Functional and patient-reported outcome of partial wrist denervation versus the Mannerfelt wrist arthrodesis in the rheumatoid wrist

Introduction

Wrist arthrodesis offers high success rates in patients with rheumatoid arthritis; however, loss of residual mobility may cause unnecessary disability. This makes wrist denervation an appealing alternative. However, there is a distinct lack of patient-reported outcome measure studies comparing these two procedures. The aim of this study was to report any change in function, pain and satisfaction following wrist arthrodesis compared to denervation in a single surgeon series of rheumatoid patients.

Patients and methods

The results of 16 wrist arthrodesis in 15 patients and 14 partial (PIN) wrist denervations in 13 patients were compared with a mean follow-up period of 39 and 22 months, respectively. The primary outcome measures were the same for both groups and included the validated patient-rated wrist evaluation questionnaire and a satisfaction questionnaire.

Results

Wrist arthrodesis significantly improved the mean total pain and functional outcome scores by 54 and 36 %, respectively, at the time of follow-up. Wrist denervation patients also reported significant improvements of 44 and 42 % in total pain and functional outcomes, respectively; 87 % reported being very satisfied with their wrist arthrodesis procedure compared to 78 % in the denervation group. No statistically significant difference in response between the groups was observed in this series of patients.

Conclusions

Both procedures enjoyed favourable results amongst patients with excellent satisfaction outcomes. PIN denervation is a simple procedure with low complication rates and we therefore consider it a valid alternative to more difficult treatment options, such as partial or total wrist arthrodesis.     

Klinisch-funktionelle Nachuntersuchung verschiedener handchirurgischer Versteifungsmethoden

Background

Total and partial arthrodesis of the wrist are currently sophisticated treatment options for many advanced pathological changes of the wrist. This retrospective study analyzed the subjective and objective outcome of different wrist arthrodesis techniques, e.g. total wrist arthrodesis, scaphotrapeziotrapezoid (STT) bone fusion and midcarpal arthrodesis.

Materials and methods

Subjective physical and mental quality of life of 98 patients (total wrist arthrodesis n?=?43, STT fusion n?=?30 and midcarpal arthrodesis n?=?25) was measured using the DASH questionnaire. The range of motion and grip strength were analyzed in 48 patients (total wrist arthrodesis n?=?21, STT fusion n?=?17 and midcarpal arthrodesis n?=?10).

Results

Patients with partial wrist arthrodesis achieved a significantly better DASH score than patients with total wrist arthrodesis. Grip strength did not show any statistically significant differences between the two groups. Patients with STT fusion showed the best range of motion of the wrist.

Conclusion

Partial arthrodesis seems to be superior to total wrist arthrodesis. Patients profit from a higher physical and mental quality of life.     

Four-corner arthrodesis with a radiolucent locking dorsal circular plate: technique and outcomes

Background

Scaphoid excision and four-corner arthrodesis (FCA) is an acceptable motion sparing procedure used to treat wrist arthritis. Recently, a locking dorsal circular plate composed of polyether-ether-ketone has been introduced (Xpode®; TriMed Inc.). The purpose of this study is to assess the efficacy of this specific plate design with regard to FCA.

Methods

A retrospective chart review of all patients who underwent FCA with an Xpode® between January 1, 2008 and December 31, 2012 was conducted. Patients were contacted and asked to return to clinic for clinical and radiographic follow-up. Patient demographics, range of motion, grip strength, and complications were collected from medical records. Patients completed a patient-rated wrist evaluation (PRWE). A paired t test was used to compare means, and p values <0.05 were considered statistically significant.

Results

Twenty-six procedures (24 patients) were identified. One patient required full wrist fusion following the initial procedure. Of the 25 remaining wrists, arthrodesis was successfully achieved in 20 (80 %). Eleven patients (13 wrists, 52 %) returned to clinic for an average follow-up of 28 months. Mean wrist extension improved from 30 to 47°, and flexion decreased from 33 to 23°. Average grip strength was 77 % of the uninjured side. The mean PRWE scores for pain and function were 19.7 and 17.1, respectively. Five patients underwent additional operations (two hardware removals, two contracture releases, and one distal radial ulnar joint arthroplasty).

