Fate of failed Meuli total wrist arthroplasty

Sixteen Meuli wrist arthroplasties in 13 patients suffering mainly from rheumatoid arthritis were revised for failure. Causes for failure were mechanical problems with the implant in three wrists, soft tissue problems in two wrists and a combination of mechanical failure and soft tissue problems in 11 wrists. Management included 11 revision arthroplasties in ten wrists, four arthrodeses and two primary soft tissue reconstructions. Twenty-six additional soft tissue procedures were required in association with the revision arthroplasties or arthrodeses. Five of the 11 revision arthroplasties had to be converted to arthrodeses after an average of 5 (range 3-8) years. After removal of a failed wrist implant union of the salvage arthrodesis was difficult to achieve in two of the nine instances. This series demonstrates that revision arthroplasty may be a useful alternative to arthrodesis for the salvage of primary wrist arthroplasties in rheumatoid patients. However, complications and reoperations may occur after both revision arthroplasty and arthrodesis.     

Ulnocarpal abutment after wrist arthrodesis

We report three patients aged from 22 to 34 years, in whom ulnocarpal abutment developed after wrist arthrodesis. Two were treated by excision of the triquetrum and one by excision of the pisiform. The three patients were seen after wrist fusion because of ulnar wrist pain on forearm rotation, which was relieved by excision of a carpal bone. Two patients had had wrist arthrodesis because of wrist pain resulting from degenerative arthritis and silicone synovitis resulting from silicone rubber replacement of the lunate as treatment for Kienb?ck's disease. One patient had had a wrist arthrodesis to treat degenerative arthritis after an intra-articular distal radius fracture. The arthrodeses were all done with an A. O. plate and iliac crest bone graft. One patient gained forearm rotation after the excision of the carpal bone and none of the patients lost rotation. The average follow-up was 16 months.     

Results of four-corner arthrodesis using dorsal circular plate fixation

PURPOSE: Four-corner arthrodesis with scaphoid excision has been used to reduce pain and preserve functional range of motion for patients with radioscaphoid arthritis. Early results of 4-corner arthrodesis with scaphoid excision using dorsal circular plate fixation are compared with reported results in the literature. METHODS: We reviewed retrospectively the first 18 four-corner arthrodeses performed with this system by 4 hand surgeons. Two patients had revision surgery for nonunions before the study that were considered failures. Eight patients returned for final radiographs, objective examination, and functional questionnaire. The average follow-up period was 20 months (range, 13-33 mo). These results were compared with reported results in the literature using alternate fixation methods. RESULTS: Radiographic union was achieved in only 3 wrists. Range of motion was 46% that of the opposite normal wrist and grip strength compared with the opposite wrist was 56%. Five patients would have the procedure again and 6 of 8 have returned to their original employment. CONCLUSIONS: Four-corner arthrodesis with scaphoid excision using a circular internal fixation plate produced a high number of nonunions. Grip strength and range of motion results also were inferior to those reported in the literature.     

Biomechanical comparison of three fixation techniques used for four-corner arthrodesis

Clinical results following four-corner arthrodesis vary and suggest that nonunion may be related to certain fixation techniques. The purpose of our study was to examine the displacement between the lunate and capitate following a simulated four-corner arthrodesis with the hypothesis that three types of fixation (Kirschner wires, dorsal circular plate, and a locked dorsal circular plate) would allow different amounts of displacement during simulated wrist flexion and extension. Cadaver wrists with simulated four-corner arthrodeses were loaded cyclically either to implant failure or until the lunocapitate displacement exceeded 1 mm. The locked dorsal circular plate group was significantly more stable than the dorsal circular plate and K-wire groups (p = 0.018 and p = 0.006). While these locked dorsal circular plates appear to be very stable our results are limited only to the biomechanical behavior of these fixation techniques within a cadaver model.     

A new plate for partial wrist fusions: results in midcarpal arthrodesis

Partial wrist fusions are commonly performed for various degenerative conditions. In this series 30 wrists had a scaphoidectomy and midcarpal arthrodesis performed with a new plate. The most common indications were SLAC and SNAC wrists. In 24 cases a four-corner arthrodesis was done and in the other six the triquetrum was not included. Mean follow-up was 3 years. Mean flexion was 31° and extension 35°. Union was achieved in all wrists despite movement being commenced early. The plates proved straightforward to use, allowing some latitude in placement. This series confirms that scaphoidectomy and midcarpal arthrodesis is a useful salvage procedure and that these plates are suitable for that purpose.     

