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.     

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.     

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.     

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.     

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.     

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.     

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.     

Limited wrist fusions: comparison of results 22 and 89 months after surgery

Limited wrist arthrodeses were performed to treat wrist diseases other than rheumatoid arthritis. The purpose of this study was to evaluate whether clinical and radiographic results noted 22 months after the procedure were maintained on re-examination an average of 89 months (range, 66-148 months) after the procedure. The study comprised 17 wrists. The average patient age was 42 years (range, 11-65 years). Two patients, both with Kienb?ck's disease, were lost to follow-up. Four radiocarpal and 11 intercarpal arthrodeses were performed. The range of motion between the first and second follow-up examination showed no significant difference. Grip strength likewise was nearly identical at both visits. At the last follow-up visit, progression of osteoarthrosis about the fusion area was noted in only 1 patient. These results suggest that the clinical and radiographic results at 22 months were maintained at the final follow-up visit and that the effect of limited wrist fusion does not deteriorate.     

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.     

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.     

Internal fixation of distal radius fractures with dorsal dislocation: pi-plate or two 1/4 tube plates? A prospective randomized study.

BACKGROUND: Severely comminuted distal radius fractures can be treated by different methods. Our routine procedure in dorsal dislocated fractures is the dorsal stabilization with two 1/4 tube plates. The new pi-plate is an other device that matches optimally the anatomy of the distal radius and allows a near half-circumferential dorsal buttress of comminuted intraarticular and extra-articular radial fractures. METHODS: In a prospective randomized study, comminuted distal radius fractures with dorsal displacement were stabilized either with two 1/4 tube plates or with the pi-plate. All patients were reviewed at 1, 3, and 6 months after surgery by thorough clinical examination and standard radiographs of both wrists. Results were analyzed and compared in both groups. RESULTS: Subjective and objective results in the pi-plate group are disappointing. Although optimal anatomic results were achieved, the complication-rate was high (14.3%) and the range of motion was limited. At final review, extension and flexion of the injured wrist had recovered to an average of 67% of the normal, contralateral side. Radial and ulnar deviation were limited to 64%, whereas pronation and supination reached 89% and 87%, respectively. Overall, results were good to excellent only in 56%. In a comparable group of patients with similar fractures and stabilization with two 1/4 tube plates, 82% of patients achieved excellent to good results, wrist motion was significantly better (p < 0.05), and no complications occurred. CONCLUSION: With open reduction, cancellous bone grafting, and internal plate fixation in comminuted distal radial fractures, excellent results can be achieved. In our experience, we cannot recommend the 7pi-plate in its current shape and prefer to stabilize distal radius fractures and dorsal fragment dislocations with two 1/4 tube plates.     

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.     

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.     

The clinical implications of scaphotrapezium-trapezoidal arthritis with associated carpal instability

PURPOSE: Common causes of dorsal intercalated segment instability (DISI) include scapholunate dissociations and scaphoid fracture nonunions. Although less common than these, scaphotrapezium-trapezoidal (STT) osteoarthritis (OA) may also be associated with the development of a DISI deformity. The clinical implications of this form of carpal instability in cases of STT arthritis are still unknown. To study the radiographic progression and incidence of this entity, we reviewed our patients and report on 24 wrists with DISI in the presence of STT arthritis. METHODS: A retrospective chart and radiographic review was performed on all patients seen between 1994 and 2004, with the diagnosis of STT arthritis to identify a subgroup of patients with DISI deformity on the presenting radiographs. Patients' clinical and surgical courses were noted. Postoperative radiographic changes were recorded, as were clinical outcomes. RESULTS: Sixteen patients with 24 wrists having STT arthritis and DISI deformity on presenting radiographs were identified. The median STT arthritis grade was 3.0 based on a modified Eaton and Glickel grading system. The median radiolunate angle was -21 degrees of dorsal tilt. All patients had normal scapholunate angles. Abnormal scaphoid extension was seen in 19 of 24 wrists as measured by the radioscaphoid angle. Concomitant carpometacarpal arthritis was seen in 67% (n = 16) of the wrists, and midcarpal arthritis was identified in 50% (n = 8) of patients. Fifteen wrists required surgery for the symptoms and were followed up for a mean of 29 months after surgery. In the surgical group the radiolunate angles increased by mean of 6 degrees after surgery. Four of the 15 wrists required revisional surgery for persistent pain. CONCLUSIONS: Patients with STT arthritis may present with carpal instability that is not related to radiographic scapholunate instability. This instability is characterized by a normal scapholunate angle with an extension stance of the scaphoid and lunate. Midcarpal arthritis may be present. Surgical intervention for patients with STT arthritis and DISI deformity may lead to radiographic progression of midcarpal instability.     

