[Development of surgical indications in the treatment of rheumatoid wrist. Report on experience based on 603 surgical cases, 1968-1994].

The author relates his experience in surgical treatment of the rheumatoid wrist based on a consecutive series of 603 cases operated from 1968 to 1994. His therapeutic indications have changed over the years after a retrospective study of the long-term results. He distinguishes conservative surgery, which combines dorsal synovectomy and relaxation stabilisation of the wrist (also called surgery of the dorsal wrist) from total arthrodesis and arthroplasty of the wrist. The results of conservative surgery after a follow-up of more than five years confirm that the disease continues in spite of synovectomy. Furthermore, relaxation stabilisation using soft tissue (extensor retinaculum and tendon transfer) is not sufficient to stabilise the wrist. Most of the time, this has to be completed by a partial radiocarpal arthrodesis. This is indicated when the carpus shows a medial translation or early in potentially progressive forms (Larsen Stage 1). In advanced forms conservative surgery consisting of partial radiocarpal arthrodesis is only indicated when the midcarpal joint appears functional after dynamic radiological examination. The author used the Swanson implant to perform 70 arthroplasties from 1973 to 1988. Long-term results show a large number of complications, which increased progressively with time. The Swanson implant was therefore abandoned in 1988. In 12 cases operated from 1979 to 1984 wrist arthroplasty was performed using Jackson's technique which consists of resection-interposition of a silastic sheath. This technique was also abandoned in 1984 due to the variable and unpredictable results obtained. At the present time, the author:-does not perform arthroplasties; increasingly completes surgery of the dorsal wrist by radiolunate arthrodesis;-has noted an increase in indications for total wrist arthrodesis. He emphasizes the importance of long-term evaluation of surgical results in rheumatoid arthritis.