J Korean Rheum Assoc.  2010 Mar;17(1):4-15. 10.4078/jkra.2010.17.1.4.

The Surgical Management of the Rheumatoid Wrist

• Kim JY
• Park JM
• Lim GI

• KMID: 2201987
• DOI: http://doi.org/10.4078/jkra.2010.17.1.4

Abstract

The wrist joint is often involved in the early stages of the rheumatoid arthritis (RA) and is regarded as a main target of the disease. Since the wrist plays a key role in the articulations of the upper extremities, appropriate treatment of this joint will preserve the patient's work ability and independence. When surgical intervention is considered, determining the disease extent is as important as the type of rheumatoid involvement. This can be achieved by performing an extensive clinical and functional assessment of the extremities. In addition, understanding radiological findings also helps to determine the type of rheumatoid destruction, and the subsequent treatment algorithms. Success of surgical management depends on a well-considered strategy in the timing of different procedures. Prophylactic surgery, such as a synovectomy of the joint or tendon could be performed in the early stages to prevent further destruction and deformation. As destruction at the radiocarpal level progresses in the later stages of the disease, reconstructive surgery such as partial joint fusion combined with ulnar head resection, total wrist fusion or wrist arthroplasty could be considered. In the event of severe destruction, definitive stabilization by total wrist fusion is indicated. A pain-free, stable wrist joint often outweighs immobility.

Keyword

Rheumatoid arthritis; Synovitis; Arthrodesis; Arthroplasty; Inflammatory wrist; Arthropathy; Surgical management; Classification systems

MeSH Terms

Arthritis, Rheumatoid
Arthrodesis
Arthroplasty
Extremities
Head
Joints
Oxalates
Synovitis
Tendons
Upper Extremity
Wrist
Wrist Joint
Oxalates

Figure

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  Fig. 1. Intraoperative finding of 28 year-old female with 4th and 5th extensor tendon ruptures due to rheumatoid arthritis. Ruptured tendons had irregular ends by an attrition and pathologic synovial tissues were attached on their surface.

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  Fig. 2. Wrist plain radiographs of 57 year-old female (A) anteroposterior view (B) lateral view: Intercarpal and radiocarpal joints were fused. Severe narrowing of distal radioulnar joint and bony spurs projected dorsally was observed.

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  Fig. 3. Plain radiographs after excision of bony spur was completed (A) anteroposterior view (B) lateral view.

Reference

1). Moran SL., Bishop AT. Clinical update: surgical management of rheumatoid hand. Lancet. 2007. 370:372–374.

2). Simmen BR., Huber H. The wrist joint in chronic polyarthritis-a new classification based on the type of destruction in relation to the natural course and the consequences for surgical therapy. Handchir Mikrochir Plast Chir. 1994. 26:182–9.

3). Cush JJ., Lipsky PE. Cellular basis for rheumatoid inflammation. Clin Orthop Relat Res. 1991. 265:9–22.

4). Ertel AN. Flexor tendon ruptures in rheumatoid arthritis. Hand Clin. 1989. 5:177–90.

5). Shapiro JS. The wrist in rheumatoid arthritis. Hand Clin. 1996. 12:477–98.

6). Backdahl M. The caput ulnae syndrome in rheumatoid arthritis. A study of the morphology, abnormal anatomv and clinical picture. Acta Rheumatol Scand Suppl. 1963. 5:1–75.

7). Ertel AN., Millender LH., Nalebuff E., McKay D., Leslie B. Flexor tendon ruptures in patients with rheumatoid arthritis. J Hand Surg Am. 1988. 13:860–6.

8). Ferlic DC. Rheumatoid flexor tenosynovitis and rupture. Hand Clin. 1996. 12:561–72.

9). Wakefield RJ., Gibbon WW., Conaghan PG., O'Connor P., McGonagle D., Pease C, et al. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum. 2000. 43:2762–70.

10). Backman C., Mackie H. Arthritis hand function test: inter-rater reliability among self-trained raters. Arthritis Care Res. 1995. 8:10–5.

11). Labi ML., Gresham GE., Rathey UK. Hand function in osteoarthritis. Arch Phys Med Rehabil. 1982. 63:438–40.

12). Evans DM., Lawton DS. Assessment of hand function. Clin Rheum Dis. 1984. 10:697–725.