Comparison of arthroplasty and arthrodesis for the rheumatoid wrist

PURPOSE: To compare the outcomes of wrist arthrodesis and arthroplasty in the treatment of rheumatoid arthritis using validated outcome patient surveys and a review of surgical complications in 2 matched cohorts. METHODS: Forty-six patients with 51 operated wrists (24 arthrodeses and 27 arthroplasties) were reviewed retrospectively at a follow-up range of 1 to 5 years. Patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) inventory, the Patient-Rated Wrist Evaluation (PRWE), and a questionnaire designed specifically for this study. Surgical complications were obtained by chart review. RESULTS: Treatment groups were well matched by patient characteristics and radiographic staging. There were no statistical differences in the survey scores between the 2 groups. Patients in the arthroplasty group, however, reported a trend toward greater ease with personal hygiene and fastening buttons. Complication rates were similar with a 56% complication rate in the arthrodesis group (22% major, 35% minor) and a 52% complication rate in the arthroplasty group (11% major, 41% minor). CONCLUSIONS: The DASH and PRWE may not be designed properly to measure impairment caused by wrist disease in patients with generalized arthritis. The results show that patients with rheumatoid arthritis can and do accommodate to a wrist arthrodesis. It should not be construed, however, that patients with rheumatoid arthritis would not prefer or obtain greater benefit from a wrist arthroplasty [corrected].     

Long term results of arthrodesis of the wrist: a 6-15 year follow up of 35 patients.

A total of 40 wrists in 35 patients were investigated 10.5 (range 6-15) years after arthrodesis. The most common diagnosis was rheumatoid disease. There were 21 Mannerfelt, and 21 plate, arthrodeses. The patients were assessed clinically and up-to-date radiographs obtained. Two Mannerfelt arthrodeses had failed to fuse. Pain during the last week before review and total satisfaction with the operation were excellent in 28 and 30 wrists, respectively. The mean score on the "Disability of arm, shoulder and hand" (DASH) questionnaire was 38 (range 2-75). Plate arthrodeses gave better results than Mannerfelt arthrodeses for all variables studied. Wrists plated in dorsal extension gave the best scores for function and strength. We conclude that either method gives good long term results. Although few of the individual differences were statistically significant, we think that fusion with plates, and in particular plates with dorsal extension, is preferable.     

A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist

This retrospective study compared plate fixation versus pin fixation in 57 patients with rheumatoid arthritis who underwent wrist arthrodesis. Fixation was achieved by using plates in 32 patients and longitudinal pins in 25 patients. Clinical follow-up averaged 29 months (range: 12-57 months) and radiographic follow-up averaged 16 months (range 12-39 months). Union occurred in 97% of the wrists fixed with plates and in 96% of the wrists fixed with pins. There were 6 (19%) complications in the plate group and 7 (28%) complications in the pin group. Three (12%) wrists fixed with pins moved from the immediate postoperative position to a position of relative volar flexion, while radiographs showed no changes in wrist position in the plate group. With both methods, successful arthrodesis stabilized the wrist in a high percentage of patients. Plate fixation offers an excellent alternative method for arthrodesis of the rheumatoid wrist.     

Radio-lunate arthrodesis

Radio-lunate arthrodesis has been carried out in 15 rheumatoid patients whose radiographs showed localised arthritis around the radio-lunate joint. Six patients had insertion of a Stanley-Shelley plate. The results were assessed from 1 to 3 1/2 years after operation and were excellent in nine wrists, good in three, fair in one and poor in three wrists. Continued carpal degeneration in 12 wrists suggests that long-term follow-up is required before this procedure can be generally recommended.     

Motion of the wrist after simulated limited intercarpal arthrodeses. An experimental study

Seven different types of intercarpal arthrodeses that are commonly used in clinical practice were simulated in wrists of cadavera by drilling two nonparallel Kirschner wires across the involved joint that was to be fused. The changes in radial deviation, ulnar deviation, dorsiflexion, and palmar flexion, and the arc of motion in two planes (radial plus ulnar deviation and dorsiflexion plus palmar flexion) were compared with control values for each specimen and with each of the other arthrodeses. All of the data were analyzed by calculating the mean and standard error of the changes in these motions of the wrist as compared with the control values for each wrist. The statistical significance of the changes was derived by the t test. For values of t greater than 2.262, the observed mean reductions in the motions were statistically significant (p = 0.05) in all wrists except those that had simulated arthrodesis of the lunate-triquetrum or the capitate-hamate joint. No statistically significant differences were noted between the effects of arthrodesis of the scaphoid-trapezium-trapezoid, scaphoid-capitate, and scaphoid-lunate joints on the motions of the wrist. All arthrodeses except those of the lunate-triquetrum and the capitate-hamate joint produced a statistically significant decrease in the total arc of motion; arthrodesis of the capitate-lunate joint produced the most statistically significant decrease in total arc of motion. In our opinion, the results of the study suggest that there is limited justification for arthrodesis of the capitate-hamate joint.(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes in hand function following wrist arthrodesis in cerebal palsy

Eleven wrists in ten patients with cerebral palsy underwent wrist arthrodesis. All patients were reviewed between 6 and 121 months after surgery. Operative technique involved AO plate fixation in nine wrists. When the distal radial physis was still open (two wrists), stabilization was achieved using K-wires. A proximal row carpectomy was performed in eight patients. Soft tissue releases were necessary in three wrists. The procedure achieved its aim of improving hygiene and cosmesis. Functional improvement in the hand was noted in eight wrists. Function was consistently improved in athetoid patients.     

