Hand Surgery
1st Edition

69
Rheumatoid Arthritis of the Wrist
Daniel B. Herren
Beat R. Simmen
Rheumatoid arthritis (RA) is the most common systemic inflammatory disease with a world-wide prevalence of approximately 1% and an incidence rate of 0.03% (1). The majority of patients develop RA between the ages of 30 and 60 years. RA is a chronic, systemic autoimmune disease that is characterized by an immunologically caused chronic inflammatory synovitis. Probably driven by a still unknown antigen response, a cascade of immunologic and inflammatory processes are mediated, which finally lead to destruction of joints and soft tissues. Genetics seem to play an important role in the pathogenesis of RA. In monozygotic twins, there is a 30% to 50% chance of that both persons are affected, compared to a 1% rate in the general population (2,3). Besides the possible genetic background of the disease, bacterial and viral infection have been speculated as trigger agents that cause RA (4,5). However, newer studies suggest that osteoclasts mediate focal bone erosion. This may offer a new approach for the treatment of this disease (6).
The onset of RA shows first an acute inflammatory reaction within the synovial membrane, which becomes congested (7). As shown by magnetic resonance imaging (MRI), the degree of synovitis correlates with the edema formation of the periarticular bone (8). Along with this acute inflammation, a complex cell transformation within the synovial cells starts, including cellular and humeral immunologic processes. Becoming chronic, as a process, the inflammation leads to the formation of the so-called rheumatoid pannus, which is a mass of granulation tissue that includes all cell mediators of chronic inflammation surrounded by a matrix of connective tissue (9). This pannus plays an important role in the destruction process of the cartilage of the affected joint and may show tumorlike characteristics.
One of the major areas of current investigation in RA includes the role of cytokines in the pathogenesis. Cyto-kines are molecules that are synthesized locally and have a strong biological effect in the cell-mediated processes of the disease. The best known cytokines are interleukin-1 (IL-1) and tumor necrosis factor α (TNF-α). Both molecules promote inflammation with stimulation of other inflammatory factors (10). The understanding of the complex mechanism in the action of these cytokines gave the rationale to the development of new drugs that fight the inflammatory process (11,12). These more biological therapies, especially the anti–TNF-α drugs, changed the face of the disease for many patients.
The advances in the understanding of the pathogenesis of RA will open new ways for therapy in the future. Besides the aforementioned anticytokine therapy, anti–T-cell therapy might be another interesting form of biological treatment. Different trials with anti–T-cell antibodies could prove some clinical benefit. Gene therapy, a completely different and new treatment approach, may bring a major revolution in the future (13).
The recognition of the pattern of progression of the disease in general may have important implications in the management of the patient. A prospective study by Masi et al. (14) described three different patterns of articular involvement: a monocyclic form that is seen in 20% of the patients who have a single cycle of disease with remission for at least 1 year, a polycyclic course in 70% of the patients with an intermittent or continuing course, and a progressive pattern in approximately 10% of patients with increasing joint involvement over a long period of time. In addition, different factors were identified as indicators of poor outcome in RA (15,16 and 17) (Table 1).
Taking all these factors together, one realizes that RA is a disease with many different faces. Thus, treatment should be individualized for every patient.
NATURAL COURSE OF THE RHEUMATOID WRIST
Adult Rheumatoid Arthritis
The wrist, as one of the main targets in RA (18,19), plays a key role in the chain of the articulations in the upper extremity. The understanding of the pathomechanics and the possible course of the disease allows an individualized management for every patient.
TABLE 1. FACTORS FOR POOR OUTCOME IN RHEUMATOID ARTHRITIS
Female gender Subcutaneous nodules
Older age Low education level
Radiologic destruction Extraarticular disease
High-titer rheumatoid factor HLA-DR4 positivity
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Three main factors play an important role in the pathologic process of wrist deformation: cartilage destruction, synovial expansion, and ligamentous laxity. The cartilaginous thinning is caused by cytochemical effects with degradation and inhibition of new cartilage synthesis (20). The synovial expansion may cause bony erosion, particularly at the sites of vascular penetration of bone, such as in the radial origin of the Testut ligament. These erosions cause sharp bony edges, which might lead to tendon rupture (21). In addition, synovial expansion causes stretching of the retaining extrinsic and intrinsic ligaments of the wrist, thus causing carpal supination and ulnar translation (22,23). The stretching of the scapholunate ligament results in a scapholunate dissociation, whereas more global laxity and instability are responsible for the ulnar translation (24). Force application across the wrist is predominantly caused by muscles which act in palmar and ulnar directions. With ongoing destruction of the rheumatoid wrist, they lose their physiologic moment arms in relation to the center of rotation and become a deforming force (22,25). Youm et al. (26), in describing the carpal height ratio, measured rheumatoid wrists and summarized the aforementioned pathomechanical effects, which create a reduction of the carpal height. Parallel to the processes at the radiocarpal and midcarpal joints, the distal radioulnar joint undergoes pathologic changes, which were first described by Backdahl (27) and subsequently were called the caput ulnae syndrome. The ulnar side of the wrist is often the first place of significant synovitis in the rheumatoid wrist. Long-term prognosis, however, is determined by the progression of the disease at the radiocarpal level. Together with progressive ligamentous laxity, a dorsal subluxation of the ulna or, even more frequently, a palmar subluxation of the carpus occurs. An associated supination of the carpus causes a luxation of the extensor carpi ulnaris (ECU), a major stabilizer of the ulnar side of the wrist and the distal ulna. The kinematics of the distal radioulnar joint change with a displacement of the center of rotation. This may cause a radioulnar impingement and a painful block in supination (28). This wrist deformity pattern has an influence in the development of deformities of the distal aspects of the hand. Shapiro et al. (29) associated radial carpal supination together with palmar subluxation with ulnar phalangeal drift (25,30), ulnar carpal translocation with radial phalangeal deviation, and loss of carpal height with swan-neck deformity of the fingers (31).
FIGURE 1. Type 1 (ankylosing) rheumatoid wrist with spontaneous fusion of the radiolunate joint.
Disease activity and, thus, deformity pattern vary considerably in RA patients. To typify the different pattern of wrist involvement, Flury et al. (32) and Simmen and Huber (33) described, based on serial radiographs over the course of the disease, three distinguished types of destruction. They are classified as type 1, 2, or 3 wrists. Type 1 rheumatoid wrists show a spontaneous tendency for ankylosis (Fig. 1); type 2 wrists show a destruction pattern that resembles the osteoarthritic wrist, with changes remaining relatively stable over time (Fig. 2); and type 3 wrists show a
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disintegration with progressive destruction and loss of alignment. Type 3 is further subdivided into types 3A and 3B: Type 3A (Fig. 3) has more ligamentous destabilization, and type 3B (Fig. 4) shows more bony destruction with, finally, complete loss of the wrist architecture. The classification into the different types of the natural course of the disease at the wrist level is based on serial radiographs with measurements of carpal height ratio (26) and ulnar translation (34). A change in the carpal height ratio of more than 0.015 or an increase of ulnar translation of more than 1.5 mm per year, or both, classifies a wrist in the type 3 category (32). An extension of this classification, combining the typing and staging of the destruction in the wrist, is presented in the section Classification and Treatment Algorithm of the Rheumatoid Wrist.
FIGURE 2. Type 2 (arthritic-arthrosis) rheumatoid wrist with a destruction pattern that is similar to osteoarthritic changes. The carpus is still well centered, with destruction of the radiocarpal and the midcarpal joints.
FIGURE 3. A type 3A (ligamentous unstable) rheumatoid wrist that shows complete dislocation of the carpus to the palmar-ulnar side, with preserved bone stock.
FIGURE 4. The type 3B (bony unstable) rheumatoid wrist with complete bony destruction, loss of bone stock, and dislocation of the carpus.
Juvenile Rheumatoid Arthritis
Juvenile rheumatoid arthritis (JRA) is the most common connective tissue disease during childhood. Clinically, it may present as a classical polyarthritis, as pauciarthritis with fewer joints involved, or as Still’s disease with more systemic symptoms, such as fever and rash. The basic inflammation mechanism and the pathophysiology is similar to RA in adults. In contrast to adults only, in approximately 20% of JRA cases, the rheumatoid factor is positive, and the diagnosis is often given by the clinical symptoms and the radiographic changes (35,36,37 and 38). The knee and the wrist are the two areas in which bony changes most commonly are seen (39). The basic medical treatment of JRA is similar to treatment in adults. It is widely accepted that the treatment in this young patients’ group should be aggressive, and the introduction of methotrexate has changed the prognosis dramatically (40,41).
Wrist involvement in JRA occurs in approximately 60% of the patients (37,38). Muscle imbalance, together with the physiologic palmar tilt of the radius and the stretched ligaments, leads to a progressive palmar subluxation of the radiocarpal joint. Spontaneous wrist joint fusion is significantly more common in patients with JRA compared to adults (42). The wrist often gets stiff in palmar flexion and ulnar deviation (37,38,42,43,44,45 and 46).
Because these patients are young, and their skeletons are often still immature, conservative therapy with splinting and physical therapy plays an important role.
