Limited wrist fusions: comparison of results 22 and 89 months after surgery

Scaphotrapeziotrapezoid Arthrodesis: Systematic Review

PURPOSE

Scaphotrapeziotrapezoid (STT) arthrodesis surgery is used for various types of wrist pathologies. The objective of our study was to perform a systematic review of complications and outcomes after STT arthrodesis.

METHODS

Several major databases were used to perform a systematic literature review in order to obtain articles reporting complications and outcomes following STT arthrodesis. The primary purpose was to identify rates of nonunion and conversion to total wrist arthrodesis. Secondary outcomes included wrist range of motion, grip strength, and Disabilities of the Arm Shoulder and Hand scores. A multivariable analysis was performed to evaluate factors associated with the primary and secondary outcomes of interest.

RESULTS

Out of the 854 records identified in the primary literature search, 30 studies were included in the analysis. A total of 1,429 procedures were performed for 1,404 patients. The pooled nonunion rate was 6.3% (95% CI, 3.5-9.9) and the rate of conversion to total wrist arthrodesis following the index STT was 4.2% (95% CI, 2.2-6.7). The mean pooled wrist flexion was 40.7° (95% CI, 30.8-50.5) and extension was 49.7° (95% CI, 43.5-55.8). At final follow-up, the mean pooled grip strength was 75.9% (95% CI, 69.3-82.5) of the nonsurgical contralateral hand. Compared with all other known indications, Kienbock disease had a statistically significant lower nonunion rate (14.1% vs 3.3%, respectively). Mixed-effects linear regression using patient-level data revealed that increasing age was significantly associated with complications, independent of occupation and diagnosis.

CONCLUSIONS

Our study demonstrated a low failure rate and conversion to total wrist arthrodesis after STT arthrodesis and acceptable postoperative wrist range of motion and strength when compared to the contralateral hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A Biomechanical Comparison of Modified Radioscapholunate Fusion Constructs for Radiocarpal Arthritis

PURPOSE

This biomechanical study compared fixation constructs used in radioscapholunate (RSL) arthrodesis. We hypothesized that plates and screws, pin plate, and headless screws would all provide similarly stable fixation constructs.

METHODS

We chose 27 fresh-frozen cadaveric extremities, 14 of which were matched pairs and randomized them into 3 groups to match age, body mass index, and sex. An RSL arthrodesis was simulated with plates and screws, pin plates, or headless compression screws via a standard dorsal approach to the wrist. Specimens were mounted into a custom jig and cycled through an arc of 120° for 5,000 cycles to simulate 6 weeks range of motion (ROM). A 9-mm stroke differential variable reluctance transducer recorded continuous displacement, and gross hardware failure in the form of screw or pin cutout was investigated after the simulation.

RESULTS

Greater distraction across the RSL articulation was observed in the headless screws compared with the plate-and-screws and pin-plate constructs, with no difference between the plates and screws and pin plates. Greater average displacement was observed in the headless screws compared with the plate-and-screws and pin-plate constructs, with no difference between the pin plates and plates and screws. Gross hardware failure was observed least in plates and screws followed by pin plates.

CONCLUSIONS

Plate-and-screw and pin-plate constructs are biomechanically superior in resisting RSL distraction compared with headless compression screws for RSL arthrodesis over 6 weeks of simulated ROM in the absence of healing.

CLINICAL RELEVANCE

The results of this study demonstrated negligible arthrodesis site distraction in the plate-and-screws and pin-plate constructs when 6 weeks of ROM was simulated. When translated to a clinical scenario, these findings may allow earlier discontinuation of external immobilization after surgery.

Four-corner arthrodesis employing the native scaphoid as the principal donor graft for advanced collapse deformity of the wrist: technique and outcomes

The purpose of this study was to determine the functional, radiographic, and subjective outcome of the authors' technique of four-corner arthrodesis using the en bloc excised scaphoid as the principal donor bone graft coupled with Kirschner wire fixation. The study comprised 40 consecutive patients with progressive Stage II and III scapholunate advanced collapse or scaphoid nonunion advanced collapse deformities. Preoperative and postoperative range of motion, grip strength, carpal height, and Michigan Hand Outcomes Questionnaire responses were assessed with a mean follow-up of 4.4 years. At an average of 7 weeks, all patients demonstrated radiographic fusion. Moreover, postoperatively, improvement in the Michigan Hand Outcomes Questionnaire domains of overall function, activities of daily living, work performance, pain, and satisfaction were statistically significant. Complications were few and no patient required revision surgery. In this study, the authors' technique results in a reliable four-corner arthrodesis with a low expectation of complications or revision surgery.

