Surgery of the wrist and hand in rheumatoid arthritis

Wrist and hand surgery in rheumatoid arthritis has continued to evolve since first being tried fifty years ago. Improvements have flowed from a better understanding of pathophysiological mechanisms, from technical progress and from more effective medical treatment. The use of methotrexate and the subsequent development of biological therapies have transformed the course of the disease, increasing the chances of positive and durable surgical results. Priority must be given to re-alignment of the wrist in order to protect the fingers. It is equally important to perform synovectomies of the extrinsic tendons and to re-align extensor tendons with the metacarpophalangeal joints. At a later stage, metacarpophalangeal arthroplasty can re-establish a useful range of mobility in these joints. Early correction of swan-neck deformity is essential. Arthrodesis of the metacarpophalangeal joint of the thumb is also beneficial as it improves finger-thumb pinch grip. These procedures are usually performed under regional block anaesthesia. They take less than two hours and the techniques employed are compatible with early mobilisation. Effective surgical management of rheumatoid arthritis requires close collaboration between surgeons, rheumatologists, physiotherapists, orthotists and occupational therapists. There are thought to be some 500 000 patients in France who might benefit from such treatment but, as yet, there are too few multidisciplinary teams equipped to manage them effectively.