Die Pisiformetransposition nach Beck zur Behandlung der Lunatumnekrose im Stadium 2 nach Kienböck

Summary BACKGROUND: Therapy for idiopathic necrosis of the lunate depends on the stage. The therapeutic strategy includes reconstruction and arthrodesis. The aim in stage II is the reconstruction of the wrist joint through a local or free vascularized bone graft. METHODS: In 13 patients, active range of motion (neutral-zero method), grip pinch (dynamometer), and pain were evaluated and compared to the uninvolved wrist. On standardized radiographs in posteroanterior projection, integration of the pisiform and development of carpal collapse in progressive degenerative arthritis were assessed. RESULTS: Sagittal wrist motion was reduced by 25 % and grip strength by 27 %. Pain improved from 1.6 points before surgery to 0.6 points after surgery. The pisiform showed osseous integration in 12 patients and separation by a hyperdense rim in one. Carpal collapse occurred in two patients. CONCLUSIONS: Following transposition of the pisiform to treat the necrotic lunate in stage II, good clinical results could be achieved and carpal collapse avoided in 84 % of the patients during the follow-up period.     

Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis

PURPOSE: The treatment of scaphoid nonunion with degenerative arthritis poses a clinical problem that is particularly challenging in cases of associated dorsal intercalated segmental instability collapse, radiocarpal and intercarpal degenerative changes, and poor scaphoid bone quality. The purpose of this study was to report our clinical experience performing a distal scaphoid resection for symptomatic scaphoid nonunion in patients with either radioscaphoid or intercarpal arthritis who have had multiple surgeries. METHODS: Nine patients with recalcitrant scaphoid nonunion and associated degenerative arthritis treated by resection of the distal scaphoid fragment were evaluated both clinically and radiographically. Eight patients were male and one patient was female; the average follow-up period was 28.6 months (range, 12-52 mo). RESULTS: Seven patients reported pain with daily use and the remaining 2 patients reported mild pain with light work before surgery, whereas after surgery 4 of the 9 patients had no wrist pain and the remaining 5 patients had only mild pain with strenuous activity. The wrist range of motion improved from 70 degrees (51.4% of the opposite wrist) to 140 degrees (94% of the opposite wrist) and grip strength improved from 18 kg (40% of the opposite wrist) to 30 kg (77% of the opposite wrist). Clinical results were excellent in 6 patients and good in 3 patients based on a modified Mayo wrist-scoring chart. Radiographically neither additional degeneration nor progress of degenerative changes was noted after surgery in 8 patients. Newly developed degenerative arthritis occurred at the proximal scapholunate capitate articulation in the remaining patient who has a type II lunate, which had a facet (medial facet) articulation with the hamate. CONCLUSIONS: The results of this study showed that distal scaphoid resection produces a satisfactory clinical outcome, requires only a short period of immobilization, and should be considered one of the surgical options for long-standing scaphoid nonunion with either radioscaphoid or intercarpal degenerative arthritis. Nevertheless care must be taken in performing this procedure on patients whose preoperative radiograph show a type II lunate.     

Surgical treatment of talar body fractures

BACKGROUND: Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment. METHODS: Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed. RESULTS: Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores. CONCLUSIONS: Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.     

Total wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: After very good midterm results with an uncemented total wrist arthroplasty we evaluated the long-term outcome in a retrospective study. METHODS: Forty uncemented anatomic physiologic (APH, Implant-Service Vertreibs-GmbH, Hamburg, Germany) wrist prosthesis implantations performed in 40 patients were reviewed. The mean follow-up period was 52 months (range, 24-73 mo) and the following parameters were examined: radiographs, grip strength, range of motion, and patient's satisfaction. RESULTS: After a good short-term outcome the results deteriorated with time. The following complications occurred: 2 infections, 3 implant failures, 2 prosthesis migrations, and 33 loosenings/dislocations. All patients (39 of 40) underwent revision surgery, and severe titanium wear in the soft tissues was found intraoperatively in all cases. It became clear that even in a non-weight-bearing joint such as the wrist, titanium alloy may wear and result in tissue metallosis when used as a bearing surface of the implant. As a salvage procedure the prosthesis was removed and an arthrodesis was performed in all patients. CONCLUSIONS: Because of the deterioration of the results including an unacceptable revision rate we currently do not consider the anatomic physiologic wrist prosthesis to be a suitable implant in patients with rheumatoid arthritis.     

