Systematic Review of Total Wrist Arthroplasty and Arthrodesis in Wrist Arthritis

Periprosthetic radius fracture after total wrist arthroplasty: A case report

Total wrist arthroplasty (TWA) is indicated in select low demand patients with pan-carpal arthritis to decrease pain and preserve motion. Complications of TWA are well described including aseptic loosening, superficial and deep infection, wound issues, component dislocation, stiffness, and both intraoperative and post-operative fracture. With 4th generation implant designs, the incidence of many of these complications have decreased, but these complications remain challenging to address. In particular, sparse literature is available for the treatment of periprosthetic radius fractures after TWA. This report describes the management of an open, periprosthetic distal third radius fracture 18 months after index TWA in a medically complex 53-year-old female with lag screw fixation and a dorsal wrist spanning plate (DSP).

Long-Term Oral Steroid Use: A Unique Risk Factor in 4-Corner Fusion Compared With Other Wrist Salvage Operations

INTRODUCTION

Salvage procedures such as proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, and total wrist arthrodesis are commonly used at the end stages of wrist arthritis. These operations have high complication rates, and significant controversy exists regarding the selection of procedure. Long-term oral glucocorticoid therapy has previously been identified as a risk factor for complications in multiple orthopedic procedures. The purpose of this study is to investigate the effect long-term oral preoperative corticosteroid use has on complications after different salvage operations for wrist arthritis.

METHODS

The National Surgical Quality Improvement Program database was queried to identify patients who underwent proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, or total wrist fusion between 2005 and 2020. Patients were classified by steroid use. Univariate analysis and multivariate logistic regression were used to assess the risk of complications.

RESULTS

A total of 1298 patients were identified. Overall, steroid use was found to be independently associated with a higher complication rate. On multivariate analysis of patients who underwent 4-corner fusion, steroid use was found to be associated with higher complication rate and surgical site infection rate. Steroid use was not associated with increased complications in patients who underwent proximal row carpectomy, total wrist arthroplasty, or total wrist fusion when examined individually.

CONCLUSION

Long-term oral corticosteroid therapy was associated with an increased risk of postoperative infections in patients who underwent 4-corner fusion, which was not found in other wrist salvage operations.

Patient reported and functional outcome measures after surgical salvage procedures for posttraumatic radiocarpal osteoarthritis - a systematic review

BACKGROUND

Posttraumatic wrist osteoarthritis is an irreversible and often progressive condition. Many surgical treatments, used in (daily) practice, aim to relieve symptoms like pain and restore function. The aim of this systematic review is to assess the patient reported and functional outcomes of the most common surgical interventions in patients with posttraumatic wrist osteoarthritis. This overview can help clinicians select the best treatment and manage patient's expectations.

METHODS

A literature search was performed in Pubmed, Embase and Cochrane for articles published between 1990 and November 2022 according to the PRISMA guidelines. The study protocol has been registered in the PROSPERO database (CRD42017080427). Studies that describe patient reported outcomes (pain and Disability of Arm, Shoulder and Hand (DASH) -score) and functional outcomes (range of motion (ROM) and grip strength) after surgical intervention with a minimal follow-up of 1 year were included. The identified surgical procedures included denervation, proximal row carpectomy, interpositional- and total arthroplasty, and midcarpal-, radiocarpal- and total arthrodesis. The pre-and postoperative outcomes were pooled and presented per salvage procedure.

RESULTS

Data from 50 studies was included. Pain score improved after all surgeries except denervation. Flexion/extension decreased after radiocarpal arthrodesis, did not show significant changes after proximal row carpectomy, and improved for all other surgeries. DASH score improved after arthroplasty, proximal row carpectomy and midcarpal arthrodesis. Grip strength improved after interposition arthroplasty and partial arthrodesis.

CONCLUSION

Evidence from this review did not support the indication for denervation in this particular patient population. In patients with SLAC/SNAC II, proximal row carpectomy might be favourable to a midcarpal arthrodesis solely based on better FE ROM of the radiocarpal joint after proximal row carpectomy. In terms of radiocarpal mobility, total wrist arthroplasty might be preferred to radiocarpal arthrodesis in patients with osteoarthritis after a distal radius fracture. More uniform measurements of outcomes would improve the understanding of the effect of surgical treatments of the posttraumatic osteoarthritic wrist.

