The rheumatoid wrist

Radiosynovectomy is effective in thumb basal joint arthritis

OBJECTIVE

Radiosynovectomy (RSO) describes the internal low-dose radiotherapy of the synovia via intra-articular administration of small radioactive particles. Since the introduction of biologics, the main aetiology of arthritic joints for RSO changed to mostly osteoarthritis with concordant change in typically affected joints. Thus, the effect of RSO in thumb basal joint arthritis (BJTh) with focus on osteoarthritis needs to be explored.

DESIGN

From 2017 to 2020, 219 BJTh were treated in 125 patients, 17 patients with rheumatoid arthritis (RA) and 108 patients with osteoarthritis (OA). The therapeutic effect was assessed using a four-step subjective scoring.

RESULTS

20% of the treated joints were symptom free, 48% had a very good response, 16% slight and 16% no response. RSO was performed in 71 patients singularly and in 54 patients repetitively. The mean response duration was 6.8 months with a maximum of 48 months. 35% of patients had post-therapeutic pain relief followed by relapse after 3 months. Response duration showed no significant difference the between first and repetitive therapy, primary responder and primary non-responder and RA and OA.

CONCLUSION

In thumb basal joint arthritis, RSO leads to response rates from 66 to 79%, mean response duration from 6 to 12 months and individual response duration 48 months. The present results are in line with previously published response rates in smaller joints. In respect to 35% of patients with relapse within 3 months post-therapy, we recommend a primary follow-up after 3-4 months.

Stenosing tenosynovitis of the extensor digitorum tendons of the hand: clinical and sonographic features

OBJECTIVE

To describe the ultrasound (US) features of 18 patients with extensor digitorum communis stenosing tenosynovitis (EDCST).

MATERIALS AND METHODS

A retrospective search in the radiologic information systems of two separate Institutions was performed to identify all patients presenting EDCST between January 2010 and September 2019. A total of 18 patients (ten males and eight females; mean age, 57.4 years) were identified and included. Sonographic examinations were retrospectively reviewed by two senior radiologists to assess morphologic changes and power Doppler activity of the extensor retinaculum (ER) and of the extensor digitorum communis (EDC) tendons and sheath. The presence of dynamic impingement between the EDC and the ER was evaluated using video clip records.

RESULTS

At the ultrasound, all patients (18/18; 100%) presented thickening of both the ER and EDC tendons associated with EDC tendon sheath effusion. Power Doppler hyperemia of the ER was inconstant and observed in 11 cases (11/18; 61.1%) as tendon sheath effusion observed in 16 cases (16/18; 88.9%). A cyst located inside the EDC of the index finger was observed in three of these patients (3/18; 17%). Dynamic examination showed impingement of the EDC against the ER during active tendon extension in all patients (18/18; 100%). Four of these patients (4/18; 22%) underwent surgery allowing diagnosis confirmation and release of EDCST, while the remaining fourteen patients (14/18; 78%) were either treated conservatively or using US-guided steroid injection.

CONCLUSION

US findings of EDCST include thickening of the ER and EDC tendons, EDC tendon sheath effusion, and in some cases presence of an EDC intratendinous cyst. Impingement of the EDC tendons against the ER is well demonstrated using dynamic US.

Union of Radiocarpal Fusion With and Without Proximal Row Carpectomy: A Systematic Review

PURPOSE

Wrist fusion provides a solution to the painful, arthritic wrist, and can be concomitantly performed with or without a proximal row carpectomy (PRC). The benefits of combining a PRC with fusion include a large amount of local bone graft for fusion and a lower number of joints needed to fuse. We hypothesized that wrist fusion combined with PRC will have a higher fusion rate than wrist fusion performed without PRC.

METHODS

A systematic review was performed to identify all papers involving wrist arthrodesis using the following databases: PubMed, Ovid, Scopus, Web of Science, and COCHRANE. A literature search was performed using the phrases "wrist" OR "radiocarpal" and "fusion" OR "arthrodesis". Inclusion criteria included complete radiocarpal fusion performed for rheumatoid, posttraumatic, or primary arthritis; union rates available; English-language study. Studies were excluded if case reports; diagnoses other than the ones listed previously; inability to abstract the data. Data collected included wrist fusions with PRC or without PRC, union rate, patient age, underlying diagnosis, and method of fixation.

