Distraction resection arthroplasty of the wrist

Proximal row carpectomy should not be done if wrist degeneration includes cartilage destruction of the capitate or lunate fossa of the radius; yet total wrist arthroplasty has been disappointing for treatment of osteoarthritis. We have used a technique we call distraction resection wrist arthroplasty in such cases. We retrospectively reviewed distraction resection wrist arthroplasty in 14 wrists and compared them to nine patients who had PRC; average follow-up was 32 months. Three patients had spastic contractures and 20 had operation for painful osteoarthritis. Patient satisfaction was high but there were four failures requiring arthrodesis (1 PRC, 3 DRA). Average postoperative wrist motion was 41 degrees of extension, 38 degrees of flexion, 11 degrees of radial deviation, and 13 degrees of ulnar deviation. Static strength averaged almost two thirds of the uninvolved side and dynamic power more than half. Differences between the DRA and PRC patients were not statistically significant in single or aggregate analysis. We believe that distraction technique extends the indications for biologic arthroplasty to patients whose only prior option was wrist arthrodesis.     

Relationship of impairment, disability and working status after reconstructive surgery of the wrist.

The aim was to study the relationship between impairment (function) and disability (participation) in wrist surgery, according to the WHO definitions. The outcome of 205 wrist operations were studied. The impairment was expressed as range of motion (ROM) and gripping force, the disability as the DASH score. There was a significant correlation between DASH and gripping force (R = 0.47). The correlation between ROM and DASH was weaker (R = 0.24). In manual workers, shorter temporary disability periods were significantly associated with lower DASH score. In (reconstructive) wrist surgery, impairment, disability and working status are significantly correlated. Gripping force measurement is a reliable tool for evaluation and gives a good impression of the disability. Preservation of some mobility is important, however the amount of ROM is not essential for the disability.     

Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis

Two cohort populations of 19 patients from separate institutions performing exclusively either a scaphoid excision and 4-corner arthrodesis (lunate, capitate, hamate, and triquetrum) or proximal row carpectomy (PRC) for scapholunate advanced collapse arthritis were compared. There were no preoperative differences with respect to age, gender, dominance, stage of arthritis, or preoperative measures of pain and function. The length of the follow-up period averaged 28 months for the 4-corner arthrodesis group compared with 19 months for the PRC patients. At the follow-up examination wrist motion revealed no significant differences in the flexion-extension arc, averaging 81 degrees in the PRC patients and 80 degrees following 4-corner arthrodesis, which was 62% and 58%, respectively, of the opposite wrist. The 4-corner arthrodesis patients maintained greater radial deviation and total percent radial-ulnar deviation of the wrist. Grip strength averaged 71% for the PRC group compared with 79% for the 4-corner arthrodesis patients. Pain relief was similar using a variety of measures and patient satisfaction was equivalent. Function was similar except that the 4-corner arthrodesis patients scored significantly higher on the mental health component of the short form-36 health status survey. No differences were seen on the physical health component or an outcome scale specifically designed for the wrist. Both PRC and scaphoid excision and 4-corner arthrodesis are motion-preserving options for the treatment of scapholunate advanced collapse arthritis with minimal subjective or objective differences in short-term follow-up evaluations.     

Four‐corner arthrodesis concentrator of Ni‐Ti memory alloy for carpal collapse

Objective: To evaluate the treatment outcomes of a four‐corner arthrodesis concentrator of Ni‐Ti memory alloy for carpal collapse. Methods: From August 2006 to November 2009, 13 patients with carpal collapse underwent scaphoid excision and four‐corner (capitate, lunate, triquetrum and hamate) arthrodesis using a four‐corner arthrodesis concentrator of Ni‐Ti memory alloy. The mean follow‐up time was 26.5 months (range, 7–38 months). Various wrist parameters, including the grip strength, range of wrist movements and degree of pain (visual analogue scales) were recorded and compared before and after surgery. Results: The average fusion time was 2.3 months (range, 2–4 months). Neither non‐union nor wound infection was found in any of the patients. By the sixth month postoperatively, the grip strength had reached an average of 32.49 ± 6.21 kg with a range of 22.3–39.7 kg, this being 80.8% of that found on the healthy side. The range of motion reached over 53.0% of that of the healthy side. Preoperatively and at 6 months postoperatively, the mean pain scores were (4.46 ± 1.27) and 1.31 ± 0.95, respectively, when resting (P < 0.05), and 7.00 ± 1.41 and 2.62 ± 1.26, respectively, when weight‐bearing (P < 0.05). The mean value of the Krimmer wrist score was 79.2 (range, 64–84). The rate of excellent and fine results was 84.6% (11/13), being excellent in three cases, good in eight and fair in two. Conclusion: Four‐corner arthrodesis using a four‐corner arthrodesis concentrator of Ni‐Ti memory alloy is an effective method for treating carpal collapse and preserving most wrist function.     

