Wrist arthroplasty using prosthesis as an alternative to arthrodesis: design, outcomes and future

Long-Term Outcomes of Wrist Arthroplasty Using the ReMotion™ Implant in Non-inflammatory Wrist Pathology

Background: Wrist arthroplasty is increasingly offered to patients with symptomatic wrist arthritis as an alternative to wrist arthrodesis. The purpose of this study was to present our outcomes with the ReMotion™ wrist arthroplasty in a consecutive series of patients with wrist arthritis from non-inflammatory conditions. Methods: Thirteen (eight women, nine dominant wrists) patients, 68 (44-85) years of age with advanced radiocarpal arthritis due to SLAC/SNAC (11) and Kienbock disease (2) had a ReMotion™ (Stryker, Michigan, USA) wrist arthroplasty implanted, and were prospectively followed for 7 (4-9) years. The outcome measures included patient-rated wrist and hand evaluation (PRWHE) score, disabilities of the arm, shoulder and hand questionnaire (QuickDASH) score, visual analogue pain score (0-10) on the radial and ulnar aspect of the wrist at rest (VASrR/VASuR) and activity (VASrA/VASuA), active wrist range of motion (AROM) including flexion, extension, ulnar and radial deviation, pronation and supination and grip and key-pinch strength measured preoperatively and at yearly follow-ups by independent hand therapists. Results: Six patients had ten re-operations during the follow-up including four revisions to a new arthroplasty. Four were considered loose at follow-up. A significant reduction in PRWHE (63 to 12), radial pain at activity (6 to 1) and increased pronation (85° v 90°) was observed. Conclusions: We found a high complication and reoperation rate, two out of 13 had no complications or reoperations. The ReMotion™ arthroplasty should be used with caution in non-inflammatory wrist patients and the patients followed closely. A high reoperation and revision rate can be expected, and surgeons familiar with revision arthroplasty procedures should perform the surgery. Level of Evidence: Level II (Therapeutic).

Total wrist arthroplasty: commentary and opinions

Total wrist arthroplasty (TWA) is gaining interest as a management option for wrist arthritis. This review article summarizes the current evidence base for TWA, focusing on the performance and survivorship of fourth-generation implants. These appear to offer satisfactory patient-reported outcomes and survivorship over the medium term, but heterogeneity between implants and patient populations complicates data interpretation. We discuss issues facing TWA practice, including surgical competency, volume, implant development and stewardship. We acknowledge the need for further research on this topic and highlight a number of questions that need answering.

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.

Impingement-related osteolysis in Motec total wrist arthroplasty: an explant analysis and review of the literature

We present five cases of osteolysis in the Motec total wrist prosthesis, three around the radial implant, one around the metacarpal implant and one around both. Three of these were progressive and required revision, and biomechanical explant analyses of these revised prostheses were performed. Ex vivo testing of the contact points of the Motec implants was also performed at maximum extension. Here, impingement occurs between the metacarpal screw and the dorsal rim of the cup (non-articulating surfaces) with the short-necked prosthesis, leading to metacarpal screw damage, titanium debris formation and osteolysis. An analysis of three previously published cases suggests that this may have been the likely mode of failure in those cases. This complication is preventable by avoiding use of the short-neck prosthesis.Level of evidence: IV.

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.

Revision of Motec Total Wrist Replacement in the Second Metacarpal

Wrist arthroplasty is becoming more commonplace, with various implant choices available. The Motec (Swemac Orthopaedics AB, Linköping, Sweden) cementless ball-and-socket system is being increasingly utilised and is designed for the distal component to be implanted into the third metacarpal. However, distal component failure is a recognised complication. We outline our experience with the revision of this component into the second metacarpal. This technical note is presented through our experience of two patients who underwent revision arthroplasty for the management of peri-prosthetic fracture of the third metacarpal. This technique has demonstrated a safe and viable solution to this complication, achieving good anatomical centre of rotation, function, range of movement and patient satisfaction. Level of Evidence: Level V (Therapeutic).

Long-term outcomes of the Universal 2 total wrist replacement: revision and loosening at 10 years and beyond

The aim of this study was to ascertain the long-term revision rates of the Universal 2 wrist prosthesis in a previously published cohort of patients with rheumatoid arthritis. The time to, and reasons for revision were determined. Radiographs were analysed to determine whether loosening had occurred in the long-term according to the Wrightington zonal classification of loosening. Seventy-eight wrists from the original cohort of 85 wrists could be identified for analysis. The longest follow-up was 16 years and 29 wrists had follow-up beyond 10 years. Seventeen wrists had been revised or were on the waiting list for revision, an overall revision rate of 22%. The 10-year survivorship was 78%. Long-term revision was commonly for periprosthetic loosening with pain and component subsidence. In those with more than 10-year follow-up, significant lucency was seen in 16 carpal components and 15 radial components. Explant analysis showed significant polyethylene wear and we postulate this is the principal reason for component loosening.Level of evidence: IV.

3D-planned corrective osteotomy of metacarpal arch disruption after Motec® wrist prosthesis

We report two cases of metacarpal arch disruption after Motec® total wrist arthroplasty, with hyperextension of the third metacarpal and dorsal protrusion of the head. Correction osteotomies of the adjacent metacarpals using preoperative 3D surgical planning were successful. This report seeks to shed light on the origin of this deformation and to recommend some operative precautions. It is important that surgeons should be aware of the existence of this complication, as disruption of the transverse metacarpal arch affects both grasp and hand esthetics. LEVEL OF EVIDENCE: IV.

