Total Wrist Arthrodesis Research Articles

Wrist fusion through centralisation of the ulna for recurrent giant cell tumour of the distal radius.

To review the outcome of wide resection and wrist fusion through centralisation of the ulna for recurrent giant cell tumour (GCT) of the distal radius in 10 patients. Records of 7 women and 3 men aged 25 to 40 years who underwent wide resection and wrist fusion through centralisation of the ulna for grade I (n=6) and grade II (n=4) recurrent GCT of the distal radius were reviewed. Functional outcome was evaluated using the modified Musculoskeletal Tumor Society scoring system. Grip strength and range of motion of the metacarpophalangeal joint were also assessed. The mean follow-up period was 45 (range, 30-60) months. All tumours were benign and there was no evidence of metastasis. The mean grip strength was 45% (range, 30-70%) of the contralateral side. All patients achieved normal range of motion of the metacarpophalangeal and interphalangeal joints, but 4 patients had an extensor lag of the thumb. The mean time to wrist fusion was 6 (range, 4-8) months: 3 to 4 months for the 6 patients with bone grafting and 5 to 6 months for the 4 patients without bone grafting who developed painful subluxation necessitating total wrist arthrodesis using a plate and morcellised bone grafts. Wrist fusion through centralisation of the ulna for recurrent GCT of the distal radius is a viable option, despite a loss of wrist motion.

Surgical Treatment of Pediatric Upper Limb Spasticity: The Wrist and Hand.

The wrist and hand are essential in the placement of the upper extremity in a functional position for grasp, pinch, and release activities. This depends on the delicate balance between the extrinsic and intrinsic muscles of the wrist and hand. Spasticity alters this equilibrium, limiting the interaction of the upper limb with the environment. Classically, pediatric patients with upper limb spasticity present with a flexed wrist, thumb-in-palm, and flexed finger posture. These contractures are typically secondary to spasticity of the extrinsic flexor muscles of the wrist and hand and intrinsic muscles of the thumb and digits. Tendon release, lengthening, or transfer procedures may help correct the resultant abnormal postures. A total wrist arthrodesis with or without proximal row carpectomy may help address the severely flexed wrist deformity. With proper diagnosis, a well-executed surgical plan, and a consistent hand rehabilitation regimen, successful surgical outcomes can be achieved.

Proximal row carpectomy in total arthrodesis of the rheumatoid wrist

BackgroundAdvanced proximal carpal row damage is common in rheumatoid arthritis (RA). Proximal row carpectomy (PRC) simplifies total wrist arthrodesis, obviating the need for an iliac bone graft. In theory, PRC also improves the chances of healing, as fusion of a single joint space is needed for the procedure to be successful. Potential effects of the loss of carpal height related to PRC are unknown. HypothesisWe hypothesised that PRC performed concomitantly with total wrist arthrodesis in patients with RA produces good clinical and radiological outcomes, without inducing loss of strength or digital deformities. Material and methodsIn 38 total arthrodeses of rheumatoid wrists, a clinical evaluation was performed, including a visual analogue scale (VAS) pain score, the Patient-Rated Wrist Evaluation (PRWE), grip strength, digital deformities, and patient satisfaction. A standard radiographic workup was obtained to assess healing and carpal height indices. ResultsAfter a mean follow-up of 50 months, the mean VAS pain score was 0.4 (range: 0–7), the mean PRWE score was 21 (range: 0–80.5), and grip strength as a percentage of the contralateral limb was 76%. The healing rate was 92% (35/38 wrists), and 34 (90%) patients reported being satisfied or very satisfied. No effects of carpal height loss on clinical or radiographic parameters was detected. DiscussionTotal wrist arthrodesis combined with PRC provides reliable and reproducible benefits. This study found no evidence of adverse effects related to the loss of carpal height. Level of evidenceIV, retrospective study.