Evaluation of a cadaveric wrist motion simulator using marker-based X-ray reconstruction of moving morphology

Surgical intervention is a common option for the treatment of wrist joint arthritis and traumatic wrist injury. Whether this surgery is arthrodesis or a motion preserving procedure such as arthroplasty, wrist joint biomechanics are inevitably altered. To evaluate effects of surgery on parameters such as range of motion, efficiency and carpal kinematics, repeatable and controlled motion of cadaveric specimens is required. This study describes the development of a device that enables cadaveric wrist motion to be simulated before and after motion preserving surgery in a highly controlled manner. The simulator achieves joint motion through the application of predetermined displacements to the five major tendons of the wrist, and records tendon forces. A pilot experiment using six wrists aimed to evaluate its accuracy and reproducibility. Biplanar X-ray videoradiography (BPVR) and X-Ray Reconstruction of Moving Morphology (XROMM) were used to measure overall wrist angles before and after total wrist arthroplasty. The simulator was able to produce flexion, extension, radioulnar deviation, dart thrower's motion and circumduction within previously reported functional ranges of motion. Pre- and post-surgical wrist angles did not significantly differ. Intra-specimen motion trials were repeatable; root mean square errors between individual trials and average wrist angle and tendon force profiles were below 1° and 2 N respectively. Inter-specimen variation was higher, likely due to anatomical variation and lack of wrist position feedback. In conclusion, combining repeatable intra-specimen cadaveric motion simulation with BPVR and XROMM can be used to determine potential effects of motion preserving surgeries on wrist range of motion and biomechanics.

Investigation of the short-term in vivo performance of metal-on-carbon fibre reinforced poly ether ether ketone Motec wrists: an explant analysis

Total wrist arthroplasty (TWA) aims to restore pain-free motion to diseased joints. One such TWA, the Motec, has demonstrated good results with acceptable complication rates. It has recently been suggested that the metal-on-carbon fibre reinforced poly ether ether ketone (Mo-CFR-PEEK) version of the Motec TWA be implanted instead of the metal-on-metal version. An explant analysis was undertaken on seven Motec Mo-CFR-PEEK TWAs, revised for a variety of reasons, after a mean time of 2 years in vivo. Compared to a new Motec implant, five of the explanted metal heads and three of the CFR-PEEK cups became smoother in vivo, suggesting self-polishing and negative skewness, indicating some material loss in vivo. Two explanted cups showed indentation marks on their rims and one of these was from component impingement with embedded metallic debris. In the short-term, the articulating surfaces of Motec Mo-CFR-PEEK TWAs did not show major damage.Level of evidence: IV.

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.

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.

Total wrist arthroplasty with the Freedom® prosthesis: a short-term follow-up

We retrospectively reviewed our series of primary total wrist arthroplasty with the Freedom® prosthesis. The primary outcome measure was revision, and secondary measures included radiographic loosening, pain, complications, movement range, grip strength and patient-reported measures. We reviewed 12 implants in 11 patients (mean age 59 years, range 45-80) with a mean radiological and clinical follow-up of 2.7 and 3 years, respectively. One radial component failed to integrate and was revised at Day 84. Four carpal components demonstrated areas of lucency. There was a statistically significant reduction in pain, and total flexion-extension increased. Despite high patient satisfaction on a ten-point visual analogue scale score (mean 8.7 out of 10), the mean patient-rated wrist evaluation, Quick Disabilities of the Arm, Shoulder and Hand and Patient Evaluation Measure scores were 52, 55 and 53, respectively. The Freedom® implant reduced pain and preserved wrist movement in our patients; however, annual surveillance is recommended due to the high incidence of early carpal component lucency.Level of evidence: IV.

A systematic review and network meta-analysis of outcomes after total wrist arthroplasty in inflammatory and non-inflammatory arthritis

This systematic review analysed the available evidence on the clinical outcomes of total wrist arthroplasty (TWA) in patients with inflammatory and non-inflammatory arthritis. After screening, 12 studies met the inclusion criteria. They involved 359 patients with 378 TWA implants. The results showed that TWA significantly improved Disabilities of the Arm, Shoulder and Hand (DASH)/Quick-DASH scores and pain visual analogue scale scores in both arthritis groups compared with preoperative values. However, there was no statistically significant difference in the outcome scores between the two groups. Three studies reported Patient-Rated Wrist Evaluation (PRWE) scores, and TWA significantly improved PRWE scores in non-inflammatory arthritis but not in inflammatory arthritis, with no significant difference in postoperative outcome scores between the two groups. Although the included studies have limitations, the review suggests that TWA may be a successful treatment for wrist pain in individuals with either inflammatory or non-inflammatory arthritis. However, further high-quality trials are needed to confirm these findings.

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.

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.

Treatment of Scaphoid Non-Unions with Custom-Made 3D-Printed Titanium Partial and Total Scaphoid Prostheses and Scaphoid Interosseous Ligament Reconstruction

PURPOSE

Treatment of scaphoid fracture sequelae is still an unsolved problem in hand surgery. Custom-made 3D-printed titanium partial and total scaphoid prosthesis and scaphoid interosseous ligament reconstruction (SLIL) are performed in cases of non-union and isolated aseptic necrosis of the proximal scaphoid pole and when it is impossible to save the scaphoid bone, respectively. This study aims to evaluate the clinical, functional and radiographic results after these two prosthesis implantations.

