Wrist Replacement Research Articles

Complications following total wrist replacement: A single-center retrospective review

Background/Purpose: Total wrist replacement (TWR) is an alternative to wrist fusion in advance wrist arthritis with the advantage of preserving the wrist motion. TWR is, however, infrequently performed in Asia-Pacific region. This study aimed to describe our institution's experience in managing complications following TWR. Methods: This study represents a single-center retrospective review of all patients who underwent TWR at the Department of Orthopedics and Traumatology, Prince of Wales Hospital in Hong Kong. The study period spans from 1 January 2004 to 1 March 2023. Recorded demographic parameters include gender, age upon surgery, pathology, types of implants, and follow-up period. Outcomes focused particularly on postoperative complications and need for revision surgery. Results: Twelve TWR from 10 Chinese-Asian patients were reviewed with a mean follow-up duration of 97.4 months. The incidence of complications in our study was as follows: loosening (16.67%), metallosis (8.3%), infection (8.3%), and stiffness (8.3%). One patient required conversion to total wrist arthrodesis due to metallosis and stiffness. Conclusion: TWR offers promising solutions for managing painful arthritic wrists. However, it's crucial to recognize that complications can arise, necessitating further surgical intervention. Surgeons must thoroughly comprehend these risks to provide informed counseling to patients and explore alternative treatment approaches.

Failure of Universal 2 Wrist Joint Replacements: A Retrieval Study

Abstract Background The Universal 2 total wrist arthroplasty was one of the most common wrist replacements, but long-term results were disappointing, due to substantial damage to the polyethylene component and, in some cases, metallosis. The purpose of this research was to investigate the underlying reasons for this polyethylene damage. Methods From a single clinical center, retrieval analysis was undertaken on six Universal 2 wrists and two additional polyethylene components. All components were analyzed at the macroscale and dimensional measurements of polyethylene components were undertaken. These were compared against known component orientation in vivo to identify areas of greatest material loss. Results Of 62 Universal 2 wrists implanted, there was a tendency for smaller implants to be revised more frequently. Of the six explanted wrists, material loss was always noticeable on the ulnar side, and to a lesser extent in the dorsal direction. Five of eight polyethylene components had failed at the base of the ulnar-side blind hole. Smaller implants tended to have less thickness at the base of the blind holes, thus explaining the failure of smaller sizes. Discoloration and surface fatigue of explants indicated oxidation of components. Average time in vivo for the explants was 13.8 years which indicates the slow nature of polyethylene oxidation. All were revised due to loosening. All were implanted in rheumatoid patients with a mean age at surgery of 56.1 years. Three of the six Universal 2 wrists, all sized Extra Small, showed severe wear of the titanium alloy carpal component. Conclusion Failure of the polyethylene components was due to a combination of inappropriate sterilization technique plus a design issue where polyethylene was thinnest on the smallest size components. Continued surveillance of patients implanted with Universal 2 wrists is recommended.

Explant analysis of a chromium nitride coated metal-on-metal total wrist replacement: A case study.

Explant analysis can provide important understanding of how artificial joints perform in the human body. The articulating surfaces of the metacarpal head and the radius cup from a chromium nitride coated metal-on-metal Motec wrist implant were analysed. Due to bone resorption and aseptic loosening, the implant was removed after 6 years in the patient, and metallosis was observed during removal. Visually, some areas of the articulating surfaces appeared polished, others were dulled. A chemical composition analysis of the metacarpal head showed that the polished surfaces were chromium rich, implying this surface was the original chromium nitride coating, whereas the dulled surfaces were cobalt rich, indicating the underlying cobalt chromium substrate. In addition, the underlying cobalt chromium substrate was an order of magnitude rougher than the polished surface, indicating the scale of damage to it. It is speculated that the loss of the coating, and the subsequent damage to the underlying substrate due to a third-body wear process, led to osteolysis and the metallosis seen at revision surgery.

Total Wrist Replacement Outcomes in the Asian Pacific Population - A Single-Centre Result.

