Limited arthrodesis for the rheumatoid wrist

Radiotriquetral arthrodesis for rheumatoid wrist with flexor tendon rupture: A case report

Flexor tendon rupture in the wrist of patients with rheumatoid arthritis is a rare complication, and there is no standard treatment for the wrist joint. Here, we present the case of a rupture of the flexor digitorum profundus of the left index finger owing to a rheumatoid wrist. Plain radiography and computed tomography showed carpal collapse, especially lunate, and arthrosis between the capitate and lunate. For stability and mobility of the wrist and index finger, resection of the lunate and radiotriquetral (RT) arthrodesis using the distal ulna as a bone graft and arthrodesis of the distal interphalangeal joint of the index finger were performed. At 2 years postoperatively, her wrist was painless and stable on radiography without recurrence of tendon rupture, and the arc of motion of the dorsal-palmar flexion of the wrist joint was 125°. RT arthrodesis could be a surgical choice of "mobile" partial wrist arthrodesis.

Radioscapholunate arthrodesis versus radiolunate arthrodesis in rheumatoid wrist surgery: Clinical and radiographic outcomes

Radiolunate arthrodesis is a validated surgical technique in rheumatoid wrist surgery. When the radioscaphoid joint is involved or when there is radiolunate instability, a radioscapholunate arthrodesis must be preferred. The objective was to compare clinical and radiographic outcomes for both types of arthrodesis. Patients were evaluated retrospectively at a minimal follow-up of 12 months after radiolunate arthrodesis (RL-A group) or radioscapholunate arthrodesis (RSL-A group). Mean follow-up was 10.7 years (1-25 years). One hundred and one patients were included in RL-A group and 26 in RSL-A group. At follow-up, pain level was significantly reduced by 3.7 points and by 2.9 points in RL-A and RSL-A groups, respectively. Mobility in flexion/extension was significantly reduced by 25° in both groups. DASH and PRWE scores were 42.9 and 41.4 in RL-A group, 41.8 and 20.6 in RSL-A group, respectively. Larsen stage for the midcarpal joint increased significantly in both groups (+0.8 in RL-A group; +0.9 in RSL-A group), carpal height index decreased (-0.03 in RL-A group (significant); -0.02 in RSL-A group (non-significant)), carpal ulnar translation index increased (+0.038 in RL-A group; +0.037 in RSL-A group), without significant difference between both groups. Nonunion rate was significantly higher in RSL-A group (62%) than in RL-A group (30%). A pain free and functional wrist can be obtained after radiolunate and radioscapholunate arthrodesis. However, arthritis lesions and carpal deformities increased with follow-up similarly with both surgical techniques. Our results have shown that radiolunate arthrodesis remains a reliable surgical procedure for advanced rheumatoid wrist.

Association between position of the fixed ulnar head and carpal translocation after the Sauvé-Kapandji procedure in patients with rheumatoid arthritis

OBJECTIVE

The Sauvé-Kapandji procedure is a common surgical procedure for rheumatoid wrist, which involves fixing dissected ulnar head to the distal radius in order to provide "bony support" to the carpus. The purpose of this study was to investigate whether the position of the fixed ulnar head was associated with postsurgical carpus translocation.

METHODS

We retrospectively reviewed radiographs of 40 patients who underwent the Sauvé-Kapandji procedure and were subsequently followed up for over two years. The association between the fixed ulnar head position and postsurgical carpus translocation was statistically analysed with a confidence interval of 95% (p < 0.05).

RESULTS

Multiple regression analysis suggested that the radial inclination of the fixed ulnar head, the absence of increases in ulnar variance, and wide "bony support" were significantly associated with less postsurgical carpal translocation.

CONCLUSION

Our study indicated that good concordance between the "bony support" and the carpus might be important in reducing postsurgical carpus translocation.

Clinical and radiographic study of partial arthrodesis for rheumatoid wrists

OBJECTIVES

To retrospectively investigate the clinical and radiographic results of partial arthrodesis for the wrists with rheumatoid arthritis (RA).

