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ARTHRODESIS OF THE WRIST WITH BIOABSORBABLE FIXATION IN PATIENTS WITH RHEUMATOID ARTHRITIS
ARTHRODESIS OF THE WRIST WITH BIOABSORBABLE FIXATION IN PATIENTS WITH RHEUMATOID ARTHRITIS N. VOUTILAINEN, T. JUUTILAINEN, H. PA¨TIA¨LA¨ and P. ROKKANEN From the Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, PO Box 266 (Topeliuksenkatu 5), Finland
Twenty-four wrist arthrodeses were performed on 18 patients with rheumatoid arthritis using a bioabsorbable self-reinforced poly-L-lactide rod as the fixation device. There was one nonunion which required a re-operation and two nonunions which did not need further treatment. The position of the arthrodesis was ulnar deviation and extension in most patients, and there was high patient satisfaction with 21 of the 24 wrists and satisfactory pain relief in 22 of the 24 wrists. This method for fusing the wrist in patients with rheumatoid arthritis appears reliable and simple to perform. Journal of Hand Surgery (British and European Volume, 2002) 27B: 6: 563–567
radial deviation) and the lateral (extension/flexion) radiographs. Evaluation of residual wrist pain, a subjective evaluation of the ability to perform activities of daily living (ADL) (Table 2) and an evaluation of patient satisfaction (Table 3) were performed at the final followup appointment (0.5–3.4 years post-operatively). Correlation matrices and two-way analysis of variance (ANOVA) were used to assess the influence on the outcome of the various parameters (Table 1). P values o0.05 were considered statistically significant. The indications for surgery were disabling pain and dysfunction of the wrist due to destructive rheumatoid disease. Each operation was performed under general or regional anaesthesia, using a tourniquet. A longitudinal incision was made on the extensor surface of the wrist and the extensor retinaculum was exposed. This was incised so as to create a radial retinacular flap, and an extensor tenosynovectomy was performed. The extensor tendons were then retracted to expose the joint capsule, which was opened with an H-shaped incision. A wrist joint synovectomy was performed, and the ulnar head was resected and retained as cancellous bone graft. The articular surfaces of the lunate, scaphoid and capitate bones were removed with an osteotome and a rongeur (Fig 1), and any palmar subluxation of the wrist joint was corrected. Carefully positioned 3.2-mm wide holes were drilled into the distal radius and the capitate, so as to produce the correct position of the fusion, and a bioabsorbable 3.2 50 mm rod (Bionx Ltd, Tampere, Finland) was passed with a forceps first into the channel within the distal radius while bending the hand into flexion. The rod was then passed into the channel within the capitate bone by distracting the wrist. The rod was made from poly-L-lactide (PLLA) with ultra-high raw material molecular weight (535,000 Da) using the selfreinforcement (SR) technique (To¨rma¨la¨, 1992) (Fig 1). As the drill holes and the rods had the same diameters, the rods fitted tightly inside the bones and only rarely migrated. The resected ulnar head bone graft was then positioned and the joint capsule was sutured. The extensor carpi ulnaris and radialis longus tendons were
