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The Rheumatoid Wrist Abstract Wrist involvement is common in patients with rheumatoid arthri- tis. 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 ten- dons may rupture because of synovial infiltration and bony irrita- tion. 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. Be- cause 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 stabil- ity of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers re- liable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of to- tal wrist replacement are still being evaluated. R heumatoid arthritis (RA) is a chronic, systemic autoimmune disease that causes chronic inflam- matory synovitis. Once the diagno- sis is made, early medical manage- ment may slow natural disease progression. 1 Despite aggressive medical management, however, many patients have persistent and progressive disease. Wrist involve- ment is exceedingly common, with >66% of patients having at least some wrist symptoms within the first 2 years of diagnosis; this num- ber increases to >90% by 10 years. 2 Surgical intervention markedly im- proves hand and wrist function for many rheumatoid patients. Careful patient selection, preoperative plan- ning, and selection of surgical tech- nique are vital. Natural History RA is a progressive disease that af- fects the wrist via three pathologic processes: cartilage degradation, lig- amentous laxity, and synovial ex- pansion with erosion. 3 Cartilage is destroyed by the chemical effects of lysosomal enzymes and free oxygen radicals released by cytokine- activated neutrophils. Synovial tis- sue hypertrophy is the sine qua non of RA, invading areas of increased vascularity first. Eventually, all joints and tendon sheaths may be- come diseased. Steven R. Papp, MD, MSc, FRCSC George S. Athwal, MD, FRCSC David R. Pichora, MD, FRCSC Dr. Papp is Assistant Professor, University of Ottawa, Ottawa Civic Hospital, Ottawa, ON, Canada. Dr. Athwal is Assistant Professor, University of Western Ontario, Hand and Upper Limb Centre, St. Joseph’s Health Care, London, ON. Dr. Pichora is Chairman, Division of Orthopedic Surgery, and Hand Fellowship Director, Queen’s University, Kingston General Hospital, Kingston, ON. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Papp, Dr. Athwal, and Dr. Pichora. Reprint requests: Dr. Papp, Ottawa Civic Hospital, Room 2-018, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9. J Am Acad Orthop Surg 2006;14: 65-77 Copyright 2006 by the American Academy of Orthopaedic Surgeons. Volume 14, Number 2, February 2006 65 The prestyloid recess of the distal ulna is an area of increased vascular- ity and early synovial infiltration. As RA progresses, the ulnar styloid un- dergoes erosion and its associated ligaments become attenuated, lead- ing to dorsal prominence of the ulnar head—the so-called caput ulnae syn- drome. 4 Proliferative synovitis of the distal radioulnar joint (DRUJ) causes arthritis and also contributes to dis- tal ulna instability. Tenosynovitis of the extensor carpi ulnaris (ECU) ten- don sheath is the third factor leading to distal ulna instability. Erosion of the palmar side of the distal radius, the waist of the scaphoid, and the triquetrum also are common. Additionally, synovitis affects many of the intrinsic and ex- trinsic wrist ligaments, including the palmar radiocarpal, scapholu- nate, and lunotriquetral ligaments. Dorsal intercalated segmental insta- bility or palmar intercalated seg- mental instability may develop with collapse. Classically, the proximal carpal row translates both palmarly and ulnarly and supinates. Cartilage degradation from lysosomal en- zymes, coupled with the abnormal wrist biomechanics caused by liga- mentous attenuation, leads to arthri- tis. Early disease involvement at the DRUJ as well as at the radiolunate and radioscaphoid joints is followed by carpal collapse and, ultimately, pancarpal arthritis. 5 Preoperative Evaluation Patients should undergo a thorough assessment, including a full history of disease activity, the specific areas of joint involvement (ie, distal radio- ulnar versus radiocarpal), current medication, and previous surgical procedures. In particular, symptoms of neck pain or neurologic deficits suggest the possibility of cervical spine instability, which require pre- operative flexion/extension cervical spine radiographs and further imag- ing. Nutritional status also may be compromised by disease and medi- cation and should be optimized pre- operatively. We prefer to continue anti-rheumatic medications (eg, methotrexate) perioperatively to avoid flare-ups, which we believe is reasonably safe to do. 6 However, newer and more potent drugs, such as anti–tumor necrosis factor-α agents (eg, infliximab, etanercept), are being used. It is important to consult with the treating rheumatol- ogist to weigh the