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AO-wrist arthrodesis: With and without arthrodesis of the third carpometacarpal joint
Original Communications AO-Wrist Arthrodesis: With and
Without Arthrodesis of the Third Carpometacarpal Ioint Ladislav Nagy, MD, Ueli Biichler, MD, Bern, Switzerland The incorporation of the third carpometacarpal joint (CMCJ-3) during wrist arthrodesis is controversial. This retrospective study of 146 consecutive wrist arthrodeses with AO plate fixation specifically addresses this question. In 79 wrist arthrodeses the CMCJ-3 was also arthrodesed, and in 67 the CMCJ-3 was simply bridged. Problems relating specifically to the CMCJ-3 could not be analyzed clearly with the plate in situ. Therefore after plate removal only 81 wrists were evaluated with respect to the CMCJ-3. Of 47 wrists that had CMCJ-3 arthrodesis and plate removal, 20 developed a nonunion. Eleven of these were painful and further surgical treatment was required. In contrast, of 34 wrists with the CMCJ-3 bridged all but one remained free of symptoms after the plate had been removed. We conclude that the CMCJ-3 must not be included in the arthrodesis when performing an AO-wrist arthrodesis. (J Hand Surg 2002; 27A:940-947. Copyright © 2002 by the American Society for Surgery of the Hand.) Key Words: Wrist arthrodesis, plate, carpometacarpal joint, nonunion.
Total wrist arthrodesis is regarded as a reliable and definitive salvage procedure for treatment of painful wrist conditions. At the expense of wrist motion, pain relief, strength, and durability are reliably obtained with high patient satisfaction. M a n y surgeons thus prefer total wrist arthrodesis to less-reliable motion-preserving treatment options such as limited carpal fusion or arthroplasty.l Although the merits of wrist arthrodesis are well documented and undisputed, some technical aspects have not been addressed sufficiently. The different techniques for
From the Hand Surgery Division, University of Bern/Inselspital, Bern, Switzerland. Received for publication July 16, 1997; accepted in revised form June 13, 2002. No benefits in any form have been received or will be receivedfrom a commercialparty related directly or indirectly to the subject of this article. Reprint requests: LadislavNagy, MD, TeamleiterHandchimrgie,Universita'tsspitalBalgrist, Forchstrasse340, 8008 Ztirich, Switzerland. Copyright© 2002 by the AmericanSocietyfor Surgeryof the Hand 0363-5023/02/27A06-0003535.00/0 doi:10.1053/jhsu.2002.35885 940
The Journal of Hand Surgery
wrist arthrodesis, while varying in the method of bone grafting and fixation, aim uniformly at fusing the distal radius and the proximal and distal carpal row into one single, rigid, bony structure. 2-16 Whereas the increasingly more popular AO-wrist arthrodesis method almost uniformly implies fixation with a dorsal compression plate between the distal radius and the third metacarpal, 1'12"17 40 there have been different proposals with regard to the inclusion of the third carpometacarpal joint (CMCJ-3) into the arthrodesis. S o m e surgeons have r e c o m m e n d e d arthrodesis of the CMCJ-31'18-20'22"23"2735-3740 and some even of the CMCJ-2 and -3.12"21"26"30"32"41Others do not arthrodese these joints at all if they are healthy.11"2531,34,39 All of these recommendations, however, have not been corroborated by data f r o m any of these researchers. On the one hand concerns about the possible metal fatigue and failure of the plate over a mobile articulation have been expressed. 19 On the other hand even in A O / A S I F wrist arthrodesis generally having nonunion rates of 0% to 1%, some cases of CMCJ-3 nonunion have been
The Journal of Hand Surgery / Vol. 27A No. 6 November 2002
reported. 1'19'z°'36"4° Having used AO/ASIF wrist arthrodesis with and without the inclusion of the CMCJ-3 extensively over the past 2 decades, the following retrospective comparative study was undertaken to clarify whether to arthrodese the CMCJ-3.
Materials and Methods Between 1984 and 2001, 146 complete wrist arthrodeses using one single, dorsal, dynamic compression plate for fixation according to the AO technique were performed at our institution. The surgical procedure was identical for all patients. The carpus was exposed from dorsal through the third extensor compartment. Before carpal surface resection the plate was applied provisionally with 2 screws into the distal radius and 2 into the third metacarpal to maintain reasonable carpal height and avoid problems with the distal radioulnar joint. Hereby the wrist was positioned in 15 ° of extension and 10 ° of ulnar deviation. An individually contoured, steel, 3.5-mm, dynamic compression plate was used in 62 wrists and the precontoured and tapered 3.5-/2.7-mm AO-titanium wrist arthrodesis plate was used in 84 wrists. The residual cartilage of the radiocarpal, midcarpal, and intercarpal joints was removed and the resulting space was packed with cancellous bone chips. The plate was then reapplied and firmly fixed to the radius and the third metacarpal with cortical bone screws. The bone graft was routinely harvested from the iliac crest except in 27 cases in which local bone material was used. The procedure included resection arthroplasty of the distal radioulnar joint in 44 wrists. In general no postoperative cast immobilization was used; thus, early functional treatment after surgery was allowed in all cases.
