Wrist joint arthrodesis. Technique and outcome

Arthrodesis of the wrist joint is indicated in degenerative joint desease, instability and restricted and painful range of motion. Further indications are: failed reconstruction, partial arthrodesis or arthroplasty/total joint replacement. The surgical technique depends mainly on the quality of bone substance and degree of joint degeneration. Differences can be made concerning the type of bone graft and osteosynthesis being used. The aim is to create, a stable joint in a good functional position. The position of arthrodesis depends on the patients needs. In patients with rheumatoid arthritis a straight position is generally accepted, where as in patients with degenerative joint desease, a slight wrist extension and ulnar deviation is preferred. A stable osteosynthesis with plates is reliable and allows early rehabilitation. We present 28 cases of arthrodesis with intramedullary rods and 61 cases of arthrodesis with plates. The complication rate was low, the functional results were good. We saw significant reduction of pain, increase of strength and handfunction. Arthrodesis of the wrist joint has proven to be a long term reliable and safe procedure. Loss of motion is accepted to obtain sufficient pain relief.     

The effectiveness of RA wrist fusion using Beta-TCP without autogenous iliac bone grafting: a report of four cases.

Wrist arthrodesis is indicated for the rheumatoid hand especially in cases with severe destruction of the carpal bones. In the arthrodesis procedure for the rheumatoid wrist, autogenous iliac bone grafting is required in most cases. However, autogenous iliac bone graft necessitates the additional surgical intervention, and can be associated with the problem of inadequate bony quality or quantity. It is thought that use of the artificial bone substitute in the procedure can lessen the surgical morbidity while supplying the consistent material without shortage of graft quantity. We have performed arthrodesis of the rheumatoid wrist using beta-TCP for four patients. Clinical results of these patients were satisfactory both in pain relief and functional improvement with complete bony healing. Therefore, this procedure seems to be an effective option for the rheumatoid wrist with severe destructive changes.     

Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: The surgical treatment of the rheumatoid wrist is key in managing the affected hand. Wrist fusion is often the treatment of choice in cases of severe destruction and deformation although most patients would prefer a motion-preserving procedure. The implantation of a wrist prosthesis might be an alternative to partial arthrodesis for selected cases. In this series we analyzed the long-term results (minimum follow-up period, 10 y) of the Swanson silicone spacer for the wrist in patients with rheumatoid arthritis. METHODS: Sixteen patients with rheumatoid arthritis with 18 silicone spacers for the wrists were reviewed after a minimum follow-up period of 10 years (average, 15 y). Subjective evaluation, clinical examination, and radiographic analysis were included. An additional 9 patients (9 wrists) were interviewed by telephone. RESULTS: In 12 of the patients the subjective result was good or very good, mostly because of adequate pain relief. The average range of motion for flexion (average, 28 degrees )/extension (average, 15 degrees ) was 43 degrees with a wide variation within the series. Radiologically all wrists had diminished residual carpal height at follow-up evaluation and 9 of the wrists had evidence of osteolysis and foreign-body granuloma. The initial good correction of the ulnar translation of the wrist was lost partially in the follow-up period (1.1 vs 4.0 mm). Three of the patients needed surgical revision within the follow-up period; all were converted to wrist fusion. CONCLUSIONS: These long-term results suggest that the silicone wrist spacer still may be considered as an alternative to wrist fusion or more complex wrist joint prostheses in patients with rheumatoid arthritis, especially in severe cases and in patients with low demands. In the long term osteolysis caused by foreign-body granulation is to be expected and has to be considered.     

The Sauvé-Kapandji procedure: a salvage operation for the distal radioulnar joint.

The Sauvé-Kapandji procedure, a distal radioulnar arthrodesis with surgical creation of a pseudoarthrosis in the distal ulna, was used to treat 11 patients. Although all patients had had at least one previous operation on the involved wrist, they were still having pain and functional limitations. Ten patients were available for follow-up, which averaged 33 months. Of the nine patients with posttraumatic arthritis, six had excellent results (a painless wrist that averaged 82 degrees of pronation and 83 degrees of supination). Three patients had good results (mild pain during activities with an identical range of forearm rotation). One patient who had rheumatoid arthritis had an excellent result for 3 years but recently had a radiocarpal wrist fusion because of radiocarpal arthritis. We have found the Sauvé-Kapandji procedure to be a reliable treatment option for intractable disorders of the distal radioulnar joint and recommend it as a salvage procedure when previous treatment has failed.     