risks and benefits of continuing perioperative medica- tions. Preoperative blood work and other tests may be guided by the medications the patient is using and their potential side effects. Anes- thetic consultation is often neces- sary, especially in patients with cer- vical spine instability. A thorough physical examination of the wrist and hand is important. Routine radiographic assessment in- cludes anteroposterior and lateral ra- diographic views of the wrist. Radio- graphic staging of each joint in the wrist and hand may be performed preoperatively, as described by Lar- sen et al 7 (Table 1). The presence of joint dislocations and bone loss should be noted. Usually, neither computed tomography nor magnetic resonance imaging is helpful in pre- operative planning. For patients with neurologic signs or symptoms, nerve conduction velocity studies and electromyography are recom- mended. Surgical Timing and Priorities The timing of wrist surgery in pa- tients with RA remains controver- sial. Factors that may influence the decision to operate include general health, other musculoskeletal sys- tem involvement (eg, hip or knee disease, shoulder or elbow patholo- gy), disease activity, patient needs, patient compliance, and surgeon ex- perience. In general, because of the potential need for ambulatory aids, it is preferable to manage lower ex- tremity problems before wrist sur- gery. Problems at the shoulder and elbow also must be considered. A hand that cannot be placed in a func- tional position because of elbow dis- ease will not be used, despite correc- tive hand and wrist surgery. Some authors advocate a proximal-to- distal order; however, first managing the most problematic joint is proba- bly more sensible. Patients with persistent synovi- tis, despite a 6-month trial of disease-modifying antirheumatic drugs and anti-inflammatory medi- cations supervised by a rheumatolo- gist, may be considered for prophy- lactic surgery. Options include tenosynovectomy, wrist synovecto- my, and DRUJ stabilization. Surgery to prevent wrist deformity, such as tendon transfer of the extensor carpi radialis longus to the ECU, also should be considered. This may be especially important before or in conjunction with metacarpopha- langeal (MCP) joint arthroplasty. Re- constructive surgery, such as tendon transfer or grafting, DRUJ recon- struction, partial or total wrist fu- sion, or wrist arthroplasty, should be considered in patients with persis- tent symptoms and a more destruc- tive clinical picture. Table 1 Larsen Radiographic Staging of Rheumatoid Arthritis Larsen Score Radiographic Status 0 No change, normal joint 1 Periarticular swelling, osteoporosis, slight narrowing 2 Erosion and mild joint space narrowing 3 Moderate destructive joint space narrowing 4 End-stage destruction, preservation of articular surface 5 Mutilating disease, destruction of normal articular surfaces The Rheumatoid Wrist 66 Journal of the American Academy of Orthopaedic Surgeons In general, it is best to accomplish as much as possible at one surgical setting. However, soft-tissue man- agement, surgical time, tourniquet time, postoperative rehabilitation, and patient factors may dictate a staged procedure. Surgical Management Extensor Tendons and the Dorsum of the Wrist At the wrist, the extensor tendons are enclosed in a synovial sheath, thus making them susceptible to rheumatoid disease. The extensor tenosynovium starts just proximal to the extensor retinaculum and ex- tends distal to it. Clinically , patients present with painless swelling as synovitis peers out from the proxi- mal and distal edges of the extensor retinaculum, giving the dorsal wrist an hourglass appearance. The exten- sor tendons are separated and con- tained in one fibrous sheath and five fibro-osseous sheaths. Tenosynovitis may be limited to one compartment or may be more generalized. Initial- ly, there is fluid production and in- flammation, but as the synovium proliferates and invades the tendon, adhesions form and may cause ten- don rupture (Figure 1). Bony deformity at the wrist also may cause extensor tendon dysfunc- tion. Rheumatoid disease of the ra- diocarpal joint and DRUJ leads to palmar subluxation and supination of the carpus and a prominent ulnar head—the caput ulnae syndrome. Ryuetal 8 reported that risk factors for tendon rupture include persistent tenosynovitis, dorsal dislocation of the ulna, and the so-called scallop sign (ie, bony erosion over the ulnar side of the distal radius). Patients with two or three of these risk fac- tors were given the option of prophy- lactic surgery, which seemed to pre- vent tendon rupture in most patients. Because of its anatomic position in the fifth dorsal compartment over- lying the ulnar head, the extensor digiti quinti (EDQ) is at high risk of attritional rupture (ie, Vaughan- Jackson syndrome). 