With respect to the treatment of the CMCJ, 2 groups were identified. In 79 wrists the surfaces of CMCJ-3 were resected and grafted with cancellous bone chips or a corticocancellous block. 19 In 67 wrists care was taken not to disturb the CMCJ-3 by leaving its capsule intact and simply immobilizing the nonarthrodesed joint by bridging the CMCJ-3 with the plate. Until April 1992 formal CMCJ-3 arthrodesis was done routinely in all cases treated. A review of the results thereafter changed our attitude, resulting in an increasing tendency to not incorporate the CMCJ-3 in the arthrodesis unless it was affected by an underlying disease process. Definitive radiocarpal consolidation was observed in 145 wrists; 1
941
nonunion needed rearthrodesis. Three plates (2 titanium and 1 steel) broke secondary to fatigue directly over the CMCJ-3 area, once after CMCJ-3 arthrodesis and twice after bridging, and were removed. With the plates in situ, symptoms possibly caused by the CMCJ-3 could not be identified conclusively or attributed to the CMCJ-3, as with the plate effectively splinting and also covering the CMCJ-3. Therefore objective clinical and radiographic assessment proved almost impossible (Fig. 1A,B). Even tomographic examination was unreliable. The evaluation of the CMCJ-3 was thus restricted to those 81 patients (55%) whose CMCJ-3 was unprotected after. implant removal, therefore being truly accessible to clinical and radiographical examination. There were 56 men and 25 women, and 49 wrists were dominant. Mean age at the time of wrist arthrodesis was 42 years (range, 17-78 y). The reasons for arthrodesis were posttraumatic wrist pain 51 wrists inflammatory arthritis 10 the final stage of Kienbrck's disease 9, and sequelae of paralysis or forearm muscle injury (11). Review of the clinical charts and previous radiographs allowed for assessing the clinical course with respect to the CMCJ-3 from date of the arthrodesis, especially incorporating observations obtained direct exposure during hardware removal up to the current condition. History taken at the occasion of the final follow-up evaluation focused on spontaneous pain, pain on motion, and stress in the CMCJ-3 area. Besides standard clinical assessment of the wrists, attention was specifically directed to the provocation of pain and motion of the CMCJ-3 by pushing the head of the third metacarpal forcefully up and down. For verification of CMCJ-3 union, standard radiographs were obtained. If the findings were not conclusive, trispiroid or computed tomograms were done. The mean follow-up interval after arthrodesis was 4.2 years (range, 2-15 y) and 1.7 years after plate removal (range, 6 mo to 7 y). Pooled t-tests and Spearman rank correlation were used for statistical analysis of the data.
Results A summary of results is given in Figure 2. In 81 wrists the implants were removed at an average of 1.4 years (range, 4 mo to 9 y) after arthrodesis. There were 43 of 62 dynamic compression [DC]-steel plates (69%) and 38 of 84 titanium wrist fusion plates (45%), which is a significant difference (r = .228, p = .006). This difference probably was created
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A
Nagy and Bfichler/AO-Wrist Arthrodesis
B
C
Figure 1. Attempted CMCJ-3 arthrodesis. (A and B) A 3.5-mm dynamic compression plate (steel): CMCJ-consolidation owing to superposition not conclusive. (C and D) Nonunion apparent after plate removal. (E and F) After successful rearthrodesis of CMCJ-3 and 2.
by our former attitude to remove the implant routinely, which was largely abandoned after the introduction of the contoured titanium wrist fusion plate. Documented complaints related to the plate, such as painful bulk or
synovitis could be found in 28 patients with DC-steel plates (65%) and in 29 patients with titanium wrist fusion plates (76%). This difference is not different statistically (r = .095, p = .3).
The Journal of Hand Surgery / Vol. 27A No. 6 November 2002 943 AO-wristarLhrodeses platesremoved
CMCJafter bridging 34
attemptedarthrodesis
united 27
hypermobile,painful 1
not united 20
painfreenon-union
\ 8 ~
1
painfulnon-union 11 8
/p
rearthrodeses 9
painfreeunionCMCJ painfreenon-unionCMCJ 34 9
~ l ~ l
3
mobile,painfree 33
1
arthrodesis 1 S
painfulnon-unionCMCJ 5
painfree,healthyCMCJ 33
Figure 2. Clinical course of all CMCJs after plate removal.
Pain clearly related to the CMCJ-3 was already present in 3 patients before plate removal; in all cases it corresponded to failure of the osteosynthesis and subsequent instability of the CMCJ-3. The plate over the third metacarpal had become loose in 2 patients (1 was infected), and the implant had fractured directly over the (pseudarthrotic) CMCJ-3 in the third patient. In the other 10 patients the CMCJ-3 became painful at an average of 30 days (range, 1 4 - 6 0 d) after plate removal; spontaneous pain relief occurred in only 1 patient 1 month after plate removal. CMCJ-3 After Attempted Arthrodesis
In these 47 wrists 38 (81%) steel plates had been used and removed, representing the older cases in the series before the introduction of the AO-wrist fusion plate (Fig. 1). Twenty wrists presented a pseudarthrosis of the CMCJ-3 (43%). The nonunion could be diagnosed with the plate in situ in 4 cases only. In 3 of these the plate had become loose distally and in 1 the implant had failed directly over the CMCJ-3 nonunion. In 7 cases the diagnosis was established immediately during surgery, motion of the CMCJ-3 with the plate removed was observed in 1 case after 6 months. In the residual 8 patients an increasingly painful but not clearly mobile
CMCJ-3 led to further scrutiny and radiographic confirmation of pseudarthrosis 30 to 149 days after implant removal (Fig. 1C,D). Five nonunions occurred with the use of a solid corticocancellous inlay graft and 15 with the insertion of bone chips, which is proportional to the frequency of the 2 techniques in our series. Nine patients were pain free. Pain, if absent before, appeared early after plate r e m o v a l - - o n average after 33 days (range, 14-60d). Painful nonunion was noted in 11 wrists. One nonunion was infected and painful. One painless nonunion was combined with malrotation of the middle finger. In 9 cases rearthrodesis with cancellous bone grafting and repeated plate fixation was carried out (Fig. 1E,F). This second attempt resulted in tomographically confirmed union and pain relief in 5 cases and persisting pseudarthrosis in 4 cases. Of the latter 3 pseudarthroses remained moderately painful. One patient then had simple implant removal without improvement and 2 patients had repeated CMCJ-3 rearthrodesis followed by successful consolidation in both cases. Of the 20 patients with CMCJ-3 nonunion, 12 still had CMCJ-3 nonunion and 4 of them remained painful after these repetitive, additional surgeries (Fig. 2). In the residual 27 patients the CMCJ-3 was found clinically stable, painless on loading, and showed radiographic union.
944 Nagy and B~ichler/AO-Wrist Arthrodesis
C
D
Figure 3, CMCJ-3 bridged. (A and B) Bridged with tapered 3.5-12.7-mm AO wrist arthrodesis plate (titanium, bone anchor from previous surgery). (C and D) Healthy and pain free CMCJ-3 after plate removal.
CMC]-3 After Bridging In these 34 wrists only 5 steel plates (15%) had been used and removed owing to the more restrictive attitude toward athrodesis of the CMCJ-3 and almost
simultaneous introduction of the titanium wrist fusion plate (Fig. 3). In 2 patients the plates (1 steel and 1 titanium) broke because of fatigue and were removed without any further symptoms.