The total wrist arthroplasty

Traditional management of wrist arthritis consists of proximal row carpectomy, partial carpal fusions, or, in the event of pancarpal arthritis, total wrist fusion. Although proximal row carpectomy and partial wrist fusions preserve some motion at the wrist while relieving pain symptoms, the quality of results obtained from these procedures is not predictable or optimal in many instances. Total wrist fusions are credited with universal pain relief at the expense of wrist motion. However, critical analysis of the results of total wrist arthrodesis shows that the results are not always consistent with what has been claimed and that pain relief is unpredictable at best. In a recent study, 14 of 22 patients who had undergone wrist arthrodesis had residual pain, and 4 of these patients had severe pain 6 years later. In another study, only 6 of 36 patients remained pain-free 4 years after wrist arthrodesis. Moreover, many patients do not like loss of motion in their wrists. In a study of wrist arthrodesis, only 40% of patients were satisfied at 1 year. In another study, 100% of patients who had wrist arthrodesis indicated that they would have a procedure performed so they could move their wrists again. Management of hip, knee, ankle, and shoulder joints has evolved from arthrodesis to arthroplasty. The wrist joint awaits the same pattern of evolution with the advent of reliable designs. In this presentation, I will first describe the design rationale of the Stryker ReMotion Total Wrist arthroplasty along with historical antecedents. Next, I will outline the technique of implantation with tips and tricks for special situations. Finally, I will discuss 10-year results and comment on future prospects of total wrist arthroplasty.

Total wrist arthrodesis with wrist fusion rod in patients with rheumatoid arthritis.

This study aims to retrospectively review the short-term surgical outcome of wrist fusion using wrist fusion rod (WFR). Six wrists of four female patients (mean age 56 years; range 51 to 62 years) with advanced stage rheumatoid arthritis of Larsen IV or V were performed total wrist fusion using WFR. Clinical outcome was assessed using a numeric rating scale of pain satisfaction level. Bony fusion, correction of palmar subluxation and ulnar deviation, rod bending angle, wrist fusion angle, and complications were assessed from radiographs. All wrists achieved painless wrist stability with bony fusion of the radiocarpal joint. Both the palmar subluxation and ulnar deviation were corrected in all patients. Two radiographic complications were observed: rod fracture in one patient and a radiolucent line in proximal metacarpal bone in another patient. Both complications might have occurred as a result of instability of the third carpometacarpal joint, but neither influenced clinical outcome. Wrist fusion angle was smaller than rod bending angle at final observation. Wrist fusion using WFR is an option for the treatment of advanced stage rheumatoid arthritis of wrist. According to our experience, the stability of third carpometacarpal joint should be assessed before surgery, and this joint should be fused if required. The bending angle of the intramedullary rod does not directly form the wrist fusion angle in contrast to the case with a dorsal wrist fusion plate.

Biomechanical testing of a new total wrist arthrodesis plate

The aim of this study was to evaluate the biomechanical properties of the APTUS wrist fusion plate in comparison to those of the AO wrist fusion plate. 6 APTUS wrist fusion plates (APTUS 2.5 TriLock Wrist Fusion Plate Long Bend) from Medartis (Basel, Switzerland) and 6 AO wrist fusion plates (= LCP Wrist Fusion Plate Standard Bend from Dupuy-Synthes, Bettlach, Switzerland) were installed according to the manufacturers' instructions on life-sized, fibre-glass reinforced polyamide models of a healthy human hand. Then fatigue testing with increasing loads on a monoaxial material testing machine was carried out and the force-movement measurements were recorded on a PC. For up to 50,000 cycles, loading was applied in a sinus-wave frequency of 4 Hz and a force ratio (FMin/FMax) of 0.1-70 N. After 50,000 cycles and then at every 10,000 cycles the load was increased by 15% until breakage or a deformation of over 15 mm at the point of force application of the implant occurred. In addition, the tear-out resistance of 5 screws of each type of plate was examined and the system tear-out resistance calculated. The mean values and standard deviations of fatigue strength, torsional moments and fatigue limits (load cycles) were checked for normal distribution and finally the results were compared by means of non-parametric and parametric statistical tests. Plate breakage occurred with the AO wrist fusion plate on average after 52,596 (SD±12,833) load cycles and with the APTUS wrist fusion plate after an average of 115,428 (SD±12,600) load cycles. For the AO wrist fusion plates, an average load of 6.3 (SD±0.8) Nm and for the APTUS plate one of 10 (SD±1.7) Nm led to failure. For the APTUS plate the screw tear-out resistance was calculated as 2,632 (SD±96) N while that for the AO plate was found to be 1,449 (SD±314) N. In comparison to the AO wrist fusion plate the APTUS wrist fusion plate has significantly higher fatigue resistance and tear-out strength. On the basis of 100,000 load cycles until bone healing in the case a wrist arthrodesis, use of the APTUS plate should enable bone healing to occur before the implant fails.