9 In most individ- uals, an isolated EDQ rupture is clin- ically silent because of the remaining extensor digitorum communis (EDC) and juncturae tendinae. Assessment for EDQ rupture is done by attempt- ing little finger extension while hold- ing the other fingers flexed into the palm. In one study, patients with loss of EDQ function were offered surgery; intraoperative findings showed perforation of the DRUJ cap- sule and direct bony contact between the ulnar head and the ruptured ten- don. 10 Early diagnosis of EDQ rup- ture may be an important indicator for preventing further extensor ten- don rupture. Left untreated, the pa- tient may experience further rupture of the EDC tendon to the fifth finger and, sequentially, to the radial-sided tendons, leading to significant dis- ability. The rheumatoid patient present- ing with an inability to extend the MCP joints likely has an extensor tendon injury. 4 This injury usually is caused by tenosynovial invasion and attrition of tendons over bony prom- inences, such as the EDQ over a prominent caput ulnae or extensor pollicis longus over Lister’s tubercle. Other causes must be considered, however, including extensor tendon subluxation, MCP joint dislocation, and posterior interosseous nerve pal- sy. Both passive and active range of motion (ROM) of the wrist and fin- gers should be documented on phys- Figure 1 A, Note the hourglass appearance as dorsal tenosynovitis peers out just distal to the extensor retinaculum (arrow). B, Dorsal midline incision and reflection of the extensor retinaculum (white arrow). The infiltrative process of the tendons leads to a toffee- like appearance (black arrow), softening, and, eventually, rupture. Steven R. Papp, MD, MSc, FRCSC, et al Volume 14, Number 2, February 2006 67 ical examination. Extensor tendon continuity is determined by palpat- ing the dorsal aspect of the wrist dur- ing active contraction in various wrist positions. On full passive wrist flexion, the tenodesis effect of intact extensor tendons normally causes MCP joint extension. When the fin- ger can actively be held in full exten- sion once it has been passively posi- tioned, then tendon subluxation caused by sagittal band attenuation is likely. Fixed contractures caused by MCP joint dislocation or arthritis also may prevent extension. Finally, the inability to extend all of the fin- gers and the thumb may be the re- sult of posterior interosseous nerve palsy at the elbow. 11 Indications for early surgical treat- ment remain controversial. 12 The goals of surgery are to decrease pain, improve function, limit progression, and prevent tendon rupture. Options include extensor tenosynovectomy, wrist joint synovectomy, and soft- tissue balancing. DRUJ instability is an important part of wrist and ten- don dysfunction, and correction of instability should be considered when performing soft-tissue proce- dures above the wrist. Once the ex- tensor tendon ruptures, the deficits are usually significant and surgery becomes necessary. Synovectomy is indicated for ac- tive or recurrent extensor tenosyno- vitis or for wrist synovitis that per- sists despite 3 to 6 months of medical management (including corticosteroid injections). Tenosyn- ovectomy is unlikely to be of value when the associated joints are stiff or ankylosed because of arthritis or deformity. Early in the disease course, dorsal tenosynovectomy and wrist synovectomy may benefit pa- tients with persistent disease. How- ever, there are conflicting data on the usefulness of these soft-tissue procedures. Some studies suggest short-term benefit without long- term effects on the natural history o f RA at the wrist. 13 Alternatively , oth- er authors believe that decreased pain, increased function, and de- creased chance of tendon rupture justify inter vening even if halting the disease process is unproved. 14,15 Although open wrist synovectomy is standard and allows inspection of all compartments as well as of the ex- tensor tendons, arthroscopic syn- ovectomy has been used successful- ly in select patients. Arthroscopic synovectomy offers the potential ad- vantage of less postoperative loss of wrist motion than with open teno- synovectomy. 16 Tenosynovectomy is performed through a midline dorsal approach to protect the radial sensory and dorsal ulnar sensory nerves. The extensor retinaculum is entered between the fifth and sixth extensor compart- ments, and a radially based flap of retinaculum is raised to the first dor- sal compar tment to allow excision of the infiltrating synovium around the extensor tendons (Figure 2). For pain relief, partial wrist denervation may be performed by resecting the terminal branch of the posterior in- terosseous nerve in the floor of the fourth extensor compartment. We prefer to enter the radiocarpal and midcarpal joints with a straight lon- gitudinal incision, although there are alternatives, such as the ligament-sparing arthrotomy de- scribed by Berger and Bishop. 