The Journal of Hand Surgery / Vol. 27A No. 6 November 2002
Two patients presented problems related to the CMCJ-3 after implant removal. One had slight joint pain appearing 2 weeks after plate removal and resolving spontaneously 2 weeks later. At follow-up examination the CMCJ-3 showed no excessive motion and no pain on motion or stress; radiographs were normal. The other patient also experienced pain over the CMCJ-3 beginning 2 weeks after plate removal, but there was a further increase in pain over the next month and he was unable to return to work. There was evident painful and excessive motion of all carpometacarpal joints, which appeared wide radiographically. The patient also displayed excessive general laxity (hyperextension of the elbows and fingers and subluxation of the distal radioulnar joints). He had arthrodesis of the CMCJ-3 and -2. During surgery the joint surfaces appeared without degeneration. Despite additional cast immobilization the arthrodesis failed to unite, the plate over the CMCJ-3 broke, and the plate over the CMCJ-2 loosened, again resulting in moderately painful motion. The patient refrained from further surgical treatment. Of the remaining patients 30 were entirely asymptomatic and 2 had overlying, generalized, 'painful conditions clearly caused by reasons other than the CMCJ-3. None of these patients experienced pain over the CMCJ-3 on stress and motion of the third metacarpal. The 2 groups compared were not statistically different in terms of age, gender, hand dominance, etiology, or ancillary distal radioulnar joint procedures. There was no correlation between the type of treatment of CMCJ-3 or the implant used and reasons of implant removal. There were however, more titanium plates in the second group (81% vs 15%, p < .001) owing to the introduction of the new implant in December 1990 and the changed policy toward the inclusion of the CMCJ-3 1 year later. CMCJ-3 pain correlated closely with nonunion (p < .001) and with the attempt of formal arthrodesis (p < .005).
Discussion In the long history of total wrist arthrodesis many different techniques have been developed. 2-16 With the evolution of internal fixation, compression-plate wrist arthrodesis has gained increasing popularity and its results compare very favorably with other established methods, m2"~7-4° Although allowing functional treatment after surgery and early use of
945
the hand without external protection, the risk of radiocarpal nonunion has been reduced to almost 0%. Despite a lack of evidence, explicit recommendations have been expressed on how the carpometacarpal joints of the second and third finger should be handled when performing a wrist arthrodesis. Most frequently simultaneous arthrodesis of the CMCJ-3 w a s a d v o c a t e d . 1'18-2°'22'23'27'35-37"4° O t h e r s u r g e o n s
have recommended arthrodesis of the third and second CMCJ. ~2,~7,21,26,30,32This may be difficult in AO wrist arthrodesis because the compression plate immobilizes only one CMCJ-3. Pech et a132 therefore have designed a special arthrodesis plate, distally expanding over both the second and the third metacarpal. A third group does not arthrodese this joint unless it also has been affected by trauma or disease. 11"25,31'34"39'41 Nonunion rates and painful sequelae at the CMCJ-3 have not been assessed systematically and respective reports in the literature are scant. Bolano and Green 17 have presented a series of 26 patients with wrist arthrodesis. Of 18 patients treated with different modalities of radiocapitate arthrodesis in which the CMCJ was not arthrodesed, 5 had symptomatic motion of the CMCJ and 2 required arthrodesis. Eight patients with AO wrist arthrodesis in which CMCJ-2 and 3 were arthrodesed did not present this problem. In 6 of these 8, however, the plate over the CMCJ was still in situ while testing for CMCJ motion. Hastings et al,~ reporting on 97 noncomplex wrist arthrodeses, have used AO wrist arthrodesis with systematic CMCJ-3 arthrodesis in 58 cases and have encountered one painful nonunion of the CMCJ-3. Only 7 of 58 patients have had implant removal at the time of evaluation. In a later review on 90 consecutive wrist arthrodeses for posttranmatic disorders, now including 57 AO wrist arthrodeses with systematic arthrodesis of the CMCJ-3, Hastings et al. 19 found 3 patients with painful nonunion of the CMCJ-3. Unfortunately no data on plate removal or implant failures were given. Nevertheless they recommended inclusion of the CMCJ-3 in the total arthrodesis of the wrist because without routine implant removal, "possible metal fatigue and failure of the plate over a mobile articulation would be a concern. ''~9 Sagerman and Palmer 36 also using dynamic compression plates in 18 wrist arthrodeses with systematic inclusion of the CMCJ-3 removed the plate in 10 wrists; 2 patients needed regrafting of the CMCJ. Houshian and SchrCder 2° used the titanium wrist fusion plate in 42 wrists, with routine arthrodesis of
946
Nagy and B~ichler/AO-Wrist Arthrodesis
the CMCJ-3. Six patients (14%) needed implant removal, 3 patients had nonunion, one of the CMCJ-3. Sauerbier et al 4° in a report on their first experience with the new AO titanium wrist fusion plate, found implant failures adjacent to the CMCJ-3 and nonunions in 3 of 35 cases, despite simultaneous arthrodesis of the CMCJ-3. LarssonY in the first series on compression-plate arthrodesis of the wrist in the English literature, refrained from resecting the CMCJ-3, had 100% union in his 23 cases, and routinely removed all plates. The CMC joints resulted painless and "showed a slight range of motion in most of the patients. ''25 Reporting on complications of 73 AO/ ASIF wrist arthrodeses, Zachary and Stern 39 have had no case of "capitate-middle metacarpal arthritis despite the fact that the joint was not arthrodesed." The plate was removed in 14 cases only (19%); implant failures were not reported. Moneim et a129 performed 26 wrist arthrodeses by using the AO technique, "carefully avoiding" the CMCJs. Despite "fair motion" in the CMCJs after plate removal in 18 wrists (69%), pain in the index and long CMCJs was not faced. Our material allows a straightforward comparison of the 2 methods of dealing with the CMCJ-3 during AO wrist arthrodesis. Clinical and radiographic assessment of the CMCJ-3, with or without arthrodesis, is not possible with a shielding implant. The ultimate function of the CMCJ-3 emerges only after removal of the plate or perhaps after mechanical failure of the implant. This may explain why potential CMCJ problems have been underestimated in reports in which the implants were retained at the time of evaluation. Indeed most of our patients were asymptomatic with respect to the CMCJ-3 as long as the plates remained in situ. Our rate of hardware removal may seem higher compared with others, but it has decreased after the introduction of the AO titanium wrist fusion plate. However, considering the persistent causes for hardware removal even this wellcontoured, tapered, and lower-profile plate cannot be considered a permanent implant. Implant failure definitely is another concern, occurring in 6 of our patients. 4 after attempted unsuccessful arthrodesis and 2 after bridging of the CMCJ-3, that is, it could not be eliminated reliably by CMCJ-3 arthrodesis. Thus when performing wrist arthrodesis the plate removal must be anticipated. Our study therefore focused only on patients with the plates removed. If the CMCJ-3 was left simply bridged, its function returned to normal and was pain free after plate
removal except for one case. If an attempt was made to arthrodese the CMCJ-3 a nonunion rate of 43% was observed. More than half of these nonunions were painful, necessitating further and sometimes repetitive surgical treatment that was not overly successful. Based on our results we strongly advise not to include the CMCJ-3 when performing an AO wrist arthrodesis unless the CMCJ shows pre-existing pathology. If a healthy CMCJ-3 was only bridged by the plate, it seems logical to remove the implant and allow physiologic motion of this joint. After attempted arthrodesis of this joint the plate should be left in place if possible because a dormant nonunion is likely to become symptomatic with discontinued shielding. Fatigue-fracture or loosening of the implant may arise over an excessively mobile and insufficiently consolidated CMCJ. In patients who developed painful CMCJ-3 nonunion after plate removal, rearthrodesis should be considered despite nonuniform results.
