A 67-year-old woman presents with a 2-month history of gradually increasing right wrist pain and swelling. She has long-standing rheumatoid arthritis that caused bilateral severe wrist arthritis for which she had a right total wrist arthroplasty 9 years ago, with an excellent result and returned to using her hand without wrist pain.
Approximately, 1 year ago she had right hip and left knee replacements and used walking aides routinely during her recoveries and continues to use aides occasionally. Subsequently, the right wrist began to hurt and intermittently swell, which has gradually worsened. Her rheumatoid arthritis and hand function have remained stable since beginning disease-modifying antirheumatic drugs (DMARDs) 5 years ago. She has no local or systemic signs of infection.
Examination shows mild diffuse dorsal wrist swelling, no erythema, satisfactory alignment and motion, and minimal tenderness. All digital flexor and extensor tendons are intact. She has no neurologic deficits.
Radiographs of the wrist show severe migration of the distal component of the total wrist implant, with surrounding carpal osteolysis. The proximal component appears stable with minimal osteolysis of the radius (▶Fig. 80.1).
Treatment options for a failed arthroplasty include revision of the implant(s), resection arthroplasty, and conversion to an arthrodesis. Revision wrist arthroplasty is often not possible when there is substantial bone loss associated with implant loosening, particularly in the carpus. Resection arthroplasty can result in an unstable joint, wrist deformity, and reduced hand strength. Conversion to a complete wrist arthrodesis will produce a stable wrist and maintain hand strength, but there are several potential technical challenges, including restoration of proper wrist height, obtaining stable fixation, and achieving bony fusion.
• Although infection is unlikely, appropriate laboratory studies and possible joint aspiration should be done to assess for infection.
• Progression of loosening is likely and therefore proceeding with operative treatment is recommended but not urgent.
• Conversion to a total wrist fusion is the best option due to the amount of carpal bone loss and the physical demands on the wrist from her use of walking aides.
DMARDs and methotrexate are discontinued for one cycle before and one cycle after surgery; however, any prednisone therapy is not altered. A dedicated wrist arthrodesis dorsal plate and a contoured cancellous femoral head structural allograft are used.
The previous skin incision over the dorsum of the hand and wrist is used. The extensor retinaculum is opened through the fourth extensor compartment and raised in continuity with the overlying skin to help preserve skin vascularity and reduce wound-healing problems. The joint capsule is opened and the implants are removed with care to preserve bone stock. Typically, the carpal component can be removed with minimal force if it is loose. To remove a well-fixed radial component, a radius osteotomy is usually required to disrupt the osteointegration of an uncemented component or to break the cement mantle of a cemented component.