Limited Wrist Arthrodesis Research Articles

Progressing arthrosis and a high conversion rate 11 (4–19) years after four corner fusion

Four corner fusion (4CF) is a limited wrist arthrodesis offered to patients with painful wrists due to scaphoid non-union advanced collapse (SNAC) or scapho-lunate advanced collapse (SLAC). A retrospective study of 42 wrists (in 36 patients), operated with 4CF using K-wires and autologous bone graft followed up after 11 (4–19) years was performed, 25 were male and mean age at surgery was 51 (22–71) years. During the follow-up period, 13 wrists were converted to total wrist arthrodesis or wrist arthroplasty, and one is scheduled for conversion (14/42, 33%) due to non-union (3), DISI and progressing arthrosis (7) or progressing arthrosis (4). Non-union was seen in 3/42 (93%) wrists, all were later converted. At the final follow-up, the patients reported residual pain, VAS = 15 and 36 at rest and activity, respectively, and QDASH/PRWHE = 32 and 31, respectively. Active range of motion (AROM) was 38% and grip-strength was 76% compared to the uninjured side. Degenerative changes were seen in 88% on CT scans at follow-up. 4CF renders an acceptable pain reduction and function in the majority of patients, but increased degeneration and a high number of conversions after a longer follow-up time is concerning.

Arthroscopic Debridement and Arthrolysis for the Treatment of Advanced Kienböck's Disease: 18-Month and 5-Year Postoperative Results

Background Salvage procedures, such as proximal row carpectomy, limited or total wrist arthrodesis, and wrist replacement, are generally preferred to treat advanced Kienböck's disease. However, these procedures are particularly aggressive and may have unpredictable results and potentially significant complications. Questions/Purpose This study aimed to present the short- to mid-term clinical and functional results of arthroscopic debridement and arthrolysis in the management of advanced Kienböck's disease. Patients and Methods Fifteen patients in whom Lichtman Stages IIIA to IIIC or IV Kienböck's disease was diagnosed and treated by arthroscopic wrist debridement and arthrolysis were included in this retrospective study. The mean age was 30 years (range: 21-45). The mean follow-up period duration was 36 months (range: 18-60). The Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS), wrist range of motion (ROM), and grip strength were measured preoperatively and then again at the final follow-up visit. Results The mean DASH and VAS scores improved from 41 (range: 31-52) and 7.1 (range: 6-8) preoperatively to 13 (range: 8-21) and 2 (range: 0-3; p < 0.001) at the final follow-up visit, respectively. The mean wrist flexion and extension values increased from 32 (range: 20-60 degrees) and 56 degrees (range: 30-70 degrees; p = 0.009) preoperatively to 34 (range: 10-65 degrees; p = 0.218) and 57 degrees (range: 30-70 degrees; p = 0.296) at the final follow-up appointment, respectively, although these findings were statistically insignificant. The mean strength of the hand grip increased from 22.7 (range: 9-33) to 23.3 (range: 10-34; p = 0.372). Conclusion Arthroscopic debridement and arthrolysis may improve wrist function and quality of life due to the preserved ROM and hand grip strength after short- to mid-term follow-up periods despite the radiographic progression of Kienböck's disease. Level of Evidence This is a Level IV, retrospective case series study.

Scaphocapitate fusion for the treatment of Lichtman stage III Kienböck's disease. Results of a single center study with literature review

