Angular deformity of the joints. Assess for possible passive correction as an indication of the degree of soft tissue contracture that may restrict surgical correction.

Instability with subluxation and dislocation of joints (Fig. 60-1)

Rheumatoid arthritis of the hands with unstable carpometacarpal and MCP joints of the right thumb with Z-deformity, subluxation of the left index and small finger proximal interphalangeal (PIP) joints, and deformity of the distal interphalangeal (DIP) joints of the right hand (see Fig. 60-1)

Swelling and tenderness of the joints from effusion and osteophytes

Presence of ganglion cysts

Restricted active range of motion

Decreased pinch and grip strength

Obtain standard posteroanterior and lateral radiographs of the involved finger and thumb.

The alignment and bone stock around the involved joint should be noted (Fig. 60-2).

Figure 60-2 shows posteroanterior radiographs of the same hands, confirming the clinical findings in Figure 60-1. In addition, there is dislocation of the MCP joint of the left thumb.

Straight dorsal incision from about the midproximal phalanx to the midmetacarpal region. Alternatively, a dorsal curvilinear incision may be used.

Extensor tendon split in the midline from the proximal phalanx proximally over the MCP joint. For the thumb and index and small fingers with two extensor tendons, the incision on the tendon is carried proximally between the two tendons. For the long and ring fingers, the incision is carried proximally to either the radial or ulnar side of the extensor tendon, taking with it a sliver of the tendon for easy repair during closure.

The PIP joint is exposed through a gentle curve over the joint and extended over the adjacent bones (Fig. 60-3).

Figure 60-3 shows the dorsal curvilinear incision over the PIP joint.

The extensor tendon is split in the midline from proximal to distal, splitting and elevating the central slip attachment and cutting the triangular ligament over the middle phalanx, elevating the lateral bands.

The collateral ligament on one side is cut to allow the articular surfaces to be exposed adequately in a “shotgun” fashion. If necessary, both collateral ligaments may be cut.

The DIP joint of the fingers and the IP joint of the thumb are exposed with an H incision, with the transverse part of the H directly over the dorsum of the joint (Fig. 60-4). Alternatively, a Y incision centered over the DIP joint may be used.

The extensor tendon is divided transversely leaving a 5-mm-long distal stump for subsequent repair. The extensor tendon is repaired at completion of the arthrodesis to maintain the balance of the intricate extensor mechanism.

The collateral ligaments on both sides are divided, allowing the joint to be hinged open dorsally.