References 1. Hastings H. Weiss A-PC, Strickland JW. Die arthrodese des handgelenks. Indikation, technik und funktionelle konsequenzen for hand and handgelenk. Orthop~ide 1993;22: 86-91. 2. Abott LC, Saunders JB, Bost FC. Arthrodesis of the wrist with the use of grafts of cancellous bone. J Bone Joint Surg 1942;24:883-898. 3. Benkeddache Y, Gottesman H, Fourrier P. Multiple stapling for wrist arthrodesis in the nonrheumatoid patient. J Hand Surg 1984;9A:256-260. 4. Campbell CJ, Keokarn T. Total and subtotal arthrodesis of the wrist. J Bone Joint Surg 1964;46A:1520-1533. 5. Carroll RE, Dick HM. Arthrodesis of the wrist for rheumatoid arthritis. J Bone Joint Surg 1971;53A:1365-1369. 6. Debeyre J, Goutallier D. Une technique d'arthrodrse du poignet par greffon iliaque intra-carpien. Rev Chir Orthop Reparatrice Appar Mot 1972;58:91-102. 7. Haddad RJ Jr, Riordan DC. Art_hrodesis of the wrist. A surgical technique. J Bone Joint Surg 1967;49A:950-954. 8. Liebolt FL. Surgical fusion ofthewristjoint. Surg Gynecol Obstet 1938;66:1008-1023. 9. MacKenzie IG. Arthrodesis of the wrist in reconstructive surgery. J Bone Joint Surg 1960;42B:60-64. 10. Mannerfelt L, Malmsten M. Arthrodesis of the wrist in rheumatoid arthritis. A technique without external fixation. Scand J Plast Reconstr Surg 1971;5:124-130. 11. Mittal RL, Jain NC. Arthrodesis of the wrist by a new technique. Int Orthop 1990;14:213-216. 12. von MOiler ME, Allgrwer M, Willenegger H. Technik der Arthrodese des Ellbogen- und des Handgelenkes. In: ME von Mtiller, ed. Manual der osteosynthese. AO-Technik. Berlin: Springer-verlag, 1969;280-281.
The Journal of Hand Surgery / Vol. 27A No. 6 November 2002 13. Babin-Chevaye J. Technique d'arthrod~se du poignet. Rev Chit Orthop Reparatrice Appar Mot 1968;54:275-277. 14. Brunelli G, Vigasio A, Battiston B, Brunelli F, Guizzi P. L'arthrodbse du poignet dans les paralysies de la main (technique personelle). Ann Chir Main Memb Super 1990; 9:47-54. 15. Lenoble E, Ovadia H, Goutallier D. Wrist arthrodesis using an embedded iliac crest bone graft. J Hand Surg 1993;18B: 595- 600. 16. Rayan GM. Wrist arthrodesis. J Hand Surg 1986;11A: 356-364. 17. Bolano LE, Green DP. Wrist arthrodesis in post-traumatic arthritis: a comparison of two methods. J Hand Surg 1993; 18A:786-791. 18. Hartigan BJ, Nagle DJ, Foley MJ. Wrist arthrodesis with excision of the proximal carpal bones using the AO/ASIF wrist fusion plate and local bone graft. J Hand Surg 2001; 26B:247-251. 19. Hastings H II, Weiss A-PC, Quenzer D, Wiedeman GP, Hanington KR, Strickland JW. Arthrodesis of the wrist for post-traumatic disorders. J Bone Joint Surg 1996;78A: 897-902. 20. Houshian S, SchrCder HA. Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases. J Hand Surg 2001;26B:355-359. 21. Izadpanah M, Klems H. Handgelenksarthrodese. Behandlungsergebnisse bei 27 patienten unter besonderer berticksichtigung der plattenosteosynthese. Arch Orthop Unfallchir 1977;88:237-248. 22. Jebson PJL, Adams BD. Wrist arthrodesis: review of current techniques. J Am Acad Orthop Surg 2001;9:53-60. 23. Kalb K, Ludwig A, Tauscher A, Landsleitner B, Wiemer P, Krimmer H. Behandlungsergebnisse nach operativer handgelenksversteifung. Handchir Mikrochir Hast Chir 1999;31:253-259. 24. Anderson GA, Thomas BP. Arthrodesis of flail or partially flail wrists using a dynamic compression plate without bone grafting. J Bone Joint Surg 2000;82B:566-570. 25. Larsson S-E. Compression arthrodesis of the wrist. A consecutive series of 23 cases. Clin Orthop 1974;99:146-153. 26. Leighton RK, Petrie D. Arthrodesis of the wrist. Can J Surg 1987;30:115-116.