17 All bony prominences that may cause tendon abrasion must be removed. Figure 2 Tenosynovectomy. A midline dorsal approach is made (double-headed arrow) to avoid the superficial radial sensory and dorsal ulnar sensory nerves. This incision offers an excellent view of the extensor compartments. A retinacular flap may be raised and reflected from ulnar to radial. APL = abductor pollicis longus, ECRB = extensor carpi radialis brevis, ECRL = extensor carpi radialis longus, EDC = extensor digitorum communis, EPB = extensor pollicis brevis, EPL = extensor pollicis longus. (Permission to reproduce this figure courtesy of the Indiana Hand Center, Manus, and Gary Schultz.) The Rheumatoid Wrist 68 Journal of the American Academy of Orthopaedic Surgeons Lister’s tubercle and a prominent ul- nar head are the most common sources of tendon abrasion. For the unstable distal ulna, a distal ulna re- section (Darrach procedure) or a dis- tal radioulnar joint fusion proximal resection (Sauvé-Kapandji procedure) is indicated to prevent further ten- don abrasion. Once the tenosynovectomy is complete, some authors advocate preserving or repairing the distal por- tion of the retinaculum to minimize the chance of extensor tendon bow- stringing. 18 We routinely lay the ex- tensor retinacular flap under the ex- tensor tendons to further protect them from abrasion. Postoperative- ly, a splint is applied for comfort, and early ROM of the fingers and wrist is begun. After a Darrach or Sauvé- Kapandji procedure, the wrist and forearm are immobilized for approx- imately 4 weeks, followed by part- time splinting with ROM exercises. Early in the disease process, ten- don transfers have been advocated for soft-tissue and wrist balancing. As the rheumatoid wrist deteriorates, the carpus translates ulnarly and pal- marly. The classic zigzag deformity of radial deviation at the wrist and ul- nar deviation at the fingers may de- velop. Although there are many con- tributing factors to ulnar drift of the fingers, the deformity is thought to originate at the wrist. 19 The Darrach procedure, which is commonly done at the same time as wrist synovec- tomy, is thought to be a risk factor for ulnar carpal subluxation because it further destabilizes the ulnar side of the wrist. 17 Extensor carpi radialis longus tendon transfer to the ECU was first described as a means to pre- vent this wrist deformity. 20 A recent retrospective study concluded that extensor carpi radialis longus tendon transfer aids in wrist stabilization, preventing ulnar carpal translation and radial deviation. The authors also noted decreased ulnar drift of the fin- gers at a mean 8.8-year follow-up. 21 This procedure also may help prevent caput ulnae syndrome by tethering the ECU tendon dorsally over the ul- nar head. Tendon Transfer for Extensor Tendon Rupture The extensor tendons and soft- tissue envelope are frequently com- promised in RA. Although antirheu- matic medications may adversely affect healing, reasonable improve- ments in hand function may be achieved by tendon transfer in pa- tients with functional limitations caused by extensor tendon rupture. For patients with tendon rupture associated with RA, primary tendon repair is rarely feasible (Figure 3). The diffuse nature of the tendon damage, combined with fibrosis, at- rophy, and retraction of the muscle, usually precludes repair. When rup- ture is diagnosed early, tendon graft- ing may be successful. 22 Some au- thors think that tendon grafting results are poor because of the long- standing nature of the disease and decreased musculotendinous unit excursion, leading to loss of flexion following grafting. 23 Tendon transfer is the most com- mon surgical choice. The simplest is side-to-side transfer, in which the distal stump of the ruptured tendon is sewn into one of the adjacent ex- tensor tendons. With rupture of mul- tiple extensor tendons, the recruit- ment of distant motors is necessary. Common options include the exten- Figure 3 A, Patient demonstrating the classic findings at the wrist of persistent dorsal tenosynovitis (arrow) and a prominent ulnar head (arrowhead). This patient also presented with a suspected extensor tendon rupture at the fifth extensor compartment. B, Intraoperative photograph of the exposed tendons and raised retinacular flap of a similar patient demonstrating an obviously arthritic and prominent ulnar head (arrow) and long-standing rupture of the extensor tendons to the ring and little fingers. (Ruptured proximal tendon in forceps and ruptured distal tendons reflected over the skin.) Steven R. Papp, MD, MSc, FRCSC, et al Volume 14, Number 2, February 2006 69 sor indicis proprius tendon and one of the flexor digitorum superficialis (FDS) muscles. The most common extensor tendon rupture involves the little finger, with rupture of the EDQ and/or the EDC to the fifth finger. This injury may be treated by simple side-to-side transfer into the intact fourth EDC tendon. In the presence of multiple tendon ruptures, recon- struction becomes more complex; fortunately, several tendon transfers are available (Table 2) (Figure 4). Flexor Tendons and Carpal Tunnel Syndrome The nine tendons and median nerve that pass under the transverse carpal ligament also may be affected by RA. A swollen flexor tenosyn- ovium may be obscured by thick volar fascia and the transverse carpal ligament and therefore may not be as clinically apparent as dorsal wrist synovitis. 