Conclusions

FCA with the Xpode® yielded reasonable results for pain and function and demonstrated a fusion rate of 80 %.     

Effect of static wrist position on grip strength

Background:

Grip strength after wrist arthrodesis is reported to be significantly less than normal. One of the reasons suggested for this decrease in grip strength is that the arthrodesis was performed in a suboptimal position. However, there is no consensus on the ideal position of wrist fusion. There is a paucity of studies evaluating the effect of various fixed positions of the wrist on grip strength and therefore, there is no guide regarding the ideal position of wrist fusion. The authors′ aim was to determine the grip strength in various fixed positions of the wrist and subsequently to find out in which position of wrist fusion the grip strength would be maximal.

Materials and Methods:

One hundred healthy adults participated in the study. For the purpose of this study, the authors constructed splints to hold the wrist in five different fixed positions: 45, 30 and 15 degrees of wrist extension, neutral and 30 degrees of wrist flexion. The grip strength in all the participants was measured bilaterally, first without a splint and then with each splint sequentially.

Results:

The average grip strength without the splint was 34.3 kg for right and 32.3 kg for the left hand. Grip strength decreased by 19–25% when the wrist was splinted. The maximum average grip strength with a splint on was recorded at 45 degrees of extension (27.9 kg for right and 26.3 kg for left side). There was a gradual increase in the grip strength with increase in wrist extension but the difference was not statistically significant (P = 0.29). The grip strength was significantly less in flexed position of the wrist (P < 0.001).     

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.     

Fusion of the wrist in rheumatoid arthritis: a clinical and functional evaluation of two surgical techniques

We retrospectively compared wrist arthrodesis using the Mannerfelt technique in 19 or an AO-plate in 23 patients with long-standing rheumatoid arthritis. The mean follow-up was for 76 months. Compared with the Mannerfelt fusion group, patients in the AO-plate group reported greater satisfaction with their wrist function (74% vs 37%, p = 0.015). Complications were reported in six wrists in the AO-plate group and two wrists in the Mannerfelt fusion group (p = 0.258). At final follow-up, 95% of patients (41) reported either no pain or only mild pain. There was improvement in flexion of the finger joints in both groups but no significant improvement in the extension lag in either group. Both methods relieve pain and improve function. Overall, the activities of daily living scores and the patients' subjective assessment of outcome tended to be higher in the AO-plate group than in the Mannerfelt fusion group, although the difference was not statistically significant. Similarly, although more postoperative complications occurred in the AO-plate group, the difference between the two groups was not statistically significant.     

Four-corner arthrodesis: influence of the position of the lunate on postoperative wrist motion: a cadaveric study

PURPOSE: Evaluate the influence of the position of the lunate on postoperative wrist motion in four-corner arthrodesis. METHODS: Six upper cadaveric limbs were evaluated, comparing the total arc of motion in each wrist after simulating four-corner arthrodesis. The lunate was fixed in 3 different positions: neutral (0 degrees ), extended (30 degrees ), and flexed (20 degrees ). Statistical analyses (ANOVA and Bonferroni tests) were carried out to establish the significance of differences in articular motion in these 3 positions. RESULTS: Significant statistical differences were observed in full wrist extension. No significant differences, however, were found in flexion-extension total arc of motion, radial deviation, or ulnar deviation. CONCLUSIONS: According to our results in this cadaveric model, the position of the lunate affects postoperative wrist flexion and extension after four-corner arthrodesis. The flexed lunate position increases postoperative wrist extension and restrains wrist flexion. Inversely, the extended lunate position improves articular flexion and limits extension. Total arc of motion of the fused wrist does not vary in the 3 lunate positions.     

Langzeitergebnisse nach Handgelenkdenervation

Background

This retrospective study examines long-term follow-up results after complete denervation of the wrist.

