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Objective: Rheumatoid arthritis (RA) causes destruction of the metacarpophalangeal (MCP) joints, leading to hand deformities, pain, and loss of function. This study prospectively assessed long-term functional and health-related quality-of-life outcomes in RA patients with severe deformity at the MCP joints., Methods: RA patients between ages 18 to 80 years with severe deformity at the MCP joints were referred to 1 of the 3 study sites. Subjects who elected to undergo silicone metacarpophalangeal joint arthroplasty (SMPA) while continuing with medical management were followed in the SMPA cohort. Subjects who elected to continue with medical management alone without surgery were followed in the non-SMPA cohort. Objective measurements included grip and pinch strength as well as arc of motion, ulnar drift, and extensor lag of the MCP joints. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Radiographs of SMPA implants were assessed and graded as intact, deformed, or fractured., Results: MHQ scores showed large improvements post-SMPA, and baseline-adjusted expected outcomes in the SMPA group were significantly better at year 7 in function, aesthetics, satisfaction, and overall score compared to non-SMPA. SMPA subjects did not improve in grip or pinch strength, but achieved significant improvement and maintained the improvement long term in ulnar drift and extensor lag., Conclusion: Benefits of the SMPA procedure are maintained over 7 years with low rates of implant fracture or deformity. Non-SMPA patients remained stable in their hand function over the 7-year study duration., (© 2016, American College of Rheumatology.)

Background: Rheumatoid arthritis patients with swan neck deformities are postulated to have greater metacarpophalangeal joint arc of motion because of their need to flex the joint to make a fist, whereas the boutonniere deformity places the fingers into the flexed position, creating less demand on the joint for grip. This study analyzes the effect of these deformities on the joint's arc of motion and hand function., Methods: The authors measured the metacarpophalangeal joint arc of motion in 73 surgical patients. Data were allocated into groups by finger and hand deformity. Linear regression models were used to analyze the effect of the deformity on the joint's arc of motion. Functional outcomes were measured by the Michigan Hand Outcomes Questionnaire and the Jebson-Taylor Test., Results: Nineteen fingers had boutonniere deformity, 95 had swan neck deformities, and 178 had no deformity. The no-deformity group had the least arc of motion at baseline (16 degrees) compared with the boutonniere (26 degrees) and swan neck (26 degrees) groups. Mean arc of motion in the no-deformity group compared with the boutonniere group at baseline was statistically significant, but all groups had similar arc of motion at long-term follow-up. Only mean Jebson-Taylor Test scores at baseline between the boutonniere and no-deformity groups were significantly different., Conclusions: The results did not support the hypothesis that swan neck deformities have better arc of motion compared with boutonniere deformity. Boutonniere deformity has worse function at baseline, but there was no difference in function among groups at long-term follow-up.

Background: It has been stated by hand surgeons that rheumatoid arthritis patients often are referred "too little and too late." The purpose of this prospective study was to evaluate outcomes of rheumatoid arthritis patients with metacarpophalangeal joint deformities (subluxation and ulnar deviation). The authors hypothesized that patients with more severe deformities would have worse outcomes after silicone metacarpophalangeal joint arthroplasty., Methods: Seventy patients who each had combined metacarpophalangeal joint ulnar drift and extensor lag greater than 50 degrees were recruited into this three-center study of silicone metacarpophalangeal joint arthroplasty. Patients were categorized into two groups based on degrees of deformity: less than 100 degrees or greater than or equal to 100 degrees. Outcomes were assessed at 6 months and 1 year based on the Michigan Hand Outcomes Questionnaire, grip/pinch strength, metacarpophalangeal joint deviation angles, the Jebsen-Taylor test, and the Arthritis Impact Measurement Scales 2 questionnaire., Results: There was no difference in outcomes at the 1-year follow-up between the two groups, after controlling for age, gender, and baseline values. Each of the outcome scores was not different between the two groups, including the six domains in the Michigan Hand Outcomes Questionnaire, grip/pinch strength, the Jebsen-Taylor test, and the Arthritis Impact Measurement Scales 2 questionnaire. However, patients with more severe hand deformities have worse ulnar drift and extensor lag after reconstruction., Conclusions: Rheumatoid arthritis patients with more severe metacarpophalangeal joint diseases will attain similarly good outcomes after reconstruction when compared with those with less severe deformities. Despite the potential barriers to silicone metacarpophalangeal joint arthroplasty in rheumatoid arthritis patients with more severe hand deformities, surgical treatment is still beneficial.

Background: Free tissue transfer is used widely for reconstruction of complex defects throughout the body. The most common cause for free flap failure remains vascular thrombosis. Currently, there exists no animal model for anastomotic vasospasm. Botulinum toxin type A has been successfully used to treat vasospasm in Raynaud's phenomenon. A blinded, vasospasm animal model was designed to determine its ability to prevent anastomotic thrombosis., Methods: Ten Sprague-Dawley-derived rats were pretreated with botulinum toxin type A subcutaneously to a randomly determined femoral vessel. Animals acted as their own controls, receiving saline to the contralateral limb. Five days postoperatively, femoral vessels were measured to determine the effect of neuromuscular blockade on diameter. Vessels were then divided and reanastomosed. Animals were subjected to a systemic treatment with a peripheral vasoconstrictor, phenylephrine, and a lower extremity thermic challenge in an ice bath. Vessel patency was recorded before cold challenge and 1 hour after., Results: Vessel diameter was consistently larger in all neuromuscularly blocked vessels. The botulinum toxin type A-treated arterial average was significantly larger than the matched control average, and the venous average was significantly larger than the matched control average. Difficulty of anastomosis and time of suturing were significantly less in the pretreated botulinum toxin type A group. Patency was maintained in 100 percent of vessels treated with botulinum toxin type A and in 44 percent of saline-treated vessels at 1 hour after vasospastic challenge., Conclusions: Botulinum toxin type A was successful in preventing thrombosis within this model. Its ability to decrease vasospasm and thrombosis may have applications for improving free flap survival in select patients.