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.     

Modularphysiologische Handgelenkprothese

Silicone wrist arthroplasty has dominated reconstructive surgery of the rheumatoid wrist for a long time. The declining success rates of Swanson wrist arthroplasty has encouraged the development of new wrist devices. Modular physiological total wrist arthroplasty represents a new wrist prosthesis generation with anatomical reconstruction of carpal height and wrist pivot. This increases the efficiency of wrist and finger tendons. Modular physiological total wrist arthroplasty was developed in 1992 and has been in clinical application since 1993. A total of 46 total wrist arthroplasties in 39 patients were carried out between 1993 and 1999. All patients suffered from rheumatoid arthritis. The mean follow-up period was 4.6 years.The postoperative total wrist score averaged 77.3 points, representing 78% good and excellent scores. Patient satisfaction and pain relief were achieved in 86% of cases. The range of motion at last follow-up averaged 56 degrees of the combined extension and flexion and 27 degrees for combined ulnar and radial deviation were maintained.The radiographic analysis of MPH total wrist arthroplasty demonstrated a secure reconstruction of carpal height and restoration of joint pivot. Failures occurred in seven wrist arthroplasties. Malalignement of the carpal and radial component and soft-tissue dysbalance were the reasons for recurrent dislocation in four cases. Three wrists were fused and one exchange arthroplasty using a constrained revision prosthesis was performed. The remaining three revision cases were caused by one deep infection and two failures of the carpal implant.     

Preliminary results of total wrist arthroplasty in rheumatoid arthritis using the Trispherical total wrist arthroplasty

Thirty-two patients underwent 38 arthroplasties for advanced rheumatoid arthritis and marked soft tissue losses. Seven wrists required repair or transfer of at least one tendon for rebalancing. All patients were improved by the implants. Thirty-four of the 38 patients were improved beyond the functional level of a painless wrist arthrodesis. Overall, there were 23 excellent, 10 good, 3 fair, and 2 poor results. The average wrist score was 90.3 points, and the average arc of motion was 38 degrees. There were three cases of migration of the third metacarpal stem and nine cases of lucency about the stems, three of which were progressive or greater than 1 mm. There were no deep infections. There was one reoperation for persistent pain and one for component loosening. There were no cases of implant failure. These results indicate that this total wrist arthroplasty is a safe, reproducible procedure for radiographic class III and IV rheumatoid disease and should be considered a first line of therapy for that group.     

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.     

Total wrist replacement using the modified Volz prosthesis

Eighteen total wrist arthroplasties in sixteen patients were done using the modified Volz prosthesis. The length of follow-up ranged from twenty-four to sixty-six months, with a mean of forty months. A 100-point scoring system was used to evaluate the outcome. Muscle imbalance developed in five wrists, the carpal component became loose in three wrists, and two prostheses dislocated. In five patients six arthroplasties (33 per cent) were considered to have failed because one reoperation or more was required for loosening of the components in two wrists, dislocation in two wrists, and muscle imbalance in two wrists. Of the remaining twelve arthroplasties (eleven patients) eight (45 per cent) had an excellent result; two (11 per cent), a good; and two (11 per cent), a poor result. The over-all rate of complications was 44 per cent. Patients who had significant preoperative deformity did poorly postoperatively. The surgeon should be prepared to perform other types of arthroplasty or an arthrodesis if the extensor tendons are structurally inadequate, as this may lead to progressive flexion deformity postoperatively.     

Trispherical total wrist arthroplasty in rheumatoid arthritis

Thirty-four patients, with 35 trispherical total wrist arthroplasties for treatment of rheumatoid arthritis, were evaluated at an average follow-up of 9 years (range, 5 to 11 years). The average preoperative score was 25 points inasmuch as all patients had severe pain and loss of function. The average postoperative score improved to 87 points since 30 wrists were free of pain. Twenty-eight wrists rated as a good-to-excellent result. The average arc of flexion and extension improved from 35 to 50 degrees. There were no deep infections or dislocations. Two wrists required revision, one for loosening and one for persistent pain, both requiring removal of the implant and arthrodesis. Postoperative tendon attrition occurred in six wrists, all of which had preoperative tendon ruptures necessitating tendon transfer. Radiographs showed radiolucencies in seven wrists, including seven around the metacarpal stem and one around the radial stem. The optimum results were achieved in those patients with intact extensor tendons before operation.     

