Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fractures in the Independent Elderly

Abstract

Objective: Despite the improvement of open reduction and internal fixation (ORIF) of distal radius fractures (DRFs) provided by locked volar plating in elderly patients, there are still complex distal DRF not amenable to any satisfactory fixation. The purpose of this article is to define irreparable acute DRF in autonomous elderly patients and to review the preliminary results of a prospective series using wrist hemiarthroplasty at the acute stage. Methods: A total of 12 wrists in 10 women were prospectively included. The average age was 74 years (range, 65-87). All patients were autonomous at home. All were intra-articular Arbeitsgemeinschaft für Osteosynthe-sefragen (AO) “C” type fractures. Circumferential comminution was present in all cases. Impaction and cartilage defect were present in all cases. All patients sustained wrist hemiarthroplasty through a single dorsal approach. The proximal part of a total wrist arthroplasty was used in 10 cases and a modified implant with a longer stem was used in 2 cases. An ulnar head resection was associated in 10/12 cases whereas the ulnar head could be kept intact in 2 wrists. Postoperative immobilization was 3 weeks followed by a splint for 3 weeks. Follow-up consisted of clinical and radiographic evaluation at 6 weeks and 2, 6, and 12 months. The average clinical and radiological follow-up was 27 months (minimum 12, maximum 41). Results: There were no dislocation, loosening, or implant removal. One wrist was reoperated on for stiffness followed by a significant improvement. Complex pain regional syndrome (CPRS) was present in 3 patients. At follow-up, Visual Analog Scale (VAS) pain was 10/100. Average Quick Disability of the Arm, Shoulder and Hand (QuickDASH) was 32 points and Patient-Rated Wrist Evaluation (PRWE) was 24.7. Mean active motion values were as follows: pronation 74°, supination 77°, extension 34°, and flexion 26°. The average grip strength was 14 kg, 67% of the contralateral side. The average wrist score was 69%. Radiologically, periprosthetic bone healing was observed in all cases. We observed 1 radial and 3 ulnar inclination of the implant. This was not observed with the longer stem implant. Discussion: Implant surgery at the acute stage for complex fractures in the elderly is an old validated concept for hip, shoulder, and elbow. Indeed some DRFs in the autonomous elderly are beyond any ORIF possibilities due to the combination of comminution and a very distal fracture line. Our results suggest that primary wrist hemiarthroplasty is a viable method to treat these difficult wrist injuries in this specific population. Further controlled prospective studies are necessary to validate this concept.