The general surgical approach is similar to that for adult RA. The indication for a surgical treatment depends on the clinical course of the disease. It is generally accepted that wrist synovitis that is persistent to medical treatment for more than 6 months should be addressed surgically (47,48,49 and 50). Pain relief after synovectomy is significant, and recurrent synovitis is uncommon. Radiosynoviorthesis is contraindicated in children (47). Owing to the aforementioned spontaneous wrist fusion pattern, corrective osteotomy with arthrodesis in a more functional position might be needed.
The distal ulna should be addressed more conservatively in children than in adults. In contrast to adults, JRA children develop, because of different epiphyseal growth, most often a shortened ulna. Open physes preclude distal ulnar resection, which would exacerbate the length discrepancy. Hemiresection arthroplasty or a Sauve-Kapandji procedure,
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combined with a synovectomy of the distal radioulnar joint, is preferred by some (39); ulnar lengthening is preferred by others (51). Some cases require a simultaneous radial corrective osteotomy. During hemiresection types of procedures, the periosteum has to be removed carefully, because children tend to reform new bone.
EPIDEMIOLOGY OF WRIST INVOLVEMENT IN RHEUMATOID ARTHRITIS
The first recognized report on RA goes back to 1800 with an article by Landré-Beauvais. As of 2003, there is still no specific diagnostic marker available, and the diagnosis relies on certain clinical, radiologic, and serologic criteria. The most commonly used criteria for the classification of RA were defined by the American College of Rheumatology. Among the criteria, arthritis of the hand joint, including the wrist, is rated with the highest sensitivity (96.6%) with a specificity of 74.8% (52). Most authors believe that the onset of RA is multifocal or that it starts in the hand (18). Usually, the wrist joint has an early involvement in the course of the disease and is rapidly destroyed once it is hit by the inflammation process (19). It might be expected that 10 years after the onset of the disease 90% of the wrist joints show symptoms compared to 75% of the shoulders and 60% of the elbows (19). There are few data available for the joint that are affected in juvenile arthritis, but it seems that the prognosis for this group of patients, regarding destruction of the wrist joint, is even worse (38).
Soft tissue involvement around the wrist is common. Pulki (53) reported on a series of 500 hospitalized patients. He found synovitis in 32% and tendon ruptures in 7%. It might be speculated, confirmed by clinical experience, that the rate of soft tissue involvement is even higher. Along with flexor tendon synovitis, median nerve compression is observed in as much as 50% of patients (54,55).
EVALUATION OF THE RHEUMATOID WRIST
Clinical Examination
RA is a disease process that affects almost all organ systems in the body and is not limited to the musculoskeletal system. On first examination of a patient who has RA, a complete history and physical are mandatory. It is important to know about conservative therapy, especially current medication. An extensive history allows the physician to learn about the patient’s needs, demands, and wishes, which are important factors when talking about indications for surgery. The presence of deformity does not necessarily lead to functional impairment. It is important to recognize the individual activity of the disease in every patient and to find possible points of improvement within the conservative treatment strategy. RA is a life-long condition, and the disease activity might change over time. Current activity, possible future course, and interaction of joint problems should always be considered (56). Lower extremity treatment in RA treats the ability to walk; treatment of the disease that affects the upper extremity preserves the patient’s ability to work and to remain independent.
The physical examination should always check the whole chain of articulations within the limb to be treated. Because the elbow joint places the hand in space, bad function of this joint might endanger the result of interventions at the level of the hand.
When assessing the function of the upper extremity, the following parameters should be checked:
  • Localized swelling and tenderness; the extent and the exact anatomic localization should be noted.
  • The degree and location of the deformity should be checked; the degree to which the deformity is actively or passively correctable should be distinguished.
  • The range of motion, using a goniometer, should be recorded according to the neutral-zero method; at the level of the hand, all joints should be measured, regardless of the planned site of intervention.
  • The examination of the wrist differentiates between the radiocarpal, midcarpal, and distal radioulnar joints.
  • Often due to marked deformity or pain, or both, the classic instability signs in the wrist might be difficult to check; do not hurt the patient more than necessary during the examination.
  • Check for tendon continuity; especially important tendons on wrist level are the radial-sided extensors. Independent function of the superficial and deep flexors must be controlled, as well as independent function of the two extensors in the second and fifth digits.
  • Compression neuropathy, especially carpal and cubital tunnel syndrome, should be ruled out; sensibility should be checked using the two-point discrimination method.
  • If applicable, strength measurement should be performed; grip strength and key pinch are recorded, using a Jamar dynamometer or a vigorimeter.
Additional Examinations
Radiologic Examination
The type and the extent of the destruction in the wrist are best seen in conventional radiographs, which should always be taken in at least two different planes, preferably in anteroposterior and true lateral views. It is not only the actual destruction that is of interest but also the evolution of the destruction over time. Radiographs that are taken in fixed intervals (depending on the activity of the disease, in 6- to 12-month intervals) give additional important information to optimize surgical treatment strategy (33,57). In the early course of the disease the radiographs should be
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read for supple signs of inflammation and destruction, such as joint effusion and erosions. Among the different radiologic classifications, the staging system that was created by Larsen, Dale, and Eek (LDE) is the most common (58) (Fig. 5). The LDE classification differentiates between six stages of destruction in which stage I represents the least extent of destruction and stage V stands for the final stage, with complete destruction of the wrist joint. Because the LDE classification only describes the extent of the actual destruction, the natural course of the disease and optimal treatment modalities are difficult to assess. The Wrightington group, which centered around the work of Hodgson et al. (59) and Alnot and Fauroux (60), tried to incorporate more practical guidelines in their rheumatoid wrist classification schemes. Despite the more practical approach, both classifications still lack the ability to anticipate future development of wrist destruction. Based on radiologic long-term analysis, Simmen and Huber (33) and Flury et al. (32) proposed a new classification of rheumatoid wrist involvement that considers the type of destruction to the possible future development of the disease, with direct consequences of surgical decisions. Three patterns of destruction are distinguished, based on the morphology of destruction and the course and duration of the disease (for details see the section Natural Course of the Rheumatoid Wrist).
FIGURE 5. Radiologic staging according to Larsen et al. (58). Stages 0 to V in the rheumatoid wrist.
Computed Tomography and Magnetic Resonance Imaging
Computed tomography (CT) and MRI are rarely indicated in the evaluation of a rheumatoid wrist. There is limited additional information that these examinations could provide. If a special hand MRI is not available, most RA patients do not tolerate the uncomfortable position on the examination table. However, MRI has a higher sensitivity and a higher negative predictive value with equal specificity than regular x-ray examination for detecting inflammatory changes (61).
For the following conditions, CT or MRI examination might be considered:
  • Evaluation of the amount and extent of synovitis in an unclear diagnosis or in the early stages of the disease (MRI)
  • Extent and localization of tenosynovitis and tendon ruptures, especially in the flexor tendons (MRI)
  • Assessment of disease activity and monitoring of response to medication (MRI) (62,63 and 64)
  • Evaluation of the distal radioulnar joint (CT)
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Sonography and Three-Phase Bone Scintigraphy
Sonography as a diagnostic tool gets more and more popular, and the introduction of high-resolution transducers with 15 MHz enhanced the diagnostic value. Experienced examiners with linear scanner mode probes achieve the precise detection of erosions and synovitis with a high intra- and interobserver reliability (65). This technology has good potential, especially in early stages of the disease, and might be an important supplement in the armamentarium of diagnostic tools.
Three-phase bone scintigraphy has the advantage of evaluation of the whole body, which might be of importance at the beginning of the disease to sort out the most actively inflammatory joints (61). However, scintigraphic changes are never as specific as they are in the other diagnostic tools and must be seen as a part of a whole examination complex.
Electrophysiology
The incidence of compression neuropathy in patients who have RA is high. Carpal tunnel syndrome in association with flexor tenosynovitis is observed in as much as 60% of the patients (66) (Fig. 6). The second most frequent involvement includes the ulnar nerve at the level of the elbow. Because the regeneration potential of compressed peripheral nerves, especially in older patients, is limited, and the results of nerve decompression generally are good, indications for the decompression procedure should be generous (67). Even in the absence of clinical symptoms, peripheral nerve damage may be present (68). Shinoda et al. (69) therefore proposed a new grading system for carpal tunnel syndrome, including clinical signs and symptoms rather than electrodiagnostic findings. This grading system facilitates operation indications and helps choose the appropriate surgical procedures.
FIGURE 6. Severe compression neuropathy of the median nerve. The arrow points to the pseudoneuroma, which developed owing to flexor tendon synovitis in the carpal tunnel.
Besides entrapment neuropathy, myelopathy and spinal cord involvement, especially at the level of the cervical spine, are common in RA (70). Because subjective and objective neurologic symptoms may develop gradually and often are masked by the joint and soft tissue involvement, patients who report bilateral disturbance of sensory motor function in the hand must be evaluated for possible pathology at the level of the cervical spine. Radiologic screening of the cervical spine includes anteroposterior and lateral views, as well as functional radiographs in active flexion and extension. The presence of cranial migration of the dens and instability of the atlantoaxial should be checked (71). If instability is suspected, MRI examination of the cervical spine is indicated, and, besides the classical electrophysiologic measurements, transcranial brain stimulation helps evaluate the central motor pathways (72).