Palmar shelf arthroplasty. A follow-up note

Palmar shelf arthroplasty was described by Albright and Chase as a successful, so-called conservative surgical alternative for the treatment of subluxation of a wrist that is affected by advanced rheumatoid arthritis. Subsequent to their report, seven wrists in six patients who had been treated with a palmar shelf arthroplasty by Albright and Chase or by their trainees were studied, after an average follow-up of nine years. All of the patients had long-term relief of pain and improved motion of the wrist, and all were satisfied with the result of the procedure. All but one patient had increased function.     

Limited wrist fusions

Seventeen patients had wrist fusions done for diseases other than rheumatoid arthritis of the wrist and carpal bones. Arthrodesis was done at the radiocarpal joint in five wrists and at the midcarpal joint in 12. There were 12 men and five women. Ages at the time of operation averaged 42 years. Follow-up ranged from 6 months to 5 years and 5 months, and with an average of 1 year and 10 months. Overall postoperative results were excellent in five wrists, good in seven, fair in two, and poor in three. Wrists with the midcarpal fusion fared better than those wrists with the radiocarpal fusion. Complications included one pseudoarthrosis and one rupture of the flexor pollicis longus tendon. In one of the 17 wrists new osteoarthritic changes surrounding the arthrodesed joints occurred.     

早期手术治疗经舟骨月骨周围骨折脱位的临床分析

目的 评价早期手术治疗经舟骨月骨周围骨折脱位的临床疗效.方法 15例经舟骨月骨周围骨折脱位的患者,采用切开复位加压螺钉和克氏针内固定.术后评估腕部疼痛、腕关节活动度、手部握力及骨折愈合,并用腕关节Krimmer评分法评估疗效.结果 13例获得6～12个月随访,平均9个月.2例出现静息痛,3例活动时疼痛.腕关节屈伸活动度（65±11）°,尺桡偏角度为（10±8）°,平均握力较健侧减少10%.X片检查3例腕关节炎,2例舟骨骨折近端骨质吸收致舟骨不愈合.11例腕舟骨愈合,平均愈合时间为4.8个月.Krimmer评分法评估总体疗效：优7例,良1例,可3例,差2例.结论 早期切开复位应用克氏针和加压螺钉同时内固定治疗经舟骨月骨周围骨折脱住手术方式可行、疗效可靠.     

Wrist arthroplasty with the trispherical total wrist prosthesis

The clinical results and long-term implant survival of wrist arthroplasty with the Trispherical total wrist prosthesis was evaluated in patients with inflammatory arthritis. Using the Hospital for Special Surgery wrist scoring system, the clinical evaluation of 35 Trispherical total wrist arthroplasties showed an excellent result in 20, good result in 8, fair result in 3, poor result in 2, and failed result requiring revision in 2 wrists at an average follow-up of 9 years. Cumulative implant survival in 67 consecutive Trispherical total wrist arthroplasties was 97% at 5 years and 93% at 10 and 12 years postoperatively. Patient satisfaction with wrist arthroplasty using the Trispherical prosthesis was excellent. We attribute the favorable long-term results obtained with the use of this prosthesis to its inherent design that allows for accurate restoration of the center of rotation of the wrist.     

Total wrist arthroplasty with Destot prostheses in patients with posttraumatic arthritis

PURPOSE: To analyze the functional and radiologic results after Destot arthroplasty, a wrist prosthesis designed for posttraumatic arthritis, and to define the indications for the use of the implant. METHODS: Using the Meuli point score system, 28 Destot total-wrist arthroplasties in 25 patients with stage 2 or 3 scaphoid nonunion advanced collapse and scapholunate advanced collapse were evaluated for 12 to 96 months after surgery. RESULTS: The overall ratings of the study group were excellent in 17 cases, good in 6, fair in 1, and poor in 4. Eighty-four percent showed improved range of motion and grip strength. Four patients experienced postoperative complications. No imbalance or dislocation was noted after surgery. CONCLUSIONS: The Destot implant seems to be a good solution to restore functional range of motion after posttraumatic wrist arthritis when arthrodesis is required by nonmanual laborers older than 50 years of age.     

