Functional Outcome Following Extensor Synovectomy and Excision of the Distal Ulna in Patients With Rheumatoid Arthritis

Outcomes of Darrach and Sauvé-Kapandji Procedures: A Systematic Review

BACKGROUND

To review the available literature on Darrach and Sauvé-Kapandji (SK) procedures and perform a systematic review to identify differences in clinical outcomes. We hypothesized that SK would have a higher complication rate without significant clinical benefit.

METHODS

A literature search was conducted using PubMed, EMBASE, Cochrane Library, and SCOPUS (from inception to January 2020) to identify studies evaluating outcomes of Darrach and SK procedures. Primary outcome measures included the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, range of motion, grip strength, complications, and overall satisfaction.

RESULTS

A total of 103 articles were identified and screened, and of these, 44 full-text articles were used for data extraction and qualitative analysis. Outcomes were similar for QuickDASH scores, grip strength, and range of motion, as was overall satisfaction. Specifically, satisfaction rates for stabilized SK and Darrach procedures in patients without rheumatoid arthritis were comparable at 70.2% and 72.6%, respectively. Average QuickDASH scores were similar (21 for Darrach and 29 for SK). Mechanical symptoms due to stump instability occur with either procedure but were higher with the Darrach procedure (12.5% compared with 6.8%). The SK had more surgery-related complications such as nonunions (2.3%), symptomatic hardware, and reoperations (6.8% compared with 3.2%).

CONCLUSIONS

Both Darrach and SK procedures provide comparable satisfaction rates regardless of the underlying pathology. Improvement in range of motion, strength, and overall function is similar for both procedures; however, the reoperation rate is higher with SK.

Twenty years' follow-up of radiocarpal arthrodesis for rheumatoid wrists

OBJECTIVES

A pain-free stable wrist is a prerequisite for patients with rheumatoid arthritis to improve their activity of daily life. The present study investigated whether or not radiocarpal arthrodesis yielded good results for more than 20 years.

METHODS

A retrospective study was performed on 20 unstable wrists in 17 patients with rheumatoid arthritis. Radiocarpal arthrodesis combined with synovectomy and the Darrach procedure was performed. Wrist pain, grip power, the range of motion, pharmacotherapy, ESR, CRP, and serial radiographs were investigated at the baseline and 20 years after the operation. Patient-reported outcomes using the mHAQ, DASH and patient's satisfaction level were investigated at the final follow-up.

RESULTS

Pain had disappeared completely in all patients at 20 years after the operation. The average grip power increased in 16 wrists (80%) and decreased in 4 wrists (20%). Wrist extension and flexion significantly decreased, and supination and pronation remained within the functional range. Radiographically, ulnar shift and palmar subluxation initially improved and remained unchanged for a long time. Fourteen patients (82.4%) with 17 wrists were satisfied with this operation.

CONCLUSION

Radiocarpal arthrodesis for rheumatoid wrists provided painless stability for a long period for 20 years or more.

Total joint arthroplasty of the distal radioulnar joint for rheumatoid arthritis

PURPOSE

To evaluate the clinical and radiological results of primary total distal radioulnar joint (DRUJ) replacement as well as reconstruction following ulnar head excision in patients with rheumatoid arthritis (RA).

METHODS

Seventeen patients with RA underwent 19 total DRUJ replacement between 2005 and 2011. Mean age at the time of the surgery was 57 years. Mean follow-up was 39 months (range, 12-79 mo). Pain level was evaluated using a visual analog scale (VAS). Pronation and supination were recorded before and after surgery. A patient satisfaction survey was used, as well as postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Related Wrist Evaluation (PRWE) scores. Ulnar translocation of the carpus was assessed radiographically, and the presence or absence of radiolucent zones around the implant were recorded.

RESULTS

The preoperative average VAS score for the 19 joints was 7.3. Pain decreased after surgery to 2.2. Pronation improved from 56° before surgery to 78° afterward, a 39% improvement. Supination improved from 57° before surgery to 71° afterward, a 27% improvement. Final scores were 24 for the DASH and 24 for the PRWE. Fifteen patients reported substantial pain relief. All patients were satisfied with their surgical result.

CONCLUSIONS

The results of this study suggest that total replacement of the DRUJ is of benefit to the patient with RA. Pronation was significantly increased and supination was increased but did not approach significance. Improvement in VAS score suggests that pain was decreased.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Radio-lunate arthrodesis in rheumatoid arthritis: outcome and techniques

BACKGROUND AND PURPOSE

The wrist is one of the most affected joints in rheumatoid arthritis. The purpose of this retrospective study was to assess clinical, functional and radiographic results of radio-lunate arthrodesis. Two different operation and fixation techniques are compared and detailed outcome after this intervention is presented.