Functional Assessment of the Rheumatoid Wrist and Hand
To evaluate the pretherapeutic state of the hand, disease progression, and outcome of treatment, specific assessment tools of wrist and hand function are needed. Functional instruments should ideally be quantifiable, valid, reliable, and sensitive to change (46). Because not only improvement of single function parameters but also general improvement of health status and quality of life should be measured, specialized tools were developed. In patients with RA, three different approaches to assess the extent to which the hand is affected might be differentiated:
  • Description of the anatomic deviation and disorders. Usually, the deformities are recorded by measuring them with the use of a goniometer, completed with photographic documentation (73). Video-based image analysis might be a newer approach to describe deformity in a more standardized fashion (74).
  • Measurement of functional deterioration. To assess the functional deterioration of a rheumatoid hand, different tests have been described (75,76,77 and 78). These tests have a more generalized approach to measure hand function and allow judgment of hand function in complex deformity patterns. However, limitations in the activities of daily living may be more important for the patient than impairment in a single complex task. Therefore, newer tools to measure hand-related function in the activities of daily living have been introduced. The focus is more on disability than on functional deterioration.
  • Assessment of disability. The tools to measure disability are usually self-administered questionnaires. There
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    are more general assessments of upper extremity function, like the Disabilities of the Arm, Shoulder, and Hand questionnaire, or more hand-related (Michigan hand outcomes questionnaire) (80) and wrist-related (patient-rated wrist evaluation questionnaire) (81) tools. All these questionnaires try to assess function under subjective aspects.
All of these tests must be performed by specialized trained therapists and allow the therapist to judge changes before and after treatment. Ideally, every patient with the diagnosis of RA should be evaluated in a standardized manner before treatment starts.
INVOLVEMENT OF THE SOFT TISSUES AROUND THE WRIST
Flexor Tendons
Tenosynovitis of the flexor tendons at the wrist is a common finding in RA. At the wrist level, it may cause locking, limitation of motion, nerve compression, and, as an end stage, rupture of tendons. Early clinical signs include localized pain, morning stiffness, triggering of single digits, and nocturnal paresthesia due to carpal tunnel syndrome. An unusual presentation might be the so-called trigger wrist, in which synovial nodules within the flexor tendons may cause triggering during the passage underneath the transverse carpal ligament (82). In rheumatoid patients, flexor tendon involvement seems to correlate with a higher disease activity. Gray and Gottlieb (83) observed a significantly higher prevalence of rheumatoid nodules, carpal tunnel syndrome, wrist extensor synovitis, and elbow epicondylitis in patients with active flexor tendon inflammation. Duche et al. (84) distinguished three main groups of synovitis: isolated carpal tenosynovitis (20%), palmodigital tenosynovitis (50%), and diffuse teno-synovitis (30%). Ruptures of flexor tendons are significantly less frequent than extensor tendon ruptures in RA (83,85,86 and 87). The two main mechanisms of tendon destruction are invasion of the tendon by the inflammatory synovial mass or attrition on prominent bony spurs, or a combination of both (86,87,88,89,90,91 and 92). Owing to its anatomic localization near the scaphoid, the flexor pollicis longus (FPL) tendon, followed by the profundus to the index finger, is the most common flexor tendon to rupture (93). It is not only a direct bony spur but also the carpal instability in advanced wrist destruction that might cause the tendon attrition (89,91). Next in the order of decreasing frequency of rupture are the profundus tendon to the little finger, for which rupture is caused by an ulnar side bony spur; the superficialis tendon to the index; and the remaining profundus tendons.
Although FPL and also index profundus ruptures often cause little disability in rheumatoid patients, aggressive indication for revision surgery is warranted to prevent further tendon rupture (for reconstructive surgery see the section Tendon Reconstruction) (Fig. 7).
FIGURE 7. Intraoperative finding of multiple extensor ruptures. The aspects of the tendon ends suggest an attrition mechanism.
Extensor Tendons
The anatomy of the extensor tendon compartments of the wrist causes a different clinical picture than the involvement of the flexor tendons. Valeri et al. (94) observed in an extensive MRI study more peritendinous effusion in the flexor compartment, whereas, in the dorsal compartments, higher degrees of tendon fluid collection or pannus within the tendon sheath, or both, was found. The extensor tendons are surrounded by tenosynovium, beginning just before the proximal border of the extensor retinaculum and continuing several centimeters distal to the retinaculum. More distally, the tendons are covered by a peritenon rather than a tenosynovium. These anatomic features defined the localization of tenosynovitis in the extensor compartment. Extensor tenosynovitis often presents as a painless soft tissue mass at the dorsum of the wrist in the area of the retinaculum or, more frequently, distal to it. Pain in the extensor tendons, unlike the flexor tendons, is unusual; in theses cases, an underlying wrist pathology must be excluded. Correlated wrist and finger extension might cause impingement of the tenosynovial mass. Extensor tendon synovitis, especially at the ulnar side of the wrist, can be the first sign of RA in a patient. The tenosynovitis may be limited to one single tendon or a tendon compartment or may be more generalized. Involvement of the first tendon compartment is rare (95). In the initial stages of inflammation, fluid production is increased, followed by synovial thickening with adhesions to the tendons (94). In the further course, the synovium continues to proliferate and creates granulomas that infiltrate the tendons. It results in weakening of the tendon with possible rupture (96). The amount of synovial mass in the extensor compartments does not correlate with the degree of tendon damage, and prediction of possible ruptures is difficult, even when MRI as a diagnostic tool is used (97). The final rupture of an extensor tendon might be the end of a process with synovial infiltration, attrition
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on bony prominence, and ischemia (95,98,99 and 100). Dorsal dislocation of the ulna and persistent tenosynovitis of more than 6 months are additional risk factors (101). Owing to its anatomic course, the tendon of the extensor digiti minimi ruptures first. This rupture might be clinically silent, because the extensor digitorum communis extends all four fingers. Therefore, patients must be checked for independent little finger extension (102). Subsequently, the tendons may rupture from ulnar to radial, whereas index tendon ruptures are rare (Figs. 7 and 8). If a patient is unable to extend all four fingers, as well as the distal end of the thumb, he or she should be evaluated for possible interosseous nerve entrapment at the level of the forearm (103).
FIGURE 8. Clinical picture of caput ulnae syndrome with ruptures of the extensor tendons to the small and ring fingers.
OPTIONS FOR NONOPERATIVE TREATMENT
The goals of the treatment of RA are the reduction of inflammation and the preservation of joint function. These goals are achieved best by a combined approach, including medical, surgical, and rehabilitation modalities (104). It is recognized that, after the onset of the disease, only 1 or 2 years are left before irreversible damage to the cartilage occurs (105). Therefore, aggressive medical treatment in early stages of the disease should be used. The decision of which type of basic medication is indicated is based on the clinical, laboratory, and radiologic findings, which define the activity and the prognosis of the disease. Despite this aggressive approach, true remission of the disease, as defined by the American College of Rheumatology (106), remains difficult to achieve. A current classification for antirheumatic drugs distinguishes between symptom-modifying antirheumatic drugs and disease-modifying antirheumatic drugs. Symptom-modifying antirheumatic drugs improve clinical symptoms without modifying the course of the disease in a certain period (e.g., nonsteroidal antiinflammatory drugs); disease-modifying antirheumatic drugs are able to prevent or even to decrease joint erosions and improve function in association with decreased inflammatory activity (e.g., methotrexate).
Antiinflammatory Agents (Nonsteroidal Antiinflammatory Drugs)
Antiinflammatory agents as potent inhibitors of cyclooxygenase and prostaglandin are an important part of the treatment in RA. These drugs have a positive influence on pain and inflammation but do not inhibit synovial proliferation; thus, they have no influence on the progression of the disease. Newer drugs with selective cox-2 inhibition should have fewer side effects. These drugs are particularly useful in the early phase of the disease, when spontaneous remission is still possible. In the later course of the disease, they have more complementary function.
Corticosteroids
Low-dose corticosteroids combined with nonsteroidal antiinflammatory drugs are particularly useful while waiting for the effect of the so-called second-line drugs or to cut a flare-up of the disease. The long-term complications are significant and increase in dosages larger than 10 mg per day. Local intraarticular or soft tissue injections of glucocorticoids remain an important weapon in well-localized processes. However, in cases of regular local recurrence, surgical treatment should be considered.
Second-Line Drugs
Second-line drugs include slow-acting drugs like antimalarial agents, gold, salazopyrin, D-penicillamine, cyclo-sporin, and methotrexate. These drug have, using different mechanisms, disease-modifying characters. With the help of these drugs, a good control of disease activity and an improved function may be achieved in approximately 30% of RA patients (107). All of these drugs have significant side effects, and close monitoring of the patients is needed. There is no doubt that the early use of methotrexate may change the course of the disease significantly (108).
Parallel to the better understanding of the pathophysiologic mechanism of RA, new therapeutic approaches were developed. The so-called biological agents target various aspects of the immunosystem that are involved in the pathologic process. In particular, anti–TNF-α and anti–IL-1 antagonists changed the therapy of RA dramatically. Several clinical trials could show that these agents significantly decrease the signs and symptoms of joint inflammation and slow down the progression of radiologic joint damage (12,108,109,110,111,112 and 113). Longer clinical follow-up studies are missing, and careful monitoring of patients is needed, because a higher incidence of infection under this medication is reported (113,114).
