Total Wrist Arthroplasty

Periprosthetic radiolucency in total wrist arthroplasty: a radiographic study

This retrospective study investigates the incidences of periprosthetic radiolucency and the position of the prosthesis in patients who underwent total wrist arthroplasty. A total of 50 patients with a mean age of 58 years (SD 11) were included. The available dorsopalmar and lateral radiographs were categorized into the following groups: immediately postoperative and 1, 2, 3, 5 and beyond 6 years postoperatively. The findings of this study indicate that periprosthetic radiolucency is a progressive phenomenon that originates at the bone adjacent to the joint line, possibly due to stress shielding. The size of the periprosthetic radiolucency showed no correlation with any clinical parameter, nor can its size be predicted by intraoperative implant positioning. However, a significant correlation was observed between a reduced implant-middle finger carpometacarpal distance and higher postoperative pain levels as well as patient dissatisfaction. Revision surgery after total wrist arthroplasty should not be solely guided by radiological signs of periprosthetic radiolucency. Instead, this study suggests that consideration for revision surgery should be reserved for symptomatic patients experiencing persistent pain and swelling accompanied by radiographic evidence of carpal implant subsidence.Level of evidence: IV.

A Changing Landscape in the Surgical Management of Wrist Arthritis: An Analysis of National Trends From 2009 to 2019

PURPOSE

The purpose of this study was to analyze the trends in the annual volume and incidence of proximal row carpectomy (PRC), four-corner fusion (4CF), total wrist arthrodesis (TWF), and total wrist arthroplasty (TWA) from 2009 to 2019 in the United States.

METHODS

The IBM Watson Health MarketScan databases were queried to identify annual case volumes for PRC, 4CF, TWF, and TWA from 2009 to 2019. The annual incidence of these procedures was then calculated based on the population estimates from the US Census Bureau. Trends in annual volume and incidence over the study period were evaluated using regression line analysis. Further subgroup analysis was conducted based on age and region.

RESULTS

From 2009 to 2019, the total case volumes for the four procedures increased by 3.4%, but the incidence decreased by 2.8%. However, PRC case volume and incidence trends significantly increased (38.2% and 29.7%, respectively), whereas 4CF remained constant. Conversely, the case volume and incidence of TWA significantly decreased (-52.2% and -54.5%, respectively), whereas TWF remained constant. When stratified by age, all four procedures decreased in the <45-year-old cohort (combined -35.1%) significantly for 4CF, TWF, and TWA. TWA decreased significantly in the <45-year-old and 45- to 65-year-old cohorts (53.6% and 63.2%, respectively). For age >65 years, the total case incidence increased by 98.9%, including a significant positive trend in TWF (175%).

CONCLUSIONS

Surgical management of wrist arthritis remains a controversial issue. However, PRC has gained recent support in the literature, and our results reflect this shift, even for the <45-year-old cohort. Furthermore, TWA declined, despite reports of positive early outcomes for fourth-generation implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Fabricating Stiffness-Matched Three Dimensional -Printed Metal Implants for Total Wrist Arthroplasty

BACKGROUND

Total wrist arthroplasty (TWA) is a motion-sparing treatment for pancarpal arthritis; however, complication rates up to 50% have limited widespread use. Implant micromotion, stress shielding, and periprosthetic osteolysis result in implant failure and revision to arthrodesis. Metal 3-dimensional (3D) printing allows for more accurate matching of surrounding bone biomechanical properties, theoretically reducing periprosthetic osteolysis. Herein, we use computed tomography to characterize the relationship of relative stiffness along the length of the distal radius with patient demographic factors.

METHODS

After institutional review, wrist computed tomography scans at a single institution between 2013 and 2021 were identified. Exclusion criteria were history of radius or carpal trauma or fracture. Collected demographics included age, sex, and comorbidities (including osteoporosis/osteopenia). Scans were analyzed using Materialize Mimics Innovation Suite 24.0 (Leuven, Belgium). Distal radius cortical density (in Hounsfield units) and medullary volume (in cubic millimeters) with relation to distance from the radiocarpal joint were recorded. Average values for each variable were used to 3D-printed distal radius trial components with stiffness matched to bone density by length.

