Total wrist arthroplasty

Although surgeons typically prefer arthrodesis for the treatment of severe wrist arthritis, the resulting sacrificed motion may significantly impair function, especially when multiple joints in the extremity are affected by arthritis. Total wrist arthroplasty enhances the performance of daily activities and is preferred by rheumatoid patients to arthrodesis. Historically, wrist replacement has had an unacceptable complication rate, particularly involving wrist imbalance and implant loosening. Recent developments in prosthetic design have substantially improved the performance and durability of wrist replacement. When performed technically well in properly selected patients, total wrist arthroplasty provides a functional, durable wrist and high patient satisfaction. Copyright © 2001 by the American Society for Surgery of the Hand     

Salvage of post-traumatic arthritis following distal radius fracture

There are practical recommendations that can be drawn from the aforementioned results. Due to the minimal morbidity of the wrist denervation, patients with good but painful wrist motion following fracture of the distal radius should first be evaluated for wrist denervation unless formal resection of the dorsal interosseous nerve has clearly been included in the previous treatment. The evaluation is performed in a standardized manner before and after test infiltration of both interosseous nerves. This evaluation includes assessment of pain, strength, and working capacity. Whereas the grip strength often does not (cannot)increase more than 10% to 20%, the subjective pain relief can be remarkable, leading to higher repetition counts and increased dexterity. Inpatients with insufficient response to the anesthetic nerve blocks, other pain sources must be sought, especially on the ulnar side of the wrist.Patients with less than functional range are candidates for complete arthrodesis. A way for further evaluation with regard to the potential of partial and complete wrist arthrodesis is trial immobilization of the wrist in a light cast ora firm reinforced brace. Trial immobilization also allows anticipating the functional deficit from loss of range of wrist motion. Due to the still-unrestricted pronation and supination, ulnar-sid-ed wrist pain may persist and will need adequate follow-up adjunct treatment. Patients who have good pain relief but are not willing to completely lose their wrist motion should be evaluated fluoroscopically or receive lateral radiographs in full flexion and extension to measure their mid-carpal joint mobility and anticipate the potential residual motion after radiocarpal fusion. Patients without pain relief from test anesthesia, trial immobilization, and no apparent distal radioulnar joint pathology are poor candidates for further operative treatment.In evaluating different salvage procedures,among all diagnoses, painful arthritis following fracture of the distal radius is the most difficult to treat and yields the poorest results. Emphasis must therefore be on better initial fracture treatment and earlier secondary reconstructive interventions. The current salvage procedures must allow further improvement or alternatives must be developed. Prosthetic replacement merits serious consideration, especially when it can be adapted to the specific post-traumatic setting. This situation is not worse than rheumatoid arthritis because the clinician is dealing with healthy and strong intact bone stock, tendons, and ligaments,and most important, complete absence of a progressive disease.     

Long-term functional results of wrist arthrodesis in rheumatoid arthritis

The purpose of this study was to evaluate the long-term effectiveness of wrist fusion on the relief of pain and also the functional capacities of the upper limbs in patients with rheumatoid arthritis (RA). Eighteen patients were assessed at a mean of 7 years after wrist arthrodesis and a mean of 17 years after the onset of RA. Radiological measurements, pain assessment and impairment rating of the upper limbs were made of the fused and non-fused sides. The average position of arthrodesis was 8 degrees of extension and 9 degrees of ulnar deviation. All patients were pleased with the procedure and had satisfactory pain relief. Impairment ratings did not detect any significant difference in the sensory and motor function of the hand when the fused and non-fused groups were compared. We conclude that in patients with rheumatoid arthritis, wrist arthrodesis is a reliable procedure that provides predictable pain relief and a high degree of satisfaction without additional functional loss in the upper limb.     

Ankle arthrodesis in rheumatoid arthritis using an intramedullary nail with fins.

We describe an intramedullary nail with fin-like longitudinal ridges that we have developed for arthrodesis of the ankle in rheumatoid arthritis. Four fins with sharp tips were attached to the distal part of a cylindrical nail to stabilize the tibiotalar and subtalar joints. We used this nail in 15 feet of 15 patients with rheumatoid arthritis who were followed for an average of 34.9 months. Postsurgery, 13 patients were allowed to bear weight immediately, as tolerated, without immobilization. By 3 weeks, these patients were able to bear weight fully. Solid fusion of the ankle joint in an acceptable position and good clinical results were obtained in all patients. The only complications were two cases of delayed wound-healing.     