Patients and methods

Between 1994 and 2000 a total of 61 complete wrist denervations of 59 patients (median age at operation 46 years) were performed. In 2009 29 patients with 30 complete wrist denervations took part in a follow-up examination after an average of 10 years. The mobility of the wrist and the grip force were examined. Pain and satisfaction with the operation were determined by means of a visual analogue scale (VAS) (0–100). The patients were asked about pain reduction and how long it lasted. Further the DASH and the Mayo Wrist Score were evaluated. Radiographs of the denervated wrist were performed and the degree of the degenerative osteoarthritis was determined according to Knirk and Jupiter.

Results

In 7 of the 36 patients examined, a partial or total wrist arthrodesis was performed. These patients were excluded from the study. Pain was improved in 28 of the 30 denervated wrists examined, in 22 the improvement lasted until the follow-up examination, whereas in 6 the pain increased after a median of 90 months. The median pain intensity was 10 at rest and 50 with activity; the satisfaction was 90. The median of the extension/flexion was 81% and the grip force 82% in comparison to the opposite hand. The DASH Score was 25 and the Mayo Wrist Score 73.

Conclusion

Complete denervation of the wrist according to Wilhelm is a treatment option for the chronically painful wrist and can lead to good grip force, mobility, sufficient pain reduction and satisfaction in the long term.     

The Mannerfelt wrist arthrodesis – A study of patient-reported outcomes in a rheumatoid population

BackgroundWrist arthrodesis has been established as a mainstay form of surgical intervention in the rheumatoid wrist. Despite this however, there is a distinct lack of patient-reported outcome measure (PROM) studies justifying the efficacy of this procedure in rheumatoid disease. The aim of this study was to report any change in function or pain following the tunnel Mannerfelt wrist arthrodesis in a single surgeon series of rheumatoid patients over a 6 year period.Methods14 consecutive patients (15 wrists) who had undergone the Mannerfelt wrist arthrodesis were followed prospectively with a mean follow up period of 45 months. No patients were lost to follow up. The primary outcome measures included the validated Patient Rated Wrist Evaluation (PRWE) questionnaire and a satisfaction questionnaire.ResultsThe mean total pain score improved from 41 points preoperatively to 14.2 points postoperatively correlating with a 65.4% improvement in overall pain outcomes. The mean total functional score improved from 83.7 points preoperatively to 45.5 points postoperatively demonstrating a 45.6% improvement in overall function at the time of follow up.ConclusionsAll patients reported an overall improvement in pain and functional capacity. The satisfaction results were excellent. All patients reported that they would elect to have the procedure again with the vast majority being ‘very pleased’ with the outcome of their surgery (93.7% very pleased and 6.3% fairly pleased). The procedure enjoyed favourable mid-term results and we recommend the tunnel Mannerfelt wrist arthrodesis for improving both pain and level of function in this group of patients.     

Partial wrist arthrodesis versus arthroplasty for distal radius giant cell tumours

Purpose

The purpose of this study was to evaluate the clinical efficacy of using the proximal fibular graft for partial wrist arthrodesis or arthroplasty after the resection of giant cell tumours of the distal radius.

Methods

Between February 2006 and August 2010, 14 patients (seven males, seven females; average age, 35.7 years) with grade II and III giant cell tumours of the distal radius were treated by tumour resection and autologous proximal fibular grafts to reconstruct the wrist in our hospital. Seven patients each were treated by wrist arthroplasty and partial wrist arthrodesis, and were followed up for 2.2–6.8 years (average, 3.9 years).

Results

All patients achieved primary healing. No tumour recurrence was observed during follow-up in any of the patients. No statistically significant difference in forearm rotation was observed between patients undergoing the two different treatments. However, wrist flexion-extension activities were significantly better and the wrist grip strengths were significantly worse in the arthroplasty group than in the arthrodesis group. The Musculoskeletal Tumour Society score did not significantly differ between the groups.

Conclusions

Overall, joint arthroplasty remains a favourable treatment with regard to the functional outcome for giant cell tumours of the distal radius; however, some of these patients may have a weaker grip strength. In comparison, partial wrist fusion appears to provide a durable and stable wrist with good long-term functional outcome.     

Radio-lunate arthrodesis in rheumatoid arthritis: outcome and techniques

Background and purpose

The wrist is one of the most affected joints in rheumatoid arthritis. The purpose of this retrospective study was to assess clinical, functional and radiographic results of radio-lunate arthrodesis. Two different operation and fixation techniques are compared and detailed outcome after this intervention is presented.

