Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: The surgical treatment of the rheumatoid wrist is key in managing the affected hand. Wrist fusion is often the treatment of choice in cases of severe destruction and deformation although most patients would prefer a motion-preserving procedure. The implantation of a wrist prosthesis might be an alternative to partial arthrodesis for selected cases. In this series we analyzed the long-term results (minimum follow-up period, 10 y) of the Swanson silicone spacer for the wrist in patients with rheumatoid arthritis. METHODS: Sixteen patients with rheumatoid arthritis with 18 silicone spacers for the wrists were reviewed after a minimum follow-up period of 10 years (average, 15 y). Subjective evaluation, clinical examination, and radiographic analysis were included. An additional 9 patients (9 wrists) were interviewed by telephone. RESULTS: In 12 of the patients the subjective result was good or very good, mostly because of adequate pain relief. The average range of motion for flexion (average, 28 degrees )/extension (average, 15 degrees ) was 43 degrees with a wide variation within the series. Radiologically all wrists had diminished residual carpal height at follow-up evaluation and 9 of the wrists had evidence of osteolysis and foreign-body granuloma. The initial good correction of the ulnar translation of the wrist was lost partially in the follow-up period (1.1 vs 4.0 mm). Three of the patients needed surgical revision within the follow-up period; all were converted to wrist fusion. CONCLUSIONS: These long-term results suggest that the silicone wrist spacer still may be considered as an alternative to wrist fusion or more complex wrist joint prostheses in patients with rheumatoid arthritis, especially in severe cases and in patients with low demands. In the long term osteolysis caused by foreign-body granulation is to be expected and has to be considered.     

Early results of the Universal total wrist arthroplasty in rheumatoid arthritis

Early results of 2 surgeons involved in a prospective study of the Universal total wrist prosthesis (KMI, San Diego, CA) are reported. Twenty-two prostheses were implanted in 19 patients for the treatment of severe rheumatoid arthritis. Two-year follow-up results of 8 wrists and 1-year follow-up results of 14 wrists were reviewed. Total arcs of motion (flexion-extension, radial-ulnar deviation, and pronation-supination) all improved significantly after arthroplasty. Individual motions that were most limited before surgery (extension, radial deviation, and supination) improved the most. Disabilities of the Arm, Shoulder, and Hand outcome scores improved 14 points at 1 year and 24 points at 2 years. Three prostheses (14%) were unstable and required further treatment; all 3 were in patients with highly active disease and severe wrist laxity. The Universal prosthesis provides a good early outcome in rheumatoid patients without severe preoperative wrist laxity.     

A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist

This retrospective study compared plate fixation versus pin fixation in 57 patients with rheumatoid arthritis who underwent wrist arthrodesis. Fixation was achieved by using plates in 32 patients and longitudinal pins in 25 patients. Clinical follow-up averaged 29 months (range: 12-57 months) and radiographic follow-up averaged 16 months (range 12-39 months). Union occurred in 97% of the wrists fixed with plates and in 96% of the wrists fixed with pins. There were 6 (19%) complications in the plate group and 7 (28%) complications in the pin group. Three (12%) wrists fixed with pins moved from the immediate postoperative position to a position of relative volar flexion, while radiographs showed no changes in wrist position in the plate group. With both methods, successful arthrodesis stabilized the wrist in a high percentage of patients. Plate fixation offers an excellent alternative method for arthrodesis of the rheumatoid wrist.     

Results of dorsal wrist synovectomies in the rheumatoid hand

Seventy-eight patients with rheumatoid arthritis had 102 dorsal wrist tenosynovectomies, intraarticular synovectomies, and Darrach resection from 1962 to 1982. Follow-up after surgery averaged 11 years, with a range from 3 to 20 years. Pain was diminished in all but 17 wrists and motion decreased an average of 13 degrees. Synovitis recurred in 16 wrists and x-ray evidence of progressive intraarticular destruction was seen in 45 wrists. Revision surgery was necessary in 28 wrists.     