The purpose of this study was to report the outcomes of scaphocapitate fusion without lunate excision for the treatment of stage III Kienböck's disease and to compare these results with historical results of limited wrist arthrodesis and proximal row carpectomy. Clinical and radiographic evaluations were performed preoperatively and at a mean of 5.8-years’ follow-up (range 1.5 to 10.5years) on 17 patients with advanced Kienböck's disease (Lichtman stages: IIIA n=4 and IIIB n=13) treated by scaphocapitate fusion without lunate excision between January 2000 and July 2015. The average DASH score was 19 points (range 2 to 61) and the PRWE score was 23 points (range 0 to 77). The average preoperative VAS for pain of 8 was significantly reduced to an average of 4 with activity (P=0.002) and 1 at rest (P=0.001). The flexion/extension arc was 91° and grip strength was 76% of the contralateral side. The preoperative mean modified carpal height ratio decreased significantly to an average of 1.14 at the latest follow-up (P=0.02). The average carpal-ulnar distance ratio was not altered (P=0.89). The radioscaphoid and scapholunate angles were restored to their normal range. Four scaphocapitate joints failed to fuse. No re-operations were performed. Scaphocapitate fusion for advanced Kienböck's disease maintains wrist motion and significantly relieves pain. Lunate excision is not necessary. Based on a literature review, our results were comparable to those of scaphotrapeziotrapezoid fusion. Proximal row carpectomy is still an option when the radius and capitate articular surfaces are free of significant chondral lesions.

Limited Wrist Arthrodesis for Scapholunate Advanced Collapse Wrist: Triangle Fixation for Four-Corner Fusion.

Limited wrist arthrodesis with scaphoid excision is a useful treatment for scapholunate advanced collapse (SLAC) of the wrist. Multiple Kirschner wires were originally used for internal fixation of the four carpal bones, however long-term cast immobilization, pin tract infection, and hardware removal are still problematic. We introduce and evaluate the clinical outcomes of an internal fixation technique; triangle fixation for four-corner fusion, using three headless screws, as an alternative to conventional multiple Kirschner wires for the treatment of SLAC wrist. Five male patients with SLAC wrist secondary to three scaphoid nonunions and two scapholunate dissociations were treated with four-corner fusion using triangle fixation with three Double-threaded Japan screws. The mean age was 59.5 years (35-79 years) and the mean follow-up period was 40 months. After surgery, short arm splints were applied for 3-4 weeks, and then range of motion exercises were initiated. Wrist range of motion and grip strength both improved postoperatively. At the final follow-up evaluation, bone union was completely achieved and satisfactory pain relief was observed in all patients. Compared with the conventional Kirschner wire technique, the present technique shortens the period of splint immobilization due to a strong compression force in a skewed position, does not require pin removal or cause pin tract infections, and provides satisfactory results.

Functional Outcome of Open Reduction of Chronic Perilunate Injuries

Perilunate injuries are complex and occasionally go unrecognized acutely. Open reduction and internal fixation is a valid treatment option for these injuries. The purpose of this study was to evaluate the functional outcome of treating chronic perilunate injuries with open reduction and internal fixation. Between 1998 and 2007, we treated 24 patients for chronic perilunate injuries. We excluded 5 patients from this study because they underwent proximal row carpectomy or limited wrist arthrodesis. We treated the remaining 19 patients with open reduction and internal fixation. Mean time from injury to surgery was 29 weeks. All patients were men, with a mean age of 27 years. A total of 13 patients had fracture dislocations (group 1); of these, 11 were transscaphoid and 2 were transscaphoid transcapitate fracture dislocations. Six patients had perilunate dislocations (group 2). Postoperative follow-up averaged 58 months. All carpal fractures healed at an average of 18 weeks. At final evaluation, the average pain scores during rest, daily activities, and manual work on a 20-point visual analog scale were 0, 2, and 3, respectively, with no significant difference between groups. The active extension and flexion of the wrist averaged 39% and 52% of the uninjured side, respectively. Grip strength averaged 87% of the uninvolved extremity. According to the Mayo wrist scoring system, 58% of all patients (69% of group 1 and 33% of group 2) achieved good to excellent results. A total of 18 patients returned to their original work activities; 14 patients (74%) were very satisfied. No patients required secondary procedures. Despite late presentation, patients with chronic perilunate injuries can be treated with open reduction internal fixation, with satisfactory results. Patients with lesser arc injuries have less successful outcome. Patients with irreducible dislocations or major articular damage may require wrist salvage procedures.