METHODS

Twenty-seven patients with long-standing rheumatoid arthritis were operated on, either by stabilisation of the arthrodesis with Shapiro staples (n = 14) or by Herbert screw (n = 13) and followed for a mean of 5.4 years.

RESULTS

Radio-lunate arthrodesis resulted in high overall and subjective satisfaction concerning function, grip and return to work. Grip strength was 35 kPa for the dominant and 26 kPa for the non-dominant hand. No revision, pseudoarthrosis or hardware failure was observed; only two conservatively treated wound healing problems were reported. The procedure resulted in a mean flexion of 26° and a mean extension of 24°; a clear improvement was also seen in activities of daily life. No difference between both groups was observed for pain, complication rate or functional outcome.

INTERPRETATION

Due to high patient satisfaction and functional outcome, radio-lunate wrist arthrodesis can be recommended independent of fixation method.

Current concepts and treatment for the rheumatoid wrist

Wrist involvement in rheumatoid arthritis (RA) is common. Within 2 years of diagnosis, more than half of patients will have wrist pain, and more than 90% will have wrist disease by 10 years. Although wrist involvement is generally thought to be less disabling than RA of the fingers and hand, it can be a significant cause of pain and disability. Severe disease with bony destruction and synovitis in the wrist can also result in soft-tissue problems including tendon ruptures. In addition to musculoskeletal involvement, systemic manifestations of RA can occur. Felty syndrome can result in a low white blood count and splenomegaly in association with RA. New generation, disease-modifying pharmacologic agents offer promise in controlling the disease progression. Surgical treatments for the diseased wrist are aimed at relieving pain and restoring function. Common procedures include: synovectomy and tenosynovectomy, tendon reconstruction, distal ulnar resection and/or distal radioulnar joint reconstruction, partial and full wrist arthrodesis, and total wrist arthroplasty.

Long term results of matched hemiresection interposition arthroplasty for DRUJ arthritis in rheumatoid patients

INTRODUCTION

The distal radioulnar joint (DRUJ) is commonly affected in rheumatoid arthritis and is associated with significant functional morbidity. The aim of our study is to review our results with matched hemi-resection interposition arthroplasty in patients with DRUJ arthritis.

METHODS

This was a retrospective study of 39 patients with 51 wrists that were treated at Queen Mary Hospital in Hong Kong from 1989 to 2007. All patients underwent matched hemi-resection interposition arthroplasty and dorsal wrist synovectomy. Long arm hinged elbow brace was used for three weeks followed by intensive rehabilitation up to twelve weeks. The indicators of outcome included range of motion assessment, pain, wrist stiffness, grip of strength and need for revision assessed during follow-up. Statistical analysis was performed with student t-test.

RESULTS

The average age of patients was 50.5 years (25 to 77 years) and there was a 35:4 female to male ratio. The average follow up was 4.5 years ranging from 1 to 18 years. Associated extensor tendon ruptures were found in 31.4% patients. The average increase in supination was from 73 degrees preoperatively to 81 degrees at long term follow up (p = 0.10 at 1 year and 0.13 at long term follow-up). The average increase in pronation was from 68 degrees preoperatively to 74 degrees on long term follow up (p = 0.57 at 1 year and 0.02 at long term follow-up). There was evidence of painless, relatively stiff but functional wrist in 37.25% of patients. There was an increase in grip strength from an average of 6.1 kilogram force preoperatively to an average of 11.5 kilogram force at follow-up (p = 0.004 at 1 year and 0.15 at long term follow-up). Complete relief of ulnar sided pain was seen in 43 wrists (84%), partial relief was seen in 7 wrists (13.7%) and no relief was found in one wrist (1.9%).

CONCLUSIONS

DRUJ arthroplasty is a rewarding procedure and most of the patients obtain pain free movement.

Effects of extensor synovectomy and excision of the distal ulna in rheumatoid arthritis on long-term function

PURPOSE

Objective outcomes data after excision of the distal ulna in rheumatoid arthritis are lacking. The aim of this study was to evaluate the functional results of this surgery in the long term.

METHODS

We prospectively collected data on range of motion (22 wrists), visual analog pain scores (14 wrists), and grip strength measured using a Jamar dynamometer (20 hands) in a group of 23 patients (26 wrists) preoperatively and at 3 months, 12 months, and a minimum of 5 years postoperatively (range, 5.3-10.4 y). The Jebsen-Taylor hand function test was administered to 9 patients at the same time points. A subgroup of patients also underwent extensor carpi radialis longus to extensor carpi ulnaris tendon transfer (11 wrists).

