Current Rheumatology Reviews - Volume 8, Issue 4, 2012

The most common surgical procedures described in the literature for rheumatoid arthritis of the wrist require a compromise between range of motion and stability. Total wrist arthrodeses, while providing pain control and stability, restrict range of motion. Implant arthroplasties, while granting range of motion, have not been proven to be durable. Fibrous non-union arthroplasties, on the other hand, can treat pain while preserving range of motion. This procedure should be considered a viable option for treating wrists with advanced destruction from rheumatoid arthritis.

The use of total wrist arthroplasty to treat end-stage arthritic wrists remains controversial because of a high rate of complications. The advent of new designs and smaller prostheses decreases complications and attitudes are gradually changing. The early results of a prospective study of one last generation total wrist arthroplasty in a series of 20 wrists with end-stage arthritic wrists (13 rheumatoid) in 19 patients are presented. There were no intra-operative complications nor reoperations or dislocations. The patients' pain scores improved from 7 preoperatively to 2 postoperatively. Wrist function improved and postoperative motion was very close to wrist functional motion. In the short term follow-up, the new generation total wrist arthroplasty seemed to provide better outcomes when compared with the old generation total wrist arthroplasty. Arthroplasty may be a viable option for the end-stage rheumatoid and osteoarthritic wrist. Longer follow- up is needed to evaluate the durability of the arthroplasty.

Wrist arthroscopy has steadily grown from a predominantly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. It cannot supplant a thorough wrist examination since it is not always possible to differentiate between a variety of asymptomatic degenerative findings and pathologic lesions but it does allow for a thorough assessment of the articular surfaces while providing a minimally invasive method for synovectomy and tissue biopsy. Although it has some applications in the treatment of inflammatory arthritides it has become a popular method for treating degenerative arthritis as well as post-traumatic arthritis involving the wrist.

The anatomy of the DRUJ predisposes it to the aggressive synovial destruction characteristic of RA. The DRUJ relies mainly on soft tissue structures for stability, therefore, the triangular fibrocartilage complex (including the TFC proper, volar and dorsal radioulnar ligaments, ulnocarpal ligaments, and subsheath of the extensor carpus ulnaris) plays a substantial role in stabilizing the DRUJ. Early diagnosis and medical treatment of rheumatoid arthritis of the DRUJ is essential to minimize the bony and soft tissue destruction that occurs as the disease severity worsens. Deformity and instability at both the radioulnar and ulnocarpal joints should be addressed if surgical management is required. Distal ulnar resection (Darrach's procedure) and DRUJ arthrodesis (Sauve-Kapandji procedure) have historically been performed to treat DRUJ arthritis, but newer interposition arthroplasty and endoprothesis techniques are currently being evaluated.

Scapholunate advanced collapse (SLAC) is a common pattern of wrist arthritis and provides a particular challenge for surgeons. This progressive pattern of degeneration has not been effectively stopped by any procedure or medication in literature at this time. Therefore, in patients with SLAC wrist, surgeons are forced to consider salvage procedures, such as four-corner arthrodesis and proximal row carpectomy. These procedures offer decreased pain at a cost of range of motion and grip strength. Our group has been utilizing a novel procedure for early SLAC combining joint resurfacing with dorsal wrist capsulodesis. Data for this surgical procedure is preliminary, with 11 procedures performed. While this procedure does relieve arthritis pain, it appears to have similar drawbacks to other salvage procedures.

Grade 3 and 4 Scapholunate Advanced Collapse (SLAC) wrist is considered the end stage of this particular pattern of arthritis. As with all arthritis the mainstay of conservative treatment consists of activity modification, splinting, nonsteroidal anti-inflammatory medications, and steroid injections. Indirect methods of treating the problem include nerve denervation and arthroscopic lavage. Direct methods of treating the arthritis include proximal row carpectomy (PRC) and scaphoid excision combined with four bone fusion (FBF) which are both motion preserving, pain relieving options, with the caveat that for PRC the capitate head needs to be fairly free of degeneration. However, Grade 3 SLAC wrist by definition includes capitate degeneration. Total wrist replacement is not popular in this post-traumatic setting due to questions of durability. The final option and salvage operation when all other treatments fail is wrist fusion.

Scaphotrapeziotrapezoid (STT) arthritis is frequently associated with other arthridites of the wrist. As an isolated clinical entity, it has unique features that should be considered when evaluating patients. This review describes the important anatomical considerations for the development of STT arthritis as well as the important factors when evaluating a patient suffering from this disease process. The surgical and nonsurgical options for the treatment of STT arthritis as well as their results are highlighted.

