Total Wrist Arthroplasty: A Single-Center Study of 219 Cases With 5-Year Follow-up

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.

The Three-Dimensional Relationship of the Axes of the Capitate and Third Metacarpal

PURPOSE

We quantified the morphology and angulation of the third metacarpal (MC3) relative to the capitate using three-dimensional computed tomography data to inform surgical procedures such as total wrist arthroplasty and wrist arthrodesis. Specifically, we report the three-dimensional location of the intersections of the long axis of MC3 axis with the capitate cortical surface, the sagittal and coronal angles between the MC3 and capitate axes, and the MC3 shaft angle in the sagittal plane. We tested the hypothesis that these metrics did not differ between women and men.

METHODS

Three-dimensional bone models of the capitate and MC3 were analyzed in 130 subjects (61M and 69F). Long axes of the MC3 and capitate were computed. The intersection of the metacarpal long axis with the cortical surface of the capitate, the angle between the metacarpal-capitate axes, and metacarpal shaft angle were calculated and compared between men and women.

RESULTS

The long axis of the MC3 intersected the capitate at two locations on the outer cortical surface of the capitate. The proximal intersection was located near the midportion of the capitate, whereas the distal intersection was typically located within the capitate-MC3 articulation. The angle between the axes of the capitate and MC3 in the sagittal plane was a mean of 15°, ranging from 5° to 23°. The mean sagittal MC3 shaft angle was 166° and ranged from 158° to 173°.There were only subtle differences in these metrics between the sexes.

CONCLUSIONS

The long axis of the MC3 penetrates the dorsal surface of the capitate about its midportion, but there is notable variation in this location as well as in the angular relationships.

CLINICAL RELEVANCE

Three-dimensional measurements of the relationships between the third metacarpal and the capitate may serve as an important reference for the placement of intramedullary wires, plates, devices, and prosthetics.

Increasing Use of Total Wrist Arthroplasty-An Australian National Joint Registry Report

Background and Purpose  There is limited literature reporting the long-term results and outcomes of total wrist arthroplasty (TWA). The aim of this study was to describe the incidence, usage, and survival of wrist arthroplasty using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Methods  Data included all primary TWA procedures from 2006 to 2021. The primary outcome assessed was revision surgery. Utilization of TWA, etiology leading to TWA, patient demographics, and surgical factors were also assessed. Results  There were 439 primary TWA procedures performed across the 16-year reporting period. Four prostheses (Motec, Universal 2, Freedom, and ReMotion) have been used, with a recent increased usage toward the Motec, which accounted for 97.4% of prostheses implanted in 2021. There has also been an increase in the number of surgeons performing TWA over time. The most common underlying etiology was osteoarthritis (72.7%), followed by rheumatoid arthritis (15.9%). Implantation for inflammatory arthropathy remained relatively constant across time; however, TWA has been utilized with increasing frequency for the treatment of osteoarthritis and other indications more recently. The cumulative percent revision at 10 years was 18.3%. Loosening accounted for 25.6% of all revisions, followed by osteolysis (12.8%), pain (12.8%), and instability (7.7%). Attempted conversion to an arthrodesis occurred in 10.3% of all revisions. Conclusion  There has been an increase in both the volume of TWA performed and the number of surgeons undertaking this procedure in Australia over the past 16 years. The Motec system has become the prosthesis of choice. Medium-term revision rates are inferior when compared with Australian data for hip, knee, and shoulder arthroplasty.

Long-Term Outcomes of Wrist Arthroplasty Using the ReMotion™ Implant in Non-inflammatory Wrist Pathology

Background: Wrist arthroplasty is increasingly offered to patients with symptomatic wrist arthritis as an alternative to wrist arthrodesis. The purpose of this study was to present our outcomes with the ReMotion™ wrist arthroplasty in a consecutive series of patients with wrist arthritis from non-inflammatory conditions. Methods: Thirteen (eight women, nine dominant wrists) patients, 68 (44-85) years of age with advanced radiocarpal arthritis due to SLAC/SNAC (11) and Kienbock disease (2) had a ReMotion™ (Stryker, Michigan, USA) wrist arthroplasty implanted, and were prospectively followed for 7 (4-9) years. The outcome measures included patient-rated wrist and hand evaluation (PRWHE) score, disabilities of the arm, shoulder and hand questionnaire (QuickDASH) score, visual analogue pain score (0-10) on the radial and ulnar aspect of the wrist at rest (VASrR/VASuR) and activity (VASrA/VASuA), active wrist range of motion (AROM) including flexion, extension, ulnar and radial deviation, pronation and supination and grip and key-pinch strength measured preoperatively and at yearly follow-ups by independent hand therapists. Results: Six patients had ten re-operations during the follow-up including four revisions to a new arthroplasty. Four were considered loose at follow-up. A significant reduction in PRWHE (63 to 12), radial pain at activity (6 to 1) and increased pronation (85° v 90°) was observed. Conclusions: We found a high complication and reoperation rate, two out of 13 had no complications or reoperations. The ReMotion™ arthroplasty should be used with caution in non-inflammatory wrist patients and the patients followed closely. A high reoperation and revision rate can be expected, and surgeons familiar with revision arthroplasty procedures should perform the surgery. Level of Evidence: Level II (Therapeutic).

Complications after total wrist arthroplasty

We reviewed the incidence and management of complications after total wrist arthroplasty, as reported in the literature, with so-called fourth-generation implants and other recent designs. While early intraoperative and postoperative complications, including fractures, tendon lacerations, infection, nerve compression, tendonitis, stiffness and chronic regional pain syndrome, had an acceptable incidence, late complications, such as periprosthetic osteolysis and implant loosening, occurred more frequently. Implant survival at 10 years was in the range of 70%-80% in most publications. Several of the implants have been modified or withdrawn. Instability and dislocation were frequent after a pyrocarbon spacer. Failed arthroplasties can be salvaged by revision arthroplasty or total wrist arthrodesis. Revision arthroplasty has a lower survival rate than primary arthroplasty and does not clearly offer important significant advantages over total wrist arthrodesis in terms of patient-reported outcome measures. Further development of prosthetic design, new materials and more knowledge on patient-related risk factors are needed.

A Changing Landscape in the Surgical Management of Wrist Arthritis: An Analysis of National Trends From 2009 to 2019

PURPOSE

The purpose of this study was to analyze the trends in the annual volume and incidence of proximal row carpectomy (PRC), four-corner fusion (4CF), total wrist arthrodesis (TWF), and total wrist arthroplasty (TWA) from 2009 to 2019 in the United States.

METHODS

The IBM Watson Health MarketScan databases were queried to identify annual case volumes for PRC, 4CF, TWF, and TWA from 2009 to 2019. The annual incidence of these procedures was then calculated based on the population estimates from the US Census Bureau. Trends in annual volume and incidence over the study period were evaluated using regression line analysis. Further subgroup analysis was conducted based on age and region.

