AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Osteoarthritis (OA) is a degenerative condition in which the articular cartilage on the surfaces of the bones that form joints progressively deteriorates. The terms osteoarthrosis and OA are often used interchangeably. Although inflammation is generally absent in this degenerative condition, most physicians commonly refer to it as OA. Hence, this is the term in daily use.¹

OA is common in weight-bearing joints. Although the wrist is not a weight-bearing joint, OA of the wrist is not an uncommon condition that orthopedic surgeons encounter in day-to-day practice.

Wrist arthritis is also common in patients with rheumatoid arthritis (RA), which is a systemic autoimmune inflammatory disorder that affects the joints; in the upper limb, the wrist is most frequently affected. RA invariably results in functional difficulty over time.²

Related eMedicine topics:
Osteoarthritis
Rheumatoid Arthritis
Rheumatoid Arthritis, Hands

Related Medscape topics:
Resource Center Arthritis
Resource Center Rheumatoid Arthritis
CME Current Management Opportunities for Improving Patient Outcomes in Rheumatoid Arthritis
CME ACR 2007: Safety and Efficacy Updates on Established Anti-TNF Agents for RA and Related Conditions
CME/CE The Role of Imaging in the Management of Rheumatoid Arthritis: What Does This Mean for my Patients?

History of the Procedure

For many decades, synovectomy of the wrist alone was used in patients with inflamed joints. This procedure is usually of the most benefit when there is considerable synovitis present, as in RA or psoriatic arthritis rather than OA.

Arthrodesis of the wrist has been used as a treatment for more than a century. Because many bones participate in the wrist joint, either a limited (partial) or a total arthrodesis of the wrist is possible.^{3, 4}

The initial procedure of wrist stabilization was performed for poliomyelitis reconstruction and spastic hemiparesis as early as 1918. In 1920, the procedure was adopted for tuberculous arthritis.

Different techniques for wrist arthrodesis with different methods of bone grafting and fixation have been described in the literature. The AO (Arbeitsgemeinschaft für Osteosynthesefragen, or Association for the Study of Osteosynthesis) technique of compression arthrodesis of the wrist has yielded good results.

Arthroplasty of the wrist has been in use for the last few decades. Initial devices were metal and plastic wrist prostheses with cement fixation that had 2 stems for distal fixation. As the wrist progressed to ulnar deviation, the procedure was changed to a single distal stem into the third metacarpal alone. Ball-and-socket design implants were associated with significant component loosening; hence, a transversely oriented, semiconstrained, ellipsoid design implant was developed. Later, semihinged implants were developed. However, the implants have not yielded the same satisfactory results seen with total hip or knee arthroplasty.

Problem

Arthritis of the wrist results in both severe pain and restriction of movement. Early in the disease, patients may have well-preserved, useful range of motion but severe pain.

Wrist arthritis is a common feature in patients with RA, who are usually treated by rheumatologists and general practitioners. In RA patients who have upper limb involvement, surgical timing is critical because procedures for treating wrist arthritis are usually successful in these patients and can influence the management of other joints of the hand and upper limb.

Frequency

The wrist joint is not commonly affected by primary OA because it is not weight bearing. However, secondary arthritis of the wrist joint is common because of the complex anatomy and kinematics involved. Approximately 1 person in 7 (13.6%) of the US population has wrist arthritis. Gout affects the wrist in 0.28% of the population. RA affects the wrist in 2.5 million people in the United States, and the general prevalence of wrist arthritis is 75%. One wrist joint is affected in 30% of patients, but it then progresses to become bilateral in 95%. The distal radioulnar joint is affected in approximately 50% of patients with rheumatoid wrist arthritis.

