops early, and then flexion contractures.
A number of patients experience changes in the cervical spine with pain, stiffness, and sometimes neurological symptoms; subluxations in the atlantoaxial joint are possible due to softening and thinning of the transverse atlas ligament; ankylosis does not develop.
Important signs of the systemic form of RA include subcutaneous rheumatoid nodules - one of the most reliable manifestations of active rheumatoid disease, often indicating damage to internal organs. Rheumatoid nodules occur in 20-25% of patients and are usually localized on the extensor surfaces of the extremities, such as the olecranon and the proximal part of the ulna. The nodules are located under the skin, can be of varying consistency - from soft, amorphous to dense masses, and are usually painless. They can be found in unusual places, such as on the vocal cords. Rheumatoid nodules, as well as rheumatoid deformity of the hand, are a marker of seropositive rheumatoid disease. Lymphadenopathy (enlargement of the elbow and other lymph nodes) is also an important indicator of the immunological activity of RA. Of the rheumatic diseases, lymphogranulomatosis-like “packets” of lymph nodes are characteristic primarily of rheumatoid disease.
Rheumatoid vasculitis- an integral part of severe rheumatoid disease. Clinically, vasculitis is manifested by arteritis of the fingertips (digital arteritis) with impaired peripheral circulation, hemorrhages, gangrene, skin ulcerations, peripheral neuropathy, pericarditis, vasculitis of internal organs, abdominal syndrome. Swelling of the ankles due to increased vascular permeability is common. Rheumatoid vasculitis usually develops in patients with severe destructive forms of arthritis, rheumatoid nodules.
Polyneuropathy is characterized by damage to the distal parts of the nerve trunks, most often the peroneal nerve, and is accompanied by severe pain and sensory disturbances. Patients complain of chilliness, numbness, burning in the arms and legs (distal sensory neuropathy), paresthesia, and sometimes severe movement disorders and foot drop develop. Rheumatoid serositis often occurs latently, but sometimes effusion pleurisy develops; the effusion may persist for months or even years. Pleurisy may be one of the first manifestations of rheumatoid disease. Prognostically, serositis, as with SLE and rheumatism, is favorable, although constrictive pericarditis may develop, requiring surgical intervention. There are two types of rheumatoid lung damage. Pulmonary vasculitis is more severe, accompanied by hemoptysis, tissue destruction and the formation of vascular cavities. Sometimes fibrosing alveolitis (diffuse interstitial pulmonary fibrosis) develops, manifested by progressive shortness of breath, rough crepitus, widespread shadows on radiographs and leading to the development of cor pulmonale. A peculiar nodular pulmonary fibrosis is observed with a combination of RA and silicosis (Kaplan syndrome). Heart damage can manifest as pericarditis, myocarditis, rarely endocarditis, coronary arteritis with the development of myocardial infarction, granulomatous aortitis. Heart defects have been described (usually isolated mitral or aortic valve insufficiency). Kidney damage is observed in 20-30% of patients with RA. Renal amyloidosis is more common, accompanied by proteinuria, nephrotic syndrome and chronic renal failure. Less commonly, glomerulonephritis develops - as part of rheumatoid disease or iatrogenic, associated with treatment with gold preparations, D-penicillamine (usually membranous) or non-steroidal anti-inflammatory drugs (chronic interstitial nephritis with necrosis of the renal papillae). Cases of necrotizing vasculitis with glomerulonephritis, sometimes with crescents, sometimes associated with treatment with D-penicillamine have been described.
60-80% of patients have moderate nonspecific changes in the liver. Hepatosplenomegaly develops in 10-12% of patients; it is characteristic of some variants of RA - Felty's syndrome, Still's disease. Sometimes the cause of liver enlargement is amyloidosis (in rare cases, accompanied by jaundice).
Blood tests reveal anemia, usually normochromic, sometimes hypochromic, the severity of which corresponds to the activity of the disease. The white blood cell count is usually normal, sometimes there is moderate eosinophilia, and thrombocytosis is often detected. Leukopenia in combination with severe anemia and thrombocytopenia is characteristic of Felty's syndrome. ESR is always increased. The course of RA is long-term, wave-like, with spontaneous remissions and exacerbations. In 25% of patients, exacerbations are observed rarely, in 50% - often, in 10-15% - a progressive course leading to complete disability, in 10-15% - persistent activity with progressive deformation. Complications of RA include amyloidosis and septic arthritis, and also iatrogenic complications. Amyloidosis deposits are found at autopsy in 20-25% of patients, but clinical signs of damage to the kidneys, liver, and other organs are observed much less frequently. There are reports of a potentiating effect of immunosuppressants on the development of amyloidosis.
Septic arthritis may develop in the affected joints, more often in patients receiving glucocorticoids. The possibility of septic arthritis should be considered when synovitis of one of the joints occurs, accompanied by fever, leukocytosis, etc. In such cases, immediate aspiration of the exudate with its examination is indicated.
Iatrogenic complications include changes in the blood system, skin and kidney damage that develop during treatment with gold preparations and D-penicillamine, damage to the gastrointestinal tract and kidneys during treatment with non-steroidal anti-inflammatory drugs.