RESULTS

A total of 50 studies were included in the analysis. There were 41 studies with no PRC, 8 studies with PRC, and 1 study with and without PRC. There were 347 patients with a PRC and 339 patients had a successfully fused wrist (97.7%). There were 1,355 patients who had a wrist fusion with no PRC, and1,303 patients had successful wrist fusion (96.2%). The difference in fusion rate between the 2 groups, 97.7% versus 96.2%, was not statistically significant.

CONCLUSIONS

There is no statistically significant difference with regards to union rate in wrist fusion with a PRC versus wrist fusion without a PRC.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Closed rupture of extensor tendon resulting from untreated Kienböck disease: A case report and a review of the literature

RATIONALE

Spontaneous closed extensor tendon rupture is a rare complication of Kienböck disease with only 23 cases reported in the English literature.

PATIENT CONCERNS

We present a case of painless attritional rupture of the extensor tendons of the right fourth finger in a 69-year-old woman with Kienböck disease and review reported cases of Kienböck disease with subcutaneous closed tendon rupture.

DIAGNOSES

Physical examination had shown mild painless swelling of the dorsum of the right hand. Plain radiographs showed a dorsally displaced fragment of collapsed lunate bone fracture (Lichtman grade IIIb). Although surgery was recommended, the patient did not desire surgery because she had no pain and no interference with the activities of daily living. Six months later, however, the patient returned to our hospital with complaints of loss of spontaneous extension of the fourth finger. CT and MRI showed aseptic necrosis and large dorsally displaced fragments of the lunate under the extensor tendons of the fingers, suggesting a subcutaneous fourth extensor tendon rupture.

INTERVENTIONS

Surgery was performed to achieve functional recovery of the ring extensor and to prevent further subcutaneous tendon rupture. The extensor digitorum communis (EDC) of the ring finger was found to be ruptured and the EDCs to the third and fifth fingers were frayed due to attrition from the protrusion of the dorsal fragmented lunate bone. Inspection of the floor of the compartment revealed that the dorsally displaced fragment of the lunate bone had perforated the wrist capsule and protruded into the fourth compartment. The dorsal and volar fragments of the lunate bone were excised completely and scaphocapitate arthrodesis followed by the reconstruction of the fourth extensor tendon was performed.

OUTCOMES

A year after the surgery, radiography showed complete union of the scaphocapitate arthrodesis. The joint motion reached 45% of normal without any pain and there was full active extension of the fourth finger.

LESSONS

Because dorsally displacement of collapsed lunate bone fragments is a risk factor for attritional closed rupture of tendons, radiography, and MRI are essential to diagnose and to treat any closed tendon rupture.

Surgical Treatment of Tenosynovitis of Extensor Tendons of Fourth Compartment of Wrist in Nonrheumatoid Patients-A Case Series of 10 Patients in India

Purpose Proliferative tenosynovitis of the extensor tendons is a very common painful wrist condition that can occur both in presence and absence of rheumatoid arthritis (RA). This study aims to evaluate a series of patients without RA, having extensor tendon tenosynovitis, its pathology, and results of surgical treatment. Materials and Methods A consecutive series of 10 patients without RA, having tenosynovitis of fourth extensor compartment were treated surgically and evaluated in the study. All patients were operated upon by a single surgeon, and intraoperative specimens were sent for histopathologic evaluation by a single pathologist. The functional outcome of the patients was evaluated by comparing the post- and preoperative wrist extension. Results All patients presented with painful mass over dorsum of the wrist, overlying the fourth extensor compartment. On clinical examination, there was severe limitation of active wrist extension with extended fingers and improvement in wrist extension on flexing the fingers. All patients had significant improvement in wrist extension after surgery. The histopathologic examination of the intraoperative samples revealed similar findings of tenosynovitis in all cases, which was different than that seen in RA. Conclusion This study reveals a distinct tenosynovitis in a group of patients without RA resembling traumatic tenosynovitis on histopathologic examination. Radiologic and intraoperative findings reveal presence of nodular mass in the affected tendon due to proliferative tenosynovitis, which blocks effective proximal excursion of the tendon, leading to decreased wrist extension. This study shows that surgical treatment in the form of tenosynovectomy gives excellent relief to these patients. Type of Study This is a Level IV, therapeutic study.