Intercarpal and radiocarpal resection arthroplasty and arthrodesis

Indications for intercarpal and radiocarpal resectionarthroplasty and fusions are osteoarthritis, KIEHNBOCK'S disease, rheumatoid arthritis and several posttraumatic disorders of the wrist joint. The resection of carpal bones leads to severe instability patterns of the wrist. In conclusion we recommend resection-arthroplasty just for treatment of the thumb carpo-metacarpal osteoarthritis. Implant resection arthroplasty of the lunate and scaphoid or total wrist implants are still causing multiple problems regarding heavy load. Therefore this implants should be confined to rheumatoid patients. Of the limited carpal arthrodeses the scaphotrapezium-trapezoid arthrodeses is the most frequent performed procedure. It can be indicated for STT-osteoarthritis, KIEHNBOCK's disease, scapho-lunate instability and scaphoid pseudarthrosis if other surgical procedures had failed presuming there are no signs of arthrosis in the radiocarpal joint. Persisting pain especially in heavy work is quite frequent after limited arthrodesis but can be greatly relieved by simultaneous wrist denervation. In advanced cases of osteoarthritis total wrist arthrodesis is still the best choice for the patient.     

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.     

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.     

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].     

Lunate migration following Darrach's procedure: a case report

We report a case of a 28-year-old female patient who underwent Darrach's procedure to her dominant right wrist affected by rheumatoid disease. She developed severe pain in the wrist 4 weeks postoperatively. Collapse of the scaphoid and proximal migration of the lunate was noted. Total wrist arthrodesis using the Arbeitsgemeinschaft für Osteosynthesefragen wrist arthrodesis plate was performed, which alleviated the pain. Darrach's procedure is described for conditions causing derangement of the distal radio-ulnar joint, the classical inflammatory cause being rheumatoid arthritis. It is however a potentially destabilising procedure. The extreme complication encountered in this case highlights the risk of Darrach's procedure if pre-existing ligamentous instability is present.     

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.     

Analgesic benefit,functional outcome,and patient satisfaction after partial wrist denervation

Partial wrist denervation is a useful palliative procedure for chronic wrist pain when reconstructive procedures are not feasible or desirable. We reviewed 19 patients who had 20 isolated anterior and posterior interosseous neurectomies with no previous or concurrent wrist surgery in a 5-year period at our institution. At an average of 2.5 years postoperatively, 80% of patients reported a decrease in pain, 45% reported normal or increased grip strength, and 73% of employed patients had returned to work. Three patients required additional procedures for pain relief (2 arthrodesis, 1 radial styloidectomies). Failure tended to occur in the first postoperative year. Poor preoperative range of motion and workers' compensation status were predictive of failure. Failure also occurred in the single patient with rheumatoid arthropathy. Two patients had subsequent arthrodeses. There were no complications related to the surgery. Overall, 85% of patients reported satisfaction with this procedure; 90% retrospectively would choose the same treatment for their chronic wrist pain. Partial denervation of the wrist via the anterior and posterior interosseous nerves is a technically easy procedure and may provide pain relief sufficient to markedly delay the need for more extensive salvage procedures in patients with wrist arthritis.     

Health status after total wrist arthrodesis for posttraumatic arthritis

PURPOSE: Total wrist arthrodesis is regarded as the most predictable way to relieve the pain of posttraumatic wrist arthritis. Wrist arthrodesis also is believed to be compatible with a high level of upper-extremity function. This study evaluated the effect of total wrist arthrodesis on both general and upper-extremity-specific health status in patients treated for posttraumatic wrist arthritis. METHODS: By using an institutional review board-approved protocol 22 patients were evaluated an average of 6 years after total wrist arthrodesis for posttraumatic arthritis. Upper-extremity-specific and general health status were measured using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short-Form 36 (SF-36) instruments, respectively. Patient satisfaction and interest in pursuing a wrist-mobilizing procedure should one become available also were assessed. Objective assessment included grip strength, digit range of motion, and radiographic fusion. RESULTS: Grip strength averaged 79% of the uninvolved wrist. The average Disabilities of the Arm, Shoulder, and Hand questionnaire score was 25. The average physical component score of the Short-Form 36 was 39 and the average mental component score was 52. Fourteen patients complained of wrist pain, including severe pain in 4 patients. Fifteen patients were satisfied or very satisfied with the result of the fusion, 5 patients were neutral, and 2 patients were mildly dissatisfied. Twenty patients would elect to have a procedure that could make their wrist move again if one were available. CONCLUSIONS: Substantial dysfunction was noted on both upper-extremity-specific and general health status measures after total wrist arthrodesis for posttraumatic conditions. Pain was improved but not eliminated.     

Wrist arthrodesis for treatment of rheumatoid arthritis

Eighty-seven wrist fusions using the technique of Millender and Nalebuff were reviewed in 79 patients with rheumatoid arthritis. Follow-up averaged 6 years and 97% of all patients had an excellent or good result. Pain was absent or mild in all patients after operation, and 95% of this patient population had improved hand function after wrist fusion. Wrist position averaged neutral in the lateral plane and 6 degrees ulnar deviation. Time to clinical fusion averaged 10.8 weeks. Complications were present in 23% of all cases, with half of these a result of symptomatic hardware. Carpal tunnel syndrome was seen after operation in five patients, all of whom had significant palmar carpal dislocation before surgery. A neutral position of the wrist with slight ulnar deviation is very functional and cosmetically acceptable for the patient with rheumatoid arthritis, even in bilateral fusions. Wrist arthrodesis for the patient with rheumatoid arthritis is a dependable procedure with a high degree of success and patient satisfaction.     