METHODS

Forty-one wrists with RA were treated by radiolunate (RL) or radiolunotriquetral (RLT) arthrodesis with ulnar head resection. The average follow-up period after surgery was 7.1 years. Preoperative radiographs of all wrists were classified according to Schulthess classification. We performed RL arthrodesis for all Type II (n = 26) and Type III wrists (n = 7), and RLT arthrodesis for Type III wrists (n = 8). Pre- and postoperative pain score (visual analog scale), grip strength, range of motion, and radiographic parameters were statistically compared.

RESULTS

Pain scores in all groups were significantly improved at final follow-up (P < 0.05). Grip strength increased from 5.9 to 12.4 (kg) significantly in Type II wrists (P < 0.01), from 7.2 to 9.1 in Type III wrists after RLT arthrodesis, but decreased from 6.9 to 6.0 in Type III wrists after RL arthrodesis. In all groups, the arc of pronation and supination improved significantly (P < 0.05), and all radiographic parameters improved.

CONCLUSIONS

RL arthrodesis for Type II wrists showed satisfactory clinical results. RLT arthrodesis would be a reliable method in case of unstable wrist joint.

Wrist kinematics after radiolunate arthrodesis

INTRODUCTION

Analysis of carpal kinematics after radiolunate and radioscapholunate arthrodesis shows good preservation of midcarpal joint congruity and motion. However, no biomechanical data exist on carpal kinematics after radiolunate arthrodesis in the wrist. Purpose of this study was to examine the individual motion of scaphoid, capitate and triquetrum after simulated radiolunate arthrodesis.

MATERIALS AND METHODS

Radiolunate arthrodesis was simulated in three fresh human cadaver wrists by means of Kirschner wires. Individual motion of the scaphoid, triquetrum and capitate relative to the radius was measured for extension/flexion and radial-ulnar deviation before and after arthrodesis. Photostereogrammetric measurement was carried out and the helical axis concept of motion was employed.

RESULTS

Global wrist motion, corresponding to capitate motion, was found to be reduced 33-50 % for extension/flexion and 25-43 % for radial-ulnar deviation. Relative motion of the scaphoid for extension/flexion was found to be reduced 20 % more and for radial-ulnar deviation 10 % more than that of the capitate. Relative motion of the triquetrum for extension/flexion was found to be reduced 30 % more and for radial-ulnar deviation 20 % more than that of the capitate. The pattern of motion of the capitate hardly changed, and that of the scaphoid, only slightly. The triquetrum lost its rotational pattern of motion and gave way to tilting movements instead. The physiological function of the scaphoid between distal radius and distal carpal row was preserved.

CONCLUSION

The presented data conform with the good clinical results obtained after radiolunate arthrodesis in the rheumatoid wrist and furthermore, encourage its use in the posttraumatic wrist.

Comparison of the Sauvé-Kapandji procedure and the Darrach procedure for the treatment of rheumatoid wrists

Abstract In surgical treatment of the rheumatoid wrist, the Darrach procedure combined with synovectomy has been the treatment of choice in the past. However, owing to the significant ulnar carpal shift observed after the Darrach procedure, the Sauvé-Kapandji (S-K) procedure has become increasingly popular. The purpose of this study was to compare the clinical results of the S-K and Darrach procedures. Thirty-two wrists in the S-K-procedure group and 31 wrists in Darrach-procedure group were examined. Before and after surgery, clinical evaluations of pain, swelling, range of motion, grip strength, and radiological findings were performed and the results were compared. Both procedures resulted in decreased pain and swelling, as well as improved rotatory motion of the forearm. The S-K procedure was shown to be superior to the Darrach procedure in reducing ulnar carpal migration and improving grip strength. On the other hand, the prevention of carpal bone destruction could not be completely achieved in either procedure.

Reconstruction of the rheumatoid hand

Previous studies have shown large variation in the rate of common surgical procedures performed for the rheumatoid hand. This article provides a comprehensive overview of each surgical treatment option for rheumatoid hand reconstruction.

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.

