Évaluation d’une modification de la technique d’arthrodèse totale du poignet rhumatoïde selon Mannerfelt. À propos de 19 cas

We studied a technical modification of Mannerfelt's total wrist fusion technique in a series of 19 wrists. A fully intramedullary technique without dorsal carpal fixation was used to protect the extensor tendons. Two intramedullary Rush pins without dorsal staples were used during the arthrodesis procedure. Nineteen rheumatoid arthritis wrists (2 bilateral cases) were reviewed with a mean follow-up of 4.9 years (range 2–10 years). Clinical outcomes were assessed using the VAS pain scale, DASH-score and wrist strength measurements. Wrist fusion was assessed on AP and lateral X-rays of the wrist. The position of the carpal Rush pin entry points and distal hook orientation were also assessed. Pain was 8.9 preoperatively and 1.1 at the last follow-up with 95% patients satisfied. Mean DASH-score was 46.9 points. The pinch strength was 79% and the grip strength was 68% of the contralateral wrist. Carpal height, carpal anterior subluxation and ulnar deviation were stable at the last follow-up. All of the wrists were in straight position and no extensor tendon ruptures were noted. Fusion was complete in all cases within 6 to 12 weeks, except in one case. The technical modification proposed in the current study — intraosseous fixation only — appears to be a good alternative to Mannerfelt's original technique. Every case treated with this modified technique had good functional results and none required pin removal.     

Wrist arthrodesis with intercalated iliac crest graft in mutilans rheumatoid arthritis

In mutilans rheumatoid arthritis (RA) patients with major wrist destruction, wrist arthrodesis is recommended. This type of arthrodesis needs carpal reconstruction and stable fixation. The goal of this study was to assess the functional and anatomical outcomes of an iliac crest graft and internal fixation with two medullary pins. Six wrists in three patients suffering from RA were reviewed clinically and radiologically at an average follow-up of 25 months. We assessed the fusion of the iliac graft with the radius and the metacarpus, the preoperative and postoperative carpal height, and the bone stock in front of the thumb. All the patients had improved functionally. The iliac graft fused with the radius in all cases and fused with the metacarpus in 5 out of 6 cases; the non-union occurred in the wrist where only one pin was used. Restoration of carpal height was associated with improvements in hand function. The bone stock was sufficient to allow implantation of a trapezial cup during a total arthroplasty of the thumb trapeziometacarpal (TMC) joint. No major complications occurred. An iliac graft and two pins through the 2nd and 3rd metacarpals were used to reconstruct the carpal height and to obtain wrist fusion. Internal fixation with only one pin is not recommended. Functional improvement can be attributed to the normal tension within the extrinsic flexors and extensors of fingers and thumb being restored because the carpal height was restored. A secondary TMC arthroplasty is theoretically possible.     

Arthrodesis of the wrist by internal fixation in rheumatoid arthritis: a follow-up study of forty-five consecutive cases

Between 1972 and 1981, 59 wrists of 44 patients destroyed by rheumatoid arthritis were arthrodesed by internal fixation with a Rush pin. This study comprises 45 wrists of 38 surviving patients--nine men and 29 women, aged 20 to 72 years. The follow-up time ranged from 1 to 11 years with a mean of 3.9 years. The surgical technique used in this study is simple and safe, and a good position of the wrist in both frontal and lateral projections can easily be achieved. The Rush pin is passed down the third metacarpal and into the radius. It stabilizes the wrist adequately. All the wrists operated on obtained a strong bony fusion of the radiocarpal joint. The complication rate was low. Five of 45 Rush pins were removed because the subcutaneously located distal tip between the metacarpals irritated tendons and skin. In one male patient a thin Rush pin broke and a pseudoarthrosis of the intercarpal joints developed; there was, however, no need to remove the pin.     

A mechanical comparison of the immediate stability of three fixation devices used in wrist arthrodesis: a cadaveric study.

This study was designed to determine which of 3 fixation devices used in wrist arthrodesis provides the greatest immediate stability along 2 axes of movement. Twenty cadaver wrists were mechanically tested. Group 1 consisted of 7 wrists stabilized using a 2.3-mm Steinmann pin. Six wrists from the second group were immobilized with a 9-hole, 3.5-mm AO dynamic compression plate. The third group consisted of 7 wrists stabilized with an 8-hole, short-bend, precontoured low-contact dynamic compression plate. Stiffness and fracture force were determined in both forced flexion and forced pronation. The results showed that the Steinmann pin was the least stable of the 3 constructs in both axes of movement. No differences were observed between the 2 compression plates for either of the 2 axes of movement.     