METHODS

Between January 2019 and July 2020, nine partial and ten total scaphoid prostheses were implanted using custom-made 3D-printed titanium implants. Evaluation criteria included carpal height ratio (CHR), radioscaphoid angle, wrist extension and flexion, radial deviation and ulnar deviation of the wrist, grip strength and pinch strength, Visual Analogue Scale (VAS), the Disabilities of Arm, Shoulder, and Hand (DASH) score, and the Patient-Rated Wrist Evaluation (PRWE).

RESULTS

Clinical, functional, and radiographic improvements were found in all outcomes analyzed for both patient groups. The VAS pain scale obtained the most remarkable improvement at the one-year follow-up. The results of the DASH scores and the PRWE were good, with a great rate of patient satisfaction at the end of the follow-up. SLIL reconstruction also provided excellent stability and prevented a mid-carpal bone collapse in the short- and medium-term follow-up.

CONCLUSIONS

A custom-made 3D-printed titanium partial or total scaphoid prosthesis is a viable solution for patients with scaphoid non-union and necrosis or complete scaphoid destruction in whom previous conservative or surgical treatment has failed.

Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report

CASE

A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA.

CONCLUSION

At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.

The communication patterns between the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve

INTRODUCTION

The superficial branch of the radial nerve (SBRN) and the lateral antebrachial cutaneous nerve (LACN) are sensory nerves coursing within the forearm in a close relationship. This high degree of overlap and eventual communication between the nerves is of great surgical importance. The aim of our study is to identify the communication pattern and overlap of the nerves, to localize the position of this communication in relation to a bony landmark, and to specify the most common communication patterns.

MATERIALS

and methods: One hundred and two adult formalin-fixed cadaveric forearms from 51 cadavers of Central European origin were meticulously dissected. The SBRN, as well as the LACN, were identified. The morphometric parameters concerning these nerves, as well as their branches and connections, were measured with a digital caliper.

RESULTS

We have described the primary (PCB) and secondary communications (SCB) between the SBRN and the LACN and their overlap patterns. One hundred and nine PCBs were found in 75 (73.53%) forearms of 44 (86.27%) cadavers and fourteen SCBs in eleven hands (10.78%) of eight cadavers (15.69%). Anatomical and surgical classifications were created. Anatomically, the PCBs were classified in three different ways concerning: (1) the role of the branch of the SBRN within the connection; (2) the position of the communicating branch to the SBRN; and (3) the position of the LACN branch involved in the communication to the cephalic vein (CV). The mean length and width of the PCBs were 17.12mm (ranged from 2.33-82.96mm) and 0.73mm (ranged from 0.14-2.01mm), respectively. The PCB was located proximally to the styloid process of the radius at an average distance of 29.91mm (ranged from 4.15-97.61mm). Surgical classification is based on the localization of the PCBs to a triangular zone of the SBRN branching. The most frequent branch of the SBRN involved in the communication was the third (66.97%). Due to the frequency and position of the PCB with the third branch of the SBRN, the danger zone was predicted. According to the overlap between the SBRN and the LACN, we have divided 102 forearms into four types: (1) no overlap; (2) present overlap; (3) pseudo-overlap; and (4) both present and pseudo-overlap. Type 4 was the most common.

CONCLUSION

The patterns of communicating branch arrangements appeared to be not just a rare phenomenon or variation, but rather a common situation highlighting clinical importance. Due to the close relationship and connection of these nerves, there is a high probability of simultaneous lesion.

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 fusion versus total wrist prosthesis: a comparative study

We present a comparative study of 41 total wrist fusions (TWFs) with contoured plate and 22 total wrist prostheses using the Universal 2™ model, with a mean follow-up of 6 years for the fusion and 6.5 years for the prosthesis. We evaluated grip strength, pain according to the visual analogue scale, functional results using the Quick Disabilities of the Arm, Shoulder and Hand and the Patient-Rated Wrist Evaluation, degree of satisfaction and complications, with no significant differences being observed in any of these variables. The results allow us to conclude that total wrist prosthesis implanted in patients with low or moderate functional demands offers medium-term functional results similar to TWF without increasing the number of complications.Level of evidence: III.

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.

Total arthrodesis for non-rheumatoid wrists: Outcomes at 5 and 20years of follow-up

INTRODUCTION

Total wrist arthrodesis (TWA) aims to obtain a painless wrist with a strong grip. Its main disadvantage is compromised mobility and for many authors it remains a rescue intervention. However, after one or more palliative interventions, TWA confers poorer results. The objective of our study was to evaluate the medium-term results of TWA, and their long-term stability.