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27. Leversedge FJ, Seller JG, Toye-Vego M, Fleming LL. Wrist arthrodesis using a wrist fusion plate. J South Orthop Assoc 1999;8:86-92. 28. Lohmann H, Buck-Gramcko, D: Indikation und ergebnisse der handgelenkarthrodesen. Handchir Mikrochir Hast Chir 1982:14:172-182. 29. Moneim MS, Pribyl CR, Garst JR. Wrist arthrodesis. Technique and functional evaluation. Clin Orthop 1997;341:2329. 30. Narr H. Indikationsbereiche, technik und ergebnisse der handgelenksarthrodese. Unfallheilkunde 1982;85:171177. 31. O'Bierne J, Boyer MI, Axelrod TS. Wrist arthrodesis using a dynamic compression plate. J Bone Joint Surg 1995;77B: 700 -704. 32. Pech J, Sosna A, Rybka V, Pokomy D. Wrist arthrodesis in rheumatoid arthritis. A new technique using internal fixation. J Bone Joint Surg 1996;78B:783-786. 33. Richards RR, Patterson SD, Hearn TC. A special plate for arthrodesis of the wrist: design considerations and biomechanical testing. J Hand Surg 1993;18A:476-483. 34. Richards RS, Roth JH. Simultaneous proximal row carpectomy and radius to distal carpal row arthrodesis. J Hand Surg 1994;19A:728-732. 35. Richterman L Weiss A-PC. Wrist fusion. Hand Clin 1997; 13:681-687. 36. Sagerman SD, Palmer AK. Wrist arthrodesis using a dynamic compression plate. J Hand Surg 1996;21B :437-441. 37. Weiss A-PC, Hastings H II. Wrist arthrodesis for traumatic conditions: a study of plate and local bone graft application. J Hand Surg 1995;20A:50-56. 38. Wetzel R, Wessinghage D. Die arthrodese des handgelenks beim polyarthritiker. Handchir Mikrochir Plast Chir 1987; 19:49 -54. 39. Zachary SV, Stern PJ. Complications following AO/ASIF wrist arthrodesis. J Hand Surg 1995;20A:339-344. 40. Sauerbier M, Kania NM, Kluge S, Bickert B, Germann G. Erste ergebnisse mit der neuen AO-handgelenk-arthrodeseplatte. Handchir Mikrochir Hast Chit 1999:31:260-265. 41. Louis DS, Hankin FM, Bowers WH. Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis. J Hand Surg 1984;9A:365-369.
Without Arthrodesis of the Third Carpometacarpal Ioint Ladislav Nagy, MD, Ueli Biichler, MD, Bern, Switzerland The incorporation of the third carpometacarpal joint (CMCJ-3) during wrist arthrodesis is controversial. This retrospective study of 146 consecutive wrist arthrodeses with AO plate fixation specifically addresses this question. In 79 wrist arthrodeses the CMCJ-3 was also arthrodesed, and in 67 the CMCJ-3 was simply bridged. Problems relating specifically to the CMCJ-3 could not be analyzed clearly with the plate in situ. Therefore after plate removal only 81 wrists were evaluated with respect to the CMCJ-3. Of 47 wrists that had CMCJ-3 arthrodesis and plate removal, 20 developed a nonunion. Eleven of these were painful and further surgical treatment was required. In contrast, of 34 wrists with the CMCJ-3 bridged all but one remained free of symptoms after the plate had been removed. We conclude that the CMCJ-3 must not be included in the arthrodesis when performing an AO-wrist arthrodesis. (J Hand Surg 2002; 27A:940-947. Copyright © 2002 by the American Society for Surgery of the Hand.) Key Words: Wrist arthrodesis, plate, carpometacarpal joint, nonunion.
Total wrist arthrodesis is regarded as a reliable and definitive salvage procedure for treatment of painful wrist conditions. At the expense of wrist motion, pain relief, strength, and durability are reliably obtained with high patient satisfaction. M a n y surgeons thus prefer total wrist arthrodesis to less-reliable motion-preserving treatment options such as limited carpal fusion or arthroplasty.l Although the merits of wrist arthrodesis are well documented and undisputed, some technical aspects have not been addressed sufficiently. The different techniques for
From the Hand Surgery Division, University of Bern/Inselspital, Bern, Switzerland. Received for publication July 16, 1997; accepted in revised form June 13, 2002. No benefits in any form have been received or will be receivedfrom a commercialparty related directly or indirectly to the subject of this article. Reprint requests: LadislavNagy, MD, TeamleiterHandchimrgie,Universita'tsspitalBalgrist, Forchstrasse340, 8008 Ztirich, Switzerland. Copyright© 2002 by the AmericanSocietyfor Surgeryof the Hand 0363-5023/02/27A06-0003535.00/0 doi:10.1053/jhsu.2002.35885 940
The Journal of Hand Surgery
wrist arthrodesis, while varying in the method of bone grafting and fixation, aim uniformly at fusing the distal radius and the proximal and distal carpal row into one single, rigid, bony structure. 2-16 Whereas the increasingly more popular AO-wrist arthrodesis method almost uniformly implies fixation with a dorsal compression plate between the distal radius and the third metacarpal, 1'12"17 40 there have been different proposals with regard to the inclusion of the third carpometacarpal joint (CMCJ-3) into the arthrodesis. S o m e surgeons have r e c o m m e n d e d arthrodesis of the CMCJ-31'18-20'22"23"2735-3740 and some even of the CMCJ-2 and -3.12"21"26"30"32"41Others do not arthrodese these joints at all if they are healthy.11"2531,34,39 All of these recommendations, however, have not been corroborated by data f r o m any of these researchers. On the one hand concerns about the possible metal fatigue and failure of the plate over a mobile articulation have been expressed. 19 On the other hand even in A O / A S I F wrist arthrodesis generally having nonunion rates of 0% to 1%, some cases of CMCJ-3 nonunion have been
The Journal of Hand Surgery / Vol. 27A No. 6 November 2002
reported. 1'19'z°'36"4° Having used AO/ASIF wrist arthrodesis with and without the inclusion of the CMCJ-3 extensively over the past 2 decades, the following retrospective comparative study was undertaken to clarify whether to arthrodese the CMCJ-3.
