IMPORTANT POINTS:
Optimization of comorbidities and nutritional status is imperative prior to proceeding with surgery.
Poor pharmacologic control of the inflammatory process can undermine the long-term success of surgery, and optimal treatment determination should be done in conjunction with the patient and his or her rheumatologist.
Anesthetic risk can be significantly higher in patients with cervical spine disease. Thus, a complete workup is necessary in patients with neck pain.
Lower extremity involvement may preclude surgery for the wrist. In addition, shoulder and elbow disease can affect the timing and decision regarding the best treatment for the wrist.
Newer-generation antirheumatologic medications (anti-tumor necrosis factor-alpha 1 inhibitors) can be successful in diminishing the inflammatory process and limit the numbers of patients who ultimately require surgery.
General indications for surgery include persistent symptoms despite a 6-month course of pharmacologic management and prophylaxis against irreversible soft tissue damage such as tendon rupture. Once they occur, the presence of tendon rupture is generally an indication for surgery.
Contraindications to surgery include poor general health or significant comorbidities. Relative contraindications for arthroplasty include insufficient bone stock, history of infection, and longstanding fixed wrist deformity. Poor proximal arm function that is not correctable through surgery may also be considered a relative contraindication to surgery.
CLINICAL/SURGICAL PEARLS/PITFALLS:
Patients with inflammatory disease require special attention to the fact that the ligaments and soft tissues are commonly lax and incompetent. This important point requires attention to technique and must be taken into account regarding outcome expectations.
Pearls/pitfalls of distal ulna resection:
The minimum amount of distal ulna bone resection (<1 cm) will help ensure stability of the ulna.
Beveling of the distal ulna will minimize the risk of soft tissue and tendon irritation for the stump.
Observe the ulna and distal radius relationship throughout the arc or pronosupination and (when applicable) flexion–extension to ensure that there is no impingement.
The ulna can be cut with a slight slope in the radial direction. This will maximize the ulnar length ulnarly and improve stability.
The dorsal capsule is often stretched as a result of the disease process. Closure of this layer can be tensioned (plicated) for added stability.
Repair of the stabilizing structures should be performed with the forearm in neutral position.
Pearls/pitfalls of Sauve-Kapandji procedure:
Much like the Darrach procedure, it is possible to resect too much ulna. Situating the proximal ulnar stump less than 35 mm from the level of the distal radioulnar arthrodesis will minimize the risk of instability.
A gap of 10 to 15 mm between the ulnar ends should sufficiently reduce the risk of regrowth without compromising long-term stability.
Take care to carefully retract and protect the dorsal sensory branch of the ulnar nerve, which is vulnerable in this procedure.
Pearls/pitfalls of ulnar head arthroplasty:
Most stems are press-fit; however, bone cement can be used when a firm fit cannot be achieved.
It is important to ensure that the ulnar length is appropriate with respect to the radius. If too short, the ulnar head can impinge into the radius and this can be painful and limit function. If too long (positive variance) ulnocarpal abutment may result. Fluoroscopy is most helpful in evaluating the ulnar length in the appropriate forearm rotation.
Care should be taken to inspect the sigmoid notch and ensure that it is generally free of irregularities, spurs, or deformities. If mild, deepening of the notch may be considered. In extensive deformity, a constrained or articulating ulnar head implant (with sigmoid notch component) may be considered.
In implants with suture holes, the holes should be positioned medially in alignment with the ulnar styloid axis distally and midline of the olecranon proximally. Securing the soft tissue attachments to these heads should be done with the forearm in neutral position.
Pearls/pitfalls of wrist arthrodesis:
The position of fusion can be catered to the patient’s needs. Generally a slight amount of extension is preferred.
When denuding the articular surface of the wrist, preservation of the volar lip of the distal radius can help protect the integrity of the carpal tunnel and maintain the length of the wrist.
Encouraging early finger range of motion is important in preventing tendon adhesions and optimizing function.
In cases of painful hardware, removal should be delayed until successful fusion is achieved
Pearls/pitfalls of total wrist arthroplasty:
High-speed burrs can be helpful in contouring the edges of the radius and help better seat the implant.
In distal component fixation, longer screws can be helpful in providing better stability and fixation. I prefer to cross the second carpometacarpal (CMC) joint with my radial screw. However, crossing the fourth CMC joint with the ulnar screw is ill advised. The excessive mobility of that joint can increase the likelihood of screw loosening or breakage.