24 Because of the fixed space of the carpal tunnel, however, pa- tients may present with symptoms of carpal tunnel syndrome (CTS) or dif- ficulty with finger flexion. Full pas- sive finger flexion with compromised active flexion, crepitus, and trigger- ing are signs of flexor tendon prob- lems. CTS is common in patients with RA. The patient may present with the classic symptoms, including numbness and paresthesias in the median innervated fingers, with worsening at night causing waking. It is essential to assess the elbow, shoulder, and neck because of the possibility of nerve compression from more proximal locations. Also, the systemic nature of rheumatoid disease may affect peripheral nerves directly. Because of the possibility of other diagnoses, confirmatory nerve conduction velocity studies and electromyography are often helpful. Shinoda et al 25 recently reported im- provement in 28 of 29 hands operat- ed on for CTS in patients with RA. Patients with loss of active flexion at the MCP or interphalangeal joints may have flexor tenosynovitis or flexor tendon rupture. In a classic study, Mannerfelt and Norman 26 doc- umented tendon rupture in the rheu- matoid hand. Extensor tendon rup- ture was most common, seen in 41 of 66 patients (62%); however, flexor Figure 4 The extensor indicis proprius (EIP) tendon is transferred to the ruptured extensor tendons of the ring and little fingers. The distal stump of the extensor EIP is sewn to the extensor digiti communis (EDC) tendon. EDQ = extensor digiti quinti. (Reproduced with permission from Ferlic D: Repair of ruptured finger extensors in rheumatoid arthritis, in Strickland JW [ed]: Master Techniques in Orthopaedic Surgery: The Hand. Philadelphia, PA: Lippincott-Raven, 19 98, p 417.) Table 2 Treatment Options for Extensor Tendon Transfers Ruptured Tendon Transfer Alternative EDM/EDC5 EDC5 side-to-side EDC4 — EDM/EDC5/EDC4 EDC4/5 side-to-side EDC3 EIP to EDC4/5 EDM/EDC5/EDC4/EDC3 EDC3 side-to-side EDC2 EIP to EDC4/5 FDS D4 to EDC4/D5 EDM/EDC2-5/EIP FDS D3 and D4 to EDC2-5 — D2, 3, 4, 5 = index, middle, ring, little fingers, respectively; EDC = extensor digitorum communis; EDM = extensor digiti minimi; EIP = extensor indicis proprius; FDS = flexor digitorum superficialis The Rheumatoid Wrist 70 Journal of the American Academy of Orthopaedic Surgeons tendon rupture also was common (25/66 [38%]). Of the flexor tendon ruptures, flexor pollicis longus (FPL) rupture was the most common (14/25 [56%]). In fact, 23 of 25 pa- tients had either FPL or index flexor digitorum profundus (FDP) tendon rupture. The authors attributed these ruptures to a combination of infiltra- tive rheumatoid disease with soften- ing of the tendons and attrition re- sulting from bony prominences. The Mannerfelt lesion occurs when the distal pole of the scaphoid and trapezium pierce the volar wrist capsule, causing FPL tendon rup- ture. 26 Ertel et al 27 described a simi- lar pattern of distinct ulnarward pro- gression of tendon ruptures, first at the FPL, followed by the index FDP and then the index FDS or middle FDP. This is in contrast to the ulnar- to-radial direction of extensor tendon ruptures on the dorsum of the wrist. Many cases of CTS or flexor teno- synovitis are minimally symptomat- ic, and function may not be compro- mised. Even rupture of the FPL or index FDP may go unnoticed by the patient (Figure 5, A). FDS ruptures are commonly missed on clinical ex- amination in the presence of intact FDP function. Even with minimal symptoms, surgery should be con- sidered to help prevent further loss of function. Patients with overt car- pal tunnel symptoms and weakness of grip and pinch usually benefit from surgery. Generally, we perform open car- pal tunnel release and flexor teno- synovectomy (Figure 5, B). Endo- scopic carpal tunnel release has been successful in the rheumatoid pa- tient; 28 however, it is offered only to patients with no sign of tenosynovi- tis. During open surgery, the flexor tendons are examined for attrition or rupture. When the FDP tendons re- main scarred together but intact, it is probably best to leave the mass alone. The floor of the carpal tunnel is explored. When there is a defect in the volar capsule with prominent bony