Arthroscopic synovectomy of the wrist in rheumatoid arthritis

We analysed the results of arthroscopic synovectomy of the wrist in 18 patients (19 wrists) with rheumatoid arthritis who had not responded to conservative treatment. The patients' symptoms were assessed using visual analogue scales for pain and satisfaction. Standard posteroanterior radiographs which were taken pre-operatively and at final follow-up were analysed using a modified Larsen scoring system (normal, 0; total destruction, 40). The mean follow-up period was 29.2 months (24 to 45). The mean pre-operative pain score was 8.58 which decreased to 3.58 one year after surgery and increased again to 4.42 at final follow-up. This suggested a gradual increase in pain with time. The mean satisfaction score was 6.26. The mean modified Larsen's score was 9.8 pre-operatively and 13.9 at final follow-up, which demonstrated the slow progression of degenerative changes. Arthroscopic synovectomy for rheumatoid arthritis of the wrist allows effective pain relief and high patient satisfaction, although any prolonged benefits will require long-term follow-up.     

Fate of failed Meuli total wrist arthroplasty

Sixteen Meuli wrist arthroplasties in 13 patients suffering mainly from rheumatoid arthritis were revised for failure. Causes for failure were mechanical problems with the implant in three wrists, soft tissue problems in two wrists and a combination of mechanical failure and soft tissue problems in 11 wrists. Management included 11 revision arthroplasties in ten wrists, four arthrodeses and two primary soft tissue reconstructions. Twenty-six additional soft tissue procedures were required in association with the revision arthroplasties or arthrodeses. Five of the 11 revision arthroplasties had to be converted to arthrodeses after an average of 5 (range 3-8) years. After removal of a failed wrist implant union of the salvage arthrodesis was difficult to achieve in two of the nine instances. This series demonstrates that revision arthroplasty may be a useful alternative to arthrodesis for the salvage of primary wrist arthroplasties in rheumatoid patients. However, complications and reoperations may occur after both revision arthroplasty and arthrodesis.     

Radiocarpal arthrodesis in the treatment of the rheumatoid wrist. A prospective midterm follow-up

This prospective study was performed to evaluate the clinical and radiological results of radiocarpal joint arthrodesis in the treatment of unstable Simmen group III and Larsen grade II or III rheumatoid wrists. Radiolunate arthrodesis was performed in 16 wrists and radioscapholunate arthrodesis in 7 wrists in 20 patients. When they were evaluated at a mean of 5.8 (range 3.5-9.8) years later, flexion was 29 degrees and extension 34 degrees , representing 67% and 92% of the preoperative values, respectively. Patient satisfaction was excellent, or good, for 20 wrists and satisfactory for 1 wrist. In two patients with poor satisfaction, arthritis progressed to the midcarpal joint and necessitated total arthrodesis of the wrist. Radiolunate joint arthrodesis, with inclusion of the scaphoid in the fusion if necessary, is a useful operation in the treatment of this degree of wrist disease as it produces a functional and pain-free wrist at the same time as preserving much of the mobility and bone stock.     

Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases

In a 4 year period (1996-1999), 42 total wrist fusions in 25 men and 17 women were performed using the AO/ASIF Titanium wrist fusion plate. The median age of the patients at the time of surgery was 41 (range, 19-72) years. The indication for fusion was post-traumatic arthritis in 29 wrists, Kienb?ck's disease in eight, rheumatoid arthritis in three, mono-arthritis in one and Volkmann's contracture in one. All patients were reviewed at a median follow-up of 23 (range, 6-50) months. The Buck-Gramcko and Lohmann score for functional evaluation was excellent in 35, good in 5 and satisfactory in 2 patients. We conclude that wrist arthrodesis with the AO/ASIF Titanium wrist fusion plate is an excellent option for treatment of various painful disorders of the wrist.     

