Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

331. Complete Wrist Arthrodesis

John C. Elfar and Andrew D. Markiewitz

DEFINITION

images Wrist arthritis occurs when the codependent joints of the wrist lose the ability to rotate, thereby impairing normal wrist kinematics.

images Wrist arthritis can originate from many causes, including osteoarthritis, degenerative arthritis, and inflammatory arthritis.

images While sacrificing motion at the wrist, arthrodesis has been shown to reliably relieve pain.

ANATOMY

images The wrist is perhaps the most complex set of joints in the body.

images The eight bones of the wrist work together to provide motion in multiple planes, governed by the complex array of soft tissue ligaments that unite them.

images Single ligament disruptions can cause degenerative change in nonadjacent bones and at times unlikely sites.

images In broad terms, the wrist is divided into two distinct rows of bones.

images The distal row, including the trapezium, trapezoid, capitate, and hamate, is united to the hand and shows little gross motion relative to the metacarpals.

images As such, the most significant articulations in the wrist occur in the proximal row bones, which are the scaphoid, lunate, and triquetrum. These proximal row bones allow the wrist to flex, extend, deviate both radially and ulnarly, and pronosupinate.

PATHOGENESIS

images Because of the many possible routes to the eventual destruction of the wrist joint, it is difficult to describe a single chain of events that leads to end-stage arthritis, most suitably treated by complete wrist fusion.

NATURAL HISTORY

images Causes of wrist degeneration and the often-predictable pattern and pace of wear are detailed in other chapters.

PATIENT HISTORY AND PHYSICAL FINDINGS

images Patients describe pain and stiffness as their major reasons for presentation. Pain limits their function and their strength.

images Most patients are less concerned with motion loss if their dominant extremity is not involved.

images If their dominant wrist is involved, patients prefer to preserve some motion even if faced with low-grade persistent pain after treatment. In this clinical setting complete wrist fusions are less often performed as the index operation.

images Physical examination findings include tenderness, soft tissue swelling, loss of motion, and pain with motion. Pinch and grip strength are reduced compared with age-matched peers and the uninvolved contralateral extremity.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Wrist arthritis is best studied with standard posteroanterior and lateral radiographs of the wrist.

images These images often reveal the cause of the degeneration together with its pattern and progression.

images Special attention is paid to the alignment of the wrist and the bone stock available for fusion and fixation.

images Computed tomography helps plan limited fusions or salvage procedures when arthritis may have spared areas of the midcarpal or proximal carpal rows.

DIFFERENTIAL DIAGNOSIS

images Limited wrist arthritis

images Extrinsic joint contracture (including calcific tendinitis)

images Inflammatory arthritis and synovitis (ie, rheumatoid, gout, or pseudogout)

images Infection

images Connective tissue diseases

NONOPERATIVE MANAGEMENT

images In most every case, the first form of treatment for wrist arthritis is nonoperative:

images Nonsteroidal anti-inflammatory medications (NSAIDs)

images Disease-modifying medications (if the cause of the degenerative process can be identified and is appropriate)

images Splinting

images A custom-made thumb spica splint allows interphalangeal motion of the thumb but limits painful wrist motion.

images Local steroid injections placed in the wrist

SURGICAL MANAGEMENT

images Alternative motion-sparing procedures, including partial wrist fusions and proximal row carpectomy, should be considered before performing a complete wrist fusion, especially in patients who have at least 60 degrees of wrist flexion–extension and have isolated articular degeneration.

images Wrist arthroplasty remains in its infancy and is associated with high revision rates and frequent implant design changes.

images Wrist arthrodesis after arthroplasty is more difficult due to bone stock loss.

images Wrist arthrodesis is the final treatment method for end-stage wrist degeneration due to multiple causes or as a salvage procedure in patients who have failed the more limited procedures mentioned above.