Etiology

Primary OA occurs because of the degeneration of the articular cartilage. Various reasons have been postulated for this occurrence, including the important roles age and genetics play. Secondary OA following trauma can result in intra-articular distal radius fractures, scaphoid fractures, scapholunate dissociation, lunate dislocations, wrist instability, intercarpal intercalated instability, and other carpal bone fractures. Kienböck disease (avascular necrosis of the lunate) can also result in wrist arthritis. Inflammatory arthritis of the wrist may be caused by RA, psoriasis, or crystal-induced arthritis, which includes gout and pseudogout.

Pathophysiology

Matrix metalloproteinases and proinflammatory cytokines (interleukin-1 [IL–1]) appear to be important mediators of cartilage destruction in patients with primary OA. IL-1 increases the synthesis of matrix metalloproteinases and, hence, plays an important role in OA.

During the initial stages of OA, fibrillation and cracking of the superficial layers of the articular cartilage occur. As the degeneration progresses, deep layers become involved, finally resulting in erosions that produce bare subchondral bone. Denatured type II collagen is found in abundance in OA articular cartilage, with a decrease in the water content and in the ratio of chondroitin-sulfate to keratan-sulfate constituents. In chronic injuries of the scapholunate ligament and in scaphoid nonunions, osteoarthritis starts in the radioscaphoid joint and progresses to the capitolunate joint. The radiolunate joint remains unaffected during the early stages.

RA, on the contrary, is a progressive inflammatory disease characterized by synovitis and joint destruction. Synovial cell proliferation results in pannus formation and fibrosis, which, in turn, result in erosion of cartilage and bone. Cytokines, prostanoids, and proteolytic enzymes mediate this process. A cell-mediated immune response to an unidentified antigen seems to be the important pathogenesis of RA. Proinflammatory cytokines, such as IL-1 and tumor necrosis factor-alpha (TNF-α), are the central mediators in RA with T-cell initiation.

In gouty arthritis, allantoin, the enzyme uricase that breaks down uric acid into a more soluble product, is deficient, resulting in tissue deposition of crystalline forms of uric acid. Although hyperuricemia is a risk factor for the development of gout, the exact relationship between hyperuricemia and acute gout is unclear. Acute gouty arthritis can occur in the presence of normal serum uric acid concentrations. Conversely, many patients with hyperuricemia may never develop gouty arthritis.

Secondary OA resulting from previous trauma to the carpal bones or ligaments results in abnormal joint reaction forces with each movement of the wrist, causing misdirected forces that lead to some combination of loading forces. This process produces degeneration of the articular cartilage, resulting in radiocarpal arthritis, selective intercarpal arthritis, or pancarpal arthritis, depending on the initial injury and subsequent healing.

Scaphoid fractures in particular can result in OA by 3 different mechanisms.

• If the fracture results in nonunion, abnormal movement occurs between the fragments, leading to an abnormal distribution of forces across the wrist and resulting in early degeneration of the radioscaphoid joint.
• In malunion, the height of the scaphoid may be reduced. Furthermore, the range of motion in 1 or more planes may be restricted, resulting in increased strain and leading to OA changes over time.
• Scaphoid fractures resulting in avascular necrosis of the proximal pole can lead to collapse and, thus, degeneration of the radioscaphoid joint, which may then involve the lunate and, subsequently, the entire wrist.

Kienböck disease results in lunatomalacia; the weakened lunate is subjected to a nutcracker effect between the prominent radius and the capitate head, causing progressive collapse. In its final stages, Kienböck disease leads to the beginning of OA in the radiolunate joint.

Related Medscape topic:
CME Update on Crystal-Induced Arthritis and Hyperuricemia From ACR 2007

Clinical

Wrist arthritis occurs commonly in persons older than 50 years. However, RA and its variants may manifest earlier. Likewise, in patients with previous trauma, secondary OA can appear at a young age.

The predominant symptom of OA is pain. Pain that is usually aggravated during the extremes of movement in the early stages gradually worsens to involve the full, available range of motion. The range of motion may also gradually deteriorate, and the OA progresses to such an extent that, in severe cases, the wrist has no movement, resulting in stiffness. However, in rare cases in which the patient has inherent hyperelasticity, as in those with Ehlers-Danlos syndrome or Marfan syndrome, the wrist may have good range of motion despite severe degenerative changes.