The short-term outcome of the modified Sauvé-Kapandji procedure regarding range of motion, carpal bone translation and bony shelf size

The Sauvé-Kapandji (S-K) procedure is a common treatment for rheumatoid wrists, but in some cases severe bone destruction makes this operative modality difficult to perform, while also resulting in a poor outcome. A modified S-K procedure for these wrists has been reported, but the clinical outcomes of the modified procedure are unclear. This study evaluated 24 wrists in 20 patients who underwent the modified S-K procedure. The mean follow-up period was 34.5 months. The clinical assessments were range of motion, carpal bone translation and bony shelf size. The range of motion and carpal bone translation were similar to those produced by the S-K procedure. In regard to bony shelf size, wrists with an excessively large bony shelf tended to have a progression of carpal bone translation toward the palmar direction due to the residual malposition of the ECU tendon. The modified S-K procedure appears to be a safe and effective surgical alternative for the treatment of severely destroyed rheumatoid wrists. Although the modified procedure allows for the adjustment of the bony shelf size, it should not be used with wrists that have an excessively large bony shelf.

Complications of limited and total wrist arthrodesis

Partial and total wrist arthrodeses have become common procedures for treating degenerative diseases arising from numerous conditions, including posttraumatic arthrosis, intercalated segment instability, inflammatory arthropathy, and carpal osteonecrosis. The goals of these two procedures are to provide pain relief and improved function by fusing arthritic or unstable joints. A thorough understanding of the complications and the best practices to avoid them is critical for the surgeon in the preoperative, intraoperative, and postoperative management of candidates for total or limited wrist arthrodesis.

Three-dimensional kinematics of the rheumatoid wrist after partial arthrodesis

BACKGROUND

Partial arthrodesis of the wrist, such as radiolunate and radioscapholunate arthrodesis, is intuitively more appealing for the treatment of the rheumatoid wrist than total arthrodesis is because it preserves some motion. However, wrist kinematics after partial arthrodesis are incompletely understood. The purpose of the present study was to evaluate the kinematics of the radiocarpal and midcarpal joints of rheumatoid wrists with use of three-dimensional computed tomography before and after partial arthrodesis.

METHODS

We selected ten wrists that were affected by rheumatoid arthritis in which the radiolunate joint was severely damaged but the midcarpal joint congruities were relatively well preserved. Six radiolunate and four radioscapholunate arthrodeses were then performed, with preservation of the joint congruity between the scaphoid, lunate, and capitate. We acquired in vivo three-dimensional kinematic data during wrist flexion-extension preoperatively and postoperatively with use of computed tomography and a markerless bone-registration technique. Postoperative midcarpal joint congruity and range of motion were compared with preoperative values.

RESULTS

The mean range of global wrist motion was 48 degrees +/- 21 degrees after radiolunate arthrodesis and 47 degrees +/- 14 degrees after radioscapholunate arthrodesis. Midcarpal joint congruities and motion between the scaphoid, lunate, and capitate were well preserved in all ten wrists. The postoperative range of capitate motion relative to the lunate was 109% of the preoperative value after radiolunate arthrodesis and 88% after radioscapholunate arthrodesis. The directions of capitate motion relative to the lunate after both types of partial arthrodesis were significantly more oblique than before the arthrodeses, changing from radiodorsal to ulnopalmar along the so-called dart-throwing motion plane (p < 0.05).

CONCLUSIONS

The results of this kinematic analysis, which showed that midcarpal motion occurred in the dart-throwing motion plane, may support the use of radiolunate and radioscapholunate arthrodeses as an alternative to total wrist arthrodesis in patients with symptomatic rheumatoid arthritis of the wrist.

Radiolunate fusion with distraction using corticocancellous bone graft for minimizing decrease of wrist motion in rheumatoid wrists

Radiolunate fusion is a limited carpal fusion procedure used for patients with rheumatoid arthritis. However, this procedure inevitably causes decreases in range of motion, especially wrist flexion. Linscheid and Dobyns described the possibility of minimizing the decrease in motion at the radiocarpal joint by slight distraction of the joint. We hypothesized for our modified procedure that a corticocancellous bone graft was inserted between the radius and the lunate with a small amount of over-correction could provide slight distraction of radioscaphoid joint and protect the joint from decreased range of motion after arthrodesis. Twelve wrists in ten patients with rheumatoid arthritis underwent radiolunate fusion. Mean age at operation was 53 years old and mean follow-up period was 5.7 years. Clinical evaluation and radiological assessment showed that decrease in range of motion was minimized compared with other procedures. Because our modified procedure can minimize decrease in motion, it is recommended.