Total knee arthroplasty in young patients with juvenile rheumatoid arthritis

BACKGROUND: Juvenile rheumatoid arthritis is a disabling and destructive condition that commonly affects the knee during childhood. Total knee arthroplasty occasionally may be necessary for the treatment of end-stage disabling arthritis of the knee in young patients. There is a paucity of available data on the results of total knee arthroplasty in adolescents. We report our experience with total knee arthroplasty in patients under the age of twenty years who had juvenile rheumatoid arthritis. MATERIALS AND METHODS: We reviewed the results of twenty-five consecutive total knee arthroplasties that had been performed at our institution between 1982 to 1997 in thirteen patients (mean age, seventeen years) with juvenile rheumatoid arthritis. The average duration of clinical follow-up was 10.7 years, and the average duration of radiographic follow-up was 6.5 years. RESULTS: The mean Knee Society pain score improved markedly from 27.6 to 88.3 points, and the mean Knee Society function score improved modestly from 14.8 to 39.2 points. There was a slight improvement in the range of motion. Symptomatic and progressive radiolucent lines were noted in two knees, one of which was revised. Two knees (one patient) required exchange of the polyethylene liner at thirteen years. There were four additional reoperations, including manipulation under general anesthesia (two knees in one patient), lysis of adhesions (one knee), and extensor mechanism realignment (one knee). CONCLUSIONS: Despite a substantial number of postoperative complications, total knee arthroplasty provided excellent relief of pain and improvement in function in this group of adolescent patients with juvenile rheumatoid arthritis.     

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.     

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.     

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.     

Early results of the Universal total wrist arthroplasty in rheumatoid arthritis

Early results of 2 surgeons involved in a prospective study of the Universal total wrist prosthesis (KMI, San Diego, CA) are reported. Twenty-two prostheses were implanted in 19 patients for the treatment of severe rheumatoid arthritis. Two-year follow-up results of 8 wrists and 1-year follow-up results of 14 wrists were reviewed. Total arcs of motion (flexion-extension, radial-ulnar deviation, and pronation-supination) all improved significantly after arthroplasty. Individual motions that were most limited before surgery (extension, radial deviation, and supination) improved the most. Disabilities of the Arm, Shoulder, and Hand outcome scores improved 14 points at 1 year and 24 points at 2 years. Three prostheses (14%) were unstable and required further treatment; all 3 were in patients with highly active disease and severe wrist laxity. The Universal prosthesis provides a good early outcome in rheumatoid patients without severe preoperative wrist laxity.     

Biaxial total wrist arthropla

Arthrodesis is a reliable and predictable method of treating patients with symptomatic radiocarpal joint destructionand should be recommended in most cases. However, some patients are not able to compensate for the lack of wrist mobility associated with wrist fusion because of multiple joint arthroses as are commonly seen in patients with rheumatoid arthritis. For these patients, total wrist arthroplasty is best described as a higher risk and higher reward procedure. A recent review of 64 cases of total wrist arthroplasty found an 83% implant survival rate at a mean follow-up period of 6.5 years. Clinical results showed excellent patient satisfaction and very good pain relief and range of motion. Of the patients who failed arthroplasty and were eligible for revision total wrist arthroplasty, 80% elected revision arthroplasty over recommended arthrodesis. This report reviews patient selection, technique, postoperative management, management of complications, and expected outcome of biaxial total wrist arthroplasty.     