images Arthrodesis can be obtained reliably and provides a stable wrist in a high-demand patient.1,2,11,13

images In patients who have undergone lower extremity joint replacements and therefore require support for ambulation, fusion of the wrist is generally regarded as a reliable procedure.

images The two most popular methods used to fuse a wrist are plate osteosynthesis and rod osteosynthesis.2,8,13

images The chief considerations when choosing between these two options are the desired position of fusion, the quality of the bone and available soft tissue coverage, and the possibility of future infection.

images The strongest grip is achieved when the wrist is fused in 20 to 30 degrees of extension. Advocates of fusion in this position favor the use of a plate and screw construct that is fabricated to reproduce this position.2,4,14 Straight wrist fusion plates are also available, and all these devices include screws and plates that match the size of the radius and the metacarpal.

images A neutral wrist position obtained with rod osteosynthesis may be more favorable for activities of daily living, including perineal care.2,3,5,11

images Plate and screw constructs rely on solid screw purchase and stable soft tissue coverage. If good-quality bone and viable soft tissues are not present, as might be the case in a patient with severe rheumatoid disease, intramedullary rod fixation may be a more effective means of fixation.

images In patients taking aggressive disease-remitting medications, the possibility of late infection should be considered. These patients may benefit from metal removal, which is often more easily accomplished after rod osteosynthesis.

Preoperative Planning

images While the use of aspirin may be continued, warfarin (Coumadin) and clopidogrel (Plavix) should be discontinued to avoid bleeding and flap complications.

images Radiographs should be reviewed before performing a wrist arthrodesis. Specific attention should be paid to the amount of available bone stock and the bony alignment.

images Intraoperative evaluation will require a fluoroscopic device. Appropriate alignment, reduction, and implant length should be confirmed before closure.

Positioning

images Patients are placed supine with the operative hand extended on a hand table extension.

images A tourniquet is applied to the proximal arm over padding.

images Before anesthesia is induced, the patient's comfortable shoulder position should be assessed. The armboard should not place the shoulder above this position. This test is especially important in rheumatoid patients with limited joint mobility.

Approach

images Both arthrodesis procedures are performed through a standard dorsal approach to the wrist.1214 A longitudinal midline dorsal incision ulnar to the tubercle of Lister is used.

images The extensor pollicis longus tendon is released from its sheath and retracted radially.12

images The fourth extensor compartment is subperiosteally elevated from the dorsum of the distal radius and retracted ulnarly.

images The posterior interosseous nerve can be dissected free and excised.

images The dorsal capsule is incised in line with the skin incision and elevated off the carpus.12

images This exposure allows for performance of concomitant procedures such as a distal ulna excision and dorsal tenosynovectomy.

TECHNIQUES

PLATE AND SCREW OSTEOSYNTHESIS

images In addition to the approach described above, the proximal portion of the third metacarpal is exposed subperiosteally.

images Expose the radioscaphoid, radiolunate, scaphocapitate, capitolunate, and third carpometacarpal joints (TECH FIG 1A), clean them of any remaining cartilage and soft tissue, and then fully denude them to below the subchondral bone.

images Maintain the general bony geometry to allow the prepared carpal bones to interdigitate effectively.

images A combination of a no. 15 blade, small curettes, and rongeurs is usually adequate for preparing the joint surfaces. Use of a water-cooled power burr and repeated penetration of the articular surfaces with a 0.045-inch smooth Kirschner wire are sometimes helpful.

images The triquetrolunate, triquetrohamate, scaphotrapezialtrapezoid, and capitohamate joints may be left undisturbed if not arthritic.

images If one expects to remove the plate at a second surgery, the second and third carpometacarpal joints can be left intact. This limits the fusion mass to the radiocarpal and midcarpal joints, preserving motion at the carpometacarpal level.

images Obtain autologous bone graft from the distal radius in two forms, a corticocancellous graft and cancellous bone chips.

images Measure the distance from the base of the third metacarpal to the radius platform and harvest a corticocancellous bone graft of equal length from the dorsal radial surface of the distal radius.

