Mateusz Gładysz FESSH prep

FESSH prep Rheumatoid hand Persistent tenosynovitis as a risk factor and indication for prophylactic tenosynovectomy, outcome of tendons invaded at surgery, placement of the extensor retinaculum beneath the tendons, continued carpal progression after dorsal synovectomy, routine histopathology of tenosynovium

Dorsal tenosynovitis and tenosynovectomy in the rheumatoid wrist

Last reviewed v1.0

FESSH-089Rheumatoid hand●●○ intermediate

Regarding dorsal (extensor) tenosynovitis of the rheumatoid wrist and its surgical treatment:

  1. 1.Dorsal tenosynovitis that persists for several months is a risk factor for spontaneous extensor tendon rupture and, especially with other risk factors, an indication for prophylactic tenosynovectomy.

  2. 2.Extensor tendons already invaded by tenosynovium at the time of dorsal tenosynovectomy commonly rupture in the following years.

  3. 3.During dorsal wrist synovectomy and tenosynovectomy, the extensor retinaculum can be placed beneath the extensor tendons, between them and the wrist joint.

  4. 4.Long-term follow-up shows that dorsal wrist synovectomy halts the progression of carpal collapse and ulnar translocation.

  5. 5.In patients with a known inflammatory arthritis, routine histopathology of the excised tenosynovium often changes management.

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Question ID
FESSH-089
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. Dorsal tenosynovitis that persists for several months is a risk factor for spontaneous extensor tendon rupture and, especially with other risk factors, an indication for prophylactic tenosynovectomy.

    True

    Ryu and colleagues identified tenosynovitis persisting for at least 6 months, dorsal dislocation of the distal ulna and a radiographic scallop sign as risk factors for extensor rupture, and prophylactic tenosynovectomy with wrist synovectomy prevented rupture in patients with two or more risk factors. In a smaller series, Hsueh and colleagues found tenosynovitis persisting for more than 1 year associated with rupture, and no rupture followed extended tenosynovectomy in wrists with tenosynovitis lasting more than 6 months.

    • Ryu J, Saito S, Honda T, Yamamoto K. Risk factors and prophylactic tenosynovectomy for extensor tendon ruptures in the rheumatoid hand. J Hand Surg Br. 1998;23(5):658-61. PMID 9821614
    • Hsueh JH, Liu WC, Yang KC, Hsu KC, Lin CT, Chen LW. Spontaneous Extensor Tendon Rupture in the Rheumatoid Wrist: Risk Factors and Preventive Role of Extended Tenosynovectomy. Ann Plast Surg. 2016;76 Suppl 1:S41-7. PMID 26808746

  2. 2. Extensor tendons already invaded by tenosynovium at the time of dorsal tenosynovectomy commonly rupture in the following years.

    False

    Brown and Brown reviewed 173 tenosynovectomies: half of the patients having prophylactic tenosynovectomy had tendon invasion, yet at a mean of 70 months extensor tendon failure had occurred in only 1 of 42 patients with invaded tendons (and 1 of 44 with normal tendons). Thirupathi and colleagues likewise found that tendons thinned at surgery remained intact over 5–14 years.

    • Brown FE, Brown ML. Long-term results after tenosynovectomy to treat the rheumatoid hand. J Hand Surg Am. 1988;13(5):704-8. PMID 3241041
    • Thirupathi RG, Ferlic DC, Clayton ML. Dorsal wrist synovectomy in rheumatoid arthritis--a long-term study. J Hand Surg Am. 1983;8(6):848-56. PMID 6643959

  3. 3. During dorsal wrist synovectomy and tenosynovectomy, the extensor retinaculum can be placed beneath the extensor tendons, between them and the wrist joint.

    True

    Thirupathi and colleagues describe a combined procedure of dorsal wrist synovectomy, extensor tenosynovectomy, excision of the distal ulna, ulnar-side stabilisation and placement of the extensor retinaculum underneath the extensor tendons. In 38 wrists followed for 5–14 years, subsequent tendon rupture was minimal and synovitis did not recur.

    • Thirupathi RG, Ferlic DC, Clayton ML. Dorsal wrist synovectomy in rheumatoid arthritis--a long-term study. J Hand Surg Am. 1983;8(6):848-56. PMID 6643959

  4. 4. Long-term follow-up shows that dorsal wrist synovectomy halts the progression of carpal collapse and ulnar translocation.

    False

    In Allieu's experience of 603 operated rheumatoid wrist cases, the disease continued despite synovectomy, and soft-tissue stabilisation with the extensor retinaculum and tendon transfer did not stabilise the wrist, so a partial (radiolunate) arthrodesis was increasingly added. In Thirupathi's series, carpal translocation occurred in 44% of wrists, and carpal collapse and ulnar translocation progressed linearly with the length of follow-up.

    • Allieu Y. [Development of surgical indications in the treatment of rheumatoid wrist. Report on experience based on 603 surgical cases, 1968-1994]. Ann Chir Main Memb Super. 1997;16(3):179-97. PMID 9453739
    • Thirupathi RG, Ferlic DC, Clayton ML. Dorsal wrist synovectomy in rheumatoid arthritis--a long-term study. J Hand Surg Am. 1983;8(6):848-56. PMID 6643959

  5. 5. In patients with a known inflammatory arthritis, routine histopathology of the excised tenosynovium often changes management.

    False

    Straszewski and colleagues reviewed 57 patients whose flexor or extensor tenosynovium was assessed histologically. In the 20 with a known inflammatory condition, histopathology changed the care of none, and the authors no longer send this tissue routinely in such patients. Histopathology changed care in only 1 of the other 37 patients (a new diagnosis of rheumatoid arthritis), and culture in 1 of 27 patients without suspected infection (a Mycobacterium marinum complex infection).

    • Straszewski A, Troyer S, Boyer MI, Goldfarb CA. Utility of Routine Histopathologic and Culture Analysis in Wrist Tenosynovectomy. J Hand Surg Am. 2026;51(5):576.e1-576.e6. PMID 41553311