In the treatment of patients with a rheumatoid wrist, the usefulness of synovectomy by a dorsal approach has been universally confirmed. However, if the clinical results are generally good after the dorsal synovectomy, this procedure does not avoid progressive joint destruction and instability.
The terms “dorsal wrist surgery” or “conservative surgery” refer to all surgical procedures (particularly designed to realign or stabilize the carpus) performed in combination with dorsal articular synovectomy. 1 In 1977, we defined the “dorsal wrist” as a surgical anatomic entity. 2
The Following Procedures Can Be Performed Simultaneously Via Dorsal Approach
- Extensor tendon synovectomy, when necessary, and extensor tendon repair in the cases of rupture;
- Articular synovectomy (radiocarpal, midcarpal, and carpometacarpal);
- Resection of the posterior interosseous nerve;
- Resection of the ulnar head with distal radioulnar synovectomy;
- Closure with anterior transposition of the extensor retinaculum, which is sutured onto the ulnar border of the carpus and the ulna;
- Posterior translocation of the extensor carpi ulnaris (ECU) tendon, maintained by a sling taken from the extensor retinaculum.
In some cases of wrist radial deviation, an extensor carpi radialis longus (ECRL) tendon transfer to the ECU tendon 3 must complete this operation.
Realignment and stabilization of the carpus are consequently assured by soft tissues, extensor retinaculum of the carpus transposed anteriorly, posterior translocation of the ECU, and, if necessary, transfer of the ECRL to the ECU.
Attempts at isolated stabilization by soft tissues or tendon transfers appear insufficient to prevent ulnar translocation and carpal subluxation if rheumatoid arthritis progresses after synovectomy. Such progress is difficult to predict, but Simmen's classification 4 is sometimes helpful in making this prediction.
In order to obtain better stabilization and better realignment of the wrist, in addition to the stabilization by soft tissues, we perform the “radiolunate fusion” described by Chamay and Linscheid. 5–7
HISTORICAL PERSPECTIVE AND DEVELOPMENT OF THE TECHNIQUE
A literature review shows what we have noted in our personal experience—despite which procedure is associated with the dorsal synovectomy (stabilization by soft-tissue procedures only, Sauvé–Kapandji procedure, or radiolunate arthrodesis), 80%–90% of the results are good (subjective results caused by a painless wrist with patient satisfaction).
Mobility after surgery is more or less reduced depending on the follow-up examination and the natural evolution of the disease. 8–14
The literature review also confirms a radiologic and clinical discordance with a radiologic evolution of osteoarticular destruction but good clinical results.
If the rheumatoid arthritis progresses, simple resection of the ulnar head results in a slight increase of the ulnar translocation of the carpus. 8,12,15
The tendinous transfers—ECRL on the extensor carpi radialis brevis and on the flexor carpi ulnaris—are efficient as concerns the radial deviation of the carpus, but do not prevent ulnar translocation. 6,10
The Sauvé–Kapandji procedure cannot correct sagittal displacements (intracarpal displacement or radiocarpal palmar subluxation) and, in fact, does not prevent ulnar translocation. 16–19
In all cases (soft-tissue procedures, Sauvé-Kapandji procedure, radiolunate arthrodesis), osteoarticular destruction continues and results in a reduced mobility, which essentially persists in the mid carpal joint. Despite this reduced mobility, the wrist remains functional. 4,8–11,18–20
In spite of progressive joint destruction, conservative surgery of the dorsal rheumatoid wrist is a good procedure with excellent relief of pain and associated improvement of function. This technique can be used in the majority of the rheumatoid wrists where the osteoarticular destruction is not too extensive. Moreover, a new operation concerning wrist arthrodesis can be performed at a later time as a result of progressive joint destruction.
In 1989, 8 we reviewed 60 cases of synovectomy of dorsal rheumatoid wrist with stabilization using only soft tissues with a follow-up of 5 years and 4 months. One third of these patients were retained for clinical analysis of the results, with a mean follow-up–examination period of 8 years and 8 months.
