How is rheumatoid arthritis (RA) of the wrist treated?

Updated: Jan 11, 2019
  • Author: Michael Neumeister, MD, FRCSC, FACS; Chief Editor: Joseph A Molnar, MD, PhD, FACS  more...
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Answer

Answer

Early treatment of synovitis of the wrist consists of synovectomy at the ulnar carpal or radial carpal sites. This procedure may help to control pain, slow the progression of the disease, and maintain motion.

A study by Lee et al indicated that arthroscopic wrist synovectomy can control synovitis in 75% of rheumatoid wrists that have been unresponsive to drug therapy. The study involved 49 patients (56 wrists) with RA who underwent arthroscopic synovectomy, with the patients evaluated for wrist pain and function after a mean 7.9-year follow-up period. There was no recurrence of synovitis in 42 wrists (75%), with the mean visual analogue scale score for wrist pain in the study having dropped from 6.3 to 1.7 and the mean Mayo wrist score (as determined from 39 wrists) having risen from 48 to 76. Patient satisfaction reached a mean visual analogue scale score of 7.9. The mean Larsen score rose from 2.2 to 3.3. [17]

A retrospective observational study by Berhouet et al indicated that in patients with RA of the wrist, combining synovectomy with transfer of the extensor carpi radialis longus to the extensor carpi ulnaris can relieve pain and prevent radiocarpal destabilization. At mean 42.5-month follow-up, the investigators found pain relieved in 14 out of 16 wrists (87.5%), with synovitis resolved in 10 wrists (62.5%). Mean increases in extension and flexion were 19.7° and 5.7°, respectively. Reducible radial deviation and ulnar translocation were cited as the primary indication for extensor carpi radialis longus transfer. [18]

RA of the wrist that has progressed beyond simple proliferative synovitis may require more radical treatments. Destruction of the distal radial ulnar joint may require excision of the distal ulna and reconstruction of the TFCC. Tendon transfer reconstruction of the ruptured extensor tendons often associated with caput ulna syndrome can be performed in the same setting as the resection of the distal ulna and synovectomy.

A few reports have indicated that the Sauvé-Kapandji procedure may be more appropriate in younger patients. [19] This procedure provides a fusion of the distal radius and ulnar head and excision of the ulnar neck. The surgery may be more beneficial in those patients who do not have significant ulnar translocation of their carpus. Stabilizing techniques for the distal ulna following resection include using a segment of the radial carpal volar ligament or slips of the extensor carpi ulnaris or flexor carpi ulnaris tendons. Stabilizing procedures following excision of the distal ulnar head may help to prevent complications such as painful forearm rotation.

A study by Ikeda et al found the Sauvé-Kapandji procedure effective on distal radioulnar joints affected by either RA or osteoarthritis. The investigators reported a significant increase in supination and decrease in palmer flexion in patients with RA, determining at 1-year follow-up that carpal alignment and ulnar stump stability had been well maintained. [20]

With destruction of the radial carpal joint, wrist fusion becomes a very functional and viable option. Numerous methods are used for wrist fusion, including the use of Steinman pins, 62-gauge K-wires, plates, and screws. These techniques require the use of autologous bone graft from the iliac crest or allograft bone material. The exact position the wrist should be in following fusion is controversial. Most surgeons prefer to fuse the wrist at an angle of approximately 10° of dorsal flexion.


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