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy

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

Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis--update on evaluation and treatment

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse are common patterns of wrist arthritis. Scaphoid nonunion advanced collapse is caused by trauma, whereas SLAC wrist may also result from chronic pseudogout and can appear bilaterally without a clear history of injury. Surgical treatment for SLAC wrist includes 4-corner arthrodesis, capitolunate arthrodesis, complete wrist arthrodesis, proximal row carpectomy (PRC), denervation, and radial styloidectomy. Scaphoid nonunion advanced collapse wrist has the additional surgical option of excision of the distal ununited scaphoid fragment. Controversy persists over the relative merits of PRC versus 4-corner arthrodesis and whether PRC may be performed in the setting of capitate arthritis.     

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.     

Long-term results after mediocarpal and total arthrodesis of the wrist--a matched paired study

AIM: Indications for total wrist arthrodesis are still a matter of discussion. The aim of this study was to investigate the long-term results (mean 118 +/- 49.5 months) of total wrist arthrodesis (TA) in comparison to mediocarpal arthrodesis (MA). METHOD: A paired study of the TA group and the MA group was performed including 22 patients after posttraumatic wrist arthrosis in each group. Subjective, objective and radiological parameters were assessed. In addition, the modified Mayo wrist score, the DASH score and the SF-36 were utilized. RESULTS: Mean pain did not differ significantly in both groups. Mean wrist function (DASH) was assessed better by MA patients (25.3 +/- 25.8) compared to TA patients (35.5 +/- 25.9; p > 0.1). Mean total wrist motion in the MA group was 66.1 % of the opposite side. The average grip strength of the TA group was 85.5 % +/- 58.4 % and of the MA group 79.9 % +/- 25.4 % of the uninvolved wrist. The Mayo score of the MA group (56.4 +/- 12.4) was significantly higher than in the TA group (65.9 +/- 16.3; p = 0.04). The SF-36 showed no significant difference between both groups. CONCLUSION: In self-assessment, pain was of higher importance then wrist motion. According to our findings the type of arthrodesis did not influence patient satisfaction. Total wrist arthrodesis should not be excluded categorically as a possible alternative to mediocarpal arthrodesis.     

Outcome of proximal row carpectomy.

Fifty-one patients who had had proximal row carpectomy between 1992 and 2002 with a minimum follow-up of one year were followed up clinically and radiologically retrospectively. Their diagnoses included Kienb?ck disease (n=21), avascular necrosis of the scaphoid (n=4), nonunion of the scaphoid with osteoarthritis (n=9), and scapholunate advanced collapse (n=17). The mean follow-up was 5 years, 8 months. The mean "disabilities of the arm, shoulder and hand" (DASH) score was 18. The mean patient-rated wrist evaluation (PRWE) score list was 25% of maximum disability for the function and pain score. Thirty-four patients (87%) were able to return to work a mean of six months after operation (range 3 weeks - 35 months). Nine patients (11%) required arthrodesis of the wrist and are considered as failures. Mean flexion of the wrist was 66%, extension 73%, radial deviation 74%, ulnar deviation 76%, and grip force 70% of the opposite side. Excision of the proximal row provided predictable and durable pain relief, restored functional movement and grip strength, and allowed returned to gainful employment in most of the patients.     

Radiocarpal arthrodesis for osteoarthritis following fractures of the distal radius.

To compare the radioscapholunate (RSL) arthrodesis and radiolunate (RL) arthrodesis as a treatment for radiocarpal osteoarthritis following fractures of the distal radius, nine patients, 23 to 70 years old (average 41) at the time of surgery, were assessed two to 33 years after surgery. The periods between injury and surgery ranged from four months to 30 years. RSL arthrodesis was performed in three cases and RL arthrodesis in six. Post-operative wrist pain disappeared in six and was decreased in the other three. In the RSL group, the total arc of wrist flexion and extension was reduced from 50 degrees pre-operatively to 35 degrees post-operatively. In the RL group, it was increased from 72 degrees to 76 degrees after surgery. Grip strength improved in most patients, from 7 to 18 kg in the RSL group, and from 16 to 27 kg in the RL group. On roentogenogram, three patients showed arthritic changes in the adjacent joints, but there were no symptoms in two of the three patients. We concluded that partial radiocarpal arthrodesis (preferably RL arthrodesis) is a reliable procedure for radiocarpal osteoarthritis following fractures of the distal radius.     