Long-term assessment of Swanson implant arthroplasty in the proximal interphalangeal joint of the hand

PURPOSE: The purpose of this study was to evaluate the clinical results of Swanson silicone implant arthroplasty of the proximal interphalangeal (PIP) joint, specifically evaluating clinical results with long-term assessment. METHODS: A retrospective review of 70 silicone implants of the PIP joint in 48 patients was performed with an average follow-up period of 6.5 years (range, 3-20 y). Clinical assessment included motion, stability, and alignment. Radiographic assessment included implant fracture, deformity, and cystic bone resorption. The pathology consisted of degenerative joint disease in 14, posttraumatic arthritis (TA) in 11, rheumatoid arthritis (RA) in 13, and idiopathic arthritis (IA) associated with collagen disease in 12 patients. Swan neck and boutonniere deformities were assessed separately. Statistical analysis of preoperative risk factors was compared with the postoperative assessment of pain, motion, and function (return to work). RESULTS: There was no significant change in the active range of motion (ROM) before and after PIP arthroplasty (26 degrees vs 30 degrees ). Correction of swan neck and boutonniere deformities was difficult, usually leading to poor results. There was improvement in maximum active extension before surgery lacking 32 degrees to after surgery lacking 18 degrees . From a statistical standpoint rheumatoid joint involvement with PIP arthroplasty had poorer results than degenerative or posttraumatic arthritis with respect to pain relief and ROM. Pain relief was present in 70% of replaced PIP joints with residual pain and loss of strength in 30%. Radiographic analysis showed abnormal bone formation (cystic changes) in 45%. There were 11 implant fractures and 9 joints that required revision surgery. CONCLUSIONS: Silicone replacement of the PIP joint is effective in providing relief of pain from arthritis but does not provide improvement in motion or correction of deformity. It provided a poorer outcome in rheumatoid disease in comparison with degenerative, posttraumatic, or idiopathic arthritis.     

Proximal row carpectomy with capitate osteochondral autograft transplantation

Proximal row carpectomy (PRC) is an effective treatment option for degenerative or posttraumatic osteoarthritis of the wrist in conditions such as scapholunate advanced collapse, scaphoid nonunion advanced collapse, Kienbock disease, and chronic fracture dislocations of the carpus. PRC involves excision of the scaphoid, lunate, and triquetrum, and relies on the articulation of the remaining capitate from the distal row to articulate with the lunate fossa. PRC offers the potential advantage of greater range of motion, technical ease, and decreased immobilization, and eliminates specific complications found with other motion-preserving procedures such as nonunion, hardware irritation, and impingement. An established relative contraindication for PRC is the presence of advanced capitolunate arthritis. Many authors have offered modifications of the traditional PRC procedure to account for the presence of capitate arthritis. A PRC technique utilizing an osteochondral autograft, from the carpal bank of excised bones, for transfer to the capitate defect is described.     

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.     

Endoprosthetic surgery of the elbow

Artificial joint replacement has found a firm place in orthopaedic surgery since its first introduction in the late 1960s. While the initial fixed bearing implants tended to progress to early loosening, the development of so-called "sloppy joints" has seen a major advance in the survival and success rate of this arthroplasty. The surgical approach and technique have also been modified in such a way as to allow a complete ventral release of a flexion contracture, while at the same time preserving the integrity of the extensor mechanism. In this way, the improvement of the biomechanics of the implant combined with diligent surgical technique have enhanced this procedure dramatically. Between 1978 and 1999, 305 GSB 3-type prosthesis were implanted, with the underlying pathologies being rheumatoid arthritis (77%), posttraumatic arthritis (21%) and degenerative arthritis (2%). The range of motion could be significantly improved from the pre-operative state for extension as well as flexion. This was even more obvious in the rheumatoid than in the posttraumatic situation. The survival rate for this type of implant was 90% at 10 years, with the implants after rheumatoid surgery faring somewhat better than those of the posttraumatics. Alternative treatment options, such as resection arthroplasty, distraction arthroplasty, or arthrodesis, are nowadays employed only in rare cases where a previous infection, personal preference or an inability by the patient to co-operate in a rehabilitation program have to be considered. The overall functional results of these types of treatments seem to be inferior to that of elbow arthroplasty. Therefore, this procedure is recommended not only for advanced degenerative and rheumatoid pathologies, but also in cases of posttraumatic arthrosis.     