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.

15-20 Year Follow-up After Wrist Arthroplasty Surgery - Revisiting the Development and Introduction of a New Prototype Concept for Total Wrist Arthroplasty

Background: Wrist arthroplasties have not achieved clinical outcomes comparable to those of shoulders and knees, being offered low-demand patients due to a high failure rate. In the 90s, there were no wrist arthroplasties available for high-demand patients. An experimental setup for the development of a new wrist arthroplasty intended for all wrist patients were done. A long-term final follow-up to evaluate the performance of the experimental arthroplasty was performed. Methods: A novel uncemented modular wrist prosthesis with conical threaded fixation, metal-on-metal coupling and ball-and-socket articulation was developed. In an experimental study, eight patients (7 men, 53 years of age) were operated between 2001 and 2003, to treat non-inflammatory primary or secondary osteoarthritis. Published mid-term results (7-9 years) demonstrated satisfactory function, but two arthroplasties were converted to arthrodesis due to infection. Results: At final follow-up 15-20 years after primary surgery, the remaining six patients still had a wrist arthroplasty (in three the original) in situ. The clinical results were good. Low pain (median = 0), Quick Disability of Arm, Shoulder and Hand (QDASH median 11) and Patient Rated Wrist and Hand Evaluation (PRWHE median = 14) scores were reported. Wrist active range of motion (AROM) was 64% and grip strength 86% compared to the opposite side. None regretted choosing arthroplasty knowing the outcome. Conclusions: Despite technical errors and the implementation of an incomplete prototype, this new concept for arthroplasty has demonstrated promising long-term fixation, a stable articulation with good range of motion, satisfactory function and pain reduction in high-demand patients. Level of Evidence: Level IV (Therapeutic).

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.

Fourth-Generation Total Wrist Arthroplasty: A Systematic Review of Clinical Outcomes

Background  The purpose of total wrist arthroplasty is to reduce pain and maintain mobility in a painful destructed wrist. First-, second-, and third-generation total wrist arthroplasties have shown unacceptable outcomes with high failure rates. In 2004, the fourth-generation total wrist implants were introduced to address the clinical problems encountered in the previous generations of total wrist implants. Methods  Outcomes and complications of fourth-generation total wrist implants were systematically reviewed in the literature (2004-present), including the Universal 2, ReMotion, Freedom, Motec, and Maestro total wrist implants. Results  The literature search yielded 114 papers, of which 18 (990 implants) were included in this systematic review. The quality of evidence was low. All implants effectively reduced pain and improved functionality of the wrist. The Motec wrist implant demonstrated the highest survival rate at 10 year follow-up (86%). Conclusion  This systematic review suggests a substantial improvement of quality in fourth-generation total wrist arthroplasty.

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.

Surgery with the Motec total wrist replacement: learning from earlier designs

The design of and applications for wrist arthroplasty continue to evolve but lag behind the results for hip and knee arthroplasty with respect to demonstrable durability and effectiveness. As we develop our knowledge, experience and the indications for wrist replacement surgery, it is important that we learn from past design and surgical experience. We report the case of a female patient treated with a Motec cementless metal-on-metal wrist replacement (Swemac Orthopaedics AB, Linköping, Sweden) for post-traumatic arthritis of the radiocarpal joint. Based on our experience with this case and others, we make two specific technical recommendations to improve the success and longevity of this implant.

[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.

Proximal-distal shift of the center of rotation in a total wrist arthroplasty is more than twice of the healthy wrist

Reproduction of healthy wrist biomechanics should minimize the abnormal joint forces that could potentially result in the failure of a total wrist arthroplasty (TWA). To date, the in vivo kinematics of TWA have not been measured and it is unknown if TWA preserves healthy wrist kinematics. Therefore, the purpose of this in vivo study was to determine the center of rotation (COR) for a current TWA design and to compare its location to the healthy wrist. The wrist COR for six patients with TWA and 10 healthy subjects were calculated using biplane videoradiography as the subjects performed various range-of-motion and functional tasks that included coupled wrist motions. An open-source registration software, Autoscoper, was used for model-based tracking and kinematics analysis. It was demonstrated that the COR was located near the centers of curvatures of the carpal component for the anatomical motions of flexion-extension and radial-ulnar deviation. When compared to healthy wrists, the COR of TWAs was located more distal in both pure radial deviation (P < .0001) and pure ulnar deviation (P = .07), while there was no difference in its location in pure flexion or extension (P = .99). Across all coupled motions, the TWA's COR shifted more than two times that of the healthy wrists in the proximal-distal direction (17.1 vs 7.2 mm). We postulate that the mismatch in the COR location and behavior may be associated with increased loading of the TWA components, leading to an increase in the risk of component and/or interface failure.

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.

My personal experience with arthroplasties in the hand and wrist over the past four decades

I summarize my changing views and practices of arthroplasty in hand surgery over the past four decades. I recommend simple resection of the trapeziectomy for advanced arthritis of the first carpometacarpal joint, silicone implants for the metacarpophalangeal joints and the proximal interphalangeal joints, and the total wrist arthroplasty for advanced wrist arthritis and collapse. I also outline technical tips of these procedures.