Hardware-related complications following radiocarpal arthrodesis using a dorsal plate.

Background Hardware-related complications more than 6 months after total wrist arthrodesis are rarely reported, and controversy remains around the inclusion of the middle finger carpometacarpal joint (CMCJ) in the fusion mass. Purpose To determine the frequency of hardware-related complications including plate fractures, screw fractures, and symptomatic plate/screw loosening, and to investigate whether failure to fuse the middle finger CMCJ contributed to these hardware complications. Patients and Methods A retrospective chart review was designed to identify long-term hardware-related complications following 122 wrist arthrodeses using plate fixation. Patients with at least 6 months of follow-up were reviewed to determine the number of complications, the involvement of the middle finger CMCJ, and the procedures required to address these complications. Results At a median of 2.5 years following arthrodesis (range, 6 months-19 years), 20 (16%) hardware-related complications occurred and included screw fracture (n = 12), plate loosening (n = 5), and plate fracture (n = 3). Thirteen (65%) of the hardware complications occurred after the CMCJ was not fused during the procedure. The CMCJ did not fuse after attempted arthrodesis in 6 additional wrists. Conclusions Persistent middle finger CMCJ micromotion was likely present in 19/20 wrists (95%) that experienced symptomatic hardware complications. Given the occurrence of hardware failures centering on this joint, it is our recommendation that, unless one plans for routine plate removal within a given timeframe, the middle finger CMCJ must be included in the fusion mass. Level 4 Therapeutic Case Series.

Long-Term Functional Outcomes After Bilateral Total Wrist Arthrodesis

To report on the long-term outcomes of bilateral total wrist arthrodeses. We conducted a review of all living patients who underwent bilateral wrist arthrodesesfrom 1980 to 2010 within a single institution. Outcome measures included pain, Disabilities of the Arm, Shoulder, and Hand questionnaire, Patient-Rated Wrist Evaluation, Michigan Hand Questionnaire, satisfaction scores, complications, and revision surgeries. Thirteen patients (26 wrists) were treated with an average follow-up of 14 years (range, 3-28 y). Average time for contralateral wrist arthrodesis was 16 months after initial wrist arthrodesis. Eleven wrists had undergone prior surgery. Eleven patients had a primary diagnosis of inflammatory arthritis. Wrists were fused from 5° flexion to 30° extension, with all but one patient's wrist fused within 10° of the contralateral wrist. There was a significant improvement in postoperative grip strength and pain levels. Postoperative Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire scores were 21, 29, and 73, respectively. Increasing age, preoperative steroid usage, and concomitant shoulder or elbow disorders were associated with worse outcomes. Twelve patients (93%) were satisfied and would repeat the surgery and 9 returned to full-time work. The major functional limitation was turning a doorknob or tight jar lid. Seven patients underwent additional surgery including 5 revision arthrodeses and 2 plate removals. Revision surgeries were more common in patients with prior surgeries or preoperative steroid usage, women, smokers, those with ipsilateral elbow dysfunction, and those with fixation with a dorsal locking plate. Bilateral total wrist arthrodesis improved pain while enabling patients with severe carpal arthrosis to maintain a satisfactory level of extremity function and quality of life. In general, patients adapted and were satisfied with functional capabilities. This is a viable salvageoption for patients with severe bilateral disease. Therapeutic III.

Total Bodily Extrusion of the Lunate: An Extreme Inferior Arc Injury: A Case Report.

A fifty-six-year-old man had an open radiocarpal and intercarpal dislocation with a radial styloid fracture, an open triangular fibrocartilage complex tear, and complete bodily extrusion of the lunate. We performed irrigation and debridement and an immediate total wrist arthrodesis. One year postinjury, the fusion had healed without infection, and the patient had functional digital range of motion, 80° of active pronation, and 60° of active supination without distal radioulnar joint instability; he had only mild pain with strenuous activities. In this severe case, we believed that total wrist arthrodesis was the most reliable treatment option, and it produced an acceptable result.

