The Wrist in Rheumatoid Arthritis

Abstract

This report deals with our experience with 160 wrists operated on since 1956 for changes produced by rheumatoid arthritis. One hundred and eighteen operations were done on the dorsum of the wrist and forty-two on the volar aspect. The operations included arthrodesis, dorsal wrist stabilization, dorsal tenosynovectomy with or without tendon repair, resection of the distal end of the ulna (Darrach operation), volar tenosynovectomy combined with tendon repair and release of the median nerve, and volar wrist synovectomy. The techniques changed with increasing experience. Synovectomy is a primary objective in any operation on a rheumatoid joint or tendon sheath. Wrist fusion is indicated for a flail wrist with marked destructive changes in the bones of the wrist and severe flexion deformity. Of the eighteen wrists fused, seventeen became solid. Wrist stabilization is being performed more often now. It is indicated for painful synovitis with or without destructive changes in the bones, volar subluxation with a weak grasp, and bilateral painful synovitis with an arc of wrist motion from 30 to 60 degrees of flexion and extension. Wrist stabilization was performed on thirty-seven wrists which were followed for an average of 2.6 years. Sixteen fused spontaneously and twenty-one had loss of wrist motion amounting to from a few degrees to 65 degrees. The average arc of motion lost postoperatively was 32 degrees. Thirty-one wrists were improved functionally and symptomatically. The remaining six wrists were still symptomatic occasionally and their ability to perform activities of daily life was not improved. Tenosynovectomy with or without a Darrach procedure was performed on fifty-six wrists. The indications were painful tenosynovitis, painful inferior radioulnar joint, and tendon rupture. Of fifty-six wrists, forty-eight showed improvement in function and were stable. Eight wrists remained symptomatic and had a recurrence of synovitis. Three of these were reoperated on. The synovitis had not recurred at the site of previous synovectomy. Forty-seven tendons were ruptured in thirty-seven wrists. The most common tendon involved was the extensor digiti minimi and extensor digitorum communis to the little and ring fingers (twenty-two). The next common tendon was the extensor pollicis longus (thirteen). When the tendons were partially involved end-to-side anastomosis was performed. This gave better results than those after tendon transfer for complete rupture of the extensor digitorum. Volar synovectomy was performed for carpal-tunnel syndrome and loss of tendon function. After thirty-four of forty-two volar tenosynovectomies there was improvement in function and complete relief of pain. The remaining eight wrists remained symptomatic. Four of the thirty-four asymptomatic wrists showed fullness over the palmar aspect at follow-up suggesting recurrence of synovitis. None of these has been re-explored. The various operative techniques for the procedures mentioned are described. An approach to the anterior aspect of the wrist joint is described for the first time.