LEVEL OF EVIDENCE

IV.

Trapeziectomy and ligament reconstruction tendon interposition for isolated scaphotrapeziotrapezoid osteoarthritis of the wrist

Isolated osteoarthritis of the scaphotrapeziotrapezoid joint is rather rare compared with thumb trapeziometacarpal osteoarthritis. The aim of this retrospective study was to evaluate the outcome of 15 consecutive patients treated with trapeziectomy/ligament reconstruction tendon interposition for isolated scaphotrapeziotrapezoid osteoarthritis of the wrist. After a mean follow-up of 54 months, 14 patients (15 wrists) were available for clinical and radiological examination. The median pain intensity was 0 on a 0-10 visual analogue scale, both at rest and with activity, mean grip strength averaged 24 kg, pinch strength 5 kg. The disabilities of the arm, shoulder and hand (DASH) score was 16, and a modified Mayo Wrist Score 84. Correlation between the degree of scaphotrapezoid osteoarthritis and pain at rest, pain with activity, and DASH score was not significant. The findings from our study suggest that trapeziectomy/ligament reconstruction tendon interposition is an effective procedure for treating isolated scaphotrapeziotrapezoid osteoarthritis, and that additional partial trapezoid excision is not necessary.

Radioscapholunate arthrodesis using low-profile dorsal pi plate

Radioscapholunate arthrodesis is a desirable method to treat isolated radiolunate arthritis or ulnar translocation of the carpal bones. An intact midcarpal joint is a prerequisite for functional range of motion. Previously, high rates of nonunion were observed with these procedures, as rigid fixation was difficult to obtain with simple Kirschner wires and screws. A successful outcome depends on bringing the scaphoid, lunate, and the radius to an anatomic alignment, and rigid fixation of the arthrodesis. We describe a technique for the arthrodesis of the radioscapholunate joint from the dorsal side using a low-profile locking Pi plate. We observed the advantages of an easy approach, better visualization of the joint, and easier manipulation of the carpal bones. The Pi plate fits on the scaphoid, lunate, and the radius with minimal adjustment. It is not necessary to remove the Lister's tubercle. Pi plate allows for rigid fixation and compression between the scaphoid, lunate, and the radius by 1 compression and 1 locking screw in scaphoid and lunate, and by 2 eccentric compression screws in the radius. Rectangular retinacular flaps were used under and over the extensor tendons. We performed these arthrodeses in patients with lunate fossa arthritis after a distal radius fracture, and with ulnar translocation of the carpus. We have observed excellent clinical results with about 50% of wrist motion preserved and no cases of nonunion or delayed union.

Radioscapholunate arthrodesis with excision of the distal scaphoid: comparison of contact characteristics to the intact wrist

PURPOSE

To evaluate the midcarpal contact characteristics at the lunocapitate (LC) and scaphotrapezio-trapezoidal (STT) joints in 3 wrist conditions: intact, after simulating a radioscapholunate (RSL) arthrodesis, and after an RSL arthrodesis with distal scaphoid excision (DSE).

METHODS

Eight fresh-frozen cadaveric specimens were tested using a custom jig with the wrist in neutral, 15° and 30° flexion and extension, 10° radial deviation, and 20° ulnar deviation. The RSL arthrodesis was performed using 2.4-mm distal radius plates with locking screws. Using a pressure sensor, contact force, average pressure, peak pressure, and contact area at the STT and LC joints were measured for 3 conditions: intact wrist, RSL arthrodesis, and RSL arthrodesis with DSE.

RESULTS

Following RSL arthrodesis, average and peak pressure at the LC joint increased significantly compared to the intact wrist. In the STT joint, the average and peak contact pressure increased significantly compared to the intact wrist. Following DSE, average and peak pressure at the LC joint increased further compared to the RSL arthrodesis condition.