Effectiveness of Four-Corner Arthrodesis with Use of a Locked Dorsal Circular Plate

Compared with traditional methods of fixation in four-corner arthrodesis, reviews of results using a dorsal circular plate (DCP) have identified higher complication rates. As the use of circular plate fixation for limited wrist arthrodesis was found to be a valuable concept per se and continued innovation and technical advancement are crucial to improve future treatment, changes in plate design were encouraged. To further evaluate the use of DCP fixation in four-corner arthrodesis, we report the first results using a radiolucent, nonmetallic (polyetheretherketone), locked DCP for four-corner arthrodesis. We retrospectively analyzed the clinical and radiographic results of 24 patients who underwent four-corner arthrodesis with a locked DCP at a minimum followup of 63months (mean, 76months; range, 63-91months). There were nine women and 15 men, with a mean age of 53years (range, 37-78years) at the time of surgery. We evaluated ROM with a goniometer and grip strength with a dynamometer. Function was assessed using QuickDASH. Radiographs were evaluated for union, carpal alignment, and hardware problems. At latest followup, ROM averaged 66% and 77% of the uninjured side in flexion-extension and radioulnar deviation, respectively. Grip strength averaged 70% of the uninjured side. The average postoperative QuickDASH score was 19.11. Union was achieved by 22 of the 24 patients. Our data show four-corner arthrodesis with a radiolucent, nonmetallic, locked DCP is an effective procedure that allows stable primary fixation as a basis for good functional outcome, provided surgical technique and quality of bone graft are adequate. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Limited wrist arthrodesis for SLAC wrist

Limited wrist arthrodesis for SLAC wrist

Using Computed Tomography to Assist With Diagnosis of Avascular Necrosis Complicating Chronic Scaphoid Nonunion

The primary aim of our study was to investigate use of long axis computed tomography (CT) in predicting avascular necrosis of the proximal pole of the scaphoid and subsequent fracture nonunion after internal fixation. In addition, we describe a new technique of measuring the position of a scaphoid fracture and provide data on its reproducibility. Thirty-one patients operated on by the senior author for delayed union or nonunion of scaphoid fracture were included. Preoperative CT scans were independently assessed for increased radiodensity of the proximal pole, converging trabeculae, degree of deformity, comminution, and fracture position. Intraoperative biopsies of the proximal pole were obtained and histologically assessed for evidence of avascular necrosis. The radiologic variables were statistically compared with the histologic findings. The presence of avascular necrosis was also compared with postoperative union status, identified on longitudinal CT scans. Preoperative CT features that statistically correlated with histologic evidence of avascular necrosis were increased radiodensity of the proximal pole and the absence of any converging trabeculae between the fracture fragments. The radiologic changes of avascular necrosis and the histologic confirmation of avascular necrosis were associated with persistent nonunion. Preoperative longitudinal CT of scaphoid nonunion is of great value in identifying avascular necrosis and predicting subsequent fracture union. If avascular necrosis is suspected based on preoperative CT, management options include vascularized bone grafts and bone morphogenic protein for younger patients and limited wrist arthrodesis for older patients. Diagnostic II.

Results of the Modified Brunelli Tenodesis for Treatment of Scapholunate Instability: A Retrospective Study of 19 Patients

