Wrist Arthritis Treatment & Management
- Author: Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth); Chief Editor: Harris Gellman, MD more...
Surgery is indicated for wrist arthritis when disabling pain emerges despite nonoperative treatment. Because the wrist is the stabilizer for effective functioning of the hand, the loss of function in the hand is also an indication for intervention.
In its early stages, synovitis must be actively treated with medical means. If there is no response to medical therapy, synovitis should be treated surgically to prevent tendon ruptures.
Deformity may be an indication for surgical intervention in selected patients, because a motion-preserving procedure may be possible when performed early. If the deformity is neglected until it becomes advanced, fusion may be the only possible treatment.[3, 13, 14]
Local destruction and biomechanical impairment should be monitored closely so that surgical opportunities are not missed. In RA patients who have upper limb involvement, surgical timing is critical because procedures for treating wrist arthritis are usually successful in these patients and can influence the management of other joints of the hand and upper limb.
Infection at the wrist is an absolute contraindication for wrist arthroplasty. Surgery may also be contraindicated in patients with poor medical status.
Splinting and Pain Relief
Nonoperative measures for wrist arthritis are primarily aimed at relieving pain. Rest in the form of splinting with removable thermoplastic splints may be useful during exacerbations, with the wrist maintained in neutral or slight dorsiflexion, its functional position. Overuse of splinting may cause wrist stiffness and weakness.
Nonsteroidal anti-inflammatory drugs are useful in controlling inflammation, thereby reducing synovitis and swelling. They are most useful in inflammatory arthritis. Antirheumatism medications with systemic steroids, methotrexate, and anti–TNF are useful in patients with RA. Allopurinol may be useful in patients with gouty arthritis of the wrist.
Steroid injections into the joint with or without local anesthetic may be performed, but results are equivocal. Methylprednisolone acetate injection into the wrist may play a role in treating degenerated triangular fibrocartilage. When combined with local anesthetic, local steroid injections may also aid in diagnosis; however, the effect is transient, and repeated injections may be needed.
Early and Late-Stage Surgical Options
The choice of surgery for wrist arthritis depends on the severity and the extent of arthritis in the wrist. In the earliest stages, when the problems are mainly caused by carpal instability (prearthritic stage), the aim of the surgery is to rectify the anatomic position and to correct the carpal instability to prevent degeneration of the wrist.
In the late stages of severe wrist arthritis, either a partial or total wrist arthrodesis or an arthroplasty may be contemplated. In the intermediate stages, when the patient has well-established arthritis but a well-preserved range of motion, no proven standard treatment has been established. The available options are wrist arthroscopic debridement and wrist denervation.
The type of arthritis, the extent of its involvement, the functional requirement of the patient, and the realistic expectations of the proposed treatment should be considered before treatment is undertaken.
Surgical options include the following:
Arthroscopic wrist procedures
Arthroscopic Wrist Procedures
Arthroscopic wrist procedures are most useful as diagnostic tools, but they are occasionally used as therapeutic procedures. An arthroscopic wrist procedure is done to examine the joint articular surfaces, and it is useful for synovial biopsy, removal of loose bodies, and wrist debridement in patients with early arthritis. Arthroscopy is most accurate for diagnosing degenerate triangular fibrocartilage lesions.[15, 16]
Arthroscopic synovectomy has recently become a well-described procedure. Aggressive arthroscopic debridement, including radial styloidectomy and partial resection of the scaphoid, has been reported. Resection of the lunate in patients with Kienböck disease may also be performed arthroscopically.
In the distal radioulnar joint, arthroscopy can be used for debridement of the triangular fibrocartilage complex and for a modified Darrach procedure that involves distal ulna resection (see images below). Arthroscopic reconstructive procedures have been described for repair of the lunate-triquetrum ligament and ulnocarpal ligament complex, as well as for capsular placation.
The wrist-denervation procedure has been adopted in neuropathic patients with wrist arthritis because these patients do not have wrist pain. Wrist denervation can be performed by means of simple division of the posterior and anterior interosseous nerves near the wrist joint through a single dorsal incision (see image below). However, some authors question this approach because several nerves innervate the wrist; instead, these authors advocate multiple small incisions to address all the contributory nerves.
In various series, results worsened after wrist denervation in patients with progressive carpal instability. Hence, in general, this procedure is indicated only in patients with chronic localized wrist pain without evidence of progressive carpal instability or collapse.