INTRODUCTION Involvement of the wrist in rheumatoid arthritis is common, and destruction of the radiocarpal, radioulnar and intercarpal joints leads to pain, deformity and impaired hand function (Blomqvist et al., 2000; Howard et al., 1993; Kobus and Turner, 1990; Millender and Nalebuff, 1973; Rayan, 1986; Vicar and Burton, 1986). Arthrodesis of the wrist is an effective technique for achieving pain relief and improving the function of the hand in patients with rheumatoid arthritis (Blomqvist et al., 2000; Howard et al., 1993; Juutilainen and Pa¨tia¨la¨, 1995; Kobus and Turner, 1990; Mannerfelt and Malmsten, 1971; Millender and Nalebuff, 1973; Pech et al., 1996; Rayan, 1986; Vicar and Burton, 1986). It is generally accepted that, as long as the wrist pain is relieved by the fusion, the resultant stiffness is well tolerated and hand function may improve. The aim of this study is to report the results of wrist arthrodesis performed with bioabsorbable (self-reinforced poly-Llactide (SR-PLLA)) rod fixation in patients with rheumatoid arthritis. PATIENTS AND METHODS Between October 1997 and October 2000, 24 wrist arthrodeses were performed on 18 patients with rheumatoid arthritis (Table 1). The patients were examined clinically and radiographically 2 and 8 weeks, and at an average of 1.7 (range 0.5–3.4) years, postoperatively (Table 1). The severity of the articular damage was assessed on the plain radiographs using the classification of Larsen et al. (1977), and most showed severe grade IV or V changes with palmar subluxation of the radiocarpal joint (Table 1). The carpal height index (CHI) (Youm et al., 1978) and the ulnar translocation index (UTI) (Youm et al., 1978) were measured to quantify the pre-operative wrist deformity and the post-operative alignment. The post-operative position of the fused wrist was determined by measuring the angle between the long axis of the radius and that of the third metacarpal on the anteroposterior (ulnar/ 563
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THE JOURNAL OF HAND SURGERY VOL. 27B No. 6 DECEMBER 2002
Table 1FPatients and the outcome of wrist fusion Patients 1
2
Objective results
Age (years)
Side
Follow-up (years)
Duration of RA (years)
Larsen grade
Fusion
M
69 61
M
71
F F
41 34
F F
63 40
F F F F
33 70 49 75
F F F F F F F
59 50 52 66 47 45 67
3.4 2.8 3.2 0.5 3.0 2.5 2.8 2.5 0.5 2.2 2.0 0.5 1.8 1.6 1.6 1.5 1.0 1.3 1.0 1.0 1.0 1.0 0.5 0.5
Over 20
F
R L L R R L R R L R R L R L R R L L R L R R R R
III III IV IV V V III V V III IV IV V IV III IV IV III IV IV V IV III IV
Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Sex
Over 20 10–20 10–20 Over 20 Over 20 5–10 10–20 Over 20 5–10 Over 20 5–10 Over 20 5–10 Over 20 Over 20 0–5 10–20
Position Ulnar deviation 41 41 21 31 121 11 51 211 181 131 161 271 181 321 71 121 101 21 01 21 31 71 131 61
Subjective results
Extension
Pain score3
Functional score4
Satisfied overall5
Satisfied with position of the fusion
91 31 201 121 01 51 41 111 91 21 251 121 31 221 91 121 101 41 21 31 11 51 111 41
0 3 0 1 1 0 1 0 0 1 0 4 0 1 0 0 0 0 0 0 1 1 1 1
300 160 330 260 30 300 170 320 320 190 200 100 200 270 140 320 320 160 190 150 230 150 340 310
9 5 9 8 4 9 7 8 10 4 9 4 8.5 5 8 10 10 9 8 8 8 6 10 9
Yes Yes Yes Yes Yes Yes No No Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
1 F = Female, M = Male; 2L = Left, R = Right; 30 = no pain, 1 = slight, intermittent pain, 3 = disturbing, intermittent pain, 4 = disturbing, continuous pain; 4Function of the hand: significantly improved = 325–420, moderately improved = 210–325, moderately impaired = 105–210 and significantly impaired = 0–105 points; 5Score =1–10.
sutured together to form an X-shaped structure (Fig 2), which enhanced compression within the wrist joint. The radial flap of the extensor retinaculum was placed under the finger extensor tendons, so as to form a gliding surface, and the wound was closed. The wrist was immobilized in a plaster cast for 2–3 weeks postoperatively, and a Hexalites splint was worn for a further 6–7 weeks. Mobilization of the elbow and the fingers was started immediately post-operatively with physiotherapy supervision.