Management of chronic scapholunate (SL) instability without osteoarthritis remains controversial. In order to recreate an SL interosseous linkage, some surgeons opt for a limited wrist arthrodesis, whereas others use soft tissue stabilization. The purpose of the current study was to review and assess the therapeutic benefit of the modified Brunelli tenodesis that used the flexor carpi radialis tendon to replicate the stabilizing ligaments of the scaphoid. Between 2001 and 2005, 19 tenodesis procedures have been performed to correct dynamic or static SL instability without osteoarthritis. On average, patients had surgery 15 months after injury. The mean follow-up was 37 months. After surgery, 15 patients had no to mild pain with a mean visual analog scale score of 3 of 10. The average wrist motion was 50 degrees extension, 41 degrees flexion, 24 degrees radial deviation, and 29 degrees ulnar deviation (75%, 73%, 68%, and 86% of the uninvolved wrists, respectively). The grip strength was 78% of the uninvolved wrists. On radiographs, the mean static SL distance was 2.4 mm (2.8 mm before surgery). There was no widening of the SL gap compared to the immediate postoperative gap. The SL angle improved from a mean preoperative value of 61 degrees to 53 degrees immediately after surgery and rose again to 62 degrees at the time of the review. One patient developed a scapholunate advanced collapse wrist stage 2. Ligament reconstruction using tendon grafts gave satisfactory results to correct reducible chronic SL instability without osteoarthritis. This repair technique achieved a relatively pain-free wrist, with acceptable grip strength and normal SL distance but with a loss in the arc of motion and a loss of correction of SL angle. Therapeutic IV.

Spider Plate Fixation

Using the Spider plate fixation device, limited wrist arthrodesis was performed on 30 patients over a 2-year period. Developed as an alternative to Kirschner wires and compression bone screws in limited intercarpal fusions, its rigid fixation was expected to yield better results. Five hand surgeons treated 24 men and 6 women with an average age of 45 years. Diagnosis included the following: scaphoid nonunion advanced collapse, scapholunate advanced collapse, scapholunate dissociation, midcarpal arthrosis, and Kienböck disease. The 8-hole regular Spider and 6-hole mini-Spider plates were applied dorsally, and patients were immobilized for 4 weeks. In a blinded study, data results showed no significant improvement when compared with bone screws and Kirschner wires. Preliminary results showed that the Spider plate yielded higher nonunion rates and less wrist motion.

Scaphoid Excision and Limited Wrist Fusion: A Comparison of K-Wire and Circular Plate Fixation

The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.

Limited wrist arthrodesis for SLAC wrist due to destruction and dislocation of silicone scaphoid implant. Two cases report

Limited wrist arthrodesis for SLAC wrist due to destruction and dislocation of silicone scaphoid implant. Two cases report

Limited wrist arthrodesis

Limited wrist arthrodesis

Experimental study of the biomechanical impact of limited intercarpal arthrodesis on the wrist

目的 探讨部分腕骨融合术后腕关节的活动范围、压力负荷及对腕关节生理状态的影响.方法选用12例新鲜腕关节标本随机分为3组,A组:舟大小融合术;B组:舟骨三角骨切除+头月融合术;C组:四角融合+舟骨切除术.通过CSS-44020系列生物力学试验机,用100 N力,以5mm/s的速度分别牵引腕关节被动掌屈、背伸、尺偏和桡偏,并测量A、B、C 3组标本的活动角度.然后,于腕关节内放置压敏片,用自制的实验架将腕关节固定于中立位,以5 N/s的压速对腕关节施压至200 N,维持60 s后测量压敏片上各组标本的受力面积和压力负荷.结果 (1) 活动范围:A组掌屈(68.4±5.2)°(±s,下同)、背伸(51.5±4.6)°、尺偏(24.5±2.3)°、桡偏(15.7±3.4)°.B组掌屈(64.5±7.1)°、背伸(60.0±5.2)°、尺偏(42.4±3.2)°、桡偏(26.9±5.2)°.C组掌屈(61.9±6.6)°、背伸(54.9±5.3)°、尺偏(27.1±3.9)°、桡偏(17.0±4.9)°.(2) 腕关节的受力面积:A组为(265.00±8.97)mm2.B组为(125.81±5.97)mm2.C组为(164.00±8.43)mm2.(3) 负荷压力:A组为(53.87±3.07)N/cm2.B组为(112.86±0.74)N/cm2.C组为(55.28±5.11)N/cm2.结论舟大小融合术、舟骨切除+四角融合术对腕关节应力负荷的影响与正常腕关节相比变化不大,而舟三角骨切除+头月融合术对腕关节的影响较大,其应力负荷的增加明显超出了正常腕关节所承受的压力负荷。