HYPOTHESIS

Our hypothesis was that the results are reliable and persistent for pain and strength, without repercussions to other joints.

MATERIAL AND METHODS

This was a single-center consecutive series of TWA performed with a dedicated plate, excluding rheumatoid wrists, evaluated at 5.4 and 21.1years of follow-up.

RESULTS

Thirty wrists were assessed at the first review and 17 reassessed at the last follow-up. At the mean follow-up of 5.4years, 93% of patients considered themselves "very satisfied" or "satisfied" with the TWA surgery. No infectious complications occurred. At the mean follow-up of 21.1years, all were "very satisfied" or "satisfied" and 88% of them considered their result stable or improved compared to the first revision. The average VAS had gone from 8.4/10 preoperatively to 1.8/10 at the first evaluation and to 0.3/10 at the last follow-up. Except for a patient with both wrists operated on for whom comparison was not possible, the strength of the operated side was on average 89.7% of that of the contralateral side (from 45% to 150%). The mean Quick DASH score was 30.3 (4.5 to 61.4) and the mean PRWE score was 32.5 (1 to 77).

DISCUSSION

TWA using a plate provides excellent results for both pain control and strength restoration. The clinical results remain stable over time, and arthrodesis at more than 20years of follow-up does not seem to have any impact on the other joints of the upper limb. After wrist surgery, the main complaint of patients is the limited range of motion, but the main cause of dissatisfaction is persistent pain. Arthrodesis can be performed first-line in case of questionable indication of partial arthrodesis on a stiff wrist because the results of TWA are better in the absence of a surgical history.

LEVEL OF EVIDENCE

IV; retrospective study.

La artroplastia de muñeca como solución a la artrosis postraumática o fracaso de artrodesis parcial: Una serie de casos

Introducción Diferentemente de la artrodesis, la artroplastia total de muñeca permite mantener um rango de movimiento funcional en pacientes operados por artrosis de diferentes causas. La evolución de los implantes pemitió llegar a una mayor tasa de éxito, con disminución de las complicaciones como el aflojamiento de componentes. Este estudio tiene como objetivo demostrar los resultados funcionales y las tasas de complicaciones en una serie de casos operados con el implante Motec (Swemac Orthopaedics AB, Linköping, Suecia) por un único cirujano.

Materiales y Métodos Se trata de un estudio retrospectivo con 14 pacientes intervenidos de artroplastia total de muñeca con el sistema Motec entre 2017 y 2022 y evaluados pre y posoperatoriamente por la Escala de Muñeca de la Clínica Mayo (Mayo Wrist Score, en inglés) y la Escala Visual Analógica (EVA). Se realizó revisión de historias clínicas en junio de 2022 y análisis estadístico con prueba t pareada considerando significativos valores de p < 0,05.

Resultados Fueron operados 13 hombres y 1 mujer, con una edad media de 64,8 (desviación estándar [DE] = 7,5) años, y el tiempo medio de seguimiento fue de 25,1 (DE = 10,9) meses. La puntuación en la Escala de Mayo presentó media preoperatoria de 23,2 (DE = 8,9) y posoperatoria de 82,8 (DE = 7), mientras la EVA preoperatoria tuvo una media de 7,6 (DE = 1,1), y la posoperatoria fue de 1 (DE = 1,2). Las diferencias en los resultados pre y posoperatorios de la Escala de Mayo y la EVA fueron estadísticamente significativas (p < 0,001).

Conclusión Como se demuestra en esta serie, las mejoras funcionales y en el dolor fueron importantes, no hubo complicaciones mayores en el período de tiempo evaluado, y la prótesis fue capaz de reemplazar las artrodesis parciales que fallaron. Los pacientes deben ser seguidos durante más tiempo, pero con la certeza de que, en caso de fracaso, aún se puede realizar una artrodesis total de muñeca.

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.

Posttreatment Imaging of the Wrist and Hand: Update 2022

Common indications for surgical procedures of the wrist and hand include acute fractures or fracture-dislocations; nonunited fractures; posttraumatic, degenerative, and inflammatory arthritides and tendinopathies; injuries to tendons, ligaments, and the triangular fibrocartilage complex; and entrapment neuropathies. Soft tissue or osseous infections or masses may also need surgical treatment. Several of these procedures require surgical hardware placement, and most entail clinical follow-up with periodic imaging. Radiography should be the first imaging modality in the evaluation of the postoperative wrist and hand. Computed tomography, magnetic resonance imaging, diagnostic ultrasonography, and occasionally nuclear medicine studies may be performed to diagnose or better characterize suspected postoperative complications. To provide adequate evaluation of postoperative imaging of the wrist and hand, the interpreting radiologist must be familiar with the basic principles of these surgical procedures and both the imaging appearance of normal postoperative findings as well as the potential complications.