Materials and Methods Between 1984 and 2001, 146 complete wrist arthrodeses using one single, dorsal, dynamic compression plate for fixation according to the AO technique were performed at our institution. The surgical procedure was identical for all patients. The carpus was exposed from dorsal through the third extensor compartment. Before carpal surface resection the plate was applied provisionally with 2 screws into the distal radius and 2 into the third metacarpal to maintain reasonable carpal height and avoid problems with the distal radioulnar joint. Hereby the wrist was positioned in 15 ° of extension and 10 ° of ulnar deviation. An individually contoured, steel, 3.5-mm, dynamic compression plate was used in 62 wrists and the precontoured and tapered 3.5-/2.7-mm AO-titanium wrist arthrodesis plate was used in 84 wrists. The residual cartilage of the radiocarpal, midcarpal, and intercarpal joints was removed and the resulting space was packed with cancellous bone chips. The plate was then reapplied and firmly fixed to the radius and the third metacarpal with cortical bone screws. The bone graft was routinely harvested from the iliac crest except in 27 cases in which local bone material was used. The procedure included resection arthroplasty of the distal radioulnar joint in 44 wrists. In general no postoperative cast immobilization was used; thus, early functional treatment after surgery was allowed in all cases.
With respect to the treatment of the CMCJ, 2 groups were identified. In 79 wrists the surfaces of CMCJ-3 were resected and grafted with cancellous bone chips or a corticocancellous block. 19 In 67 wrists care was taken not to disturb the CMCJ-3 by leaving its capsule intact and simply immobilizing the nonarthrodesed joint by bridging the CMCJ-3 with the plate. Until April 1992 formal CMCJ-3 arthrodesis was done routinely in all cases treated. A review of the results thereafter changed our attitude, resulting in an increasing tendency to not incorporate the CMCJ-3 in the arthrodesis unless it was affected by an underlying disease process. Definitive radiocarpal consolidation was observed in 145 wrists; 1
941
nonunion needed rearthrodesis. Three plates (2 titanium and 1 steel) broke secondary to fatigue directly over the CMCJ-3 area, once after CMCJ-3 arthrodesis and twice after bridging, and were removed. With the plates in situ, symptoms possibly caused by the CMCJ-3 could not be identified conclusively or attributed to the CMCJ-3, as with the plate effectively splinting and also covering the CMCJ-3. Therefore objective clinical and radiographic assessment proved almost impossible (Fig. 1A,B). Even tomographic examination was unreliable. The evaluation of the CMCJ-3 was thus restricted to those 81 patients (55%) whose CMCJ-3 was unprotected after. implant removal, therefore being truly accessible to clinical and radiographical examination. There were 56 men and 25 women, and 49 wrists were dominant. Mean age at the time of wrist arthrodesis was 42 years (range, 17-78 y). The reasons for arthrodesis were posttraumatic wrist pain 51 wrists inflammatory arthritis 10 the final stage of Kienbrck's disease 9, and sequelae of paralysis or forearm muscle injury (11). Review of the clinical charts and previous radiographs allowed for assessing the clinical course with respect to the CMCJ-3 from date of the arthrodesis, especially incorporating observations obtained direct exposure during hardware removal up to the current condition. History taken at the occasion of the final follow-up evaluation focused on spontaneous pain, pain on motion, and stress in the CMCJ-3 area. Besides standard clinical assessment of the wrists, attention was specifically directed to the provocation of pain and motion of the CMCJ-3 by pushing the head of the third metacarpal forcefully up and down. For verification of CMCJ-3 union, standard radiographs were obtained. If the findings were not conclusive, trispiroid or computed tomograms were done. The mean follow-up interval after arthrodesis was 4.2 years (range, 2-15 y) and 1.7 years after plate removal (range, 6 mo to 7 y). Pooled t-tests and Spearman rank correlation were used for statistical analysis of the data.
Results A summary of results is given in Figure 2. In 81 wrists the implants were removed at an average of 1.4 years (range, 4 mo to 9 y) after arthrodesis. There were 43 of 62 dynamic compression [DC]-steel plates (69%) and 38 of 84 titanium wrist fusion plates (45%), which is a significant difference (r = .228, p = .006). This difference probably was created
942
A
Nagy and Bfichler/AO-Wrist Arthrodesis
B
C
Figure 1. Attempted CMCJ-3 arthrodesis. (A and B) A 3.5-mm dynamic compression plate (steel): CMCJ-consolidation owing to superposition not conclusive. (C and D) Nonunion apparent after plate removal. (E and F) After successful rearthrodesis of CMCJ-3 and 2.
by our former attitude to remove the implant routinely, which was largely abandoned after the introduction of the contoured titanium wrist fusion plate. Documented complaints related to the plate, such as painful bulk or
synovitis could be found in 28 patients with DC-steel plates (65%) and in 29 patients with titanium wrist fusion plates (76%). This difference is not different statistically (r = .095, p = .3).
The Journal of Hand Surgery / Vol. 27A No. 6 November 2002 943 AO-wristarLhrodeses platesremoved
CMCJafter bridging 34
attemptedarthrodesis
united 27
hypermobile,painful 1
not united 20
painfreenon-union
\ 8 ~
1
painfulnon-union 11 8
/p
rearthrodeses 9
painfreeunionCMCJ painfreenon-unionCMCJ 34 9
~ l ~ l
3
mobile,painfree 33
1
arthrodesis 1 S
painfulnon-unionCMCJ 5
painfree,healthyCMCJ 33
Figure 2. Clinical course of all CMCJs after plate removal.