spicules (most commonly scaphoid tubercle), then a bony dé- bridement is done. Volar capsular ro- tation flap to provide soft-tissue cov- erage of resected bony areas is illustrated in Figure 6. In patients with severe palmar subluxation of the carpus, partial or total wrist fu- sion should be considered to prevent further tendon damage. FPL tendon rupture may be man- aged in several ways. Primary tendon repair is rarely possible. Because rup- ture commonly occurs within the car- pal tunnel and not in the fibro- osseous canal, a short tendon graft using the palmaris longus may be pos- sible. The results of grafting are de- pendent on supple joints and a com- pliant, functional musculotendinous unit. Tendon transfer using FDS ten- don from the ring finger is an option if preserving thumb motion is impor- tant, such as in a young, active pa- tient with well-controlled disease. Thumb interphalangeal fusion is the simplest and most reliable solution. In patients with rupture of the FDP to the index finger, distal interpha- langeal joint fusion or side-to-side FDP transfer are reasonable options. With rupture of both the FDP and the FDS to the index finger, tendon trans- fer using the FDS of the middle or ring finger may be perfor med. For any other flexor-sided tendon rupture, op- tions include fusion, side-to-side re- pair, tendon transfer, and tendon grafting. Taking into consideration the patient’s compromised function and disease severity usually leads to Figure 5 A, Clinical examination demonstrating fullness in the carpal tunnel as well as functional loss of the flexor pollicis longus tendon of the thumb and of both the flexor digitorum superficialis and the flexor digitorum profundus to the index finger. B, Intraoperative photograph demonstrating the palmar aspect of the wrist with severe flexor tenosynovitis and multiple flexor tendon ruptures in a 60-year-old man with rheumatoid arthritis. Steven R. Papp, MD, MSc, FRCSC, et al Volume 14, Number 2, February 2006 71 considering the simplest solution first (Table 3). Distal Radioulnar Joint In rheumatoid disease, the DRUJ is often affected early. It is important to have a comprehensive under- standing of the anatomy of the area of the wrist involving the DRUJ, tri- angular fibrocartilage, and ulnar- sided ligaments. 29 Patients may present with a con- stellation of symptoms. In many cas- es, the disease first affects the stabi- lizing ligaments. A patient with a prominent ulnar head may present with minimal symptomatology. Ul- nar head prominence may present with mild to moderate synovitis of the extensor tendons or synovitis of the radiocarpal joint (Figure 7). In other patients, the instability alone or, more commonly, arthritic chang- es in the DRUJ, cause pain and crep- itus during forear m rotation. Pa- tients also may present with extensor tendon rupture. On examination, the so-called pi- ano key sign is present. With this test, downward pressure is applied to the dislocated ulnar head, which temporarily relocates, only to redis- locate dorsally when pressure is removed. ROM in the flexion/ extension and supination/pronation arcs should be noted. Proximally, an arthritic radioulnar joint may be a source of limited rotation; therefore, the elbow should be examined. Plain radiographs are necessary, including anteroposterior and later- al views with the forearm in neutral position. Although rarely required, computed tomography may be the most accurate technique for detect- ing subtle DRUJ subluxation. 30 Ear- ly findings may include soft-tissue swelling, diffuse osteopenia, and marginal erosion in the area of the ulnar styloid. Later, more obvious arthritic changes and dislocations may present. To plan the surgical procedure, radiographs should be studied for radioulnar joint sublux- ation, ulnar variance, bone loss, and Figure 6 A, Carpal tunnel release and capsular exposure. B, The scaphoid tubercle may pierce the volar capsule, leading to FPL attrition. C, Primary closure of the volar capsule may be possible after scaphoid débridement. D, When direct closure is not possible, volar capsule rotation may be performed. Dashed line indicates the planned volar capsule rotation flap. E, Complete volar capsular rotation flap. C = capitate, FCR = flexor carpi radialis, FDP = flexor digitorum profundus, FDS = flexor digitorum superficialis, FPL = flexor pollicis longus, L = lunate, S = scaphoid, T = trapezium. (Reproduced with permission from Feldon et al: Rheumatoid arthritis and other connective tissue diseases, in Green DP, Hotchkiss RN, Pederson WC [eds]: Green’s Operative Hand Surgery. Philadelphia, PA: Churchill Livingstone, 1999, vol 2, p 1669.) Table 3 Treatment Options for Flexor Tendon Rupture Ruptured Tendon Treatment Alternative FPL IP fusion or PL graft FDS to FPL FDP D2 DIP fusion Side-to-side repair, FDS D4 to FDP FDS + FDP D2 FDS D3/4 to