Radiolunäre Arthrodese: Erfahrungen mit der gekreuzten Schraubenosteosynthese

Radiolunate arthrodesis is a common operation performed in patients with rheumatoid arthritis. Osteosynthesis with crossed screws has been used since mid 2000 in the author’s hospital. In the present article, the complication rate associated with this method was determined and compared to other methods. From 1987–2005, a total of 75 wrists in 57 patients were operated, 27 wrists with crossed screws. A questionnaire was completed for 47 wrists, and a total of 42 wrists were examined at follow-up. Average time of follow-up was 10.5 years (range: 3–21 years). Patient satisfaction was high: on 44 questionnaires (from a total of 47) this question was answered with ‘very satisfied’ and ‘satisfied’. Average Disabilities of the Arm, Shoulder and Hand (DASH) score was 41 points. Average range of motion was 59°for extension/flexion. There was one case of pseudarthrosis in the patient group receiving crossed screws (27 operated wrists), which less than with the other methods. There were fewer complications (including removal of metal due to dislocation) with the crossed screws than with other methods of osteosynthesis.     

Percutaneous K-wire fixation versus palmar plating with locking screws for Colles' fractures

Different methods exist to treat distal radius fractures. A prospective randomized study was conducted to establish whether palmar plate fixation with locking screws gave better results than percutaneous K-wire fixation in patients over 50 years of age. Only fractures with dorsal displacement after a simple fall were included in the study. Twenty wrists were treated with K-wires and 20 with a plate. Radiological parameters were measured on preoperative radiographs and at five weeks postoperatively. Clinical results and DASH scores were determined at three months postoperatively and at more than one year. No significant difference in radial inclination, palmar tilt, clinical outcome and DASH score was found between plating and K-wires, but the mean difference in ulnar variance between pre- and postoperative radiographs was significantly better with plates. It can be concluded that plates were superior to K-wires in restoring ulnar variance, but functional outcome was similar with both techniques.     

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.     

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.     

Komplexe Fragmentation der distalen Radiusgelenkfläche

Background

Complex fragmentation of the distal radial articular surface often results in three major problems: some fragments are too small for stabilisation by standard plates or screws; in addition, substantial loss of articular surfaces and metaphyseal/subchondral bony defects frequently occur.

Material and methods

To solve these problems the following strategy was developed: the fixation of small articular fragments was performed by small K-wires that were placed subchondrally and countersunk in the bone. In case of lost articular surfaces a silicone foil was inserted intra-articularly to induce a cartilage-like tissue. Bony defects were replaced by iliac crest bone grafts. Additional stability was achieved by dorsal and volar plate fixation or bridge plating.

Results

An average of 53° of extension, 44° of flexion, 74° of pronation, and 66° of supination were achieved. The grip strength was an average of 61% of that in the contralateral limb. The average radiographic measurements were -5° of palmar inclination, 21° of ulnar inclination, and 0 mm of positive ulnar variance. A good or excellent functional result was achieved for five of seven wrists according to the rating system of Gartland and Werley. According to the modified Mayo Wrist Score four of five wrists achieved a good and one a fair result.The DASH Score averaged 19 (6–59) points.

Conclusions

The applied treatment resulted in stable, mobile wrists with reasonable alignment and nearly even articular surfaces. The functional results were similar to those reported by other authors for less complex distal radius fractures. This strategy seems to be a rational approach to the reconstruction of severely comminuted intra-articular fractures of the distal radius.     

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.