Pyrolytic carbon arthroplasty for posttraumatic arthritis of the proximal interphalangeal joint

PURPOSE: To prospectively evaluate the subjective and objective functional outcome of patients treated with a pyrolytic carbon proximal interphalangeal (PIP) joint arthroplasty for posttraumatic arthritis. METHODS: Five patients (7 joints) with traumatic injuries to the PIP joint were followed up for more than 1 year after pyrolytic carbon arthroplasty. All patients were treated with surgical reduction and stabilization at the time of the initial injury, but at a minimum of 6 months after the initial injury they had persistent pain, loss of motion, and functional limitations. All patients had a stable PIP joint with a satisfactory extensor mechanism but had radiographic evidence of posttraumatic arthritis. Patients were evaluated before and after arthroplasty with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and visual analog scale and by radiographic and physical examination. RESULTS: At an average of 17 months, the mean DASH questionnaire score was unchanged. The pain rating on the visual analog scale was 6 out of 10 before surgery and 4 out of 10 after surgery; this change was not statistically significant. The average range of motion of the PIP joint decreased by 10 degrees at the last evaluation. Grip strength improved from an average of 47 lb to 63 lb after surgery. CONCLUSIONS: The subjective and objective functional outcomes in 5 patients more than 1 year after pyrolytic carbon PIP joint arthroplasty for PIP joint trauma were disappointing. For posttraumatic patients, we no longer use pyrolytic carbon PIP joint arthroplasty.     

Der posttraumatische karpale Kollaps Verlauf und Therapiekonzept

Significant progress has been made in the understanding of carpal kinematics and posttraumatic disorders of the wrist. The importance of stabilization of the scaphoid is well known. More and more ligament injuries of the proximal carpal row have been diagnosed in cases of severe arthrotic changes. Long-standing scaphoid nounion or scapholunate ligament injuries can lead to progressive carpal collapse due to a break of the continuity of the proximal carpal row. SLAC-wrist (scapholunate advanced collapse) and SNAC-wrist (scaphoid nonunion advanced collapse) after missed fusion of scaphoid fractures should be differentiated. Severity of degenerative changes is classified into three stages. Salvage procedures preserving wrist mobility, like midcarpal fusion, are preferable to total wrist fusion because of the functional benefit. With complete excision of the scaphoid and fusion of the midcarpal joint, all arthritic joint surfaces are eliminated and motion is preserved in the radiolunate joint which is usually spared of degenerative changes.     

Four bone versus capito-lunate limited carpal fusion. Report of 40 cases

Fourty patients with limited carpal fusion have been retrospectively reviewed. The aim of this study was to compare the results of four bone fusions (30 wrists) versus capitolunate fusion (11 wrists). Follow-up averaged 30 months with a range of 15-96 months. Twelve patients presented SLAC-wrist (scapho-lunate advanced collapse) and fourteen with SNAC-wrist (sapho-non union advanced collapse). There were seven cases of primitive wrist arthritis, one mid-carpal instability, one sequella of Fenton's syndrome, one Preiser's disease and two Kienbock's disease. All 40 patients were evaluated by the same observer. In terms of range of motion, the capito-lunate fusion led to better results than the four bone fusions with a gain of 10 degrees in volar flexion and 12 degrees in radial deviation. Results in term of post operative pain are similar in the two groups of patients with 90% painless wrist in four bone fusion and 81% with capito-lunate fusion. Results for strength were equivalent. Radiological bone fusion was obtained within nine weeks. Absence of fusion was observed in two patients with capito-lunate fusion. Our result in terms of joint motion and strength are similar to those found in the literature. Correction or not of the DISI deformity during the procedure did not affect the results (on 19 patients). The Four bone fusion procedure is still a good treatment in SLAC or SNAC wrist. Capito-lunate fusion remains a good choice, despite the risk of non-fusion.     