Deformity is another feature of wrist arthritis. This is common in RA, in which deformity may be complicated by association with subluxation of the radiocarpal and inferior radioulnar joints. Swelling of the wrist is one of the most common manifestations of RA and may occur because of synovial thickening.

Because the wrist stabilizes the hand for functioning, pain and deformity may result in the loss of such function with weakness of the hand grip. Wrist deformity and instability reduce support for the hand to grasp, impairing dexterity, whereas stiffness and the inability to extend the wrist deprive the fingers of the tenodesis effect.

Attrition rupture of the tendons may occur, specifically when they glide over the rough osteophytes, resulting in loss of function in the fingers. The flexor pollicis longus tendon is prone to such ruptures over the distal pole of the scaphoid; this is called a Mannerfelt lesion. Cases have been described in the literature in which the flexor pollicis longus, flexor digitorum superficialis, and flexor digitorum profundus tendons to the index finger all are ruptured, with osteophytes at the distal pole of the scaphoid. Likewise, the small and ring finger extensor digitorum communis tendons are prone to attrition ruptures.

Persistent synovitis at the distal radioulnar joint may result in dorsal subluxation of the distal ulna, crepitus during forearm pronation and supination, deformity of the carpus, and rupture of the extensor digitorum communis tendons—this is called caput ulna syndrome. Because the tendons in the flexor and extensor compartments of the wrist have a synovial lining, synovitis of the wrist results in tenosynovitis in most cases, and it may lead to tendon subluxation, tendon adhesion, and, finally, tendon rupture.

Classic rheumatoid wrist arthritis begins with radial deviation of the wrist, resulting in ulnar head prominence. This progresses to supination and ulnar translation of the carpus, finally leading to volar subluxation of the radiocarpal joint. Crepitus in the wrist becomes more apparent as joint disease progresses.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgery is indicated for wrist arthritis when disabling pain emerges despite nonoperative treatment. Because the wrist is the stabilizer for effective functioning of the hand, the loss of function in the hand is also an indication for intervention. In its early stages, synovitis must be actively treated with medical means. If there is no response to medical therapy, synovitis should be treated surgically to prevent tendon ruptures. Deformity may be an indication for surgical intervention in selected patients, because a motion-preserving procedure may be possible when performed early, whereas neglecting such patients in the early stages may relegate them to later treatment with fusion only.^{3, 5}

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The wrist extends from the distal border of the pronator quadratus up to the carpometacarpal joints of the fingers. It is a complex hinge joint that involves the distal radius, distal ulna, 7 carpal bones (among which the pisiform acts mainly as a sesamoid), and the base of 5 metacarpal bones. The wrist joint can be divided into radiocarpal, midcarpal, and intercarpal joints. The movements available in the joint are dorsiflexion, palmar flexion, radial deviation, ulnar deviation, and a combination of 2 or more of these movements.

The wrist functions by positioning the hand in relation to the forearm, providing a mechanical advantage, and also acts as a stabilizer for effective functioning of the hand. The motor fiber units that produce wrist motion arise proximally in the forearm, cross the wrist, and then are inserted distally to the wrist without any attachment to the carpal complex.

The unique kinetics of the carpal bones depend on the intricate carpal geometry (and arrangement), ligament function, and muscle activity. Carpal bones are arranged in 2 rows. From radial to ulnar, the proximal row consists of the scaphoid, lunate, triquetrum, and pisiform, whereas the distal row has the trapezium, trapezoid, capitate, and hamate. Accessory carpal bones are present in 1.6% of the population, one of which is the os centrale carpi, which sits between the scaphoid, capitate, and trapezoid and may be responsible for the condition "clicky wrist."