RESULTS Solid bony union was achieved in 21 of 24 wrists (Fig 3). Clinical and radiographical nonunion of the left wrist of a 40-year-old woman required re-operation: in this case the SR-PLLA rod had migrated into the medullary canal of the radius. The arthrodesis was then stabilized with Kirschner wires and the wrist fused uneventfully. Another patient had radiographical and clinical nonunion of the radiocarpal and one intercarpal joints, but did not require re-operation. No complications other than nonunion occurred. The mean pre-operative carpal height index was 0.36 (range 0.11–0.49) and post-operatively, it was 0.39
(range 0.19–0.56), reflecting correction of wrist subluxation. The mean pre- and post-operative ulnar translocation indices were both 0.24 (pre-operative range, 0.03–0.49: post-operative range, 0.05–0.40), but the UTI improved by 0.02–0.24 in ten of the 12 patients with severe pre-operative ulnar translocation (UTIo0.25). The average position of the fusion was with 81 (range 121 to 321) ulnar deviation and 81 (range 41 to 251) extension (Table 1). Satisfactory pain relief was observed in all but two wrists (both with nonunion) (Table 1), and the overall satisfaction with the outcome of surgery was high (mean 8: range 4–10) (Table 1). Two of the dissatisfied patients had nonunions and the other had bilateral fusions and found the stiffness of both wrists uncomfortable. The maximum improvement was achieved in 0–6 months in 12 wrists, 6–12 months in eight wrists and 12–18 months in two wrists. Two wrists with short follow-up were still recovering at their 6-month follow-up appointments. Seven patients wished that their wrists had been fused 1–10 years earlier. Older patients were more satisfied with the position of fusion than younger ones (Po0.001), and patients with fusions in near-neutral radio-ulnar deviation were more satisfied than those in greater ulnar deviation (Po0.05). Three patients were dissatisfied with the position of the
WRIST ARTHRODESIS IN RA
565
Table 2FEvaluation of the functional outcome by assessing the patients’ ability to perform daily tasks, modified by Jebsen et al. (1969) Activities of daily life testing criteria Personal care/hygiene examination Combing hair Fastening and unfastening a button Perineal care Brushing the inside of the teeth Brushing the outside of the teeth Tying the shoelaces Diet/food preparation examination Turning a faucet on and off Pouring from a pitcher Drinking from a glass Using a knife Using a fork Unscrewing and screwing of a jar lid Turning a spatula Occupational/Miscellaneous examination Using a hammer Using a screwdriver Opening a door by a handle Turning a key Standing up from a seated position whereby force is placed upon the wrist Driving a car Signing one’s name Using a broom
Fig 1 Arthrodesis of the right wrist of a patient with rheumatoid arthritis. The finger extensor tendons have been retracted. The joint surfaces have been resected, and the self-reinforced polyL-lactide rod (arrow pointing) is seen before implantation within the radius and capitate.
Scoring: easier post- than pre-operatively = 20 points; no change = 10 points; more difficult post- than pre-operatively = 0 points. Maximum score = 420 points. The function of the hand was considered clearly improved if the score was 325–420, moderately improved if 210–325, moderately impaired if 105–210 and clearly impaired if 0–105 points.
Table 3FEvaluation of the personal satisfaction of the patients on the outcome of the wrist arthrodesis (Weiss et al., 1995) The patient reviews these questions on personal satisfaction Are you satisfied with the fused wrist? What activities can’t you do with this wrist that you used to do? Do you wish that you had had the fusion surgery earlier? Would you prefer a different position of the fused wrist? How long did it take for the wrist to attain maximum improvement after fusion? The patient then, on a scale from 1 to 10 (10 = excellent), rates the wrist after the fusion in terms of overall function and pain relief
wrist which caused functional difficulties with tasks such as working on a computer and reaching up for objects from high shelves. One patient was dissatisfied with the appearance of the fused wrist. Nine patients found that some activities were impossible to perform after the fusion, especially picking up small objects from the floor. The subjective ADL functional scores showed that the function of the hand for daily life activities improved significantly or moderately in 12 arms, but was
Fig 2 Diagram of the arthrodesis, and the tenodesis of the extensor carpi radialis longus and extensor carpi ulnaris tendons.
moderately impaired in ten and significantly impaired in two. The patients with the high functional scores were more satisfied than those with low functional scores (Po0.001).
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THE JOURNAL OF HAND SURGERY VOL. 27B No. 6 DECEMBER 2002
Fig 3 Arthrodesis of the left wrist of a 52-year-old woman. (a, b) Pre-operative anteroposterior and lateral views; (c, d) anteroposterior and lateral views showing solid bony union 1 year post-operatively.