Methods

Twenty-seven patients with long-standing rheumatoid arthritis were operated on, either by stabilisation of the arthrodesis with Shapiro staples (n = 14) or by Herbert screw (n = 13) and followed for a mean of 5.4 years.

Results

Radio-lunate arthrodesis resulted in high overall and subjective satisfaction concerning function, grip and return to work. Grip strength was 35 kPa for the dominant and 26 kPa for the non-dominant hand. No revision, pseudoarthrosis or hardware failure was observed; only two conservatively treated wound healing problems were reported. The procedure resulted in a mean flexion of 26° and a mean extension of 24°; a clear improvement was also seen in activities of daily life. No difference between both groups was observed for pain, complication rate or functional outcome.

Interpretation

Due to high patient satisfaction and functional outcome, radio-lunate wrist arthrodesis can be recommended independent of fixation method.     

Custom-made wrist prosthesis in a patient with giant cell tumor of the distal radius

Introduction

Treatment for giant cell tumors of the distal radius is challenging when motion is to be preserved. As standard wrist prostheses typically do not achieve favorable results, we treated a 36-year-old man with giant cell tumor of the distal radius with a new, custom-made implant.

Methods

A custom-made wrist prosthesis with a long shaft was designed according to the patient’s X-ray findings. After complete tumor resection, the prosthesis was subsequently implanted into the distal radius without complications.

Results

Two months after surgery, range of motion was 30°-0-25° for extension/flexion, 10°-0-5° for ulnar/radial abduction, 80°-0-0 for pronation/supination, complete range of motion for the fingers, and a grip strength of 6 kg. Two years after surgery, implant position was still correct and range of motion was 45°-0-10° for extension/flexion, 10°-0-20° for ulnar/radial abduction, and 80°-0-10° for pronation/supination. Grip strength was 16 kg, and DASH score was 25 compared to 39 before surgery. The patient returned to work as a craftsman.

Conclusion

Custom-made wrist prostheses could become a practical option in patients with large defects of the distal radius who desire to preserve wrist motion.     

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.     

Less invasive surgery with wrist arthroscopy for distal radius fracture

Background

We developed a surgical procedure that can facilitate arthroscopic intervention for volar locking plate fixation for distal radius fracture (DRF) with a less invasive technique. This study is to investigate the effectiveness of our original procedure for the treatment of DRF.

Methods

One hundred fifty-five wrists of 153 consecutive patients underwent our original procedure: the plate presetting arthroscopic reduction technique (PART) for DRF. The fractures consisted of 37 extra-articular and 118 intra-articular fractures. The fractures were reduced, anatomical alignment was regained with the aid of an image intensifier, and the volar locking plate was preset. Wrist arthroscopy was then performed and the intra-articular condition assessed. If there were any residual dislocations of the intra-articular fragments, these were reduced arthroscopically, and soft tissue injuries were subsequently treated. The traction was then removed, and the plate was securely fixed. One hundred forty-five patients were followed up from 12 to 48 months. The final outcome was evaluated with the Mayo modified wrist score and Disability of the Arm, Shoulder and Hand questionnaire (DASH). The effectiveness of arthroscopy was also investigated.

Result

On arthroscopic inspection, intra-articular dislocations were found to be residual in 35.2 %, even if reduction seemed to have been achieved when viewed with the image intensifier. Scapholunate interosseous ligament injury was recognized in 28.9 %, and triangular fibrocartilage complex injury was observed in 63.2 %. The final outcome was 112 excellent, 31 good, and 2 fair. The mean DASH score was 4.1.

Conclusion

We developed the PART to simplify the combination of volar locking plating and arthroscopy. This technique was less invasive and effective in the treatment of DRF.     

Four-corner fusion of the wrist: clinical and radiographic outcome of 31 patients

Background

Four-corner fusion is a rational surgical option for the management of degenerative conditions of the wrist. Most related studies have compared four-corner fusion with scaphoid excision or proximal row carpectomy, with a variety of reported results. To enhance the literature, we performed this study to evaluate a series of patients with degenerative conditions of the wrist treated with four-corner fusion using 3 surgical techniques and to discuss the clinical and radiographic outcome of the patients.