Proximal row carpectomy: review of rheumatoid and nonrheumatoid wrists

Proximal row carpectomy was first done in 1939 and was indicated for treatment of posttraumatic problems or Kienb?ck's disease. Use of this procedure in patients with rheumatoid arthritis has not been reported. Our series consists of eighteen wrists, nine with rheumatoid arthritis, and nine with other various nonrheumatoid conditions. Follow-up ranged from 12 to 120 months and included x-ray films and assessment of pain, range of motion, balance, grip strength, and patient satisfaction. Our results showed only two of the eight rheumatoid wrists to be satisfactory; failure was caused by pain and imbalance. Of the nonrheumatoid wrists, six of the eight were satisfactory, although in one of the six sclerosis is developing between the capitate and radius. Proximal row carpectomy is not recommended for the rheumatoid wrist but may be useful where other pathologic conditions are involved if the remaining articular surfaces are uninvolved.     

Comparison of arthroplasty and arthrodesis for the rheumatoid wrist

PURPOSE: To compare the outcomes of wrist arthrodesis and arthroplasty in the treatment of rheumatoid arthritis using validated outcome patient surveys and a review of surgical complications in 2 matched cohorts. METHODS: Forty-six patients with 51 operated wrists (24 arthrodeses and 27 arthroplasties) were reviewed retrospectively at a follow-up range of 1 to 5 years. Patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) inventory, the Patient-Rated Wrist Evaluation (PRWE), and a questionnaire designed specifically for this study. Surgical complications were obtained by chart review. RESULTS: Treatment groups were well matched by patient characteristics and radiographic staging. There were no statistical differences in the survey scores between the 2 groups. Patients in the arthroplasty group, however, reported a trend toward greater ease with personal hygiene and fastening buttons. Complication rates were similar with a 56% complication rate in the arthrodesis group (22% major, 35% minor) and a 52% complication rate in the arthroplasty group (11% major, 41% minor). CONCLUSIONS: The DASH and PRWE may not be designed properly to measure impairment caused by wrist disease in patients with generalized arthritis. The results show that patients with rheumatoid arthritis can and do accommodate to a wrist arthrodesis. It should not be construed, however, that patients with rheumatoid arthritis would not prefer or obtain greater benefit from a wrist arthroplasty [corrected].     

Teilarthrodesen und Fusionen am rheumatischen Handgelenk

The hand (wrist and fingers) is one of the regions most frequently affected by rheumatic arthritis (RA). Obviously, the functional handicap affects activities of daily living and imposes an additional psychological burden, because the nature of the alterations means that the clinical picture can be interpreted as RA from external appearances. Thus, treatment of the rheumatoid wrist is a prodigious challenge for hand surgeons. Radiolunate arthrodesis (RLA), as pioneered by Chamay and Della-Santa, has become an established surgical technique for stabilizing and relieving pain in wrists destroyed by RA. RLA has been described by Stanley as the "golden standard" for the treatment of rheumatoid wrists. For patients with a severe wrist deformity and pain, a complete wrist arthrodesis may be the only viable surgical option.     

Total wrist arthroplasty. Experience with Swanson flexible silicone implants, 1982-1988.

In a study of the results of silicone rubber arthroplasty of the wrist 18 patients (19 operated wrists) were re-examined after a mean follow up of five years. Experience with the ulnar head implant was discouraging, and it was not used in the last eight wrists. This did not affect the outcome, patients having good supination and pronation without pain. The range of motion with the radiocarpal prostheses was 0-70 degrees, mean 39 degrees. Radiological results showed severe subsidence in all patients followed up for more than two years, and prosthetic fracture in five (26%), which was disappointing. Nevertheless the patients had a useful range of motion and all but two were relieved of pain. By the patients' own assessments 16 wrists were considered good, one fair, and two poor. Predictors of failure (prosthetic fracture) were poor alignment before operation, postoperative range of motion of more than 50 degrees, and rupture of the carpal extensor tendon. With these reservations we recommend the silicone spacer as the best solution for most patients with severe problems of the wrist as a result of rheumatoid arthritis.     