Does restricted wrist motion influence the disability of the upper limb?

The purpose of this study was to correlate wrist motion (ROM) and disability of the upper limb. A total number of 205 patients who had undergone various wrist operations were included in this study, in which the range of motion of the wrist was correlated with the DASH (disability of arm, shoulder and hand) score. There was a significant correlation between the DASH score and the ROM of the wrist, but the correlation was rather weak (r = 0.24). Inclusion of patients with wrist arthrodesis resulted in a stronger correlation. Preservation of some ROM of the wrist is worthwhile. Evaluation of corporeal damage should be adapted in a more functional way.     

Résultats cliniques et radiologiques à dix ans de recul moyen de l’arthrodèse capito-lunaire. Série monocentrique de 12 patients

The aim of the study was to evaluate long-term results of capitolunate arthrodesis for the treatment of posttraumatic degenerative wrist disorders. A capitolunate arthrodesis was performed on 12 patients, three women and nine men, of 45 years on average (28–66). Ten patients were manual workers. Dominant side was involved in seven cases. Indications were nine scapholunate dissociations (SLAC) and three scaphoid non-unions (SNAC) with degenerative lesions. Fixation of the arthrodesis was performed with K-wires in seven, K-wires and staples in two, and only staples in three. Patients were reviewed at 118 months of average follow-up (72–168). One complete wrist arthrodesis was necessary one year after the capitolunate arthrodesis for an evolutive painful osteoarthritis. For the 11 remaining patients, pain on visual analogic scale (VAS) was 0.5. The flexion/extension arc was decreased of 25° and strength of 6 kg compared to preoperative values. DASH score was equal to 33.7 points, Cooney score to 77.2 points and Mayo score to 82.8 points. Radiolunate and capitolunate angles were decreased of 4.9° and 6.2° respectively compared to preoperative values. Some complications occurred: evolutive osteoarthritis between triquetrum and lunate in two, non-union of the arthrodesis in one, and reflex sympathetic dystrophy in two. Nine patients were able to return to their previous professional activities. Capitolunate arthrodesis allowed restoring a pain free and functional wrist in eight out of the 11 patients reviewed. Results were maintained with follow-up. It is a satisfactory therapeutic alternative to four corners fusion for chronic instability of the wrist with osteoarthritis.Level of evidenceIV.     

Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.     

Special aspects of wrist arthritis management for SLAC and SNAC wrists using midcarpal arthrodesis: results of bilateral operations and conversion to total arthrodesis

Although midcarpal wrist arthrodesis is recognized as a standard procedure to treat scapholuate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) of the wrist, little has been reported about patients with bilateral involvement and the number, cause, and results of failed cases requiring conversion to total wrist arthrodesis. This study investigated the results of 20 patients with bilateral procedures and of 22 patients who underwent total wrist fusion after failed midcarpal arthrodesis out of an overall group of 907 patients treated by this method during a 12-year period. Of these, 16 bilateral and 20 converted cases were reexamined after an average of 48 months and 42 months, respectively. Patients after bilateral midcarpal arthrodesis experienced a pain reduction by an average of 54% of the preoperative pain values at rest and by 56% at stress on the visual analog scale (scale range: 0 to 100) and from intolerable (3.7) to pain only during stress (1.9) on the verbal scale (scale range: I to 4). A mean arc of wrist extension and flexion of 53 degrees on the right and 49 of the left wrist was preserved. The mean DASH score was 45 points and 70% of the patients felt impaired only during certain activities. Total arthrodesis reduced pain in 18 of 20 reexamined wrists by 67% of the previous values after the failed partial arthrodesis at rest and by 46% at stress on the visual analog scale andfrom intolerable pain (3.7) to pain only during stress (2.1) on the verbal scale. Seven of the 20 reexamined patients noted complete pain relief at rest and two also under stress conditions. The DASH score averaged 39 points. A mean Krimmer score of 46 points and a mean Buck-Gramcko and Lohman evaluation of 6 points represented a satisfactory result. Grip strength of the operated hand averaged 53% of the opposite side. Subjectively, 30% felt impaired only during certain activities, 55%felt considerably and 15% strongly limited in daily life. However, all but two patients were satisfied with the secondary total wrist fusion as pain was considerably reduced. Midcarpal arthrodesis reliably reduced pain and preserved valuable wrist mobility thus improving daily activity and quality of life also in bilateral carpal collapse. In the rare cases when midcarpal arthrodesis failed, total wrist arthrodesis markedly improved the complaints in most patients, but in contrast to other studies complete pain was seldom.     

