Prosthetic Design in Total Wrist Arthroplasty

Total Wrist Arthroplasty Versus Wrist Fusion in Rheumatoid Arthritis

Total wrist fusion (TWF) and total wrist arthroplasty (TWA) are viable treatment options for the rheumatic wrist. TWF fuses through the carpus to stabilize the wrist in 10° to 15° of extension and neutral coronal alignment. Although TWF can be performed with many implants, dorsal fusion plates are best supported. TWA has the advantage of preserving wrist motion but has historically had unacceptable complication rates. The current fourth and fifth generation implants represent significant improvements and have acceptable long-term survivorship and complication rates. Both TWF and TWA can improve quality of life and hand function in patients with rheumatoid arthritis.

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.

Wrist arthrodesis combined with a bulk bone allograft for implant loosening after total wrist arthroplasty: A case report

Total wrist arthroplasty (TWA) is a challenging procedure for wrist joints severely destroyed by rheumatoid arthritis. The most common postoperative complication of TWAs is the loosening of the carpal component. Revision surgeries for failed TWAs can be complicated owing to severe bone loss and concomitant soft-tissue problems. Here, we report a case (68-year-old woman with a history of rheumatoid arthritis for 24 years) of severe aseptic loosening of semi-constrained TWA and its salvage surgery. During the primary arthroplasty procedure, severe instability at the second through fifth carpometacarpal joints was observed and arthrodesis of these joints was required. The radiographs obtained 9 months after surgery showed loosening of the carpal component. Subsequently, she suffered a stroke, resulting in a loss of follow-up, and higher stress was loaded on her upper extremities during standing and walking. In the radiograph taken at her revisit 25 months after the primary surgery, the subsidence of the carpal component progressed and loosening of the radial component was observed. Total wrist arthrodesis was performed using a bulk bone allograft of the femoral head, combined with a penetrating Wrist Fusion Rod®. Rapid bone union was achieved without soft-tissue irritation. We conclude that wrist arthrodesis with a bulk bone allograft combined with an intramedullary nail is a reasonable option for failed total wrist arthroplasty.

Technique for Failed Total Wrist Arthroplasty Conversion to a Total Wrist Arthrodesis with Allograft Interposition

The frequency of prosthetic total wrist arthroplasty continues to increase. With this increase comes the expected subsequent increase in need for revision or salvage procedures. The technique presented here involves the use of a cortical allograft interposition graft to restore bone stock and length for failed total wrist arthroplasty.

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.

Total Wrist Arthroplasty Alignment and Its Potential Association with Clinical Outcomes

Purpose  There is a lack of quantitative research that describes the alignment and, more importantly, the effects of malalignment on total wrist arthroplasty (TWA). The main goal of this pilot study was to assess the alignment of TWA components in radiographic images and compare them with measures computed by three-dimensional analysis. Using these measures, we then determined if malalignment is associated with range of motion (ROM) or clinical outcomes (PRWHE, PROMIS, QuickDash, and grip strength). Methods  Six osteoarthritic patients with a single type of TWA were recruited. Radiographic images, computed tomography images, and clinical outcomes of the wrists were recorded. Using posteroanterior and lateral radiographs, alignment measurements were defined for the radial and carpal components. Radiographic measurements were validated with models reconstructed from computed tomography images using Bland-Altman analysis. Biplanar videoradiography (<1mm and <1 degree accuracy) was used to capture and compute ROM of the TWA components. Linear regression assessed the associations between alignment and outcomes. Results  Radiographic measures had a 95% limit-of-agreement (mean difference ±  1.96 × SD) of 3 degrees and 3mm with three-dimensional values, except for the measures of the carpal component in the lateral view. In our small cohort, wrist flexion-extension and radial-ulnar deviation were correlated with volar-dorsal tilt and volar-dorsal offset of the radial component and demonstrated a ROM increase of 3.7 and 1.6 degrees per degree increase in volar tilt, and 10.8 and 4.2 degrees per every millimeter increase in volar offset. The carpal component's higher volar tilt was also associated with improvements in patient-reported pain. Conclusions  We determined metrics describing the alignment of TWA, and found the volar tilt and volar offset of the radial component could potentially influence the replaced wrist's ROM. Clinical Relevance  TWA component alignment can be measured reliably in radiographs, and may be associated with clinical outcomes. Future studies must evaluate its role in a larger cohort.

Long-Term Results of the Modular Physiological Wrist Prosthesis (MPW®) in Patients with Inflammatory Diseases

The wrist is among the predilection sites of over 90% of cases of rheumatoid arthritis (RA). In advanced cases, total wrist arthroplasty (TWA) is an alternative to arthrodesis. The aim of this study is to present the long-term results of the modular physiological wrist prosthesis (MPW^®) and to match them in context with the results of a standard population survey. In a retrospective study with follow-up, patients with an MPW^® endoprosthesis were evaluated concerning the clinical and radiological outcome, complications were reviewed (incidence and type), and conversion to wrist fusion was assessed. Patient function measurements included the Mayo wrist score, the patient-specific wrist test, and therefore the DASH score (arm, shoulder, and hand). Thirty-four MPW^® wrist prostheses were implanted in 32 patients, including thirty primary implantations and four changes of the type of the endoprosthesis. Sixteen patients (18 prostheses) underwent clinical and radiological follow-up. The average follow-up time was 8.5 years (1 to 16). Poor results of the MPW prosthesis are caused by the issues of balancing with luxation and increased PE wear. Salvage procedures included revision of the TWA or fusion. In successful cases, the flexion and extension movement averaged 40 degrees. The grip force was around 2.5 kg. The common DASH score was 79 points, with limited and problematic joints of the upper extremity. The MPW wrist prosthesis offered good pain relief and functional movement in over 80% of cases. The issues of dislocation and increased PE wear prevent better long-term results, as do the joints affected. A follow-up study with fittings under a contemporary anti-rheumatic therapy with biologicals suggests increasing score results. Type of study/level of evidence: Case series, IV.

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.

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.

Update on the operative treatment of scapholunate instability for radiologists. II. Salvage procedures, total wrist arthrodesis, and total wrist arthroplasty

Scapholunate (SL) instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management, and postoperative follow-up of SL instability. In the final stage of SL instability, known as scapholunate advanced collapse, progressive degenerative changes occur at the carpal level. The goals of this article are to review the surgical options available for addressing the different stages of scapholunate advanced collapse, along with an emphasis on normal postoperative imaging and complications associated with each surgical option.

The Biomechanical Impact of Digital Loss and Fusion Following Trauma: Setting the Patient up for Success

Surgeons managing mutilating hand injures are faced with difficult decisions between attempting to salvage remaining or injured digits or proceeding to amputation and fusion. Through application of a basic understanding of hand biomechanics, the surgeon may more accurately predict what motion and function can best be salvaged. This article provides an explanation of how amputation, fusion, and tendon loss can affect postoperative hand motion. The surgeon can use these concepts in planning the reconstruction or preparing the foundation for secondary reconstructive procedures to achieve the highest functional outcome for the patient.