DISCUSSION Mannerfelt and Malmsten (1971) reported their results for wrist arthrodesis using a Rush pin and two metal staples. There are now several modification of this technique (Barbier et al., 1999; Kobus and Turner, 1990). Alternative fixation techniques, such as metal plate or screw fixation, have also been introduced (Howard et al., 1993; Pech et al., 1996; Rehak et al., 2000), and fusion rates of between 96% and 100%, have been reported, with the infrequent pseudo-arthroses
usually being asymptomatic (Rosen and Weiland, 1998). Other complications can occur after wrist arthrodeses with rates of up to 23% (Kobus and Turner, 1990; Rehak et al., 2000). These complications include poor wound healing, median nerve compression and symptoms due to the fixation device. Removal of metal pins, plates and screws because of migration or discomfort are relatively common (Howard et al., 1993; Kobus and Turner, 1990; Mannerfelt and Malmsten, 1971; Millender and Nalebuff, 1973; Pech et al., 1996; Rayan, 1986; Vicar and Burton, 1986).
WRIST ARTHRODESIS IN RA
The surgical technique in the present study was described by Juutilainen and Pa¨tia¨la¨ (1995). The bioabsorbale rod is made of PLLA, which degrades in the presence of water and living tissues over several years (Bo¨stman et al., 1995). The mechanism of degradation is mainly hydrolysis, and the carbon dioxide and water produced are excreted through respiration (Williams, 1981). Previous experimental and clinical studies suggest that PLLA is not toxic and is highly biocompatible (Bo¨stman and Pihlajama¨ki, 2000). The mechanical properties of PLLA implants are improved by self-reinforcement during manufacture (To¨rma¨la¨, 1992), and they are suitable for fixation of cancellous bone fractures and arthrodeses (Rokkanen et al., 2000). Juutilainen and Pa¨tia¨la¨ (1995) performed 18 wrist arthrodeses on patients with rheumatoid arthritis, and bony union was achieved in all their cases. The SR-PLLA rod was implanted longitudinally, within the radius and capitate and stabilized the arthrodesis in both the extensor–flexor and ulnar–radial planes. Tenodesis of the extensor carpi radialis longus and extensor carpi ulnaris tendons applies compression to the arthrodesis, and prevents dorsal subluxation of the distal ulna during rotation of the forearm. A plaster cast was used post-operatively to provide further rotational stability. In our study, one nonunion had to be revised, but the overall complication rate was low when compared with studies using other methods of fixation (Kobus and Turner, 1990; Rehak et al., 2000). Placement of the arthrodesis in slight extension and ulnar deviation has been suggested as ideal, allowing maximal function of the hand after wrist fusion (Barbier et al., 1999; Pryce, 1980; Ryu et al., 1991). Although the highest levels of satisfaction in our study were found in patients with slight ulnar deviation, the degree of extension did not influence patient satisfaction and the position of the wrist had no impact on the functional outcome. Older patients had higher levels of satisfaction, probably as their functional demands were less. Hand function subjectively improved in 12 wrists but deteriorated in ten. This may indicate that some patients are better able than others to adapt to stiffness of the wrist. Moreover, rheumatoid involvement of other joints of the upper limb may also affect the function of the hand, and this was not investigated in the present study. All but two patients (22 wrists) had satisfactory pain relief and all but three (21) were satisfied with their outcome, demonstrating that patients tolerate the restrictions caused by a stiff wrist provided it is painless. While arthroplasty of the wrist continues to have high failure and complication rates (Brase and Millender, 1986; Meuli and Fernandez, 1995), arthrodesis remains the best method of managing a rheumatoid wrist.