The five main etiologies of wrist osteoarthritis are: a) Scapholunate instability leading to Scapholunate advanced collapse (SLAC) b) Scaphoid nonunion leading to Scaphoid Nonunion Advanced Collapse (SNAC) c) Distal radius intra-articular malunion d) Kienbock stage IV e) Chondrocalcinosis. The two last diseases are not post-traumatic. We discuss the advancement of arthritis in different stages, and the possibilities of limited carpal arthrodesis to fuse the joints involved in arthritis, taking care to preserve the intact joints. This retains a certain amount of motion at the wrist. It is always better to avoid total wrist arthrodesis which is less and less performed, due to the good long-term results of limited carpal arthrodeses.

Recent research in the field of joint osteoarthritis (OA) indicates that osteoarthritis is in fact not a disease of joint cartilage. Rather, the cartilage wear seen in OA should be regarded as the end-stage of a disease that originates in the tissues supporting the joint. Therefore, it has been suggested that the joint should be viewed as a “synovial organ”, where any part of that organ, be it the cartilage, subchondral bone, synovium, ligament, nerve or periarticular muscle, may be involved in the development of joint OA. Proprioception and neuromuscular control of a joint are dependent on intact functions in ligaments, preserved joint innervation and adequate reflex control of periarticular muscles to stabilize the joint. One of the described potential contributors to joint OA is thus a failure of joint proprioception. The aim of this article is to review our current knowledge of proprioception and functional joint stability, how this relates to the development of OA in the hand and wrist, and how clinical interventions may protect against progressive OA following ligament injury.

Biomechanical studies have shown that surgical treatments for osteoarthritis and rheumatoid arthritis frequently decrease the amount of possible wrist motion, alter the load distribution between the radius and ulna and increase the contact pressure in the wrist joint. Both wrist motion and carpal bone motion are decreased with carpal bone arthrodesis and wrist ligament injury. Relative loading between the distal radius and ulna is altered by ulnar shortening. Carpal bone fusion alters the wrist joint contact pressure. Research continues to be needed to biomechanically examine the consequences of surgical treatments as well as to evaluate the long term clinical consequences of surgery.

It is estimated that rheumatoid arthritis affects 1.3 million adults in the United States. Ninety to ninety-five percent of those patients have wrist involvement. Surgical procedures for the rheumatoid wrist are briefly reviewed. Hand therapy treatment for the surgical and non-surgical patient is then discussed. Special attention is given to the importance of individualized treatment and evidence-based practice.

Systemic lupus erythematosus (SLE) is a complex multisystem autoimmune disease with a relapsing and remitting course, and neuropsychiatric complications of SLE (NPSLE) are associated with increased morbidity and mortality. In general, the diagnosis of NPSLE is difficult because no single laboratory marker or imaging modality serves as a gold standard, and the diagnosis is primarily clinical. However, recent studies have provided evidence that many cytokines and chemokines, as well as autoantibodies, may be involved in the neuropsychiatric manifestations of SLE. This is supported by the finding that several repertoires of cytokines/chemokines are detectable in the central nervous systems of NPSLE patients during active disease. In addition, we have recently shown elevated levels of the soluble form of CX3CL1, amembrane- bound CX3C chemokine, in the cerebrospinal fluid of patients with active NPSLE. This review will discuss the involvement of cytokines and chemokines in the pathogenesis of NPSLE and evaluate their significance as a useful laboratory parameter of active neuropsychiatric disease.

Multiple abnormalities in pain processing have been reported in patients with chronic musculoskeletal pain syndromes including fibromyalgia (FM). These changes include mechanical and thermal hyperalgesia, decreased thresholds to mechanical and thermal stimuli (allodynia) as well as central sensitization, all of which are fundamental to the generation of clinical pain. In addition to pain, self-reported symptoms like negative mood, non-refreshing sleep, and dyscognition, are common in FM. The pathogenesis of FM is only partially understood, but peripheral tissue changes and nervous system abnormalities have been implicated. These tissue abnormalities include decreased blood flow, increased levels of muscle metabolites, and degenerative joint changes. Indirect evidence from interventions that decrease tonic peripheral impulse input in patients with FM suggest that their overall pain and hyperalgesia is dependent on signaling from deep tissues. At least some of this peripheral impulse input seems to undergo abnormal pain processing in the central nervous system including increased pain facilitation as well as inadequate pain inhibition. Thus interventions that either decrease peripheral input and/or improve central pain processing abnormalities appear to be promising strategies for FM patients. The 1990 FM classification criteria were instrumental for research that greatly improved our current understanding of FM mechanisms. These criteria required widespread pain and mechanical hyperalgesia at ≥ 11 out of 18 body sites (tender points). In 2010 new FM criteria were introduced which only require self-reported somatic and cognitive symptoms, use complex scoring algorithms, and lack any objective mechanistic assessments. This lack of objective biomarker, however, may limit the usefulness of the new FM Criteria for research and clinical practice. Overall the diagnosis as well as the treatment of FM may benefit from improved classification criteria which should include relevant disease biomarkers that are fundamental for the development and persistence of FM and other chronic musculoskeletal pain syndromes, like abnormal central nervous system processing abnormalities of nociceptive signals.