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Review Article Plastic and Aesthetic Research

Surgical treatment of synovial-collagen

disorders of the hand

H. Kirk Watson , Purnell Traverso , Lois Carlson , Daniel Mastella , Ronit Wollstein 2,3
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1 Department of Orthopedic Surgery, Division of Hand and Upper Extremity Surgery, The Hand Center, Glastonbury, CT 06033, USA.
2 Department of Orthopedic Surgery,The Technion School of Medicine, Haifa 31096, Israel.

3 Department of Plastic Surgery, University of Pittsburgh Medical School, Pittsburgh, PA 15261, USA.
Address for correspondence: Prof. Ronit Wollstein, 3550 Terrace Street, Pittsburgh, PA 15261, USA. E-mail: ronitwollstein@gmail.com
ABSTRACT
Critical relationships between collagen and synovium exist and affect the function of the hand.
Understanding these relationships enhances the ability to perform surgery including procedures
addressing soft tissue and joint pathology. We present a series of surgical procedures based on this
principle.
Key words:
Collagen, hand, plastic, surgery, synovium

INTRODUCTION “communicates” with the adjacent collagen structures and
may cause collagen thickening and multiple symptomatic
The practice of hand surgery requires an understanding of changes. Surgery may be needed to: (1) remove inflamed
the anatomy, the intimate relationships between collagen synovium; (2) increase space around affected structures
and synovium, and the ultimate function of the hand. This and (3) remove abnormal tissues (such as osteophytes) that
is critical to the performance of surgery ranging from occur secondary to the effects of the inflamed synovium
skin coverage following a crush injury to tendon or toe on adjacent collagen structures. This surgical approach
transfers in congenital hand cases. We present a series of decreases symptoms and may enhance joint longevity.
surgical procedures based on this understanding.
Pathologic conditions resulting in synovial irritation or SURGICAL SERIES
inflammation involve an array of molecular pathways, which
can lead to the pathologic deposition of collagen in the hand Rheumatoid arthritis
and wrist. Chronically inflamed synovium will thicken adjacent The deformities in the hand in rheumatoid arthritis often
collagen and create these phenomena (the “collasyn theory”). follow a predictable pattern. The formula is destructive
In the hand, collagen and synovial tissue are anatomically synovitis plus load equals deformity. If viewed through the
closely associated. The support structures, mostly made up of lens of the collasyn theory, synovitis will rupture tendons
collagen (bones, tendons, ligaments), are lined with synovial at the distal edge (load area) of the extensor retinaculum.
tissue in areas where tissue motion requires a reduction in Synovitis also stimulates protective over‑activity of the
the coefficient of friction. intrinsics, creating abnormal loads in the fingers. These
loads most often create pressure on the dorsoradial
Surgical procedures must address the inflamed synovium, capsule and ligaments of the metacarpophalangeal (MP)
which, by virtue of its close anatomic proximity,
joint resulting in volar and ulnar subluxation of the
proximal phalanx. If there is insufficient synovitis in the
Access this article online MP joint, the MP joints will not subluxate. The intrinsic
Quick Response Code: loads then are transmitted to the fingers, resulting in swan
Website: necks, boutonnieres, dislocations or even interphalangeal
www.parjournal.net
fusion. Applying this concept allows prediction of
expected deformity on clinical examination. Tight
DOI: intrinsics (positive Bunnell test) should be released early,
10.4103/2347-9264.153192 removing the load component of the destructive formula.
The ulnar drift and deformities of the wrist are the result

Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015 47