A Scaphoid Osteochondral Autograft for Reconstruction of the Lunate Fossa of the Distal Part of the Radius After a Complex Open Fracture: A Case Report.

Complex fractures of the distal part of the radius in high-energy injuries or in elderly osteopenic patients often have extensive articular comminution. Often, these small fragments are not amenable to primary fixation. In high-energy open fractures, there may be substantial bone loss or missing osteochondral fragments. Moreover, concomitant carpal fractures are often present, as well as associated radiocarpal and carpal dislocations that offer additional challenges. Primary total wrist arthrodesis has been suggested for treatment of these difficult injuries1. Motion-preserving salvage procedures include total wrist arthroplasty, limited wrist fusion, and proximal row carpectomy (PRC). Total wrist arthroplasty is contraindicated in younger, more active patients because current implants require a low-demand lifestyle, and complication rates following surgery remain high2. Limited wrist fusion and PRC require an intact lunate fossa and thus may not be options in cases with substantial loss of articular surface. Autogenous osteochondral graft reconstruction of the articular surface of the distal part of the radius has been described in some small case series3-7. PRC involves resection of the scaphoid, lunate, and triquetrum, allowing the capitate to articulate with the lunate facet of the distal part of the radius. The scaphoid is therefore an ideal potential osteochondral donor graft for salvage of the lunate fossa when PRC is to be performed because it does not require a separate graft harvest procedure and does not cause additional donor-site morbidity. We report a case of a complex open radiocarpal fracture-dislocation with bone loss, demonstrating salvage of the lunate facet of the distal part of the radius with a scaphoid osteochondral autograft. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A twenty-five-year-old man was involved in a rollover motor vehicle collision and was transferred to …

RSL Fusion with Excision of Distal Scaphoid and Triquetrum: A Cadaveric Study

Radioscapholunate (RSL) fusion has been utilized for treatment of radiocarpal arthritis for patients with an intact midcarpal joint. This preserves midcarpal joint motion while alleviating pain. Dart thrower's motion (DTM), which has been emphasized recently, is mainly a midcarpal joint motion. Question A cadaveric study was designed to measure and compare the range of motion (ROM) of the human wrist before and after an RSL fusion, followed by distal scaphoid excision, and finally excision of the triquetrum. Methods Twelve embalmed adult cadaveric upper limbs were assessed. The wrist motion was measured with an electrogoniometer. Measurements of the flexion-extension plane and radial-ulnar deviation plane were obtained for baseline after capsulotomy, after simulated RSL fusion with memory staples, after distal scaphoidectomy, and after excision of the triquetrum. Results The effects of scaphoid and triquetrum excision were expressed as improvements in movement over that of the preceding step. RSL fusion alone resulted in a decrease of the flexion-extension (F-E) arc by 36% and the radioulnar deviation (R-U) arc by 30%. Excision of the distal scaphoid with RSL improved the F-E arc by 34% and the R-U arc by 34%. With excision of the triquetrum, the F-E arc improved further by 13% and the R-U arc by 21%. The ROM of the simulated RSL fusion with distal scaphoidectomy is improved with excising the triquetrum, mainly through an increase in ulnar deviation motion. RSL fusion with distal scaphoidectomy and triquetrectomy can be an alternative to total wrist arthrodesis for patients with an intact midcarpal joint.

Klinisch-funktionelle Nachuntersuchung verschiedener handchirurgischer Versteifungsmethoden

Total and partial arthrodesis of the wrist are currently sophisticated treatment options for many advanced pathological changes of the wrist. This retrospective study analyzed the subjective and objective outcome of different wrist arthrodesis techniques, e.g. total wrist arthrodesis, scaphotrapeziotrapezoid (STT) bone fusion and midcarpal arthrodesis. Subjective physical and mental quality of life of 98 patients (total wrist arthrodesis n = 43, STT fusion n = 30 and midcarpal arthrodesis n = 25) was measured using the DASH questionnaire. The range of motion and grip strength were analyzed in 48 patients (total wrist arthrodesis n = 21, STT fusion n = 17 and midcarpal arthrodesis n = 10). Patients with partial wrist arthrodesis achieved a significantly better DASH score than patients with total wrist arthrodesis. Grip strength did not show any statistically significant differences between the two groups. Patients with STT fusion showed the best range of motion of the wrist. Partial arthrodesis seems to be superior to total wrist arthrodesis. Patients profit from a higher physical and mental quality of life.