The results are reasonably good for the single dorsal incision for wrist denervation, in which both the posterior and the anterior interosseous neurectomy are performed. Although wrist denervation does not improve the underlying wrist arthritis, even pancarpal neurectomy with multiple incisions does not preclude further surgery to the wrist.
Synovectomy may be especially useful in patients with RA when the synovitis is only moderate and bony changes are absent; however, medical treatment is the first choice to control acute synovitis. Dorsal synovectomy is indicated to avoid tendon ruptures when the synovitis persists for more than 6 weeks despite medical treatment.
Distal ulnar resection is performed by fusing the head of the ulna to the sigmoid notch of the distal radius with a cancellous screw, resulting in distal radioulnar joint fusion. This is called the Sauve-Kapandji procedure (see image below).
Ulnar-head resection is commonly performed in RA because the distal radioulnar joint is more often involved in RA than in OA of the wrist. The wrist tends to deviate and subluxate toward the ulna, resulting in ulnar-head prominence and impingement, which produces significant symptoms in RA but not in OA.
Fusion of the wrist, either limited or total, plays an important role in the surgical treatment of wrist arthritis. Limited fusion consists of fusion of only part of the carpal bones involved by arthritis; this procedure has the advantage of preserving motion in the remaining part of the carpus that is not affected by arthritis.
The principles of arthrodesis of the wrist include the following:
The articular surfaces should be denuded down to the bleeding subchondral bone
At least half of the joint surfaces being fused should be prepared
Rigid fixation devices to hold the fusion site permit early physiotherapy and rehabilitation
The carpal bones should be reduced to their original position before fusion; this is vital in limited arthrodesis
Bone grafting may be required
Triscaphe arthrodesis involves fusion of the scaphoid, trapezium, and trapezoid bones. The external bony relationship, however, should be preserved to prevent bony collapse or the development of arthritis in the neighboring joints. Triscaphe arthrodesis is indicated only when arthritis is confined to the scaphotrapeziotrapezoid joint. This type of fusion is contraindicated if significant degenerative changes are present in the radioscaphoid joint.
Patients with lunate-triquetrum joint arthritis usually have ulnar wrist pain. After lunate-triquetrum arthrodesis, mean ranges of motion are 77% palmar flexion, 80% dorsiflexion, 95% radial deviation, and 90% ulnar deviation, as compared with the normal, unaffected side.
Radioscaphoid arthrodesis is generally performed when degenerative changes from wrist arthritis involve the entire radiocarpal joint with sparing of the midcarpal joint, as happens after distal radius fractures. This fusion is accomplished with an autogenous bone graft with or without bone substitute added, and it requires rigid fixation.
After this fusion, 33% of normal wrist motion can be regained because of the preserved midcarpal joint. However, this percentage of regained normal wrist motion can be improved to 50-60% by excising the distal pole of the scaphoid during the procedure.
Four-corner fusion is based around the head of the capitate, involving the capitate, lunate, hamate, and triquetrum, and is used for scapholunate advanced collapse, also known as SLAC wrist. During the procedure, the lunate should be carefully reduced back into its anatomic position to regain 60% of normal motion in the wrist. The range of motion after 4-corner fusion depends on good articular surface congruity between the lunate and lunate fossa of the distal radius.
Scapholunocapitate fusion is indicated in patients with midcarpal arthritis but without radiocarpal arthritis. Care must be taken to reduce the scapholunate joint before fusion. Radial styloidectomy should be performed in conjunction with this procedure to prevent impingement. The range of normal wrist motion that can be expected after scapholunocapitate fusion is 33-50%.
Radiolunate fusion is indicated in isolated radiolunate arthritis that occurs after die-punch fractures of the distal radius. Capitolunate joint destruction is an absolute contraindication for this procedure, but bone grafting is essential in radiolunate fusion to elevate the lunate to prevent carpal collapse. Unlike undercorrection, overcorrection with lunate elevation is well tolerated because loss in carpal height results in a decrease in wrist motion and wrist instability. See images below.
Total wrist fusion
Total wrist fusion (TWF) is indicated in patients with pancarpal arthritis and is a successful option in patients with OA of the wrist from any cause (see images below). Although limited arthrodesis provides relatively unsatisfactory pain control, TWF is reliable for pain control. The disadvantage is loss of motion in any plane, which interferes with certain functions of the hand.
Wrist arthrodesis usually improves grip strength, and the hand can be used for most functions without difficulty. However, because the wrist is devoid of its motion, tasks such as working in restricted spaces and attending to personal hygiene may be especially difficult for patients. Despite these limitations, TWF remains the criterion standard treatment for wrist arthritis.
