Total Wrist Arthrodesis: An Update on Indications, Technique and Outcomes

Abstract

Painful end-stage wrist osteoarthritis (OA) unresponsive to conservative treatment is frequently managed with total wrist arthrodesis (TWA), which might render pain alleviation and ameliorate function, pain, and grip strength. Usual indications for TWA include inflammatory arthritis, idiopathic degenerative OA and posttraumatic OA, Kienböck's illness, brachial plexus palsy, cerebral paralysis, infraclavicular brachial plexus blocks and other spastic and contracture base illnesses, scapholunate advanced collapse, scaphoid nonunion advanced collapse, and failure of other surgical techniques such as after failed total wrist arthroplasty, four-corner fusion, proximal row carpectomy and severe ligament injuries (this procedure is carried out when all other treatment alternatives have failed to control the individual's symptoms). TWA is commonly carried out with a dorsal plate fixed from the distal radius to the third metacarpal. However, other surgical procedures have been reported, including intramedullary fixation and new implants that do not cross the third carpometacarpal joint or some procedures without utilizing hardware for example using a vascularized fibular grafting In individuals with rheumatoid arthritis. TWA has been shown to give persistent and painless stability for 20 years or more. The rate of adverse events for TWA ranges from 0.1% to 6.1%, though some authors have published that it can be as high as 27%. The most common adverse events are tendon ruptures, peri-implant fractures of the third metacarpal, the need for hardware removal, and constant pain at the third carpometacarpal joint. In idiopathic degenerative OA, the reoperation rate following TWA has been reported as high as 63%. While TWA can render foreseeable pain alleviation and ameliorate function, orthopedic surgeons should remember that this surgical technique is not without its risks and that the accessibility of many surgical procedures requires orthopedic surgeons to scrupulously contemplate the risks and benefits of each alternative for the individual in front of them.

Keywords: Failed wrist arthroplasty; Post-traumatic osteoarthritis; Radiocarpal osteoarthritis; Total wrist arthrodesis; Wrist osteoarthritis; Wrist salvage operations.

Figure 1 (a-b)

Total wrist arthrodesis (TWA) for painful post-traumatic osteoarthritis after distal radius fracture malunion by means of plate and screws: (a) Lateral radiograph of distal radius fracture malunion with post-traumatic arthrosis (carpal instability non-dissociative). (b) Postoperative lateral radiographs after TWA. Note short bend in the plate to pre-position the wrist for power grip

Figure 2 (a-d)

Total wrist arthrodesis (TWA) for painful idiopathic osteoarthritis with no prior injury by means of an intramedullary device. The patient had pain since one year ago and failed to respond to conservative treatment: (a) Preoperative anteroposterior (AP) radiograph; (b) Preoperative lateral view; (c) Postoperative AP radiograph; (d) Postoperative lateral view