FIGURE 9. Cock-up resting splint with dorsal cover.
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Radiosynoviorthesis
Radiosynoviorthesis is a synovectomy with the use of radioisotopes. The most commonly used isotopes are yttrium 90, rhenium 186, and erbium 169. These isotopes act with β-rays in the absence of α-rays. The choice of which isotope is used depends on the joint that is to be treated and on the activity of the disease. Yttrium, for example, is the agent of choice for hip and knee synovectomy owing to its deep penetration. Rhenium is chosen for middle-sized joints, such as the wrist and the elbow, and erbium is more frequently used in small joints. Radiosynoviorthesis can only be used in closed joint spaces, and, therefore, its use, for example, in the shoulder, where rotator cuff lesions are frequent, is limited. The results of the synoviorthesis depend on the stage of the disease (the earlier the better), the joint that is treated (the knee has better results than the wrist), and the amount of synovitis. To enhance the results of synoviorthesis, a preceding surgical synovectomy may be performed. Usually, a interval of 6 to 8 weeks after surgery is needed to allow the joint capsule to heal. Indications for synoviorthesis decreased parallel to the reduction of synovitis that was observed with the new therapeutic agents.
Role of Physical and Occupational Therapy
In the team approach of fighting RA, physical, and especially occupational, therapists play an important role. The goals of physical and occupational therapy are pain alleviation and maintenance or improvement of mobility and function, as well as maintenance of strength. The traditional, well-established methods of physical therapy can be used to achieve theses goals. It is of crucial importance to respect the patient’s individual disease pattern and activity, as well as his or her personal needs and preferences. Multijoint involvement forces the therapist to set priorities and to establish a balanced treatment plan. Newer therapy forms, such as aqua jogging, have become more popular.
FIGURE 10. Dynamic wrist splint for mobilization in palmar flexion.
FIGURE 11. Assistive device for cutting bread.
It is important to document the patient’s status on a regular basis, including functional photographs. This documentation helps to judge the efficacy of a therapy and is an important additional source of information when a surgical strategy is chosen.
Splints are an important work horse in occupational therapy and require high technical skills, as well as an understanding of the pathophysiology of the disease. Modern thermoplastic materials offer an almost infinite variety of splints (Figs. 9 and 10).
Preoperative indications for splints are
  • Resting splints for painful inflamed joints
  • Correction of deformities with static or dynamic splints
  • Inhibition or correction of tissue contraction
The postoperative indications for splints include
  • Stabilization of the joint in physiologic axes
  • Protection of sutured tissues
  • Stretching of postoperative contractions
  • Training of assistive or resistive joint mobility
Ergonomic instruction helps protect the affected joints. The patients must learn to keep optimal posture in leisure, as well as during activity. The use of assistive devices in the activities of daily living might preserve the patient’s independence (Fig. 11).
SURGICAL MANAGEMENT OF THE RHEUMATOID WRIST
Timing of Surgery
The success of surgical reconstruction highly depends on a well-considered strategy in timing the different surgical
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procedures. The goals of surgical interventions in RA include alleviation of pain, functional improvement, prevention of future deformity, and cosmesis. Table 2 summarizes the factors that might influence the indications for surgical procedures. Whenever possible, surgery should be performed under stable medical conditions; this provides a fitter patient and allows the identification of the most active parts of the local disease (115). The following general rules, based on the work done by Souter (56,115), should serve as a rough guideline when choosing priorities in the surgical sequence (Table 3). To classify surgical interventions in RA, Souter (115) also established a ranking system of operations. Based on the parameters of elimination of pain, improvement of function, preventive value, cosmetic improvement, and hazard of complications, with a maximum score of 20 points, the possible operations are ranked as first-order (more than 15 points), second-order (12 to 15 points), or third-order (less than 12 points) interventions. At the level of the hand and wrist, Table 4 lists the corresponding procedures. It is certainly advised, if there is a choice, to start with a first-order intervention or a so-called winner operation. This gives confidence to the patient, as well as to the referring physician.
TABLE 2. FACTORS THAT INFLUENCE THE INDICATIONS FOR RHEUMATOID ARTHRITIS SURGERY
Concomitant musculoskeletal involvement Patient’s desires
General health condition Compliance
Disease activity Social environment
Patient’s needs Medical environment
Table 4 considers the possible combination of operations within the hand and wrist or within other anatomic regions. As a multijoint disease, rheumatoid patients often require an almost endless number of interventions, and one might be tempted to pack as much as possible into one single procedure. A combination of foot and hand operations may make sense, if there are no crutches needed for the protection of the lower limbs postoperatively. To restore prosupination, ulnar head resection with dorsal wrist synovectomy might be combined with radial head resection and elbow synovectomy. A careful analysis of the needs during rehabilitation is important before a combined procedure is proposed.
TABLE 3. SOME GENERAL RULES FOR RHEUMATOID SURGERY
Lower limb before upper limb
From proximal to distal
Painful joints first
Prophylaxis versus reconstruction versus salvage
Consider combinations: hand and foot, elbow and wrist, wrist and metacarpophalangeal joints
Start with a winner operation (Table 4)
TABLE 4. RANKING OF OPERATIONS ACCORDING TO THE EFFECT THAT CAN BE EXPECTED
Ranking Operation
First order Caput ulnae resection
Dorsal tenosynovectomy
Arthrodesis of first MCP joint
Synovectomy of flexor tendons
Second order Arthroplasty of the MCP joints
Arthrodesis of the proximal interphalangeal joints
Correction of swan-neck deformity
Carpal synovectomy
Carpal arthrodesis (arthroplasty)
Third order Synovectomy of MCP joints
Correction of boutonnière deformity
Proximal interphalangeal arthroplasty (carpal arthroplasty)
MCP, metacarpophalangeal.
Adapted from Souter W. Planning treatment of the rheumatoid hand. Hand 1979;11:3.
In general, despite the aggressive medication and the nature of the disease, bone and soft tissue healing are considered to be normal in RA. Whether immunosuppressive medication should be discontinued in the perioperative phase is still controversial. Studies (116,117) and personal experience suggest the continuation of the medication; the possible benefits of discontinuation do not outweigh the risk of a flare-up of the disease.
Prophylactic Surgery
Synovectomy of the Wrist Joint
Before wrist synovectomy is indicated, ideally, a classification of the type of destruction is useful. According to the Schulthess classification (33), types 1 (ankylosis) and 2 (arthritic) wrists may qualify for this procedure, whereas, in type 3 wrists (destabilization), in addition to the synovectomy, bony stabilization is needed. In early stages of the disease, it may be difficult to distinguish these different types.
The removal of synovitis decreases the pressure in the joint and may have some sort of prophylactic effect before the synovial mass has stretched the retaining structures (118). In addition, some denervation effect is supposed (119,120,121,122 and 123). With the newer second-line drugs, the number of isolated wrist synovectomies is decreasing. The main effect of synovectomy is pain relief but often at the expenses of some wrist motion, especially in flexion (124,125,126,127 and 128). To diminish this problem, arthroscopic synovectomy might be considered in selected cases of localized synovitis if no extensor tendon or distal ulna treatment is needed (129,130,131 and 132).
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In general, the indications for carpal synovectomy include
  • Persistent synovitis that does not respond to adequate medication for more than 6 months
  • Persistent pain and localized tenderness without major bony deformation
  • Treatment in combination with dorsal tenosynovectomy or treatment of the distal ulna, or both
Technical Aspects
The rheumatoid wrist is approached via a dorsal straight incision that is centered over the axis of the third metacarpal. The subcutaneous tissue dissection is limited on the radial side by the identification and protection of the delicate superficial branches of the radial nerve and on the ulnar border of the wrist by the identification of the superficial branch of the ulnar nerve. The extensor retinaculum is longitudinally divided in the interval between the fifth and sixth extensor compartments. If needed, an extensor synovectomy is performed. The terminal branch of the posterior interosseus nerve is identified on the radial floor of the fourth extensor compartment and is resected for approximately 2 cm. The wrist joint is opened with a longitudinal incision in the axis of the capitate, and two triangular flaps raised from the radius, or it is opened with the approach that was described by Berger (133) (Figs. 12 and 13). This gives access to the radiocarpal and midcarpal joints, and synovectomy can be performed by using special rongeurs. An extension device might help reach all corners of the wrist joint. The capsule is closed preferably with absorbable sutures. Testing the closure on the operation table, the surgeon must ensure that the closure is not too tight and does not limit flexion. In cases of capsular defects, the distal part of the retinaculum is used as capsular reinforcement. The authors prefer to divide the retinaculum in any case and to protect the tendons distally by placing the distal one-third to the distal one-half of the retinaculum underneath the extensor tendons. There is no need for formal reconstruction of the different extensor compartments, but the sixth compartment, containing the ECU, must be recentered over the distal ulna. Some authors advocate, in cases of beginning ulnar translation, a tendon transfer of the extensor carpi radialis longus to the extensor carpi radialis brevis (125,134,135), a method that the authors do not perform. If needed, subcutaneous drainage is placed, and the skin is closed carefully.
