S44 SURGICAL STABILISATION OF PAINFUL AND UNSTABLE WRIST IN R.A.

Abstract

According to authors investigating problems with the hand in rheumatoid arthritis (RA), up to 95 % of patients suffer due to wrist involvement after 8–12 years from the onset of the disease. In a high activity and a progressive pattern of RA, wrist damage occurs earlier. The question is what to do when pain and instability are dominant factors and at the same time the x-rays show only a mild or moderate degree of destruction of the joint. Trying to find an alternative procedure to a more radical surgery, in 1995 I started surgical stabilization using a pedicled flap of the joint capsule and the extensor retinaculum.

Material and methods: 44 wrists in 36 patients were treated with this method. The patients were 34 women and 2 men at the ages from 24 to 73 (49 on average). The follow-up was from 2 to 9 years (average > 6). The operation was done through a dorsal approach. After synovectomy of the wrist, the capsular pedicled flap was prepared, in a case of subluxation, the carpal bones were repositioned and two mattress strong stitches were put on through the capsule flap and proximal and distal row of carpal bones. The joint was closed with single stitches. Depending on the pathology, hemi- or total- resection of the ulnar head was combined with the procedure. In some cases, a repair of the ruptured extensor tendons was necessary. Immobilisation in the palmar splint for 6 weeks was recommended, and then a rehabilitation program started.

Results: 25 wrists (63 %) at the latest follow-up were free from pain and stable, 8 (20 %) were stable but mildly and occasionally painful, 4 were moderately painful, and 3 needed arthrodesis because of the marked bone destruction and pain. The power of the combined grip was significantly improved in 31 wrists (77 %); moderate improvement was in 6 cases (15%).

Conclusion: Stabilisation of the painful and unstable wrist with the use of the method described above gives good results and seems to be a valuable procedure even in selected cases qualified as arthrodesis.