27.1 Introduction

Independent elderly patients presenting with acute distal radius fractures (DRF) represent a specific subgroup that has been identified previously. ¹ The so-called “irreparable DRF” (IDRF) as previously defined ² are within this subgroup.

There is a widespread use of volar plating for acute IDRF in elderly patients. ^{3 , 4} However, this is associated with a high incidence of complications and there is doubt about the clinical benefit of volar plating in the most severe acute DRF in elderly patients. ^{5 , 6}

Treating acute complex fractures of the shoulder and elbow in the elderly with primary joint hemiarthroplasty is a well-established and validated concept. ⁷ Several authors have recently proposed extending this concept to the wrist. ^{2 , 8 9 , 10}

The purpose of this chapter is to outline the benefits of treating acute IDRF in the independent elderly with immediate wrist hemiarthroplasty (WHA).

27.2 Current Therapeutic Options for Acute IDRF in the Independent Elderly

Until recently, there was no reliable option for treating IDRF in elderly patients. ² Compared with a dependent elderly with minimal functional needs for whom a plaster cast without any trial reduction is typically the best option, an independent elderly person warrants a more ambitious treatment. Despite frequent comorbidities, they may still drive a car and participate in relatively sophisticated activities of daily living (ADL). Each possible treatment option has risks and benefits.

Closed reduction and plaster casting may give a good outcome despite very abnormal distal radial bone alignment, but some patients will have significant functional impairment as well as deformity. ^{6 , 11} Percutaneous manipulation and K-wiring works infrequently in maintaining satisfactory bone alignment due to the very limited purchase into osteoporotic fracture fragments. ³ External fixation in elderly patients is particularly cumbersome. ⁴ Moreover, the ligamentotaxis provided by external fixation alone allows for good reduction in the coronal plane but typically not in the sagittal plane due to the relative weakness of the dorsal ligamentous capsule compared with the volar capsule. ¹²

Distraction plating has been recently proposed for IDRF in elderly patients. However in a recent paper, ¹³ it was reported that the postoperative immobilization period was long. The mean delay to plate removal was 30 months. Moreover, we find this carries a potential for appreciable skin complications in the elderly.

Volar plating is currently the gold standard for acute displaced DRF in the elderly whatever their severity. However, in the study by Orbay and Fernandez, ³ only 33% of fractures were classified as AO type “C” fractures. This may have skewed their results. A level I study by Arora and Gabl ⁵ showed that ORIF with volar plating in this group of patients did not provide any improvement in terms of function and ranges of motion when compared with closed reduction and cast immobilization. We agree that successful volar plating is very difficult to achieve in elderly IDRF cases and there is a high risk of secondary displacement as well.

Immediate distal radius replacement with a hemiarthroplasty is a new option based on a concept which is widely used for irreparable shoulder and elbow intra-articular fractures. There are already a few papers related to this topic that report favorable results. ^{2 , 8 , 14}

27.3 Current Evidence

In the series of Roux ⁸ there were six cases of acute DRF in the elderly treated with primary WHA. The results of this subgroup were not reported separately. Using the same implant, Vergnenègre et al ¹⁴ reported the outcome of WHA for acute IDRF with satisfactory functional results and no implant removal at a mean follow-up of 27 months. However, this implant is large. In the event of implant removal, the loss of bone stock would be very difficult to reconstruct. This is not the case with the bone-preserving WHA used in our series. Metal-on-cartilage contact between the implant and the convexity of the articular cartilage of the proximal carpal row is not the best contact for an arthroplasty. However, metal-on-cartilage contact is well accepted for shoulder and elbow hemiarthroplasties after acute trauma.

27.4 Author’s Experience

We have performed 24 hemiarthroplasties in 22 independent elderly women treated for acute IDRF at a single institution between April 2011 and December 2018. The senior author (GH) operated on 21 wrists; the other three wrists were operated under supervision. All patients had some comorbidities but all were independent at home. Their mean age was 77 (range 66–88) years. The mean delay from injury to surgery was 4 (range 1–7) days.

We used the radial part of the SBI-Stryker ReMotion total wrist arthroplasty in 12 wrists and a specifically designed WHA (Cobra, Groupe Lepine) in 12 wrists. Cement was used with one of the 12 ReMotion and one of the Cobra implants. Ulnar head resection was performed in 18 wrists (75%), 92% of the ReMotion, and 60% of the Cobra when the sigmoid notch was not reconstructable. We have had to revise two wrists within 2 weeks after the index operation. One radially deviated ReMotion due to implantation of a stem that was too short was replaced with a Cobra, and one small Cobra implant was replaced with a large ReMotion implant.

The surgical technique has been reported previously ² ; it is in essence the same for either implant.

We have reviewed a total of 13 patients with a minimum follow-up of 24 (mean 39; range 24–57) months. Subjectively, we assessed pain with a visual analog scale (VAS) from 0 to 10, the QuickDash, the patient-related wrist evaluation (PRWE), and a VAS evaluation of function. Objectively, we assessed forearm and wrist ranges of motion and measured grip strength. The Lyon wrist score ¹⁵ was calculated. It included a VAS for pain, a VAS of functional limitations in forearm rotation (range 0–10), and wrist flexion extension and objective measurements. The Lyon wrist score allowed a diamond-shape representation of clinical results.

The follow-up radiological criteria included periprosthetic osteolysis as defined and measured by the treating surgeon, as well as evaluation of the translation of the carpus. Coronal and sagittal inclinations of the implant were also evaluated relative to the long axis of the radius.

No dislocation, loosening, or infection was reported. Apart from the immediate replacement of two implants for mechanical reasons, we have not had to remove any implants. Three patients were diagnosed with complex regional pain syndrome type I (CRPS I). All resolved within 18 months. One patient had a further operation 20 months after the index operation because of finger stiffness due to tendon adhesions at the wrist level along with a tendency to ulnar deviation of the wrist. We performed an extensor tenolysis and transfer of the extensor carpi radialis longus (ECRL) tendon to the extensor carpi radialis brevis (ECRB) tendon. At final follow-up her clinical status was improved and she had nearly full restoration of finger flexion.

The mean VAS for pain was 1/10 (range 0–3). The mean QuickDASH score was 24% and the mean PRWE score was 21% (Table 27.1). Among the 11 cases with combined WHA and ulnar head resection, no patient reported symptomatic radioulnar impingement.

Radiologically, there was no measurable subsidence of the implants, periprosthetic osteolysis, or appreciable carpal erosions. Radiographic bone healing around the implants was satisfactory in all but one case. One wrist showed a dorsal bony defect on the lateral radiograph after 1 year. This defect was present on the early postoperative radiographs suggesting insufficient dorsal bone coverage of the implant during the operation. We did not see any translation of the carpus relative to the implant in the coronal or sagittal planes (Fig. 27.1, Fig. 27.2, Fig. 27.3, Fig. 27.4).