The subjective assessment was excellent and good in 71% of patients at the follow-up examinations conducted at 5 and 8 years. Pain relief was excellent in 70% of the patients. The range of extension decreased from 35° to 31.78°, and flexion decreased from 33.1° to 17°. The range of radial deviation decreased from 9.6° to 3.7°, and ulnar deviation decreased from 18.6° to 7.6°. The loss of flexion–extension increased from 28% at the follow-up examination conducted at 5 years to 33% at the most recent follow-up examination. The loss of inclination increased from 25% to 41.5%.
At the most recent follow-up examination, the carpal height (0.54 ± 0.03) decreased from 0.45 to 0.38 and 0.36. The ulnar translation (0.10 ± 0.03) increased from 0.117 to 0.169 during the follow-up–examination period of 5 years. The radiologic findings demonstrated that this procedure does not prevent local progression of the disease; there was an increase of Larsen's stage, deterioration of ulnar and palmar sliding, and a decrease of the carpal height. Thus, stabilization by soft tissue only is insufficient.
Therefore, from 1984 to 1994, 16,21 in some cases, we added a radiolunate fusion. The indication for this combined procedure is steadily increasing. Seventy-seven cases of dorsal wrist surgery with radiolunate arthrodesis were performed between 1984 and 1991, out of which, 35 wrists were assessed in 33 patients. The average follow-up–examination period was 39 months. The subjective assessment was excellent for 23 wrists, good for 8 wrists, and poor for 4 wrists. Pain experienced after surgery was mild in 3 wrists, and no pain was experienced after surgery in 32 wrists. At the time of follow-up, flexion–extension averaged 41°, and inclination averaged 17°. The loss of flexion–extension amounted to 34%, and the loss of inclination amounted to 26%. There was no change in carpal height, and the ulnar translation decreased from 0.15 to 0.11. One radiolunate nonunion was encountered. Two patients had a Kirschner wire removed early as a result of pain they were experiencing that was caused by incorrect wire positioning (Figs. 1A–D).
The patients with severe rheumatoid arthritis are often operated on many times, because of upper- and lower-limb joint involvement. Thus, the most secure operation has to be performed to avoid reoperation. The surgical procedure has to be opposed to the natural history of the rheumatoid-wrist involvement with instability and joint destruction and to prevent extensor-tendon ruptures. The preventive procedures—tenosynovectomy, ulnar head resection, radioulnar joint and radiocarpal joint synovectomy, repositioning of the ECU tendon (with or without a tendon transfer)—are indicated in the early stages without seeing progressive destruction of the joint on radiographic examination. In the other cases, with instability and/or joint destruction, a reconstructive procedure must be combined with the preventive procedures, because they do not avoid progressive subluxation and/or bone loss of the rheumatoid wrist. The interpositional arthroplasty of the wrist in rheumatoid arthritis gave good clinical results, but the recurrent instability and bone loss are the disadvantages of this technique that we ignored for a long time. In patients with instability of the wrist, good bone stock, and undamaged midcarpal joint, we favor to use partial wrist arthrodesis rather than using radiolunate arthrodesis. Nevertheless, progressive destruction of the midcarpal joint can occur because of progressive rheumatoid disease and mechanical overloading. Long-term outcome is needed to assess definitively the indication of the partial wrist arthrodesis in the rheumatoid wrist. We advise total wrist arthrodesis in the end stages with the severe joint destruction that is caused by the high rate of complications after total wrist arthroplasty (loosening, dislocation) and Silastic wrist implant (fracture, silicone synovitis). The lack of bone stock after these procedures fail remains a concern with regard to the difficulties that are associated with the performance of a new procedure.
EVALUATION/INDICATIONS BEFORE SURGERY
Clinical Evaluation of the Wrist and Global Evaluation of the Upper Limb
Functional evaluation of the wrist must be carried out, but the shoulder, elbow, and hand also must be assessed.