Background: Total wrist replacement (TWR) is rarely done in the Asia-Pacific region. The aim of this study is to report the surgical outcomes and experience of TWR in patients with advanced arthritis. Methods: This is a retrospective review of all TWR patients in the Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Hong Kong, which is a university tertiary centre, from January 2004 to March 2023. Recorded demographic parameters include gender, age upon surgery, pathology, types of implants and follow-up period. The surgical outcome parameters include range of motion, grip strength, wrist function assessment, radiological and clinical complications and any related secondary operations. Postoperative X-ray and clinical notes were reviewed. All wrist function assessments were performed by specialised occupational therapists according to protocol. Results: The study included a total of 12 wrists of 10 patients, all Chinese-Asian, with a mean age of 61.4 years at surgery. Larsen grade V arthritis constituted 50% and grade IV 16.7% of the patients, amongst which 33% had volar subluxation. The mean follow-up period was 97.4 months (21-205 months). The mean grip strength was 64.2% of the unaffected side. The mean postoperative Disabilities of Arm, Shoulder and Hand (DASH) score was 41.12% and patient-rated wrist/hand evaluation (PRWE) score 18.0. Complication incidence was 16.67% for loosening, 8.3% for metallosis and 8.3% for infection. One patient required conversion to total wrist arthrodesis due to metallosis. No patient suffered from dislocation, periprosthetic fracture and infection. Conclusions: TWR is an effective and safe alternative to total wrist arthrodesis with comparable outcomes. Our series outcomes are satisfactory and in line with literature. With meticulous soft tissue release and balancing, volar subluxation can also be corrected and may not be a contraindication. Level of Evidence: Level IV (Therapeutic).

Arthroplasty of the hand and wrist

Arthrosis and autoimmune arthritis frequently lead to major impairment of hand function. Primary therapy consists of well- tried conservative treatments and joint preserving surgical options for special indications. In advanced stages silicon spacers remain the gold standard surgical option for replacement of proximal interphalangeal and metacarpophalgeal joints of the fingers. Alternatively, surface replacement prostheses can restore the biomechanical properties of these joints more porperly. In case of the carpometacarpal (CMC) joint of the thumb, arthroplasty is gaining popularity as modern implants show excellent mid-term outcome. Although current forth generation implants for wrist replacement are promising, total wrist arthroplasty is currently reserved for exceptional indications.

Revision of Motec Total Wrist Replacement in the Second Metacarpal.

Wrist arthroplasty is becoming more commonplace, with various implant choices available. The Motec (Swemac Orthopaedics AB, Linköping, Sweden) cementless ball-and-socket system is being increasingly utilised and is designed for the distal component to be implanted into the third metacarpal. However, distal component failure is a recognised complication. We outline our experience with the revision of this component into the second metacarpal. This technical note is presented through our experience of two patients who underwent revision arthroplasty for the management of peri-prosthetic fracture of the third metacarpal. This technique has demonstrated a safe and viable solution to this complication, achieving good anatomical centre of rotation, function, range of movement and patient satisfaction. Level of Evidence: Level V (Therapeutic).

Intermediate and Long-Term Outcomes of the Universal 2 Total Wrist Replacement.

Introduction Arthritis of the wrist can lead to severe functionally debilitating pain which, after failed conservative measures, may require treatment with total wrist replacement (TWR). Various prosthetic designs, such as the Universal 2 implant, have been developed in attempts to combat the multitude of complications faced with replacing a complex and highly mobile joint. Having previously published short-term outcome results for the Universal 2 prosthesis, we now present the long-term survival data. Materials and Methods 19 patients underwent 21 TWR using the Universal 2 prosthesis between September 2004 and March 2008. Outcome data were collected in the form of Patient-Rated Wrist Evaluation (PRWE) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires at short- (mean 4.8 years), intermediate- (mean 11.1 years), and long-term (mean 15.6 years) intervals. Nonparametric and Kaplan-Meier survival analysis was performed. Results At long-term follow-up, 7 out of the original 21 TWRs had required a revision or fusion procedure, or 7 out of 11 when excluding those lost to follow-up or who had died. At the intermediate follow-up, only one patient had required a revision procedure. Kaplan-Meier survival analysis demonstrated a median survival of 12.9 years and a 10-year survival probability of 68.1%. There was a statistically significant improvement from preoperative PRWE at short-term ( p = 0.001) and intermediate ( p = 0.01) follow-ups. This was not seen at the long-term follow-up ( p = 0.068). After an initial improvement in DASH score at short-term follow-up ( p = 0.003), the intermediate and long-term DASH scores were not significantly different from preoperative. Conclusion The Universal 2 poses a reasonable TWR implant choice for patients with debilitating arthritis. However, despite excellent short-term follow-up outcomes, longer term follow-up shows the design does continue to be plagued by implant failure and instability.

Long-term outcomes of the Universal 2 total wrist replacement: revision and loosening at 10 years and beyond.

