Posttraumatic Radiocarpal Arthritis

Key Points

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Before embarking for salvage procedures, conservative treatment and corrective osteotomy should have been considered.
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If these measures are inapplicable or fail, partial or extensive wrist denervation should be considered.
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Partial or total wrist (TW) arthrodesis or arthroplasty are the next options to be considered, arthroplasties being more suited for the low-demand/elderly patients.
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If the midcarpal joint is intact, a radioscapholunate (RSL) arthrodesis is another option. In low-demand patients, hemi-arthroplasty might be an alternative.
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In patients who request a final procedure, or in the case of panarthritis, TW arthrodesis (or as an alternative in the elderly/low-demand patient: TW arthroplasty) is preferred.

Panel 1: Case Scenario

A 26-year-old construction worker sustained an intraarticular distal radial fracture (DRF) in his dominant right hand side. The fracture was conservatively treated and healed with a step-off in the radial joint surface. Some pain remained but this was tolerable and he returned to his previous employment.

Thirteen years later, he complained of increasing wrist pain and episodes of numbness in his radial sided fingers. After carpal tunnel decompression and resection of the terminal posterior interosseous nerve, the symptoms radiating to the fingers disappeared. However, his wrist pain persisted despite a change of profession, use of splints, analgesics, and intraarticular steroid injections. Radiographs revealed moderate osteoarthritis in the radiocarpal joint including the lunate fossa ( Fig. 1 ). How would you counsel him?

Importance of the Problem

Wrist degeneration after intraarticular DRFs is caused either by a direct blow to the cartilage, or joint surface disruption with step-offs and gaps. Joint degeneration can also develop as a result of extra-articular malunited fractures with altered angulations. Concurrent ligament injuries, if present, contribute to carpal incongruence and altered pressure areas.

In younger, nonosteoporotic patients, the prevalence of OA following DRFs has been reported as high as 32%–50% and frequently causes impairment. Ultimately the condition may end in a partial or TW arthrodesis and sometimes in inability for the patient to return to his or her habitual occupation. In elderly, low-demand patients posttraumatic wrist arthritis is better tolerated.

Main Question

Which procedures can we offer to a patient with a painful osteoarthritic wrist after a DRF and which outcomes can we expect?

Current Opinion

Conservative treatment is the first action to be taken in order to relieve the symptoms of painful posttraumatic OA. This includes nonsteroid antiinflammatory drugs, analgesics, cortisone injections, and splinting. There is time to carefully choose the right surgical option since spontaneous improvement of symptoms may occur as time goes by and the wrist stiffens. Some ligament injuries can also stabilize by time and, furthermore, proprioceptive training may reduce symptoms. However, even though splints and orthoses usually work well, they cannot always be used during work and are seldom a long-term solution. If severe symptoms persist, surgical treatment is indicated.

Wrist denervation could be the first surgical move before embarking for salvage procedures. RSL arthrodesis is an option if the midcarpal joint is preserved ( Fig. 2 ). TW arthrodesis is indicated in young patients who want a final solution, or as a salvage procedure in case of RSL failure ( Fig. 3 ). Prosthetic TW replacement is an alternative to TW arthrodesis especially in elderly, low-demand patients ( Fig. 4 ). In recent years, hemi-arthroplasty and interpositional pyrocarbon arthroplasty have been proposed as alternatives. Other salvage procedures for the wrist, including four corner arthrodesis and proximal row carpectomy, are less common options after DRF since a prerequisite for these procedures is an intact lunate facet of the radius. However, these procedures might be advised if the lunate facet is intact, or has been properly restored, while a concurrent scapholunate injury has caused a carpal collapse and subsequent OA.

Prosthetic replacement of the wrist may offer reduction of pain, preserved range of motion, and improved function but the long-term durability in different subgroups of patients is not well established. Although by many considered a panacea, TW arthrodesis is not a guarantee for freedom of pain and return to work.

Finding the Evidence

Search Strategy

Articles were selected through searches made in Cochrane, Embase, and Medline databases ( Fig. 5 ). The searches were based on the following terms: wrist, radiocarpal joint, osteoarthritis, arthroplasty, hemi-arthroplasty, replacement, implant, denervation, styloidectomy, carpectomy, fusion, arthrodesis, salvage. Only articles written in English, German, or French were considered. Anatomical and cadaver studies were excluded as well as articles published before the year of 2000 in order to avoid obsolete methods and implants. Cohorts with less than 10 cases and (review) articles without original data were excluded. Series that also included rheumatoid arthritis or Kienböck’s disease were also excluded if the DRFs could not be assessed separately. A total of 2831 articles were identified (Cochrane n = 120, Embase n = 1370, and Medline n = 1858). After deleting duplicates ( n = 973), 1858 articles were accepted for further review by using Rayyan® online software. The articles were reviewed independently and blindly by three reviewers. Two hundred and nine abstracts rendered interest by at least one of the three reviewers. After joined discussion, 37 abstracts were accepted for full-text review. A considerable amount of articles were excluded because of mixed patient cohorts, without specification of the data for DRFs. Finally, only four articles were found to meet inclusion and exclusion criteria. One more article dealt specifically with wrist arthritis after DRF. It was a review article without original data but made reference to a previous publication with relevant data. We decided to include that publication instead. By further reducing the restrictions and accepting articles that included posttraumatic OA in general and not solely on the basis of DRF, eight additional articles were selected.

