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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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A Systematic Review of Arthroplasty Compared to Arthrodesis in the Rheumatoid Wrist
Christi M. Cavaliere, MD, Kevin C. Chung, MD, MPH.
University of Michigan, Ann Arbor, MI, USA.

Introduction: Rheumatoid arthritis (RA) affects approximately 1% of the U.S. population. Surgical management of the rheumatoid wrist remains controversial. The most common treatment for diffuse painful wrist is arthrodesis, which gives pain relief at the expense of motion. Total wrist arthroplasty (TWA) was introduced over three decades ago as a motion preserving alternative to arthrodesis. TWA has not gained widespread application due to concerns for high failure rates, variable functional outcomes, and substantial cost. New advances in TWA may lead to better outcomes than earlier generation prostheses. A rigorous comparison of outcomes for TWA and arthrodesis is necessary in the optimal discussion with patients regarding these two options. The purpose of this systematic review is to scientifically evaluate the existing literature for outcomes of TWA compared to arthrodesis in patients with RA. This comparison of surgical outcomes will provide an essential tool for evidence-based decision making.
Methods: Literature review was carried out using the Medline Database from 1966 to October 2006. Search terms for arthroplasty included “wrist and arthroplasty.” Terms for arthrodesis included “wrist and arthrodesis” and “wrist and fusion.” Abstract review identified articles describing either procedure in rheumatoid patients. Studies describing silicone arthroplasty were excluded because this technique is no longer used. Inclusion criteria were English language, human, and at least 80% of patient population with RA. Exclusion criteria included review articles, >20% of patients with diagnosis other than RA or unable to extract individual patient data. Data extraction included surgical technique, age, follow-up, and preoperative and postoperative assessment including pain, range of motion (ROM) and grip. Complication and re-operation rates were recorded. Patient satisfaction was recorded when available. The analyses included descriptive and summary statistics.
Results: The initial abstract review identified 150 articles for arthroplasty. Following formal article review, 19 relevant studies were included in the arthroplasty analysis. Approximately 600 wrist arthroplasty procedures were represented. For arthrodesis, the abstract review identified 205 studies for formal article review. Data from 14 studies represented approximately 560 wrist arthrodesis procedures. Comparison of outcomes for pain showed that arthrodesis provides more reliable relief than arthroplasty. Similar total complication and revision rates were reported. Satisfaction was high for both procedures. (Table 1). Post-operative ROM was reviewed to evaluate whether arthroplasty achieves motion within a functional range. Of 12 studies reporting appropriate data, only two showed an average ROM within functional range.
Table 1

OutcomeArthroplastyArthrodesis
No pain or mild pain77%99%
Complication rate35%23%
Revision/ re-operation rate
(Salvage arthrodesis)
11%
(12%)
15%
Patient satisfaction91%96%

Conclusions: Based on this rigorous systematic review, outcomes for arthrodesis are comparable and possibly better than outcomes for arthroplasty. Arthroplasty provides the benefit of motion preservation, but is significantly more costly than arthrodesis. In this era of cost-conscious medical care, use of expensive interventions must be supported by evidence of superior outcomes. Existing data based on this systematic review do not support the widespread application of arthroplasty for treatment of the rheumatoid wrist.
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