Handgelenksynovektomie und radiokarpale Stabilisierung durch Sehnentransfer

Summary Goal of Surgery Prevention of ulnar drift after synovectomy and resection of ulnar head through tendon transfer. Indications Chronic rheumatoid arthritis with incipient ulnar drift in stage I to III according to Larsen and al. (1983) 12]. Contraindications Absolute: Advanced destruction of radiocarpal joint. Relative: Marked palmar displacement of carpus. Preoperative Work Up If patient under corticosteroid treatment, continue this medication during surgery (see Tables 1 and 2). Anterior-posterior oblique and lateral radiographs of wrist including distal radius. Positioning and Anaesthesia Patient supine, arm on arm board. Tourniquet. Brachial plexus anaesthesia or general anaesthesia. Surgical Technique Synovectomy of extensor tendons and of radiocarpal, radioulnar and intercarpal joints through a dorsal approach. Division and resection of the interosseous branch of the radial nerve. Resection of ulnar head. Repositioning and stabilization of the extensor carpi ulnaris muscle. Reduction of the carpal bones and looping of the ulnar half of the extensor carpi radialis brevis tendon into the tendon of the extensor carpi ulnaris. Postoperative Management Palmar padded slab, with wrist in neutral position for 10 days. After 2 weeks active exercises of wrist, physiotherapy for approximately 6 weeks. Possible Complications Haematoma. Injury to sensory branch of radial nerve, tendons and/or vessels. Detachment of transferred tendon. Results From 1988 to 1992 64 patients underwent the combined synovectomy with tendon transfer. 59 of which had additionally a resection of the ulnar head. 56 patients could be followed up for an average of 46.8 months (15 to 72 months). All patients suffered from chronic rheumatoid arthritis. All patients had slight limitation of wrist motion, however, the pro- and supination was slightly improved. Pain was either markedly reduced or eliminated. Decrease of swelling and increase of strength in over half of the patients. The radiologic aspect was unchanged in 73%, deteriorated slightly in 25% and markedly in 2% of the patients. Index of ulnar translocation remained generally unchanged. Subjective assessment: 11 patients excellent, 36 good. 7 satisfactory and 2 poor.

Diakoniekrankenhaus Bad Kreuznach (Chefarzt: Dr. H. Thabe)