Surgery of the Hand in Patients with Systemic Sclerosis: Outcomes and Considerations

EARL R. BOGOCH and DAGMAR K. GROSS

ABSTRACT.

Objective. To assess the current status of hand surgery in patients who have systemic sclerosis (SSc) and to elucidate special issues of surgery in this patient group.

Methods. A systematic review of English language original studies of surgical procedures of the hand in patients with SSc was performed using Medline, PreMedline, Embase, and Web of Science, from 1975 to March 15, 2004.

Results. Thirty-four studies were reviewed: 5 describing surgical procedures on joints, 13 on calcinosis removal, and 20 on digital sympathectomy. When the hand is affected by advanced contracture and deformity due to scleroderma, a nominal measured improvement in position and function may lead to a substantial improvement in the patient's adaptive ability to perform certain activities of daily living. A major concern is the potential for postoperative digital ischemia secondary to vascular involvement, as most of these patients exhibit blood vessel wall changes and Raynaud's phenomenon. Surgical wounds generally heal well following fusion of the proximal interphalangeal (PIP) or distal interphalangeal joint. Correction of severe flexion contractures of the PIP joint improves function and may reduce the frequency of dorsal skin ulceration. Recurrent digital tip ulceration occurs in 31.8–71.4% (median 45.2%) of scleroderma patients, reported to progress to gangrene and autoamputation in 14–29% of cases. Microsurgical revascularization of the hand, digital arterial reconstruction, and peripheral sympathectomy may improve digital vascular perfusion, heal digital ulcers, and relieve pain. Subcutaneous calcifications occur in 8.9–73.1% (median 44.1%) of SSc patients, most commonly at the fingertip, causing pain, functional impairment, and ulceration. Calcinosis can be partially removed with a high-speed burr or carbon dioxide laser.

Conclusion. The goals of surgery for advanced SSc affecting the hand are limited and include pain relief through sympathectomy and increased perfusion, repositioning the digit, providing a functional position of fusion, and modest mobilization through resection arthroplasty. (J Rheumatol 2005;32:642-8)

Key Indexing Terms:

CALCINOSIS
HAND
JOINT
SURGERY
SYMPATHECTOMY
SYSTEMIC SCLEROSIS

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From the Department of Surgery, Division of Orthopaedic Surgery, Martin Family Centre for Arthritis Care and Research, Mobility Program, St. Michael's Hospital, University of Toronto; and MedSci Communications & Consulting Co., Toronto, Ontario, Canada.

E.R. Bogoch, MD, Professor, Department of Surgery, University of Toronto, Director, Mobility Program, St. Michael's Hospital; D.K. Gross, MSc, President, MedSci Communications & Consulting Co.

Address reprint requests to Dr. E.R. Bogoch, 55 Queen St. East, Suite 800, Toronto, Ontario M5C 1R6, Canada. E-mail: bogoche@smh.toronto.on.ca

Submitted June 1, 2004; revision accepted October 12, 2004.

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