Arthroscopic Synovectomy of Wrist in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting multiple joints. Wrist involvement is common. Patients with persistent symptoms despite medical management are candidates for surgery. Synovectomy can provide pain relief and functional improvement for rheumatoid wrist. Arthroscopic synovectomy is a safe and reliable method, with minimal postoperative morbidity. This article reviews the role, technique, and results of arthroscopic synovectomy in the rheumatoid wrist.

Diagnostic modalities for distal radioulnar joint

The first imaging modality in patients suspected of distal radioulnar joint pathology should be conventional radiography to exclude or diagnose wrist pathology including osteoarthritis, rheumatoid arthritis, calcium pyrophosphate deposition disease, (healed) fractures, or impaction syndromes. When conventional radiography is inconclusive, high resolution 3 Tesla magnetic resonance imaging is advised. We provide a broad overview of the literature regarding the use of intra-articular contrast both with computed tomography (CTA) or magnetic resonance imaging (MRA). Conventional arthrography and unenhanced computed tomography are not indicated. This article discusses the most useful imaging techniques in terms of clinical indications, patient positioning, technical imaging requirements, and diagnostic performance in patients with suspected distal radioulnar joint pathology. Furthermore, the most prevalent pathologies are discussed, with the focus on imaging characteristics in both stable and unstable distal radioulnar joints.

Concomitant Total Wrist and Total Elbow Arthroplasty in a Rheumatoid Patient

Background Concomitant arthroplasty has been described to have several benefits over multistage procedures. Ipsilateral total elbow and total shoulder arthroplasty has been reported with good outcomes in upper extremity concomitant arthroplasty. Case Description A 65-year-old woman presented with ipsilateral left-sided wrist and elbow joint degeneration as a result of longstanding rheumatoid arthritis. Concomitant total wrist and total elbow arthroplasty was performed with satisfactory results at both joints. She tolerated the procedure well and had an uneventful clinical course postoperatively. Literature Review Currently, no literature exists that describes one-stage total wrist and total elbow arthroplasty. Individually, total wrist and total elbow arthroplasty have both been reported to result in good outcomes and patient satisfaction. Previous studies have reported the utility of concomitant ipsilateral upper extremity procedures with a one-stage total elbow and total shoulder arthroplasty having been identified as a cost-saving procedure with expedited return to functionality versus a two-stage procedure. Clinical Relevance Patients with ipsilateral degenerative changes in the wrist and elbow should be considered on an individual case basis for concomitant total wrist and total elbow arthroplasty.

Perioperative Treatment of Patients with Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decrease in the need for orthopaedic intervention in this population. However, a substantial percentage of patients with the disease fail optimal pharmacologic treatment and still require surgical intervention. A thorough understanding of medical considerations in these patients and improved knowledge of the medical complications caused by the disease process and the pharmacologic therapy used to treat it may lead to improved preoperative planning and medical clearance, which may ultimately improve the overall postoperative outcome.

Long-term functional outcomes after bilateral total wrist arthrodesis

PURPOSE

To report on the long-term outcomes of bilateral total wrist arthrodeses.

METHODS

We conducted a review of all living patients who underwent bilateral wrist arthrodeses from 1980 to 2010 within a single institution. Outcome measures included pain, Disabilities of the Arm, Shoulder, and Hand questionnaire, Patient-Rated Wrist Evaluation, Michigan Hand Questionnaire, satisfaction scores, complications, and revision surgeries.

RESULTS

Thirteen patients (26 wrists) were treated with an average follow-up of 14 years (range, 3-28 y). Average time for contralateral wrist arthrodesis was 16 months after initial wrist arthrodesis. Eleven wrists had undergone prior surgery. Eleven patients had a primary diagnosis of inflammatory arthritis. Wrists were fused from 5° flexion to 30° extension, with all but one patient's wrist fused within 10° of the contralateral wrist. There was a significant improvement in postoperative grip strength and pain levels. Postoperative Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire scores were 21, 29, and 73, respectively. Increasing age, preoperative steroid usage, and concomitant shoulder or elbow disorders were associated with worse outcomes. Twelve patients (93%) were satisfied and would repeat the surgery and 9 returned to full-time work. The major functional limitation was turning a doorknob or tight jar lid. Seven patients underwent additional surgery including 5 revision arthrodeses and 2 plate removals. Revision surgeries were more common in patients with prior surgeries or preoperative steroid usage, women, smokers, those with ipsilateral elbow dysfunction, and those with fixation with a dorsal locking plate.