RESULTS

From 2009 to 2019, the total case volumes for the four procedures increased by 3.4%, but the incidence decreased by 2.8%. However, PRC case volume and incidence trends significantly increased (38.2% and 29.7%, respectively), whereas 4CF remained constant. Conversely, the case volume and incidence of TWA significantly decreased (-52.2% and -54.5%, respectively), whereas TWF remained constant. When stratified by age, all four procedures decreased in the <45-year-old cohort (combined -35.1%) significantly for 4CF, TWF, and TWA. TWA decreased significantly in the <45-year-old and 45- to 65-year-old cohorts (53.6% and 63.2%, respectively). For age >65 years, the total case incidence increased by 98.9%, including a significant positive trend in TWF (175%).

CONCLUSIONS

Surgical management of wrist arthritis remains a controversial issue. However, PRC has gained recent support in the literature, and our results reflect this shift, even for the <45-year-old cohort. Furthermore, TWA declined, despite reports of positive early outcomes for fourth-generation implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Clinical and Patient-Reported Outcomes After Total Wrist Arthroplasty and Total Wrist Fusion: A Prospective Cohort Study with 2-Year Follow-up

Background

The functional benefits of total wrist arthroplasty (TWA) over total wrist fusion (TWF) are unknown. The purpose of this prospective cohort study was to compare TWA and TWF with respect to functional outcomes and activity limitations at up to 2 years postoperatively.

Methods

Between 2015 and 2020, we enrolled all adult patients undergoing TWA or TWF for the management of symptomatic end-stage wrist arthritis at 1 hand surgery department. The primary outcome was the Patient-Rated Wrist Evaluation (PRWE). The secondary outcomes were the visual analog scale (VAS) for pain at rest, on motion, and on loading; grip strength; Disabilities of the Arm, Shoulder and Hand (DASH); and range of motion. Patients completed questionnaires and were examined by the same physiotherapist at baseline and at 3, 6, 12, and 24 months postoperatively. Mixed-model analyses adjusting for age, diagnosis, the preoperative value of the dependent variable, and time since surgery were performed to compare differences in PRWE scores, VAS pain scores, and grip strength between TWA and TWF.

Results

Of the 51 patients who had been included at baseline, 47 (18 in the TWA group and 29 in the TWF group) responded to questionnaires and underwent examinations at up to 2 years postoperatively. At baseline, the 2 groups did not differ in terms of age, sex, diagnosis (inflammatory or noninflammatory arthritis), PRWE score, VAS pain score, grip strength, DASH score, or range of motion. No differences between the groups were found for the PRWE (β, -0.1; 95% confidence interval [CI], -14 to 13; p = 0.99), VAS pain at rest (β, -3.3; 95% CI, -15 to 9; p = 0.58), VAS pain on loading (β, -5.3; 95% CI, -22 to 11; p = 0.52), or grip strength (β, -0.02; 95% CI, -0.18 to 0.14; p = 0.80) on the adjusted mixed-model analyses.

Conclusions

Among patients with symptomatic end-stage wrist arthritis, those who underwent TWA did not demonstrate short-term outcomes, including patient-reported disability, pain, and grip strength, superior to those of patients who underwent TWF. These findings call into question the widespread use of TWA.

Level of Evidence

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Complication rates and modes of short and medium-term failure in Motec total wrist arthroplasty: an international cohort study

The aim of this study was to analyse the short- and medium-term complications of the Motec total wrist arthroplasty (TWA). Identifying exact modes of failure and their causes should allow surgeons to avoid or mitigate these risks in the future. Retrospective analysis of prospectively collected data from six hand surgeons at five international centres provided details of 171 Motec TWAs. The mean follow-up was 5.8 years (range 18 months to 12 years). There were 33 (19%) complications within our cohort, with a revision rate of 8.2% (14 revisions). There was no difference in complication rates between metal-on-metal and metal-on-polymer articulations. Failure of osseointegration was the most common complication. Problems with soft tissue balancing, implant impingement related osteolysis, bony impingement and metacarpal fracture were found to be other preventable causes of failure in this series. Elimination of these preventable complications will improve survival rates for this implant.Level of evidence: IV.

Total Wrist Arthroplasty With a New Design, 20 Cases With 8-Year Follow-Up

PURPOSE

Total wrist arthroplasty (TWA) is an established motion-preserving alternative to arthrodesis in the treatment of wrist arthritis, but post-TWA complications requiring additional surgery remain an issue. A new TWA design has been proposed. The purpose of this study was to report the outcome of a cohort study of 20 patients who underwent surgery using the new TWA design.

METHODS

Patients were assessed before surgery and at 1, 2, and 8 years after surgery for visual analog scale (VAS) pain scores, wrist range of motion, hand grip strength, and patient-reported outcome measures (PROMs). Radiographic examination was conducted for evidence of prosthetic loosening. Reasons for revision were analyzed.

RESULTS

In total, 24 reoperations were performed, including 12 revisions in 6 patients. Patient-reported outcome measures improved significantly at the 2-year follow-up compared with preoperative values. Hand grip strength, wrist extension, and VAS pain scores improved significantly at the 2-year follow-up. No radiographic loosening of the components was observed, but backing out of the carpal screws was noted in 16 of the 20 cases.

CONCLUSIONS

The new TWA resulted in improved VAS pain scores, PROMs, wrist extension, and hand grip strength. The high frequency of reoperation is a concern, and modification of the implant is needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Safety and efficacy of a novel three-dimensional printed microporous titanium prosthesis for total wrist arthroplasty in the treatment of end-stage wrist arthritis

Background: Total wrist arthroplasty is an effective treatment for end-stage wrist arthritis from all causes. However, wrist prostheses are still prone to complications such as prosthesis loosening and periprosthetic fractures after total wrist arthroplasty. This may be due to the wrist prosthesis imprecise matching with patient's bone. In this study, we designed and developed a personalized three-dimensional printed microporous titanium artificial wrist prosthesis (3DMT-Wrist) for the treatment of end-stage wrist joint, and investigated its safety and effectiveness. Methods: Total wrist arthroplasty was performed using 3DMT-Wrist in 14 cases of arthritis between February 2019 and December 2021. Preoperative and postoperative visual analog scale scores, QuickDASH scores, wrist range of motion, and wrist grip strength were evaluated. Data were statistically analyzed using the paired samples t-test. Results: After 19.7 ± 10.7 months of follow-up, visual analog scale decreased from 66.3 ± 8.9 to 6.7 ± 4.4, QuickDASH scores decreased from 47.4 ± 7.3 to 28.2 ± 7.6, grip strength increased from 5.6 ± 1.4 to 17.0 ± 3.3 kg. The range of motion improved significantly in palmar flexion (30.1° ± 4.9° to 44.9° ± 6.5°), dorsal extension (15.7° ± 3.9° to 25.8° ± 3.3°), ulnar deviation (12.2° ± 3.9° to 20.2° ± 4.3°) and radial deviation (8.2° ± 2.3° to 16.2 ± 3.1). No dislocation or loosening of the prosthetic wrist joint was observed. Conclusion: Total wrist arthroplasty using 3DMT-Wrist is a safe and effective new treatment for various types of end-stage wrist arthritis; it offers excellent pain relief and maintains the range of motion.

