Wrist Osteoarthritis


148 Wrist Osteoarthritis


Randy Bindra MD


Gold Coast Private Hospital, Southport, Queensland, Australia


Clinical scenario



  • A 50‐year‐old accountant complains of right wrist and left thumb pain. He recalls a wrist sprain occurring over 10 years ago. Over the past two years, his pain has been gradually worsening. He describes a dull, aching pain worse with activity in the right wrist. In addition, he complains of insidious onset of left thumb pain, worse with pinching and gripping activities.
  • Radiographs show evidence of radioscaphoid arthritis and scapholunate advanced collapse (SLAC) wrist on the right and scaphotrapeziotrapezoidal (STT) arthritis on the left.

Top three questions



  1. In patients with wrist osteoarthritis with involvement of the radiocarpal and midcarpal joint, is arthroplasty more appropriate than total wrist fusion?
  2. In patients with radioscaphoid arthritis, and preservation of the radiolunate joint, does proximal row carpectomy (PRC) result in better wrist motion than four‐corner arthrodesis (4CA)?
  3. In patients with STT joint arthritis is excisional arthroplasty (either distal scaphoid excision or trapeziectomy with ligament reconstruction) more effective than STT joint arthrodesis?

Question 1: In patients with wrist osteoarthritis with involvement of the radiocarpal and midcarpal joint, is arthroplasty more appropriate than total wrist fusion?


Rationale


Total wrist arthroplasty (TWA) is a newer treatment option for the management of wrist osteoarthritis in low‐demand individuals. Earlier ball‐and‐socket designs were associated with high loosening and dislocation rates. Current implants are better designed to be more stable with lesser range of motion (ROM) and better bony fixation.


Clinical comments


Wrist arthroplasty is indicated when other options such as PRC and partial fusion are not viable and the patient desires to retain wrist mobility. Examples of this situation would be bilateral wrist arthritis or occupation‐specific situations, such as in musicians.


Available literature and quality of the evidence


Most of the literature available currently comprises case series and retrospective analyses. There is only one level III retrospective review which compares the outcomes of arthroplasty and arthrodesis of the wrist. Additionally, other literature on TWA is focused on patients with rheumatoid arthritis, which is outside the scope of this chapter.


Findings


Nydick and colleagues’ study compared patient outcomes between two groups patients of whom 15 underwent wrist arthrodesis and seven had arthroplasty.1 Mean Disabilities of the Arm, Shoulder, and Hand (DASH) Visual Analog Scale (VAS) scores were not statistically different between groups. However, mean Patient‐Rated Wrist Evaluation (PRWE) was statistically significant: 31 versus 73 for TWA and arthrodesis, respectively. These questions from the PRWE were statistically significant and supportive of TWA: cut meat using a knife, fasten buttons, pushing up from a chair, personal care activities, and household work (p = 0.01). There was one complication of fixed wrist contracture in the arthroplasty group, two patients in the arthrodesis group had delayed union, and one required symptomatic screw removal.


In a retrospective review of 56 patients with a mean age of 52 years, who had undergone uncemented Motec wrist arthroplasty, Reigstad and colleagues found that the patients had greater ROM and grip strength at a mean of eight years following surgery.2 Compared to preoperative values grip strength had increased by 3 kg (p <0.05) and ROM had increased from 97 to 126° (p <0.05). At final follow‐up, 27 of 56 patients were working. The 10‐year Kaplan–Meier survival of the implants was 86%.


In retrospective review of 23 wrists in 22 patients with the Maestro TWA, Nydick et al. noted that patients had a statistically significant reduction in pain from 8 to 2 (p <0.05) at mean follow‐up of 28 months.3 Complications occurred in seven of the 23 patients: four wrist contractures, one implant failure, one deep infection, and one instability.


In a multicenter registry of the Remotion TWA implant, Boeckstyns reported a significant reduction in pain scores by 42 points at a mean two‐year follow‐up (p <0.01).4 The revision rate in this series was 3.7% with an estimated survival rate of 90% at four years.


Total wrist fusion (TWF) of the wrist has been used effectively for pain relief in the past. Weiss et al. reported being able to achieve pain relief in all of their 28 patients who underwent TWF for post‐traumatic arthritis and enabled 13 of patients to return to full‐time work, without restriction.5 Four patients required re‐operation due to discomfort of the extensor tendons following the surgery. In another study of 23 patients with TWF by Weiss and colleagues, 15 were able to return to full‐time work at the average follow‐up of 54 months.6


Results are not universally favorable. De Smet et al. found that many patients continued to have ongoing pain following fusions. Only six of 36 patients were pain free with activity at the time of follow‐up of four years.7 Many complications were seen in this study; 21 patients required re‐operation following TWF where 18 required removal of metalwork and three required revision.


Resolution of clinical scenario


In this patient with post‐traumatic wrist osteoarthritis, with pan‐carpal changes, either arthroplasty or total fusion may be considered. The procedure selected will be dependent on the patient’s activity level and desire to retain wrist mobility and their understanding of the limitations imposed by TWA and possibility of conversion of arthroplasty to fusion in the long term.


Question 2: In patients with radioscaphoid arthritis, and preservation of the radiolunate joint, does proximal row carpectomy (PRC) result in better wrist motion than four‐corner arthrodesis (4CA)?


Rationale


Early stages of wrist arthritis with isolated involvement of the radioscaphoid joint are amenable to either PRC or 4CA. If the radiolunate and midcarpal joints are preserved, both procedures can provide pain relief while preserving wrist motion, but have different recovery periods and complications.


Clinical comment

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Wrist Osteoarthritis

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