The capitate head is the key to centering the distal component appropriately.
Appropriate initial alignment of the radial guides will go a long way toward ensuring correct placement of the radial component. I find fluoroscopy to be extremely helpful in confirming the alignment prior to preparing the distal radial surface or canal.
In cases of significant or severe shortening and volar subluxation of the carpus, it may be necessary to release some of the volar supporting structures to get the wrist out to length. Unfortunately, this can destabilize the wrist following TWA. It is important to consider a “plan B” in these patients and prepare an alternative surgery such as arthrodesis if the amount of soft tissue dissection is too much and the instability risk is too great.
When trialing the radial component, it should fit flush with or below the dorsal lip of the distal radius:
It may be difficult to get 4.5-mm screws into the carpus (and metacarpal) in patients with good bone quality. In these cases, overdrilling with a 2.0-mm drill can prepare the screw canals enough to allow easier cancellous screw placement.
Ideally the wrist should be stable to 40 to 50 degrees of extension, 30 to 40 degrees of flexion, and 40 degrees of radioulnar motion. No more than 2 to 3 mm of laxity with dorsal–palmar translation and 2 to 4 mm of separation should exist following trial implantation.
Following implantation, if the proximal component is loose, the surgeon has two options: (1) impaction bone grafting with cancellous bone or (2) cementing the component (especially in patients with poor bone quality).
Patients who are active should be cautioned about the limitations following TWA so that they can decide whether this is the right procedure for them.
VIDEO:
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Lateral view of wrist prior to making cuts
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Dorsal view of wrist prior to making cuts
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Broaching the radius
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Trialing the implant and assessing stability and ROM
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Impacting the final radial component
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Impacting the final carpal component
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Demonstrating the polyethylene cap on the distal component
HISTORY/INTRODUCTION/SCOPE OF PROBLEM
Inflammatory arthritides include a family of disorders whereby an autoimmune-mediated process results in pain, arthritis, and deformity. Because of the systemic nature of these conditions, multiple joints are commonly affected. In severe cases, the amount of joint destruction and subsequent deformity can be marked when compared to osteoarthritis. Common seropositive arthritides include rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriatic arthritis, Reiter’s syndrome, and inflammatory osteoarthritis. Although many of the inflammatory conditions overlap with regard to symptoms and clinical presentation, different types of inflammatory arthropathies demonstrate differing characteristics. This necessitates special consideration regarding specific surgical treatments. When compared to RA, psoriatic arthritis is less likely to be symmetric. In addition, skin and nail abnormalities occur in these patients. They also carry an increased risk of infection following surgery. SLE can affect multiple organ systems including the skin, kidneys, and vascularity. In contrast to RA, the disease process affects periarticular tissues and spares the synovium. Joint laxity is common and stability may be difficult to achieve following surgery. Reiter’s syndrome commonly affects younger males and is defined as a triad of clinical features: arthritis, conjunctivitis, and urethritis. As a result, treatment options must take into consideration the younger age and increased activity levels of these patients. Arthritis mutilans is a form of advanced inflammatory osteoarthritis and closely mimics RA. Principle affected areas include hands, feet, and spine.
Rheumatoid arthritis is the most commonly encountered and primarily affects the synovium and tenosynovium. This often results in damage to adjacent tissues including cartilage, ligaments, bone, and tendons. The etiology remains unclear. The mechanism of degeneration is linked to the effects of neutrophil infiltration, which releases free radicals and lysosomal enzymes resulting in damage to local tissues. A wide variety of medical treatments have been described to subdue the autoimmune-mediated process. Mainstays include prednisone and methotrexate. However, newer-generation medications that inhibit tumor necrosis factor (TNF; Enbrel, Remacade, Areva, etc.) have proved useful in diminishing the synovitis and symptoms of RA. This, fortuitously, has resulted in less patients ultimately requiring surgery.
Rheumatoid involvement of the wrist is common, although it is thought to be less clinically relevant or better tolerated than RA of the hands and fingers. Within 2 years of diagnosis, two thirds of patients have noted some wrist pain, and greater than 90% of patients will have symptoms or involvement by 10 years. Unfortunately, RA of the wrists can be disabling and painful. Severe involvement can also result in adjacent soft tissue disease as in conditions like Vaughan-Jackson syndrome, which is an attritional rupture of the fourth and fifth extensor tendons secondary to RA of the distal radioulnar joint. The degree of wrist involvement and collapse remains important because it can predict outcomes of more distal surgery.