CONCLUSIONS

Our findings showed increased contact pressures in the STT and LC joint following RSL arthrodesis, which may explain the clinical findings of midcarpal arthritis. Also, although DSE may improve short-term range of motion and clinical incidence of midcarpal arthritis, our findings showed that this comes at a cost, as the remaining portions of the midcarpal joint are subject to higher forces and pressures following DSE.

CLINICAL RELEVANCE

Radioscapholunate arthrodesis results in increased midcarpal contact pressures that may explain the clinical incidence of midcarpal arthritis. Excision of the distal scaphoid further increases contact pressures in the remaining midcarpal joint and may further increase the incidence of midcarpal arthritis. These alterations in contact characteristics of the midcarpal joint should be considered when excising the distal scaphoid for improved range of motion.

Modified total trapezial and partial trapezoidal excision and ligament reconstruction tendon interposition reduces symptoms in isolated scaphotrapezial-trapezoid arthritis of the wrist

Trapezial excision arthroplasty with ligament reconstruction and tendon interposition (LRTI) modified to include proximal trapezoid excision was performed on 12 wrists in 10 patients with symptomatic, isolated scaphotrapezial-trapezoid (STT) arthritis. Wrist range of motion, lateral pinch and grip strength, and analog pain scores were measured pre- and post-operatively. Mean follow-up was 18 (11-42) months. Post-operatively, reported pain scores uniformly decreased (p < 0.0001). Mean range of wrist flexion increased from 48 to 53° (p < 0.05) and extension from 51 to 55° (p < 0.05). There was also an overall increase in mean grip strength from 15.6 to 19.2 kg and pinch strength from 3.5 to 4.3 kg. Modified Mayo Wrist Scores were excellent in six cases, good in three, and fair in one. Our results suggest that modified total trapezial, partial trapezoidal excision and LRTI could be an effective surgical alternative in cases of isolated STT arthritis.

High fusion rates with circular plate fixation for four-corner arthrodesis of the wrist

BACKGROUND

Scaphoid excision and four-corner fusion is commonly performed to reconstruct advanced scapholunate collapse and scaphoid nonunion with collapse. Metallic plates were introduced for achieving fixation of the four carpal bones. Although the developer reported high rates of fusion, several other early reports of circular plate fixation suggest higher complication rates and inferior outcomes compared with traditional fixation techniques.

QUESTIONS/PURPOSES

To clarify the controversy in the literature we determined the fusion rates, complications, and functional outcomes of patients having circular plate fixation for four-corner fusion.

METHODS

We retrospectively reviewed 15 patients treated for radioscaphoid arthritis with four-corner fusion using circular plate fixation. The minimum followup was 11 months (mean, 22 months; range, 11-39 months).

RESULTS

Radiographic union was achieved by all 15 patients. There was only one postoperative complication. ROM was 71% and grip strength was 78% of the opposite normal side.

CONCLUSIONS

Our results compare favorably with those using traditional fixation techniques. ROM measurements seem superior to those reported in the literature.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic partial wrist fusion

The wide intraarticular exposure of the wrist joint under arthroscopic view provides an excellent ground for various forms of partial wrist fusion. Combining with percutaneous fixation technique, arthroscopic partial wrist fusion can potentially generate the best possible functional outcome by preserving the maximal motion pertained with each type of partial wrist fusion because the effect of extraarticular adhesion associated with open surgery can be minimized. From November 1997 to May 2008, the author had performed 12 cases of arthroscopic partial wrist fusion, including scaphotrapeziotrapezoid fusion in 3, scaphoidectomy and 4-corner fusion in 4, radioscapholunate fusion in 3, radiolunate fusion in 1, and lunotriquetral fusion in 1 case. Through the radiocarpal or midcarpal joint, the corresponding articular surfaces were denuded of cartilage using arthroscopic burr and curette. Carpal bones involved in the fusion process were then transfixed with K wires percutaneously after alignment corrected and confirmed under fluoroscopic control. Autogenous cancellous bone graft or bone substitute were inserted and impacted to the fusion site through cannula under direct arthroscopic view. Final fixation could be by multiple K wires or cannulated screw system. Early mobilization was encouraged. Surgical complications were minor, including pin tract infection, skin burn, and delay union in 1 case. Uneventful radiologic union was obtained in 9 cases, stable fibrous union in 2, and nonunion in 1. The average follow-up period was 70 months. Symptom was resolved or improved, and functional motion was gained in all cases. All surgical scars were almost invisible, and aesthetic outcome was excellent.