Analysis of radiocarpal and midcarpal motion in stable and unstable rheumatoid wrists using 3-dimensional computed tomography

PURPOSE

The kinematic evaluation of carpal motion, especially midcarpal motion, in rheumatoid arthritis (RA) has been extremely difficult because of limited imaging techniques previously available. The purpose of this study was to evaluate the amount of radiocarpal and midcarpal motion in the flexion-extension plane in both stable and unstable rheumatoid wrists using three-dimensional computed tomography.

METHODS

We acquired in vivo kinematic data on 30 wrists with RA by three-dimensional computed tomography with the wrist in 3 positions: neutral, maximum flexion, and maximum extension. All cases were radiographically classified into 1 of 2 subtypes, the stable form or unstable form, according to the classification by Flury et al. We evaluated the precise range of radiocarpal and midcarpal motion using a markerless bone registration technique and calculated the individual contributions to the total amount of wrist motion in the flexion-extension plane in the different radiographic subtypes of RA.

RESULTS

The average range of motion of radiocarpal and midcarpal joint was 27 degrees +/-15 and 32 degrees +/-17, respectively. The average contribution of midcarpal motion to the total amount of wrist motion was 54%. The average contribution of midcarpal motion in the unstable form was 67%, which was significantly higher than 47% (p< .05) in the stable form.

CONCLUSIONS

Midcarpal motion of rheumatoid wrists in the flexion-extension plane was better preserved than previously thought. The contribution of midcarpal motion to the total amount of wrist motion was significantly greater (p< .05) in the unstable form than in the stable form of RA.

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.

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.

Le poignet rhumatoïde

Wrist involvement in Rheumatoid Arthritis (RA) is frequent, variable in its presentation, heterogeneous in its evolution and has an important impact on the function of the affected hand. Surgery must be indicated within the framework of a structured medical and surgical approach that considers the whole patient. Surgical treatment at the wrist level is indicated in cases of resistant chronic pain, persistent articular synovitis, or chronic tenosynovitis and also in cases of painful limitation of supination, risk of complications due to wrist deformity and tendinous or neurological complications. The surgical goal in RA is to restore correct function but not neccessarily normal anatomy, with the goal of achieving a painless, stable wrist, correctly positioned. Motion depends on the status of the different joints and on the bone stock. Knowledge of the natural progression of the disease helps in the surgical decision making process. The pathogenesis and patterns of deformity, the clinical and X-ray appearances and the various techniques applied to the surgery of the rheumatoid wrist are studied and discussed including palmar wrist and dorsal wrist procedures, conservative and non-conservative options.

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.

Radioscapholunate arthrodesis

Although RSL fusion is a viable option for isolated radiocarpal arthritis, the enthusiasm for this procedure should be tempered with the reality that kinematics of the wrist is not entirely suited for independent midcarpal flexion and extension [10]. Limited wrist flexion and extension is expected following a successful RSL arthrodesis. The effects of imposed abnormal kinematics are further shown by the high incidence of RSL nonunions, occurrence of scaphoid fractures, and postoperative deterioration of the midcarpal joint [15,22]. In a young patient with posttraumatic arthritis or rheumatoid arthritis limited to the radiocarpal joint, however, RSL arthrodesis remains a viable alternative to complete wrist arthrodesis if the midcarpal joint is normal. Internal fixation with plates and screws and distal scaphoid excision are technical alternatives to consider when an RSL arthrodesis is performed.

Long-term follow-up study of radiocarpal arthrodesis for the rheumatoid wrist

PURPOSE

Pain-free stability of the wrist is a prerequisite for the rheumatoid hand to maintain power and perform various tasks. The purpose of this study was to investigate whether a radiocarpal (radiolunate, radioscapholunate, or radiolunotriquetral) arthrodesis produces a stable wrist and whether the results remain satisfactory for more than 10 years.