FIGURE 12. A: Dorsal wrist approach with radial-based capsulotomy. Outline of the incision. B: Dorsal wrist approach with radial-based capsulotomy after elevation of the capsular flap with good exposure of the radiocarpal and midcarpal joints. C, capitate; DIC, dorsal intercarpal ligament; DRC, dorsal radiocarpal ligament; H, hamate; L, lunate; LT, lunotriquetral; R, radius; S, scaphoid; T, triquetrum. (From Berger RA, Bishop AT. A fiber-splitting capsulotomy technique for dorsal exposure of the wrist. Tech Hand Upper Extrem Surg 1997;1:2–10, with permission.)
During the rehabilitation process, the wrist is placed in a resting splint in the intrinsic-plus position. Gently, movement might be started after secured skin healing. The aggression in the rehabilitation process should be individualized according to the healing properties of the patient and the preoperative status and intraoperative findings. Wrists that tend to be unstable should be protected longer, whereas stiff wrists may be mobilized more aggressively. All patients need some sort of wrist protection for at least 4 to 6 weeks.
Synovectomy of the Tendons
Extensor Tendons
Similar indications for extensor tendon synovectomy are given as those in the indication list of wrist synovectomy. Persistent,
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even painless, swelling in the extensor compartment after adequate medical treatment indicates a surgical intervention. Clinically, it is almost impossible to select patients with the highest likelihood of tendon rupture. Rarely, isolated extensor tenosynovectomy is performed, because most patients with RA have some sort of involvement of the distal radioulnar joint or the radiocarpal compartment that must be addressed at the same time. In cases of tendon rupture, patients must be informed of the consequences of tendon reconstruction or untreated ruptures (see the section Extensor Tendons in the section Tendon Reconstruction).
Flexor Tendons
The two main indications for isolated flexor tendon synovectomy are carpal tunnel syndrome and revision of tendon ruptures. As outlined in the section Flexor Tendons in the section Involvement of the Soft Tissues around the Wrist, carpal tunnel is frequent in RA, and a generous indication for decompression, together with a tendon revision and synovectomy, is given. In cases of flexor tendon rupture, a revision is almost mandatory to prevent further tendon damage. Decompression of the median nerve with tenosynovectomy is an effective procedure with little morbidity. It is possible to combine dorsal wrist surgery with decompression of the carpal tunnel, because no special requirements in the rehabilitation procedures are needed for the flexor synovectomy.
Technical Aspects
The flexor tendons at wrist level in RA are usually addressed with an open, classical, extended carpal tunnel approach. Endoscopic carpal tunnel release might be reserved for the rare cases of isolated median nerve compression without suspicion of significant flexor synovitis. The authors prefer an incision that is centered in the extension of the fourth finger in the area of Guyon’s canal. Depending on the expansion of the synovitis, the incision might be extended proximal to the wrist crease; in most patients, it is sufficient to approach directly over the carpal tunnel. In the rare cases of simultaneous compression of the ulnar nerve at the wrist level, a decompression of the ulnar nerve in Guyon’s canal may be performed simultaneously. After division of the palmar aponeurosis, the transverse carpal ligament is visualized and divided completely on the most ulnar border. This secures a good coverage of the median nerve with the radial site of the divided ligament. A formal neurolysis is not recommended, to avoid scarring within the nerve. Flexor tendon revision and synovectomy can now be performed. Special attention has to be paid to the floor of the carpal tunnel; sharp bony edges should be identified and smoothed with the use of a rongeur. Partial flexor tendon laceration may be débrided. A minimum of 40% to 50% of the tendon must be intact; otherwise, tendon reinforcement might be advocated. Although several possibilities of reconstruction of the transverse carpal ligaments are described, the authors prefer to leave the carpal canal open, and only skin closure is performed. In the rehabilitation process, excessive wrist flexion should be avoided, and the wrist should be protected in a removable night splint in intrinsic-plus position for as long as 6 weeks. Functional use for light daily activities is encouraged.
FIGURE 13. A: Dorsal wrist approach with ulnar-based capsulotomy. Outline of the incision. B: Dorsal wrist approach with ulnar-based capsulotomy after elevating the capsular flap with good exposure of the distal radioulnar (DRU) joint. DRC, dorsal radiocarpal ligament; L, lunate; T, triquetrum; tf, triangular fibrocartilage. (From Berger RA, Bishop AT. A fiber-splitting capsulotomy technique for dorsal exposure of the wrist. Tech Hand Upper Extrem Surg 1997;1:2–10, with permission.)
Treatment of the Distal Radioulnar Joint
The treatment of the distal radioulnar joint has, besides functional and, therefore, reconstructive aspects, a significant prophylactic importance. It is a frequent target of RA destruction.
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According to Resnick (136), synovial proliferation is observed in three areas of the distal radioulnar joint: distal to the ulnar head, in the prestyloid recess, and in the recess of the ECU tendon. This is important to recognize when a synovectomy of the distal radioulnar joint is performed. The damage of the synovitis is related to the duration and degree of inflammation, as well as the mechanical stress of the anatomical structure (137). The synovitis invades the triangular fibrocartilage complex and the palmar and dorsal radioulnar ligaments, resulting in destabilization of the distal radioulnar joint. The synovial infiltration of the ECU tendon provokes a palmar subluxation of the tendon with further instability (138). Parallel processes at the dorsal lip of the sigmoid notch enhance this situation (139). The classic caput ulnae syndrome, as described by Backdahl (27), is an end stage of this destruction process and shows a characteristic dorsal prominence of the distal ulna in combination with a local bulge of the synovia and possible signs of tendon rupture. The mobility of the forearm rotation is markedly reduced and painful. Instability of the distal radioulnar joint may produce a painful clicking in prosupination.
However, deformation alone is not necessarily an indication for surgery. Often, a combination of pain and functional impairment, together with the need to prevent further damage, sets the indication for a surgical procedure (140). A more aggressive approach is required in cases of extensor tendon rupture to prevent further damage (141). There is a controversial discussion about the use of local steroids in this area; first, the infiltration often treats only a part of the complex distal radioulnar joint (120), and, second, an already damaged tendon might be weakened further (120,140,142).
The basic principle of the surgical correction of the distal radioulnar joint in RA includes
  • Joint and tendon synovectomy
  • Partial or total resection of the ulnar head
  • Stabilization of the ulnar stump
  • Stabilization of the radiocarpal joint if needed
There are only early cases, most often in younger patients, with limited destruction, which might qualify for joint and tenosynovectomy only. In the majority of cases, the distal ulna has to be addressed by complete or partial resection or by fusion of the distal radioulnar joint with a Sauve-Kapandji procedure. Complete resection of the ulnar head was first described by Darrach (143) for treatment of sequelae after distal radius fractures. This concept was later adapted for the rheumatoid hand first by Smith-Peterson et al. (144) and subsequently by many other investigators (27,53,87,120,122,125,140,142,145,146,147,148,149,150,151,152,153,154,155 and 156). The general results of the combined approach with synovectomy and ulnar head resection are consistent with good to excellent pain relief and a minimal incidence of recurrent synovitis and symptomatic distal ulnar stump instability (125,127,157,158). However, critical analysis, especially of higher-demand patients, shows a significant rate of failures and unsatisfactory results, such as instability of the distal ulnar stump (159,160 and 161) and a significant increase in ulnar wrist translocation (140,151,162,163). To overcome these problems, different variations of ulnar head resection, such as the Bower’s hemiresection-interposition arthroplasty (164) or the matched ulnar resection according to Watson (165), were also proposed for the rheumatoid wrist. These techniques have the advantage of leaving some of the stabilizing structures of the ulnar side of the wrist, although a correction of the carpal subluxation and a complete stabilization of the distal radioulnar joint are difficult to achieve. Greater popularity, especially among the European surgeons, has been noted for the Sauve-Kapandji procedure (166) in which the distal ulnar stump is fused more proximally to the radius with an ulnar pseudarthrosis. This procedure preserves the stabilizing elements on the ulnar aspects of the wrist. Several series reported good results for rheumatoid conditions (60,167,168,169,170,171 and 172), although unstable distal ulnar stumps are also reported (170). Different procedures were proposed to prevent or to correct this ulnar stump instability. The most popular are stabilization slings from the ECU or the flexor carpi ulnaris (161,164) or the pronator quadratus interposition transfer (173). Because most distal ulnar stumps tend to be dorsally dislocated, it makes more sense to use flexor carpi ulnaris tenodesis. In addition, once ulnar translation is started, it is unlikely that this process can be stopped with a Sauve-Kapandji operation (174). Those cases need a stabilization on the level of the radiocarpal joint.
Another method to treat a destroyed distal radioulnar joint is ulnar head replacement. It was first described by Swanson (175), who used a silicone cap for better stabilization of the ulnar side of the wrist. Several studies proved unsatisfactory results in the long term (176,177) with these implants, and, therefore, this technique is no longer recommended. Subsequently, different implants have been developed, as a more constrained articulation with two components (178,179) or as a simpler replacement of the distal ulna with a ceramic head (180). These implants were primarily developed as salvage for recurrent instability after failed surgery at the distal ulna. Their long-term results will determine if more generous indications might be justified.