Quality of Evidence

All selected articles had methodical flaws, including low number of patients and low quality of evidence ( Tables 1–4 ). Generally, preoperative patient-reported outcome measures (PROMs) were missing. Reported postoperative PROMs were not easily comparable between studies.

Table 1

Summary of Findings Related to Denervation Procedures.

Publication	Study Design	Number of Cases	Technique	Follow-Up	Pain	PROM
Schweizer et al. (2006)	Retrospective	71 (11 DRF, no RA)	Extensive (complete)	9.6 (1–23) years	35 None or little 20 Moderate 15 Considerable or severe	DASH-score 33 for DRF
Radu et al. (2010)	Retrospective	70 (43 to f.u., 30 hereof PT)	29 Extensive, 14 partial	51 (18–97) months	63%–64% PT had pain reduction. Better in extensive denervation	DASH-score 38–46 for PT

DASH , disabilities of arm, shoulder and hand questionnaire; DRF , distal radial fracture; f.u. , follow-up; PT , posttraumatic; RA , rheumatoid arthritis.

Table 2

Summary of Findings Related to Radioscapholunate Arthrodesis.

Publication	Study Design	Number of Cases	Technique	Follow-Up	Union	Wrist Motion Degrees Mean (Range)	Pain	OA at FU	Outcome
Beyermann and Prommersberger (2000)	Retro	18 DRF	No DS. K-wire fixation	19 (6–66) months	1 Required reoperation	F: 23 (5–40) ^a E: 24 (10–40) ^a R: 9 (0–20) U: 16 (10–25)	VAS score in activity: 3.6 (0–9) VAS score at rest: 0.6 (0–20)	No MC-joint OA	DASH score 26 (3–55)
Degeorge et al. (2019)	Retro	85 PT, 75 at FU	Locking T-plate/screws/staplers/K-wires 25 with DS, 50 without DS	9 (1–21) years	24% nonunion (less after DS)	45% had functional mobility ^b	33% had no or slight pain	MC OA in 44% (independent of DS)	QDASH score 31–40 Good in 80% with DS, 40% without DF ^b
Garcia-Elias et al. (2005)	Retro (comparing with literature)	16 (13 DRF)	K-wires. All with DS in own series, no DS in selected literature	34 (12–70) months	All united	F: 36 (16–52) E: 36 (25–50) R: 16 (10–28) U: 29 (5–32) (F better than in literature)	13/16 no or slight pain. 3 occasional pain (better than in literature)	No MC OA after DRF. (1/3 in literature had MC OA)	NA
Muhldorfer-Fodor et al. (2012)	Retro	61, 35 for f.u. (hereof 32 DRF)	K-wires 20 DS, 15 no DS	23–28 (10–47) months	3 nonunions (all without DS)	F with DS: 25 (25–50) F without DS: 20 (0–45) E with DS: 28 (0–50) E without DS: 28 (0–40) R with DS: 12 (0–25) R without DS: 7 (0–15) U with DS: 17 (5–35) U without DS: 16 (0–30)	VAS score with DS: 4.5 (0–8.5) VAS score without DS: 3.6 (0–8)	6 MC OA with DS 6 MC OA without DS 14 of the initial 61 patients had a TW arthrodesis	DASH score with DS: 43 (12–83) DASH score without DS: 44 (9–81)
Nagy and Büchler (1997)	Retro	15 DRF	Plates and screws, no DS	8 (7–12) years	4 nonunions (2 converted to TW arthrodesis, 1 re-RSL)	F: 18 (6–356) E: 32 (20–55) R: 3 (− 25 to 10) U: 25 (5–45)	11 no pain 1 occasional pain 3 considerable pain	3 progressive OA 5 nonprogressive OA	NA
Quadlbauer et al. (2017)	Retro	11 DRF	Locking frame plate. DS in all	63 (30–97) months	No nonunions	F: 63 (30–97) ^c E: 42 (20–60) ^c R: 10 (0–20) U: 25 (20–30)	VAS score 2 (0–5)	No MC OA	DASH score 24 (4–68)