Synovitis and swelling is the sine qua non of RA ( Fig. 10-1 ). Pain and functional limitation often bring a patient for clinical evaluation. Deformity is a frequent finding in severe or longstanding disease. In the wrist, the ulnar aspect is a common site of involvement. Dorsal synovitis is more readily evident because of the more superficial position of the synovial-lined structures compared to the palmar aspect of the wrist. The prestyloid recess of the ulna is an area of increased vascularity. It is therefore susceptible to the inflammatory process resulting in cartilage erosion and attenuation of the nearby ligaments and soft tissues. This ultimately results in dorsal and ulnar displacement of the distal ulna or caput ulna syndrome ( Fig. 10-2 ). Volar synovitis and arthritis can also be extensive, and, although clinically less readily evident, may be dangerously silent. These patients may initially present with tendon ruptures such as the flexor pollicis longus (FPL), usually secondary to arthritis and spur formation of the scaphotrapeziotrapezoid (STT) joint as originally described by Mannerfelt and Norman. In longstanding or severe disease, subluxation of the carpus, usually in a palmar and radial direction, is commonly seen as the carpal bones slide down the radial and volar slopes of the distal radius. Among other factors, this deformity indicates incompetence of the palmar ligaments and supporting structures.
Clinical examination reflects the synovitic and inflammatory process. Crepitus is common in assessing the joint motion actively and passively. Tenderness is usually noticeable at the areas of more involved destruction and swelling. Palpation of tension, irregularities, or catching of tendons as they move within or around the synovitis can be noted as the inflammatory process progresses. Pain with resisted flexion or extension can reflect not only joint involvement, but also significant tenosynovitis. Failure to actively flex or extend the digits entirely is likely an indication of tendon rupture. However, additional causes must be considered and include volar subluxation or dislocation of the metacarpophalangeal (MP) joints, extensor tendon subluxation, or posterior interosseous neuropathy (which can result from irritation of the nerve as a result of synovitis of the radiocapitellar joint at the elbow). Neurovascular structures can also be victimized by the inflammatory process at the wrist, and conditions such as carpal tunnel syndrome are common in patients with RA. The disease process can affect the nerves directly. In addition, the tenosynovitis, synovitis, and erosive changes of the carpus increase the volume within the carpal tunnel and diminish the space for the nerve. Fortunately, studies suggest that the median nerve responds favorable to carpal tunnel release.
Radiographs typically show cartilage erosion and bony deformity. Based on a large review of plain films, a classification has been proposed by Larsen and colleagues that continues to be used ( Table 10-1 ). Joint space narrowing is most commonly noted earliest at the distal ulna, the lateral outline of the scaphoid, and subchondral margin of the radius. Typically, radiographic involvement of the midcarpal joint, especially the head of the capitate, is a later finding or noted only in more advanced disease. Ankylosis can occur in severe or longstanding RA.
| Larsen Stage | Radiographic Appearance |
|---|---|
| 0 | Normal joint |
| 1 | Periarticular swelling, osteoporosis, slight narrowing |
| 2 | Erosion and mild joint space narrowing |
| 3 | Moderate destructive changes and joint space narrowing |
| 4 | End-stage destruction, preservation of articular surface |
| 5 | Mutilating disease, destruction of normal articular surfaces |
Although additional imaging modalities are not routinely used, studies such as computed tomography (CT) scans and magnetic resonance imaging (MRI) may be useful in discerning additional information in evaluating patients with RA. MRI can be helpful in elucidating the extent of synovitis or tenosynovitis. CT scans will give a good sense of the amount of bone destruction, extent of arthritis, and presence of ankylosis in the wrist.
INDICATIONS/CONTRAINDICATIONS FOR SURGERY
Many factors must be considered in regard to the timing and options for surgery of persons with rheumatoid arthritis. Patients require a comprehensive evaluation. A complete history of the disease process and whole body involvement (if any) is necessary. Nutritional status of patients with RA can be affected by both the disease process and the medications for treating the disease process. Optimization of comorbidities and nutritional status is imperative prior to proceeding with surgery. It is also important to understand that poor pharmacologic control of the inflammatory process can undermine the long-term success of surgery. Thus, decisions regarding surgery and determining the best treatment should be done in conjunction with the patient and his or her rheumatologist. Patients with neck pain or radicular symptoms require thorough workup starting with cervical radiographs. Anesthetic risk can be significantly higher in patients with cervical spine disease. Lower extremity involvement (when significant) may preclude surgery for the wrist because the use of weightbearing assistive devices may place significant strain on the upper extremity joints and undermine the success of surgery for the upper limbs. In addition, shoulder and elbow disease can affect the timing and decision regarding the best treatment for the wrist.