Long-term results of dorsal stabilization in the rheumatoid wrist

Dorsal stabilization was performed on 85 rheumatoid wrist in 62 patients for an average follow-up of 6.8 years. Of these, 37 wrists were followed an average of 10 years. The chief component was pain in 79 of the wrists. Pain, on a scale of 0 to 100, showed a preoperative score of 32 and postoperative ratings of 89 for the total group and 96 for the long-term group. Range of motion decreased in virtually all patients. Spontaneous ankylosis occurred in eight wrists. Because of the presence of associated deformities, usually subluxated metacarpophalangeal joints, evaluation of functional improvement of the wrist was difficult. Those hands in which metacarpophalangeal subluxations were corrected or prevented showed maximum functional improvements. The procedure is beneficial for long-term relief of pain and maintenance of a range of motion which arthrodesis would eliminate.     

Functional assessment of bilateral wrist arthrodeses

We studied the functional results of 18 wrist arthrodeses in nine patients with rheumatoid arthritis. Objective evaluation included radiographic assessment, goniometer assessment of the upper extremity (UE), range of motion (ROM), grip and pinch strength, and the Jebsen-Taylor function test. Subjective evaluation consisted of a questionnaire that compared the upper extremity function of various activities of daily living preoperatively and postoperatively. The mean total range of motion for all patients was below normal on the dominant and nondominant sides, as was the average grip and pinch strength. Results of the Jebsen-Taylor test, compared with results of normal persons, were normal 38% of the time and abnormal 62% of the time. Subjective evaluation revealed postoperative improvement of the hand function in seven patients, whereas the function in two patients remained the same. Bilateral wrist arthrodeses does not seem to adversely affect function of the upper extremity in spite of abnormal grip strength and upper extremity range of motion.     

Health status after total wrist arthrodesis for posttraumatic arthritis

PURPOSE: Total wrist arthrodesis is regarded as the most predictable way to relieve the pain of posttraumatic wrist arthritis. Wrist arthrodesis also is believed to be compatible with a high level of upper-extremity function. This study evaluated the effect of total wrist arthrodesis on both general and upper-extremity-specific health status in patients treated for posttraumatic wrist arthritis. METHODS: By using an institutional review board-approved protocol 22 patients were evaluated an average of 6 years after total wrist arthrodesis for posttraumatic arthritis. Upper-extremity-specific and general health status were measured using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short-Form 36 (SF-36) instruments, respectively. Patient satisfaction and interest in pursuing a wrist-mobilizing procedure should one become available also were assessed. Objective assessment included grip strength, digit range of motion, and radiographic fusion. RESULTS: Grip strength averaged 79% of the uninvolved wrist. The average Disabilities of the Arm, Shoulder, and Hand questionnaire score was 25. The average physical component score of the Short-Form 36 was 39 and the average mental component score was 52. Fourteen patients complained of wrist pain, including severe pain in 4 patients. Fifteen patients were satisfied or very satisfied with the result of the fusion, 5 patients were neutral, and 2 patients were mildly dissatisfied. Twenty patients would elect to have a procedure that could make their wrist move again if one were available. CONCLUSIONS: Substantial dysfunction was noted on both upper-extremity-specific and general health status measures after total wrist arthrodesis for posttraumatic conditions. Pain was improved but not eliminated.     

The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis

Various types of internal fixation have been used to achieve arthrodesis of both the ankle and subtalar joints. We have investigated the use of a standard 95 degree angled blade plate as a method of more rigid internal fixation to achieve arthrodesis of these joints. The purpose of this retrospective study was to review our clinical and radiographic results in adults using a blade plate applied through a posterior approach to fuse the ankle and subtalar joints. METHODS: Between April 1995 and June 2000, 10 tibiotalocalcaneal arthrodeses were performed using a posterior approach and a blade plate for internal fixation. There were 10 adults (five men and five women) whose average age was 64 years (range, 42 to 80 years). The indication for the procedure was severe pain which was unresponsive to nonoperative management in patients with arthritic joints. Preoperative diagnoses included six patients with post-traumatic arthritis, two with primary degenerative arthritis, one with rheumatoid arthritis, and one with post-polio deformity. An average of 1.7 previous operations had been performed on the affected ankle. RESULTS: Clinical and radiographic follow-up was performed for all patients at an average of 37 months (range, 12 to 71 months) postoperatively. All 10 patients achieved a solid fusion. The mean time to radiographic fusion was 14.5 weeks (range, 9 to 26 weeks). The operation resulted in plantigrade feet in all patients with an average tibia-floor angle of 2.3 degrees of dorsiflexion and an average of 5 degrees of hindfoot valgus. Patients had excellent pain relief, however function did not improve as much. Complications occurred in three patients. One patient required a small split-thickness skin graft for wound healing, one experienced a transient posterior tibial nerve neuropraxia, and one developed a deep venous thrombosis in the nonoperative leg at six weeks postoperatively. Three patients required removal of the blade plate because of discomfort, which promptly cleared. CONCLUSIONS: Arthrodesis provides excellent pain relief for patients with painful arthritic deformities of the ankle and subtalar joints. Using a posterior approach, a blade plate for internal fixation and bone grafts resulted in a solid fusion for all our patients. This method is particularly effective in large patients with a mild-moderate hindfoot deformity.     