Materials and methods

We retrospectively studied 31 patients (24 men, 7 women; mean age, 43 years; 9 heavy manual laborers) who underwent four-corner fusion of their wrists for degenerative conditions from 2005 to 2015. Internal fixation was done using multiple Kirschner wires (14 patients), headless compressive screws (8 patients), or a circular plate (9 patients). Mean follow-up was 4 years (1–11 years). We evaluated the clinical outcome with the Patient-Rated Wrist Evaluation (PRWE) score and fusion with radiographs.

Results

All patients experienced improvement of their pain, function, range of motion and grip strength (p < 0.05). Twenty-three patients (74 %) reported no pain, and eight patients reported mild, occasional pain. Twenty-one patients (68 %) were able to do usual and specific activities. Mean wrist motion improved to 70 % and mean grip strength improved to 85 % of opposite wrist. Two heavy manual labor patients requested a job modification because of wrist impairment. Radiographs of the wrist showed fusion of all fused joints in 28 (90.3 %) patients and partial fusion in three patients (9.7 %). No patient with partial fusion required a reoperation for symptomatic nonunion until the period of this study. Three patients experienced complications (10 %). Two patients treated with a circular plate experienced complex regional pain syndrome and painful implant impingement; another patient treated with Kirschner wires and headless compression screws experienced radiolunate arthritis from impingement of the lunate screw to the radius.

Conclusions

Four-corner fusion is a reliable limited wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation.

     

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.     

Outcomes after radiocarpal dislocation: a retrospective review

Background

Radiocarpal dislocations are rare, high-energy injuries. High morbidity and poor functional outcomes are common. Currently, there is limited data on functional outcomes following treatment of this injury.

Methods

A retrospective review was conducted analyzing the radiographic and clinical outcome of patients treated for a radiocarpal dislocation from 1979 to 2010. Outcome assessments included wrist range of motion, grip strength, Mayo wrist score, patient-rated wrist evaluation (PRWE), and disabilities of the arm, shoulder and hand (DASH) score. Statistical analysis was performed with the Student’s t test.

Results

Twenty-six patients (26 wrists) were treated for a radiocarpal dislocation during the study period; 23 wrists were treated acutely (within 4 weeks of injury), and 3 were treated after a delayed presentation (>4 weeks). Clinical follow-up of more than 6 months was available in 17 patients. Three patients (12 %) underwent primary fusion as initial treatment (two radioscapholunate fusion; one total wrist fusion). Four wrists (24 %) failed initial treatment and were salvaged with scapholunate ligament reconstruction (one wrist) or partial wrist fusion (three wrists). Seventeen patients completed PRWE and DASH questionnaires with a mean of 14.6 years following surgery (range 2–32 years). Subjective outcomes tended to be superior in those patients treated with ligament reconstruction versus partial or complete wrist fusion; however, comparisons were not statistically significant.

Conclusion

Radiocarpal dislocations result in significant osseous and ligamentous injury to the distal radius and carpus. Early recognition and treatment of radiocarpal dislocations with open reduction, internal fixation, and repair of ligaments may result in improved long-term functional outcomes when compared to acute partial or complete wrist arthrodesis.     

Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up

Purpose

Patients with an upper brachial plexus lesion can suffer from dysfunction, joint deformities and instability of the shoulder. The goal of this study was to determine pain, shoulder function, patient satisfaction and muscle strength in shoulder arthrodesis in patients with an upper brachial plexus lesion more than 15 years after surgery.

Methods

We retrospectively studied 12 patients with a brachial plexus lesion of mean age 46 years (27–61). At a mean of 19.8 years (15.4–30.3) after shoulder arthrodesis, patient-reported outcome measures (PROMs), range of motion (e.g., active and passive), patient satisfaction, strength of the affected and non-affected side (e.g., maximum isometric strength in Newton in forward and retroflexion, ab- and adduction, internal and external rotation) and position of fusion were obtained. PROMS consisted of the Visual Analogue Scale (VAS; 0–100, 0 being painless) for pain and the Disabilities of the Arm, Shoulder and Hand Score (DASH; 0–100, 0 being the best score) for function.