Diagnosis and differential diagnosis of rheumatoid arthritis

The diagnosis is based on the characteristic clinical picture, radiological changes and laboratory data.
The most important clinical signs are persistent polyarthritis with symmetrical damage to the metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints, gradual involvement of new joints, the presence of subcutaneous rheumatoid nodules, morning stiffness for more than 30 minutes.
X-rays reveal marginal erosions (usurs), resembling mouse bites, on the surface of the affected bone. Erosions, as a rule, are small in size, irregular in shape and not surrounded by a zone of osteosclerosis. They are observed not only in RA, but also in ankylosing spondylitis, psoriatic arthropathy, and gouty arthritis. In addition to erosions, there is a narrowing of the joint space as a result of thinning and destruction of cartilage and osteoporosis of the epiphyses of the bones. Sometimes cysts are observed, in advanced stages - destruction of the ends of the bones, ankylosis, flexion contractures. Subluxations of joints (including joints of the cervical spine) may be detected. The earliest changes develop in the small joints of the hands and feet, so if RA is suspected, radiography of these joints should be performed.
Among laboratory parameters, the most important for diagnosis is the detection of rheumatoid factors in serum (in the Waaler-Rose reaction). The study of synovial fluid is of particular importance - weak formation of a mucous (mucin) clot when synovial fluid is added to diluted acetic acid, low glucose content. Sometimes a biopsy of the synovium or subcutaneous rheumatoid nodule can help make the diagnosis.
When making a diagnosis, you can rely on the latest criteria of the American Rheumatological Association (1987):
1) morning stiffness lasting at least 1 hour;
2) arthritis (with swelling of many tissues or effusion) of three or more of the following joints - proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle, metatarsophalangeal;
3) arthritis of the hand joints, with swelling of at least one of the following joints - wrist, metacarpophalangeal or proximal interphalangeal;
4) symmetrical arthritis;
5) rheumatoid nodules - subcutaneous nodules on protruding areas of bones, extensor surfaces or near joints;
6) rheumatoid factor in blood serum;
7) typical radiographic changes, including erosions and periarticular osteoporosis.
Symptoms meeting criteria 1-4 must persist for at least 6 weeks. RA is diagnosed if at least 4 criteria are present.

Diagnosis of advanced rheumatoid disease with typical symmetrical arthritis, rheumatoid nodules and serum rheumatoid factor is not difficult. However, in the early stages or when the clinical picture is blurred, differential diagnosis should be carried out with a number of diseases.
Ankylosing spondylitis, psoriasis, Reiter's syndrome, Crohn's disease and ulcerative colitis may be accompanied by peripheral arthritis. Asymmetry of arthritis, damage to predominantly medium and large joints of the lower extremities, distal interphalangeal joints, sacroiliitis or spondylitis, the presence of urethritis, ulcers on the oral mucosa, iritis, colitis, seronegative arthropathy in the patient’s relatives, and the absence of rheumatoid factor are of differential diagnostic importance. For the diagnosis of ankylosing spondylitis, the presence of sacroiliitis and the detection of HLAB27 are of particular importance. With Reiter's syndrome, characteristic urological (urethritis, balanitis) and ocular (conjunctivitis) manifestations are observed, sometimes short-term, requiring a targeted search. With psoriatic arthritis, typical changes in the skin and nails can be detected.
In SLE, peripheral arthritis is common, but less pronounced than in RA; it is usually not accompanied by erosions and persistent deformities. Rarely developing deformities (ulnar deviation, reversible deformity of the fingers in the form of a “swan neck”) may be associated with damage to the periarticular tissues. Rheumatoid factors may be detected in low titers. SLE is confirmed by the presence of typical facial erythema, polyserositis (usually pleurisy), nephritis, central nervous system damage, severe leukopenia and thrombocytopenia, lupus cell phenomenon and antinuclear factor.
Deforming osteoarthritis can occur with primary damage to the joints of the hands, however, even in the presence of inflammatory changes, it is easily distinguishable from RA. It affects the distal interphalangeal joints and the first metacarpal joint, rarely the proximal interphalangeal joints, and the metacarpophalangeal joints are almost never affected.
Gout is characterized by recurrent attacks of sharply painful monoarthritis of the big toe, knee, etc. The joints of the hands are not affected. Subcutaneous tophi (sometimes mistaken for rheumatoid nodules), elevated serum uric acid levels, and crystals in the tophi and synovial fluid are often found. Despite the seemingly clear differences in the clinical picture of RA and gouty arthritis, cases of overdiagnosis of RA due to gout are not uncommon.
Sometimes RA has to be differentiated from acute infectious arthritis, sarcoidosis, tuberculosis, Sjogren's syndrome, etc.

