What is the recommended approach for a patient with a degenerative joint in the wrist, considering surgery involving tendon stretching, possibly due to underlying conditions such as osteoarthritis (OA) or rheumatoid arthritis (RA)?

Surgical Management of Degenerative Wrist Joint Disease

For degenerative wrist joint disease requiring surgery, the primary surgical options are partial wrist fusion (particularly scaphoid excision with four-corner fusion), proximal row carpectomy, or complete wrist arthrodesis—NOT tendon stretching procedures, which are not a recognized treatment for wrist osteoarthritis. 1

Critical Clarification on "Tendon Stretching"

• Tendon stretching is not a standard surgical procedure for degenerative wrist arthritis 1, 2
• You may be referring to tendon interposition arthroplasty, which involves placing tendon tissue between joint surfaces as a cushion, not stretching tendons 3
• This technique is occasionally used for specific conditions like chronic distal radioulnar joint dislocations with cartilage destruction, but it is not first-line treatment for typical wrist osteoarthritis 3

Stepwise Treatment Algorithm Before Surgery

First-Line Conservative Management (Must Exhaust Before Surgery)

• Education and ergonomic training with activity pacing and assistive devices for all patients 1
• Hand exercises focusing on range of motion, strengthening, and function improvement 1
• Orthoses/splinting for symptom relief, particularly for thumb base involvement, with long-term use advocated 1
• Topical NSAIDs as first-line pharmacological treatment due to superior safety profile 1
• Oral analgesics (acetaminophen up to 4g/day first, then oral NSAIDs at lowest effective dose for limited duration) 1

Second-Line Invasive Non-Surgical Treatment

• Intra-articular corticosteroid injections for painful flares when conservative measures fail 1, 2, 4
• Failure of corticosteroid injections indicates readiness for surgical consideration 2, 4

Surgical Indications (All Must Be Present)

Surgery should only be considered when: 1, 2

• Radiographic evidence of osteoarthritis is present
• Marked disability and reduced quality of life exist
• Pain significantly limits activities of daily living
• All conservative and non-surgical invasive treatments have failed

Evidence-Based Surgical Options for Wrist OA

For Scapholunate Advanced Collapse (SLAC) or Scaphoid Nonunion Advanced Collapse (SNAC)

Partial wrist fusion (Watson procedure/four-corner fusion): 5, 6

• Provides pain-free wrist in 80% of cases
• Preserves 50% of mobility with good grasping strength
• Stable results for at least 10 years
• Most commonly used procedure for advanced wrist arthritis 5, 6

Proximal row carpectomy: 5, 6

• Provides similar results to partial fusion if capitate cartilage is preserved
• Best for patients not involved in heavy manual labor
• Maintains joint contact surface and load transmission 5

Scaphocapitolunate arthrodesis with radial styloidectomy: 6

• Maintains more physiologic joint surface for radiocarpal load sharing
• Results in 70-degree flexion-extension arc and 23-degree radioulnar deviation
• Pain relief achieved in all patients (13 of 20 pain-free postoperatively)
• Preserves normal ulnar-sided joints of carpus 6

For End-Stage Disease

Total wrist arthrodesis (fusion): 5

• Reliable outcome for pain relief and strength restoration
• High patient satisfaction rates
• Minimal repercussions from loss of mobility
• Fewer complications than other salvage procedures
• Appropriate as first-line treatment in severe cases or revision surgery 5

Complete wrist denervation: 5

• Provides pain relief in almost 80% of cases
• Preserves motion and strength
• Safe and effective with no age limit
• Allows other procedures to be performed in future if needed 5

Common Pitfalls to Avoid

• Never proceed to surgery without exhausting conservative measures first—the evidence-based algorithm mandates stepwise progression through non-pharmacological, pharmacological, and invasive non-surgical options 2, 4
• Avoid combined surgical procedures (e.g., two procedures simultaneously) as they offer no advantages but significantly higher complication rates (RR = 2.12) compared to single procedures 1, 2
• Be aware of hardware migration risk with headless compression screws in midcarpal fusions—requires at least 8 months of clinical and radiographic follow-up 7
• Do not use disease-modifying antirheumatic drugs (conventional or biological) for osteoarthritis treatment 1

Nuances in Surgical Decision-Making

• For thumb base (carpometacarpal) OA specifically: trapeziectomy with or without ligament reconstruction is the procedure of choice, not wrist fusion procedures 1, 2
• For interphalangeal joint OA: arthrodesis or arthroplasty should be considered rather than wrist-level procedures 1
• Radiographic staging typically underestimates arthroscopic staging—accurate assessment requires arthroscopy in many cases 8