Among all these possibilities, the authors prefer the following surgical approaches to the rheumatoid distal radio-ulnar joint:
  • Ulnar head resection is combined with dorsal tenosynovectomy in elderly and less-demanding patients.
  • The Sauve-Kapandji procedure, if needed, is combined with a flexor carpi ulnaris tenodesis or a pronator transposition in younger, more demanding RA patients.
  • Type 3 wrists (destabilization), according to the Schulthess classification, need additional stabilization of the radiocarpal joint.
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  • In cases with unsalvageable, functionally unacceptable, recurrent instability of the distal ulna, an ulnar head prosthesis may be considered.
Technical Aspects
In any case, even if only the distal radioulnar joint is addressed, a similar approach to that used for dorsal wrist synovectomy (see the section Synovectomy of the Wrist Joint) is recommend. First, it allows the overview of all extensor compartments, and, second, in RA, the likelihood of future surgery of the radiocarpal joint is high.
After the incision of the dorsal retinaculum in the interval between the fifth and sixth compartments, a tenosynovectomy is performed. The distal radioulnar joint is exposed through a longitudinal incision, starting just proximal to the triangular fibrocartilage. Joint synovectomy is performed, and, in cases with a mainly preserved distal radioulnar joint, bony spurs might be removed. In the indication of ulnar head removal, the distal ulna is resected together with the periosteum as distally as possible, just proximal to the proximal end of the sigmoid notch. The complete removal of the periosteum prevents the so-called carrotlike appearance of the ulnar stump after a longer follow-up. Free forearm rotation with no impingement to the radius must be checked on the operation table. For the Sauve-Kapandji procedure, after completion of the local synovectomy and removal of the cartilage on both joint surfaces, the forearm is held in a neutral position, and a pin is inserted at the side of the later screw, fixing the ulna to the radius. The position of the pin is controlled under fluoroscopy. The distance to create the pseudarthrosis should not be more than 10 to 12 mm and should be placed as distally as possible. The bone segment should be removed together with the periosteum to prevent calcifications. The pin is then replaced by a 2.7-mm cannulated screw. There is no need for bone grafting of the cartilage defect; in contrast, Rothwell et al. (181) described a simplified technique in which the distal radioulnar joint is not formally exposed before screw fixation. The screw must not be placed bicortically; in contrast, a too-long implant may cause extensor tendon irritation in the first extensor compartment. In cases of marked overlength of the ulna, the distal stump might be proximalized before definitive fixation. If needed, a distally based sling of the flexor carpi ulnaris is harvested (caveat: be aware of the proximity of the ulnar nerve), and a tenodesis through a drill hole in the ulna stump is completed. For the ulnar head resection or the Sauve-Kapandji procedure, the capsule is carefully closed by using strong single sutures with absorbable material, which are placed while the assistant reduces the distal ulna to the palmar side. Together with the refixation of the retinaculum, the ECU is recentered.
For rehabilitation, the wrist is protected in a so-called sandwich splint with a dorsal cover. This stabilizes the distal ulna while gentle forearm rotation in this splint is started, as soon as the patients tolerates it. The splint should be worn for 6 weeks. In the case of a Sauve-Kapandji operation, radiographs taken after this time should show bony fusion.
Reconstructive Surgery
Partial Fusion
The expected natural course of the disease at the radiocarpal level has great implications for the decision of which surgical procedure should be performed. Type 1 and 2 wrists have a low probability of undergoing radiocarpal dislocation. Therefore, surgical treatment, including the aforementioned wrist and tendon synovectomy and usually ulnar head resection, gives satisfactory long-term results (57,59,134,146,149,150,152,155,156,163,182,183,184,185,186 and 187). In contrast, type 3 wrists, because of ligamentous or bony destruction, or both, require a procedure that provides realignment and stability. It is important to classify the wrist as early as possible in the course of the disease. It is easier to distinguish the different forms if the destruction is not too advanced. In later stages of the disease, an original type 2 wrist, which is considered stable, might undergo significant carpal collapse and may begin to mimic type 3 (unstable) evolution. Partial fusion of the rheumatoid wrist has, in early stages, a prophylactic character, whereas, in an established deformation pattern, a reconstructive element might be attributed.
The concept of partial fusion in rheumatoid wrists was first described by Chamay et al. (188) and later by Linscheid and Dobyns (189). Chamay et al. (188) applied their observation of spontaneous radiolunate fusion with preserved functional range of motion and long-term stability to the treatment of rheumatoid deformities. The idea of limited fusion in the rheumatoid wrist includes the realignment of the subluxed carpus by reduction of the proximal carpal row combined with long-term stability. In cases of excessive radiocarpal damage, the concept of limited wrist fusion might be expanded to a radioscapholunate fusion (152). A review of the literature shows good clinical results and high patient satisfaction for limited wrist fusion in rheumatoid patients. The range of motion varies postoperatively but, on average, is reported to be in functional range (188,189,190,191,192,193,194,195,196,197,198,199 and 200). It should be noted, however, that most series observed deterioration over time with ongoing destruction of the wrist (189,191,192,194,196,197,199,200,201 and 202) (Fig. 14). Advanced disease stages and already destabilized wrists should therefore be treated by total wrist fusion (191). Because the radiolunate fusion provides stability on the ulnar side of the wrist, it is usually combined with an ulnar head resection. It is possible to perform radiolunate fusion together with a Sauve-Kapandji procedure (Fig. 15). Although there may be a theoretical advantage to that approach, no series so far has shown superior results.
Technical Aspects
The same approach to the wrist is used as described in the section Synovectomy of the Wrist Joint. After the access to
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the carpus, a complete synovectomy is performed. The indication for radiolunate fusion with ulnar translation of the wrist or destruction of the radiolunate fossa with at least some preservation of the radioscaphoid fossa, or both, is confirmed. In the authors’ experience, even quite significant cartilage alterations in the scaphoid fossa are clinically well tolerated, and the indication for partial fusion versus total fusion should be generous. In cases of complete destruction of the radiocarpal joint and preservation of the midcarpal joint, radioscapholunate fusion with or without midcarpal arthroplasty (203) might be considered. The remaining cartilage is removed from the radiolunate joint to the subchondral cancellous bone, maintaining the curvature of both articulating elements to allow good matching of the lunate with the radius. The lunate is inset so that the radius covers approximately two-thirds of the lunate. The reduction is held with a preliminary Kirschner wire. Fluoroscopic radiographic examination should be performed to confirm the correct position of the lunate in all planes. In cases of severe bone deficiency, a bone graft, often harvested from the resected ulnar head, might be used. The internal fixation may be performed with titanium power staples with a dimension of 13 mm × 10 mm (Fig. 16); when good bone quality is present, with a 2-mm mini condylar plate; or by other methods (Fig. 17). The arrangement of the staplers is critical; ideally, two to three staplers should be placed in different converging angles to prevent redislocation (Fig. 18). The wrist capsule is closed in such a way that the implants are completely covered. This is important, especially when a condylar plate is used, to avoid tendon irritation.
FIGURE 14. A: Initial radiograph of a rheumatoid wrist with ulnar drift of the carpus and destruction of the radiocarpal joint. B: Three months after radiolunate fusion. There is already cyst formation in the scaphoid and ongoing destruction of the scaphoradial joint. C: Eighteen months after radiolunate fusion. There is a marked carpal collapse and destruction of the midcarpal joint. The wrist was converted in a total wrist fusion.
Postoperatively, the wrist is immobilized for 6 to 8 weeks, depending on the bone quality, in a splint or a plaster cast. After radiologic evidence of healing, wrist mobilization can be started.
The most common complication in radiolunate fusion is malpositioning of the hardware. Staples or screws can
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penetrate or bridge the midcarpal joint and can cause damage to the cartilage, thus necessitating hardware removal (189,192,198,200). This complication must be considered a technical error, because careful fluoroscopic intraoperative checks can avoid this problem.
FIGURE 15. Combined radiolunate fusion and Sauve-Kapandji procedure.
The fusion rate in all series is high and consistently exceeds 90%. Despite this high success rate, cases with severely affected bone quality and strong deviating forces may fail to fuse. Good internal fixation, best performed with staples or a mini plate, and cast immobilization for 6 to 8 weeks are mandatory.
FIGURE 16. Radiolunate fusion with power staplers. There is a correct position of the lunate in both planes.
FIGURE 17. Different types of radiolunate fusion fixations. (From Herren DB, Simmen BR. J Am Soc Surg Hand 2002;2:21–32, with permission.)
Total Wrist Fusion
There is an ongoing discussion of whether to fuse a destroyed rheumatoid wrist or to indicate a radiocarpal arthroplasty (204). Despite the good clinical results of complex wrist arthroplasty (205,206,207,208 and 209), the complication rate remains high. In addition, wrist arthroplasty requires good bone stock and a reasonable or reconstructible tendon balance, two conditions that are rarely present in advanced
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rheumatoid destruction. Silicon wrist spacers offer an alternative, although they are only recommended by most investigators in low-demand patients (210,211,212 and 213). A more complete discussion on wrist arthroplasty is found in a separate chapter.