Management of non-united four-corner fusions

PURPOSE

Wrist degeneration, resulting from scaphoid nonunion or scapholunate ligamentous disruption, is widely managed with scaphoid excision with four-corner fusion. There are no specific details in the literature regarding "salvage" of nonunion after attempted "four-corner fusions" or the patient outcomes. The purpose of this paper is to present the results of patients who underwent treatment for nonunion after four-corner fusion, the subsequent surgeries done for wrist salvage and the functional results.

METHODS

We reviewed, retrospectively, 37 patients who underwent limited wrist fusion using circular plate fixation, of which eight cases (22%) went on to nonunion and necessitated revision surgeries with plate exchange and bone graft. (Table 1) Five of eight patients were available to return to the clinic, and the wrist range of motion and the disabilities of the arm, shoulder, and hand (DASH) score were recorded.

RESULTS

The average DASH score was 46 (range, 15 to 60.8). Grip on the affected limb was, on the average, 62% of the contralateral limb. Average arc of wrist motion was 70 degrees (35.7 degrees of flexion and 34.3 degrees of extension). Three of the five patients were laborers, and two returned to the previous employment. The remaining two patients returned to their previous sedentary jobs. All patients reported difficulty with recreational activities involving heavy activity.

CONCLUSIONS

Complications of four-corner arthrodesis using circular plate fixation were recorded, revealing a high number of nonunions and hardware failures. All nonunions were salvaged with allograft or autogenous grafting with plate revision; however, the patients did have considerable limitations.

L’arthrodèse capitato-lunaire par hauban dans l’arthrose du poignet

PURPOSE OF THE STUDY

Treatment of degenerative osteoarthritis of the wrist is aimed at preserving wrist motion and force while reducing pain. Limitation of the degenerative processes to certain joints raises the possibility of intracarpal arthrodesis, e.g. capitolunate arthrodesis. We present results of this procedure with a tension band wire in patients with arthritic degenerative disease of the wrist.

MATERIAL AND METHODS

The series included 20 patients reviewed at mean 47 months. Mean age was 53.5 years. Pain was the main complaint. Wrist force and motion were decreased in all patients. All patients presented osteoarthritic disease of the wrist with preservation of the radiolunate space. The operation consisted in total scaphoidectomy and capitolunate arthrodesis maintained with a tension band wire. Force, pain (Mayo clinic score) and force (Jamar dynamometer) were recorded. The Cooney function score was determined and six patients completed the French Dash questionnaire. Radiolunate and capitolunate angles were noted as well as the index of carpal height measured preoperatively and at last follow-up.

RESULTS

Nineteen of the 20 arthrodeses fused. A revision graft was successful for the one nonunion. Pain was the only clinical factor which improved significantly (p<0.0001) in all patients. Lunatum extension (DISI) and capitatum flexion did not have any effect on functional outcome. Sixteen patients resumed their activities at the same level.

DISCUSSION

The results of this series are similar to those in the literature concerning four-way arthrodesis. Capitatolunate arthrodesis with partial arthrodesis of the carpus has been proposed for arthritic degeneration of the wrist with a preserved radiolunate space. We prefer this procedure to four-way arthrodesis because useful motion and wrist force are preserved with constant and effective significant pain relief.

A Prospective Outcomes Study of Four-Corner Wrist Arthrodesis Using a Circular Limited Wrist Fusion Plate for Stage II Scapholunate Advanced Collapse Wrist Deformity

BACKGROUND

Scapholunate advanced collapse wrist deformity is a common pattern of degenerative arthrosis of the wrist. This study prospectively evaluated a series of patients who underwent four-corner fusion using a circular plate internal fixation technique.

