INTRODUCTION
Treatment of the rheumatoid wrist includes preventive, reconstructive, and salvage surgery. It is undertaken only after careful evaluation of the problems, deformity, and needs of the individual patient. In some patients, preventive surgery such as synovectomy of the radiocarpal and/or distal radioulnar joint (DRUJ) is appropriate. In others, reconstructive surgery such as tendon transfers or salvage procedures such as DRUJ reconstruction, partial or total wrist fusions, and wrist arthroplasty are appropriate. Not infrequently, a patient requires a combination of procedures in all three categories.
PATIENT EVALUATION
We encourage patients to express all their concerns regarding their upper extremities, including pain, functional deficits, and appearance. We ask them specifically about the outcome that they would like and expect from surgical treatment, and we point out that they probably have adapted to their deformity(ies) and limitations and may have to adjust to a new and different way of using their hands after surgery.
We examine the entire upper extremity and record active and passive range of motion of the digits, wrist, forearm, elbow, and shoulder. We evaluate for signs and symptoms of tenosynovitis, synovitis, instability, and nerve compression, especially carpal tunnel syndrome.
It is important to evaluate the elbow and shoulder fully. If either of these joints has very limited flexion, then shoulder and elbow function should be addressed before the wrist.
Rheumatoid arthritis can affect three distinct sets of structures: the extensor tendons, the DRUJ, and the radiocarpal joint. A careful physical examination is the key to identifying the true cause of the problem and is crucial in planning effective treatment.
For example, if dorsal wrist swelling is present, it is important to differentiate wrist synovitis from dorsal tenosynovitis. Wrist synovitis usually is painful and causes tenderness and swelling on the dorsal aspect of the wrist. However, the area of swelling does not move with the extensor tendons during finger motion. In contrast, dorsal tenosynovitis rarely is painful or tender but usually does move with the extensor tendons. The radiocarpal joint can be significantly affected by rheumatoid arthritis, and the patient may present with pain and tenderness, but not palpable synovitis.
Persistent DRUJ synovitis may result in “caput ulnae syndrome,” manifested by dorsal dislocation of the distal ulna, supination deformity of the carpus, and bone spur formation on the ulna with secondary tendon ruptures. Thus, on physical examination, it is important to examine the function and integrity of the tendons to the digits, especially the extensor tendons. It is also important to evaluate the metacarpophalangeal (MP) joints, since reconstruction of these joints may be necessary at the same time as wrist surgery.
Radiographs should include neutral posteroanterior (PA), lateral, and oblique views of the wrist and hand to evaluate the MP, radiocarpal, and distal radioulnar joints. The radiographic appearance may not always correlate with the clinical findings. For example, radiographs may show severe joint destruction, whereas the patient’s symptoms may be minimal.
Radiographs also are necessary for surgical planning. If an intramedullary rod is to be used to stabilize a wrist fusion, the metacarpal and distal halves of the radius are evaluated for deformity, and medullary diameter is measured to determine rod size and to confirm that intramedullary fixation is possible. This is particularly important in a patient with juvenile rheumatoid arthritis because distal radius deformity and/or very narrow medullary canals often preclude the use of rods for internal fixation.
Ulnar translocation of the lunate on posteroanterior radiographs is an important finding, since this is an indication for partial arthrodesis of the wrist to prevent further translocation and wrist collapse. However, careful evaluation of the radiographs may reveal a small shelf of bone extending from the ulnar side of the radius, which supports the lunate and which may prevent progressive ulnar translocation. This may not be apparent until the distal ulna is resected.
Lateral and/or oblique radiographs can show volar bone spikes, particularly on the scaphoid. Debridement of these spikes can prevent attrition tendon ruptures of the flexor tendons, particularly the flexor pollicis longus (Mannerfelt lesion).