Complications of trapeziometacarpal arthrodesis using plate and screw fixation

PURPOSE: This study was designed to determine the complications associated with plate and screw fixation of thumb trapeziometacarpal arthrodesis and to compare these results with a previous report from our institution using K-wire fixation. METHOD: We retrospectively reviewed 26 trapeziometacarpal arthrodeses that used plate and screw fixation. The most common diagnosis was primary osteoarthritis and the average follow-up evaluation was 40 months. Nineteen patients were available for a clinical follow-up examination and radiographs. These results were compared with the previously published K-wire fixation group that consisted of 59 arthrodeses with an average follow-up period of 84 months. RESULTS: There were 2 (8%) painful nonunions. There were 6 (23%) hardware malpositions, most frequently associated with a screw in the trapeziotrapezoid joint. Seven (27%) arthrodeses had a second procedure, most commonly hardware removal. Twenty-one (81%) of the patients were satisfied and reported they would have arthrodesis again. In the K-wire fixation group 4 of 59 (7%) arthrodeses went on to nonunion and 2 of 59 required a secondary procedure; patient satisfaction was high (98%). CONCLUSIONS: K-wire and plate and screw fixation have comparable union rates. In the plate and screw fixation group, however, the satisfaction rate was lower and a second surgery was more common. We now recommend pin fixation when performing trapeziometacarpal joint arthrodesis.     

Current status of wrist arthrodesis

AIM: In order to ascertain the value and future of wrist arthrodesis we assessed the results of 47 wrist arthrodeses performed at the Departments of Orthopaedic and Trauma Surgery of the University of Goettingen between 1980 and 1998. METHOD: In a retrospective analysis we examined the patients clinical and radiological records. Evaluating the results we used the score described by Lohmann and Buck-Gramcko in order to consider function, pain, strength and assessment of the patient him/herself. RESULTS: 93.6 % of all cases could be examined. We found a wrist arthrodesis in posttraumatic arthritis in 22 cases and in rheumatoid arthritis in 25 cases. Plate (n = 30) and Rush-Pin osteosynthesis (n = 17) were used as surgical procedures. In all patients we found a successfully stabilised wrist, although in 3 trauma cases a further surgical procedure was necessary. A better function of the wrist was reached in every patient. The majority of the patients had no pain and an acceptable strength. The results obtained showed good and excellent results in 86.4 % of the wrist arthrodesis for post-traumatic arthritis and in 90.9 % for rheumatoid arthritis. CONCLUSION: The increase in quality of life, especially in patients suffering from rheumatoid arthritis, shows the procedure of wrist arthrodesis to be a still worthwile surgery.     

不同内固定在舟大小多角骨融合术中稳定性的比较研究

目的 比较舟骨和大、小多角骨(scaphoid-trapezium-trapezoid,STT)融合器与克氏针在STT融合术中内固定强度的差异.方法 12侧新鲜冷冻尸体前臂标本,随机分为融合器组(使用STT融合器)和克氏针组(使用克氏针)2组,模拟进行STT融合术,术后以夹具固定于腕动力测试仪上模拟腕关节主要活动.活动前后均拍摄腕关节标准正侧位X线片,测量桡舟角、桡舟间距、舟骨长度及STT融合体稳定角.结果 融合器组:当腕关节运动范围增加到屈曲45°、背伸40°、尺偏30°、桡偏15°时,客观指标与初始状态相比较变化差异均无统计学意义(P＞0.05).克氏针组:当腕关节运动范围增加到屈曲35°、背伸30°、桡偏10°时,客观指标与初始状态相比较变化差异均有统计学意义(P＜0.05).尺偏30°运动后融合体稳定角与初始状态相比较差异有统计学意义(P＜0.05).结论 STT融合器在舟骨和大、小多角骨融合术中内固定强度大于传统内固定物中的克氏针.     