Operative Behandlungsmöglichkeiten bei fortgeschrittenem karpalen Kollaps (SNAC/SLAC wrist)

Longstanding and untreated scaphoid fractures and scapholunate dissociations lead to painful destruction of the wrist with carpal collapse. The severity of degenerative arthrosis is classified in three stages and can be treated adequate operatively. SNAC wrist (scaphoid nonunion advanced collapse) after failed fusion of the scaphoid and SLAC wrist (scapholunate advanced collapse) after scapholunate dissociation should be differentiated. The reconstruction of the scaphoid or scapholunate ligament in stage II and III is no reasonable option. Motion preserving procedures such as proximal row carpectomy or midcarpal arthrodesis are preferable in this situation. Thirty-one male patients (average 41 years) were treated for SNAC or SLAC wrist with midcarpal arthrodesis. All patients were reexamined, the mean follow-up was 15 months. Grip strength was measured with the Dexter-System, pain was evaluated by a visual analogue scale (VAS 0-100). Patients' daily activities and general quality of life were estimated with the DASH-questionnaire. Pain was reduced to 50% compared to the preoperative situation. Grip strength improved to 60% of the opposite side. Active range of motion reached 50% of the contralateral wrist. Total DASH-score reached 39.0. Nonunion at the fusion site necessitated additional surgery in four patients resulting in total wrist arthrodesis. 80% of the patients returned to their original occupation. Midcarpal fusion is a reliable procedure for treating the difficult condition of advanced carpal collapse if proper realignment of the carpus is performed. The DASH-score reflects the subjective impressions of the patients in daily life and justifies the choice of a salvage procedure preserving wrist mobility. Total wrist fusion represents the last line of defense.     

Wrist arthroplasty with a new generation of prostheses in patients with rheumatoid arthritis.

The function of the wrist is frequently considerably impaired by early destruction in patients with rheumatoid arthritis. The aim of endoprosthetic arthroplasty is to restore functional use and provide freedom from pain. In our study a newly developed, uncemented wrist prosthesis was implanted in 30 patients (24 women and 6 men) with advanced destruction of the wrist. This wrist prosthesis is a hydroxyapatite-coated cobalt-chrome prosthesis with a titanium coating of the articular surfaces. The radial component has an articular surface inclination of 10 degrees toward the ulna, and the carpal component, which is anchored with its tip in the distal carpal bones and third metacarpal bone, has a double articular surface with a radial inclination of 10 degrees. At the 18-month follow-up visit, the following parameters were examined: x-ray, grip strength, range of motion, and the patient's subjective satisfaction. Good improvement of function was found in 92% of the patients; 87% were free of pain. Eighty-eight percent of the patients rated the outcome of surgery as good. If the indication is accurately diagnosed, this wrist prosthesis can markedly improve function, which in turn leads to high patient acceptance. Various salvage procedures remain open because of the minimal loss of bone stock and the uncemented implantation of the prosthesis.     

Capitolunate arthrodesis with scaphoid and triquetrum excision

A retrospective two-center outcome study was designed to evaluate the results of capitolunate arthrodesis with scaphoid and triquetrum excision mainly for scapholunate advanced collapse patterns of arthritis. Fourteen wrists in 14 patients were evaluated objectively by standard parameters and subjectively by the Short Musculoskeletal Functional Assessment at an average of 28 months after surgery (range, 14-51 months). All patients were men between the ages of 20 and 70 years (average, 49 years). Two patients had a painful nonunion and one had persistent pain despite conversion to a solid wrist arthrodesis. One patient had x-ray evidence of progressive radiolunate narrowing, but only occasional pain. Postoperative wrist flexion-extension arc was 53 degrees and radioulnar deviation arc was 18 degrees. Grip and pinch strengths were 71% and 75%, respectively, of the normal contralateral wrist. The results of our study indicate that capitolunate arthrodesis with scaphoid and triquetrum excision is comparable to other motion-preserving operative procedures for scapholunate advance collapse.     

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.     

Total wrist arthroplasty. Experience with Swanson flexible silicone implants, 1982-1988.