OPERATIVE INDICATIONS
The indications for surgery of the rheumatoid wrist are disabling pain unrelieved by nonoperative treatment and/or deformity or instability that limits hand function. The radiographic appearance of the wrist influences, but does not determine, treatment. Frequently, we find that the pain and disability are associated with involvement of the DRUJ, even though the patient has minimal radiocarpal motion and moderate destruction on radiographs. In these cases, we recommend distal ulnar surgery without radiocarpal reconstruction. However, if both joints are painful, appropriate radiocarpal and DRUJ surgery is necessary.
Wrist Synovectomy
The indications for wrist synovectomy are controversial because there are no long-term studies that show that surgery will change the natural history of the disease and because it is difficult to do a complete synovectomy in a joint as complex as the wrist. Synovectomy is indicated for patients whose overall disease is under relatively good medical control and who do not have a fixed deformity, but who continue to have localized synovitis despite two or three steroid injections over a 6- to 9-month period and whose radiographs show minimal changes in the radiocarpal joint ( Fig. 58-1 A and B). The ideal patient for a wrist synovectomy is a young active patient with isolated wrist synovitis and good medical control of the disease with good motion and radiographic appearance.
If the wrist has a radial deviation deformity that can be corrected passively, an extensor carpi radialis longus (ECRL) to extensor carpi ulnaris (ECU) tendon transfer may be added, particularly when MP joint arthroplasties are to be done concomitantly. 18,19 Occasionally, a patient has primary ulnar deviation of the MP joints, causing a secondary radial deviation of the wrist. In these few cases, passive correction of the MP joints corrects the wrist deformity. Therefore wrist surgery may not be needed if the wrist is painless and realigns after MP joint treatment ( Fig. 58-2 A and B).
We have found that synovectomy can be a pain-relieving procedure in spite of moderate radiographic destruction of the radiocarpal joint. Therefore, if other wrist surgery is being performed and there is clinical evidence of radiocarpal synovitis, we would perform a synovectomy even in patients with more advanced radiographic destruction. We usually combine wrist denervation with synovectomy.
Standard open synovectomy allows wrist denervation to be done through the same incision, whereas arthroscopic synovectomy is less invasive and is effective and well tolerated by most patients. Wrist denervation can be done through a small separate incision proximal to the extensor retinaculum.
Distal Radioulnar Joint Surgery
DRUJ synovitis causes destruction of the triangular fibrocartilage complex (TFCC) very early in the course of the disease and results in instability of the DRUJ and a prominent ulna. When there is destruction of the TFCC, we recommend a distal ulnar excision with soft tissue reconstruction of the DRUJ. The most pressing indications for DRUJ surgery are extensor tendon ruptures and/or a painful dislocated or subluxated DRUJ with a prominent distal ulna and limited forearm rotation. Painless limited forearm rotation is a relative indication for DRUJ reconstruction.
The options for surgical treatment include the following: (1) distal ulnar excision of the Darrach type combined with synovectomy of the DRUJ and reconstruction of the TFCC and joint capsule; (2) fusion of the distal ulna to the sigmoid notch of the radius with resection of a proximal segment of the ulna to allow forearm rotation (Sauvé-Kapandji procedure); (3) hemiarthroplasty procedure as advocated by Bowers and Watson and colleagues, combined with tendon transfers when necessary; and (4) ulnar head replacement or total DRUJ replacement. We have been pleased with the results of the Darrach-type resection and soft tissue reconstruction and have not found that the Sauvé-Kapandji procedure decreases ulnar translocation or has a significantly better outcome compared with distal ulnar excision for patients with rheumatoid arthritis involvement of the DRUJ.
Radiocarpal Surgery
The options for radiocarpal salvage include partial or total wrist fusion and wrist arthroplasty. The choice of proceduredepends on the extent of bone and soft tissue destruction, the status of the adjacent joints, and the specific requirements of the patient. In most cases, we prefer total wrist fusion, especially when there is marked deformity and instability of the radiocarpal joint ( Fig. 58-3 ). Wrist fusion is a definitive operation that provides a pain-free, well-aligned, and stable wrist. We consider wrist fusion in the rheumatoid patient to be the standard against which all other salvage procedures must be measured. We often perform a DRUJ reconstruction simultaneously at the time of wrist fusion.