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 for Posttraumatic Wrist Osteoarthritis: A Cohort Study Comparing Three Indications

Scapholunate ligament ruptures and scaphoid nonunion with consecutive advanced collapse (SLAC and SNAC wrists) as well as intra-articular distal radius fractures (DRF) are prone to cause posttraumatic wrist osteoarthritis. The aim of this study was to compare the outcomes of these indications for total wrist arthroplasty. We included 13, 11, and 8 patients with an overall mean age of 60 ± 9 years in the SLAC, SNAC, and DRF cohort, respectively. After an average follow-up period of 6 ± 3 years, we found no difference between our groups regarding pain levels and functional scores, although these parameters significantly improved compared to preoperative parameters. Complication and revision rates revealed no significant difference. However, significantly higher extension, arc of range of motion values in the flexion-extension, as well as in radial-ulnar deviation plain were detected in the SLAC compared to the DRF group. Finally, TWA proved to show a beneficial performance in all three investigated indications.

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.

Comparative outcomes of total wrist arthrodesis for salvage of failed total wrist arthroplasty and primary wrist arthrodesis

A retrospective study compared outcomes of total wrist arthrodesis as a salvage for total wrist arthroplasty versus primary total wrist arthrodesis. Seventy-one wrists were reviewed after a minimum follow-up of 12 months. Thirty-two wrists with failed total wrist arthroplasty were converted to a wrist arthrodesis and 39 wrists received a primary wrist arthrodesis. Seven converted wrist arthrodeses and five primary arthrodeses failed to fuse. Mean patient-rated wrist and hand evaluation scores and work-related questionnaire for upper extremity disorders scores were 43 and 39 for converted total wrist arthrodesis and 38 and 33 for the primary total wrist arthrodesis. Overall, there were 25 complications in 15 patients in the converted wrist arthrodesis group and 21 complications in 16 patients after a primary wrist arthrodesis. The results between the two groups were slightly in favour of patients with a primary wrist arthrodesis. Therefore, we conclude that the timing, primary or conversion, of total wrist arthrodesis could influence patient outcomes.Level of evidence: III.

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.

Risk Factors for Infection Following Total Wrist Arthroplasty and Arthrodesis: An Analysis of 6641 Patients

Background: Infection following wrist arthroplasty (WA) or wrist fusion (WF) is an uncommon but difficult complication often resulting in explantation and prolonged courses of antibiotics. The purposes of this study are to: (1) characterize the demographic trends of individuals undergoing WA and WF; (2) determine the incidence of postoperative infection; and (3) identify risk factors for postoperative infection. Methods: The PearlDiver database was used to query 100% Medicare Standard Analytic files from 2005 to 2014. Patients undergoing WA or radiocarpal WF were identified using Current Procedural Terminology (CPT) codes. Diagnosis for infection within 1 year of operative intervention was assessed by International Classification of Diseases, Ninth Revision codes or CPT codes related to infection. Multivariable logistic regression analyses were performed to evaluate the risk factors for postoperative infection. Results: Of the 6641 patients included, 1137 (17.1%) underwent arthroplasty and 5504 (82.9%) underwent arthrodesis. Within 1 year of the index procedure, 3.5% had a diagnosis of, or procedure for, postoperative infection (WA: n = 40 of 1137; WF: n = 192 of 5504). Risk factors for infection following WA include age >85, tobacco use, depression, diabetes mellitus, and chronic kidney disease. Risk factors following radiocarpal WF include male sex, age >85, body mass index <19 kg/m², depression, diabetes mellitus, and chronic kidney disease. Posttraumatic origin of wrist arthritis was a risk factor for infection following both WA and WF. Conclusions: Infection following WA and WF is relatively uncommon in a nationally representative Medicare database cohort. Risk factors common to both WA and WF include age >85, depression, diabetes mellitus, chronic kidney disease, and posttraumatic arthritis.

Predictive value of quantitative sensory testing for acute and chronic postsurgical pain after total joint arthroplasty: a systematic review