The aim of this study was to ascertain the long-term revision rates of the Universal 2 wrist prosthesis in a previously published cohort of patients with rheumatoid arthritis. The time to, and reasons for revision were determined. Radiographs were analysed to determine whether loosening had occurred in the long-term according to the Wrightington zonal classification of loosening. Seventy-eight wrists from the original cohort of 85 wrists could be identified for analysis. The longest follow-up was 16 years and 29 wrists had follow-up beyond 10 years. Seventeen wrists had been revised or were on the waiting list for revision, an overall revision rate of 22%. The 10-year survivorship was 78%. Long-term revision was commonly for periprosthetic loosening with pain and component subsidence. In those with more than 10-year follow-up, significant lucency was seen in 16 carpal components and 15 radial components. Explant analysis showed significant polyethylene wear and we postulate this is the principal reason for component loosening.Level of evidence: IV.

Total Wrist Replacement: State of the Art, Challenges and Pitfalls: A Comparative Review

Background Total wrist replacement (TWR) as motion-preserving procedure continues to be critically discussed in the literature, although the complication rates have been significantly reduced with the current 3rd generation designs compared with older types. Possible reasons for this are often also a lack of knowledge about the currently available evidence, the complication management, and the lack of practical experience by the surgeons. Methods Based on an extended review of literature and own experience, the aim of this article is to give practicable insights for the clinician on: (1) biomechanical fundamentals, (2) differences in design, survivorship and functional outcome between the recent types, (3) possible pitfalls, and (4) failures and salvage options. Results The goal of TWR is that the overall wrist motion is maintained respectively improved despite it works with a locked midcarpal joint. Regarding survivorship and functional outcome the Maestro is (was) being superior over all other types that is (was) based on features in design. There is no scientific evidence as to why the Maestro was withdrawn from the marketplace by the company. For assessment of instability and/or impingement the use of dynamic radiographs is recommended. The problem of TWR is unchanged failure of the carpal components primarily based on mechanical dysbalance, and secondarily followed by metal and/or polyethylene wear, but surgical revision of asyptomatic periprosthetic osteolysis without safe radiagraphic signs of loosening is only required in not more than 20% of cases. For a failed TWR, revision TWR or conversion to total wrist arthrodesis are viable salvage options. Conclusions The knowledge about recent evidence and features in design of the available types, exact assessment of radiographic findings, presence of technical skills by the surgeons, and observance of the patient's expectations are the basic requirements for a successful TWR.

Results of interposition arthroplasty with the Amandys® pyrocarbon implant in rheumatoid wrist at a mean 5 years’ follow-up

Management of severe joint involvement in rheumatoid wrist is controversial. The gold-standard is total wrist fusion, but total wrist replacement offers a motion-conserving alternative. The purpose of this study was to present the results of interposition arthroplasty with the Amandys® pyrocarbon implant in rheumatoid wrist. We performed a retrospective review of 28 arthroplasties for rheumatoid wrist arthritis. Eighteen females and 5 males were included, with a mean age of 55.7 years. Mean follow-up was 64 months. We measured range of motion, grip strength, and pain (on VAS). Function was evaluated preoperatively and at last follow-up with the DASH and PRWE scores. Mean range of motion in flexion–extension was maintained while mean inclination and rotational range of motion showed significant improvement. Mean grip strength increased from 10 kg to 17 kg. Mean pain score decreased from 6/10 to 2/10. Mean PRWE and QuickDASH scores decreased from 62/100 to 25/100 and from 62/100 to 36/100, respectively. Three patients underwent early reoperation to reposition a dislocated implant. No implants had to be removed. Amandys® pyrocarbon arthroplasty is a reliable alternative to total fusion or total replacement in rheumatoid wrist. Indications must be limited to well-aligned wrists with competent capsule-ligament structures.

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.

Surgery with the Motec total wrist replacement: learning from earlier designs

The design of and applications for wrist arthroplasty continue to evolve but lag behind the results for hip and knee arthroplasty with respect to demonstrable durability and effectiveness. As we develop our knowledge, experience and the indications for wrist replacement surgery, it is important that we learn from past design and surgical experience. We report the case of a female patient treated with a Motec cementless metal-on-metal wrist replacement (Swemac Orthopaedics AB, Linköping, Sweden) for post-traumatic arthritis of the radiocarpal joint. Based on our experience with this case and others, we make two specific technical recommendations to improve the success and longevity of this implant.

Functional outcomes after salvage procedures for the destroyed wrist: an overview.