In patients with progressive ulnar translocation (with or without carpal dissociation or proximal row destruction), a partial wrist fusion (radius to proximal carpal row) may prevent further deterioration and, if the midcarpal joint is spared, preserve some motion ( Fig. 58-4 A and B). A partial wrist fusion may preserve 40 to 50 degrees of wrist motion and usually alleviates the wrist pain. It is not always a definitive procedure because progressive destruction of the joint may require revision to a total wrist fusion.
Silicone wrist arthroplasty was developed in the mid-1970s and is no longer performed. Total wrist arthroplasty has become more reliable, but is still used infrequently for our patients with rheumatoid arthritis. We restrict the procedure to low-demand patients who have bilateral disease and require some motion in one wrist. The ideal patient would have a well-aligned wrist, intact wrist extensor tendons, moderate range of motion, and good bone stock. We consider the need for ambulatory aids a contraindication to wrist implant arthroplasty ( Fig. 58-5 A–C). Total wrist arthroplasty provides motion similar to proximal row carpectomy, radiolunate arthrodesis, and scaphoid excision with midcarpal fusion. Contraindications to total wrist arthroplasty are bone loss, which would compromise stability of the prosthesis; infection; unreconstructable tendon rupture; and the patient’s need to do heavy lifting or activities that would apply impact loading to the wrist.
Radiocarpal reconstruction done solely to improve range of motion is not indicated. A painless well-aligned wrist with minimal motion provides good function, and rarely is any surgery indicated in such wrists.
SURGICAL TECHNIQUE
General
All of our wrist surgery is done under tourniquet control. A brachial tourniquet is carefully applied to avoid twisting the skin and is padded and inflated to approximately 100 mm above systolic pressure. When needed, we use double tourniquets that are alternated hourly to decrease the localized nerve compression and prolong safe tourniquet time. We prefer a straight longitudinal dorsal skin incision centered over the wrist joint. The length of the incision depends on the specific procedure to be done. Zig-zag or S-shaped incisions should not be used because of the increased risk of delayed wound healing and/or skin necrosis. The skin flaps are kept as thick as possible by taking the dissection directly to the extensor retinaculum before flaps are raised. The dorsal veins and cutaneous nerves are preserved in the subcutaneous flaps. Parallel transverse incisions are made proximal and distal to the retinaculum, allowing the retinaculum to be reflected as a flap. The fourth compartment is opened in a Z fashion, and the posterior interosseous nerve, which lies on the floor of the fourth compartment, is resected to partially denervate the wrist joint ( Fig. 58-6 A–D).
The extensor pollicis longus tendon is identified to prevent injury. The vertical septum between each compartment is divided. The radial-based flap is usually hinged on the septum between the second and third compartments or on the septum between the first and second compartments if the second compartment needs a tenosynovectomy. The ulnar flap is hinged on the septum between the fourth and fifth compartments. Hypertrophic tenosynovium is removed from each of the tendons. Badly frayed tendons are reinforced with running or mattress sutures. Pockets or nodules of tenosynovium invading tendon substance are removed and the tendon repaired as previously described. We do not open the first compartment unless there is clinical evidence of disease.
Synovectomy
The radiocarpal joint is exposed through a transverse capsular incision over the proximal carpal row. A distally based flap of capsule is elevated to expose the midcarpal joints. Traction applied to the hand distracts the joints and allows the synovectomy to be done with a small rongeur. A small blunt elevator can be used to provide better exposure within the joint. Periarticular erosions are curetted. Synovium is removed from between the triquetrum and the triangular fibrocartilage.