Scientific editor: Strokina O.A., therapist, functional diagnostics doctor.
November, 2019.

Rheumatoid arthritis is an inflammatory disease characterized by symmetrical damage to the joints and inflammation of the internal organs.

Prevalence and causes

As of 2018, about 300 thousand patients with rheumatoid arthritis were recorded in Russia (~0.61% of the adult population). In the world as a whole, the percentage of patients ranges from 0.5 to 2%.

Women suffer 3 times more often than men. The peak incidence of rheumatoid arthritis is 40-55 years, but it also occurs at a younger age. Half of the patients lose their ability to work in the first 3-5 years of the disease.

The cause of rheumatoid arthritis is unknown. Recently, researchers have been inclined to believe that the leading cause of the development of rheumatoid arthritis is a combination of internal factors (genetics, production of sex hormones) and environmental factors (bacterial and viral infections, occupational hazards, stress).

It has been proven that smoking is a leading external factor in the development of pathology. The results of a large-scale study have been published showing that passive smoking in childhood also significantly increases the risk of developing rheumatoid arthritis in adulthood.

Symptoms of rheumatoid arthritis

The development of the disease occurs gradually. First, general symptoms and mild symptoms of joint damage appear.

General signs

• Fatigue - usually appears several weeks or months before other symptoms develop. Fatigue can be either constant or periodic.
• A slight increase in body temperature in combination with joint symptoms (temperatures above 38C are usually not typical for rheumatoid arthritis).
• Eye problems (itching, inflammation or discharge) - Sjögren's syndrome.
• Losing weight.

Rheumatoid nodules are dense subcutaneous formations, in typical cases localized in areas that are often subject to trauma (for example, in the area of ​​the olecranon, on the extensor surface of the forearm). Observed in 20-50% of patients. Very rarely found in internal organs (for example, in the lungs).

In some cases, an enlarged spleen is observed.

Also, with rheumatoid arthritis, signs of osteoporosis (this is bone loss) and amyloidosis may appear.

Ulcers on the skin of the legs and inflammation of the arteries are common.

Photo: localization of rheumatoid nodules

Joint damage

Symmetry of joint damage is an important feature of rheumatoid arthritis (for example, the right and left elbow joints or the right and left knee joints are affected)

Fatigue is one of the "debilitating" symptoms of rheumatoid arthritis (as with many other autoimmune diseases). The problem of combating fatigue and fatigue in autoimmune diseases has recently received increasing attention; according to a 2018 study, pathological fatigue is one of the reasons for decreased performance in people with rheumatoid arthritis.

Photo: target joints and mechanism of joint damage in early stage rheumatoid arthritis.

Nonspecific blood parameters

• Anemia due to a slowdown in iron metabolism in the body caused by impaired liver function;
• Decrease in the number of platelets, neutrophils.

Common patterns of onset of the disease

Rheumatoid arthritis can start in different ways. The most common joint symptoms characteristic of the onset of the disease are described below:

• Pain and stiffness increase gradually, most often in the small joints of the hands. Typically, manifestations are not related to the time of day. Symmetrical joints are necessarily affected. The duration of the increase in symptoms is several months.
• Pronounced stiffness of the joints of the hands and feet in the morning. In this case, early detection of rheumatoid factor in the blood is typical.
• Recurrent tenosynovitis, especially often in the area of ​​the wrist joints (inflammation of the tendon, characterized by swelling, pain and a distinct creaking sound during movement).
• Inflammation of the knee or shoulder joints, followed by rapid involvement of the small joints of the hands and feet.

It is also worth keeping in mind that in a significant proportion of patients, rheumatoid arthritis begins with uncharacteristic manifestations, for example, with inflammation of large rather than small joints.