METHODS

A retrospective review was performed on 25 wrists of 25 patients with rheumatoid arthritis who had radiocarpal arthrodesis. All patients had a synovectomy of the extensor tendons and the wrist joint combined with a Darrach procedure. The indications for radiocarpal arthrodesis included radiographic changes in Larsen-Dale-Eek grades II to IV, midcarpal joint space of greater than 1 mm, and ulnar shift or palmar subluxation of the carpus. The presence of scapholunate dissociation was an optional indication. The mean follow-up period was 13 years (range, 10-18 y) and radiographs taken just before the surgery and 0 to 2 years, 2 to 5 years, 5 to 10 years, and more than 10 years after the surgery were evaluated as were pain relief, swelling, grip power, range of motion, and complications.

RESULTS

Pain was resolved for 22 of the patients and 3 experienced occasional mild pain. Swelling generally decreased, grip power increased significantly, flexion decreased, and forearm rotation increased significantly. The complication rate was low. Radiographically ulnar shift and palmar subluxation improved initially and were maintained at the time of the 10-year follow-up evaluation; carpal collapse improved initially but returned to the preoperative level by the time of the 5-year follow-up evaluation. The midcarpal joint space was preserved in 16 wrists, and all but 1 wrist (in a patient with mutilating type of the disease) remained stable.

CONCLUSIONS

Radiocarpal arthrodesis for treatment of the rheumatoid wrist results in good stability with preservation of motion despite radiographic progression of the disease. We therefore recommend this treatment for the unstable wrist with moderate deterioration.

Radiocarpal fusion

Limited wrist fusion is a common and often effective method of treatment for many painful wrist conditions. When post-traumatic, inflammatory and noninflammatory arthritis affects only the articular surfaces of the proximal carpal joint, a limited radiocarpal fusion can be considered. Specific indications are painful arthritis following distal radial fractures, rheumatoid arthritis with ulnar shift of the carpus, scapholunate instability with radioscaphoid arthritis, and stage IV Kienbock's disease. It is necessary for the midcarpal joint surfaces to be essentially normal. Either a radioscapholunate or radiolunate fusion can be performed, depending on the underlying condition. Up to 70 degrees of wrist flexion-extension can be obtained after a radioscapholunate fusion. Keys to a successful postoperative result are proper alignment of the scaphoid and lunate, use of bone graft or bone graft substitute and careful positioning of internal fixation devices. Evidence of radiographic union is usually seen by eight weeks. Nonunion rates are quoted to be from 10 to 20%.

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.

Synovectomy combined with the Sauvé-Kapandji procedure for the rheumatoid wrist

The aim of synovectomy-stabilization (synovectomy combined with the Sauvé-Kapandji procedure) of the rheumatoid wrist is to obtain a stable painless wrist, retaining enough mobility for function. Thirty-nine wrists were retrospectively examined, at a mean follow up of 64.8 months. The improvement in pain was very significant. We noticed a decrease in wrist motion affecting both flexion and radial deviation. The arthritic change in the wrist continued to increase. We noticed a mean ulnar shift of 2.2 mm and a mean increase in the radial deviation of the wrist of 7 degrees. Only transfer of the extensor carpi radialis longus tendon to the extensor carpi radialis brevis tendon was effective in correcting radial deviation of the carpus. Ninety-seven per cent of patients were very satisfied or satisfied. These encouraging results, even at advanced stages of wrist arthritis, have prompted us to lessen the indications for wrist arthrodesis.