The most widely used procedures for salvaging a destroyed wrist are four-corner arthrodesis, radiocarpal arthrodesis, proximal row carpectomy, total wrist arthrodesis, and total wrist replacement or resurfacing. The purpose of this article is to give an overview of the functional results obtained with the various salvage procedures and of the common methods for assessing the surgical outcomes. The outcomes are assessed by clinical measurements and scoring methods, but the actual functional status and well-being of the patients should be presented together with patient-reported outcomes. No salvage procedure can restore entirely full wrist function. Understanding indications, risks, and the outcomes of these procedures would favour a better decision for surgery and help choose the proper treatment from among the surgical options discussed with patients.

Survival Rate on a 10-Year Follow-Up of Total Wrist Replacement Implants: A 23-Patient Case Series.

Background According to current literature, the estimated average survival rate for Remotion, the total wrist implants, is above 90% on an 8-year follow-up. We examined our series of Remotion to calculate its survival rate on a 10-year follow-up. Case Description A total of 23 cases of total wrist implants were reviewed. The case series included 22 patients, 18 females and 4 males, of an average age of 55 years. The case series included 19 inflammatory rheumatic diseases, 3 Kienböck disease, and 1 posttraumatic arthrosis. Conclusion The average survival rate of our case series was 95.7% on a 4-year follow-up, 91.3% on a 6-year follow-up, and 69% on a 10-year follow-up. On our review, the QuickDASH score, pain, wrist extension range of motion, and grip strength were improved postoperatively. No difference was shown between preoperative and postoperative values for wrist flexion, pronation, and supination. The case series included a septic case, treated by arthrodesis, and three total wrist implants displacements, two of which were treated by carpal implant, and the remaining one was treated by arthrodesis. Clinical Relevance The survival rate of the total wrist replacement implant Remotion was estimated to be 69%.

Systematic Review of Total Wrist Arthroplasty and Arthrodesis in Wrist Arthritis.

Background End-stage wrist arthritis has traditionally been treated with a total wrist fusion. There is a recent trend toward motion preserving surgery in the form of total wrist replacement. Questions Is there a functional benefit to performing a total wrist replacement instead of a total wrist fusion in patients with end-stage wrist arthritis? Is there any difference in secondary outcome measures including pain, grip strength, and range of motion? Does the risk of adverse events and treatment failure differ between the two techniques? Methods A systematic literature search was performed to identify studies reporting either total wrist arthrodesis or arthroplasty for end-stage wrist arthritis. Studies were systematically screened and assessed for risk of bias and quality. Data were extracted and reviewed. Results A total of 43 studies were included in the review: 17 on arthrodesis, 24 on arthroplasty, and 2 matched cohort studies. This represented 669 index arthrodesis operations in 603 patients, and 1,371 index arthroplasty operations in 1,295 patients. A significant improvement in functional outcome was seen with both interventions. Similar improvements were seen in pain scores, and modest improvements were seen in grip strength. Range of motion following arthroplasty improved to a functional level in two studies. Complication rates were higher after arthroplasty (range: 0.2-9.5%) than those after arthrodesis (range: 0.1-6.1%; p = 0.06). Fourth-generation implants (range 0.1-2.9%) performed better than earlier designs (range: 0.2-8.1%; p = 0.002). Implant revision rates ranged from 3.5 to 52.6%. Fourth-generation prostheses survival rates were 78% at 15 years (Universal 2), 86% at 10 years (Motec), 90% at 9 years (Re-Motion), and 95% at 8 years (Maestro). Conclusion The newer fourth-generation wrist implants appear to be performing better than earlier designs. Both wrist arthrodesis and wrist arthroplasty improve function, pain, and grip strength. The risk of complication following wrist replacements is higher than that after total wrist arthrodesis.

Survivorship of Revision Wrist Replacement.