The timing of surgery remains somewhat controversial. Nonsurgical measures including rest, splinting, antiinflammatory medications, and local injections can be effective in relieving pain in many patients. Pharmacologic treatment of RA can be helpful in curbing the disease process. Medications such as prednisone and methotrexate continue to be routinely used. Newer-generation antirheumatologic medications (anti-TNF alpha 1 inhibitors) have become a mainstay in the treatment of many patients with RA. They can be successful in diminishing the inflammatory process and limit the numbers of patients who ultimately require surgery. Although some investigators still feel that cessation of antirheumatic medications (at least regarding methotrexate and steroids) are necessary perioperatively, the data suggest that it is unnecessary and difficulties with healing and infections are not increased when keeping patients on these medications.
Many surgeons feel that persistent symptoms despite a 6-month course of pharmacologic management of the disease are an indication for surgery. Exceptions include cases in which surgery would be prophylactic against irreversible soft tissue damage such as tendon rupture. Once this occurs, the presence of tendon rupture is generally an indication for surgery (to minimize further soft tissue destruction).
Surgical treatment options vary depending on the degree of joint destruction, patient needs, and symptoms. Options include synovectomy, tenosynovectomy, tendon reconstruction or transfer, complete or partial distal ulna resection or stabilization, partial or complete wrist arthrodesis, ulnar head replacement, and total wrist arthroplasty (TWA).
Contraindications to wrist surgery include poor general health or presence of significant comorbidities. Relative contraindications for arthroplasty include insufficient bone stock, history of infection, and longstanding fixed wrist deformity. Poor proximal arm function that is not correctable through surgery also may be considered a relative contraindication to wrist surgery. Additional contraindications more specific for TWA will be discussed in that section.
This chapter will discuss each of the surgical treatments described previously. However, because the primary focus of this chapter is on arthroplasty, the joint replacement sections will be covered in the most detail—particularly ulnar head arthroplasty and total wrist arthroplasty.
SURGICAL MANAGEMENT
Soft Tissue Procedures
Dorsal Synovectomy
In large part because it is more clinically evident, dorsal wrist synovitis and tenosynovitis are more commonly treated than the volar wrist. The synovial sheath in the dorsal wrist lies just proximal to the extensor retinaculum and extends distal to it. Tenosynovitis may be localized in a single compartment or be more diffuse and multicompartmental. Risk factors for extensor tendon rupture include persistent tenosynovitis, dorsal subluxation/dislocation of the distal ulna, and radiographic evidence of bony erosions of the ulnar side of the distal radius. Rupture of the extensor digiti minimi (EDM) tendon in the fifth dorsal compartment or Vaughan-Jackson syndrome can result from synovitis, arthritic changes, and instability of the distal radioulnar joint (DRUJ). The presence of this injury is generally an indication for synovectomy, tenosynovectomy, and removal of the offending bony spurs to prevent further tendon rupture.
Tenosynovectomy and synovectomy can be helpful in decreasing pain and swelling in patients with RA. The benefit of this procedure is more likely to be experienced in patients who have generally well-maintained motion and minimal bone destruction. However, the long-term benefits are somewhat debatable. Ochi and colleagues reported that, although short-term benefits of synovectomy were realized, there was no appreciable improvement with respect to disease progression in the long term.