15-20 Year Follow-up After Wrist Arthroplasty Surgery - Revisiting the Development and Introduction of a New Prototype Concept for Total Wrist Arthroplasty

Background: Wrist arthroplasties have not achieved clinical outcomes comparable to those of shoulders and knees, being offered low-demand patients due to a high failure rate. In the 90s, there were no wrist arthroplasties available for high-demand patients. An experimental setup for the development of a new wrist arthroplasty intended for all wrist patients were done. A long-term final follow-up to evaluate the performance of the experimental arthroplasty was performed. Methods: A novel uncemented modular wrist prosthesis with conical threaded fixation, metal-on-metal coupling and ball-and-socket articulation was developed. In an experimental study, eight patients (7 men, 53 years of age) were operated between 2001 and 2003, to treat non-inflammatory primary or secondary osteoarthritis. Published mid-term results (7-9 years) demonstrated satisfactory function, but two arthroplasties were converted to arthrodesis due to infection. Results: At final follow-up 15-20 years after primary surgery, the remaining six patients still had a wrist arthroplasty (in three the original) in situ. The clinical results were good. Low pain (median = 0), Quick Disability of Arm, Shoulder and Hand (QDASH median 11) and Patient Rated Wrist and Hand Evaluation (PRWHE median = 14) scores were reported. Wrist active range of motion (AROM) was 64% and grip strength 86% compared to the opposite side. None regretted choosing arthroplasty knowing the outcome. Conclusions: Despite technical errors and the implementation of an incomplete prototype, this new concept for arthroplasty has demonstrated promising long-term fixation, a stable articulation with good range of motion, satisfactory function and pain reduction in high-demand patients. Level of Evidence: Level IV (Therapeutic).

Fourth-Generation Total Wrist Arthroplasty: A Systematic Review of Clinical Outcomes

Background  The purpose of total wrist arthroplasty is to reduce pain and maintain mobility in a painful destructed wrist. First-, second-, and third-generation total wrist arthroplasties have shown unacceptable outcomes with high failure rates. In 2004, the fourth-generation total wrist implants were introduced to address the clinical problems encountered in the previous generations of total wrist implants. Methods  Outcomes and complications of fourth-generation total wrist implants were systematically reviewed in the literature (2004-present), including the Universal 2, ReMotion, Freedom, Motec, and Maestro total wrist implants. Results  The literature search yielded 114 papers, of which 18 (990 implants) were included in this systematic review. The quality of evidence was low. All implants effectively reduced pain and improved functionality of the wrist. The Motec wrist implant demonstrated the highest survival rate at 10 year follow-up (86%). Conclusion  This systematic review suggests a substantial improvement of quality in fourth-generation total wrist arthroplasty.

Intra Articular Injection of Autologous Microfat and Platelets-Rich Plasma in the Treatment of Wrist Osteoarthritis: A Pilot Study

No injection treatment has been proven to be effective in wrist osteoarthritis. When conservative measures fail, its management involves invasive surgery. Emergence of biotherapies based on adipose derived stem cells (ADSC) offers promising treatments for chondral degenerative diseases. Microfat (MF) and platelets-rich plasma (PRP) mixture, rich in growth factors and ADSC could be a minimally invasive injectable option in the treatment of wrist osteoarthritis. The aim of this uncontrolled prospective study was to evaluate the safety of a 4 mL autologous MF-PRP intra-articular injection, performed under local anesthesia. The secondary purpose was to describe the clinical and MRI results at 12 months of follow-up. Patients' data collected were: occurrence of adverse effects, Visual analog scale (VAS), Disabilities of the Arm, Shoulder and Hand score (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, wrist strength, wrist range of motion and 5-level satisfaction scale. No serious adverse event was recorded. A statistically significant decrease in pain, DASH, PRWE and force was observed at each follow-up. Our preliminary results suggest that intra-articular autologous MF and PRP injection may be a new therapeutic strategy for wrist osteoarthritis resistant to medical symptomatic treatment prior to surgical interventions.

Locked Intramedullary Total Wrist Arthrodesis: A Report of Three Patients With Distal Screw Migration

Intramedullary (IM) fixation for the total wrist arthrodesis (TWA) is supposed to lower the hardware complication rate by eliminating soft tissue irritation. In this report, we present three patients with distal metacarpal screw migration requiring unplanned secondary surgery for screw removal in one patient while it was managed nonoperatively in the other two. All three patients had complete radiocarpal fusion by four months postop. There was no attempted third carpometacarpal (CMC) fusion in any of our patients. Screw migration was found between 1.5-3.5 months postop and remained stable until the final follow-up in the nonoperatively managed patients. One patient with screw removal continued to have mild tenderness over the third CMC, which was managed nonoperatively.

Total Wrist Arthroplasty with Integra Freedom® Implants: A Pilot Study with a New Evaluation System

INTRODUCTION

Recent innovations in wrist arthroplasty implants have led to remarkable improvements in terms of results with improved stability and preservation of bone stock. Despite the advances in such implants, poor outcomes and frequent complications still affect this procedure, not allowing a wider use of this treatment in wrist arthritis.The purpose of this study is to assess the preliminary mid-term results of a Wrist Arthroplasty System (Freedom^®, Integra Lifesciences, Princeton, USA) in patients with rheumatoid arthritis or secondary osteoarthritis of the wrist and to propose a new classification system.

MATERIALS AND METHODS

We examined 12 patients (7 with rheumatoid arthritis and 5 with secondary osteoarthritis of the wrist) who underwent total wrist arthroplasties performed by a single surgeon using the fourth-generation prosthesis. Pre- and post-operative pain on a visual analogue score, functional parameters measured with Mayo Wrist score, patient-rated wrist evaluation score, range of motion, and radiographic analysis were collected.

RESULTS

At a mean follow-up of 48 (SD 16.9) months a significant improvement (p < 0.0001) of the mean visual analogue, Mayo and PRWE scores following total wrist arthroplasty was observed. Wrist movements improved significantly (p < 0.001).

CONCLUSION

We achieved significant improvements in pain relief, performance, and satisfaction both in rheumatic and non-rheumatic patients, confirmed by our scoring system.

LEVEL OF EVIDENCE

Level IV, case series.

Total Wrist Arthroplasty-A Systematic Review of the Outcome, and an Introduction of FreeMove-An Approach to Improve TWA

The Swanson silicone prosthesis was one of the first devices to realize total wrist arthroplasty (TWA). It has been used regularly since the early 1960s. This systematic review of the literature evaluated the status quos of TWA. The present study was conducted according to the PRISMA guidelines. A literature search was made in Medline, PubMed, Google Scholar, and the Cochrane Library databases. The focus of the present study was on implant survivorship and related functional outcomes. Data from 2286 TWA (53 studies) were collected. Fifteen studies were included for the analysis of implant survivorship. Fifteen studies were included for the analysis of pain. Twenty-eight studies were included for the analysis of the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Grip strength was tracked in 16 studies. The range of motion (RoM) was evaluated in 46 studies. For supination and pronation, 18 articles were available. Despite some methodological heterogeneities, TWA may be effective and safe in pain reduction and improving function and motion. There is still a range for a future improvement of the procedure.