Wrist arthrodesis

Twenty consecutive patients were treated with wrist arthrodesis. Nine patients had rheumatoid arthritis, and eleven patients had a variety of other arthritic conditions. The average follow-up time was 34 months. Clinical examination and roentgenograms showed that eighteen patients had solid fusion of their wrists, with an average of 11 weeks of immobilization. Two patients had delayed union--one of them removed his cast after the operation. No reason for the delayed union was found in the second patient, who had rheumatoid disease. Ultimately, both patients had solid fusions after a total immobilization time of 20 weeks and 16 weeks, respectively. Solid fusion, pain relief, and satisfactory functional results can be achieved following wrist arthrodesis. Prerequisites for obtaining such results are as follows: First preoperative assessment of the patient's upper extremity level of function and range of motion (ROM) of all other joints of the extremity, and radiographic assessment of wrist and hand deformities. Second, during surgery, rigid fixation should be obtained and wrist deformity if present, as in rheumatoid disease, should be corrected. Third, a postoperative rehabilitation program should include range of motion of other joints, muscle strengthening, and functional activities.     

Intercarpal and radiocarpal resection arthroplasty and arthrodesis

Indications for intercarpal and radiocarpal resectionarthroplasty and fusions are osteoarthritis, KIEHNBOCK'S disease, rheumatoid arthritis and several posttraumatic disorders of the wrist joint. The resection of carpal bones leads to severe instability patterns of the wrist. In conclusion we recommend resection-arthroplasty just for treatment of the thumb carpo-metacarpal osteoarthritis. Implant resection arthroplasty of the lunate and scaphoid or total wrist implants are still causing multiple problems regarding heavy load. Therefore this implants should be confined to rheumatoid patients. Of the limited carpal arthrodeses the scaphotrapezium-trapezoid arthrodeses is the most frequent performed procedure. It can be indicated for STT-osteoarthritis, KIEHNBOCK's disease, scapho-lunate instability and scaphoid pseudarthrosis if other surgical procedures had failed presuming there are no signs of arthrosis in the radiocarpal joint. Persisting pain especially in heavy work is quite frequent after limited arthrodesis but can be greatly relieved by simultaneous wrist denervation. In advanced cases of osteoarthritis total wrist arthrodesis is still the best choice for the patient.     

Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.     

Limited arthrodesis for the rheumatoid wrist

Limited arthrodesis of the proximal carpal row to the radius, synovectomy of the extensor tendons and the wrist joint, and a Darrach procedure were carried out in 25 unstable painful rheumatoid wrists that had ulnar shift and/or palmar subluxation of the carpus. The average follow-up period after the operation was 3 years. Satisfactory results were obtained with relief of pain, improved forearm rotation, and increased grip strength. The average degree of extension and flexion was reduced, respectively, 70% and 54% at follow-up compared with the preoperative range. Postoperative x-ray films showed deterioration in the lunocapitate joint in 12 wrists; however, the wrists remained stable and painless.     

Primary stability of shoulder arthrodesis using cannulated cancellous screws

There are no biomechanical studies available concerned with the primary stability of shoulder arthrodesis. The aim of our biomechanical investigations was to ascertain a minimal material combination with high primary stability for shoulder arthrodesis. For that purpose, the primary stability of 6 different forms of screw arthrodesis was investigated under the stress of abduction, adduction, anteversion, and retroversion. The mean values of the screw arthrodeses were compared with those of a 16-hole plate arthrodesis. All tests were carried out on 24 human specimens without destruction by use of a materials testing machine. The most stable form of screw arthrodesis for the load directions of abduction, adduction, anteversion, and retroversion results from a specific configuration of screws comprising 3 horizontal humeroglenoid screws and 3 vertical acromiohumeral screws (318.5 +/- 99.0 N). For three forms of arthrodesis, each with 3 humerus-glenoid screws (299.9 +/- 95.4 N), no significant difference (P = .530) was found compared with a 16-hole plate arthrodesis (293.4 +/- 89.3 N). The plate arthrodeses only achieved higher power values on abduction and adduction stress in comparison with screw arthrodesis with 3 humerus-glenoid screws. The difference was insignificant. Because arthrodesis with 3 humerus-glenoid screws was significantly more stable on stress of anteversion and retroversion, this particular screw arthrodesis is considered superior to plate arthrodeses. The use of the most stable form of screw arthrodesis may reduce nonunion.     

腕关节部分融合治疗退行性腕关节炎的疗效

目的评价头骨、月骨、三角骨及钩骨四关节融合治疗退行性腕关节炎的效果。方法1997年7月～2002年12月应用腕关节部分融合术创伤性腕关节炎治疗20例,术后随访15个月,随访检查包括术后腕关节疼痛程度、腕关节活动度、握力以及患侧X线检查。视觉模拟评分法评价疼痛程度。腕关节总体功能评价采用Krimmer腕关节评分表。结果腕疼痛值静息时为2.1,用力后为5.3;屈伸活动度为64°(对侧126°);尺桡偏为30°(对侧57°);平均握力为24kg(对侧40kg)。Krimmer腕关节评分值为67。X线检查头、月、三角及钩骨均融合。结论腕关节部分融合后能保存腕关节部分功能,是治疗退行性腕关节炎有效的方法。