Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.     

Partial Fusion of the wrist - an alternative procedure to the total wrist arthrodesis

Despite the important observations that have been made concerning biomechanics and function of the wrist joint in recent years, the surgeon is still confronted with a huge number of delayed posttraumatic disorders of this joint. In the past, total wrist fusion was the leading salvage procedure, whereas today several salvage procedures are available to solve these problems. Partial wrist fusions are supposed to stabilize the carpus, immobilize destroyed articulating surfaces while allowing motion in the unharmed parts of the wrist. Acknowledging pathobiomechanical laws, they have been used for a growing number of indications with a large benefit. The patients profit of better functional results than can be observed in patients with total arthrodesis of the wrist. Furthermore, partial wrist fusion provides a more stable situation and the absence of pain for a longer period of time. However, further studies evaluating the clinical outcome of these salvage procedures are necessary and to be expected in the near future.     

Limited arthrodesis for the rheumatoid wrist

Limited arthrodesis of the proximal carpal row to the radius, synovectomy of the extensor tendons and the wrist joint, and a Darrach procedure were carried out in 25 unstable painful rheumatoid wrists that had ulnar shift and/or palmar subluxation of the carpus. The average follow-up period after the operation was 3 years. Satisfactory results were obtained with relief of pain, improved forearm rotation, and increased grip strength. The average degree of extension and flexion was reduced, respectively, 70% and 54% at follow-up compared with the preoperative range. Postoperative x-ray films showed deterioration in the lunocapitate joint in 12 wrists; however, the wrists remained stable and painless.     

Partial arthrodesis for the rheumatoid wrist

The correct treatment of wrist deformation in the patient who has rheumatoid arthritis has a major impact on the preservation of function of the hand. Surgical decisions should be individualized, based on the patient's needs and the future development of deformation. Partial wrist arthrodesis in rheumatoid wrists is an excellent tool to preserve stability and functional mobility in the long term. In cases of severe destruction complete wrist fusion should be considered alternatively.     

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.     

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].     

Multiple stapling for wrist arthrodesis in the nonrheumatoid patient

Twenty-five out of 26 consecutive wrist fusions carried out by means of staple fixation alone had follow-up for an average of 40 months. This technique avoids corticocancellous bone grafting, achieves good stability in variable wrist positions with minimal splintage, and seems to avoid serious complications. Fusion occurred in 25 cases in an average of 3 1/5 months with complications in three cases and uneventful results in 22 cases (88%). Two patients were operated on a second time. Fifty-six percent of this patient population requested removal of the staples. This technique does not shorten the time to fusion, but it does obviate extensive plaster immobilization and the morbidity rate of bone grafting.     

Management of the rigid arthritic flatfoot in adults: triple arthrodesis

The traditional surgical treatment for adults with a rigid, arthritic flatfoot is a dual-incision triple arthrodesis. Over time, this procedure has proved to be reliable and reproducible in obtaining successful deformity correction through fusion and good clinical results. However, the traditional dual-incision triple arthrodesis is not without shortcomings. Early complications include lateral wound problems, malunion, and nonunion. Long-term follow-up of patients after a triple arthrodesis has shown that many develop adjacent joint arthritis at the ankle or midfoot. This particular problem should be considered an expected consequence, rather than a failure of the procedure. Although the indications for and surgical techniques used in triple arthrodesis have evolved and improved with time (predictably improving results in the intermediate term), the triple arthrodesis should be regarded as a salvage procedure. Certain measures can be taken by the surgeon to avoid some problems. If patients are at risk for lateral wound complications, the arthrodesis could be performed through a single medial incision. However, this can make some aspects of the CC fusion more difficult. Implants would have to be inserted percutaneously, which prevents the surgeon from using either staples or plates. If a patient were to need a lateral column lengthening through a CC distraction fusion, this would not be possible medially. If either the ST or CC joints have minimal degenerative changes, they could be spared through a double or modified double arthrodesis, respectively. Although these procedures that deviate from the traditional triple arthrodesis offer promise, further study is required to better define their role in treatment of the rigid, arthritic AAFD. Triple arthrodesis is, by no means, a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of hindfoot positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to anticipate postoperative problems and provide modifications in traditional technique for certain patients.     

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.     

Partial arthrodesis of the wrist: An investigation in cadavers

Partial arthrodesis of the wrist was performed on six cadavers in order to study the residual excursion of the wrist. Arthrodesis between the radius and scaphoid left 40 per cent extension/flexion and 61 per cent radial/ulnar deviation. Arthrodesis between the radius, scaphoid and lunate left 36 per cent extension/flexion and 59 per cent radial/ulnar deviation. Arthrodesis between the capitate, scaphoid and lunate left 59 per cent extension/flexion and 91 per cent radial/ulnar deviation.     

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.     

四角融合术在治疗腕部疾患中的应用进展

1984年Watson和Ballet在系统回顾4000多张腕部X线片后，提出了舟月进行性腕塌陷（scapholunate advanced collapse，SLAC）的概念，并系统描述了SLAC的临床表现、诊断和治疗方法，首次进行四角融合术（four—corner arthrodesis），即头状骨、月骨、三角骨和钩骨融合，是一种重建腕关节功能的部分腕骨融合手术方式，目前常常联合舟骨切除用于治疗各种原因引起的SLAC。[第一段]     

Calcium phosphate cement in wrist arthrodesis: three cases

Background With degenerative pathologies, arthrodesis of the wrist is a procedure reserved for preservative interventions that have failed. The least invasive procedure is Gill's technique, as modified by Luboshitz. To improve the results, we proposed a study of the advantages of local application of calcium phosphate cement. Methods The procedure consisted of refreshing the remaining articular surfaces, obtaining a dorsal corticocancellous graft from the distal radius, and replacing the bone substance lost when removing the graft with calcium phosphate cement followed by smoothing flat the arthrodesis area to limit tendon conflicts. Results In our three cases with an average follow-up of 23 months, no complications were noted and radiological consolidation was achieved in 2 months. Conclusions In view of this short series, we think that the addition of calcium phosphate cement to Gill's technique as modified by Luboshitz should improve the results of arthrodesis of degenerative wrists.     

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.