Purpose This study aims to report the 5-year survivorship of revision wrist arthroplasties and to report midterm clinical and radiological results. Materials and Methods All patients receiving a revision wrist arthroplasty in our unit between January 1, 1997 and October 31, 2010 were identified, and clinical notes retrospectively analyzed for Quick Disabilities of the Arm, Shoulder and Hand (quickDASH), Patient Evaluation Method (PEM), Patient-Rated Wrist Evaluation (PRWE), the range of movement, and visual analog score (VAS). In cases where patient review had not occurred within the past year, they were invited for assessment, and this data was included in the analysis. Plain radiographs were analyzed for loosening of each component. The 5-year survival was plotted using Kaplan-Meier analysis. Results Of the 19 patients identified, 1 was lost to follow-up and therefore excluded from all analyses. Mean age at revision wrist arthroplasty was 55.8 years and the mean time from primary to revision wrist arthroplasty was 6.7 years. At revision arthroplasty, 7 patients received the Biaxial implant (DePuy, Inc., Warsaw, IN) and 11 received the Universal II implant (Integra, Inc., Plainsboro, NJ). The 5-year implant revision survivorship was 83%. Depending on the variable of interest, clinical data were available for either three, four or five patients. At final follow-up (mean: 10.4 years), mean visual analog score was 2.9, mean quickDASH 57, mean PEM 49, mean PRWE 61, and mean arc of flexion/extension was 26 degrees. Radiological data were available for 12 patients, with evidence of gross loosening present in around 60% of the carpal components and 50% of the radial components at mean 6.7 years. Conclusion Revision wrist replacement implant survival is acceptable, but the majority of the surviving implants are radiologically loose. It is not clear at this time whether they are better or worse than a fusion after a failed primary wrist arthroplasty. Clinical Relevance It is reasonable to offer revision wrist arthroplasty in selective cases, but regular clinical and radiological follow-up is recommended.

Universal 2 Wrist Arthroplasty in Rheumatoid Arthritis.

Purpose The aim of this study was to evaluate the mid- to long-term outcomes and complications in patients affected by rheumatic diseases treated with the Universal 2 (U2) total wrist arthroplasty (TWA). Methods We reviewed, in a retrospective, noncontrolled cohort study, 22 patients affected by rheumatoid arthritis (RA), who underwent U2 total wrist replacement between March 2003 and January 2014 for the treatment of 23 rheumatoid wrists with the aim of obtaining the remission of pain and a range of motion (ROM) useful for daily activities, according to the patients' demands, as an alternative to total wrist arthrodesis. The cohort of patients included 20 females and 2 males, with a mean age of 54.9 years. Residual pain, preoperative ROM, postoperative ROM increases, grip strength, radiographic changes, long-term complications, and reasons for revision or failures were evaluated. Results In this study, 22 patients were evaluated at a mean follow-up of 82.3 months (range: 2-12 years). All patients had good or complete pain relief, the mean visual analogue scale pain score was 0.82. The mean grip strength improved and postoperatively was 11 kg (Jamar). The mean total ROM of flexion-extension was 72.3 degrees; radial-ulnar deviation 24.9 degrees. The mean QuickDASH score of 49 and patient rate wrist/hand evaluation of 41.7 a revision surgical procedure in six cases (26%): in two cases, a carpal component revision procedure and in four cases, total implant failures requiring either conversion to a Swanson spacer or wrist joint fusion. Conclusion TWA provides pain relief, preserves motion, and improves function in severe degenerative RA. Our results at a mid- to long-term follow-up with the U2 prosthesis were encouraging and represent, when indicated, a valid alternative to fusion which is less appealing for RA patients. Level of Evidence Level of evidence is therapeutic IV.

Universal 2 total wrist arthroplasty

The Universal 2 wrist replacement is considered my many to be the implant of choice in patients with inflammatory arthropathy requiring joint replacement. The procedure is discussed in this article and technical aspects considered.

Total wrist arthroplasty: a systematic review of the evidence from the last 5 years

We reviewed evidence on total wrist replacement from the last 5 years. Eight articles met a minimum set standard. The results of 405 prostheses were available, including seven different manufacturers. The mean follow up was 2.3-7.3 years with an average age of 52-63. Rheumatoid arthritis was the indication in 42% of patients. Motec demonstrated the best post-operative DASH scores. Only Maestro achieved a defined functional range of motion post-operatively. Universal 2 displayed the highest survival rates (100% at 3-5 years), while Elos had the lowest (57% at 5 years). Biaxial had the highest complication rates (68.7%), while Remotion had the lowest (11%). Wrist arthroplasty preserves some range of motion. Functional scores improved and were maintained over the mid- to long-term. Complication rates were higher than wrist fusion, with reports of radiological loosening and osteolysis. The evidence does not support the widespread use of arthroplasty over arthrodesis, and careful patient selection is essential.

Wrist &amp; Hand

The June 2014 Wrist &amp; Hand Roundup360 looks at: aart throwing not quite as we thought; two-gear, four-bar linkage in the wrist?; assessing outcomes in distal radial fractures; gold standard Swanson’s?; multistrand repairs of unclear benefit in flexor tendon release; for goodness’ sake, leave the thumb alone in scaphoid fractures; horizons in carpal tunnel surgery; treading the Essex-Lopresti tightrope; wrist replacement in trauma? and radial shortening reliable in the long term for Kienbock’s disease