CONCLUSIONS

Bilateral total wrist arthrodesis improved pain while enabling patients with severe carpal arthrosis to maintain a satisfactory level of extremity function and quality of life. In general, patients adapted and were satisfied with functional capabilities. This is a viable salvage option for patients with severe bilateral disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

The role of imaging in diagnosing diseases of the distal radioulnar joint, triangular fibrocartilage complex, and distal ulna

OBJECTIVE

The purpose of this article is to review the anatomy, biomechanics, and multimodality imaging findings of common and uncommon distal radioulnar joint (DRUJ), triangular fibrocartilage complex, and distal ulna abnormalities.

CONCLUSION

The DRUJ is a common site for acute and chronic injuries and is frequently imaged to evaluate chronic wrist pain, forearm dysfunction, and traumatic forearm injury. Given the complex anatomy of the wrist, the radiologist plays a vital role in the diagnosis of wrist pain and dysfunction.

Modified Sauvé-Kapandji procedure for rheumatoid wrists: a long-term study with a minimum follow-up of 5 years

OBJECTIVES

We performed a modified Sauvé-Kapandji procedure for treating disorders of distal radioulnar joint in patients with rheumatoid arthritis (RA). This procedure involves resecting the distal part of the ulna, rotating the resected portion by 90° and fixating it with the distal part of the radius for shelf plasty. The purpose of this study was to examine the clinical and radiographic outcomes of this procedure with more than 5 years' follow-up.

METHODS

We studied 32 wrists of 27 RA patients with the mean follow-up of 93.1 months after operation. Pain, grip strength and range of motion of the wrist were examined clinically, while two indices for evaluation of ulnar and palmar translation of the carpus, carpal translation index and palmar carpal subluxation ratio were calculated on radiographs.

RESULTS

The wrist pain reduced in all cases. Range of motion increased significantly regarding pronation and supination but decreased significantly regarding flexion. Change in grip power was not significant. No significant differences were recognized between radiographic indices, suggesting carpal alignment was maintained well throughout the follow-up period.

CONCLUSIONS

We think this procedure could be applied for distal radioulnar joint disorders in RA patients with promising clinical as well as radiographic outcomes over a long period.

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.

Total wrist arthroplasty

This article reviews the history of total wrist arthroplasty as a treatment option for painful, nonfunctional wrists in disease states. Technologic advances in materials, wear properties, and manufacturing now account for increased implant longevity. They may also improve total wrist replacement design, survival, and hence patient function. Also, alternative surgical treatments such as distal radius hemiarthroplasty may serve as a treatment option for patients with higher activity levels and diffuse arthritis. With careful patient selection, soft tissue considerations, and novel implant designs, TWA may become a viable treatment staple for patients with functional wrist disability.

Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists

Rheumatoid arthritis (RA) is a progressively destructive disease. Gradual loss of hand function in RA patients affects their ability for self-care and interferes with their productivity in society. The continuing improvement in the medical management of RA has markedly decreased the incidence of RA hand surgery. In contrast to RA, osteoarthritis (OA) has less inflammatory reaction in the joints and is characterized by degradation of cartilage, resulting in joint destruction and osteophyte formation. The initial treatment of OA is medication and therapy. Steroid injection into affected joints can provide short-term relief, though repeat injections carry a cumulative risk of weakening the soft tissue. In this article the authors share their extensive experience in RA and OA hand surgery to provide a clear discussion of the indications and outcomes of its practice.

Ultrasonographic evaluation of degenerative changes in the distal radioulnar joint: correlation of findings with gross anatomy and MR arthrography in cadavers

OBJECTIVE

To determine the accuracy of ultrasonography (US) in the evaluation of degenerative changes in the distal radioulnar joint (DRUJ).