The use of a pyrocarbon capitate resurfacing implant in chronic wrist disorders

The present study describes the technique and results of proximal row carpectomy with resection of the head of the capitate and replacement with a pyrocarbon capitate resurfacing implant. The major indication for surgical treatment was arthritic changes on the head of the capitate. Patients were assessed by range of motion, grip strength, pain and functional scoring, and radiographic studies. In most patients, wrist function was improved and pain relief was obtained. This surgical procedure may represent a good alternative to total and partial wrist arthrodesis.

AB0286 Combination of biologic treatment and orthopedic surgery of the upper extremity in the patients with rheumatoid arthritis

BackgroundBy tight control of disease activity using biological agents, patients’ motivation to undergo orthopedic surgery is raised to achieve higher level of activities in daily living (ADL) and quality of...

Long-Term Results of Bone-Retinaculum-Bone Autograft for Scapholunate Instability

To report long-term follow-up of scapholunate interosseous ligament reconstruction with bone-retinaculum-bone autograft in patients with dynamic scapholunate instability. Of the 14 patients from the previously reported cohort who had bone-retinaculum-bone autograft for dynamic instability, 6 returned for clinical examination and radiographs, 3 were reached by telephone, and 2 were lost to follow-up. The remaining 3 had salvage procedures (2 total wrist arthrodeses and 1 proximal row carpectomy) between the prior report and the current study and thus reached an endpoint, at 2 to 4 years. For the 6 who returned, outcome measurements included scapholunate angle and gap, radiographic evidence of secondary arthritis, wrist extension and flexion, grip strength, and Mayo wrist score. Follow-up averaged 11.9 years (range, 10.7-14.1 y). Clinical and radiographic outcomes deteriorated moderately from the prior report. Mayo wrist score averaged 83. There were 3 failures, resulting in 1 proximal row carpectomy and 2 total wrist arthrodeses. Findings at repeat surgery in the failed group included an intact graft without any apparent abnormalities, a partially ruptured graft (after a subsequent re-injury), and a completely resorbed graft. Bone-retinaculum-bone autograft reconstruction is a viable treatment option for dynamic scapholunate instability in which the scaphoid and lunate can be reduced. Results may deteriorate but are similar to those reported previously from other techniques. Problems with graft strength or stiffness may necessitate further surgery.

Reconstruction of the Rheumatoid Wrist: Fibrous Nonunion Arthroplasty

The most common surgical procedures described in the literature for rheumatoid arthritis of the wrist require a compromise between range of motion and stability. Total wrist arthrodeses, while providing pain control and stability, restrict range of motion. Implant arthroplasties, while granting range of motion, have not been proven to be durable. Fibrous non-union arthroplasties, on the other hand, can treat pain while preserving range of motion. This procedure should be considered a viable option for treating wrists with advanced destruction from rheumatoid arthritis. Keywords: Rheumatoid, wrist, Fibrous non-union arthroplasty, Arthritis, Reconstruction

Limited Carpal Arthrodeses for the Treatment of Wrist Osteoarthritis

The five main etiologies of wrist osteoarthritis are: a) Scapholunate instability leading to Scapholunate advanced collapse (SLAC) b) Scaphoid nonunion leading to Scaphoid Nonunion Advanced Collapse (SNAC) c) Distal radius intra-articular malunion d) Kienböck stage IV e) Chondrocalcinosis. The two last diseases are not post-traumatic. We discuss the advancement of arthritis in different stages, and the possibilities of limited carpal arthrodesis to fuse the joints involved in arthritis, taking care to preserve the intact joints. This retains a certain amount of motion at the wrist. It is always better to avoid total wrist arthrodesis which is less and less performed, due to the good long-term results of limited carpal arthrodeses.