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Infection at the wrist is an absolute contraindication for wrist arthroplasty. Surgery may also be contraindicated in patients with poor medical status.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Local destruction and biomechanical impairment may progress at different rates relative to the rates at which systemic serologic parameters change.
• If the local destruction and biomechanical impairment are not closely monitored, surgical delay occurs—and surgical opportunities can be missed.

Imaging Studies

• Radiographic findings in wrist posteroanterior and lateral views reveal degenerative changes.
• • The important areas to focus on are the radioscaphoid joint, the radiolunate joint, around the capitate, and the scaphotrapeziotrapezoid joint. However, all the joints should be individually evaluated for evidence of OA.
  • In general, surgical procedures are based on assessments of the radioscaphoid joint, radiolunate joint, and head of the capitate, which forms the main articulation of the midcarpal joint. The exact surgical option is directly related to which joints are preserved and which joints are destroyed.
• Bone scanning may show hot spots, but findings are not specific and do not provide additional information.
• Arthrography is not useful in common practice, but this modality can be combined with arthroscopy to enhance information.
• Computed tomography (CT) scanning may be useful to delineate the problem in individual bones and their articulations; however, it is not routinely used for primary OA or RA.
• Magnetic resonance imaging (MRI) is especially useful to assess instability caused by ligamentous tears but not for established OA of the wrist.^{6, 7}

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

Nonoperative measures for wrist arthritis are primarily aimed at relieving pain in the wrist. Rest in the form of splinting with removable thermoplastic splints may be useful during exacerbations. Care should be taken when splinting is used because overuse may result in a poor outcome as a result of wrist stiffness and weakness produced by immobilization. The wrist is usually maintained in neutral or slight dorsiflexion, which is the functional position for the wrist.

Nonsteroidal anti-inflammatory drugs are useful in controlling inflammation, thereby reducing synovitis and swelling. They are most useful in inflammatory arthritis. Antirheumatism medications with systemic steroids, methotrexate, and anti–TNF are useful in patients with RA. Allopurinol may be useful in patients with gouty arthritis of the wrist.

Steroid injections with or without local anesthetic into the joint may be performed; however, the results are equivocal. Methylprednisolone acetate injection into the wrist may play a role in treating degenerate triangular fibrocartilage. When combined with local anesthetic, local steroid injections may also aid in diagnosis; however, the effect is transient, and repeated injections may be needed.

Surgical therapy

Surgery for wrist arthritis depends on the severity and the extent of arthritis in the wrist.⁵ In the earliest stages, when the problems are mainly caused by carpal instability (prearthritic stage), the aim of the surgery is to rectify the anatomic position and to correct the carpal instability to prevent degeneration of the wrist. In the late stages of severe wrist arthritis, either a partial or total wrist arthrodesis or an arthroplasty may be contemplated. In the intermediate stages, when the patient has well-established arthritis but a well-preserved range of motion, no proven standard treatment has been established. The available options are wrist arthroscopic debridement and wrist denervation.

Arthroscopic wrist procedures

Arthroscopic wrist procedures are most useful as diagnostic tools, but they are occasionally used as therapeutic procedures. An arthroscopic wrist procedure is done to examine the joint articular surfaces, and it is useful for synovial biopsy, removal of loose bodies, and wrist debridement in patients with early arthritis. Arthroscopy is most accurate for diagnosing degenerate triangular fibrocartilage lesions.⁸

Arthroscopic synovectomy has recently become a well-described procedure. Aggressive arthroscopic debridement, including radial styloidectomy and partial resection of the scaphoid, has been reported. Resection of the lunate in patients with Kienböck disease may also be performed arthroscopically. In the distal radioulnar joint, arthroscopy can be used for debridement of the triangular fibrocartilage complex and for a modified Darrach procedure that involves distal ulna resection. Arthroscopic reconstructive procedures have been described for repair of the lunate-triquetrum ligament and ulnocarpal ligament complex, as well as for capsular placation.