Chronic lunotriquetral instability: Diagnosis and treatment

Fourteen patients with chronic lunotriquetral instability were evaluated. Forced wrist extension was the most common mechanism of injury. Fourteen patients underwent lunotriquetral arthrodesis. Arthrograms were positive in 9 of the 12 performed. In three cases abnormalities not identified by arthrography were demonstrated by arthroscopy. The follow-up period aver-aged 27 months. X-ray films showed fusion in 12 cases. One pseudarthrosis was asymptomatic. A second pseudarthrosis required a rearthrodesis that became solid 8 weeks after surgery. One patient had persistent wrist pain. Wrist motion compared to the contralateral side aver-aged 85%, 88%, 83% and 80%, respectively, for flexion, extension, ulnar deviation, and radial deviation. Grip strength compared to the contralateral side averaged 93%. Lunotriquetral instability is a clinical diagnosis confirmed by arthrography or arthroscopy. Lunotriquetral fusion reliably relieves pain while maintaining functional wrist motion and grip strength. The long-term effects of lunotriquetral fusion on carpal kinematics and wrist function are unknown.     

Use of free vascularized fibular graft for congenital ulnar pseudarthrosis: surgical decision making in the growing child

Congenital pseudarthrosis of the ulna may cause growth disturbance and progressive forearm deformity, leading to functional compromise of the upper extremity. Treatment is challenging, and surgical decision making must take into account three goals of treatment: bony healing, distal radioulnar joint (DRUJ) stability, and continued skeletal growth. Four cases of congenital ulnar pseudarthrosis treated with free vascularized fibular graft are presented here. In two cases, the vascularized fibular graft included the proximal fibular epiphysis to reconstruct the DRUJ and ulnocarpal joints. Average age of the four patients at time of vascularized fibular grafting was 10 years (range 3-16 years). Patients had undergone up to three previous failed operations. A step-cut osteotomy technique with rigid internal fixation was used in all patients. Donor-site distal tibiofibular arthrodesis was performed in skeletally immature patients when appropriate. At average follow-up of 60 months (range 33-83 months), all patients achieved bony union with full wrist range of motion compared with the contralateral extremity. The DRUJ was stable in all patients. Two skeletally immature patients with concomitant epiphyseal transfer showed continued skeletal growth. Two patients nearing skeletal maturity achieved revascularization of the distal ulna. Free vascularized fibular grafting is a successful option in the treatment of congenital ulnar pseudarthrosis. Reconstruction of the distal radioulnar and ulnocarpal joints using concomitant proximal fibular epiphyseal transfer should be considered in the skeletally immature patient with distal ulnar involvement.     

The rheumatoid wrist

Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.     

Compression arthrodesis of finger joints

Compression arthrodesis is useful for treatment of finger and thumb joints in arthrosis, scleroderma, hypermobile joints, paralytic deformities, and rheumatoid arthritis. A dorsal incision exposes the joint. Its surfaces are prepared in a ball-and-socket arrangement using a high-speed burr. A longitudinal pin 1.1 mm in diameter is passed distally and then retrograde to determine the angle of fusion and to prevent migration of bone ends as the longitudinal compression is applied. Transverse pins 1.5 mm in diameter are put in one-third of the distance from the joint. A Charnley clamp, as modified by Micks and Hager, is applied and tightened. At 6 weeks, the arthrodesis is checked for solidity and, if stable, X-rays are examined for new bone. When solid, the joints should be protected by external splinting for an additional 2 weeks to be sure that the fusion is complete. Compression arthrodesis was obtained in 49 of 54 joints. Solid fusion was usually attained within 6 weeks, without loss of mobility of other joints.     