Photo: deformed joints with rheumatoid arthritis

Diagnostics

Important signs

American Rheumatological Association Diagnosis Criteria for Rheumatoid Arthritis. Presence of at least 4 of the following:

• morning stiffness for more than 1 hour;
• arthritis of 3 or more joints;
• arthritis of the joints of the hands;
• symmetrical arthritis;
• rheumatoid nodules;
• positive rheumatoid factor;
• radiographic changes.

Laboratory research

In general and biochemical blood tests:

• anemia,
• increase in ESR,
• increased levels of C-reactive protein.

Rheumatoid factor (antibodies to immunoglobulins class M) is positive in 70-90% of cases.

High values ​​of ACCP (antibodies to cyclic citrullinated peptide).

The joint fluid is cloudy, with low viscosity, and the number of leukocytes and neutrophils is increased.

Instrumental studies

If the X-ray results are ambiguous, the doctor may prescribe an MRI of the joints, because MRI is a more sensitive method.

According to indications, an ultrasound of small joints or radiography of large ones may be prescribed. If lung damage is suspected, a CT scan is prescribed.

Treatment of rheumatoid arthritis

Drug therapy includes the use of three groups of drugs:

• basic drugs
• non-steroidal anti-inflammatory drugs (NSAIDs)
• glucocorticoids

Basic drugs

The main drugs for basic therapy of rheumatoid arthritis are:

• Methotrexate
• Leflunomide
• Sulfasalazine
• Hydroxychloroquine

In Russia, the standard of treatment is therapy with methotrexate or its combination with sulfasalazine and hydroxychloroquine. Basic drugs should be started as early as possible.

Basic drugs that are ineffective for 1.5-3 months should be replaced or their combinations with hormones in small doses should be used, which can reduce the activity of rheumatoid arthritis.

Six months is a critical period from the onset of symptoms of joint damage, no later than which effective basic therapy must be selected.

During treatment with basic drugs, disease activity and side effects are carefully monitored. It is necessary to monitor indicators of general blood count, AST, ALT and creatinine.

Important! During treatment with methotrexate, to reduce the risk of adverse reactions, it is recommended to take folic acid, at least 5 mg per week. It is taken 24 hours after taking methotrexate.

Nonsteroidal anti-inflammatory drugs

The most commonly used NSAIDs are:

• diclofenac,
• nimesulide,
• meloxicam,
• ketoprofen,
• celecoxib.

These drugs have minimal side effects and retain high anti-inflammatory and analgesic activity.

At the beginning of treatment, when the inflammatory process is active, meloxicam (Movalis) is prescribed at 15 mg/day, and later switched to 7.5 mg/day. as maintenance therapy.

Nimesulide is prescribed at a dose of 100 mg twice a day.

Celecoxib (Celebrex) is prescribed 100-200 mg twice a day.

For elderly people, selection of the dosage of the drug is not required. However, in patients with a body weight below average (50 kg), it is advisable to start treatment with the lowest recommended dose.

The combination of two or more non-steroidal anti-inflammatory drugs should be avoided as their effectiveness remains unchanged and the risk of side effects increases.

Glucocorticosteroids (hormones)

With a high degree of inflammation activity, hormones are used, and in cases of systemic manifestations of rheumatoid arthritis - in the form of pulse therapy (hormones alone or in combination with a cytostatic - cyclophosphamide), without systemic manifestations - in the form of a course of treatment. Prednisolone is usually used.

Hormones are also used as maintenance anti-inflammatory therapy when other medications are ineffective.

In some cases, hormones are used as local therapy.

Ointments, creams, gels based on non-steroidal anti-inflammatory drugs (ibuprofen, piroxicam, ketoprofen, diclofenac) are used in the form of applications to inflamed joints.

To enhance the anti-inflammatory effect, applications of the above-mentioned ointment forms of drugs are combined with applications of a dimethyl sulfoxide solution at a dilution of 1:2-1:4.

Complementary therapy

In the absence of a response to standard drug treatment in patients with highly active rheumatoid arthritis, plasmapheresis and lymphocytapheresis are used.

An important point in the treatment of rheumatoid arthritis is the prevention of osteoporosis - restoration of the disturbed calcium balance in the direction of increasing its absorption in the intestines and reducing excretion from the body.

This is what diet is used for. with a high calcium content.

Sources of calcium are dairy products (especially hard cheeses, as well as processed cheese; to a lesser extent cottage cheese, milk, sour cream), almonds, hazelnuts and walnuts, etc., as well as calcium supplements in combination with vitamin D or its active metabolites.