Pain clearly related to the CMCJ-3 was already present in 3 patients before plate removal; in all cases it corresponded to failure of the osteosynthesis and subsequent instability of the CMCJ-3. The plate over the third metacarpal had become loose in 2 patients (1 was infected), and the implant had fractured directly over the (pseudarthrotic) CMCJ-3 in the third patient. In the other 10 patients the CMCJ-3 became painful at an average of 30 days (range, 1 4 - 6 0 d) after plate removal; spontaneous pain relief occurred in only 1 patient 1 month after plate removal. CMCJ-3 After Attempted Arthrodesis
In these 47 wrists 38 (81%) steel plates had been used and removed, representing the older cases in the series before the introduction of the AO-wrist fusion plate (Fig. 1). Twenty wrists presented a pseudarthrosis of the CMCJ-3 (43%). The nonunion could be diagnosed with the plate in situ in 4 cases only. In 3 of these the plate had become loose distally and in 1 the implant had failed directly over the CMCJ-3 nonunion. In 7 cases the diagnosis was established immediately during surgery, motion of the CMCJ-3 with the plate removed was observed in 1 case after 6 months. In the residual 8 patients an increasingly painful but not clearly mobile
CMCJ-3 led to further scrutiny and radiographic confirmation of pseudarthrosis 30 to 149 days after implant removal (Fig. 1C,D). Five nonunions occurred with the use of a solid corticocancellous inlay graft and 15 with the insertion of bone chips, which is proportional to the frequency of the 2 techniques in our series. Nine patients were pain free. Pain, if absent before, appeared early after plate r e m o v a l - - o n average after 33 days (range, 14-60d). Painful nonunion was noted in 11 wrists. One nonunion was infected and painful. One painless nonunion was combined with malrotation of the middle finger. In 9 cases rearthrodesis with cancellous bone grafting and repeated plate fixation was carried out (Fig. 1E,F). This second attempt resulted in tomographically confirmed union and pain relief in 5 cases and persisting pseudarthrosis in 4 cases. Of the latter 3 pseudarthroses remained moderately painful. One patient then had simple implant removal without improvement and 2 patients had repeated CMCJ-3 rearthrodesis followed by successful consolidation in both cases. Of the 20 patients with CMCJ-3 nonunion, 12 still had CMCJ-3 nonunion and 4 of them remained painful after these repetitive, additional surgeries (Fig. 2). In the residual 27 patients the CMCJ-3 was found clinically stable, painless on loading, and showed radiographic union.
944 Nagy and B~ichler/AO-Wrist Arthrodesis
C
D
Figure 3, CMCJ-3 bridged. (A and B) Bridged with tapered 3.5-12.7-mm AO wrist arthrodesis plate (titanium, bone anchor from previous surgery). (C and D) Healthy and pain free CMCJ-3 after plate removal.
CMC]-3 After Bridging In these 34 wrists only 5 steel plates (15%) had been used and removed owing to the more restrictive attitude toward athrodesis of the CMCJ-3 and almost
simultaneous introduction of the titanium wrist fusion plate (Fig. 3). In 2 patients the plates (1 steel and 1 titanium) broke because of fatigue and were removed without any further symptoms.
The Journal of Hand Surgery / Vol. 27A No. 6 November 2002
Two patients presented problems related to the CMCJ-3 after implant removal. One had slight joint pain appearing 2 weeks after plate removal and resolving spontaneously 2 weeks later. At follow-up examination the CMCJ-3 showed no excessive motion and no pain on motion or stress; radiographs were normal. The other patient also experienced pain over the CMCJ-3 beginning 2 weeks after plate removal, but there was a further increase in pain over the next month and he was unable to return to work. There was evident painful and excessive motion of all carpometacarpal joints, which appeared wide radiographically. The patient also displayed excessive general laxity (hyperextension of the elbows and fingers and subluxation of the distal radioulnar joints). He had arthrodesis of the CMCJ-3 and -2. During surgery the joint surfaces appeared without degeneration. Despite additional cast immobilization the arthrodesis failed to unite, the plate over the CMCJ-3 broke, and the plate over the CMCJ-2 loosened, again resulting in moderately painful motion. The patient refrained from further surgical treatment. Of the remaining patients 30 were entirely asymptomatic and 2 had overlying, generalized, 'painful conditions clearly caused by reasons other than the CMCJ-3. None of these patients experienced pain over the CMCJ-3 on stress and motion of the third metacarpal. The 2 groups compared were not statistically different in terms of age, gender, hand dominance, etiology, or ancillary distal radioulnar joint procedures. There was no correlation between the type of treatment of CMCJ-3 or the implant used and reasons of implant removal. There were however, more titanium plates in the second group (81% vs 15%, p < .001) owing to the introduction of the new implant in December 1990 and the changed policy toward the inclusion of the CMCJ-3 1 year later. CMCJ-3 pain correlated closely with nonunion (p < .001) and with the attempt of formal arthrodesis (p < .005).
Discussion In the long history of total wrist arthrodesis many different techniques have been developed. 2-16 With the evolution of internal fixation, compression-plate wrist arthrodesis has gained increasing popularity and its results compare very favorably with other established methods, m2"~7-4° Although allowing functional treatment after surgery and early use of
945
the hand without external protection, the risk of radiocarpal nonunion has been reduced to almost 0%. Despite a lack of evidence, explicit recommendations have been expressed on how the carpometacarpal joints of the second and third finger should be handled when performing a wrist arthrodesis. Most frequently simultaneous arthrodesis of the CMCJ-3 w a s a d v o c a t e d . 1'18-2°'22'23'27'35-37"4° O t h e r s u r g e o n s