Wrist denervation

The wrist-denervation procedure has been adopted in neuropathic patients with wrist arthritis because these patients do not have wrist pain. Wrist denervation can be performed by means of simple division of the posterior and anterior interosseous nerves near the wrist joint through a single dorsal incision. However, some authors question the validity of such a rationale because several nerves innervate the wrist; hence, these authors advocate multiple small incisions to address all the contributory nerves.

In various series, results worsened after wrist denervation in patients with progressive carpal instability. Hence, in general, this procedure is indicated in patients with chronic localized wrist pain without evidence of progressive carpal instability or collapse. The results are reasonably good for the single dorsal incision for wrist denervation, in which both the posterior and the anterior interosseous neurectomy are performed. Although wrist denervation does not improve the underlying wrist arthritis, even pancarpal neurectomy with multiple incisions does not preclude further surgery to the wrist. Therefore, selective denervation can be considered for patients who suffer chronic wrist pain but who do not have carpal instability or collapse.

Synovectomy

Synovectomy may be especially useful in patients with RA when the synovitis is only moderate and bony changes are absent; however, medical treatment is the first line of treatment to control acute synovitis. Dorsal synovectomy is indicated to avoid tendon ruptures when the synovitis persists for more than 6 weeks despite medical treatment.

Ulnar resection

Distal ulnar resection is performed by fusing the head of the ulna to the sigmoid notch of the distal radius with a cancellous screw, resulting in distal radioulnar joint fusion. This is called the Sauve-Kapandji procedure (see Image 19).

Ulnar-head resection is commonly performed in RA because the distal radioulnar joint is more often involved in RA than in OA of the wrist. The wrist tends to deviate and subluxate toward the ulna, resulting in ulnar-head prominence and impingement, which produces significant symptoms in RA but not in OA.

Arthrodesis

Fusion of the wrist, either limited or total, plays an important role in the surgical treatment of wrist arthritis. Limited fusion consists of fusion of only part of the carpal bones involved by arthritis; this procedure has the advantage of preserving motion in the remaining part of the carpus that is not affected by arthritis.

The principles of arthrodesis of the wrist include the following:

• The articular surfaces should be denuded down to the bleeding subchondral bone.
• At least half of the joint surfaces being fused should be prepared.
• Rigid fixation devices used to hold the fusion site permit early physiotherapy and rehabilitation.
• The carpal bones should be reduced to their original position before fusion; this is vital in limited arthrodesis.
• Bone grafting may be required.

Triscaphe arthrodesis

Triscaphe arthrodesis involves fusion of the scaphoid, trapezium, and trapezoid bones. The external bony relationship, however, should be preserved to prevent bony collapse or the development of arthritis in the neighboring joints. Triscaphe arthrodesis is indicated only when arthritis is confined to the scaphotrapeziotrapezoid joint. This type of fusion is contraindicated if significant degenerative changes are present in the radioscaphoid joint.

Lunate-triquetrum arthrodesis

Patients with lunate-triquetrum joint arthritis usually have ulnar wrist pain. After lunate-triquetrum arthrodesis, mean ranges of motion are 77% palmar flexion, 80% dorsiflexion, 95% radial deviation, and 90% ulnar deviation, as compared with the normal, unaffected side.

Radioscaphoid arthrodesis

Radioscaphoid arthrodesis is generally performed when degenerative changes from wrist arthritis involve the entire radiocarpal joint with sparing of the midcarpal joint, as happens after distal radius fractures. This fusion is accomplished with an autogenous bone graft with or without bone substitute added, and it requires rigid fixation. After this fusion, 33% of normal wrist motion can be regained because of the preserved midcarpal joint. However, this percentage of regained normal wrist motion can be improved to 50-60% by excising the distal pole of the scaphoid during the procedure.

Four-corner fusion

Four-corner fusion is based around the head of the capitate, involving the capitate, lunate, hamate, and triquetrum, and is used for scapholunate advanced collapse, also known as SLAC wrist. During the procedure, the lunate should be carefully reduced back into its anatomic position to regain 60% of normal motion in the wrist. The range of motion after 4-corner fusion depends on good articular surface congruity between the lunate and lunate fossa of the distal radius.