Medium-Term Outcomes for Amandys Implant: A 5-Year Minimum Follow-Up of 63 Cases

Background  Amandys is a pyrocarbon interposition implant used as a therapeutic alternative to total wrist fusion (TWF) or total wrist arthroplasty (TWA) in painful and disabling extensive destruction of the wrist. Objective  To review mid-term outcomes in a continuous prospective series of patients who underwent wrist arthroplasty Amandys with a minimum follow-up of 5 years. Methods  Clinical evaluation included a satisfaction survey, pain, two functional scores, the short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the Patient-Rated Wrist Evaluation (PRWE), active wrist mobility, and grip strength compared with the contralateral side. Radiological evaluation was used to detect implant subsidence, carpal migration, bone lysis, or implant malposition. All per- and postoperative complications were collected. Results  Fifty-nine patients (63 procedures) were evaluated with a mean follow-up of 7 years; 57% of the patients were males, and the mean age was 58 years. Among the patients, 90% were satisfied or very satisfied. Pain was significantly improved, with a gain of 4/10 ( p  < 0.001). Functional outcomes also improved between the second and fifth year of follow-up. Active mobility was preserved and grip strength was significantly improved by 7 kg ( p  < 0.001). No implant subsidence or carpal migration was observed. Ten patients (11.9%) underwent revision surgery for conflict (1%), rotation (6%), or implant dislocation (5%). All complications and revisions occurred early with no new events after 1 year of follow-up. Discussion  Mid-term clinical and radiological outcomes were stable with improvement of functional scores. The survival rate was comparable to that reported for TWF with conserved mobility. We report fewer complications compared with those reported for TWA or TWF. Early instability of the implant was the main etiology of the revisions. Repositioning of the implant was successful. No conversion to TWA or TWF was necessary. Conclusions  Mid-term outcomes of the Amandys implants were encouraging. Patients conserved good wrist motion with improved strength and functional scores. The implant was well tolerated. Functional outcomes continue to improve with the follow-up. The survival rate remains stable after 2 years. The level of evidence of this study is IV (therapeutic case series).

Unplanned Reoperation and Implant Revision After Total Wrist Arthroplasty

Background: Total wrist arthroplasty (TWA) is a treatment option for many debilitating wrist conditions. With recent improvements in implant design, indications for TWA have broadened. However, despite these improvements, there are still complications associated with TWA, such as unplanned reoperation and eventual implant removal. The goal of this study was to identify risk factors for an unplanned reoperation or implant revision after a TWA at 2 academic medical centers between 2002 and 2015. Methods: In this retrospective study, 24 consecutive TWAs were identified using CPT codes. Medical records were manually reviewed to identify demographic, patient- or disease-related, and surgery-related risk factors for reoperation and implant removal after a primary TWA. Results: Forty-six percent of wrists (11 of 24 TWAs performed) had a reoperation after a median of 3.4 years, while 29% (7 of 24) underwent implant revision after a median of 5 years. Two patients had wrist surgery prior to their TWA, both eventually had their implant removed (P = .08). There were no risk factors associated with reoperation or implant removal. Conclusion: Unplanned reoperation and implant removal after a primary TWA are common. Approximately 1 in 3 wrists are likely to undergo revision surgery. We found no factors associated with reoperation or implant removal; however, prior wrist surgery showed a trend toward risk of implant removal after TWA.

Arthroplasty in the hand: what works and what doesn't?

This review describes the different possibilities for arthroplasties at the proximal interphalangeal joint, thumb carpometacarpal joint, distal radioulnar joint, metacarpophalangeal joint and the wrist. For each joint, the indication for arthroplasty is explained, the surgical technique with the suitable implant is described and a brief summary of the outcomes reported in the literature is given.

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.

Proximal Row Carpectomy with Total Scapoidectomy vs. Conventional Carpal Resection for ReMotion Total Wrist Arthroplasty

High complication rates in total wrist arthroplasty (TWA) still lead to controversy in the medical literature, and novel methods for complication reduction are warranted. In the present retrospective cohort study, we compare the outcomes of the proximal row carpectomy (PRC) method including total scaphoidectomy (n = 22) to the manufacturer’s conventional carpal resection (CCR) technique, which retains the distal pole of the scaphoid (n = 25), for ReMotion prosthesis implantation in non-rheumatoid patients. Mean follow-up was 65.8 ± 19.8 and 80.0 ± 28.7 months, respectively. Pre- and postoperative clinical assessment included wrist flexion-extension and radial-ulnar deviation; Disability of Arm, Shoulder, and Hand scores; and pain via visual analogue scale. At final follow-up, grip strength and satisfaction were evaluated. All complications, re-operations, and revision surgeries were noted. Clinical complications were significantly lower in the PRC group (p = 0.010). Radial impaction was detected as the most frequent complication in the CCR group (n = 10), while no PRC patients suffered from this complication (p = 0.0008). Clinical assessment, grip strength measurements, and the log rank test evaluating the re-operation as well as revision function showed no significant difference. All functional parameters significantly improved compared to preoperative values in both cohorts. In conclusion, we strongly recommend PRC for ReMotion prosthesis implantation.

A systematic review of outcomes of wrist arthrodesis and wrist arthroplasty in patients with rheumatoid arthritis

Surgical management of end-stage rheumatoid wrists is a contentious topic. The standard surgical treatment has traditionally been wrist arthrodesis. Wrist arthroplasty, however, offers an alternative that preserves some wrist motion. A systematic review of MEDLINE, EMBASE and CENTRAL databases was conducted. Data from 23 studies representing 343 cases of wrist arthrodesis and 618 cases of wrist arthroplasty were included. Complication rates were 17% for arthrodesis and 19% for arthroplasty, and both procedures were effective at alleviating pain and improving grip strength. Functional assessment by Disabilities of the Arm, Shoulder, and Hand and Patient-Related Wrist Evaluation of arthroplasty patients revealed clinically meaningful functional improvement compared with preoperative measurements. In contrast to previously published findings both procedures demonstrated comparable complication rates. While this can be speculated to be from advancements in prosthetics, robust long-term follow-up data on wrist arthroplasty are not available yet.

Salvage of the Failed Total Wrist Arthroplasty: A Systematic Review

Background  Although the performance of total wrist arthroplasty systems has improved, failure is encountered and is a major challenge to manage. Questions  Does physical function improve with surgical management of the failed wrist arthroplasty? Is there an improvement in secondary outcome measures including pain, grip strength, and range of motion? What are the reasons for failure in primary total wrist arthroplasty? What are the complications associated with revision of the failed total wrist arthroplasty? What are the survival profiles of the different revision strategies? Methods  A systematic review of available literature was performed. Studies were systematically assessed, and data extracted from suitable studies for review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were adhered to. The study protocol was modified from a previous protocol published on the PROSPERO database. Results  Fourteen studies were identified considering 218 patients/214 index operations with a follow-up duration following revision surgery of 2 months to 21 years (silicone wrist arthroplasty-42 cases; nonsilicone wrist arthroplasty-172 cases). The functional outcome of revision surgery was infrequently recorded and documented with only short-term assessments undertaken. Complications were seen in 1:2 revision procedures, with re-revision surgeries required in 21.6% of revised primary nonsilicone arthroplasties. Re-revision rate following a revision arthrodesis was 21.4% (15/70 cases) compared with revision arthroplasty of 34.8% (32/92 cases). Revision arthrodesis nonunion rate was 17.5% (22 cases). Conclusion  This review has confirmed the high level of surgical complexity and the likelihood of a complicated postoperative outcome when salvaging a failed wrist replacement. Level of Evidence  This is a Level 3, systematic review study.