RESULTS

At one year, there were improvements in wrist pronation and supination, which were maintained at final follow-up. Active radial deviation decreased significantly at 3 months (p = .01) and one year (p = .02); this remained reduced at final follow-up (not significant). Wrist extension and active ulnar deviation showed slight improvements by one year, but reduced to levels below that measured preoperatively by final follow-up. Wrist flexion was significantly reduced at all time points postoperatively. Grip strength showed improvement from 10.0 kg (standard deviation [SD] 4.1 kg) preoperatively to 12.5 kg (SD 4.6 kg) 1 year after surgery and returned to preoperative levels (9.5 kg, SD 5.6 kg) by final follow-up. Wrist pain was significantly reduced from a mean score of 5 (SD 4) preoperatively to 2 (SD 2) postoperatively (p = .01). The Jebsen-Taylor hand function test showed improvements in writing and card turning.

CONCLUSIONS

In the long term, excision of the distal ulna in rheumatoid patients results in an improvement in some aspects of hand function. There is a significant (p = .01) reduction in wrist pain but a reduction of wrist flexion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Validity and responsiveness of the Jebsen-Taylor Hand Function Test

PURPOSE

The aim of this study was to demonstrate the validity and responsiveness of the Jebsen-Taylor Hand Function Test (JTT) in measuring hand function in patients undergoing hand surgery, compared with the Michigan Hand Outcomes Questionnaire (MHQ).

METHODS

A prospective cohort of patients with rheumatoid arthritis (n = 37), osteoarthritis (n= 10), carpal tunnel syndrome (n = 18), and distal radius fracture (n = 46) were evaluated preoperatively and at 9 to 12 months of follow-up. We administered the JTT and MHQ. We performed correlation and receiver operating characteristic analyses to evaluate the validity of the JTT as a measure of disability. Effect size and standardized response means were calculated to determine responsiveness.

RESULTS

Correlation studies revealed poor correlation of the JTT with MHQ total scores and subsets that relate to hand function. Patients with high MHQ scores generally perform well on the JTT; however, patients with good JTT scores do not necessarily have high MHQ scores. Receiver operating characteristic curves for each condition showed that the change in JTT total score had poor ability to discriminate between high and low MHQ score subjects, with an area under the curve result of 0.52 to 0.66 for each condition. Effect size and standardized response means for all states showed greater responsiveness with the MHQ for each condition compared with the JTT.

CONCLUSIONS

We found poor correlation between the change in JTT and absolute JTT scores after surgery compared with change in MHQ and absolute MHQ scores. In addition, the JTT had poor discriminant validity based on the MHQ as a reference. This study showed that the time to complete activities does not correlate well with patient-reported outcomes. We conclude that the JTT should not be used as a measure of disability or clinical change after surgical intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Treatment of the wrist in rheumatoid arthritis

Wrist involvement is common in rheumatoid arthritis and affects up to 50% of patients within the first 2 years after the onset of the disease, including bilateral involvement. It is a progressive disease that destroys the articular cartilage and surrounding soft tissues, thus leading to severe deformities. Radiological changes are characteristic and include narrowing of the joint line, cysts, and periarticular osteoporosis. Clinical changes are characterized by different scoring systems, indicating different therapeutic options. Surgical orthopedic treatment options include joint-preserving techniques to prevent further damage (radiosynoviorthesis, synovectomy, or axial correction with tendon transfers in earlier stages) and joint replacing techniques to restore function (arthrodesis, resection arthroplasty or total joint arthroplasty in later stages). This article reviews pathologic changes in the rheumatoid hand and their surgical treatment alternatives.

The rheumatoid wrist

Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.

Hand surgery in rheumatoid arthritis: state of the art and suggestions for research

OBJECTIVE

The role of surgery in the clinical management of patients with rheumatoid arthritis (RA)-associated hand dysfunction is still a subject of controversy. The efficacy of surgery in RA-associated hand dysfunction is assessed through an exhaustive review of published studies.

METHODS

A high-sensitivity search strategy was used to identify in MedLine and CENTRAL original studies related to hand and wrist surgery in RA patients. We selected articles including at least two adult RA patients which evaluated clinical outcomes through an observational or experimental design. Eligible studies were evaluated by standardized criteria. Two investigators independently used a pre-defined form to extract data about patient population, intervention, follow-up and clinical outcomes. Disagreements were discussed and resolved.

RESULTS

One hundred and ninety-six papers met inclusion criteria. Only five were randomized trials, while most studies followed an observational design, often of poor quality. As such, we could not pool data for statistical analysis; however, we were still able to provide a best evidence synthesis. A positive trend suggesting the efficacy of total carpal arthrodesis and metacarpophalangeal arthroplasty in reducing pain and improving function seemed to emerge from the published studies.

CONCLUSIONS

Despite recent advances in medical treatment, surgery still plays a role in the clinical management of RA-associated hand dysfunction. However, the majority of the available studies showed methodological flaws that prevented a clear definition of both surgical indications and criteria for choosing any specific procedure. Suggestions for further investigations are also provided.