Management of Complications after Salvage Procedures of the adiocarpal and Distal Radioulnar Joint

16 Management of Complications after Salvage Procedures of the Radiocarpal and Distal Radioulnar Joint

Michel E. H. Boeckstyns, Peter Axelsson, Marion Burnier, Guillaume Herzberg, and Marjolaine Walle

Abstract

Partial wrist arthrodeses are relatively common motion-preserving procedures in both patients with rheumatoid arthritis (RA) and in nonrheumatoid patients. However, nonunion is a rather frequent complication. Union after total wrist (TW) arthrodesis is more reliable but obviously connected with an important functional disability, especially in nonrheumatoid patients and in RA patients with bilateral wrist destruction. Persistent pain is a frequent problem in nonrheumatoid patients.

TW replacement is another motion-preserving salvage procedure. Osteolysis and prosthetic loosening is then a concern. Contraindications are patients with poor bone stock and poor bone quality, young and physically very active patients, patients with pronounced joint laxity, patients with spontaneously ankylotic wrists, and noncompliant patients.

Symptomatic ulnar instability after Darrach’s or Sauvé-Kapandji’s procedures for distal radioulnar joint (DRUJ) problems is relatively frequent. Several soft tissue procedures to reduce the symptoms have been described. Prosthetic hemi- or total replacement of the DRUJ can also be used, but the technique and the learning curve may be challenging.

Keywords: arthrodesis, partial arthrodesis, total arthrodesis, joint replacement, radiocarpal joint, wrist, distal radioulnar joint

16.1 Radiocarpal and Total Wrist Arthrodesis

16.1.1 Definition of the Problem

Partial radiocarpal arthrodesis and total wrist (TW) arthrodesis are relatively common procedures that may be performed in two very distinct groups of patients, i.e., rheumatoid arthritis (RA) or nonrheumatoid patients. A specific analysis of their complications is seldom published. However, knowledge of these potential complications is interesting not only for scientific purposes but also because there are alternative treatments for both procedures. Therefore, potential complications of partial/total wrist arthrodesis should be discussed with each patient in a comprehensive informed consent manner, should surgery be chosen for this particular patient.

Complications after Radiolunate and Radioscapholunate Arthrodesis

Nonunion and secondary deterioration of the midcarpal joint are the most frequently reported complications.

Radiolunate (RL) Arthrodesis

In rheumatoid patients, RL arthrodesis is traditionally performed as open surgery,2 although the use of arthroscopy has recently been advocated.³^,⁴ A distal ulna resection or Sauvé-Kapandji’s (S-K) procedure is often combined with RL arthrodesis.² The indication to perform these procedures in a patient having a stable medical treatment is a painful wrist with caput ulnae syndrome, sometimes rupture(s) of the extensor tendons, and a radiographic carpal anterior and ulnar slide with severe involvement of radiocarpal joint space and a relative preservation of the midcarpal joint.

In nonrheumatoid patients, RL arthrodesis is traditionally performed as open surgery,⁵ although some authors may also consider the use of arthroscopy.³ A distal ulna resection or S-K procedure may be combined with RL arthrodesis, but the ulnar head should be preserved, if possible, in most of the nonrheumatoid patients.³ The most frequent indications are painful articular distal radius malunion and chronic posttraumatic ulnar translation of the carpus, which usually is the consequence of a failed treatment or missed radiocarpal dislocation. In the following, the most common complications are reviewed and discussed.

Reduced Wrist Mobility

Some limitation of wrist motion should be expected after any partial wrist arthrodesis.⁶ This should not be considered as a complication provided that 20 to 40 degrees of painless active wrist extension is preserved, which corresponds to a functional wrist.

Nonunion

Borisch and Haussmann⁷ reported on 91 RL arthrodeses for rheumatoid patients at a mean follow-up of 5 years. No nonunion was reported. There are very few reports of RL arthrodesis in nonrheumatoid patients. Saffar⁵ reported on a series of 11 RL arthrodeses performed mainly for symptomatic malunion after distal radial fractures. Only one nonunion was reported, salvaged by a bone grafting revision.