FDP PIP/DIP fusion D2, 3, 4 = index, long, ring fingers, respectively; DIP = distal interphalangeal; FDP = flexor digitorum profundus; FDS = flexor digitorum superficialis; FPL = flexor pollicis longus; IP = interphalangeal; PIP = proximal interphalangeal; PL = palmaris longus The Rheumatoid Wrist 72 Journal of the American Academy of Orthopaedic Surgeons ulnocarpal translation and carpal su- pination deformity. In the rare situation of persistent DRUJ synovitis with no evidence of arthritis or instability, synovectomy may be considered. Because the DRUJ is so often involved early in the disease course, more definitive distal ulnar procedures may eventu- ally be required. Although good out- comes have been reported with liga- mentous reconstruction in the posttraumatic group, 31 the natural history of ligamentous laxity in pa- tients with RA has led most sur- geons away from using these types of procedures. More commonly, bony procedures, such as the Darrach or Sauvé-Kapandji procedure, are per- formed. Distal Ulna Resection: The Darrach Procedure Although the Darrach procedure has a long, favorable clinical history, it also has the most described com- plications. 32,33 Nevertheless, when done correctly, this procedure re- mains a reliable surgical option for most patients with RA. The Darrach procedure may be performed through the same skin in- cision as that used for an extensor tenosynovectomy or wrist fusion. The ulnar head is resected just prox- imal to the point of contact between its articular surface and the sigmoid fossa of the distal radius. The radial side of the distal ulnar stump may be rounded to minimize impingement as well as to increase the surface area of any potential contact between the radius and ulna (Figure 8). A distally based flap of volar capsule is sewn to the dorsal ulnar stump to control distal ulnar instability. The ECU tendon is relocated back to its dorsal position using a radially based flap of extensor retinaculum. Currently , we favor the Darrach procedure as a re- liable treatment option in older or less active RA patients, or in pa- tients with severe erosion of the dis- tal ulnar head. 34 Failure after the Darrach proce- dure commonly occurs as the result of recurrent instability or pain caused by radioulnar impingement. In fact, dynamic convergence is common but not always symptom- atic. 35 These complications may be minimized with good surgical tech- nique to preserve and repair soft- tissue constraints. 36 Some authors advocate an ECU tenodesis as an im- portant part of the initial procedure to minimize the risk of instability. 37 Occasionally, an unstable or painful distal ulnar stump after the Darrach procedure requires revision. Several revision procedures have been de- scribed, including a combined ECU and flexor carpi ulnaris tenode- sis 38,39 and pronator quadratus inter- position. 40 Distal ulnar prosthetic replace- ments, such as the uHead prosthesis (SBI, New York, NY), are another op- tion. There are concerns related to the ability of the prosthesis to offer long-term stability, considering the poor soft-tissue envelope. To help stabilize the ulnar head, this pros- thesis has an area for reattachment of the ECU subsheath and triangular fibrocartilage. Scheker et al 41 de- signed a semiconstrained total DRUJ prosthesis to address persistent in- stability. The long-term durability of these prostheses under physiologic Figure 7 A, Clinical photograph of a patient with rheumatoid arthritis of the right hand who presented with a painful and clinically dislocated distal radioulnar joint. B, Lateral radiograph confirming the dislocated distal radioulnar joint. Figure 8 Same patient as in Figure 7. Anteroposterior radiograph after the Darrach procedure was performed. The slope of the distal ulnar resection is parallel to the slope of the distal radius to minimize impingement symptoms. Steven R. Papp, MD, MSc, FRCSC, et al Volume 14, Number 2, February 2006 73 load is unproved. Nonetheless, early results are very promising, 41 and res- toration of the normal anatomy may better restore function on a long- term basis. Sauvé-Kapandji Fusion The Sauvé-Kapandji procedure of- fers another treatment alternative for DRUJ disease in the rheumatoid wrist. Some authors have noted fur- ther destabilization of the carpus with the Darrach procedure, leading to ulnar translation. 