images Take care to avoid disrupting the radial cortex of the distal radius (and thereby destabilizing the bone) and removing the cortex on which the plate will eventually sit.

images Outline the graft using a wire driver and a 0.045-inch Kirschner wire, and then harvest it with a sharp osteotome and mallet.

images After removing this graft, harvest cancellous bone from the site and tightly pack it between the prepared bony surfaces.

images In cases of severe deformity, the carpus may be held in general alignment with temporary Kirschner wires.

images Key the corticocancellous graft into the space between the third metacarpal base and the radius platform.

images This graft will be located directly under the plate

(TECH FIG 1B).

images Choose the desired wrist fusion plate and secure it distally to the third metacarpal with appropriately sized screws.

images Plate options include a long bend, a short bend, and a straight plate (Synthes USA).

images In selected instances, the second metacarpal may be used rather than the third metacarpal.

images With the carpus aligned and the prepared joints reduced and grafted, apply the plate to the distal radius in a compression mode using appropriately sized screws. Complete the fixation with additional screws (TECH FIG 1C,D).

images Any remaining bone graft is added in and around the prepared joints.

images Close the capsule with absorbable suture. If needed, the extensor retinaculum may be split, with one portion repaired deep to the extensor tendons to allow coverage of prominent portions of the plate. The other portion is repaired superficial to the tendons to resist “bowstringing.” Transpose the extensor pollicis longus tendon into the subcutaneous space. Close the skin in the usual manner.

images Strongly consider using a drain.

images A sterile dressing and below-elbow volar splint are applied.

images

TECH FIG 1  A. Joints within the wrist that are decorticated and grafted: optional (O) or required (R). B. Use of a corticocancellous bone graft from the distal radius. The graft is keyed into the space between the third metacarpal base and the radius platform. The plate is placed on top. Cancellous graft is packed into prepared joints. C,D. PA and lateral radiographs following a wrist arthrodesis using a dorsal plate. (C,D: Courtesy of P.J. Stern, MD.)

FUSION WITH STEINMANN RODS

images Fusion with Steinmann rods is performed using a technique similar to that described above, typically in patients with advanced inflammatory arthritis.

images Because bone loss and deformity are substantive, precise joint preparation and reduction is not possible and the goal is generation of a fusion mass.

images Typically, cancellous autograft taken from the distal radius is used between the prepared bony surfaces.

images Fixation may be accomplished using an intramedullary rod inserted through the head of the third metacarpal (TECH FIG 2AD).

images As an alternative, two rods can be inserted between the second and third, and third and forth metacarpals (TECH FIG 2E,F). These are usually smaller pins that produce an interference fit in the radius shaft.

images

TECH FIG 2  A,B. Complex wrist collapse secondary to rheumatoid arthritis treated with an intramedullary rod and wiring. Ulnar impaction symptoms developing at the distal radioulnar joint. C,D. Less severe wrist disease in a different patient was treated with a Darrach resection and wrist arthrodesis. E,F. PA and lateral radiographs after wrist arthrodesis in a different patient with rheumatoid arthritis was undertaken using two Steinmann pins inserted through the second and third, and third and fourth intermetacarpal spaces. (A–D: Courtesy of P.J. Stern, MD; E,F: Copyright Thomas R. Hunt III, MD.)

images Placing an intramedullary rod through the third metacarpal head necessitates an incision in the dorsal web space and in the sagittal band.

images Metacarpophalangeal joint replacement may eventually be required.

images Choose the largest pin that will fit within the metacarpal and advance it retrograde through the reduced carpus and into the radius.

images A second smaller derotation pin can be placed through the radial styloid into the carpus and metacarpals to prevent rotation.

images Alternatively, a figure 8 wire can be placed around the third metacarpal and through the radius to compress the construct.

images If the metacarpophalangeal joints have already been replaced, two Steinmann pins through the second and third web spaces may be effective.