Secondary Deterioration of the Midcarpal Joint

In the series by Borisch and Haussmann,7 there was a 6% revision rate to TW arthrodesis for secondary midcarpal arthrosis or arthritic destruction. Four percent displacements or malpositioning of the osteosynthesis material were reported. Trieb² reported secondary deterioration of the midcarpal joint in about 40% in a long-term follow-up study. He mentioned that this complication should not necessarily be considered as a failure of this procedure. We share this opinion since we observed in our series a constant but very slow secondary degeneration of the midcarpal joint that was most often well tolerated in RA patients. Overall, the complication rate after RL arthrodesis for RA wrist is low.⁷^,⁸^,⁹^,¹⁰ In the series by Safar,⁵ secondary osteoarthritis (OA) in adjacent joints was not reported. The ulnar head was preserved in 72% of the cases. We have the same experience. It is our opinion that maintaining the height of the radiolunate original joint (with a massive corticocancellous bone graft if necessary) is of paramount importance if the secondary degeneration of the radioscaphoid joint is to be avoided.

Radioscapholunate (RSL) arthrodesis

In rheumatoid patients, RSL arthrodesis is traditionally performed as open surgery, often in conjunction with resection of the ulnar head. The indication is the same as for RL arthrodesis in a patient with a more severely destroyed radioscaphoid joint space. There are very few reports of RSL arthrodesis in RA patients since the RL arthrodesis usually provides satisfactory results.

Reduced Wrist Mobility

Garcia Elias emphasized the usefulness of combining RSL arthrodesis with distal scaphoid excision in terms of flexion and radial deviation.¹¹ This was confirmed in subsequent series.¹²^,¹³^,¹⁴^,¹⁵

Nonunion

Ishikawa et al⁸ and Honkaken et al¹⁶ reported on small series of RSL in RA patients with a 100% union rate and very few complications.

In nonrheumatoid patients, RSL arthrodesis follows the same indication as for RL arthrodesis when there is also destruction of the radioscaphoid joint space. The surgical approach is usually dorsal but an anterior approach has recently been recommended.¹²

Mühldorfer-Fodor et al¹⁵ reported on 47 cases of RSL arthrodesis for posttraumatic OA at a mean follow-up of 2 years (20 with distal scaphoidectomy). There was a 20% nonunion rate in the group where distal scaphoidectomy was not performed. Distal scaphoidectomy appeared to lessen the risk of nonunion and to improve radial deviation. Degeorge et al¹³ reviewed 75 cases of RSL for posttraumatic OA at a mean of up to 9 years. RSL was performed alone in 33, with distal scaphoid excision in 26, and distal scaphoid excision with triquetrum excision in 16. Fifty-six percent had combined distal scaphoid excision. The nonunion rate was 42% after RSL without distal scaphoid excision and only 9% with distal scaphoid excision. They concluded that after resection of the distal scaphoid, there might be less stress on the radioscaphoid arthrodesis, resulting in a better healing rate.

Secondary Deterioration of the Midcarpal Joint

In the series by Mühldorfer-Fodor et al,¹⁵ there was a 20% of secondary arthrosis in adjacent joints in both groups. In the series by Degeorge et al,¹³ the rate of secondary midcarpal OA was 44%. This rate was not influenced by distal scaphoid excision.

Complications after Total Wrist Arthrodesis

Persistent pain and hardware irritation is a frequent problem in nonrheumatoid patients.

In rheumatoid patients, TW arthrodesis is most often performed using a Mannerfelt pin technique.¹⁷^,¹⁸ The results in terms of pain relief are usually very good as well as the union rate.² The postoperative disability due to a nonmobile wrist is not a complication per se.

Malpositioned Arthrodesis

Poor arthrodesis position should be considered as a complication since not enough extension impairs prehension in patients with already weakened fingers. Barbier et al¹⁹ reported on 18 cases, with 44% presenting at follow-up with a wrist position in either slight flexion or less than 10 degrees of extension. The average position of TW arthrodesis was 8 degrees of extension and 9 degrees of ulnar deviation. Three patients would have preferred a more functional position.

Nonunion and Hardware Problems

Recently, Dréano et al¹⁷ reported on a series of 19 cases. There were 1 nonunion, 21% painful prominence of hardware, and 21% pin migration or breakage. Kluge et al¹⁸ reported on 93 cases using a modified Clayton-Mannerfelt technique with 2% nonunion, 3% prominence of hardware, and 2% third metacarpal fracture.

Overall, nonunion is very rare after TW arthrodesis but hardware problems do exist and should be minimized. We sometimes use multiple k-wire fixation in order to provide a tailored extension-ulnar deviation position and to minimize hardware problems.