have recommended arthrodesis of the third and second CMCJ. ~2,~7,21,26,30,32This may be difficult in AO wrist arthrodesis because the compression plate immobilizes only one CMCJ-3. Pech et a132 therefore have designed a special arthrodesis plate, distally expanding over both the second and the third metacarpal. A third group does not arthrodese this joint unless it also has been affected by trauma or disease. 11"25,31'34"39'41 Nonunion rates and painful sequelae at the CMCJ-3 have not been assessed systematically and respective reports in the literature are scant. Bolano and Green 17 have presented a series of 26 patients with wrist arthrodesis. Of 18 patients treated with different modalities of radiocapitate arthrodesis in which the CMCJ was not arthrodesed, 5 had symptomatic motion of the CMCJ and 2 required arthrodesis. Eight patients with AO wrist arthrodesis in which CMCJ-2 and 3 were arthrodesed did not present this problem. In 6 of these 8, however, the plate over the CMCJ was still in situ while testing for CMCJ motion. Hastings et al,~ reporting on 97 noncomplex wrist arthrodeses, have used AO wrist arthrodesis with systematic CMCJ-3 arthrodesis in 58 cases and have encountered one painful nonunion of the CMCJ-3. Only 7 of 58 patients have had implant removal at the time of evaluation. In a later review on 90 consecutive wrist arthrodeses for posttranmatic disorders, now including 57 AO wrist arthrodeses with systematic arthrodesis of the CMCJ-3, Hastings et al. 19 found 3 patients with painful nonunion of the CMCJ-3. Unfortunately no data on plate removal or implant failures were given. Nevertheless they recommended inclusion of the CMCJ-3 in the total arthrodesis of the wrist because without routine implant removal, "possible metal fatigue and failure of the plate over a mobile articulation would be a concern. ''~9 Sagerman and Palmer 36 also using dynamic compression plates in 18 wrist arthrodeses with systematic inclusion of the CMCJ-3 removed the plate in 10 wrists; 2 patients needed regrafting of the CMCJ. Houshian and SchrCder 2° used the titanium wrist fusion plate in 42 wrists, with routine arthrodesis of
946
Nagy and B~ichler/AO-Wrist Arthrodesis
the CMCJ-3. Six patients (14%) needed implant removal, 3 patients had nonunion, one of the CMCJ-3. Sauerbier et al 4° in a report on their first experience with the new AO titanium wrist fusion plate, found implant failures adjacent to the CMCJ-3 and nonunions in 3 of 35 cases, despite simultaneous arthrodesis of the CMCJ-3. LarssonY in the first series on compression-plate arthrodesis of the wrist in the English literature, refrained from resecting the CMCJ-3, had 100% union in his 23 cases, and routinely removed all plates. The CMC joints resulted painless and "showed a slight range of motion in most of the patients. ''25 Reporting on complications of 73 AO/ ASIF wrist arthrodeses, Zachary and Stern 39 have had no case of "capitate-middle metacarpal arthritis despite the fact that the joint was not arthrodesed." The plate was removed in 14 cases only (19%); implant failures were not reported. Moneim et a129 performed 26 wrist arthrodeses by using the AO technique, "carefully avoiding" the CMCJs. Despite "fair motion" in the CMCJs after plate removal in 18 wrists (69%), pain in the index and long CMCJs was not faced. Our material allows a straightforward comparison of the 2 methods of dealing with the CMCJ-3 during AO wrist arthrodesis. Clinical and radiographic assessment of the CMCJ-3, with or without arthrodesis, is not possible with a shielding implant. The ultimate function of the CMCJ-3 emerges only after removal of the plate or perhaps after mechanical failure of the implant. This may explain why potential CMCJ problems have been underestimated in reports in which the implants were retained at the time of evaluation. Indeed most of our patients were asymptomatic with respect to the CMCJ-3 as long as the plates remained in situ. Our rate of hardware removal may seem higher compared with others, but it has decreased after the introduction of the AO titanium wrist fusion plate. However, considering the persistent causes for hardware removal even this wellcontoured, tapered, and lower-profile plate cannot be considered a permanent implant. Implant failure definitely is another concern, occurring in 6 of our patients. 4 after attempted unsuccessful arthrodesis and 2 after bridging of the CMCJ-3, that is, it could not be eliminated reliably by CMCJ-3 arthrodesis. Thus when performing wrist arthrodesis the plate removal must be anticipated. Our study therefore focused only on patients with the plates removed. If the CMCJ-3 was left simply bridged, its function returned to normal and was pain free after plate
removal except for one case. If an attempt was made to arthrodese the CMCJ-3 a nonunion rate of 43% was observed. More than half of these nonunions were painful, necessitating further and sometimes repetitive surgical treatment that was not overly successful. Based on our results we strongly advise not to include the CMCJ-3 when performing an AO wrist arthrodesis unless the CMCJ shows pre-existing pathology. If a healthy CMCJ-3 was only bridged by the plate, it seems logical to remove the implant and allow physiologic motion of this joint. After attempted arthrodesis of this joint the plate should be left in place if possible because a dormant nonunion is likely to become symptomatic with discontinued shielding. Fatigue-fracture or loosening of the implant may arise over an excessively mobile and insufficiently consolidated CMCJ. In patients who developed painful CMCJ-3 nonunion after plate removal, rearthrodesis should be considered despite nonuniform results.
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27. Leversedge FJ, Seller JG, Toye-Vego M, Fleming LL. Wrist arthrodesis using a wrist fusion plate. J South Orthop Assoc 1999;8:86-92. 28. Lohmann H, Buck-Gramcko, D: Indikation und ergebnisse der handgelenkarthrodesen. Handchir Mikrochir Hast Chir 1982:14:172-182. 29. Moneim MS, Pribyl CR, Garst JR. Wrist arthrodesis. Technique and functional evaluation. Clin Orthop 1997;341:2329. 30. Narr H. Indikationsbereiche, technik und ergebnisse der handgelenksarthrodese. Unfallheilkunde 1982;85:171177. 31. O'Bierne J, Boyer MI, Axelrod TS. Wrist arthrodesis using a dynamic compression plate. J Bone Joint Surg 1995;77B: 700 -704. 32. Pech J, Sosna A, Rybka V, Pokomy D. Wrist arthrodesis in rheumatoid arthritis. A new technique using internal fixation. J Bone Joint Surg 1996;78B:783-786. 33. Richards RR, Patterson SD, Hearn TC. A special plate for arthrodesis of the wrist: design considerations and biomechanical testing. J Hand Surg 1993;18A:476-483. 34. Richards RS, Roth JH. Simultaneous proximal row carpectomy and radius to distal carpal row arthrodesis. J Hand Surg 1994;19A:728-732. 35. Richterman L Weiss A-PC. Wrist fusion. Hand Clin 1997; 13:681-687. 36. Sagerman SD, Palmer AK. Wrist arthrodesis using a dynamic compression plate. J Hand Surg 1996;21B :437-441. 37. Weiss A-PC, Hastings H II. Wrist arthrodesis for traumatic conditions: a study of plate and local bone graft application. J Hand Surg 1995;20A:50-56. 38. Wetzel R, Wessinghage D. Die arthrodese des handgelenks beim polyarthritiker. Handchir Mikrochir Plast Chir 1987; 19:49 -54. 39. Zachary SV, Stern PJ. Complications following AO/ASIF wrist arthrodesis. J Hand Surg 1995;20A:339-344. 40. Sauerbier M, Kania NM, Kluge S, Bickert B, Germann G. Erste ergebnisse mit der neuen AO-handgelenk-arthrodeseplatte. Handchir Mikrochir Hast Chit 1999:31:260-265. 41. Louis DS, Hankin FM, Bowers WH. Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis. J Hand Surg 1984;9A:365-369.