Results

At latest follow-up, the median VAS pain score was 49 (0–96) and 0 for, respectively, the affected and unaffected side. The DASH was 15 (8–46), meaning a reasonable to good function of the upper extremity. Active and passive retroflexion was significantly different (p = 0.028). All subjects stated that in the same situation they would undergo a shoulder arthrodesis again. The unaffected side was significantly stronger in every direction. Arthrodesis showed position of fusion of 31° (12–70) abduction, 20° (10–50) forward flexion and 22° (? 14 to 58) internal rotation. The unaffected side was significantly (p ≤ 0.05) stronger in every movement direction.

Conclusion

At a mean of 20 years after shoulder arthrodesis, patients with an upper brachial plexus lesion are still satisfied with a good to moderate functional improvement.

Level of evidence III

A retrospective cohort study.

     

Mediokarpale Teilarthrodese des Handgelenks mittels Spiderplatte

Objective

Pain relief while preserving wrist motion in advanced carpal collapse.

Indications

Advanced carpal collapse stage II/III due to scaphoid non-union, scapholunate ligament tear, idiopathic radiocarpal osteoarthritis, aseptic osteonecrosis of the scaphoid (Preisser??s disease). A relative indication is chronic midcarpal instability.

Contraindications

Osteoarthrisis of the lunate. Radiocarpal instability with ulnar translation of the wrist.

Surgical technique

Dorsal curved incision between the 3rd and 4th dorsal extensor compartment. Partial wrist denervation (posterior interosseous nerve). Raising of a radial pedicled capsule flap. Complete extirpation of the scaphoid without fragmentation. Cartilage removal of all the joint facets for arthrodesis. Reduction of the lunate and temporary fixation with K?wires between the triquetrum and capitate and the triquetrum and lunate. Milling the plate hole exactly in central position of the four carpal bones. The plate should not protrude from the bone to avoid impingement with the dorsal limb of the radius. Transferring of spongiosa harvested from the removed scaphoid into the arthrodesis gap. Fixation of the 8-hole plate with 2?screws in each of the four carpal bones. Fluoroscopy of the screw fitting. Control of the correct wrist articulation (motion test). Lavage of the wrist. Suture of the capsule flap. Redon drain, wound closure, dorsal splinting.

Postoperative management

Dorsal splint for 3?weeks; finger mobilization up to complete fist closure starting on postoperative day?1. From week 4?C6, active wrist motion, from week 7?C10 with increasing load. Return to work after 11?C12 weeks. CT scan in cases of delayed union, abnormal function, or persistence of pain.

Results

Between 2002 and 2008, 36?four-corner fusions (32?male, 4?female) with the spider plate were performed in 24 right and 12 left wrists. The mean age of the patients at surgery was 48?years (range 32?C71?years). Follow-up examinations were performed in 11 patients. The Krimmer and Rudolf scores were determined: 1?excellent, 7?good, 2?satisfactory, and 1?poor result were found. The mean grip strength was 51% relative to the opposite wrist. The mean range of motion (ROM) for wrist extension/flexion was 56% of the opposite side. Wrist extension/flexion averaged 24/0/32° and ulnar/radial deviation was on average 20/0/19°. Pain during activity was on average 2.2 based on the visual analogue scale (0?C10). One delayed bony union due to a screw breakage, which required total wrist fusion, was observed.     

Arthrodesis of the wrist with bioabsorbable fixation in patients with rheumatoid arthritis

Twenty-four wrist arthrodeses were performed on 18 patients with rheumatoid arthritis using a bioabsorbable self-reinforced poly-L-lactide rod as the fixation device. There was one nonunion which required a re-operation and two nonunions which did not need further treatment. The position of the arthrodesis was ulnar deviation and extension in most patients, and there was high patient satisfaction with 21 of the 24 wrists and satisfactory pain relief in 22 of the 24 wrists. This method for fusing the wrist in patients with rheumatoid arthritis appears reliable and simple to perform.