Technique
Although most surgeons favor an open approach for dorsal synovectomy, an arthroscopic technique and outcomes has been published. Advantage of the arthroscopic technique are that it allows for minimal dissection, less morbidity, and improved postoperative motion when compared to the open technique. Limitations include the fact that the surgeon can only address wrist synovitis; thus the procedure should be limited to only those patients. I prefer the open technique ( Fig. 10-3 ). It allows me to treat synovitis of both the wrist and tendon inflammation. The procedure is done through a longitudinal incision centered over the dorsal wrist. The fourth extensor compartment or the fourth or fifth extensor compartment interval is used and appropriate radial- and ulnar-based flaps are created. Alternatively, the interval between the third and fourth compartments can be used. Essentially all of the tenosynovium is thoroughly excised. Initially, it is fairly easy to remove the inflammation from the tendons. This can be done with a rongeur to peel off the tendons. Adherent tenosynovium can be sharply dissected with a knife or tenotomy scissor. On completion of the tenosynovectomy, a posterior interosseous neurectomy is routinely performed. The maneuver is fairly easy to do. The posterior interosseous nerve (PIN) lies in the floor of the fourth compartment. The tendons can be safely retracted and a 1-cm segment of the terminus of the nerve is sharply removed just proximal to the joint line. Retraction of the tendons allows for clear exposure of the wrist capsule. In severe cases of DRUJ arthritis, there is often disruption of the dorsal capsule and ligaments and bone spurs are readily seen through the defect. Otherwise the DRUJ can be exposed through the floor of the fifth compartment and synovectomy and bony spur excision can be performed through this approach. Depending on the stability of the distal ulna following synovectomy and debridement, soft tissue stabilization or a more definitive procedure can be performed such as complete or partial distal ulna resection, Sauve-Kapandji, or ulnar head arthroplasty. These are described in greater detail later in the chapter. Abundant synovitis can be peeled from the dorsum of the wrist. I prefer a standard Mayo approach (Berger anatomic approach) to the wrist which is a V-shaped tendon-splitting approach in line with the dorsal radiocarpal ligament and the dorsal intercarpal ligament. This will allow for near-complete exposure of the dorsal carpus. The approach can be extended radially and ulnarly along the distal dorsal rim of the radius to facilitate further visualization radially and ulnarly when necessary.
On completion of the synovectomy, the ligament-sparing interval can be neatly closed. I prefer to close the retinaculum over the extensor tendons to prevent bow-stringing. The extensor pollicis longus tendon is left out superficial to the retinaculum because it would otherwise be vulnerable to injury, adhesions, and rupture as it courses around Lister’s tubercle. An alternative to reconstructing the extensor retinaculum is to lay the extensor retinaculum beneath the extensor tendons to further protect them from abrasion. Depending on the quality of hemostasis, the wound is closed over a drain. The wrist is immobilized for a minimum of 2 weeks, while allowing early finger range of motion. If bony procedures at the DRUJ are necessary, the wrist is immobilized for 4 to 6 weeks.
Concomitant procedures can be performed at the time of synovectomy. In cases of significant wrist collapse and deformity, a reasonable procedure includes transfer of the extensor carpi radialis longus (ECRL) tendon to the extensor carpi ulnaris (ECU) tendon to correct the radial deformity and help restore balance. This can also be helpful in neutralizing or correcting ulnar drift of the digits. An alternative procedure includes a lengthening or release of the ECRL.
Flexor Tenosynovectomy and Volar Wrist Synovectomy
Because of its location deep to the transverse carpal ligament, volar wrist synovitis and tenosynovitis usually are clinically less evident compared to dorsal swelling. Nine tendons crowd into the carpal tunnel along with the median nerve. Tendonitis and tenosynovitis combined with the relative inelasticity of the carpal tunnel render the tendons vulnerable to injury and tear. In addition, the attritional effects of osteophytosis and degenerative changes of the carpus can result in tendon injury. The FPL is the most commonly injured followed by the flexor tendons of the index finger. Tendon irritation and even rupture may be clinically mild and can be missed on evaluation. A contributing factor includes the fact that many patients with RA are taking immunosuppressive medications that can subdue the pain. Any sign of pain with resistive flexion or loss of function can be viewed as an indication for surgery. Prompt surgery can afford the best chance at repair and reconstruction of tendonopathy or rupture and will hopefully minimize further injury.
Technique
Flexor tenosynovectomy and synovectomy can be performed through an extended carpal tunnel approach to the wrist and hand. Care is taken to avoid injury to the palmar sensory branch of the median nerve. The carpal tunnel is released and affords visualization of the flexor tendons and Parona’s space. Generally, synovitis can be significant within the carpal tunnel and a complete and thorough debridement can be performed. The extent of the dissection is based on the degree of inflammation encountered. On completion of tenosynovectomy, attention can turn toward the volar aspect of the wrist and carpus. In many cases bony spurs of the STT joint will be seen to have eroded through the wrist capsule. These can be readily debrided and complete synovectomy can be performed ( Fig. 10-4 ). Care must be taken to avoid destabilization of the extrinsic and intrinsic ligaments, which typically are affected by the disease process.
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