13). Souter WA. Planning treatment of the rheumatoid hand. Hand. 1979. 11:3–16.

14). Shott S. Effect of early synovectomy on the course of rheumatoid arthritis. J Rheumatol. 1993. 20:199.

15). Resnick D. Rheumatoid arthritis of the wrist: why the ulnar styloid? Radiology. 1974. 112:29–35.

16). Linscheid RL., Dobyns JH. Rheumatoid arthritis of the wrist. Orthop Clin North Am. 1971. 2:649–65.

17). Thirupathi RG., Ferlic DC., Clayton ML. Dorsal wrist synovectomy in rheumatoid arthritis-a long-term study. J Hand Surg Am. 1983. 8:848–56.

18). Ishikawa H., Hanyu T., Tajima T. Rheumatoid wrists treated with synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. J Hand Surg Am. 1992. 17:1109–17.

19). Watson HK., Ryu JY., Burgess RC. Matched distal ulnar resection. J Hand Surg Am. 1986. 11:812–7.

20). Vincent KA., Szabo RM., Agee JM. The Sauve-Kapandji procedure for reconstruction of the rheumatoid distal radioulnar joint. J Hand Surg Am. 1993. 18:978–83.

21). Ruby LK., Ferenz CC., Dell PC. The pronator quadrates interposition transfer: an adjunct to resection arthroplasty of the distal radioulnar joint. J Hand Surg Am. 1996. 21:60–5.

22). Swanson AB. Implant arthroplasty for disabilities of the distal radioulnar joint. Use of a silicone rubber capping implant following resection of the ulnar head. Orthop Clin North Am. 1973. 4:373–82.

23). McMurtry RY., Paley D., Marks P., Axelrod T. A critical analysis of Swanson ulnar head replacement arthroplasty: rheumatoid versus nonrheumatoid. J Hand Surg Am. 1990. 15:224–31.

24). van Schoonhoven J., Fernandez DL., Bowers WH., Herbert TJ. Salvage of failed resection arthroplasties of the distal radioulnar joint using a new ulnar head prosthesis. J Hand Surg Am. 2000. 25:438–46.

25). Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection interposition technique. J Hand Surg Am. 1985. 10:169–78.

26). Chamay A., Della Santa D., Vilaseca A. Radiolunate arthrodesis. Factor of stability for the rheumatoid wrist. Ann Chir Main. 1983. 2:5–17.

27). Della Santa D., Chamay A. Radiological evolution of the rheumatoid wrist after radio-lunate arthrodesis. J Hand Surg Br. 1995. 20:146–54.

28). Vicar AJ., Burton RI. Surgical management of the rheumatoid wrist-fusion or arthroplasty. J Hand Surg Am. 1986. 11:790–7.

29). Cobb TK., Beckenbaugh RD. Biaxial total-wrist arthroplasty. J Hand Surg Am. 1996. 21:1011–21.

30). Kistler U., Weiss AP., Simmen BR., Herren DB. Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis. J Hand Surg Am. 2005. 30:1282–7.

31). Rayan GM. Wrist arthrodesis. J Hand Surg Am. 1986. 11:356–64.

32). Pryce JC. The wrist position between neutral and ulnar deviation that facilitates the maximum power grip strength. J Biomech. 1980. 13:505–11.

33). Clayton ML. Surgical treatment at the wrist in rheumatoid arthritis: a review of thirty-seven patients. J Bone Joint Surg Am. 1965. 47:741–50.

34). Stanley JK., Hullin MG. Wrist arthrodesis as part of composite surgery of the hand. J Hand Surg Br. 1986. 11:243–4.

35). Juutilainen T., Patiala H. Arthrodesis in rheumatoid arthritis using absorbable screws and rods. Scand J Rheumatol. 1995. 24:228–33.

36). Rehak DC., Kasper P., Baratz ME., Hagberg WC., McClain E., Imbriglia JE. A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist. Orthopedics. 2000. 23:43–8.

37). Bora Jr. FW, Osterman AL, Thomas VJ, Maitin EC, Polineni S. The treatment of ruptures of multiple extensor tendons at wrist level by a free tendon graft in the rheumatoid patient. J Hand Surg Am. 1987. 12:1038–40.