Open and closed arthrodesis of the rheumatoid wrist using a modified (Stanley) Steinmann pin

In a series of 21 patients (22 wrists) with rheumatoid arthritis, arthrodesis of the wrist was done using a modified Steinmann pin (Stanley) either by an open or closed technique. The open technique, which included fragmenting the carpal bones (12 cases), was mainly used when additional procedures were needed simultaneously. The closed technique simply required insertion of the Stanley pin under fluoroscan control through a small incision over the metacarpal head. Nine out of 12 wrists treated with the open technique and nine out of ten of those treated by the closed technique were successfully fused. Complications were few. A single patient was dissatisfied due to continuing pain. Two out of the four pins that migrated (both involving the open technique) have been removed.     

Prospective study of a new total wrist arthroplasty: short term results

We present early results (average 32 months follow-up, minimum 12 months) of a prospective study of the ReMotion? total wrist arthroplasty in a series of 20 wrists (19 patients) with end-stage arthritic wrists (of whom 13 were rheumatoid). Overall there were no intra-operative complications, dislocations or reoperations. We observed one carpal and one radial loosening--both in rheumatoid patients. Neither was symptomatic enough to warrant reoperation. In the rheumatoid group of 13 wrists there was an average of 41% clinical score improvement. According to the Meuli score there were seven excellent, five good and one poor result. In the non-rheumatoid group of seven wrists there was an average of 27% clinical score improvement. According to the Meuli score there were two excellent, two good, two fair and one poor result. In the short term follow-up of this series, the ReMotion? total wrist arthroplasty provided better results and less devastating complications than the old generation total wrist arthroplasties. Longer follow-up is needed to validate these early results.     

Scaphoid Excision and Limited Wrist Fusion: A Comparison of K-Wire and Circular Plate Fixation

The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.     

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].     

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.     

Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation

Twenty-two consecutive patients (23 wrists) underwent open reduction internal fixation of dorsal perilunate dislocations and fracture-dislocations through combined dorsal and volar approaches. One of 5 experienced wrist surgeons performed these procedures within an average of 3 days of injury (range, 0-26 days) and intercarpal fixation was kept within the proximal carpal row. Motion was instituted an average of 10 weeks (range, 5-16 weeks) after injury. All patients were males. The average age at the time of injury was 32 years (range, 16-60 years). The average follow-up period was 37 months (range, 13-65 months). Average flexion-extension motion arc and grip strength in the injured wrist were 57% and 73%, respectively, compared with the contralateral wrist. The scapholunate angle increased and the revised carpal height ratio decreased over time, which was statistically significant for both measurements. Three patients (3 wrists) required wrist arthrodesis and a fourth patient had an immediate scaphoid excision and 4-corner arthrodesis secondary to an irreparable scaphoid fracture. One patient required a proximal row carpectomy to treat septic arthritis. Nine of the remaining 18 wrists had radiographic evidence of arthritis, most often at the capitolunate or scaphocapitate articulations. Short form-36 mental summary scores were significantly greater than age- and gender-matched US population values; physical summary scores were significantly less. The disabilities of arm, shoulder, and hand evaluation, Mayo wrist score, and patient-rated wrist evaluation all reflected loss of function. Seventy-three percent of all patients had returned to full duties in their usual occupations and a total of 82% were employed.     

Mannerfelt arthrodesis of the wrist joint in patients with chronic polyarthritis. A retrospective analysis of 24 cases

AIM: Mannerfelt established his technique of wrist arthrodesis with stabilisation by an intraosseous rushpin as a secure method for patients with rheumatoid arthritis. This study was performed to evaluate the mid-term results in a consecutive group of patients. METHODS: Out of a group of 39 operations 24 wrist arthrodeses (61%) in 19 patients have been followed 12-96 months postoperatively (average 44 mths) by clinical testing and radiographic examination. All operations were performed in the original technique. All patients suffered from rheumatoid arthritis in an advanced stage (Larsen III-V). RESULTS: All but one patient were free of pain. Function and strength of the hand increased significantly in all patients. All patients had additional resection of the ulnar head that led to normal pro-supination of the forearm. 18 patients were very satisfied with the result of the procedure. All but one of the wrists showed complete fusion. In one case there was an intraoperative perforation of the pin through the radial cortex, in another case we saw a fissure of the shaft of the third metacarpal bone. One patient showed a dysesthesia in the third finger. CONCLUSION: The results in this group of patients confirmed the advantages of Mannerfelt's technique such as simple operative technique, high fusion rate and low incidence of complications.     

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.     