Total Wrist Arthroplasty: A 10-Year Follow-Up

PURPOSE

To assess long-term implant survival in total wrist arthroplasty (TWA), comparing 4 different implants.

METHODS

In a prospective cohort of 124 patients, 136 TWAs were evaluated 5 years and 10 years after surgery. The TWAs were implanted between 2005 and 2009. The primary outcome was implant survival. Survival analysis was performed with revision and radiographic loosening as the final end point. Revision was defined as exchange of whole or parts of the prosthesis. Implant loosening was assessed using radiographic examination at the 5-year and 10-year follow-up. Secondary outcome measures included wrist range of motion, hand grip strength, visual analog scale (VAS) pain scores, and patient-related outcome measures, including Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and Canadian Occupational Performance Measure (COPM).

RESULTS

Total cumulative implant survival was 92% with revision as the primary end point. When including a nonrevised radiographic loose implant as a failure, total implant survival was 75%. Radiographic loosening differed significantly between the implants with a range in frequency from 0% to 37.5%. At the 10-year follow-up, assessing the nonrevised TWAs, range of motion was preserved compared with preoperative values. Significant improvement was recorded for hand grip strength, VAS pain scores, and patient-related outcome measures at the 10-year follow-up compared with preovperative values.

CONCLUSIONS

High 10-year implant survival was found when defining the primary end point as revision of any cause. When including radiographic loosening of the implant in the survival analysis, implant survival was considerably lower. However, radiographic loosening does not seem to correlate with changes in secondary outcome measures, questioning the need for revision surgery in these cases.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Explant analysis of a Maestro™ wrist prosthesis and calculation of its lubrication regime

Explant analysis can provide key insights to understanding failures of artificial joints and thus how they might be improved for the ultimate benefit of patients. There are no previous reports of explant analysis of an artificial wrist joint. In this study, an explanted metal-on-polymer Maestro wrist was analysed both in macro and nanoscales to estimate its biotribological performance. The articulation was formed between a cobalt chromium carpal head and an ultrahigh molecular weight polyethylene bearing. The surface roughness values of its articulating surfaces and the backside of the articulation were measured. On average, the articulating surface roughness values were calculated as 0.06 ± 0.02 μm and 1.29 ± 0.63 μm for the cobalt chromium carpal head and ultrahigh molecular weight polyethylene bearing, respectively. Both surfaces had negative skewness, indicating a preponderance of valleys. On the articulating surface of the carpal head, light scratches were observed, and no impingement was observed throughout the component. The polymeric surface had a polished appearance. It had unidirectional scratches at the centre of the articulation, pits of different sizes on its articulating surface, and matt white subsurface regions. The backside of the UHMWPE bearing and the convex surface of the radial body that it was sitting on, were found to have average surface roughness values of 4.23 ± 0.69 μm and 5.57 ± 1.05 μm, respectively. The difference in the means was not significant (p > 0.05). Taking the articulating surface roughness values, the lubrication regime that the explanted Maestro wrist operated under in vivo was estimated for varying physiological conditions, i.e. varying loads, entraining velocities and lubricant viscosities. In every case considered, the explant was found to operate under boundary lubrication.

Acute Complications in Total Wrist Arthroplasty: A National Surgical Quality Improvement Program Review

Background  The study sought to assess the patient-based variables, surgical risk factors, and postoperative conditions associated with readmission after total wrist arthroplasty (TWA). Materials and Methods  All patients undergoing TWA were identified from the National Surgical Quality Improvement Program dataset from 2005 to 2016. Patient demographics, medical comorbidities, surgical characteristics, and outcomes were examined to isolate predictors for readmission within 30 days postoperatively. Results  A total of 57 patients were identified to have undergone TWA. The average patients were 62.3 (13.8) years old, female (57.7%), and most were treated in the outpatient setting (67.3%). Comorbid conditions included smoking (17.3%), diabetes (15.4%), and chronic steroid therapy (15.4%). No complications were identified in the 30-day postoperative period. There was a trend for increasing utilization of TWA over the years included. Conclusion  TWA is a safe procedure with low complication rates in the acute postoperative period. Increasing utilization is likely a result of improved outcomes and cost-effectiveness of TWA. Level of Evidence  This is a Level II, prognostic study.

Salvage Operation for a Failed Total Wrist Prosthesis and Darrach Procedure by Total Wrist Revision and Distal Radioulnar Joint Arthroplasty

An unstable distal ulnar stump after Darrach resection, alongside pathology of the radiocarpal joint, is difficult to manage without fusion of at least one joint. Currently, no standard 2-in-1 arthroplasty is available. We report the case of a 72-year-old woman with loosening of the radial stem of a Universal 2 total wrist prosthesis combined with radioulnar impingement after a Darrach procedure. Because of poor radial bone stock, the standard fixation technique of a semi-constrained distal radioulnar joint prosthesis (Aptis) was not possible. We present a technique to fix the semi-constrained distal radioulnar joint prosthesis as well as a total wrist prosthesis by a custom 3-dimensional printed flange prosthesis to the ulnar border of the radius. Three years after surgery, the patient remained pain-free, with 60° flexion, 75° extension, 80° pronation, and 80° supination.

Re-motion total wrist arthroplasty: 39 non-rheumatoid cases with a mean follow-up of 7 years

We evaluated the outcomes of the Re-motion total wrist arthroplasty in 39 non-rheumatoid patients. The mean follow-up was 7 years (range 3-12). Postoperative wrist flexion-extension and radial-ulnar deviation as well as the scores of the Disability of Arm Shoulder and Hand questionnaire and the visual analogue scale pain scores improved significantly. Complications occurred in 13 wrists, five of which required further surgery. The most frequent complication was impingement between the scaphoid and the radial implant (n = 5), which can be avoided by complete or almost complete scaphoid resection. Periprosthetic radiolucency developed around the radial component in three cases and three radial screws loosened. Despite the incidence of high implant survival in 38 of 39 wrists over 7 years (97%), the complication rate is not satisfying. Knowledge of the risk of complications and patient selection are essential when making the decision to choose wrist arthroplasty over arthrodesis. Level of evidence: IV.

High re-operation and complication rates 11 years after arthrodesis of the wrist for non-inflammatory arthritis

AIMS

Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis.

PATIENTS AND METHODS

A total of 76 patients, including 53 men and 23 women, with a mean age of 50 years (21 to 79) underwent wrist arthrodesis. Complications and re-operations were recorded. At a mean follow-up of 11 years (2 to 18), 63 patients completed questionnaires, and 57 attended for clinical and radiological assessment.