High rate of complications and radiographic loosening of the biaxial total wrist arthroplasty in rheumatoid arthritis: 32 wrists followed for 6 (5–8) years

Background and purpose

The third generation of total wrist arthroplasty (TWA) was designed to solve the early loosening problem, but there have been few long-term follow-ups. We present the outcome of the biaxial total wrist prosthesis (no longer available) after 5–8 years of follow-up.

Patients and methods

40 biaxial wrist prostheses were implanted uncemented in 36 patients with rheumatoid arthritis. 32 wrists were followed clinically and radiographically. 7 prostheses had been revised at median 21 (8–71) months; 1 patient died from an unrelated cause. Mean follow-up of the remaining 32 wrists was 6 (5–8) years. Kaplan-Meier survival analysis was performed with revision defined as failure.

Results

Survival after 7 years was 81% (95% CI: 64–91). There were 31 complications. 22 wrists showed radiographic loosening. Range of motion improved, except for pronation. The mean DASH score improved and the median postoperative pain score (from 0 to 10) was 0 (0–6) at rest and 0 (0–7) during activity.

Interpretation

One quarter of the prostheses had been revised and radiographic loosening had occurred in two thirds of the cases. Radiographic and clinical follow-up is therefore necessary for patients with this implant.The wrist is affected in one half of patients with rheumatoid arthritis during the first 2 years after onset of the disease, increasing to > 90% after 10 years (Trieb 2008). The first generation of wrist implants was developed in 1967 (Swanson 1973). It consisted of one flexible piece of silicone hinge. The initial results were promising, but stress at the silicone implants caused disintegration of the silicone with severe inflammatory reactions and mechanical failure. The second-generation implants were developed in the early 1970s (Volz 1976, Meuli 1980). They usually included 2 metal components that articulated by means of a ball-and-socket or hemispheric design. The main problem with these prostheses was loosening of the metacarpal component, joint imbalance, and dislocation. The third generation, such as the biaxial wrist prosthesis, was designed to solve these problems (Costi et al. 1998). Many prostheses of this type have been used in the past, but no long-term evaluation has been published.Previous literature on the biaxial wrist prosthesis showed satisfactory pain relief, an improvement in range of motion, and satisfactory function after follow-up of 6, 3, and 4 years but also loosening, infections, and dislocation (Cobb and Beckenbaugh 1996, Courtman et al. 1999, Takwale et al. 2002). We analyzed the outcome of this prosthesis in 36 patients (40 prostheses) after 6 (5–8) years of follow-up.     

Long-term results of dorsal stabilization in the rheumatoid wrist

Dorsal stabilization was performed on 85 rheumatoid wrist in 62 patients for an average follow-up of 6.8 years. Of these, 37 wrists were followed an average of 10 years. The chief component was pain in 79 of the wrists. Pain, on a scale of 0 to 100, showed a preoperative score of 32 and postoperative ratings of 89 for the total group and 96 for the long-term group. Range of motion decreased in virtually all patients. Spontaneous ankylosis occurred in eight wrists. Because of the presence of associated deformities, usually subluxated metacarpophalangeal joints, evaluation of functional improvement of the wrist was difficult. Those hands in which metacarpophalangeal subluxations were corrected or prevented showed maximum functional improvements. The procedure is beneficial for long-term relief of pain and maintenance of a range of motion which arthrodesis would eliminate.     

Proximal scaphoid rib graft arthroplasty

We prospectively reviewed 14 patients with deficiency of the proximal pole of the scaphoid who were treated by rib osteochondral replacement arthroplasty. Improvement in wrist function occurred in all except one patient with enhanced grip strength, less pain and maintenance of wrist movement. In 13 patients wrist function was rated as good or excellent according to the modified wrist function score of Green and O'Brien. The mean pre-operative score of 54 (35 to 80) rose to 79 (50 to 90) at review at a mean of 64 months (27 to 103). Carpal alignment did not deteriorate in any patient and there were no cases of nonunion or significant complications. This procedure can restore the mechanical integrity of the proximal pole of the scaphoid satisfactorily and maintain wrist movement while avoiding the potential complications of alternative replacement arthroplasty techniques and problems associated with vascularised grafts and salvage techniques.