[Development of surgical indications in the treatment of rheumatoid wrist. Report on experience based on 603 surgical cases, 1968-1994]

The author relates his experience in surgical treatment of the rheumatoid wrist based on a consecutive series of 603 cases operated from 1968 to 1994. His therapeutic indications have changed over the years after a retrospective study of the long-term results. He distinguishes conservative surgery, which combines dorsal synovectomy and relaxation stabilisation of the wrist (also called surgery of the dorsal wrist) from total arthrodesis and arthroplasty of the wrist. The results of conservative surgery after a follow-up of more than five years confirm that the disease continues in spite of synovectomy. Furthermore, relaxation stabilisation using soft tissue (extensor retinaculum and tendon transfer) is not sufficient to stabilise the wrist. Most of the time, this has to be completed by a partial radiocarpal arthrodesis. This is indicated when the carpus shows a medial translation or early in potentially progressive forms (Larsen Stage 1). In advanced forms conservative surgery consisting of partial radiocarpal arthrodesis is only indicated when the midcarpal joint appears functional after dynamic radiological examination. The author used the Swanson implant to perform 70 arthroplasties from 1973 to 1988. Long-term results show a large number of complications, which increased progressively with time. The Swanson implant was therefore abandoned in 1988. In 12 cases operated from 1979 to 1984 wrist arthroplasty was performed using Jackson's technique which consists of resection-interposition of a silastic sheath. This technique was also abandoned in 1984 due to the variable and unpredictable results obtained. At the present time, the author:-does not perform arthroplasties; increasingly completes surgery of the dorsal wrist by radiolunate arthrodesis;-has noted an increase in indications for total wrist arthrodesis. He emphasizes the importance of long-term evaluation of surgical results in rheumatoid arthritis.

Long-term results of radioscapholunate fusion following fractures of the distal radius

Fifteen patients with radioscapholunate (RSL) fusion for traumatic lesions of the radiocarpal junction, whose short-term results have been previously reported, were reassessed after an average follow-up time of 8 years. Five patients had undergone wrist fusion because of non-union or early progressive arthritis. Of the ten wrists with retained mobility, eight continued to function satisfactorily. Two wrists were painful for reasons other than secondary midcarpal arthritis. Patient satisfaction was comparable in both groups with the wrist score better for wrists with residual motion. The survival of RSL partial wrist fusion corresponded inversely with the number of preceding operations and the range of motion before partial fusion. Secondary midcarpal arthritis, if present, arose early and was well tolerated. Failures were strongly linked to technical mistakes and complications.

Does wrist fusion cause destruction of the first carpometacarpal joint in rheumatoid arthritis? 18 patients followed for 2-6 years

We evaluated radiographic destruction of the first carpometacarpal joint (CMC I) in 18 hands with wrist fusions and compared it with the unoperated contralateral hands preoperatively and after a follow-up of a mean of 4.4 (2-6) years. Patients were obtained from a prospective 20-year follow-up study of 103 patients with seropositive rheumatoid arthritis. The degree of destruction in the CMC I-joints was evaluated with Larsen grades. The mean value of Larsen indices for CMC I was 0.9 before wrist fusion and 2.5 (p < 0.001) at the follow-up, compared to 0.8 and 1.3 (p = 0.06) in the control hands, respectively. No preoperative difference was found between the hands to be fused and the control hands, but the difference was significant (p = 0.009) after the follow-up.

Excision of the distal ulna in rheumatoid arthritis. Is the price too high?

Patients with rheumatoid arthritis who underwent excision of the distal ulna were reviewed and the operated wrist was compared with the non-operated side in the 40 patients who had the procedure performed unilaterally. Radiological assessment showed that the radiocapitate measurement of carpal translocation was the most consistent and that excision of the distal ulna was not associated with statistically significant collapse, ulnar translocation or radial rotation of the carpus. 61% of wrists spontaneously developed a radial shelf or limited radiocarpal fusion following excision of the distal ulna, compared to 21% of non-operated wrists. However, there was no statistically significant difference in carpal collapse or ulnar translocation between these two groups.

Fibrous stabilization of the rheumatoid wrist

19 patients (mean age 59.8 years) underwent fibrous stabilization of the wrist for rheumatoid arthritis. 17 patients were reviewed after a mean follow up of 24.5 months (range 13-40 months). There were four excellent, 11 good, and two poor results according to modified Koka and D'Arcy (1989) criteria. The poor results were due to deep infection in one patient and an unbalanced wrist due to ruptured radial extensors in another. The pre-operative range of wrist movement was an important determinant of the frequency of radio-carpal and/or mid-carpal fusion and the final post-operative range of movement.