Synovectomy of the DRUJ is done through a longitudinal incision proximal to the triangular fibrocartilage. The forearm is rotated to provide exposure while the synovectomy is performed. Bone spurs are removed from the distal ulna and radius, and periarticular erosions are curetted.
After synovectomy, a very tight capsular closure is done to limit the range of wrist flexion and extension if there is evidence of interosseous ligament disruption. If the radioulnar joint is unstable, the joint capsule is closed with the hand in supination, and the forearm is splinted in supination. If there is severe DRUJ instability, a soft tissue procedure to stabilize the joint should be done using part of the ECU or the flexor carpi ulnaris. Rarely, a more anatomic DRUJ reconstruction can be performed, as described by Adams and Berger. However, in these patients the best solution often is a resection of the distal portion of the ulna with stabilization, as described in the text that follows. After the capsule has been closed and reefed, the retinaculum is reconstructed. Since the retinaculum was opened in a Z fashion, it is usually closed in a slightly lengthened side-to-side fashion to prevent overtightening. Rarely, part of the retinaculum is placed deep to the tendons to cover bone spurs and thereby protect the extensor tendons. If needed, the ECU is relocated from its subluxated volar position to its normal dorsal position using an ulnar-based retinacular flap to restore wrist balance. Tendon transfers to restore wrist balance are described later.
Excision of Distal Ulna
The extensor retinaculum is reflected, and the compartments are opened as previously described. A longitudinal incision is made over the distal ulna. The capsule and TFCC are reflected from the distal ulna and protected. It is important to preserve the distal attachment of the TFCC to the carpus. The triangular fibrocartilage has an attachment to the fovea, and sharp dissection is the easiest way to detach this tissue. It is possible that the TFCC has been partially or totally destroyed by the disease and therefore is not present. The periosteum is elevated, and retractors are placed around the ulna to protect the soft tissues, especially the neurovascular bundle volar to the ulna. The distal ulna is divided with a microsaw or osteotome just proximal to the sigmoid notch. Approximately 2 cm of bone are resected. A towel clip is used to apply traction to the bone while the soft tissue attachments are released. The forearm is rotated from full pronation to full supination to ensure that there is no impingement on the radius. The radial and ulnar cortex should be beveled to prevent sharp edges that could impinge during rotation. The dorsal cortex of the ulna is also beveled and smoothed to prevent attritional injury of the extensor tendons postoperatively. Hypertrophic synovium is removed, as are osteophytes on the radius.
The amount of ulnar resection is kept to a minimum. Only enough ulna is resected so that the ulnar stump is proximal to the sigmoid notch to prevent impingement. If excessive bone is resected, stability of the remaining ulna may become compromised. The TFCC is reattached to the dorsal and ulnar corner of the radius to augment stability and to help correct carpal supination. Although this ligament is frequently stretched, eroded, and/or partially destroyed, careful dissection allows the remnants of the TFCC to be sutured to the radius and/or radioulnar capsule. The dorsal radioulnar joint capsule is sutured tightly to stabilize the ulna, and redundant capsular tissue is imbricated to provide additional support. The closure is done with the wrist in neutral or supination.
If the triangular fibrocartilage is inadequate for this reconstruction, a distally based flap of volar capsule can be elevated to reconstruct the ligament, or, the distal ulna can be stabilized with a distally based strip of the ECU tendon passed through the distal ulna.
Replacement of the Distal Ulna
Rarely, a distal ulnar resection with stabilization is not successful in the rheumatoid patient. In this case, a distal ulnar head replacement or DRUJ replacement may be needed.