Scapholunocapitate fusion

Scapholunocapitate fusion is indicated in patients with midcarpal arthritis but without radiocarpal arthritis. Care must be taken to reduce the scapholunate joint before fusion. Radial styloidectomy should be performed in conjunction with this procedure to prevent impingement. The range of normal wrist motion that can be expected after scapholunocapitate fusion is 33-50%.

Radiolunate fusion

Radiolunate fusion is indicated in isolated radiolunate arthritis that occurs after die-punch fractures of the distal radius. Capitolunate joint destruction is an absolute contraindication for this procedure, but bone grafting is essential in radiolunate fusion to elevate the lunate to prevent carpal collapse. Unlike undercorrection, overcorrection with lunate elevation is well tolerated because loss in carpal height results in a decrease in wrist motion and wrist instability.

Total wrist fusion

Total wrist fusion (TWF) is indicated in patients with pancarpal arthritis and is a successful option in patients with OA of the wrist from any cause. Although limited arthrodesis provides relatively unsatisfactory pain control, TWF is reliable for pain control; however, the disadvantage is loss of motion in any plane, which interferes with certain functions of the hand. Wrist arthrodesis usually improves grip strength, and the hand can be used for most functions without difficulty. However, because the wrist is devoid of its motion, tasks such as working in restricted spaces and attending to personal hygiene may be especially difficult for patients. Despite these limitations, TWF remains the criterion standard treatment for wrist arthritis.⁹

TWF is achieved by decorticating the distal end of the radius and the carpal bones, especially the scaphoid, lunate, capitate, and base of the second and the third metacarpals. In the past, bone grafts taken from either the distal radius or the iliac crest were used, with or without bone substitute to encourage fusion. However, with the use of modern arthrodesis plate systems, bone grafting is no longer required. Ideally, the wrist is placed in 10-60° extension and slight ulnar deviation for effective functioning of the hand (mainly grip strength).

TWF has been a success in most patients who received an AO compression plate specially designed for it. This plate spans from the distal shaft of the radius across the carpus and lies over the second or third metacarpal. The plate is secured to the underlying bones with cortical and cancellous screws after first preparing the bed as discussed earlier. It is important to destroy and decorticate the joints underlying the plate and to fill them with bone graft material to achieve fusion. In patients with poor bone stock, especially in those with RA, an intramedullary pin arthrodesis, such as a Stanley pin or an ordinary Steinmann pin, can be used to stabilize the TWF passing from the second or third metacarpal to the distal radius shaft through the carpal bones.

Proximal-row carpectomy

The proximal-row carpectomy procedure is indicated for severe radiocarpal arthritis, with complete sparing of the radiolunate joint and no degenerative changes over the head of the capitate. The radioscaphocapitate ligament prevents the ulnar translation of the capitate from the distal radial articular surface. Thus, it should be carefully protected when its attached scaphoid is removed during proximal-row carpectomy. The head of the capitate does not have a surface congruent with the lunate fossa. However, after excision of the scaphoid, lunate, and triquetrum (proximal row), the results are generally satisfactory. Point-loading forces may be present, and secondary OA may develop in the neighboring joints at a later time.

Partial ulnar head replacement

In isolated distal radioulnar joint arthritis, a pyrocarbon spacer has been developed to substitute the damaged articular cartilage of the ulnar head. The fibrotriangular cartilage and the extensor carpi ulnaris sheath are preserved during the procedure. The aim of the prosthesis is to separate the 2 forearm bones throughout the range of supination and pronation, resulting in relief of pain from the distal radioulnar joint. Prosthetic replacement of the distal ulna restored stability to the DRUJ in patients with partial or complete excision of the ulnar head or DRUJ arthrosis and corrected radioulnar impingement.¹⁰

Total wrist arthroplasty

In patients with polyarthritis, as in RA, total wrist arthroplasty may be preferred over TWF, because the latter has the disadvantages of restricted motion that cause difficulty with personal hygiene and other tasks. In patients with RA, because other joints are involved with arthritis, even a decreased painless range of motion in the wrist may be helpful. The results after total wrist arthroplasty are improving as new implants are developed.¹¹

Preoperative details

The type of arthritis, the extent of its involvement, the functional requirement of the patient, and the realistic expectations of the proposed treatment should be considered before treatment is undertaken.