RESULTS

Thirty-two patients met inclusion criteria. Distal radius cortical bone density progressively increased proximal to the radiocarpal joint, whereas medullary volume decreased; changes in both plateaued 20 mm proximal to the joint. Distal radius material properties differed by age, sex, and comorbidities. Total wrist arthroplasty implants were fabricated to match these variables as proof of concept.

CONCLUSIONS

Distal radius material properties vary along the bone length; conventional implants do not account for this variance. This study showed 3D-printed implants can be created to match bone properties along the length of the implant.

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.

A systematic review on the management of idiopathic avascular necrosis of the scaphoid (Preiser's disease)

BACKGROUND

Treatment options for patients with Preiser's disease are challenging and varied. This article thus provides a systematic review of existing studies on the outcomes of the treatments for patients suffering from Preiser's disease in order to investigate the most appropriate management of Preiser's in each stage of the disease.

METHODS

We followed PRISMA guidelines while performing the study, and reviewed 107 papers in all languages from 1981 till November 2020 and included 42 studies that met the eligibility criterion. Studies investigating the outcome of one or more treatment options for Preiser's disease were eligible. Besides, quantitative analysis on 130 individuals (135 wrists) of the included studies was performed.

RESULTS

The results show that in stages II and III, pain score reduces more in surgical approach than in conservative treatment. In stage II of the Preiser's, Vascularized Bone Grafting (VBG) was more effective in pain alleviation and improvement in wrist range of motion (ROM) and Mayo Modified Wrist Score (MMWS) than immobilization. Proximal Row Carpectomy (PRC) in stage III causes more pain relief and ROM improvement than VBG and conservative treatments like prescribing NSAIDs. Inconsistent evidence was found in case studies of stage IV; however, they generally favour PRC and SILASTIC implants. Surgical studies of stage I are not yet enough for making a conclusive assessment.

CONCLUSION

Surgical treatment outcomes seem more satisfactory in all Preiser's disease stages. Specifically, VBG for patients of stage II provided they have no scaphoid degenerative changes, and PRC seems more satisfactory for stage III.

LEVEL OF EVIDENCE

IV; systematic review of case reports and case series on Preiser's disease.

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.

A "Congenitally Adapted" TFCC Tear in Radial Longitudinal Deficiency: Case Report and Review of Literature

We present a case of chronic wrist pain in a 14-year-old child with mild radial longitudinal deficiency and radiographic carpal collapse due to the absence of the scaphoid. Wrist arthroscopy demonstrated synovitis and a tear to the TFCC, which would be called "degenerative," according to the Palmer classification. This was debrided, and the patient is still asymptomatic at long-term follow-up. Review of the literature found one paper with a similar observation in a 17-year-old adolescent. We propose that paediatric "degenerative" tears ought to be called "congenitally adapted" tears.

Pseudotumor after Total Wrist Arthroplasty Mimicking a Neoplasm

Background  Total wrist arthroplasty can lead to a variation of complications. One of these is the formation of a pseudotumor. Although this complication is well known after total hip arthroplasty, it is rare in patients with wrist implants. Case Description  A 55-year-old man with a Universal 2 (Integra, Plainsboro, NJ) wrist prosthesis was seen with a progressive mass on the radial side of his wrist since 1 year, initially suspicious for a neoplasm. However, after exploration, histopathology confirmed a particle-induced foreign body reaction. Literature Review  There is little literature on pseudotumor formation after total wrist arthroplasty. Currently, there is no clear consensus about the etiology of pseudotumors but possible causes may include foreign body reaction, hypersensitivity, and wear debris. Clinical Relevance  This case report shows that particle debris-induced pseudotumors should be considered when a patient with a wrist prosthesis presents with a mass suspicious for a neoplasm. In addition, treatment options of pseudotumors after wrist arthroplasty in literature is discussed.

