Total Wrist Arthroplasty

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

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

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Strain shielding in distal radius after wrist arthroplasty with a current generation implant: An in vitro analysis

A systematic review of peer reviewed articles has shown that the main cause for wrist arthroplasty revision is carpal and radial prosthetic loosening and instability. To improve arthroplasty outcomes, successive generations of implants have been developed over time. The problem with the current generation of implants is the lack of long-term outcomes data. The aim of the present work was to test the hypothesis that the current generation Maestro WRS implant has a stress, strain and stability behaviour which may be associated with a reduced risk of long-term radial component loosening. This study was performed using synthetic radii to experimentally predict the cortex strain behaviour and implant stability considering different load conditions for both intact and implanted conditions. Finite element models were developed to assess the structural behaviour of cancellous-bone and bone-cement, these models were validated against experimentally measured cortex strains. Measured cortex strains showed a significant reduction between intact and implanted states. Cancellous bone adjacent to the radial body component suffers a two to threefold strain reduction, comparing with the intact condition, while along the radial stem, in the axial direction, a strain increase was observed. It is concluded that the use of contemporary Maestro WRS implant changes the biomechanical behaviour of the radius and is associated with a potential risk of bone resorption by stress-shielding in the distal radius region for wrist loads in the range of daily activities.

An Unusual and Complicated Course of a Giant Cell Tumor of the Capitate Bone

A 51-year-old female patient presented with a carpal giant cell tumor (GCT) of the right capitate bone. The lesion was initially misdiagnosed as having an osteomyelitis. First, the diagnosis of a benign GCT was confirmed by histological examination. Second, an intralesional curettage and packing of the cavity with cancellous iliac crest bone grafts combined with a fusion of the third carpometacarpal (CMC III) joint were carried out. Third, due to a secondary midcarpal osteoarthritis and a secondary scaphoid nonunion, the CMC III joint fusion plate was removed and the midcarpal joint completely excised. Fourth, in the absence of recurrence of GCT, a four-corner fusion (4CF) with a corticocancellous iliac crest bone graft and complete excision of the scaphoid bone had to be performed. Fifth, a total wrist arthroplasty (TWA) was performed due to hardware failure of 4CF with migration of a headless compression screw into radiocarpal joint which led to erosion of articular surface of the distal radius. At the 3-year follow-up that includes a 1-year follow-up after TWA, there was no recurrence of GCT, and the TWA was not failed. The patient reported that she would have the motion-preserving TWA again.

Prosthetic Design in Total Wrist Arthroplasty

Total wrist arthroplasty (TWA) provides a motion-preserving alternative to total wrist arthrodesis for low-demand patients with debilitating pancarpal arthritis. The earlier generation total wrist implants had high complication and failure rates. Advances in prosthetic design have contributed to improved clinical outcomes and implant survivorship. The current fourth-generation implants allow for expansion of indications for TWA. Careful patient selection remains critical; patients with high-demand lifestyles and poor bone stock may not be candidates. Long-term studies on implant survival and patient outcomes are critical for the current generation total wrist implants in assessing their long-term value compared with total wrist arthrodesis.

Can Total Wrist Arthroplasty Be an Option for Treatment of Highly Comminuted Distal Radius Fracture in Selected Patients? Preliminary Experience with Two Cases

We present two case reports of successful primary shortening of the forearm and total wrist arthroplasty (TWA) using the new angle-stable Maestro Wrist Reconstructive System (WRS) for treatment of highly comminuted distal radius fracture in selected autonomous patients. In a 56-year-old male patient with adequate bone stock, insertion of the noncemented Maestro WRS was combined with ulnar shortening osteotomy. In an 84-year-old female patient with poor osteoporotic bone stock, insertion of the radial cemented Maestro WRS was combined with ulnar head resection. Both patients could resume their work without additional surgery after TWA. At the 1-year follow-up, there were no changes in position of either implant without signs of loosening, no impingement, and no instability of the distal radioulnar joint or the distal ulna stump. All clinical parameters (DASH score, pain through VAS, and grip strength) were satisfactory. Both patients reported that they would have the same procedure again. Further experience is needed to validate this concept.

Wrist arthroplasty: where do we stand today? A review of historic and contemporary designs

Earlier generations of wrist arthroplasty were limited to low demand patients. Bone fixation problems, excessive wear, and adverse designs resulting in loosening, imbalance, and dislocation led to the withdrawal of a number of models. Contemporary wrist prostheses aim at replacing wrist arthrodesis in the majority of patients with radiocarpal destruction, including high demand cases. Contraindications are wrist imbalance, insufficient soft tissue, or bone stock and infection. Various designs, fixation principles, bearing materials, and articulations have been employed. Some of the devises (RE-MOTION™, Motec(®)) demonstrate promising short- to midterm results, and calls for cautious optimism.

Clinical outcomes of total wrist arthroplasty

PURPOSE

Current indications for total wrist arthroplasty include patients with symptomatic end stage posttraumatic wrist arthritis, rheumatoid arthritis, and Kienböck disease, as an alternative to wrist arthrodesis. Arthroplasty may have advantage over arthrodesis because of the ability to retain motion. The purpose of this study was to evaluate the short-term clinical outcomes and complications of the Maestro Total Wrist System.

METHODS

We report the results of a retrospective review of 23 total wrist prostheses implanted in 22 patients. We administered the visual analog pain scale and Mayo wrist and Disabilities of the Arm, Shoulder, and Hand questionnaires. We reviewed wrist motion, grip strength, radiographs, and complications.

RESULTS

At a mean follow-up of 28 months (range, 4-55 mo), the Disabilities of the Arm, Shoulder, and Hand score and Mayo wrist score were 31 and 54, respectively. Mean pain scores improved from 8.0 to 2.2. The mean wrist flexion-extension arc was 90°. Radiographs revealed no evidence of prosthetic loosening. Grip strength averaged 60% of the strength of the opposite hand. Complications occurred in 7 of 23 patients. One failure occurred as a result of deep infection in a patient with prior intercarpal fusion, and was successfully converted to a wrist fusion.

CONCLUSIONS

Total wrist arthroplasty performed for pancarpal arthritis as an alternative to wrist arthrodesis can yield successful outcomes with low short-term failure rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.