Postoperative details

Because the function of the hand depends on regaining digital motion with postoperative physiotherapy and rehabilitation, all patients should receive adequate physical therapy as early as possible, depending on the type of surgical treatment they received.

Patients who undergo limited arthrodesis are immobilized in a below-elbow cast for 4 weeks and then begin physical therapy to regain as much wrist function as possible. Because TWF with plate and screw fixation provides a rigid and stable construct, postoperative plaster immobilization is seldom necessary. Patients can be protected with a removable splint during the initial few weeks, and physical therapy for the hand can be commenced immediately after surgery. In properly selected patients with adequate bone stock, total wrist arthroplasty yields good results; physical therapy should be commenced immediately after surgery, beginning with gentle mobilization exercises and gradually progressing to resistance exercises in a few weeks.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The complications of wrist arthritis surgery are different for each type of surgery. However, in general, a fusion surgery can result in nonunion or fibrous union with pain at the wrist on movement. Wrist stiffness and decreased range of movement with pain at the wrist can complicate arthroplasty. The power in the hand grip may be reduced, especially after arthroplasty. Instability is also a known complication after wrist arthroplasty.

In general, wrist surgery can be complicated by infection, which may lead to implant removal and, in severe cases, may progress to amputation, though this is rare. Neurovascular injury, implant loosening, implant failure, and periprosthetic fractures are other complications.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The outcome of wrist fusion is generally satisfactory and is usually better in patients with RA than those with OA.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Advanced implant designs and fixation in the bone for total wrist arthroplasty may become available to improve the durability and functional results in patients with high demand and poor bone stock.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Severe wrist arthritis.
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Media file 2:  The clinical presentation of wrist arthritis can be severe deformity, especially in patients with rheumatoid arthritis.
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Media file 3:  Rheumatoid arthritis of the wrist.
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Media file 4:  Osteoarthritis of the wrist.
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Media file 5:  Osteoarthritis of the wrist, lateral view.
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Media file 6:  Range of motion may be normal in hyperelastic individuals despite underlying wrist arthritis. See Image 7.
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Media file 7:  Same patient as in Image 6.
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Media file 8:  Synovitis of the wrist with extensor tenosynovitis.
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Media file 9:  Universal incision of the wrist.
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Media file 10:  Extensor retinaculum of the wrist.
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Media file 11:  Exposure of the distal end of the ulna for a Darrach procedure.
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Media file 12:  After resection of the distal ulna.
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Media file 13:  Radiolunate fusion with staples.
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Media file 14:  Follow-up of radiolunate fusion (limited arthrodesis) shows good dorsiflexion and palmar flexion.
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Media file 15:  Intramedullary pin fixation for wrist arthrodesis.
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Media file 16:  Total wrist fusion using an AO (Arbeitsgemeinschaft für Osteosynthesefragen, or Association for the Study of Osteosynthesis) plate in osteoarthritis of the wrist.
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Media file 17:  Total wrist fusion using an AO (Arbeitsgemeinschaft für Osteosynthesefragen, or Association for the Study of Osteosynthesis) plate in a person with rheumatoid arthritis of the wrist.
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Media file 18:  Wrist arthroplasty in rheumatoid arthritis of the wrist.
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Media file 19:  Distal radioulnar joint fusion with distal ulnar resection (Sauve-Kapandji procedure).
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
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• References

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Article Last Updated: Jan 23, 2008