General Assessment (Clinical and Biologic)
A complete general functional evaluation of the patient is necessary, including the lower limb (foot, ankle, knee, and hip), to evaluate if the patient must use walking sticks and to allow for surgical planning. 22
The patient must be informed of complications associated with any kind of wrist surgery. He should be aware of the decrease in range of motion of the wrist that he will experience after surgery. Nevertheless, the patient must be reassured that their wrist will remain functional and mobile, contrary to the situation present after total arthrodesis.
Radiologic Evaluation is Carried Out According to Larsen's Classification of the Rheumatoid Wrist
The following dynamic radiographs are required:2,8,16 anteroposterior films in the neutral position (radial and ulnar deviation) and lateral films in the neutral position (wrist flexion and wrist extension). This dynamic assessment is necessary to analyze the ulnar translation, the palmar subluxation, and particularly, the respective mobility of the radiocarpal and the midcarpal joints in flexion–extension of the wrist.
Radiologic signs of Larsen's 23 classifications III and IV, even in the presence of midcarpal involvement, is not a contraindication to partial arthrodesis if the midcarpal joint is mobile on the functional lateral radiograph.
Radiologic evolution over time must be carried out to classify the rheumatoid wrist according to Simmen 4 (Type 1, Type 2, and Type 3).
A Friberg notch, at the distal part of the radius in front of the ulnar head, is a good sign as an indication for urgent synovectomy to avoid tendons rupturing.
Our indications have consequently evolved in the course of a series of 603 wrists operated on for more than 26 years, between 1968 and 1994. 24,25 To date, we no longer perform arthroplasty. We ceased performing Jackson's interposition arthroplasties in 1985 and Swanson implants in 1988. Actually, the dorsal rheumatoid wrist surgery is combined with a radiolunate arthrodesis in early stages and a wrist arthrodesis in end stages.
From the skin to the capsule
The dorsal incision is straight and longitudinal. The skin is manipulated with precaution, considering its fragile condition in rheumatoid arthritis.
The subcutaneous tissues are dissected as close to the dorsal retinaculum as possible and up to the sensory branches of the radial and ulnar nerve (Fig. 2).
The dorsal retinaculum is incised between the extensor digiti quinti and the ECU. The retinaculum is lifted up from the compartments of the radial wrist extensors (Fig. 3).
Tenosynovectomy of all extensor tendons is performed, if necessary. If there is rupture of the extensor tendons, they are reconstructed by tendinous transfer or graft at the end of the wrist's surgical procedure.
The posterior interosseous nerve is isolated, and its distal sensory branch is resected (cut and resected 1 cm long) (Fig. 4).
The Articular Procedures: Articular Synovectomy, Resection of the Ulnar Head, and Radiolunate Arthrodesis, if Necessary
The capsular incision depends on the surgical procedure. When an isolated articular synovectomy of the radiocarpal and midcarpal joints is indicated, we perform two horizontal incisions: the proximal one above the radiocarpal ligament for the radiocarpal joint's synovectomy and the distal one between the radiocarpal ligament and the dorsal intercarpal ligament for the midcarpal joint's synovectomy (Fig. 4). When in addition to the articular synovectomy, a radiolunate arthrodesis is indicated, we perform an inverted U-incision (Fig. 5). The distal radioulnar joint approach is performed through an extension of the vertical incision on the ulnar side in a proximal direction.
Synovectomy of radiocarpal and midcarpal joints is performed with a rongeur (Fig. 6).
Resection of the ulnar head is performed with an oscillating saw at the level of the proximal end of the sigmoid notch of the radius. Synovectomy of the radioulnar joint is performed. Smoothing and rounding of the ulnar stump is carried out (Fig. 6).
Radiolunate fusion is performed to stabilize the wrist in two planes, to correct not only the ulnar translation but also the anterior subluxation or volar instability (rarely dorsal instability) of the lunate.
The radiolunate fusion is prepared by resection of the articular cartilage surfaces of the lunate and the radius with a gouge up to the scapholunate crest of the radius. The bone is freshened with a burr.