Mannerfelt arthrodesis of the wrist joint in patients with chronic polyarthritis. A retrospective analysis of 24 cases

AIM: Mannerfelt established his technique of wrist arthrodesis with stabilisation by an intraosseous rushpin as a secure method for patients with rheumatoid arthritis. This study was performed to evaluate the mid-term results in a consecutive group of patients. METHODS: Out of a group of 39 operations 24 wrist arthrodeses (61%) in 19 patients have been followed 12-96 months postoperatively (average 44 mths) by clinical testing and radiographic examination. All operations were performed in the original technique. All patients suffered from rheumatoid arthritis in an advanced stage (Larsen III-V). RESULTS: All but one patient were free of pain. Function and strength of the hand increased significantly in all patients. All patients had additional resection of the ulnar head that led to normal pro-supination of the forearm. 18 patients were very satisfied with the result of the procedure. All but one of the wrists showed complete fusion. In one case there was an intraoperative perforation of the pin through the radial cortex, in another case we saw a fissure of the shaft of the third metacarpal bone. One patient showed a dysesthesia in the third finger. CONCLUSION: The results in this group of patients confirmed the advantages of Mannerfelt's technique such as simple operative technique, high fusion rate and low incidence of complications.     

The Wrightington classification of rheumatoid wrist x-rays: A guide to surgical, management

We have reviewed the pre-operative radiological appearances, the type of operation performed and the results of surgery of 234 wrists in 179 patients with rheumatoid arthritis. Based on this, a classification of X-rays of the rheumatoid wrist is described. It is designed to provide practical guidance to the surgeon who is planning surgery in a patient with rheumatoid disease. The surgical choices at each stage of the disease are briefly discussed.     

Bilateral traumatic dislocations of Volz total wrist arthroplasties: a case report

Bilateral traumatic dislocations of Volz total wrist arthroplasties in a patient with rheumatoid arthritis occurred 7 years after the initial surgical procedures. Treatment consisted of closed manipulation and reduction of both wrists followed by temporary splinting. Good function was restored in both wrists without operative intervention. No fractures or loosening at the bone cement interface was encountered.     

Results of Mannerfelt wrist arthrodesis for rheumatoid arthritis in relation to the position of the fused wrist

Purpose

The wrist is involved early in rheumatoid arthritis and is often severely affected. A stable wrist is crucial to good hand function, which often necessitates a fusion. One of the most commonly used techniques in rheumatoid patients is the Mannerfelt arthrodesis. In this retrospective study the outcome and the patient’s subjective satisfaction are presented and compared to other techniques. Also the influence of the position of the wrist following a fusion procedure is analysed.

Methods

Thirty-four wrists were retrospectively analysed using radiological measurements, functional scores such as the Disabilities of the Arm, Shoulder and Hand (DASH) and a pain assessment. The objective function of the hand with the fused wrist was assessed.

Results

In 92.6 % of wrists the patients rated their satisfaction as good or excellent. The mean DASH score post-operatively was 63.3. Of the wrists, 17 were fixed in a median flexed position of 13° and 17 wrists in a median extended position of 8°. There was no statistically significant correlation between the position of the wrist and the satisfaction or objective function. The rate of fusion was 94.1 %.

Conclusions

The Mannerfelt arthrodesis achieves good results and provides a high rate of satisfaction and pain relief in our study. It has major advantages compared to other wrist fusion techniques in the rheumatoid patient. We could not show clear statistical evidence for better results in either a flexed or an extended position, but the ratings of the patients indicated better subjective results with a slightly extended position of the arthrodesis.     

Limited wrist fusions

Seventeen patients had wrist fusions done for diseases other than rheumatoid arthritis of the wrist and carpal bones. Arthrodesis was done at the radiocarpal joint in five wrists and at the midcarpal joint in 12. There were 12 men and five women. Ages at the time of operation averaged 42 years. Follow-up ranged from 6 months to 5 years and 5 months, and with an average of 1 year and 10 months. Overall postoperative results were excellent in five wrists, good in seven, fair in two, and poor in three. Wrists with the midcarpal fusion fared better than those wrists with the radiocarpal fusion. Complications included one pseudoarthrosis and one rupture of the flexor pollicis longus tendon. In one of the 17 wrists new osteoarthritic changes surrounding the arthrodesed joints occurred.     