ABSTRACT

Quantitative sensory testing (QST) can be useful to identify high-risk patients for the development of chronic postsurgical pain. This systematic review aims to assess if presurgical sensory sensitivity measured using QST is associated with acute and chronic postsurgical pain after total joint arthroplasty. A systematic search was performed in September 2020 in PubMed, EMBASE, Web of Science, and Scopus, using terms related to total joint arthroplasty and QST. Prospective studies were included if they reported an association between presurgical QST and postsurgical pain in adults with osteoarthritis undergoing primary unilateral total joint arthroplasty. From 2994 identified studies, 18 met the inclusion criteria (1869 patients). Total knee arthroplasty was the most common surgery (16 studies), and pressure pain threshold was the most common test (11 studies), followed by dynamic measures (9 studies). Postsurgical pain was assessed at acute (5 studies), subacute (2 studies), and chronic (13 studies) time points. Risk of bias was assessed using the Quality in Prognosis Studies tool and evaluated as low to moderate in most domains. Fourteen studies reported at least one statistically significant association between QST and pain (acute: 4 studies, subacute: 1 study, and chronic: 9 studies). Pressure pain threshold was associated with postsurgical pain in 6 studies (of 11, 55%), heat pain threshold in 2 studies (of 6, 33%), conditioned pain modulation in 1 study (of 6, 17%), and temporal summation of pain in 5 studies (of 8, 63%). The predictive role of presurgical QST for postarthroplasty pain remains unclear, mainly because of heterogeneous methodologies and inconsistent results.

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.

In vivo articular contact pattern of a total wrist arthroplasty design

Total wrist arthroplasty (TWA) designs suffer from relatively high complication rates when compared to other arthroplasties. Understanding the contact pattern of hip and knee replacement has improved their design and function; however, the in vivo contact pattern of TWA has not yet been examined and is thus the aim of this study. We hypothesized that the center of contact (CoC) is located at the geometric centers of the carpal component and radial component in the neutral posture and that the CoC moves along the principal arcs of curvature throughout primary anatomical motions. Wrist motion and implant kinematics of six patients with the Freedom® total wrist implant were studied during various tasks using biplanar videoradiography. The location of the CoC of the components was investigated by calculating distance fields between the articular surfaces. We found the CoC at the neutral posture was not at the geometric centers but was located 3.5 mm radially on the carpal component and 1.2 mm ulnarly on the radial component. From extension to flexion, the CoC moved 10.8 mm from dorsal to volar side on the carpal component (p < 0.0001) and 7.2 mm from volar to dorsal on the radial component (p = 0.0009). From radial to ulnar deviation, the CoC moved 12.4 mm from radial to ulnar on the carpal component (p < 0.0001), and 5.6 mm from ulnar to radial on the radial component (p = 0.009). The findings of this study may eventually improve TWA success by advancing future designs through a more accurate understating of their kinematic performance in vivo.

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.

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.

Universal 2™ total wrist arthroplasty: A single-surgeon 6.5-year follow-up study of 22 prostheses

Total wrist arthroplasty remains controversial, with the few studies undertaken being heterogeneous and having low patient numbers. This prospective study involved 22 Universal 2™ total wrist prostheses implanted by the same surgeon between 2003 and 2017. There were 13 women and nine men with an average age of 56 (42-69.5) years. Indications for total wrist arthroplasty were post-traumatic arthritis, rheumatoid arthritis and Kienböck's disease. The mean follow-up was 6.5 (3-17) years. Two failed implants required total wrist fusion. Postoperative pain, grip strength, QuickDASH, patient-rated wrist evaluation, and Mayo wrist scores improved significantly compared with preoperative scores. The prosthesis preserved equal or slightly greater range of motion than the preoperative range of motion, sufficient to undertake activities of daily living and improve quality of life. Postoperative radiographs 1 month after the surgery and then annually showed signs of bone deterioration in 64% of implants, most osteolysis without loosening, compatible with asymptomatic function. Although a high number of radiographic signs of implant changes were apparent in the midterm, 91% of prostheses are still in place. The long-term survival of this implant is uncertain. LEVEL OF EVIDENCE: Therapeutic IV.

Outcomes of Revision Total Wrist Arthroplasty

In this study, we analyzed the outcomes of revision total wrist arthroplasty done over a 40-year period. During this period, 76 consecutive revision total wrist arthroplasties were done in 69 patients with a mean age of 56 and a follow-up of 10.3 years. Patients commonly experienced pain relief, with 58 (91%) experiencing no or mild pain postoperatively. There was no statistically significant change in flexion or extension, but a statistically significant decrease in ulnar deviation and a corresponding increase in radial deviation. However, a high rate of complications and repeat revision surgery were observed. The primary indications for a repeat revision surgery were distal loosening (n = 11), proximal loosening (n = 1), deformity and pain (n = 8), periprosthetic infection (n = 3), dislocation (n = 2), subluxation (n = 1), intraoperative fracture (n = 1), and suspected metal allergy (n = 1). Complications were distal loosening (n = 15), proximal loosening (n = 3), dislocation (n = 7), intraoperative fracture (n = 7), postoperative fracture (n = 2), and component fracture (n = 3). When advising the patient, clear information must be given about the high rate of complications connected with revision arthroplasty and the risk of further revision, eventually leading to total wrist fusion.