METHODS AND MATERIALS

Ten cadaveric specimens were obtained. US evaluation of cartilage degeneration and thickness was performed by two independent and blinded readers (R1 and R2). Gross anatomy and MR arthrography evaluated by two readers in consensus served as the reference standard. The joint surface not accessible to US was measured.

RESULTS

US interreader agreement was non-existent for cartilage thickness measurements and moderate for cartilage degeneration grading (weighted kappa = 0.41). Comparing US and MR imaging evaluation, there was no correlation between US R1 and MR imaging (Pearson correlation coefficient [PCC] = 0.352) and a moderate correlation between US R2 and MR imaging (PCC = 0.570) concerning cartilage thickness measurements. Concerning cartilage degeneration grading, there was a moderate to strong (R1 Spearman correlation coefficient [SCC] = 0.729)/R2 SCC = 0.767) correlation concerning cartilage degeneration grading. Comparing US and gross anatomic evaluation, there was no correlation for US R1 (PCC = 0.220) and a strong correlation for US R2 (PCC = 0.922) concerning cartilage thickness measurements, and a strong to moderate correlation (R1 SCC = 0.808/R2 SCC = 0.597) concerning cartilage degeneration grading. The mean sector of the articular surface of the ulna head not accessible to US was 13°.

CONCLUSION

In conclusion the DRUJ is accessible to US except in the central 13° sector of the joint surface. US was approved to be sufficient in demonstrating advanced stages of cartilage degeneration. Thus, US of the DRUJ is recommended in patients suffering from ulnar-sided wrist pain.

Proliferative extensor tenosynovitis of the wrist in the absence of rheumatoid arthritis

PURPOSE

Proliferative tenosynovitis in the fourth extensor compartment is common in patients with rheumatoid arthritis. It may also occur in the absence of rheumatoid arthritis; the purpose of this study is to describe this clinical condition in a series of patients, to report the results of surgical intervention, and to compare histological findings to those typically seen in rheumatoid tenosynovitis.

METHODS

This study presents a retrospective case series of 11 patients who do not have rheumatoid arthritis, who had proliferative tenosynovitis of the fourth extensor compartment treated surgically. Relevant features of the clinical presentation, physical examination, radiographic findings, and results of attempts at conservative treatment are described. Surgical pathology specimens were reviewed by a single pathologist to define common histological features and to compare the histology to that which is classically seen in rheumatoid tenosynovitis.

RESULTS

All patients presented with a painful wrist mass over the fourth extensor compartment. Characteristic in physical examination was severe limitation of active wrist extension with the fingers extended, with improvement when the fingers were flexed into a fist. After tenosynovectomy, wrist extension and grip strength improved. Examination of the surgical pathology specimens revealed a spectrum of pathological findings generally consistent with traumatic tenosynovitis, but a few specimens had rheumatoid-like features.

CONCLUSIONS

A review of this case series of patients with tenosynovitis but without rheumatoid arthritis demonstrates a distinct clinical condition of exuberant proliferative extensor tenosynovitis blocking proximal tendon excursion, thereby causing pain and limited active wrist extension, as well as a less distinct histological condition with a constellation of findings generally resembling traumatic tenosynovitis. In this group of patients, surgical tenosynovectomy generally yields excellent results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Basal thumb arthritis

Basal thumb arthritis is a common condition seen in hand clinics across the United Kingdom and is often associated with other pathological conditions such as carpal tunnel syndrome and scaphotrapezial arthritis. Typically, patients complain of pain localised to the base of the thumb. This pain is often activity related, particularly after excessive use involving forceful pinch. A detailed history and examination is normally all that is needed to make the diagnosis. Provocative manoeuvres may be helpful in localising symptoms to the basal joint with degenerative changes or synovitis. Radiographs are useful for confirming the diagnosis and staging the disease in order to plan for surgery. The mainstay of initial treatment of basal thumb arthritis of any stage is activity modifications, rest, nonsteroidal anti-inflammatory drugs, exercises and splinting. A variety of surgical procedures are available to treat the condition when conservative measures have failed, in order to control symptoms and improve function. We review the current literature and discuss the clinical aspects of this condition, staging, and treatment options available, and the difficulties treating this group of patients.