Lee Ramsay Straub

The Wrist in Rheumatoid Arthritis: Surgical Treatment And Results

This report deals with our experience with 160 wrists operated on since 1956 for changes produced by rheumatoid arthritis. One hundred and eighteen operations were done on the dorsum of the wrist and forty-two on the volar aspect. The operations included arthrodesis, dorsal wrist stabilization, dorsal tenosynovectomy with or without tendon repair, resection of the distal end of the ulna (Darrach operation), volar tenosynovectomy combined with tendon repair and release of the median nerve, and volar wrist synovectomy. The techniques changed with increasing experience. Synovectomy is a primary objective in any operation on a rheumatoid joint or tendon sheath. Wrist fusion is indicated for a flail wrist with marked destructive changes in the bones of the wrist and severe flexion deformity. Of the eighteen wrists fused, seventeen became solid. Wrist stabilization is being performed more often now. It is indicated for painful synovitis with or without destructive changes in the bones, volar subluxation with a weak grasp, and bilateral painful synovitis with an arc of wrist motion from 30 to 60 degrees of flexion and extension. Wrist stabilization was performed on thirty-seven wrists which were followed for an average of 2.6 years. Sixteen fused spontaneously and twenty-one had loss of wrist motion amounting to from a few degrees to 65 degrees. The average arc of motion lost postoperatively was 32 degrees. Thirty-one wrists were improved functionally and symptomatically. The remaining six wrists were still symptomatic occasionally and their ability to perform activities of daily life was not improved. Tenosynovectomy with or without a Darrach procedure was performed on fifty-six wrists. The indications were painful tenosynovitis, painful inferior radioulnar joint, and tendon rupture. Of fifty-six wrists, forty-eight showed improvement in function and were stable. Eight wrists remained symptomatic and had a recurrence of synovitis. Three of these were reoperated on. The synovitis had not recurred at the site of previous synovectomy. Forty-seven tendons were ruptured in thirty-seven wrists. The most common tendon involved was the extensor digiti minimi and extensor digitorum communis to the little and ring fingers (twenty-two). The next common tendon was the extensor pollicis longus (thirteen). When the tendons were partially involved end-to-side anastomosis was performed. This gave better results than those after tendon transfer for complete rupture of the extensor digitorum. Volar synovectomy was performed for carpal-tunnel syndrome and loss of tendon function. After thirty-four of forty-two volar tenosynovectomies there was improvement in function and complete relief of pain. The remaining eight wrists remained symptomatic. Four of the thirty-four asymptomatic wrists showed fullness over the palmar aspect at follow-up suggesting recurrence of synovitis. None of these has been re-explored. The various operative techniques for the procedures mentioned are described. An approach to the anterior aspect of the wrist joint is described for the first time.

The Surgery of Gout in the Upper Extremity

1. Despite the development of more effective uricosuric agents for the control of the manifestations of gout, there still remain patients who fail to respond to therapy and in whom crippling deformities develop.2. An analysis of twenty-one patients indicates that a carefully planned surgical program

Spontaneous rupture of extensor tendons in the hand associated with rheumatoid arthritis.

Spontaneous rupture of the extensor tendons of the hand has been found in five patients with long-standing rheumatoid arthritis and subluxation of the distal end of the ulna at the inferior radio-ulnar joint. Findings at operation in three of these patients indicated that the rupture was caused by degenerative changes in the floor of the extensortendon groove in the region of the distal end of the ulna. Satisfactory results were obtained by tendon repair combined with resection of the distal end of the ulna.

Synovectomy and débridement of the elbow in rheumatoid arthritis.

In 1963 a technique for complete synovectomy and appropriate debridement of the elbow joint through a transolecranon approach was developed. Twenty-eight synovectomies and debridements of the elbow joint were carried out in twenty-six patients with rheumatoid arthritis. The minimum follow-up was one

Congenital absence of the fibula.

A limb with an absent fibula is truly a limb dysplasia, with serious anomalies in the foot, the tibia, and the femur. Tibial bowing is not affected by weight-bearing and braces. It may regress spontaneously, but will not progress. Tibial osteotomies will unite. The treatment required must be specific for each patient. It is suggested, however, that amputation should be performed early whenever shortening of more than three inches is anticipated. Every effort should be made to perform a Syme type of amputation because the heel pad provides a durable stump which lengthens with growth.Framitz and O’Rahilly suggested that anatomical termmms be used fom’ all comigeimital defects to emisure uniform classificatiomi. Paraxial fibulam’ hemmiimiielia is time amiatomimical term for congenital absemice of the fibula ; terminal complete paraxial fihular hemninielia is absemmce of the fibula and correspondimig portiomi of the foot ; tem’immimial incomiiplete paraxial fihular hemnimmielia is a similar deformimity imm which part of the defective fibula is presemit ; imitei’calary complete paraxial fibular hemninielia is commiplete absemice of the fibula with a mmmore or less complete foot; amid immtem’calary imicomsiplete paraxial fibular hemnimsielia is a simnilar amionialy iii which a portioms of the fibula is present. The fibula is the mimost commmnmo)mmlycomsgemiitally absent lomig boric followed, in order of frequemicy, by the m’adius, feniur, tibia, ulmia, amid humerus . Specific causes of such defects ai’e umukumowmi. There is mio evidemice of a gemietic i)asis. It has been shosvmi expem’iimmemmtally , however, that metabolic or mechamiical disturbammces to) the emimhm’yo before limimb-bud foi’mmiatioim (between six amid eight weeks of hummian gestatiomi) cams cause such defects. In experimental amiimiials, such an(Inialics have beemm produced by radiatiomm, deficiemit diet, and irujectiomis of immsulimi at the am pm’opi’iate timsie .