RESULTS

Of the 76 patients, 46 (60.5%) had complications, resulting in 65 re-operations, mainly related to the plate and screws. In the 63 patients who completed the questionnaires, the mean Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) score was 36 (0 to 91), the mean Patient-Rated Wrist and Hand Evaluation (PRWHE) score was 40 (0 to 96), and 14 patients (22%) reported no wrist pain. Grip strength, pinch strength, and pronation and supination were significantly reduced compared with the contralateral forearm. The outcome was worse in patients who had previously undergone surgery to the wrist, and those with complications. A total of 13 are awaiting further re-operations, giving a total re-operation rate of 63% (40/63).

CONCLUSION

We observed complications and re-operations throughout the follow-up period and therefore consider wrist arthrodesis to be more complicated than previously assumed. Many of the patients never got used to or accepted their stiff wrists and reported a substantial reduction in function and residual pain. Motion-sparing surgery should be offered prior to wrist arthrodesis. Cite this article: Bone Joint J 2019;101-B:852-859.

Bony anatomy of the third metacarpal and relationship with the capitate: a computed tomography study

PURPOSE

The purpose of this study was to accurately establish the anatomical variability of the third metacarpal, its medullary canal, and the relationship with the capitate in the context of high rates of component loosening still seen in total wrist arthroplasty.

METHODS

CT scans of a 100 hands (age: 41 ± 14 years (range: 16-71 years); male/female ratio: 53/47) were studied to establish the detailed anatomy of the third metacarpal and the capitate.

RESULTS

Although the shape of the third metacarpal and the angles formed with the capitate were highly variable, the third metacarpal length was longer in males (p < 0.001), the proximal cortical bone was thicker (p < 0.001) and the sagittal metacarpal-capitate axis offset was greater (p = 0.01). A relationship was found between the total length of the metacarpal and the distance to the isthmus from the base (r = 0.63; p < 0.0001) which was unaffected by gender. No age-related relationships were significant.

CONCLUSION

The anatomy of the third metacarpal and capitate varies considerably more than has been alluded to in current wrist arthroplasty literature. Differences between males and females can likely be attributed to hand size. The distance of the isthmus from the base can be predicted from the total length of the metacarpal with a standard error of 1.9 mm.

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%.

Trends and Demographics in the Utilization of Total Wrist Arthroplasty

BACKGROUND

Health disparities exist among many patient populations, with race, payer status, hospital size and access to teaching versus non-teaching hospitals potentially affecting whether certain patients have access to the benefits of total wrist arthroplasty (TWA).

METHODS

The National Inpatient Sample Database (NIS) was queried from 2001 to 2013 for TWA using the ICD-9 code 81.73. Patient-level data included age, sex, race, payer status, and year of discharge. Hospital-level data included hospital bed size, location, teaching status, and region.

RESULTS

There were 1,213 patients identified who underwent TWA between 2001 and 2013. Total number of procedures decreased from 88 TWAs in 2001 to 65 in 2013. The yearly volume ranged from 33 in 2005 to 128 in 2007. The male-female ratio was 2.5 to 1. The majority of TWA procedures were performed at urban teaching hospitals (60.8%).

CONCLUSIONS

The NIS database shows a downward trend of total wrist arthroplasty utilization. The majority of total wrist arthroplasties were performed at urban teaching hospitals indicating treatment occurs most often at academic centers of excellence.

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.

Wrist arthroplasty using prosthesis as an alternative to arthrodesis: design, outcomes and future

We developed an uncemented screw-shaped ball-and-socket wrist prosthesis and modified it during a decade of trails from 1996 to 2005. The final Motec® wrist prosthesis was launched in 2006. Since then we have used this prosthesis in 110 wrists (110 patients) from 2006 to 2018. This article reviews the design, functional outcomes, complications, clinical usefulness and possible future modifications of the Motec® wrist prosthesis.

Surgical technique: about a new total and isoelastic wrist implant (Prosthelast®)

This study describes a new total wrist implant (Prosthelast^®) designed to reduce the risk of distal migration of the carpal component. The Prosthelast^® implant consists in a one-block radial implant replacing the metaphysis and the articular surface fixed to a radial elastic centromedullar wire and a carpal component in titanium with an articular condylar surface in polyethylene. We operated on five patients (three male patients and two female patients) and followed them up for 12 months on average. Two of the patients presented with rheumatoid arthritis of the wrist, and an ulnar osteotomy (Darrach procedure) was carried out at the same time of the arthroplasty. All clinical variables improved postoperatively (Quick DASH score, pain score, range of motion) except from wrist flexion which was reduced. No patients underwent revision surgery. Two patients presented with a periprosthetic radiolucent loosening around the radial component, but no implant migration was observed. Overall, the preliminary results of our case series show that the new Prosthelast^® implant presents comparable short-term results to those described in the literature. We will follow up the patients to verify that long-term results are as satisfactory as the short-term results.

Revision Arthroplasty of the Wrist in Patients With Rheumatoid Arthritis, Mean Follow-Up 6.6 Years

PURPOSE

Management of failed total wrist arthroplasty (TWA) can be challenging; surgical treatment options include salvage arthrodesis, revision arthroplasty, and resection arthroplasty. There are few studies regarding salvage arthrodesis, and revision arthroplasty has been infrequently investigated. The aim of the study was to report the outcome after revision arthroplasty of the wrist.

METHODS

A retrospective cohort of 16 revision TWAs was evaluated between 2003 and 2016. Data were collected before surgery and 1 and 5 years after surgery. The indication for revision arthroplasty was failed TWA. The primary end point was implant survival. Secondary outcome measures included visual analog scale (VAS) pain scores, range of motion, handgrip strength, and functional scoring with the Canadian Occupational Performance Measure (COPM), Patient-Rated Wrist Evaluation (PRWE), and Disabilities of the Arm, Shoulder, and Hand (DASH).

RESULTS

Mean follow-up was 6.6 years. Synthetic bone graft was used in 9 cases, allograft corticocancellous bone graft in 1 case, and cement in 6 cases. Of the 16 revision TWAs, 4 were re-revised, 1 because of infection, and 3 cases underwent total wrist arthrodesis. In the non-re-revised cases, range of motion and grip strength was preserved compared with preoperative results. The VAS pain score in activity improved, but not significantly, at 1 (median, 1; range, 0-4.5) and 5 years after surgery (median, 0) compared with before surgery (median, 5). The COPM performance and satisfaction as well as PRWE scores improved significantly at 1 year (median COPM performance, 4.8; COPM satisfaction, 5.6; and PRWE, 24) and improved, but not significantly, at the 5-year follow (median COPM performance, 4.8; COPM satisfaction, 5.0; and PRWE, 37) in the non-re-revised cases.