Clinical, functional, and radiological results of the Amandys® interposition arthroplasty in 13 cases of wrist osteoarthritis

Amandys® pyrocarbon interposition arthroplasty is intended for widespread arthritis of the wrist. The aim of this study was to assess the clinical, functional, and radiological results of this arthroplasty with a minimum follow-up of 12 months. This retrospective single-center study brought together all osteoarthritis indications that can benefit from an Amandys® arthroplasty. Twenty-one implants were used between January 2011 and October 2018. There were seven cases of distal radius malunion, eight SLAC wrists, two SNAC wrists, two cases of Kienböck's disease at Lichtman's stage 4, and two aftermaths of inflammatory arthritis. Twenty-four percent of patients had previously undergone another type of surgery for this wrist arthritis. Six implants were removed, five early for dislocation and one after 6 years for chronic pain. Thirteen patients were reviewed with an average follow-up of 40.7 months (21-90). The average pain level on a visual analog scale was 3.1/10 (0-7). The mean range motion was 36° flexion (10-60) and 33° extension (15-50). The mean grip strength at the last follow-up was 14.8 kg (2-30) (43% of contralateral). The average QuickDASH and PRWE functional scores were 37.9/100 (0-80) and 29.6/100 (0-83.5), respectively. Amandys® interposition arthroplasty is an interesting alternative to total wrist fusion or total wrist prosthesis for widespread arthritis of the wrist. For the implant to be stable, the capsulo-ligamentous systems must be intact.

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.

[Revision surgery after total wrist arthroplasty]

BACKGROUND

Wrist arthroplasty is still an exceptional indication in the field of hand surgery. In recent years, it has become increasingly accepted as an alternative to wrist arthrodesis as the ultima ratio for panarthrosis or similar destruction of the wrist. In particular, the patient's desire for functional integrity also plays an important role.

COMPLICATIONS

While there were often complications with earlier prosthesis designs of the older generations and only a short survival rate could be achieved, this has improved, if the indication of the so-called fourth generation prostheses is done properly. Survival rates of over 10 years are no longer uncommon, even without revision operations. Currently, the indication for hemiarthroplasty has been increasing, particularly in the case of post-traumatic destruction. Those who are seriously interested in endoprosthesis should also be able to treat the associated complications. The present article is intended to provide an overview of common or potential complications in the context of wrist arthroplasty and to demonstrate possible solutions by presenting case studies. The basics of primary implantation are, therefore, not discussed. Reference is made to further literature.

Patient characteristics affecting knowledge of the possibility of surgical reconstruction for rheumatoid hand and wrist deformities

OBJECTIVES

We aimed to investigate patient characteristics affecting their knowledge of surgical reconstruction for rheumatoid hand and wrist deformities, and to investigate such characteristics affecting their hope of receiving hand surgery if patients with rheumatoid arthritis (RA) knew surgical reconstruction options.

METHODS

We carried out a questionnaire survey for all patients with RA who came to our outpatient department of rheumatology. Multivariate logistic regression analysis was performed to examine significant characteristics associated with the knowledge of surgical reconstruction and patients' hope of receiving hand surgery.

RESULTS

In total, 687 patients were evaluated in this study and 337 (49%) reported knowledge about surgical reconstruction. A multivariate logistic regression analysis showed that patients with good control of disease activity and with long-lasting hand and wrist deformities were significantly associated with having knowledge of surgical reconstruction. Among the 337 patients with knowledge, only 122 (36%) expressed a hope of receiving hand surgery. The statistical analysis showed that younger age and surgical history were significantly associated with the hope of receiving surgery.

CONCLUSION

Surgeons and rheumatologists should enlighten patients about the importance of hand surgery to achieve functional remission in this new era of treatment for patients with RA.

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.

Computed tomography-based three-dimensional preoperative planning for total wrist arthroplasty

Total wrist arthroplasty is indicated for severely damaged joints; however, it is sometimes difficult to place the implant in the proper position. We report a case of total wrist arthroplasty using computed tomography (CT)-based 3D planning. After a 3D digital model of the wrist was reconstructed using preoperative planning software, the computer-aided design models of the implant were superimposed on the wrist and the appropriate size and position of the implant were determined. During surgery, the planned parameters were measured using a slide gauge to reproduce the planned position of the implant. The size of the implant used at surgery was the same as in 3D planning. Comparing the CT before and after surgery, the position of the implant was almost the same as in 3D planning on the radial side, but the carpal side was placed 7 mm proximal to the position in preoperative planning. Two years after surgery, the patient had no complications and radiography showed no obvious signs of aseptic loosening. Our method may contribute to a reduced incidence of complications, such as intraoperative fracture and postoperative dislocation, leading to improve long-term outcomes of total wrist arthroplasty.