FIGURE 18. Radiolunate fusion with a 2-mm condylar plate. Despite good initial reposition, there was redislocation of the carpus back to initial deformity. Subjectively, there was no pain, and no revision was needed.
Most wrists with advanced rheumatoid disease require a definitive stabilization by total wrist fusion. A pain-free, stable wrist joint often outweighs the disadvantage of the lack of mobility (154,156,199,204,214,215,216,217,218,219,220,221,222,223,224 and 225). Although bilateral wrist fusion is still a subject of controversy (204,226), personal experience and a publication by Rayan et al. (227) effectively show high patient acceptance even for bilateral fusion. However, subjectively, most patients would like to have at least one mobile wrist. Two main concerns dominate the discussion that surrounds wrist arthro-desis: the position of fusion and the surgical technique to obtain secure and stable fixation.
A functional range of motion has been found to consist of 10 degrees of flexion and 35 degrees of extension for most activities of daily living (228). By analyzing different tasks, activities concerning personal care and hygiene were found to be performed in slightly flexed wrist positions. However, besides overall function, wrist position seems to affect grip strength. Flexed wrist posture is associated with decrease of grip strength, whereas there is no difference in strength between neutral (0 degrees) and an extended fusion position (229,230). In patients who have RA, associated elbow and shoulder disease, as well as bilateral hand involvement, has to be taken into consideration when choosing the ideal arthro-desis position. Lateral deviation affects the position and the function of the fingers, especially with coexisting ulnar drift at the metacarpophalangeal (MCP) joint level. Five degrees to 10 degrees of ulnar deviation are needed to counterbalance an ulnar drift of the fingers (22,137,231). Most investigators prefer a neutral flexion-extension position with mild ulnar deviation for wrist fusion in rheumatoid patients (149,152,153,183,216,227,232,233). In the authors’ experience, an individual decision has to be made for every patient. Preoperative evaluation can be performed with splints in different wrist positions. In most cases, a neutral or slightly flexed position for the dominant hand, to facilitate personal care, and a slightly extended position for the nondominant hand combined with 5 to 10 degrees of ulnar deviation are chosen.
Different fixation methods for wrist fusion have been described in the literature. Since the first description by Clayton 1965 (183), which was later popularized by Mannerfelt and Malmsten (232), different investigators have favored the Rush or Steinmann pin technique in the original method or with slight modifications (199,214,215,216,217,218 and 219,221,222,223,224 and 225,234,235). There are some reports of radiocarpal fusion using bone grafts with or without absorbable internal fixation (220,236,237). Bone grafting alone had a longer time to fusion than a combination of bone grafting and internal fixation (215). As an alternative to the pin technique, plate fixation for wrist fusion is popular (238,239), especially in posttraumatic conditions. A comparison between plate and pin fusion techniques in rheumatoid patients showed no significant difference in the clinical results or in the complication rate (240).
However, pin fixation has some significant advantages over the plate fixation in RA. RA is more frequent in women, who, with small wrist sizes, cannot always accommodate the plate, which is often too bulky to be applied. In
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addition, the soft tissue and skin conditions may not be ideal to cover a plate adequately, and, most often, a secondary removal of the implant is needed. In severe RA, bone quality might be so poor that no screw fixation is possible at all. Rheumatoid patients also have a high fusion rate that tends to require less rigid fixation than osteoarthritic patients. Lastly, pin osteosynthesis is clearly less costly.
FIGURE 19. Patient with severe dislocation of both wrists.
Technical Aspects
To perform a total wrist fusion, the wrist is approached in the same way as that previously described for wrist synovectomy or partial fusion. Some of the rheumatoid wrists have a severe deformation with ulnar and palmar dislocation (Fig. 19). In such circumstances, because of contracted soft tissue, some shortening of the radius is required to allow reduction of the wrist. In RA, wrist fusion is almost always performed together with the removal of the ulnar head. After resection of the radius, the radiocarpal and the midcarpal joints are débrided down to cancellous bone. If the reduction is possible without too much tension on the soft tissues, the pin insertion point in the third metacarpal is prepared. The proximal one-third of the third metacarpal, the interval between the second and third metacarpals, or the intramedullary shaft of the third metacarpal can be chosen (Fig. 20). If the axis is more favorable, the second metacarpal can also be used. When using the proximal one-third insertion technique, an ulnar lateral bone window of approximately 6 by 4 mm is made. A special tapered rasp is then used to open the canal for the pin. The rasp should be directed to the middle of the capitate, perforating the proximal carpal row in the scaphoid or the lunate. A Rush pin that is 2.5 to 3.5 mm in diameter and approximately 15 to 25 cm in length is then bent to accommodate the desired fusion position and is advanced from the metacarpal to the radius. Alternatively, the pin can be placed through a hole that is made in the head of the third metacarpal and is driven proximally in an intramedullary fashion, although this method fixes the angle of fusion to neutral, or it can be driven into the junction of the bases of the second and third metacarpals, allowing some control over the angle of fusion but slightly less rigid fixation. Before final placement of the rod, cancellous bone graft from the ulnar head is placed. If additional rotation stability is required, two or
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three titanium staples may be placed to bridge the former radiocarpal joint (Fig. 21). Postoperatively, a splint is applied for 1 to 2 weeks, followed by a cast for 6 to 7 weeks, until radiographic fusion has occurred.
FIGURE 20. A–C: Techniques of pin fixation in total wrist fusion. MCP, metacarpophalangeal. (From Herren DB, Simen BR. J Am Soc Surg Hand 2002;2:21–32, with permission.)
FIGURE 21. A: Complete dislocation of a rheumatoid wrist type 3. B: Final radiograph after completed Rush pin and staple augmentation total wrist fusion.
Nonunion is rare in patients who have RA. The average fusion rate in the literature is more than 90% (199,216,217,218 and 219,222,224,225,232,234,235,238,242). In the Rush pin technique, care should be taken at the insertion point of the pin at the metacarpal base. Predrilling of holes before opening the cortex might prevent iatrogenic fractures. In using the Steinmann pin technique, between the metacarpals or in an intramedullary fashion in the third metacarpal, one must ensure good fixation of the pin into the distal radius and a good interference fit of the pin at the metacarpal bases or within the third metacarpal. The most common problem, especially when using the Rush pin technique, is obtaining the desired wrist position. Exact planning and careful prebending of the rod are helpful.
Tendon Reconstruction
Extensor Tendon Reconstruction
As outlined in the section Extensor Tendons in the section Involvement of the Soft Tissues around the Wrist, rupture of extensor tendons is the final stage of a complex pathomechanical process. The best treatment of tendon rupture is prevention with early aggressive treatment of the distal radioulnar joint and the accompanying tenosynovitis.
It is mandatory, when planning extensor tendon reconstruction, to assess wrist and MCP joint function. Any wrist correction or treatment of MCP joint dysfunction, or both, should be best performed together with the tendon reconstruction. No tendon reconstruction can mobilize a subluxed MCP joint, and a secondary procedure that consists of MCP joint reconstruction and extensor tenolysis may not give satisfactory results (95). If there is any doubt about MCP joint function, traction on the distal ends of the tendons for reconstruction demonstrates the quality of MCP joint extension ability. If needed, subluxed extensor tendons should be recentered over the MCP joints at the same time that the extensor reconstruction is performed.
Direct end-to-end repair of ruptured tendon in rheumatoid patients is almost never feasible. The long-standing process of tendon attrition creates a wide zone of destruction within the tendon. Therefore, the most frequently used techniques for extensor tendon repair are tendon transfer and, in selected cases, tendon reconstruction with a free tendon graft (92,98,243,244 and 245). With two sites of suture lines, the free tendon graft has the disadvantage of greater possibility of adherence, although Bora et al. (243) reported no differences between free tendon grafts and tendon transfers. As free tendon grafts, the palmaris longus tendon or, in cases of wrist fusion, a graft from the radial wrist extensors might be used. The use of toe extensor tendons in RA must be carefully chosen to avoid secondary morbidity.
Tendon transfers might be performed as end-to-side transfers or end-to-end reconstruction. Table 5 gives an overview of possible transfer settings for the different rupture scenarios. The best tendon for transfer is the extensor indicis proprius (EIP) tendon, followed by the flexor superficialis of the ring and middle fingers. The use of wrist extensor tendons is not advised because the excursion of the wrist motors is significantly less than that of the finger extensor tendons, thus producing incomplete motion. The prognosis of tendon reconstruction is best in single or double tendon rupture, whereas the treatment of multiple ruptures is considered as a salvage procedure (92,246). The rupture of the extensor tendons to the thumb is often an
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isolated event, which is best treated with a transfer of the EIP to the extensor pollicis longus tendon.
TABLE 5. POSSIBLE TENDON TRANSFER SETS IN THE DIFFERENT CLINICAL SCENARIOS
Ruptured tendons Transfer Alternatives
EDM EDM to EDC V No treatment
EDM, EDC V EDC V to EDC IV EDC V to EDC IV
EIP to EDM
EDM, EDC V, EDC IV EIP to EDM (+ EDC V)
EDC IV to EDC III
 
EDM, EDC V, EDC IV, EDC III EIP to EDC IV and V
EDC III to EDC II
Flexor digitorum superficialis IV to EDC IV and V
EIP to EDC III
EDC, extensor digitorum communis; EDM, extensor digiti minimi; EIP, extensor indicis proprius.