METHODS

Patients with symptomatic stage II scapholunate advanced collapse wrist deformity were treated with scaphoid excision and four-corner fusion using the Spider Limited Wrist Fusion Plate (KMI, San Diego, Calif.). Patients were prospectively evaluated at 6 months and 1 year using a standard study protocol with radiographs, functional tests, and an outcomes questionnaire. Outcomes were compared with those of historical series from the literature.

RESULTS

Eleven patients were enrolled and 10 patients completed their 1-year follow-up. Grip strength, lateral pinch strength, and Jebsen-Taylor test scores at 1 year were not significantly different from preoperative values. Mean active range of motion was 87 degrees preoperatively and 74 degrees at 1-year follow-up (p = 0.19). The Michigan Hand Outcomes Questionnaire showed no significant improvement in function, activities of daily living, work, pain, or patient satisfaction. The mean pain scores decreased from 54 preoperatively to 42 1-year postoperatively (p = 0.30), indicating persistent wrist discomfort. Three patients had broken screws: one was asymptomatic, one required 3 months of strict wrist immobilization, and one was reoperated for symptomatic nonunion.

CONCLUSIONS

Four-corner fusion using the first-generation Spider plate technique has the advantage of earlier mobility and more patient comfort from absence of protruding Kirschner wires; however, patients continued to have disabling pain, functional limitations, work impairment, and low satisfaction scores postoperatively. Although limited by a small patient sample, this series presents outcomes data that may be useful in counseling patients who are contemplating four-corner fusion using this internal fixation device. Further investigation is necessary to evaluate the biomechanical properties of the Spider plate. The data suggest that better implants should be designed to avoid implant failure, which occurred in three of the 11 patients in this series.

Scaphotrapeziotrapezoid arthrodesis for arthritis

The main indications for scaphotrapeziotrapezoid (STT) fusion are STT arthritis, rotary subluxation of the scaphoid, and Kienbock disease. The results of this procedure in the literature for each indication are discussed, as are the advantages, disadvantages,and alternative procedures. This article discusses the authors' surgical technique and results. The authors believe this procedure is a viable one in specific clinical scenarios.

Salvage of post-traumatic arthritis following distal radius fracture

There are practical recommendations that can be drawn from the aforementioned results. Due to the minimal morbidity of the wrist denervation, patients with good but painful wrist motion following fracture of the distal radius should first be evaluated for wrist denervation unless formal resection of the dorsal interosseous nerve has clearly been included in the previous treatment. The evaluation is performed in a standardized manner before and after test infiltration of both interosseous nerves. This evaluation includes assessment of pain, strength, and working capacity. Whereas the grip strength often does not (cannot)increase more than 10% to 20%, the subjective pain relief can be remarkable, leading to higher repetition counts and increased dexterity. Inpatients with insufficient response to the anesthetic nerve blocks, other pain sources must be sought, especially on the ulnar side of the wrist. Patients with less than functional range are candidates for complete arthrodesis. A way for further evaluation with regard to the potential of partial and complete wrist arthrodesis is trial immobilization of the wrist in a light cast ora firm reinforced brace. Trial immobilization also allows anticipating the functional deficit from loss of range of wrist motion. Due to the still-unrestricted pronation and supination, ulnar-sid-ed wrist pain may persist and will need adequate follow-up adjunct treatment. Patients who have good pain relief but are not willing to completely lose their wrist motion should be evaluated fluoroscopically or receive lateral radiographs in full flexion and extension to measure their mid-carpal joint mobility and anticipate the potential residual motion after radiocarpal fusion. Patients without pain relief from test anesthesia, trial immobilization, and no apparent distal radioulnar joint pathology are poor candidates for further operative treatment.In evaluating different salvage procedures,among all diagnoses, painful arthritis following fracture of the distal radius is the most difficult to treat and yields the poorest results. Emphasis must therefore be on better initial fracture treatment and earlier secondary reconstructive interventions. The current salvage procedures must allow further improvement or alternatives must be developed. Prosthetic replacement merits serious consideration, especially when it can be adapted to the specific post-traumatic setting. This situation is not worse than rheumatoid arthritis because the clinician is dealing with healthy and strong intact bone stock, tendons, and ligaments,and most important, complete absence of a progressive disease.