Resurfacing capitate pyrocarbon implant after proximal row carpectomy: A litterature review

Up to a decade ago, to treat patients with chronic wrist pain due to advanced stages of arthritis, surgeons had four main solutions: partial or total wrist arthrodesis, total wrist prosthesis and proximal row carpectomy (PRC). Since 2010, a new technique has been described in literature using the Resurfacing Capitate Pyrocarbon Implant (RCPI), combined to PRC. The aim of this article is to review the literature and determine the indications, outcomes and complications associated with RCPI. An electronic literature research was carried out and pertinent articles were selected. Surgical technique, results and complications described in those articles are presented. From this review of the literature, authors conclude that Resurfacing Capitate Pyrocarbon Implant can be considered as a good alternative to arthrodesis and total wrist arthroplasty, at any ages, when proximal row carpectomy alone would not be indicated.

Salvage procedure after malunited distal radius fractures and management of pain and stiffness

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

Case Report of Customized Distal Radius Prosthesis Replacement: An Alternative Treatment for Post-traumatic Unreconstructable Intraarticular Distal Radius Malunion

Severely comminuted intraarticular distal radius malunion can significantly affect a patient's quality of life. To date, there is no ideal solution. We propose customized distal radius prosthesis replacement as a treatment option. A 33-year-old policeman presented with left wrist deformity and loss of motion for five months following a distal radius fracture AO (Arbeitsgemeinschaft für Osteosynthesefragen) type-C3 which had been fixed with a volar locking plate incorporate with external fixation and Kirschner wire (K-wire) augmentation for two months. He needed to rely on wrist motion for work. Therefore, we fabricated a customized distal radius prosthesis based on his contralateral normal anatomy to replace the malunion site. The patient was satisfied and able to return to work two months after the operation. Thirty months later, the range of motion had improved from fixed 40° flexion and fixed 70° pronation deformity to 73° flexion, 79° extension, 75° supination, and 85° pronation. His DASH (Disabilities of the Arm, Shoulder, and Hand) score had improved from 80 to 14.2. His pain score, as measured by the visual analog scale, improved from eight preoperatively to two. Unreconstructable intraarticular malunion of the distal radius is a challenging problem with no treatment consensus. Customized distal radius prosthesis may provide a successful treatment option. Future research should elucidate long-term outcomes.

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

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

Functional Outcomes After Salvage Procedures for Wrist Trauma and Arthritis (Four-Corner Fusion, Proximal Row Carpectomy, Total Wrist Arthroplasty, Total Wrist Fusion, Wrist Denervation): A Review of Literature

Background:

Several salvage procedures for the arthritically destroyed wrist exist. Each of these has advantages as well as disadvantages.

Aims:

The aim of this article is to give practical insights for the clinician on: (1) biomechanical and clinical fundamentals of normal and impaired wrist motion; (2) difficulties in assessment of postoperative outcome between measured motion by the surgeon and self-reported outcome by the patient; (3) indications for each procedure; and (4) differences in functional outcome between partial and complete motion-preserving as well as complete motion-restricting salvage procedures.

Methods:

In trend, Proximal Row Carpectomy (PRC) is slightly superior over four-corner fusion (4CF) in terms of functional outcome, but the methodology-related postoperative motion is decreased for both procedures. Furthermore, PRC is easier to perform, needs lower costs, and has fewer complications than 4CF. Total Wrist Arthroplasty (TWA) has the advantage compared to PRC and 4CF that the preoperative motion values are preserved, but it is limited by decreased load-bearing capacity for the wrist. Total Wrist Fusion (TWF) is associated with a higher load-bearing capacity for the wrist than TWA, but it is limited for carrying out essential activities of daily living. Both PRC and 4CF can be combined primarily by wrist denervation. Wrist denervation alone does not impair the movement of the wrist.

Results and Conclusion:

Salvage procedures for the arthritically destroyed wrist should be detected regarding patients age- and gender-related claims in work and leisure. Not all of them can be successfully re-employed in their original occupations associated with high load-bearing conditions.

[Total wrist arthroplasty-a review]

BACKGROUND

Total wrist arthroplasty is still a rare procedure. This issue is being discussed controversially, particular in German-speaking countries. Lately, its acceptance has risen, especially as an alternative to wrist fusion regarding treatment of panarthritis or similar pathologies. Previous arthroplasty designs had short survival spans and devastating complications.

THE CURRENT SITUATION

Currently, these problems have been reduced by the development of fourth generation arthroplasty systems. Nowadays, survival spans of 10 years and more can be seen on a regular basis. The development of hemi-arthroplasty may be of interest, especially for traumatic destruction of the distal radius. This review outlines the current state of wrist arthroplasty and is based on the author's 15 years of experience.