Preliminary results of total wrist arthroplasty in rheumatoid arthritis using the trispherical total wrist arthroplasty

Thirty-two patients underwent 38 arthroplasties for advanced rheumatoid arthritis and marked soft tissue losses. Seven wrists required repair or transfer of at least one tendon for rebalancing. All patients were improved by the implants. Thirty-four of the 38 patients were improved beyond the functional level of a painless wrist arthrodesis. Overall, there were 23 excellent, 10 good, 3 fair, and 2 poor results. The average wrist score was 90.3 points, and the average arc of motion was 38 degrees. There were three cases of migration of the third metacarpal stem and nine cases of lucency about the stems, three of which were progressive or greater than 1 mm. There were no deep infections. There was one reoperation for persistent pain and one for component loosening. There were no cases of implant failure. These results indicate that this total wrist arthroplasty is a safe, reproducible procedure for radiographic class III and IV rheumatoid disease and should be considered a first line of therapy for that group.

Arthrography in the rheumatoid wrist joint. A preliminary report.

Arthrograms were performed on patients with rheumatoid arthritis of the wrist. Fifty cadavera and seven normal patients served as controls. Sixty arthrograms on thirty-eight patients with rheumatoid arthritis were studied. The abnormalities demonstrated consisted of corrugated pattern of the synovial cavity (90 per cent), communication between radiocarpal and inferior radio-ulnar joint (70 per cent), between radiocarpal and mid-carpal joints (70 per cent), and between the wrist joint and the extensor tendon sheaths (21 per cent). One abnormality was suggestive of a diagnosis of rheumatoid arthritis and more than one was considered characteristic of the disease in the wrist joint. The abnormalities were present even before plain roentgenograms showed erosive changes. The findings in the fifteen wrists operated on correlated well with the plain roentgenographic and arthrographic findings. The interosseous ligaments and articular discs were often destroyed as early on six months after the onset of disease. The soft-tissue involvement is an important cause of volar dislocation of the wrist and dorsal subluxation of ulna and tendon rupture. The knowledge gained by arthrography has contributed evidence for early synovectomy of the wrist joint in rheumatoid arthritis.

Long-term results of dorsal stabilization in the rheumatoid wrist

Dorsal stabilization was performed on 85 rheumatoid wrists in 62 patients for an average follow-up of 6.8 years. Of these, 37 wrists were followed an average of 10 years. The chief component was pain in 79 of the wrists. Pain, on a scale of 0 to 100, showed a preoperative score of 32 and postoperative ratings of 89 for the total group and 96 for the long-term group. Range of motion decreased in virtually all patients. Spontaneous ankylosis occurred in eight wrists. Because of the presence of associated deformities, usually subluxated metacarpophalangeal joints, evaluation of functional improvement of the wrist was difficult. Those hands in which metacarpophalangeal subluxations were corrected or prevented showed maximum functional improvements. The procedure is beneficial for long-term relief of pain and maintenance of a range of motion which arthrodesis would eliminate.

A critical analysis of alignment factors influencing functional results following trispherical total wrist arthroplasty

In a study of the impact of selected patient factors and alignment variables on functional results of total wrist arthroplasty, functional score and range of motion were found to be improved and incidence of component shift and progressive radiolucent lines decreased by proper positioning of the implant center of rotation and restoration of carpal height. Angulation of the implant stems was secondary in importance to the other positioning variables with respect to overall function and durability. A neutral alignment range for this implant arthroplasty was proposed. Within this neutral range, functional score averaged 94 points and range of motion averaged 68 degrees. There were no reoperations, component shifting, or progressive radiolucent lines, and all wrists rated an excellent score.

Extra-Abdominal Desmoid of the Hand

A twenty-eight-year-old Negro woman was seen with a painful, tender mass over the proximal border of the hypothenar muscles in the right hand. Both the mass and the tenderness had been present for two years without any antecedent history of trauma or infection. Up until six weeks before admission, neither the size of the mass nor the tenderness had shown any change. At that time, however, the patient began to feel “pins and needles” in both the ring and little fingers, which would frequently waken her at night; but she did not notice any sensory changes. She also became aware of the fact that the mass had grown in size. Examination of the right hand revealed a firm, slightly tender mass about two centimeters in