In nonrheumatoid patients, TW arthrodesis is most often performed using a dorsal plating technique, although some authors are using less invasive hardware.20^,²¹ Several authors have emphasized that there may be significant complication rates after this procedure. This knowledge is useful when discussing with a patient the choice of TW arthrodesis versus TW replacement. Sauerbier et al²² reported on 60 cases at a mean of 3 years follow-up with AO plate fixation. Sixty-two percent underwent surgery before TW arthrodesis. He found 95% with persistent pain and 8% of reoperations. De Smet and Truyen²³ reported on 36 cases at a mean of 7 years follow-up and fixation with AO plate and bone graft. There were 83% with persistent pain at follow-up and 58% reoperations.

16.1.2 Treatment of Complications: Nonunion and Hardware Problems

Failure of SL and RSL arthrodesis due to nonunion can in selected cases be salvaged by a new attempt to obtain union by performing revision of all fibrous tissue in the interosseous spaces, filling these with cancellous bone graft, and performing a stable internal fixation. However, often the solution will be to convert a partial arthrodesis to a TW arthrodesis. An alternative solution is conversion to a TW replacement. Reoperation of a failed TW arthrodesis will usually be a new TW arthrodesis as described for the partial arthrodeses.

In the case of pain due to hardware problems (nerve and tendon irritation or subcutaneous prominence of the fixation material), the advice is to remove the hardware after consolidation of the arthrodesis.

16.1.3 Rehabilitation

As a general rule, the wrist is immobilized in a cast or splint until bony union of the arthrodesis is radiographically ascertained. However, in low-demand RA patients the casting period may be a few weeks only (mainly to relieve postoperative pain). If a rigid and solid fixation of the arthrodesis is performed (usually plate and screw fixation), immobilization can be omitted in all compliant patients. If the bone is very osteoporotic, locking screws are recommended.

16.1.4 Tips and Tricks

●RSL arthrodesis in RA patients has a higher risk of nonunion and severe stiffness when compared with RL arthrodesis. RL arthrodesis is usually sufficient to stabilize an RA wrist.

●Because of the strong association with caput ulnae syndrome, stabilized distal ulnar head resection or S-K procedure is often combined with RL arthrodesis in RA patients. Ulnar head replacement is rarely indicated.

●RL arthrodesis is a reliable motion-preserving procedure in case of chronic ulnar translation of the carpus in nonrheumatoid patients, provided that the height of the carpus is preserved or restored.

●The addition of a resection of the distal pole of the scaphoid in RSL arthrodesis in nonrheumatoid patients has a positive influence on both bone healing and residual postoperative motion.

A TW replacement option (see next) should be discussed, especially in bilateral wrist destruction. However, TW arthrodesis is preferred in heavy manual workers and noncompliant patients.

16.2 Total and Interpositional Wrist Replacement

16.2.1 Definition of the Problem

Prosthetic wrist replacement is an alternative option for the treatment of painful destroyed wrists, mainly in older, low-demand patients. First-generation implants—silicone spacers—gave promising early results in RA patients but the long-term results were discouraging due to a high incidence of failure, mainly breakage of the implant.²⁴ The procedure has been abandoned in the wrist. The next generations consisted of bulky multicomponent implants, requiring substantial bony resection. Long-term implant survival has been deceiving.²⁵ The fourth-generation of implants was introduced in the late 1990s.²⁶ In the following, the most important complications are analyzed.

Early Postoperative Complications: Periprosthetic Infection and Instability

The incidence of early deep infection is less than 2% with current implant techniques and the use of perioperative antibiotics.²⁷^,²⁸ Clinical signs of an acute infection after TW replacement are pain, erythema, edema, prolonged postoperative wound effusion, or dehiscence. Serial blood tests including C-reactive protein (CRP) and white blood cell count confirm the diagnosis.

Instability with dislocation was common with the first version of the Universal implant (Integra, Plainsboro, NJ, USA) but this problem has been solved with the modified versions, the Universal 2 (Integra, Plainsboro, NJ, USA) and the Freedom (Integra, Plainsboro, NJ, USA), and has not been a major problem with the Re-motion (Stryker, Kalamazoo, MI, USA), the Maestro (Biomet, Warsaw, IN, USA), or the Motec (Swemac, Linköping, Sweden). Nevertheless, patient selection is of paramount importance and the severely destroyed unstable wrist or other conditions causing general joint laxity are still relative contraindications. A rheumatoid wrist stage 3 according to the Simmen classification (Fig. 16‑1) is considered a contraindication by many surgeons not only because of instability but also due to lack of bone stock.

Fig. 16.1 (a, b) Severely unstable rheumatoid wrist (Simmen stage 3). Prosthetic replacement is generally considered contraindicated in this condition.

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