Partial arthrodesis for the rheumatoid wrist

The correct treatment of wrist deformation in the patient who has rheumatoid arthritis has a major impact on the preservation of function of the hand. Surgical decisions should be individualized, based on the patient's needs and the future development of deformation. Partial wrist arthrodesis in rheumatoid wrists is an excellent tool to preserve stability and functional mobility in the long term. In cases of severe destruction complete wrist fusion should be considered alternatively.     

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].     

Limited wrist arthrodesis: a laboratory study

By means of an external fixator, 11 limited wrist "fusions" in eight freshly frozen cadaver wrists were studied. An electrogoniometer measured perfusion and postfusion range of motion, and the percentage of loss of motion was determined and then averaged for all eight wrists. The three fusions that crossed the radiocarpal row lost approximately 55% flexion/extension (F/E). The five fusions that crossed the intercarpal row lost approximately 27% F/E, and the three fusions within a single carpal row lost approximately 12% F/E. These results may be helpful to determine which limited wrist fusion to perform.     

Median nerve compression complicating arthrodesis of the rheumatoid wrist

The frequency and pathogenesis of median nerve compression complicating the Rush pin method of fusing the rheumatoid wrist was evaluated retrospectively. This complication was encountered in 14/50 wrists (28%). In 7 hands the carpal tunnel was explored, mostly within 2 weeks after fusion. In addition to signs of acute entrapment of the median nerve the most constant finding was that the volar edge of the resected distal end of the radius was prominent and projected into the bottom of the carpal tunnel caused by too vigorous correction of the subluxed carpus. Obviously the median nerve was squeezed or angulated at the volar edge of the radius. After median nerve release and resection of the bony prominence all patients regained full sensibility within the period of observation (in average 2.5 years). It is concluded that this mechanism of nerve entrapment should be realized when fusion of a severely destructed rheumatoid wrist is considered.     

Functional and patient-reported outcome of partial wrist denervation versus the Mannerfelt wrist arthrodesis in the rheumatoid wrist

Introduction

Wrist arthrodesis offers high success rates in patients with rheumatoid arthritis; however, loss of residual mobility may cause unnecessary disability. This makes wrist denervation an appealing alternative. However, there is a distinct lack of patient-reported outcome measure studies comparing these two procedures. The aim of this study was to report any change in function, pain and satisfaction following wrist arthrodesis compared to denervation in a single surgeon series of rheumatoid patients.

Patients and methods

The results of 16 wrist arthrodesis in 15 patients and 14 partial (PIN) wrist denervations in 13 patients were compared with a mean follow-up period of 39 and 22 months, respectively. The primary outcome measures were the same for both groups and included the validated patient-rated wrist evaluation questionnaire and a satisfaction questionnaire.

Results

Wrist arthrodesis significantly improved the mean total pain and functional outcome scores by 54 and 36 %, respectively, at the time of follow-up. Wrist denervation patients also reported significant improvements of 44 and 42 % in total pain and functional outcomes, respectively; 87 % reported being very satisfied with their wrist arthrodesis procedure compared to 78 % in the denervation group. No statistically significant difference in response between the groups was observed in this series of patients.

Conclusions

Both procedures enjoyed favourable results amongst patients with excellent satisfaction outcomes. PIN denervation is a simple procedure with low complication rates and we therefore consider it a valid alternative to more difficult treatment options, such as partial or total wrist arthrodesis.     

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.     

Long-term functional results of wrist arthrodesis in rheumatoid arthritis

The purpose of this study was to evaluate the long-term effectiveness of wrist fusion on the relief of pain and also the functional capacities of the upper limbs in patients with rheumatoid arthritis (RA). Eighteen patients were assessed at a mean of 7 years after wrist arthrodesis and a mean of 17 years after the onset of RA. Radiological measurements, pain assessment and impairment rating of the upper limbs were made of the fused and non-fused sides. The average position of arthrodesis was 8 degrees of extension and 9 degrees of ulnar deviation. All patients were pleased with the procedure and had satisfactory pain relief. Impairment ratings did not detect any significant difference in the sensory and motor function of the hand when the fused and non-fused groups were compared. We conclude that in patients with rheumatoid arthritis, wrist arthrodesis is a reliable procedure that provides predictable pain relief and a high degree of satisfaction without additional functional loss in the upper limb.     

Technique of intramedullary fixation for arthrodesis of the wrist in rheumatoid arthritis.

We did 18 arthrodeses of the wrist in 16 patients with rheumatoid arthritis using an intramedullary fixation technique. There were 15 women and one man, whose ages at operation ranged from 47 to 71 years (mean 58). Follow up ranged from 13 to 68 months (mean 27). The operative technique consists of a combination of intramedullary placement of two Kirschner (K)-wires and an autogenous bone graft. At follow up bony union was apparent in all cases. K-wires came out of the metacarpal joints in two cases. Paraesthesiae in the median nerve distribution occurred in two cases which both recovered within three months.     

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.     

An alternative technique for revision arthrodesis of the rheumatoid wrist: a case report

Few studies address the problem of failed rheumatoid wrist arthrodesis. We report a case of this difficult complication that was treated with a new technique of arthrodesis, which includes both the ulnocarpal and radiocarpal sites with 2 intramedullary nails and an ulnar ostectomy.     

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.     

Limited wrist arthrodesis versus radial osteotomy for advanced Kienb?ck's disease--for a fragmented lunate.

Thirty-eight patients with advanced Kienb?ck's disease treated by limited wrist arthrodesis (LWA: n = 10) or radial osteotomy (RO: n = 28) for a fragmented lunate were retrospectively examined after an average of 47.9 and 68.1 months, respectively. Compared with pre-operative values, the active flexion-extension range of motion decreased by about 16.0 degrees in LWA and increased approximately 9.7 degrees in RO and the grip strength improved by approximately 7.5 kg in LWA and 8.0 kg in RO. In both groups, radiographs showed no significant progression of carpal collapse. Although LWA caused some decrease in wrist flexion-extension, both procedures are appropriate for surgical treatment of advanced Kienb?ck's disease. Most patients experienced a reduction in pain and were able to return to work.     

Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.