Locked Intramedullary Total Wrist Arthrodesis

Total wrist arthrodesis is commonly performed using fixation plates, which can produce soft tissue irritation, often require removal, and limit the ability to position the hand in space. The Skeletal Dynamics IMPLATE is an intramedullary total wrist fusion device designed to provide stable fixation while avoiding the problems associated with plates. Radial and metacarpal locked intramedullary nails are inserted and joined by a connector. Desired hand placement is achieved by selecting the proper connector length and angle, then orienting it appropriately. Fusion mass compression is obtained by virtue of longitudinal threads on the radial nail that allow for length adjustment. Seven wrists in three men and four women were treated with this device and followed for a minimum of 24 weeks. In all cases, local cancellous bone graft was used and the third carpometacarpal (CMC) joint incorporated into the fusion. The median age was 49 (range, 28-71) years. Indications for fusion were two posttraumatic arthritides, three rheumatoid arthritides, one spastic deformity, and one infection. Patients were evaluated before surgery and at final follow-up using the Fernandez pain score and grip strength measurements using a hand-held dynamometer. All patients improved their grip strength and decreased their pain scores. All fusions united, and none of the patients presented dorsal soft tissue problems or required implant removal. One rheumatoid patient required secondary surgery for removal of a retained palmar osteophyte. This device delivers stable fixation, facilitates hand placement, and does not require removal.

Proximal Row Carpectomy Combined with Wrist Hemiarthroplasty

Proximal row carpectomy (PRC) combined with distal radius hemiarthroplasty is a relatively novel procedure that rivals total wrist arthrodesis and offers a new surgical treatment option for select patients with painful, end-stage wrist disease. We present our early experience with this procedure. A retrospective chart review was conducted for nonrheumatoid patients diagnosed with wrist arthritis and subsequently treated with wrist hemiarthroplasty combined with PRC. The minimum follow-up duration was 12 months. Preoperative and postoperative flexion, extension, and grip strength were recorded. Postoperative radiographic findings were assessed. The Patient-Rated Wrist Evaluation (PRWE) questionnaire was administered to gauge postoperative pain and function. The records of 10 patients were reviewed. The mean age was 64 years and the mean postoperative follow-up duration was 19 months. Postoperative flexion, extension, and grip strength were all found to be less than the preoperative levels. The mean postoperative PRWE score for pain and function were 26 and 23, respectively. The complications were diverse and occurred at a relatively high rate. PRC combined with distal radius hemiarthroplasty is a novel procedure that offers a potential surgical option for the treatment of wrist arthritis in select patients. Our early experience has lead us to modify our technique with regard to the implant material, and at this stage, the surgical technique and the most appropriate implant may require further optimization. The level of evidence for this study is IV (therapeutic).

Langzeitergebnisse nach Handgelenkdenervation

This retrospective study examines long-term follow-up results after complete denervation of the wrist. Between 1994 and 2000 a total of 61 complete wrist denervations of 59 patients (median age at operation 46 years) were performed. In 2009 29 patients with 30 complete wrist denervations took part in a follow-up examination after an average of 10 years. The mobility of the wrist and the grip force were examined. Pain and satisfaction with the operation were determined by means of a visual analogue scale (VAS) (0-100). The patients were asked about pain reduction and how long it lasted. Further the DASH and the Mayo Wrist Score were evaluated. Radiographs of the denervated wrist were performed and the degree of the degenerative osteoarthritis was determined according to Knirk and Jupiter. In 7 of the 36 patients examined, a partial or total wrist arthrodesis was performed. These patients were excluded from the study. Pain was improved in 28 of the 30 denervated wrists examined, in 22 the improvement lasted until the follow-up examination, whereas in 6 the pain increased after a median of 90 months. The median pain intensity was 10 at rest and 50 with activity; the satisfaction was 90. The median of the extension/flexion was 81% and the grip force 82% in comparison to the opposite hand. The DASH Score was 25 and the Mayo Wrist Score 73. Complete denervation of the wrist according to Wilhelm is a treatment option for the chronically painful wrist and can lead to good grip force, mobility, sufficient pain reduction and satisfaction in the long term.