- Indications:
- painful or unstable wrist joint w/ advanced destruction due to OA,
RA, post traumatic arthritis,
SLAC wrist,
spastic flexion contracture, degenerative scaphoid non-union, unsuccessful wrist arthroplasty, and
Keinbock's dz;
- this procedure is more beneficial for young, active pts or middle aged pts, but not for elderly pts;
- PreOp Considerations:
- in the
rheumatoid wrist note that application of a dorsal plate increases the chances of dorsal wound dehiscence;
-
ulnocarpal impaction
- if preoperative radiographs demonstrate abutment between between the distal ulna and the triquetrum in addition to loss
of supination, then consider the need for radial lengtening w/ bone graft;
-
bone grafting:
- cancellous bone grafting (iliac or local) is sufficient when there is no significant loss of carpal bone stock nor cyst formation;
- cortico-cancellous bone grafting may be indicated w/ severe bone resorption or significant cyst formation (however,
complication rate is higher);
- ROM of other joints:
- remember that the elbow and shoulder joints will have to compensate for loss of wrist motion;
- Dorsal Approach to the Wrist:
- w/ severe deformity, consider wider exposure to the
first dorsal compartment inorder to allow excision of the radial styloid;
- individual carpal bones and distal radius are exposed w/ wrist hyperflexion;
- articular cartilage is removed w/ rongeur;
-
proximal row carpectomy:
- consider performing a proximal row carpectomy procedure so that the proximal capitate and hamate are fused
into the distal radial surface;
- the proximal row carpectomy is especially indicated for patients with ulnar positive varience, because it eliminates the
common occurence of ulnotriquetral impingement following arthrodesis;
- after proximal carpal row is excised, the carpi can be used as bone graft;
- the standard fusion technique then procedes on, using the standard fusion plate;
- references:
- Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis.
DS Louiset al.
J. Hand Surg. Vol 9-A. 1984. p 365-369.
- Wrist arthrodesis in post traumatic arthritis: a comparison of two methods.
LE Bolano et al.
J. Hand Surg. Vol 18-A. 1993. p 786-791.
-
fusion:
- most surgeons prefer not to fuse the index CMC joint;
- whether to fuse the long CMC joint remains controversial (sparing the joint allows it to participate in power grip);
- ref:
AO-wrist arthrodesis: With and without arthrodesis of the third carpometacarpal joint
-
intrinsic compartment release:
- it has been observed that intrinsic tightness in the of the index and long digits is a frequent complication of wrist fusion, and
may be related to occult compartment syndrome;
- to manage this potential problem, consider releasing the dorsal fascial compartments;
-
ulnar head:
- in RA consider resection of the ulnar head, and then using it for bone graft;
- Position of Arthrodesis:
- w/ non RA wrist, 10 deg of dorsiflexion is ideal because its allows position for power gripping;
- maximum grip is generated in 35 deg of dorsiflexion but this interferes with ADL's;
- in pts w/
RA (see
RA wrist), neutral or flexed position is more desirable;
- in frontal plane, position of 5-10 deg of ulnar deviation is perferred in order to counter balance zig zag collapse and
ulnar drift;
- note that despite the usual recommendations, some patients will prefer slightly more flexion or extension in the wrist;
- if possible, consider casting the wrist before surgery in extension and the neurtral position to determine
which position is more comfortable for the patient;
- references:
- The relationship between wrist position, grasp size, and grip strength. SW O'Driscoll et al.
J. Hand Surg. Vol 17-A. 1992. p 169-177.
- Methods of Fixation:
-
pin Fixation:
- in the report by DC Rehak et al (Orthopedics. Jan 2000. Vol 23. No 1. p 43), the authors compared use of pin fixation vs 3.5 mm reconstruction plate;
- wrists showed a tendency for migration into volar flexion (3-6 deg) from the initial intra-operative position;
-
3.5 mm reconstruction plate:
- in the report by DC Rehak et al (Orthopedics. Jan 2000. Vol 23. No 1. p 43), the authors compared use of pin fixation vs 3.5 mm reconstruction plate;
- technique involved placement of the extensor retinaculum beneath the extensor tendons;
- 3-4 screws are placed in the distal radius and two screws are placed in the metacarpal, and if possible one screw in the capitate;
- wrists had an average 5 deg of extension and 5 deg of ulnar deviation;
-
synthes plate:
- 8 hole titanium, w/ 2.7 mm screws inserted into the distal 4 holes, and 3.5 mm holes in the proximal 4 holes;
- in order to have the wrist in 10 deg of dorsiflexion, a contoured plate is necessary;
- often the dorsal articular lip will have to be sculpted and Lister's tubercle will have to be removed inorder to achieve
a flat bed for the plate;
- most often the plate is applied to the long metacarpal so that 3 cortical screws can be inserted into the
metacarpal and 4 screws in the radius (often a screw will also be inserted into the capitate)
- in some cases, the plate will be attached to the index metacarpal, if this optimizes the wrist position (for
ulnar deviation) or if it optimizes plate fit;
- in some cases, the plate must be placed obliquely across the dorsal radial surface inorder to get the optimal
amount of ulnar deviation;
- Wound Closure:
- consider detaching the ECRB insertion and then moblizing it over the plate and incorporating it into the capsular
closure (this may help prevent wound dehicience;
- Post Op:
- Volar Splint for 2 weeks;
- unionn is usually achieved by 3 months;
- plate is not removed unless it causes symptoms;
- Case Example:
- Complications:
- extensor tenosynovitis most common complication and is related to prominent plate and screws;
- intrinsic contracture;
- carpal tunnel syndrome;
- non union of the CMC joint;
-
RU joint instability:
- ulno-carpal abutment:
- references:
- Ulno-carpal abutment after wrist arthrodesis.
TE Trumble et al.
J. Hand Surg. Vol 13. p 11-15. 1988.
Wrist arthrodesis in paralyzed arms of children.
Wrist arthrodesis in rheumatoid arthritis. A comparison of two methods of fusion.
An in vitro analysis of wrist motion: the effect of limited intercarpal arthrodesis and the contributions of the radiocarpal and midcarpal joints.
Arthrodesis of the Wrist for Post Traumatic Disorders.
H. Hastings MD, A.C. Weiss MD, D. Quener MD, G.P. Wiedeman MD, K.R. Hanington MD, and J.W. Strickaland MD. JBJS Vol 78-A, No 6. June 1996.
Complications following AO/ASIF wrist arthrodesis.
SV Zachary and PJ Stern.
J. Hand Surg. Vol 20-A. 1995. p 339-344.
Long-Term Follow-Up Study of Radiocarpal Arthrodesis for the Rheumatoid Wrist.