This is followed by reduction of ulnar translation and of the anterior subluxation. This reduction is performed by external manual maneuvers for the ulnar translation and by direct maneuvers on the lunate.
Intraoperative radiologic control is carried out in the anteroposterior and lateral planes. Internal fixation of the arthrodesis is carried out with two 1.2-mm Kirschner wires in a proximal and distal direction. Additional fixation is done with staples. The remaining space between the radius and the lunate is packed with cancellous bone removed from the ulnar head (Fig. 7).
Soft Tissues' Stabilization and Closure
The radiocarpal capsule is closed with the wrist in slight flexion to avoid losing flexion after surgery. Stabilization of the ulnar stump is carried out with mattress stitches anchored into the ulnar border of the dorsal retinaculum.
Anterior transposition of the retinaculum is performed under the extensor tendons. The ECU is repositioned in its normal dorsal position. A trip of the extensor retinaculum is split and looped around the ECU tendon (Fig. 8). Skin and subcutaneous tissues are closed with interrupted stitches in one layer over a suction drain.
Stabilization with soft tissue only
Stabilization with soft tissue only is indicated in some cases of rheumatoid wrist without progressive destruction of the joint seen on radiographic examination (Simmen's Type 3).
The ECRL can be transferred into the ECU or into the extensor carpi radialis brevis. 3,25 We carry out stabilization by tendon transfer of the ECRL into the ECU to correct radial deviation of the carpus. However, over time this does not prevent the ulnar translocation of the carpus if the rheumatoid arthritis progresses. 12,17
Stabilization by radioscapholunate arthrodesis
Stabilization by radioscapholunate arthrodesis 26 is indicated in cases of palmarflexed scaphoid that is caused by scapholunate dissociation, because there is a high risk of flexor tendons rupturing (flexor pollicis longus and flexor indicis profundus) secondary to attrition at the level of the scaphoid tubercle.
A radioscapholunate arthrodesis is performed after correction of the palmarflexed scaphoid. The correct position of the scaphoid and of the lunate is checked radiographically during the procedure. Staples and 1.2-mm Kirschner wires assure internal fixation.
Stabilization by Sauvé–Kapandgi procedure
We have limited experience of this procedure (arthrodesis of the radioulnar joint and distal ulnar pseudarthrosis). Widely used by Alnot 27 and others, 10 this procedure is also used by Taleisnik 19 for young patients presenting a painful pronosupination. According to Shapiro, “It is a better procedure than simple excision when ulnar translocation is impending but not severe enough to justify stabilization by radiolunate fusion. It does not correct and prevent carpal subluxation and does not correct existing ulnar translocation.”18
This procedure is indicated for patients requiring a radiolunate fusion in whom the bony surface opposite the lunate can be augmented by the addition of the ulnar head to the radiolunate fusion mass. Its main drawback is the potential for instability of the ulnar stump. The distal end of the pseudarthrosis should be as distal as possible, on the neck of the ulna. 14 Instability of the ulnar stump must be prevented at the time of surgery, usually by using the pronator quadratus brought up dorsally through the osteotomy space and attached to the ulnar stump as a palmar teno- or myodesis. 19
- Injury of sensory branches of radial or ulnar nerves.
- Infection: if superficial, the stitches should be removed. Antibiotic therapy should be given based on culture and sensitivity study. If the infection is deep, debridement should be added.
- Wound-healing disturbances: sutures with tension should be released.
- Adhesions causing tenodesis of extensors: adhesions should be freed. Early exercises are recommended after surgery.
- Nonunion of arthrodesis: a renewed arthrodesis, only in the presence of pain.
- Elevation of hand.
- Removal of the drain after 24 hours.
- Change of dressing on the second day after surgery.
- Removal of stitches after 3 weeks.
- Immobilization of the wrist in a removable dynamic orthesis with extensor spring for 45 days.
- Early mobilization of all finger joints except in case of extensor repair.
- Early mobilization of the wrist if the stability of the arthrodesis is sufficient (21–45 days).
- Kirschner wires and staples are removed only if they cause discomfort (as a result of positioning errors).
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