Arthrodesis of the Wrist by the Method of Mannerfelt: A Follow-Up Of 19 Patients

Twenty-four wrists in 21 patients were treated with arthrodesis by the Mannerfelt method. Seventeen patients had rheumatoid arthritis and 4 osteoarthrosis. Stable radiocarpal ankylosis was obtained within 3 months in all cases. Postoperative complications were few and slight. Fusion of the carpo-matacarpal joints occurred spontaneously in a number of the patients. Minor mobility in the carpo-metacarpal joints of the transfixed digit was not the cause of essential complaints. It was not necessary to remove the osteosynthesis material in any patient. At follow-up all patients but 3 were satisfied with the position of the wrist, aimed to be close to neutral.     

Results of Mannerfelt wrist arthrodesis for rheumatoid arthritis in relation to the position of the fused wrist

Purpose

The wrist is involved early in rheumatoid arthritis and is often severely affected. A stable wrist is crucial to good hand function, which often necessitates a fusion. One of the most commonly used techniques in rheumatoid patients is the Mannerfelt arthrodesis. In this retrospective study the outcome and the patient’s subjective satisfaction are presented and compared to other techniques. Also the influence of the position of the wrist following a fusion procedure is analysed.

Methods

Thirty-four wrists were retrospectively analysed using radiological measurements, functional scores such as the Disabilities of the Arm, Shoulder and Hand (DASH) and a pain assessment. The objective function of the hand with the fused wrist was assessed.

Results

In 92.6 % of wrists the patients rated their satisfaction as good or excellent. The mean DASH score post-operatively was 63.3. Of the wrists, 17 were fixed in a median flexed position of 13° and 17 wrists in a median extended position of 8°. There was no statistically significant correlation between the position of the wrist and the satisfaction or objective function. The rate of fusion was 94.1 %.

Conclusions

The Mannerfelt arthrodesis achieves good results and provides a high rate of satisfaction and pain relief in our study. It has major advantages compared to other wrist fusion techniques in the rheumatoid patient. We could not show clear statistical evidence for better results in either a flexed or an extended position, but the ratings of the patients indicated better subjective results with a slightly extended position of the arthrodesis.     

Arthrodesis of the Wrist by the Method of Mannerfelt: A Follow-Up Of 19 Patients

Twenty-four wrists in 21 patients were treated with arthrodesis by the Mannerfelt method. Seventeen patients had rheumatoid arthritis and 4 osteoarthrosis. Stable radiocarpal ankylosis was obtained within 3 months in all cases. Postoperative complications were few and slight. Fusion of the carpo-matacarpal joints occurred spontaneously in a number of the patients. Minor mobility in the carpo-metacarpal joints of the transfixed digit was not the cause of essential complaints. It was not necessary to remove the osteosynthesis material in any patient. At follow-up all patients but 3 were satisfied with the position of the wrist, aimed to be close to neutral.     

Improvement of the bone-pin interface strength in osteoporotic bone with use of hydroxyapatite-coated tapered external-fixation pins. A prospective, randomized clinical study of wrist fractures

BACKGROUND: Achieving adequate fixation strength in osteoporotic bone is a challenge. In this study, we examined the use of hydroxyapatite-coated tapered external-fixation pins for the fixation of wrist fractures in patients with osteoporosis. METHODS: Twenty female patients with osteoporosis and a fracture of the wrist were divided into two paired groups and randomized to receive either standard tapered pins or hydroxyapatite-coated tapered pins. Two pins were inserted in the distal part of the radius, two pins were inserted in the second metacarpal, and an external fixation device was mounted. All fixation devices were removed six weeks after surgery. RESULTS: The mean pin-insertion torque (and standard deviation) was 461 +/- 254 Nmm in the group managed with standard pins and 332 +/- 176 Nmm in the group managed with hydroxyapatite-coated pins (p = 0.01). The mean pin-extraction torque was 191 +/- 155 Nmm in the group managed with standard pins and 600 +/- 214 Nmm in the group managed with hydroxyapatite-coated pins (p < 0.0001, power 95%). The mean extraction torque was lower than the corresponding insertion torque at each pin position in the group managed with standard pins (p < 0.05), whereas the mean extraction torque was higher than the corresponding insertion torque at each pin position in the group managed with hydroxyapatite-coated pins (p = 0.001). Two patients managed with standard pins and no patient managed with hydroxyapatite-coated pins had a pin-track infection. Pain during pin removal did not differ between the two groups. CONCLUSIONS: The present study showed that hydroxyapatite-coated tapered external-fixation pins provided improved fixation in the treatment of wrist fractures in patients with osteoporosis.     

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.     

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.     

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.     

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.