Comparative results of resection of the distal ulna in rheumatoid arthritis and post-traumatic conditions

The purpose of this study was to determine whether the results of resection of the distal ulna differed depending upon the underlying aetiology of the condition. Patients with rheumatoid arthritis were compared with patients with post-traumatic wrist complaints. Fifty resections in 40 patients (eight male, 32 female) were assessed with respect to pain, range of motion, and grip strength. Of the 23 rheumatoid wrists, 86% were pain-free following surgery; however, only 36% of the patients in the trauma group reported pain relief postoperatively. Pain relief in post-traumatic patients was more predictable when distal radioulnar joint arthrosis was identified as the sole cause of wrist pain.     

The role of arthroscopic synovectomy in patients with undifferentiated chronic monoarthritis of the wrist

We investigated the clinical response to arthroscopic synovectomy in patients with undifferentiated chronic monoarthritis (UCMA) of the wrist. Arthroscopic synovectomy was performed on 20 wrists in 20 patients with UCMA of the wrist who had not responded to non-steroidal anti-inflammatory drugs. The mean duration of symptoms at the time of surgery was 4.3 months (3 to 7) and the mean follow-up was 51.8 months (24 to 94). Inflamed synovium was completely removed from the radiocarpal, midcarpal and distal radioulnar joints using more portals than normal. After surgery, nine patients had early remission of synovitis and 11 with uncontrolled synovitis received antirheumatic medication. Overall, there was significant improvement in terms of pain relief, range of movement and Mayo score. Radiological deterioration was seen in five patients who were diagnosed as having rheumatoid arthritis during the follow-up period. Lymphoid follicles and severe lymphocyte infiltration were seen more often in synovial biopsies from patients with uncontrolled synovitis. These results suggest that arthroscopic synovectomy provides pain relief and functional improvement, and allows rapid resolution of synovitis in about half of patients with UCMA of the wrist.     

Volar dislocation of the extensor carpi ulnaris tendon on magnetic resonance imaging is associated with extensor digitorum communis tendon rupture in rheumatoid wrists

PURPOSE: Extensor tendon rupture in rheumatoid wrists is a common problem and causes immediate dysfunction of the digits. The best treatment for tendon rupture may be prophylactic management, although the factors associated with tendon rupture must first be identified. The purpose of this study was to evaluate structures around rheumatoid wrists using magnetic resonance imaging with forearm rotation and to identify factors associated with extensor tendon rupture as indications for prophylactic surgery. METHODS: The subjects were 34 patients (40 wrists) with active rheumatoid arthritis. The extensor digitorum communis (EDC) tendons were ruptured in 15 wrists. Magnetic resonance imaging of the wrists was performed in maximally pronated and supinated positions of the forearm. Axial images of the distal radioulnar joints (DRUJs) were selected to evaluate DRUJ synovitis, dorsal tenosynovitis, volar dislocation of the extensor carpi ulnaris (ECU) tendon, sigmoid notch angle, and the radioulnar ratio (RUR) (ie, the degree of DRUJ subluxation). RESULTS: No significant correlations were found between EDC tendon rupture and DRUJ synovitis, dorsal tenosynovitis, or RUR in pronation. Extensor digitorum communis tendon rupture correlated significantly with volar ECU tendon dislocation, sigmoid notch angle, and RUR in supination. Radioulnar ratio correlated significantly with volar ECU tendon dislocation only in supination and not in pronation. Thus, DRUJ subluxation was advanced even in the supinated wrist with volar ECU tendon dislocation. As a factor associated with EDC tendon rupture, volar ECU tendon dislocation had 87% sensitivity and 76% specificity. CONCLUSIONS: Volar ECU tendon dislocation is associated with increased RUR in supination and EDC tendon rupture. Volar ECU tendon dislocation can thus be considered a factor associated with EDC tendon rupture, and its presence may indicate the need for prophylactic surgical intervention in a subset of rheumatoid arthritis patients.