Total wrist arthrodesis using bowed crossed K-wires

Union of Radiocarpal Fusion With and Without Proximal Row Carpectomy: A Systematic Review

PURPOSE

Wrist fusion provides a solution to the painful, arthritic wrist, and can be concomitantly performed with or without a proximal row carpectomy (PRC). The benefits of combining a PRC with fusion include a large amount of local bone graft for fusion and a lower number of joints needed to fuse. We hypothesized that wrist fusion combined with PRC will have a higher fusion rate than wrist fusion performed without PRC.

METHODS

A systematic review was performed to identify all papers involving wrist arthrodesis using the following databases: PubMed, Ovid, Scopus, Web of Science, and COCHRANE. A literature search was performed using the phrases "wrist" OR "radiocarpal" and "fusion" OR "arthrodesis". Inclusion criteria included complete radiocarpal fusion performed for rheumatoid, posttraumatic, or primary arthritis; union rates available; English-language study. Studies were excluded if case reports; diagnoses other than the ones listed previously; inability to abstract the data. Data collected included wrist fusions with PRC or without PRC, union rate, patient age, underlying diagnosis, and method of fixation.

RESULTS

A total of 50 studies were included in the analysis. There were 41 studies with no PRC, 8 studies with PRC, and 1 study with and without PRC. There were 347 patients with a PRC and 339 patients had a successfully fused wrist (97.7%). There were 1,355 patients who had a wrist fusion with no PRC, and1,303 patients had successful wrist fusion (96.2%). The difference in fusion rate between the 2 groups, 97.7% versus 96.2%, was not statistically significant.

CONCLUSIONS

There is no statistically significant difference with regards to union rate in wrist fusion with a PRC versus wrist fusion without a PRC.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Cost-Effectiveness Analysis Comparing Proximal Row Carpectomy and Four-Corner Arthrodesis

Background:

The optimal surgical treatment for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) remains unclear. To inform clinical decision-makers, we conducted a cost-effectiveness analysis comparing proximal row carpectomy (PRC) and four-corner arthrodesis (FCA).

Methods:

A Markov microsimulation model was used to compare clinical outcomes, costs, and health utilities between PRC and FCA. The model used a 10-year time horizon and a 1-month cycle length, and it was evaluated from the societal perspective. Utilities and clinical parameters including transition probabilities for debridement for infection, removal of implants, conversion to total wrist arthrodesis, revision FCA, and revision total wrist arthrodesis were obtained from published literature. Timing of complications was estimated from the literature. Direct medical costs were derived from Medicare ambulatory surgical cost data, and indirect costs for missed work due to surgical procedures and complications were included. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analysis and 1-way threshold analysis for utilities were performed.

Results:

In the base-case model, PRC dominated FCA (i.e., PRC had lower cost and greater effectiveness). The mean (and standard deviation) for the total cost and QALYs per patient were $30,970 ± $5,931 and 8.24 ± 1.28, respectively, for PRC and $44,526 ± $11,205 and 8.23 ± 1.26, respectively, for FCA. In the probabilistic sensitivity analysis, PRC dominated FCA in 57% of the 1 million iterations. The cost-effectiveness acceptability curve indicated that PRC is the most cost-effective strategy regardless of the willingness-to-pay threshold up to $100,000/QALY.

Conclusions:

PRC dominated FCA in the base-case analysis and in the probabilistic sensitivity analysis. These results suggest that PRC is the optimal strategy for Stage-I or II SLAC and for SNAC in patients ≥55 years of age.

Level of Evidence:

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Wrist Arthrodesis in Rheumatoid Arthritis by Parallel K Wires and Ulna Autograft: A Case Report

Case description

Nowadays, management of end-stage rheumatoid wrist remains controversial between fusion and arthroplasty. We present a simple method of rheumatoid wrist fusion in a 56-year-old woman, using parallel Kirschner (K) wires and local ulna graft. Wrist fusion was achieved at 8 weeks, while implants are removed a month later without any complications in the immediate or late postoperative period.

Conclusion

Management of end-stage rheumatoid wrist with parallel wires remains a simple, versatile, and reliable method to achieve wrist fusion without any complication due to hardware or the disease by itself.

How to cite this article

Hemanthakumar G, Sathish M, Muthalagan N. Wrist Arthrodesis in Rheumatoid Arthritis by Parallel K Wires and Ulna Autograft: A Case Report. J Orth Joint Surg 2020;2(1):38–40.

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.

Calcium phosphate cement in wrist arthrodesis: three cases

BACKGROUND

With degenerative pathologies, arthrodesis of the wrist is a procedure reserved for preservative interventions that have failed. The least invasive procedure is Gill's technique, as modified by Luboshitz. To improve the results, we proposed a study of the advantages of local application of calcium phosphate cement.

METHODS

The procedure consisted of refreshing the remaining articular surfaces, obtaining a dorsal corticocancellous graft from the distal radius, and replacing the bone substance lost when removing the graft with calcium phosphate cement followed by smoothing flat the arthrodesis area to limit tendon conflicts.

RESULTS

In our three cases with an average follow-up of 23 months, no complications were noted and radiological consolidation was achieved in 2 months.

CONCLUSIONS

In view of this short series, we think that the addition of calcium phosphate cement to Gill's technique as modified by Luboshitz should improve the results of arthrodesis of degenerative wrists.