Total wrist arthroplasty

Normal wrist motion is accomplished by a complex interaction of multiple articulations involving the radius, ulna, and carpal bones. Total wrist arthroplasty cannot duplicate this intricate system, but it can potentially produce a stable, pain-free joint with functional range of motion. Achieving a functional and durable outcome requires proper patient selection, careful preoperative planning, and accurate implantation. Because arthroplasty poses greater risks than arthrodesis, low demand patients with special needs or desires for wrist motion are the best candidates. In particular, patients with arthritis involving multiple joints of the upper limbs often find tasks of daily living easier when some wrist motion is preserved. Other patients may choose arthroplasty over arthrodesis to better maintain their ability to perform vocational and avocational activities. Regardless of a patient's desire for arthroplasty, he or she must accept the lifetime of restricted activities imposed by an artificial wrist, which are similar to any other joint replacement. Complications may include infection, imbalance, implant breakage, dislocation, and loosening. Revision arthroplasty or conversion to an arthrodesis are options for the failed total wrist.     

Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: The surgical treatment of the rheumatoid wrist is key in managing the affected hand. Wrist fusion is often the treatment of choice in cases of severe destruction and deformation although most patients would prefer a motion-preserving procedure. The implantation of a wrist prosthesis might be an alternative to partial arthrodesis for selected cases. In this series we analyzed the long-term results (minimum follow-up period, 10 y) of the Swanson silicone spacer for the wrist in patients with rheumatoid arthritis. METHODS: Sixteen patients with rheumatoid arthritis with 18 silicone spacers for the wrists were reviewed after a minimum follow-up period of 10 years (average, 15 y). Subjective evaluation, clinical examination, and radiographic analysis were included. An additional 9 patients (9 wrists) were interviewed by telephone. RESULTS: In 12 of the patients the subjective result was good or very good, mostly because of adequate pain relief. The average range of motion for flexion (average, 28 degrees )/extension (average, 15 degrees ) was 43 degrees with a wide variation within the series. Radiologically all wrists had diminished residual carpal height at follow-up evaluation and 9 of the wrists had evidence of osteolysis and foreign-body granuloma. The initial good correction of the ulnar translation of the wrist was lost partially in the follow-up period (1.1 vs 4.0 mm). Three of the patients needed surgical revision within the follow-up period; all were converted to wrist fusion. CONCLUSIONS: These long-term results suggest that the silicone wrist spacer still may be considered as an alternative to wrist fusion or more complex wrist joint prostheses in patients with rheumatoid arthritis, especially in severe cases and in patients with low demands. In the long term osteolysis caused by foreign-body granulation is to be expected and has to be considered.     

Wrist arthrodesis for treatment of rheumatoid arthritis

Eighty-seven wrist fusions using the technique of Millender and Nalebuff were reviewed in 79 patients with rheumatoid arthritis. Follow-up averaged 6 years and 97% of all patients had an excellent or good result. Pain was absent or mild in all patients after operation, and 95% of this patient population had improved hand function after wrist fusion. Wrist position averaged neutral in the lateral plane and 6 degrees ulnar deviation. Time to clinical fusion averaged 10.8 weeks. Complications were present in 23% of all cases, with half of these a result of symptomatic hardware. Carpal tunnel syndrome was seen after operation in five patients, all of whom had significant palmar carpal dislocation before surgery. A neutral position of the wrist with slight ulnar deviation is very functional and cosmetically acceptable for the patient with rheumatoid arthritis, even in bilateral fusions. Wrist arthrodesis for the patient with rheumatoid arthritis is a dependable procedure with a high degree of success and patient satisfaction.     

Stabile mediokarpale Teilarthrodese bei fortgeschrittenem karpalen Kollaps (SNAC-Wrist und SLAC-Wrist)

In a retrospective study, the indications and results after miniplate and spider plate osteosynthesis for stable midcarpal arthrodesis of the wrist after ?scaphoid nonunion advanced collapse“ (SNAC) wrist and ?scapho-lunate advanced collapse“ (SLAC) wrist were evaluated. The diagnosis was confirmed by conventional X-rays as well as magnetic resonance imaging/computed tomography and/or arthroscopy of the wrist. The principle of a stable midcarpal arthrodesis lies in the reduction of pain in the wrist by elimination of the arthrosis in the damaged joint, stabilization of the carpus, and sustainment and improvement of the movement of the wrist. From 1998 until 2007, 83 patients were stably treated with spider plates or other plates, and autogenous spongiosa graft. In 76 cases, a clinical and radiological follow-up examination was performed on average 48 months after operation. Within 6–8 weeks, the fusion was completed without external fixation. Three weeks after operation, physiotherapy was started. In the follow-up examination, the average range of motion from extension to flexion was 75°; the average grip strength about 85% compared with the other hand. Pain was reduced to 28 points on the visual analogue scale (VAS 1–100). The mean DASH score postoperatively was 22.1 points. Only two patients received a full arthrodesis two years after the first operation. All the other patients showed clinically good or excellent results, arthodesis was radiographically stable, and function was clinically convincing. In only one case was an arthrosis of the radiolunate joint with a slight ulnar translocation found in the X-ray. However, this X-ray pathology had no influence on the movement or pain of the wrist. Stable arthodesis guarantees early functional movement without pain in case of correct diagnosis and exact implementation of the steps of this challenging operation.     