Long-term functional results of wrist arthrodesis in rheumatoid arthritis

The purpose of this study was to evaluate the long-term effectiveness of wrist fusion on the relief of pain and also the functional capacities of the upper limbs in patients with rheumatoid arthritis (RA). Eighteen patients were assessed at a mean of 7 years after wrist arthrodesis and a mean of 17 years after the onset of RA. Radiological measurements, pain assessment and impairment rating of the upper limbs were made of the fused and non-fused sides. The average position of arthrodesis was 8 degrees of extension and 9 degrees of ulnar deviation. All patients were pleased with the procedure and had satisfactory pain relief. Impairment ratings did not detect any significant difference in the sensory and motor function of the hand when the fused and non-fused groups were compared. We conclude that in patients with rheumatoid arthritis, wrist arthrodesis is a reliable procedure that provides predictable pain relief and a high degree of satisfaction without additional functional loss in the upper limb.     

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.     

Radiolunäre und radioskapholunäre Arthrodese bei chronischer Polyarthritis

INTRODUCTION: In 75% of all cases of rheumatoid arthritis the wrist is affected and in 12% is the region of initial manifestation of this chronic inflammatory joint disease. To prevent destruction of the wrist through carpal dislocation, radiolunate and radioscapholunate arthrodeses have increased in importance. METHODS: During a 6.5-year period, 28 radiolunate and 4 radioscapholunate arthrodeses were performed in 30 patients. The indication for operation was progressive carpal translation and increasing subluxation of the wrist in which existent radiological damage had not reached more than grade III according to the classification of Larsen and co-workers. RESULTS: The results obtained during the follow-up study (median: 17.3 months) showed in most treated patients after partial arthrodesis of the wrist no or fewer complaints concerning swelling and pain and an acceptable remaining range of motion of the wrist in everyday life. In patients with preoperatively existing ulnar deviation less than 15 degrees progressive carpal collapse and dislocation could be mostly prevented. CONCLUSION: All told radiolunate and radioscapholunate arthrodeses successfully stabilized the wrist in patients suffering from rheumatoid arthritis.     

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

Introduction

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

Patients and methods

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

Results

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

Conclusions

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

Proximal row fusion as a solution for radiocarpal arthritis

A retrospective study evaluated the function of thirty-six patients treated by radius-scaphoid-lunate arthrodesis for painful posttraumatic radiocarpal arthritis from 1982 through 1987, and determined whether the procedure created arthritis or other functional problems in the remaining joints. Thirty-one men and five women with a mean age of 41 years were studied. The standard surgical technique employed iliac crest bone graft and internal fixation. Seven patients required revision of the proximal fusion to complete wrist fusion because of pain; arthritic changes in the midcarpal joint had been noted in these patients at the time of the limited fusion. The remaining twenty-nine patients required no further surgical treatment. Grip strength averaged 70% of the uninvolved side. The average arc of wrist flexion and extension was forty-eight degrees. Eighteen patients returned to their original employment, in many cases to heavy labor. Five did not return to work because of wrist problems. We conclude that the probability of a good functional result is high for this procedure if there is no midcarpal arthritis.     

Proximal row carpectomy

Excision of the proximal carpal row has proven over the past 60 years to be an effective technique for certain disorders of the wrist, including degenerative sequelae of scapholunate ligament dissociation and scaphoid nonunions, Kienböck disease, Preisser disease, and other fracture-dislocations of the wrist. The durability of this procedure may be due to remodeling of the capitate head to the lunate fossa. Poor results have been noted in patients with rheumatoid arthritis and arthrogrypotic wrist deformities. Preservation of relatively normal cartilage of the capitate head as well as the lunate fossa is critical for success of this procedure. Average outcomes of this procedure include a wrist extension-flexion arc of 75° and grip strength of 60% of the uninvolved wrist. Revision to total wrist arthrodesis is required in 10% of patients. Approximately 90% have pain relief and can return to moderate use activity. Copyright © 2001 by the American Society for Surgery of the Hand     

Teilarthrodesen und Fusionen am rheumatischen Handgelenk

The hand (wrist and fingers) is one of the regions most frequently affected by rheumatic arthritis (RA). Obviously, the functional handicap affects activities of daily living and imposes an additional psychological burden, because the nature of the alterations means that the clinical picture can be interpreted as RA from external appearances. Thus, treatment of the rheumatoid wrist is a prodigious challenge for hand surgeons. Radiolunate arthrodesis (RLA), as pioneered by Chamay and Della-Santa, has become an established surgical technique for stabilizing and relieving pain in wrists destroyed by RA. RLA has been described by Stanley as the "golden standard" for the treatment of rheumatoid wrists. For patients with a severe wrist deformity and pain, a complete wrist arthrodesis may be the only viable surgical option.