Correlation between carpal rotational alignment and postoperative wrist range of motion following total wrist arthroplasty

BACKGROUND

Although total wrist arthroplasty (TWA) has become a common treatment option for wrists with damage due to rheumatoid arthritis (RA), the optimal implant axial alignment for TWA has been inadequately studied. This study was performed to investigate the relationships between implant alignment and carpal rotational alignment and the wrist range of motion (ROM) following TWA.

METHODS

This study included 18 patients who underwent TWA using a DARTS® Total Wrist System (Teijin Nakashima Medical, Okayama, Japan) for wrist RA. Pre- and 6-month postoperative computed tomography scans were performed, including the radial volar line (Rv), capitohamate axis (CH), and Rv-CH angle in axial scans. The wrist ROM was also measured. The relationship between the Rv-CH angle and ROM was examined.

RESULTS

The mean Rv-CH angle showed significant wrist pronation from 73.0° to 83.4° postoperatively. We observed a significant positive correlation (0.58) between the postoperative Rv-CH angle and extension and a significant negative correlation (- 0.56) between the postoperative Rv-CH angle and flexion.

CONCLUSIONS

Implantation of the DARTS® TWA prosthesis resulted in pronation of the carpal axial alignment, which was correlated with postoperative wrist extension. The volar cortex of the distal radius can be a novel reference axis for adequate implant placement.

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.

Surgical Treatment of Wrist Arthritis in Young Patients

Surgical treatment of wrist arthritis in the younger patient population remains a challenging issue, and various surgical options need to be carefully considered for each patient. Proximal row carpectomy and 4-corner arthrodesis have proven to be reliable options for reducing pain and restoring adequate function in most young high-demand patients if the lunate facet is spared. Selective neurectomy has proven to be a promising stand-alone or complementary procedure for the treatment of pain that is associated with wrist arthritis in patients of all ages, with spared motion and the opportunity to perform additional procedures if pain continues. Alternative procedures, including capitolunate arthrodesis, total wrist arthrodesis, radial styloidectomy, total wrist arthroplasty, and wrist hemiarthroplasty, have considerable strengths and weaknesses and need to be studied further in younger patients.

A Systematic Review of Radiolunate and Radioscapholunate Arthrodesis

Purpose

The aims of this systematic review were to examine the use of radiolunate (RL) or radioscapholunate (RSL) arthrodesis as surgical management for patients with advanced radiocarpal arthritis that failed conservative management and to assess postoperative outcomes.

Methods

We reviewed articles from PubMed, EMBASE, and Web of Science from inception through December 2019. We identified complete manuscripts written in English reporting on RL or RSL arthrodesis for treatment of wrist pathology that included the primary outcomes (pain or grip strength) and at least 2 secondary outcomes (range of motion, patient-reported outcomes, or nonunion). Data pooling was used to calculate weighted averages.

Results

We identified 2,252 articles and selected 13 for inclusion. Across all studies, RSL arthrodesis was performed for 180 patients (49% female; 45 years old) and RL for 94 (87% female; 50 years old). Both procedures exhibited improvements in pain score and grip strength. Both cohorts demonstrated postoperative changes in flexion-extension arc, flexion, extension, ulnar deviation, supination, and pronation after data pooling. The nonunion rate for RSL was 15% versus 2% for RL, whereas the rate of progression to total wrist arthrodesis for RSL and RL was 4% and 0%, respectively.

Conclusions

Both RL and RSL arthrodesis can be successfully used to manage debilitating radiocarpal arthritis by affording patients with pain reduction. Each has its own benefits, in which RSL arthrodesis provides a total arc of motion within the functional demands of most activities of daily living, and RL arthrodesis has low rates of nonunion and progression to total wrist arthrodesis. Further research is needed to compare the 2 surgeries directly and prospectively in comparable patient groups.

Type of study/level of evidence

Therapeutic III.