567
References Barbier O, Saels P, Rombouts J, Thonnard J (1999). Long-term functional results of wrist arthrodesis in rheumatoid arthritis. Journal of Hand Surgery, 24B: 27–31. Blomqvist P, Haglund U, Knutson K et al. (2000). Rheumatic diseases – surgical treatment. Acta Orthopaedica Scandinavica (Supplementum), 71: 34–43. Brase D, Millender L (1986). Failure of silicone rubber wrist arthroplasty in rheumatoid arthritis. Journal of Hand Surgery, 11A: 175–183. Bo¨stman O, Pihlajama¨ki H (2000). Clinical biocompatibility of biodegradable orthopaedic implants for internal fixation: a review. Biomaterials, 21: 2615–2621. Bo¨stman O, Pihlajama¨ki H, Partio E, Rokkanen. P (1995). Clinical biocompatibility and degradation of polylevolactide screws in the ankle. Clinical Orthopaedics and Related Research, 320: 101–109. Howard A, Stanley B, Getty C (1993). Wrist arthrodesis in rheumatoid arthritis. A comparison of two methods of fusion. Journal of Hand Surgery 18B: 377–380. Jebsen RH, Taylor N, Trieschmann RB, Trotter MJ, Howard LA (1969). An objective and standardized test of hand function. Archives of Physical Medicine&Rehabilitation, 50: 311–319. Juutilainen T, Pa¨tia¨la¨ H (1995). Arthrodesis in rheumatoid arthritis using absorbable screws and rods. Scandinavian Journal of Rheumatology, 24: 228–233. Kobus R, Turner R (1990). Wrist arthrodesis for treatment of rheumatoid arthritis. Journal of Hand Surgery, 15A: 541–546. Larsen A, Dale K, Eek M (1977). Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiologica, Diagnosis 18: 481–491. Mannerfelt L, Malmsten M (1971). Arthrodesis of the wrist in rheumatoid arthritis. Scandinavian Journal of Plastic and Reconstructive Surgery, 5: 124–130. Meuli H, Fernandez D (1995). Uncemented total wrist arthroplasty. Journal of Hand Surgery, 20A: 115–122. Millender L, Nalebuff E (1973). Arthrodesis of the rheumatoid wrist. Journal of Bone and Joint Surgery, 55A: 1026–1034. Pech J, Sosna A, Rybka V, Pokorny D (1996). Wrist arthrodesis in rheumatoid arthritis. A new technique using internal fixation. Journal of Bone and Joint Surgery, 78B: 783–786. Pryce J (1980). The wrist position between neutral and ulnar deviation that facilitates maximum power grip strength. Journal of Biomechanics, 13: 505–511. Rayan G (1986). Wrist arthrodesis. Journal of Hand Surgery 11A: 356–364. Rehak D, Kasper P, Baratz ME, Hagberg WC, McClain E, Imbriglia JE (2000). A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist. Orthopaedics, 23: 43–48. Rokkanen PU, Bo¨stman O, Hirvensalo E et al. (2000). Bioabsorbable fixation in orthopaedic surgery and traumatology. Biomaterials, 21: 2607– 2613. Rosen A, Weiland A (1998). Rheumatoid arthritis of the wrist and hand. Rheumatic Disease Clinics of North America, 24: 101–128. Ryu J, Cooney W, Askew L, An K-N, Chao EYS (1991). Functional ranges of motion of the wrist joint. Journal of Hand Surgery 16A: 409–419. To¨rma¨la¨ P (1992). Biodegradable self-reinforced composite materials: manufacturing structure and mechanical properties. Clinical Materials, 10: 29–34. Vicar A, Burton R (1986). Surgical management of the rheumatoid wrist – Fusion or arthroplasty. Journal of Hand Surgery 11A: 790–797. Weiss A, Wiedemann G, Quenzer D, Hanington K, Hastings H, Strickland J (1995). Upper extremity function after wrist arthrodesis. Journal of Hand Surgery 20A: 813–817. Williams DF (1981). Enzymic hydrolysis of polylactic acid. Engineering in Medicine, 10: 5–7. Youm Y, McMurtry R, Flatt A, Gillespie T (1978). Kinematics of the wrist. Journal of Bone and Joint Surgery, 60A: 423–431.