A drug that can be classified as a basic antiosteoporetic agent is myacalcic. It is available for intramuscular administration at 100 IU and as a nasal spray; is prescribed according to the regimen together with calcium preparations (calcitonin) and vitamin D derivatives.

Laser therapy is also used in the treatment of rheumatoid arthritis. Especially for severe exacerbations of rheumatoid arthritis, extracorporeal treatment methods (primarily hemosorption and plasmapheresis) have been widely used in recent years.

Laser therapy is especially indicated at an early stage of the process. The course does not exceed 15 procedures.

In order to reduce pain and eliminate spasms of periarticular tissues, cryotherapy (cold treatment) is used for a course of 10-20 procedures.

In order to influence allergic processes, improve tissue nutrition and eliminate inflammation, other physical treatment methods are also used.

If more persistent changes in the joints appear and in the absence of signs of high activity, hydrocortisone phonophoresis, magnetic therapy, and pulsed currents are prescribed.

Physical therapy and massage are prescribed to all patients in order to relieve muscle spasms and quickly restore joint function.

All patients with rheumatoid arthritis should be systematically observed and examined by a rheumatologist.

Patients with a slowly progressive course without damage to internal organs should see a rheumatologist once every 3 months. If there is damage to internal organs, patients are examined by a rheumatologist once every 2-4 weeks.

Spa treatment for patients with rheumatoid arthritis is recommended annually outside the exacerbation phase.

In case of a benign course of the process without pronounced changes in the joints, the use of radioactive baths in Tskaltubo and Belokurikha is indicated; with a typical progressive process - treatment with hydrogen sulfide baths in Sochi, Sernovodsk, Pyatigorsk, Kemeri; for severe deformities and contractures - treatment with mud applications in Evpatoria, Saki, Pyatigorsk, Odessa.

Symmetry means damage to the joints of the same name on both sides. In addition, with RA, the entire joint is involved in the process, unlike osteoarthritis, when only those areas that are most exposed to mechanical stress are affected.

9. What is pannus?

The primary focus of the inflammatory process in RA is localized in the synovial membrane of the joint. The inflammatory infiltrate consists of mononuclear cells, mainly T lymphocytes, as well as activated macrophages and plasma cells, some of which produce rheumatoid factor. Synovial cells rapidly proliferate, the synovial membrane swells, thickens, and forms outgrowths into the underlying tissue. This synovial membrane is called pannus; it has the ability to grow into bone and cartilage tissue, leading to the destruction of joint structures.

It is important to note that polymorphonuclear leukocytes (PMNL) are practically not found in the synovial membrane, while they predominate in the synovial fluid. Neutrophil proteolytic enzymes also promote the destruction of articular cartilage.

10. List the most common deformities of the hands in RA. Fusiform swelling- synovitis of the proximal interphalangeal joints, which acquires the shape of a spindle.

"Boutonniere" type deformation- persistent flexion of the proximal interphalangeal joint and extension of the distal interphalangeal joint, caused by weakness of the central fibers of the extensor tendon and displacement of the lateral fibers of this extensor to the palmar side; as a result, the finger seems to be threaded through the buttonhole.

Swan neck deformity- contractures developed due to persistent contraction of the flexor muscles of the metacarpophalangeal joints, as well as hyperextension in the proximal interphalangeal joints and flexion in the distal interphalangeal joints.

Ulnar deviation of fingers with incomplete dislocations in the metacarpophalangeal joints.

A. Deformations of the fingers like a “swan neck” (II-IV fingers) and like a “boutonniere” (V finger). B. Ulnar deviation of the fingers (note the rheumatoid nodules). (From: Revised Clinical Slide Collection on the Rheumatic Diseases. Atlanta, American College of Rheumatology, 1991; with permission.)

11. List the most common foot deformities with ra.

The inflammatory process in the metatarsophalangeal joints leads to subluxation of the metatarsal heads and, ultimately, to the most common deformity of the toes in patients suffering from RA - "claw-shaped" or "hammer-shaped" fingers fingers. These patients have problems wearing shoes because they often rub their toes, which can cause calluses or ulcers. In addition, the fibrofatty “cushions” that are normally located under the heads of the metatarsal bones are displaced, exposing the latter. In this case, the process of walking is accompanied by very severe pain; calluses develop on the plantar surface of the distal phalanges (patients compare their sensations to walking on sharp stones). Involvement of the metatarsal joints in the process causes flattening of the arch and valus deformity of the foot.