Technical Aspects
The wrist is approached in the same manner as already described. Extensor tendon status is explored after synovectomy. Free gliding of the distal end of the ruptured tendon is confirmed by pulling on the distal stump; otherwise, tenolysis must be performed. Partially attenuated tendons are débrided and reinforced with a free tendon graft if needed (more than 60% to 70% loss). The tendons are prepared for the transfer. The EIP tendon is divided at the level of the index MCP joint with a separate incision. The EIP tendon is on the more ulnar side of the two tendons. The flexor digitorum superficialis tendon of the ring finger is harvested over a Bruner type of incision, proximal to the proximal interphalangeal (PIP) joint. The stumps of the distal end of this tendon are fixed to the palmar plate to prevent swan-neck deformity. The proximal musculotendinous unit is brought through the interosseous membrane to the dorsal aspect of the wrist or over the radial border. The radial routing has the advantage to keep the transferred tendon away from the damaged ulnar wrist compartment, and the pull of the tendon counters ulnar wrist translocation (95). The end-to-side and end-to-end reconstructions are performed by using the weaving technique that was described by Pulvertaft (247). Ideally, three tendon passages, each transposed 90 degrees to the other, are used, secured with several single sutures. To adjust the tension on the transfer is probably the most difficult part of the intervention. As a general rule, the transferred muscle–tendon unit should be slightly overstrained, compared to the neighbor digits. This may be tested best with the teno-desis effect in wrist flexion-extension; in cases of wrist fusion, the tension must be judged according to the spontaneous position of the fingers. When in doubt, it is better to have too much tension, because stretching in the rehabilitation process is almost always possible, whereas spontaneous shortening is never observed. At least one strip of the extensor retinaculum should be reconstructed to prevent bowstringing, but it must be checked that no interference with the site of tendon weaving occurs.
Postoperatively, the wrist is immobilized in 20 to 30 degrees of extension with the MCP joints in minimal flexion; the PIP and distal interphalangeal are left free for immediate mobilization. After 4 weeks, wrist remobilization may be started. Dynamic splinting is only necessary when a significant flexion loss is observed.
Flexor Tendon Reconstruction
As outlined in the section Involvement of the Soft Tissues around the Wrist, the flexor tendon that ruptures most commonly in RA is the FPL, followed by the profundus tendon of the index finger. Rupture of flexor tendons in the region of the finger pulleys is rare, and most flexor tendons rupture in the carpal canal. Principally, this is a good zone for safe flexor tendon reconstruction with minimal danger of postoperative adhesions. In cases of flexor tendon rupture, a surgical revision is mandatory to prevent further ruptures. Before revision surgery and possible tendon reconstruction, the following points should be clarified:
  • How much functional loss does the patient have with the ruptures?
  • What is the general condition of the wrist and finger joints?
  • Is the patient suitable for a possible long rehabilitation process with a unpredictable result?
As an alternative to tendon reconstruction, interphalangeal joint fusion, especially in already arthritic joints, might be indicated with far fewer rehabilitation difficulties. If the indication to flexor tendon reconstruction is given, the following reconstruction principles might be recommended (21,85,87,92,93,248):
  • Isolated FPL ruptures are reconstructed with a transfer of a superficialis tendon, preferably from the ring finger, depending on the conditions of the other tendons.
  • Ruptures of profundus tendons are best transferred with an end-to-side tenodesis to an intact adjacent profundus tendon.
  • In cases of rupture of the profundus and superficialis tendons in one finger, a tendon transfer from an intact superficialis is performed.
  • Some investigators have recommended bridge grafts (21,85); others, including the authors, prefer tendon transfers (93).
  • Isolated superficialis tendon ruptures, which are rare, need no reconstruction.
Technically, the palmar wrist is opened similarly to the technique that was described in the section Flexor Tendons in the section Involvement of the Soft Tissues around the Wrist with an extensile carpal tunnel approach. Tendon transfer or bridging is performed with the same techniques as in extensor tendon reconstruction.
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TABLE 6. UNIVERSAL CLASSIFICATION OF TYPING AND STAGING OF INFLAMMATORY WRIST ARTHROPATHY
Universal wrist classification in inflammatory polyarthropathy
Type of disease
   Slow progressive type without significant OA (destructive type)
   Slow progressive type with marked OA changes (reactive type)
   Progressive soft tissue disruption (ligamentous type)
   Progressive bony destruction (mutilans type)
   Spontaneous intercarpal ankylosis (juvenile type)
Stage of disease
   Early, erosions with or without early reducible translation (LDE stages I and II)
   Translation, translocation, volar subluxation, nonreducible, with or without radiocarpal OA (LDE stages III and IV)
   Some or all of the previous characteristics with midcarpal joint loss
   Disorganized wrist, with or without significant bone substance loss
   Intercarpal ankylosis
LDE, Larsen, Dahle, and Eek classification; OA, osteoarthritis.
Adapted from Stanley JK, Lluch A, Herren DB, et al. Universal wrist classification in inflammatory polyarthropathy (in preparation).
In rehabilitation, dynamic splinting that is similar to flexor tendon sutures is advocated. A Kleinertlike splint with the wrist in almost neutral position or only slightly flexed for 4 weeks is needed. Tendon transfers, as well as tendon grafts, are more stable than direct tendon sutures and might be treated more aggressively, especially in cases of early limitation in finger motion. Most often, the rehabilitation is prolonged, and flexion or extension loss is possible. Ertel et al. (85), in their series, achieved active motion in 88% of their cases, with an average range of motion in the thumb interphalangeal joint of 23 degrees and an average range of motion in the PIP of the digits of only 55 degrees.
Salvage Procedures
The definition of wrist salvage procedures in RA is quite difficult. Some authors might believe that wrist fusion is already considered as a salvage, because it implies a definitive end in the treatment ladder. However, in the disease course of RA patients, a multitude of interventions is to be expected, and there is no space for experimental procedures. In the wrist, resection interposition arthroplasty might be considered a salvage procedure together with silicone wrist replacement. The latter is described in Chapter 79, Wrist Arthroplasty.
TABLE 7. FREQUENCY OF OBSERVED COMBINATIONS
Disease type Stage of disease
I II III IV V
A: Destructive Very common in early disease Very common Severe disease Late stage Rare
B: Reactive Very common in early disease Very common Common Uncommon Uncommon
C: Ligamentous Not commonly seen at this stage Common Rare Common Never
D: Mutilans Common Uncommon Uncommon Common Never
E: Juvenile Common in early disease Common Common Very rare Very common
Resection (Interposition) Arthroplasty
The rationale of resection arthroplasty, with or without interposition, includes the removal of destroyed opposing articular surfaces together with the need to preserve some motion. Proximal row carpectomy, which is successfully used for other pathologic wrist conditions, does not work in the rheumatoid wrists (249). The lunate fossa is often destroyed in RA, and the important palmar ligaments are too stretched to stabilize the distal row.
In proper resection arthroplasty, parts of the proximal or distal row, together with the distal radius, are resected, often combined with interposition of some biological material. The most popular biological materials are tendons, fascia, or capsular sheet (250,251,252,253 and 254). Taleisnik (203) proposed a combined radiocarpal fusion with a midcarpal arthroplasty using a silicone interposition.
All of theses procedures were more or less abandoned in favor of real joint replacement or wrist fusion. Nevertheless, newer attempts to optimize these procedures, together with possible failures of modern implants, may give this approach a revival in the future.
CLASSIFICATION AND TREATMENT ALGORITHM OF THE RHEUMATOID WRIST
A treatment algorithm may always be discussed controversially. A disease, such as RA, with so many different faces may profit from a certain classification. Besides typing and staging wrist involvement in RA, the distribution of certain categories should describe surgical consequences. The classifications that are presented in Tables 6, 7 and 8 are based on the observations of experienced RA surgeons and summarize the ideas of Stanley et al. (255).
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TABLE 8. TREATMENT OPTIONS ACCORDING TO THE TYPE AND THE STAGE OF THE DISEASE IN THE WRIST
Disease type Stage of disease
I II III IV V
A: Destructive Synovectomy; soft tissue balancing ± ulnar head surgery R(S)L fusion; ulnar head surgery Capitate head replacement + R(S)L fusion; ± ulnar head surgery TWR TWR or pan-arthrodesis TWR or pan-arthrodesis
B: Reactive Synovectomy; soft tissue balancing ± ulnar head surgery R(S)L fusion; ulnar head surgery Capitate head replacement + R(S)L fusion; TWR TWR or pan-arthrodesis TWR or pan-arthrodesis
C: Ligamentous   R(S)L fusion ± ulnar head surgery Panarthrodesis Panarthrodesis  
D: Mutilans R(S)L fusion ± ulnar head surgery Panarthrodesis Panarthrodesis Panarthrodesis  
E: Juvenile Synovectomy; soft tissue balancing ± ulnar head surgery Panarthrodesis Panarthrodesis Panarthrodesis Panarthrodesis
R(S)L, radio(scapho)lunate fusion; TWR, total wrist replacement.
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