CONCLUSIONS

Revision arthroplasty of the wrist is a valid motion-preserving option to wrist arthrodesis in the management of failed TWA. However, the outcome is uncertain and as many as 25% require additional surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Universal 2 total wrist arthroplasty: high satisfaction but high complication rates

The Universal 2 total wrist arthroplasty is intended to alleviate wrist pain and restore function. There is limited evidence regarding its success and safety. We report outcomes in 48 wrists of 46 patients with Universal 2 arthroplasty between 2006 and 2014. We recorded range of motion of the operated wrist, patient satisfaction, complication and revision rates, and radiological appearances of the wrists with mean follow-up of 7 years (3.5 to 11 years). We found a significant improvement in DASH scores after surgery, with active range of wrist motion being 33° flexion and 24° extension. Thirty-nine patients would undergo the procedure again if he had similar wrist problems. Twenty-three patients had loosening of at least one component of the implant. Complications were found in 13 wrists; seven underwent revision. We conclude that the Universal 2 arthroplasty produces significant improvements in DASH scores and high levels of satisfaction of the patients. However, the surgery has a high complication rate.

LEVEL OF EVIDENCE

IV.

[Research progress of artificial wrist joint prosthesis]

Objective

To summarize the research progress of the artificial wrist joint prosthesis.

Methods

Domestic and abroad literature concerning artificial wrist joint prosthesis was reviewed and analyzed thoroughly.

Results

Artificial wrist joint prosthesis has been developed to the 4th generation. The artificial wrist joint arthroplasty has advantages of pain relief and functional improvement and can achieve ideal short-term effectiveness. But there are some problems, such as loosening, subsidence, fracture, and dislocation of prosthesis. The long-term effectiveness of the 3rd and 4th generation prosthesis still need to be followed up.

Conclusion

The biomechanics of wrist joint is extremely complicated, which results in less application and slow development of artificial wrist joint prosthesis. Early-term effectiveness of artificial wrist joint arthroplasty is basically satisfactory, but there are still some long-term complications. So the artificial wrist joint prosthesis remains to be developed.

High Survivorship and Few Complications With Cementless Total Wrist Arthroplasty at a Mean Followup of 9 Years

BACKGROUND

Total wrist arthroplasty (TWA) has been described as traditionally being performed with fixation in the radius and carpus with cement. The TWA implant used in our series has been associated with promising results in studies with up to 6 years followup; however, studies evaluating survivorship, pain, and function with this implant are limited. QUESTION/PURPOSE: (1) To report ROM and pain scores after wrist reconstruction with cementless fourth-generation TWA at a mean followup of 9 years (range, 4.8-14.7 years). (2) To report complications of a cementless fourth-generation TWA and the cumulative probability of not undergoing a revision at a mean followup of 9 years.

METHODS

This is a retrospective case series of 69 patients who were treated for pancarpal wrist arthritis between 2002 and 2014. Of those, 31 had inflammatory arthritis (rheumatoid arthritis [n = 29], juvenile rheumatoid arthritis [n = 1], and psoriatic arthritis [n = 1]); all of these patients received TWA with the cementless implant studied in this investigation. Another 38 patients had osteoarthritis or posttraumatic arthritis; in this subgroup, 28 patients were 65 years or younger, and all underwent wrist fusion (none were offered TWA). Ten patients with osteoarthritis were older than 65 years and all were offered TWA; of those, eight underwent TWA, and two declined the procedure and instead preferred and underwent total wrist arthrodesis. The mean age of the 39 patients who had TWA was 56 ± 8.9 years (range, 31-78 years) at the time of surgery; 36 were women and three were men. The patients who underwent TWA were seen at a minimum of 4 years (mean, 9 years; range, 4-15 years), and all had been examined in 2016 as part of this study except for one patient who died 9 years after surgery. The dominant wrist was involved in 60% (25) of the patients. All patients were immobilized for 4 weeks postoperatively and then underwent hand therapy for 4 to 6 weeks. Pain and ROM were gathered before surgery as part of clinical care, and were measured again at latest followup; at latest followup, radiographs were analyzed (by the senior author) for evidence of loosening, defined as any implant migration compared with any previous radiograph with evidence of periimplant osteolysis and bone resorption. Subjective pain score was assessed by a verbal pain scale (0-10) and ROM was measured with a goniometer. Complications were determined by chart review and final examination. Kaplan Meier survival analysis was performed to estimate the cumulative probability of not undergoing a revision.

RESULTS

The mean preoperative active ROM was 34^o ± 18° flexion and 36° ± 18° extension. Postoperatively, the mean active ROM was 37° ± 14° flexion and 29° ± 13° extension. The mean difference between the preoperative pain score (8.6 ± 1.2) and postoperative pain score (0.4 ± 0.8) was 8.1 ± 1.9 (p < 0.001). Implant loosening occurred in three (7.7%) patients. No other complications occurred in this series. Kaplan-Meier survivorship analysis estimated the cumulative probability of remaining free from revision as 78% (95% CI, 62%-91%) at 15 years.

CONCLUSION

Cementless fourth-generation TWA improves pain while generally preserving the preoperative arc of motion. The cumulative probability of remaining free from revision at 14.7 years after the index procedure is 77.7% (95% CI, 62.0%-91.4%). Future studies should compare alternative approaches for patients with endstage wrist arthritis; such evaluations-which might compare TWA implants, or TWAs with arthrodesis-will almost certainly need to be multicenter, as the problem is relatively uncommon.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Four-Year Outcomes of Midcarpal Hemiarthroplasty for Wrist Arthritis

PURPOSE

The purpose of this study was to review the average 4-year outcomes of a cohort of patients with wrist arthritis, treated by a single surgeon with a novel prosthetic hemiarthroplasty of the midcarpal joint. We hypothesized that midcarpal hemiarthroplasty would improve range of motion and grip strength of patients with wrist arthritis, with a complication profile comparable with that of alternative solutions for wrist arthritis.

METHODS

We reviewed a series of 20 patients treated with a midcarpal hemiarthroplasty at an average of 4 years following surgery. Patients were evaluated objectively with grip strength, wrist range of motion, serial radiographs, and subjectively surveyed with Disabilities of the Arm, Shoulder, and Hand (DASH) and Mayo scores.

RESULTS

Range of motion increased by a mean 33° in flexion-extension and 10° in radial-ulnar deviation compared with preoperative range of motion. Mean grip strength improved to 20.8 kg from 14.1 kg, and Mayo and DASH scores also significantly improved. Three patients had a manipulation under anesthesia for stiffness. One patient required open reduction internal fixation of an unstable fourth carpometacarpal joint after falling. Two patients were revised to a total wrist arthroplasty and 1 to a wrist fusion.

CONCLUSIONS

Midcarpal hemiarthroplasty provides improved wrist range of motion, grip strength, and patient-reported outcome scores compared with preoperative values, with a complication profile comparable with that of other surgical options for patients with wrist arthritis. Advantages of midcarpal arthroplasty include retention of the native distal carpal row, preservation of midcarpal motion, as well as the option for conversion to a total wrist arthroplasty should revision be required.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Role of Wrist Arthroscopy in Kienbock Disease

Kienbock disease (KD) is a disease of uncertain etiology, leading to chondral and osseous change in the lunate and wrist. Traditionally, Lichtman's classification of KD, based on radiographic appearances, has been used to direct treatment. Diagnostic wrist arthroscopy allows direct assessment of the lunate and surrounding articulations. Wrist arthroscopy can also serve as a therapeutic tool for performing debridement, resection, or arthrodesis procedures. The new Lichtman-Bain algorithm takes into consideration the status of the lunate, the effect on the wrist, and surgical and patient factors to guide management.

