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

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.

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.