In a study of the results of silicone rubber arthroplasty of the wrist 18 patients (19 operated wrists) were re-examined after a mean follow up of five years. Experience with the ulnar head implant was discouraging, and it was not used in the last eight wrists. This did not affect the outcome, patients having good supination and pronation without pain. The range of motion with the radiocarpal prostheses was 0-70 degrees, mean 39 degrees. Radiological results showed severe subsidence in all patients followed up for more than two years, and prosthetic fracture in five (26%), which was disappointing. Nevertheless the patients had a useful range of motion and all but two were relieved of pain. By the patients' own assessments 16 wrists were considered good, one fair, and two poor. Predictors of failure (prosthetic fracture) were poor alignment before operation, postoperative range of motion of more than 50 degrees, and rupture of the carpal extensor tendon. With these reservations we recommend the silicone spacer as the best solution for most patients with severe problems of the wrist as a result of rheumatoid arthritis.     

Results of resection of the head of the ulna]

A follow up of 57 wrists with resection of caput ulnae shows different value to different groups of patients. The painful arthrosis of distal radioulnar joint gives indication in posttraumatic cases. Release of pain and improvement of range of motion will be achieved; loss of strength is the most impairing problem for younger patients. 13 patients out of 21 with posttraumatic deformities were satisfied with the post-operative outcome; 13 patients showed significant loss of strength, too. In case of rheumatoid arthritis with caput-ulnae-syndrome the resection is without alternative, needs to be combined with the arthrodesis of radiolunar-joint, if necessary. 20 of 34 rheumatics were satisfied with the outcome after resection of caput ulnae; in 6 cases an ulnar drift was evident, which implied simultaneous or later partial arthrodesis of the wrist. For all patients release of pain decided on their satisfaction with surgery.     

Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist)

SUMMARY: Outcome evaluation of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist). PURPOSE: Scaphoid nonunion or scapholunate ligament instability results in carpal collapse and subsequent arthrosis. These conditions, termed SLAC-wrist and SNAC-wrist, are the most common patterns of arthrosis in the wrist. The purpose of this retrospective study was the evaluation of functional outcomes following midcarpal arthrodesis and of patients' satisfaction with these outcomes. METHODS: Forty-nine patients were reexamined at a mean follow-up time of 47 months. Active range of motion (AROM) was verified with a goniometer; grip strength was measured with a JAMAR-Dynamometer II. Pain was evaluated by a visual analogue scale from zero to 100 (VAS 0-100) for stress and under resting conditions. Patients' upper-extremity functioning was captured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Radiographic evaluation of bony consolidation was verified by conventional x-ray. RESULTS: Postoperative AROM was 56% and grip strength was 76% compared with the contralateral side. The DASH score was 29 points. Pain relief was 34% at rest and 31% after stress. Forty-five patients demonstrated bony consolidation in x-ray control. Six patients (12%) further required a total arthrodesis of the wrist because of pain or absence of bony consolidation. CONCLUSION: Our data demonstrate that midcarpal arthrodesis is a reliable procedure for treating SLAC- and SNAC-wrists in stages II and III and, furthermore, one which preserves some range of motion. Total wrist fusion should only be used in exceptional circumstances.     

Radiolunäre und radioskapholunäre Arthrodese bei chronischer Polyarthritis

INTRODUCTION: In 75% of all cases of rheumatoid arthritis the wrist is affected and in 12% is the region of initial manifestation of this chronic inflammatory joint disease. To prevent destruction of the wrist through carpal dislocation, radiolunate and radioscapholunate arthrodeses have increased in importance. METHODS: During a 6.5-year period, 28 radiolunate and 4 radioscapholunate arthrodeses were performed in 30 patients. The indication for operation was progressive carpal translation and increasing subluxation of the wrist in which existent radiological damage had not reached more than grade III according to the classification of Larsen and co-workers. RESULTS: The results obtained during the follow-up study (median: 17.3 months) showed in most treated patients after partial arthrodesis of the wrist no or fewer complaints concerning swelling and pain and an acceptable remaining range of motion of the wrist in everyday life. In patients with preoperatively existing ulnar deviation less than 15 degrees progressive carpal collapse and dislocation could be mostly prevented. CONCLUSION: All told radiolunate and radioscapholunate arthrodeses successfully stabilized the wrist in patients suffering from rheumatoid arthritis.     

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.