Radiocarpal arthrodesis in the treatment of the rheumatoid wrist. A prospective midterm follow-up

This prospective study was performed to evaluate the clinical and radiological results of radiocarpal joint arthrodesis in the treatment of unstable Simmen group III and Larsen grade II or III rheumatoid wrists. Radiolunate arthrodesis was performed in 16 wrists and radioscapholunate arthrodesis in 7 wrists in 20 patients. When they were evaluated at a mean of 5.8 (range 3.5-9.8) years later, flexion was 29 degrees and extension 34 degrees , representing 67% and 92% of the preoperative values, respectively. Patient satisfaction was excellent, or good, for 20 wrists and satisfactory for 1 wrist. In two patients with poor satisfaction, arthritis progressed to the midcarpal joint and necessitated total arthrodesis of the wrist. Radiolunate joint arthrodesis, with inclusion of the scaphoid in the fusion if necessary, is a useful operation in the treatment of this degree of wrist disease as it produces a functional and pain-free wrist at the same time as preserving much of the mobility and bone stock.     

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy

PURPOSE: The purpose of this study was to assess wrist pain, range of motion, and the presence of radiographic midcarpal degenerative joint disease (DJD) in patients who had a distal scaphoidectomy in association to a radioscapholunate (RSL) arthrodesis and to compare these findings with prior studies of patients with only an RSL fusion. METHODS: Sixteen patients with radiocarpal DJD treated by RSL arthrodesis and distal scaphoidectomy were evaluated retrospectively for pain relief and range of motion at an average follow-up period of 37 months (range, 12-84 mo). Radiographs were assessed for the presence of secondary radiographic midcarpal DJD. RESULTS: Complete pain relief was obtained in 10 patients, 3 patients complained of slight pain during strenuous loading, and 3 patients had occasional pain with regular activities. The average postoperative ranges of motion were 32 degrees of flexion, 35 degrees of extension, 14 degrees of radial deviation, and 19 degrees of ulnar deviation. Two patients exhibited secondary midcarpal DJD. These results are significantly better compared with those previously published about RSL arthrodesis alone in terms of residual pain and decrease of wrist radial deviation and flexion. CONCLUSIONS: Patients who require an RSL arthrodesis for the treatment of severe localized radiocarpal DJD appear to have less pain and to retain more flexion and radial deviation if the distal scaphoid is excised concomitantly. This associated procedure also may help prevent secondary midcarpal DJD.     

Preliminary results of total wrist arthroplasty in rheumatoid arthritis using the Trispherical total wrist arthroplasty

Thirty-two patients underwent 38 arthroplasties for advanced rheumatoid arthritis and marked soft tissue losses. Seven wrists required repair or transfer of at least one tendon for rebalancing. All patients were improved by the implants. Thirty-four of the 38 patients were improved beyond the functional level of a painless wrist arthrodesis. Overall, there were 23 excellent, 10 good, 3 fair, and 2 poor results. The average wrist score was 90.3 points, and the average arc of motion was 38 degrees. There were three cases of migration of the third metacarpal stem and nine cases of lucency about the stems, three of which were progressive or greater than 1 mm. There were no deep infections. There was one reoperation for persistent pain and one for component loosening. There were no cases of implant failure. These results indicate that this total wrist arthroplasty is a safe, reproducible procedure for radiographic class III and IV rheumatoid disease and should be considered a first line of therapy for that group.     

Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases

In a 4 year period (1996-1999), 42 total wrist fusions in 25 men and 17 women were performed using the AO/ASIF Titanium wrist fusion plate. The median age of the patients at the time of surgery was 41 (range, 19-72) years. The indication for fusion was post-traumatic arthritis in 29 wrists, Kienb?ck's disease in eight, rheumatoid arthritis in three, mono-arthritis in one and Volkmann's contracture in one. All patients were reviewed at a median follow-up of 23 (range, 6-50) months. The Buck-Gramcko and Lohmann score for functional evaluation was excellent in 35, good in 5 and satisfactory in 2 patients. We conclude that wrist arthrodesis with the AO/ASIF Titanium wrist fusion plate is an excellent option for treatment of various painful disorders of the wrist.