Five- to 10-Year Prospective Follow-Up of Wrist Arthroplasty in 56 Nonrheumatoid Patients

PURPOSE

The goal of the study was to evaluate the clinical and radiological outcomes of a cementless wrist arthroplasty with minimum 5-year follow-up in nonrheumatoid patients.

METHODS

Fifty-seven (40 male) patients with end-stage arthritis changes received an uncemented ball-and-socket total wrist arthroplasty (Motec Wrist). Function was evaluated before surgery and at yearly follow-ups. Visual analog scale at rest and activity, quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), active range of motion (AROM), and grip-strength were recorded. Standardized radiographs were taken to assess osteolysis, loosening, and subsidence.

RESULTS

Fifty-six patients were followed for a mean of 8 years (SD, 2 years). Eight wrists were reoperated with arthrodesis (4) or a new arthroplasty (4) owing to distal component loosening (3), infection (2), pain/fixed malposition (2), or proximal and distal component loosening (1). One radiocarpal dislocation was reduced closed and remained stable. Improved QuickDASH score and visual analog scale pain score both at rest and during activity were found at the last follow-up, as well as increased AROM (97° vs 126°) and grip strength (21 kg vs 24 kg). The radiological follow-up demonstrated loosening in 2 wrists. Thirty-five patients were working at surgery (17 manual labor) and 27 (11 manual labor) at follow-up. The 10-year Kaplan-Meyer survival of the implants was 86% for revision for any cause; 2 additional arthroplasties are loose (but not revised), giving a survival rate of 82% if these are revised prior to 10 years of observation.

CONCLUSIONS

An uncemented total wrist arthroplasty can provide long-lasting unrestricted hand function in young and active patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Total Wrist Arthroplasty Versus Wrist Fusion: Utilization and Complication Rates as Reported by ABOS Part II Candidates

BACKGROUND

The aim of this study was to assess national trends in the utilization and complication rates of total wrist arthroplasty (TWA) and total wrist fusion (WF) as identified via review of the American Board of Orthopedic Surgery (ABOS) Part II candidate database.

METHODS

The ABOS Part II candidate database is a collection of cases reported by candidates of the ABOS Part II board certification oral exam. The ABOS database was queried for all TWA and WF cases performed from 2005 to 2014. Linear regression analyses were used to assess trends in procedure utilization. Treatment diagnoses, patient characteristics, and reported complications were also compared between the 2 treatment cohorts.

RESULTS

No significant increases in the proportion of candidates performing TWA or WF, number of TWA or WF cases, nor the number of TWA or WF cases performed per candidate performing those procedures were noted during the study period. Significantly less TWA cases were performed when compared with WF cases (68 vs 327; P = .006). Patients undergoing TWA were significantly older ( P = .005), more likely female ( P < .001), and more likely to have a diagnosis of osteoarthritis ( P = .003) than patients undergoing WF. There were no significant differences in complication rates, including postoperative infection, nerve palsy, or rate of secondary surgery, between the TWA and WF cohorts.

CONCLUSIONS

Utilization of both TWA and WF has remained unchanged among emerging career orthopedic surgeons. Although WF is performed nearly 5 times more frequently than TWA, our short-term findings suggest that TWA compares favorably with WF.

Does Total Wrist Arthroplasty for Treatment of Posttraumatic Wrist Joint Osteoarthritis in Young Patients Always Lead to Restriction of High-demand Activities of Daily Living? Case Report and Brief Review of Recent Literature

Background:

Posttraumatic ulnar carpal translocation is a very rare condition that is caused either by fracture-dislocation injury or by purely ligamentous injury of the wrist. Its prognosis is poor and development of posttraumatic pancarpal wrist joint osteoarthritis is inevitable, and options for treatment are total wrist fusion or total wrist arthroplasty.

Methods:

A 24-year-old male sustained a fracture-related injury in his left wrist that was accompanied with a second ligamentous distorsion-related injury 1 year later in the same wrist. Seven years after first injury, a posttraumatic pancarpal wrist joint osteoarthritis has developed that was caused by posttraumatic ulnar carpal translocation. The patient was treated by total wrist arthroplasty with use of the Maestro^TM Wrist Reconstructive System.

Results:

With our patient, it is unclear whether posttraumatic ulnar carpal translocation occurred either as result of the first fracture-related injury or as result of the second ligamentous distorsion-related injury or as result of both injuries. The 31-year-old patient could be reemployed completely in his original occupation as a mechanic for big agriculture machines and load his wrist with more than 10 pounds. In order to preserve motion, the patient reported that he would undergo the same total wrist arthroplasty a second time were it necessary.

Conclusion:

We report on a young male receiving total wrist arthroplasty and resulting in good restoration of his high-demand claims in activities of daily living, respectively. However, it cannot be concluded that total wrist arthroplasty is to be preferred generally over total wrist fusion in young patients. Essential prerequisite for this motion-preserving procedure is the compliance of patients.

Total Wrist Arthroplasty

Total wrist arthroplasty using current design implants has evolved into a fairly predictable procedure for rheumatoid, osteoarthritic, and posttraumatic patients. Although complications can occur, the incidence of these has dropped over the past decade with implant design modifications. The article summarizes the current use of total wrist arthroplasty and touches on issues of revision surgery, secondary fusion, complications, wrist fusion takedown, and radiolucency around implants. Technical tips are also provided for both primary and revision surgery.

Kienböck Disease and Arthroscopy: Assessment, Classification, and Treatment

The assessment and management of Kienböck Disease (KD) has always been a conundrum. The Lichtman classification has traditionally been used to guide treatment based on imaging. Arthroscopy provides a direct visualization of the articular surface, allows probing of the surfaces, and enables minimally invasive techniques to be performed. The Lichtman-Bain classification is a new classification that takes into account the osseous, vascular, and cartilage aspects of the lunate and the secondary effects on the wrist. It identifies the important prognostic factors including age, the status of the lunate, and the status of the wrist. With arthroscopy, the articular surfaces of the lunate can be assessed to better understand the status of the lunate. The lunate can be defined as intact, compromised, or not reconstructable. If the lunate is intact then lunate decompression (forage) and arthroscopic assisted bone grafting can be performed. If the lunate facet and capitate are functional, then a proximal carpectomy can be performed. This can be performed as an arthroscopic procedure. Assessment of the wrist includes assessment of the adjacent articular surfaces of the central column articulations (radiocarpal and midcarpal articulations). Instability of the proximal carpal row can also be assessed. The radioscaphoid articulation is often preserved except in late KD, which allows the scaphocapitate fusion to be a good surgical option. This can now be performed as an arthroscopic procedure. Once the radioscaphoid articulation is degenerate, a salvage procedure is required.