Treatment of Wrist Deformity Caused by Advanced Rheumatoid ArthritisRheumatoid arthritis is one of the many diseases that fall under the umbrella of arthritis. It is one of the most outwardly obvious arthritis types because of the way it can deform the joints, often the fingers and wrists. Rheumatoid arthritis is an inflammatory disease in which the joints become inflamed and swollen, and quite painful. Eventually, as the inflammation gets worse and the shape of the joint is changed, patients can find it more and more difficult to use the joint.
Although rheumatoid arthritis is associated with aging, anyone can get it at any age. The author of this article discussed the case of a 38-year-old woman who had had rheumatoid arthritis for 10 years. Her treatments over the years included strong medications called methotrexate and others in the anti-TNF agent groups. She has had both knees replaced. At this point, the patient was not having any signs of arthritis in the shoulders or elbows, but her wrists were affected severely. On a scale of zero to 10, with zero being no pain and no difficulty moving or using the wrist and 10 being the worst possible pain and inability to use the wrist, the patient scored her right wrist (her dominant hand) as a nine and the left as a six.
The question the author posed about this case was what type of surgery would be best for this patient. According to current opinion, the best procedure would be an arthrodesis, or the fusing of bones in the wrist. This would allow for realigning the wrists and making them more stable. At the same time, the surgery would fix the breakdown of the joints.
Total wrist arthrodesis is a common surgery and doctors feel that it is a reliable form of treatment if the wrist is severely destroyed from rheumatoid arthritis. One disadvantage to the surgery is by fusing the bones, the wrist becomes less flexible, but the benefit of pain relief and stability proves to be more desirable. In cases such as with this patient, who needs both wrists corrected (bilateral) as opposed to just one (unilateral), there is discussion about the best way to fuse the bones together. One recently published article says that with bilateral repair, one wrist should be fused slightly bent in towards the body and the other slightly outward, toward the shoulder.
Bilateral repair itself brings about discussion: should it be done at all? The general feeling is that while it is beneficial for the patient to undergo general anesthetic only once and have bilateral repair, being unable to use both hands poses problems attending to activities of daily living, such as personal hygiene.
Another option for surgery is the wrist replacement, or arthroplasty. In the past, many wrist replacements have failed. Either the wrists aren't balanced properly, they become dislocated, or the implant fails, but these are with the older types of implants. The newer implants have a higher success rate. Advantages of the replacement include studies that show patients who had the replacement were more able to perform personal hygiene tasks than patients who had the arthodesis and they had range of motion that wasn't available after arthrodesis. There have been patients who had both wrists done, but one with the arthrodesis and one with the replacement. In following up with the patients, researchers found that the patients were most satisfied with the wrist with the replacement. That being said, the disadvantage of the replacement is the risk of the implant breaking or failing.
The author wrote that there is not enough evidence to support either surgery being better than the others. The studies that have been done are small and subjective. Currently, the gold standard, or the treatment most widely used and supported, for rheumatoid arthritis of the wrist is arthrodesis. However, as the replacements become more advanced and new designs are developed, replacements may become more common because of their advantages when they function correctly.
Guillaume Herzberg, MD, PhD. Management of Bilateral Advanced Rheumatoid Wrist Destruction. In Journal of Hand Surgery. September 2008. Vol./ 33A. No. 7.
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