LIMITED WRIST ARTHRODESIS VERSUS RADIAL OSTEOTOMY FOR ADVANCED KIENBÖCK'S DISEASE — FOR A FRAGMENTED LUNATE

Thirty-eight patients with advanced Kienböck's disease treated by limited wrist arthrodesis (LWA: n = 10) or radial osteotomy (RO: n = 28) for a fragmented lunate were retrospectively examined after an average of 47.9 and 68.1 months, respectively. Compared with pre-operative values, the active flexion-extension range of motion decreased by about 16.0 degrees in LWA and increased approximately 9.7 degrees in RO and the grip strength improved by approximately 7.5 kg in LWA and 8.0 kg in RO. In both groups, radiographs showed no significant progression of carpal collapse. Although LWA caused some decrease in wrist flexion-extension, both procedures are appropriate for surgical treatment of advanced Kienböck's disease. Most patients experienced a reduction in pain and were able to return to work.

Results of limited wrist arthrodesis

目的 评价头骨、月骨、三角骨及钩骨四关节融合治疗退行性腕关节炎的效果.方法 1997年7月～2002年12月应用腕关节部分融合术创伤性腕关节炎治疗20例,术后随访15个月,随访检查包括术后腕关节疼痛程度、腕关节活动度、握力以及患侧X线检查.视觉模拟评分法评价疼痛程度.腕关节总体功能评价采用Krimmer腕关节评分表.结果腕疼痛值静息时为2.1,用力后为5.3;屈伸活动度为64°(对侧126°);尺桡偏为30°(对侧57°);平均握力为24 kg(对侧40 kg).Krimmer腕关节评分值为67.X线检查头、月、三角及钩骨均融合.结论腕关节部分融合后能保存腕关节部分功能,是治疗退行性腕关节炎有效的方法。

Limited wrist arthrodesis for the treatment of osteoarthritis associated with scaphoid nonunion

Limited wrist arthrodesis for the treatment of osteoarthritis associated with scaphoid nonunion

ONE THOUSAND INTERCARPAL ARTHRODESES

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while eliminating pain. Selective fusion of specific carpal units can be used in degenerative arthritis, rotary subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienböck’s disease, and congenital synchondrosis or partial fusion of specific carpal joints. This report presents our experience with more than 1000 limited wrist arthrodeses, and provides a review of the indications and technical considerations for specific intercarpal fusions, and subsequent results. To date this is the largest series of intercarpal arthrodeses and the study has demonstrated that these techniques are reliable and effective in dealing with a wide range of wrist disorders.

Proximal row carpectomy versus limited wrist arthrodesis for advanced Kienböck's disease

The outcomes in 20 patients with advanced Kienböck's disease treated by proximal row carpectomy (seven patients) or limited wrist arthrodesis (13 patients) were reviewed retrospectively. Postoperatively, the results were more satisfactory in terms of wrist pain, the range of wrist flexion-extension, and grip strength following limited wrist arthrodesis than after proximal row carpectomy, although the differences were not statistically significant. We recommend scaphotrapeziotrapezoid arthrodesis in selected patients with advanced Kienböck's disease who have a fragmented lunate.

Limited wrist arthrodesis for the salvage of SLAC wrist

We report the results of limited wrist arthrodesis, a salvage procedure for SLAC wrist. It involves excision of the scaphoid, radial styloidectomy and fusion of the lunate to the capitate and the triquetrum to the hamate, using cancellous lag screws. Twenty-four wrists in 22 patients were reviewed retrospectively at an average follow-up of 23 months. Seventeen of the 22 patients had no pain or mild pain and had retained a mean arc of motion of 48°. Grip strength was 70% of the other side. Four of the 24 patients developed non-unions, two of which had successful revision to limited wrist arthrodesis. The other two required pan arthrodesis of the wrist. Two other patients with persisting pain in spite of solid fusion were also treated by pan arthrodesis of the wrist. Radial styloidectomy did not result in early failure of this procedure and secondary ulnar translocation of the carpus was not seen.