Background: Total wrist arthrodesis is a reliable procedure for severely deteriorated and unstable rheumatoid wrist. In 1999, we developed a new wrist fusion rod (WFR), a cannulated titanium rod could be buried into the third metacarpal with proximal fins and a transverse pin to prevent the rod migration and rotation in the medullary canal. After bone preparation, the 4 mm diameter rod was inserted through a guide pin in ante-grade fashion from the carpus to the neck of the third metacarpal to prevent metacarpal fracture. Then the rod was inserted in retrograde fashion into the radius with an introducer, and countersunk until the distal end of the reached the metacarpal isthmus. After burying the rod, it was bent to the desired angle using a special bender.

Materials and Methods: Total wrist arthrodesis was performed using this rod on 39 wrists in 33 patients with rheumatoid arthritis (6 males and 27 females). Their radiographic change was Larsen grade IV or V with subluxation at the radiocarpal joint. The mean age at the operation was 60 yrs. old (28 to 75), and the mean duration of the disease was 12 yrs. (3 to 40). The mean follow-up period was 39 mos. (5 to 75). Supplemental fixation with staples was incorporated in this intramedullary fixation. Iliac bone was grafted on 8 mutilated wrists in 8 patients. Postoperative immobilization using a short arm cast or a wrist brace was continued for 8 weeks.

Results: Preoperative pain and swelling disappeared in all operated wrists, and grip strength increased in 31 wrists (79%). The mean preoperative grip strength increased from 97 mmHg to 124 mmHg postoperatively. Subluxated wrist was reduced and fused in slight extension and slight ulnar deviation. The rod did not migrate distally or proximally in the medullary canal. Bony fusion was obtained in 36 wrists (92%). Four rods (10%) were broken due to an overuse or a fall before completion of fusion; however, they did not cause any pain. There were no major complications.

Conclusion: Using this WFR, rigid fixation at the desired angle was obtained in the total wrist arthrodesis on rheumatoid wrist. It is technically simple, safe and fast to use.

Objective: The objective of this study was to clarify the clinical outcome of upper-extremity surgeries for the rheumatoid patients using the Japanese version of the DASH Disabilities of the Arm, Shoulder and Hand questionnaire and to investigate whether the outcome was affected by the activity of the disease.

Materials and methods: One hundred and twenty seven surgical procedures in 103 rheumatoid patients (male: 26, female: 77) were included in this study. Surgeries were performed in 4 shoulders (HHR: 4), 35 elbows (TEA: 28, synovectomy: 6 etc.), 60 wrists (Kapandji: 6, radiolunate arthrodesis: 28, total arthrodesis: 7, extensor tendon reconstruction: 19 etc), and 28 hands (MP Swanson: 13, PIP fusion: 7, thumb IP fusion: 4 etc.). The patients’ average age at the surgery was 61 years and an average duration of the disease was 11 years. The DASH (function/symptoms) score and DAS (Disease Activity Score) 28-CRP(4) were taken just before the surgery and an average of 1 year and 3 months after the surgery. According to the EULAR’s improvement criteria, disease activity and response to the medical treatment was determined.

Results: The preoperative DASH score decreased in 96 surgical procedures (76%) postoperatively and the average score decreased from 50 to 38 (n=127, p< 0.01). Change in the score was −17 in shoulder surgeries (n=4, p=0.17), −12 in elbow surgeries (n=35, p< 0.01), −12 in wrist surgeries (n=60, p< 0.01) and −10 in hand surgeries (n=28, p< 0.05). The DASH score in the patients with preoperative HDA (high disease activity: n=16, from 70 to 57, p< 0.01) remained high compared to those with preoperative LDA (low disease activity: n=23, from 45 to 32, p< 0.01) and MDA (moderate disease activity: n=88, from 47 to 36, p< 0.01). Decrease in the score was more prominent in the patients with good response to the medical treatment (n=34, −22, p< 0.01) than those with moderate response (n=38, −11, p< 0.01) or no response (n=55, −6, p< 0.05). There was no significant decrease in the postoperative score in the patients with increased DAS28-CRP (4) (n=26, −1, p=0.822).

Conclusions: The clinical outcome of upper-extremity surgeries for the rheumatoid patients was good. Control of the disease activity by the medical treatment proved to be one of the important factors to produce a favourable outcome of surgical treatment.