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Management of the end-stage rheumatoid wrist is controversial. The most common treatment is total wrist fusion. Total wrist arthroplasty offers a motion-preserving alternative. Comparison of outcomes for total wrist arthroplasty and total wrist fusion is necessary for evidence-based decision making. The purpose of this systematic review was to scientifically evaluate the existing literature for outcomes of both procedures in rheumatoid arthritis.A MEDLINE database review was performed. Search included “wrist and arthroplasty,” “wrist and arthrodesis,” and “wrist and fusion.” Silicone arthroplasty was excluded. Data extraction included demographic information, surgical technique, pain, and active arc of motion. Complications and satisfaction were recorded.Literature review identified 1750 citations that were screened for inclusion criteria. Formal review identified 18 total wrist arthroplasty studies representing approximately 500 procedures. Data from 20 total wrist fusion studies represented over 800 procedures. Comparison of outcomes showed that total wrist fusion provides more reliable relief than total wrist arthroplasty. Complication and revision rates were higher for total wrist arthroplasty. Satisfaction was high in both groups. Postoperative motion was reviewed to evaluate whether arthroplasty provides a functional active arc of motion. Of 14 studies reporting appropriate data, three showed average active arc of motion within the functional range.In this systematic review, outcomes for total wrist fusion were comparable and possibly better than those for total wrist arthroplasty in rheumatoid patients. In this era of cost-conscious medical care, expensive interventions must demonstrate superior outcomes. Existing data do not support widespread application of total wrist arthroplasty for the rheumatoid arthritis wrist.