images Closure is similar to that described above.

images

POSTOPERATIVE CARE

images Patients are placed into a removable brace 2 weeks after surgery and started on active finger flexion–extension exercises as well as pronation and supination.

images Patients with an extensor lag due to dorsal swelling are started on a program of dynamic extension with an outrigger splint until full active extension is regained.

images Strengthening is reserved for when the radiographs demonstrate union. Union usually takes 6 to 8 weeks but is prolonged in smokers. Comorbidities may also affect healing rates.

images If patient compliance is an issue, a cast may be used for the first 4 weeks to protect the construct with plate osteosynthesis.

images A cast is recommended for 4 to 6 weeks when using Steinmann rods until the patient's wrist is nontender.

images Therapy may also need to be modified depending on any additional procedures performed.

COMPLICATIONS

images Infection

images Nonunion, delayed union, and malunion

images Dorsal wrist tenderness

images Tendon adhesions and ruptures

images Neuromas and complex regional pain syndromes

images Pin migration

images Wound breakdown

OUTCOMES

images Wrist arthrodesis boasts a high fusion rate, a high satisfaction rate, and a low complication rate.1,5,7,8,9,13 It is for this reason that fusion of the wrist is selected in patients who can tolerate fewer trips to the operating room for secondary procedures.

images While more satisfying than rod stabilization in rheumatoid patients (74% vs. 37%), plate fixation may require tenolysis or plate removal after arthrodesis.1,11 Satisfaction may be affected by the patient's underlying disease.

images Housian and Schroder6 found that plate removal was common (15%) due to the complications listed above but was successful in relieving symptoms.

REFERENCES

1.     Barbier O, Saels P, Rombouts JJ, et al. Long-term functional results of wrist arthrodesis in rheumatoid arthritis. J Hand Surg Br 1999; 24B:27–31.

2.     Calundruccio JH. Osteoarthritis of the wrist. In: Trumble TE, ed. Hand Surgery Update 3. Rosemont, IL: ASSH, 2003:528–529.

3.     Clendenin MP, Green DP. Arthrodesis of the wrist: complications and their management. J Hand Surg Am 1981;6:253–257.

4.     Hartigan BJ, Nagle DJ, Foley MJ. Wrist arthrodesis with excision of the proximal carpal bones using the AO/ASIF wrist fusion plate and local bone graft. J Hand Surg Br 2001;26B:247–251.

5.     Hayden RJ, Jebson PJ. Wrist arthrodesis. Hand Clin 2005;21:631–640.

6.     Housian S, Schroder HA. Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases. J Hand Surg Br 2001;26B:355–359.

7.     Jebsen PJ, Adams BD. Wrist arthrodesis: review of current techniques. J Am Acad Orthop Surg 2001;9:53–60.

8.     Krimmer H. Radiocarpal and total wrist arthrodesis. In: Berger RA, Weiss AP, eds. Hand Surgery. Philadelphia: Lippincott Williams & Wilkins, 2004:1319–1337.

9.     Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of scaphoid non-union. J Bone Joint Surg Am 1984;66A:504–509.

10. Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid nonunion: a review of fifty-three cases. J Bone Joint Surg Am 1985;67A: 428–432.

11. Toma CD, Machacek P, Bitzan P, et al. Fusion of the wrist in rheumatoid arthritis: a clinical and functional evaluation of two surgical techniques. J Bone Joint Surg Br 2007;89B:1620–1626.

12. Weil C, Ruby LK. The dorsal approach to the wrist revisited. J Hand Surg Am 1986;11A:911–912.

13. Weiss AC, Wiedeman G Jr, Quenzer D, et al. Upper extremity function after wrist arthrodesis. J Hand Surg Am 1995;25A:813–817.

14. Weiss AP, Hastings H. Wrist arthrodesis for traumatic conditions: a study of plate and local graft application. J Hand Surg Am 1995;20A: 50–56.



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