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.     

Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): operative technique and outcome assessment

Thirty-six patients with stage II or III SNAC and SLAC wrists were treated by midcarpal arthrodesis and complete scaphoid excision. When assessed at a mean follow-up of 25 months, pain was significantly reduced both under resting and stress conditions. The active range of motion was 54% of the contralateral wrist and grip strength was 65% of the non-operated hand. The mean DASH score was 28 points, the Mayo wrist score was 63 points, and the Krimmer wrist score was 68. Correlation of the wrist scores with the DASH values demonstrated a significant correlation. Our data demonstrate that midcarpal fusion with complete excision of the scaphoid is a reliable procedure for treating advanced carpal collapse.     

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.     

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis: long-term follow-up

Radioscapholunate arthrodesis is the treatment of choice for symptomatic, degenerative radioscapholunate osteoarthritis. We report on three patients after radioscapholunate arthrodesis with a follow-up of 22-28 years. There were no short-term postoperative complications; range of motion and strength were stable. All three patients showed radiological evidence of progressive, but clinically asymptomatic midcarpal osteoarthritis. The conversion rate for radioscapholunate to panarthrodesis of the wrist is reported at 31% with follow-ups of more than five years, invariably due to either non-union, or progressive, symptomatic midcarpal osteoarthritis. Primary excision of the distal pole of the scaphoid during radioscapholunate arthrodesis probably plays an important role in avoiding these conditions in the long-term. This measure allows a residual range of motion more than previously believed; considering that the dart thrower's motion is the physiological axis of wrist motion.     

Osteochondral resurfacing (OCRPRC) for capitate chondrosis in proximal row carpectomy

PURPOSE: Proximal row carpectomy (PRC) can be an effective treatment option for arthritis of the wrist, but the operation is contraindicated when there is substantial arthritis of the capitate head. We describe a new technique that involves resurfacing of the capitate when there is chondrosis by using osteochondral grafts harvested from the resected carpal bones. The purpose of this study was to assess the outcomes of patients who had osteochondral resurfacing in the setting of PRC (OCRPRC) for capitate chondrosis and to determine how they compare with published results of conventional PRC. METHODS: Patients having PRC who had grade II to IV (Modified Outerbridge Scale) capitate chondrosis underwent osteochondral resurfacing of the capitate. Preoperative and postoperative pain level, employment status, range of motion (ROM), grip strength, and Mayo wrist scores were assessed, and Student's t-test was used. Postoperative Disability of the Arm, Shoulder and Hand (DASH) scores were also calculated. RESULTS: Eight patients with an average age of 53 years were followed up for 18 months. Preoperatively, 7 patients described their pain as moderate to severe; postoperatively, 7 patients described their pain as mild to no pain. Preoperative arc of motion was 84 degrees (74% of the contralateral side); postoperative arc of motion was 75 degrees (66% of the contralateral side). Preoperative grip strength was 29 kg, or 62% of the contralateral side; postoperative grip strength was 34 kg, or 71% of the contralateral side. Preoperative Mayo wrist score was 51 ("poor"); postoperative Mayo wrist score was 68 ("fair"). Average postoperative DASH score was 19.5. Follow-up radiographs showed that 75% of patients had mild to no degeneration. Magnetic resonance imaging at 21 months postoperatively showed graft incorporation. No complications were encountered. CONCLUSIONS: Our results with osteochondral resurfacing compare favorably with the published results of conventional PRC in terms of pain relief, employment status, ROM, and grip strength.     

部分腕骨融合术或切除术对腕关节运动影响的实验研究

目的 研究临床常用的部分腕骨融合术或切除术对腕关节运动的影响程度。方法 将１２侧新鲜上肢处理后,固定于特制的测试架上,在腕背部打入２根或多根克氏针,作舟头骨、舟大小多角骨、舟月骨、月三解骨、桡月骨、ｆｏｕｒ ｃｏｒｎｅｒ、头月骨融合术、舟骨切除＋ｆｏｕｒ ｃｏｒｎｅｒ、舟骨切除＋头月融合术。观测腕关节正常运动活动范围,及作上述不同部分腕骨融合术后腕关节屈曲、伸腕、尺偏、桡偏度数。结果 桡舟月骨融合