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

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

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

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

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

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

Boutonniere Deformity: A Review of Considerations before Treatment and Current Treatment Options

Central slip injury is a common occurrence in hand trauma. When the base of the middle phalanx, which is the contact part of the central tendon, is weakened or damaged, extension lag or restriction would be found in the proximal interphalangeal (PIP) joint and the distal interphalangeal joint becomes hyperextended, presenting buttonhole or boutonniere deformation. Buttonhole deformation has limited cases that a hand surgeon can experience, and there is still no clear guideline for treatment, so treatment tends to depend on the knowledge and experience of the treating doctor. In this review, the factors to be considered in determining the treatment of boutonniere deformity are discussed, and nonsurgical or surgical treatment is considered. Treatment of the PIP joint in boutonniere deformity is a difficult task. Understanding the cause of the deformity, the time point and the stage of deformity, the relationship to the biomechanical changes in adjacent joints, the patient’s functional limitations, and the condition of the joint will improve treatment decisions and outcomes. Based on these considerations, an appropriate treatment should be chosen among nonsurgical or surgical treatments. Various surgical options were introduced but none of method guarantee the optimal outcome. Sufficient understanding of deformity and sufficient consultation and cooperation with the patient regarding the treatment process, outcome, and rehabilitation are necessary.

Traumatic Boutonnière Deformity of the Thumb

Two Cases Of Boutonnière Deformity After Trauma Are Presented In Patients Without Rheumatic Disease. One Of Them Suffered An Assault and the other a high-energy accident. Both cases were misdiagnosed. The first case presented an injury of the dorsoradial capsule of the metacarpophalangeal (MCP) joint and the second case presented an injury of the adductor pollicis (AP) which is an unusual finding regarding this kind of deformity. The surgical treatment failed up to two times in the first case hile in the second case it failed once.