TWF is achieved by decorticating the distal end of the radius and the carpal bones, especially the scaphoid, lunate, capitate, and base of the second and the third metacarpals. In the past, bone grafts taken from either the distal radius or the iliac crest were used, with or without bone substitute to encourage fusion. However, with the use of modern arthrodesis plate systems, bone grafting is no longer required.
Ideally, the wrist is placed in 10-60° extension and slight ulnar deviation. This positioning permits effective functioning of the hand (mainly grip strength).
TWF has been a success in most patients who received an AO compression plate specially designed for it. This plate spans from the distal shaft of the radius across the carpus and lies over the second or third metacarpal. The plate is secured to the underlying bones with cortical and cancellous screws after the bed is prepared as discussed earlier.
It is important to destroy and decorticate the joints underlying the plate and to fill them with bone graft material to achieve fusion. In patients with poor bone stock, especially in those with RA, an intramedullary pin arthrodesis (see image below), such as a Stanley pin or an ordinary Steinmann pin, can be used to stabilize the TWF passing from the second or third metacarpal to the distal radius shaft through the carpal bones.
Total wrist arthroplasty
In patients with polyarthritis, as in RA, total wrist arthroplasty may be preferred over TWF, because the latter has the disadvantages of restricted motion that cause difficulty with personal hygiene and other tasks. In patients with RA, because other joints are involved with arthritis, even a decreased painless range of motion in the wrist may be helpful. The results after total wrist arthroplasty are improving as new implants are developed. See image below.
The proximal-row carpectomy procedure is indicated for severe radiocarpal arthritis, with complete sparing of the radiolunate joint and no degenerative changes over the head of the capitate. The radioscaphocapitate ligament prevents the ulnar translation of the capitate from the distal radial articular surface. Thus, it should be carefully protected when its attached scaphoid is removed during proximal-row carpectomy.
The head of the capitate does not have a surface congruent with the lunate fossa. However, after excision of the scaphoid, lunate, and triquetrum (proximal row), the results are generally satisfactory. Point-loading forces may be present, and secondary OA may develop in the neighboring joints at a later time.
Partial Ulnar Head Replacement
In isolated distal radioulnar joint arthritis, a pyrocarbon spacer has been developed to substitute the damaged articular cartilage of the ulnar head. The fibrotriangular cartilage and the extensor carpi ulnaris sheath are preserved during the procedure.
The aim of the prosthesis is to separate the 2 forearm bones throughout the range of supination and pronation, resulting in relief of pain from the distal radioulnar joint. Prosthetic replacement of the distal ulna restored stability to the DRUJ in patients with partial or complete excision of the ulnar head or DRUJ arthrosis and corrected radioulnar impingement.[21, 22]
This is a novel procedure for radiocarpal arthritis, during which previously partial fusion or proximal row carpectomy is performed. The prerequisite for this procedure is a well-preserved distal row in active patients with debilitating symptoms. The KinematX design is one such prosthesis that is an anatomic design prosthesis.
Because the function of the hand depends on regaining digital motion with postoperative physiotherapy and rehabilitation, all patients should receive adequate physical therapy as early as possible, depending on the type of surgical treatment they received.
Patients who undergo limited arthrodesis are immobilized in a below-elbow cast for 4 weeks and then begin physical therapy to regain as much wrist function as possible. Because TWF with plate and screw fixation provides a rigid and stable construct, postoperative plaster immobilization is seldom necessary. Patients can be protected with a removable splint during the initial few weeks, and physical therapy for the hand can be commenced immediately after surgery.
In properly selected patients with adequate bone stock, total wrist arthroplasty yields good results; physical therapy should be commenced immediately after surgery, beginning with gentle mobilization exercises and gradually progressing to resistance exercises in a few weeks.
The complications of wrist arthritis surgery are different for each type of surgery. However, in general, a fusion surgery can result in nonunion or fibrous union with pain at the wrist on movement. Wrist stiffness and decreased range of movement with pain at the wrist can complicate arthroplasty. The power in the hand grip may be reduced, especially after arthroplasty. Instability is also a known complication after wrist arthroplasty.
In general, wrist surgery can be complicated by infection, which may lead to implant removal and, in severe cases, may progress to amputation, though this is rare. Neurovascular injury, implant loosening, implant failure, and periprosthetic fractures are other complications.
Advanced implant designs and fixation in the bone for total wrist arthroplasty may become available to improve the durability and functional results in patients for whom surgery is strongly indicated but whose bone stock is poor.
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