42,43 The Sauvé- Kapandji procedure offers the advan- tage of preserving the ulnar support structures of the wrist via retention of the ulnar head and fusion of the DRUJ. Resection of 10 to 15 mm of the distal ulna is planned just prox- imal to the DRUJ, and the perios- teum is removed to diminish chanc- es of regrowth. The DRUJ is entered, and the remaining cartilage from both the ulna and radius is denuded. The distal ulnar stump is translated slightly proximally to prevent any ulnocarpal abutment and to reten- sion the ulnocarpal ligaments. The distal fragment is then temporarily pinned. Proper positioning is con- firmed with fluoroscopy. Kirschner wire (K-wire) fixation is acceptable; however, we prefer to exchange the K-wires for one or two small- diameter interfragmentary screws. Once stabilized, gentle forearm rotation should demonstrate move- ment through the resection site with no impingement. The remaining lo- cal soft tissues, including the prona- tor quadratus, may be sewn into the resection gap. Four weeks of long arm casting in the neutral position is followed by a physiotherapy proto- col supervised by a hand therapist. Vincent et al 44 reported excellent pain relief in 17 rheumatoid patients using this technique and favor it be- cause of their “dissatisfaction with clinical results of the Darrach proce- dure.” W e currently favor this proce- dure in most active patients with RA and have found it to be reliable, with a low complication rate. Distal ulnar stump instability, impingement, and extensor tendon rupture may occur after this procedure, but they are not as commonly reported as they are with the Darrach procedure. 45 Partial Wrist Fusion Radiolunate and radioscapholu- nate ar throdesis offer consistent pain relief, wrist stabilization, and preservation of some wrist mo- tion. 46,47 Indications for limited ra- diocarpal fusion include advanced radiocarpal arthritis and radiocarpal instability with sparing of the mid- carpal joint. The standard dorsal approach to the wrist is performed. If necessary, an extensor retinacular flap is raised and the extensor tendons are débrided. The radiocarpal and mid- carpal joints are explored and corre- lated with preoperative expectations. Wrist joint synovectomy is per- formed. The radiolunate joint is de- nuded of any remaining cartilage, and the lunate is positioned against the lunate fossa of the distal radius for fu- sion. Bone graft (most commonly dis- tal radius or the resected distal ulna bone) may be used to improve con- solidation. When the radioscaphoid joint is severely affected, a radio- scapholunate fusion may be pre- ferred, whereby the lunate is gently reduced and held in a neutral posi- tion for fusion, correcting any carpal malalignment and ulnocarpal trans- lation. If the lunate is left in exces- sive extension, wrist flexion may be limited. Importantly, complete resto- ration of carpal height and carpal translation in patients with long- standing fixed defor mity may be harmful, causing midcarpal sublux- ation or rotation and precipitating ac- celerated secondary arthrosis. 48 Fu- sion rates are high, and fixation may be accomplished using K-wires, sta- ples, screws, or mini-condylar plates. In the presence of mild to moder- ate arthritic changes in the midcar- pal joint, partial wrist fusion com- bined with wrist denervation still seems to offer reliable pain relief. Al- though the midcarpal joint may en- counter more stresses following a partial wrist fusion, there is little ev- idence of rapid deterioration com- pared with nonoperated wrists. 47 Total Wrist Fusion Versus Arthroplasty For the patient with advanced ar- thritic changes, either wrist fusion or arthroplasty may be considered (Figure 9). Long-term studies on wrist fusion have reported it to be safe and reliable. 49,50 Techniques for total wrist fusion include intramed- ullary rods or plates. 51 The AO (Syn- thes, Paoli, PA) low-profile wrist fu- sion plate has become a popular choice for this procedure. Its design allows the wrist to be fused in ap- proximately 10° of extension with a low-profile contour over the third metacarpal. In a recent study on to- tal wrist fusion using this plate, Meads et al 52 reported excellent rates of fusion and low rates of soft-tissue complication, with only a 15% rate of hardware removal. Although ex- cellent rates of fusion with in- tramedullary fixation have been re- ported, 53 the plate technique allows for more rigid fixation and earlier mobilization, which are crucial in patients with RA. Compared with intramedullary fixation, plate fixa- tion offers more reliable mainte- nance of wrist position. 51 Although wrist arthrodesis offers reasonable functional results and is an excellent treatment option for pa- tients with RA, patients report diffi- culties with certain activities of dai- ly living, such as opening a jar, writing, and personal hygiene. These problems may be magnified in pa- tients with shoulder, elbow, finger, and bilateral wrist involvement. Ul- timately, wrist fusion remains a reli- able treatment option at the expense of motion. Wrist arthroplasty offers improvement in pain and deformity, with the advantage of preserved or improved motion. Vicar and Bur- ton 54 reported on patients treated with wrist arthrodesis on one side The Rheumatoid Wrist 74 Journal of the American Academy of Orthopaedic Surgeons