Tendon Transfers to Restore Wrist Balance
In patients with a radial deviation deformity that is passively correctable, relocation of the ECU tendon or a tendon transfer such as the ECRL to the ECU may correct the deformity without the need for a bone procedure. This is especially important when there is ulnar deviation of the MP joints. Careful preoperative examination is necessary to ensure that the cause of the radial deviation deformity stems from wrist pathology rather than MP joint pathology before performing the transfer (see Fig. 58-2 ). The effect of ECU relocation can be tested preoperatively: the wrist is placed in supination, and if the ECU can ulnar-deviate the wrist in this position, then surgical relocation of the ECU dorsally will help to correct the radial deviation deformity. If the ECU cannot ulnar-deviate the wrist with the forearm in supination, an ECRL-to-ECU tendon transfer can be done. This transfer maintains the ECU in the dorsal position, augments active ulnar deviation, helps prevent carpal supination, and opposes ulnar translocation.
This tendon transfer is done as follows. After other dorsal wrist surgery such as dorsal tenosynovectomy and/or synovectomy is completed, the ECRL is detached from the second metacarpal. The tendon usually is rerouted volar to the finger extensors and sutured to the ECU with the wrist in the corrected position. If needed to prevent extensor tendon bowstringing, the ECRL can be placed over the finger extensors, as suggested by Poietevin. The wrist is splinted in neutral position with the fingers left free for 4 weeks after surgery.
Total Wrist Arthrodesis
A tenosynovectomy and distal ulnar excision are done before the arthrodesis, if necessary. The capsule is incised longitudinally, and the radiocarpal joint is exposed and preserved for closure. If there is a significant deformity, the radial capsule and first dorsal extensor compartment tendons are released. This can simplify exposure of the radius and allow removal of a prominent radial styloid. The joint is exposed by flexing the carpus. A synovectomy is done with rongeurs. Articular cartilage and sclerotic bone are removed from the radius and carpal bones using a rongeur and/or osteotome. The amount of bone removed depends on the degree of deformity and destruction. In patients with volar subluxation of the carpus, there is usually significant volar and ulnar erosion of the radius. In such cases, more radial and dorsal bone must be removed to correct the deformity and realign the wrist. If there is considerable destruction of the proximal carpal row, a proximal row carpectomy provides bone graft and allows the distal carpus to be fused to the radius. We do not include the carpometacarpal joints during arthrodesis in a patient with rheumatoid arthritis. Except in unusual cases, bone graft is not necessary for wrist arthrodesis in these patients.
We routinely use internal fixation for a rheumatoid wrist fusion. Traditionally, we have used Steinmann pins, although a plate such as the Synthes wrist fusion plate can be used if there is good bone stock and satisfactory soft tissue.
Several alternatives are available for placement of the pins. Pins placed through one of the metacarpals, across the carpus, and into the radius predetermine that the wrist is fused in neutral flexion/extension. Placement of smaller-diameter pins between the metacarpals, across the carpus, and into the radius allows the wrist to be placed in slight extension. We use at least two Steinmann pins.
Metacarpal to Radius Technique
One pin is inserted through the third metacarpal or occasionally the second metacarpal. The pin is placed through the dorsal aspect of the metacarpal head. Satisfactory MP joint motion is preserved postoperatively, since this part of the metacarpal head does not articulate with the base of the proximal phalanx during functional motion. An MP joint arthroplasty can be performed at the same time if the MP joint is destroyed or is subluxated. A second pin is placed between the metacarpals, usually between the third and fourth metacarpals or occasionally between the second and third metacarpals ( Fig. 58-7 ). Alternatively, two pins placed between the metacarpals and inserted across the carpus and into the radius can be used ( Fig. 58-8 A and B).
Related posts:
Ulnar Head and Styloid Fractures
Traumatic Extensor Carpi Ulnaris Disruption: Subluxation, Dislocation, Rupture
Management of Soft Tissue Contractures Around the Distal Radioulnar Joint
Lunotriquetral Ligament Instability/Tear: Acute and Chronic
Arthroscopic Resection of Distal Scaphoid and Tendon Interposition for Isolated Scaphotrapeziotrapezoid Arthritis
Bone Tumors of the Hand and Wrist
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