Acknowledgements
Received: 19 September 2001 Accepted after revision: 26 April 2002 Nina Voutilainen, Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, P.O. Box 266 (Topeliuksenkatu 5), FIN-00029 HUS, Finland. Tel.: +358-9-4711; Fax +358-9-471 87481; E-mail:nina.voutilainen@hus.fi
This study was supported by The Research Foundation of Rheumatoid Diseases in Finland, The Cultural Foundation of Satakunta and The Academy of Finland.
r 2002 The British Society for Surgery of the Hand. Published by Elsevier science Ltd. All rights reserved. doi: 10.1054/jhsb.2002.0806, available online at http://www.idealibrary.com on
Twenty-four wrist arthrodeses were performed on 18 patients with rheumatoid arthritis using a bioabsorbable self-reinforced poly-L-lactide rod as the fixation device. There was one nonunion which required a re-operation and two nonunions which did not need further treatment. The position of the arthrodesis was ulnar deviation and extension in most patients, and there was high patient satisfaction with 21 of the 24 wrists and satisfactory pain relief in 22 of the 24 wrists. This method for fusing the wrist in patients with rheumatoid arthritis appears reliable and simple to perform. Journal of Hand Surgery (British and European Volume, 2002) 27B: 6: 563–567
radial deviation) and the lateral (extension/flexion) radiographs. Evaluation of residual wrist pain, a subjective evaluation of the ability to perform activities of daily living (ADL) (Table 2) and an evaluation of patient satisfaction (Table 3) were performed at the final followup appointment (0.5–3.4 years post-operatively). Correlation matrices and two-way analysis of variance (ANOVA) were used to assess the influence on the outcome of the various parameters (Table 1). P values o0.05 were considered statistically significant. The indications for surgery were disabling pain and dysfunction of the wrist due to destructive rheumatoid disease. Each operation was performed under general or regional anaesthesia, using a tourniquet. A longitudinal incision was made on the extensor surface of the wrist and the extensor retinaculum was exposed. This was incised so as to create a radial retinacular flap, and an extensor tenosynovectomy was performed. The extensor tendons were then retracted to expose the joint capsule, which was opened with an H-shaped incision. A wrist joint synovectomy was performed, and the ulnar head was resected and retained as cancellous bone graft. The articular surfaces of the lunate, scaphoid and capitate bones were removed with an osteotome and a rongeur (Fig 1), and any palmar subluxation of the wrist joint was corrected. Carefully positioned 3.2-mm wide holes were drilled into the distal radius and the capitate, so as to produce the correct position of the fusion, and a bioabsorbable 3.2 50 mm rod (Bionx Ltd, Tampere, Finland) was passed with a forceps first into the channel within the distal radius while bending the hand into flexion. The rod was then passed into the channel within the capitate bone by distracting the wrist. The rod was made from poly-L-lactide (PLLA) with ultra-high raw material molecular weight (535,000 Da) using the selfreinforcement (SR) technique (To¨rma¨la¨, 1992) (Fig 1). As the drill holes and the rods had the same diameters, the rods fitted tightly inside the bones and only rarely migrated. The resected ulnar head bone graft was then positioned and the joint capsule was sutured. The extensor carpi ulnaris and radialis longus tendons were
INTRODUCTION Involvement of the wrist in rheumatoid arthritis is common, and destruction of the radiocarpal, radioulnar and intercarpal joints leads to pain, deformity and impaired hand function (Blomqvist et al., 2000; Howard et al., 1993; Kobus and Turner, 1990; Millender and Nalebuff, 1973; Rayan, 1986; Vicar and Burton, 1986). Arthrodesis of the wrist is an effective technique for achieving pain relief and improving the function of the hand in patients with rheumatoid arthritis (Blomqvist et al., 2000; Howard et al., 1993; Juutilainen and Pa¨tia¨la¨, 1995; Kobus and Turner, 1990; Mannerfelt and Malmsten, 1971; Millender and Nalebuff, 1973; Pech et al., 1996; Rayan, 1986; Vicar and Burton, 1986). It is generally accepted that, as long as the wrist pain is relieved by the fusion, the resultant stiffness is well tolerated and hand function may improve. The aim of this study is to report the results of wrist arthrodesis performed with bioabsorbable (self-reinforced poly-Llactide (SR-PLLA)) rod fixation in patients with rheumatoid arthritis. PATIENTS AND METHODS Between October 1997 and October 2000, 24 wrist arthrodeses were performed on 18 patients with rheumatoid arthritis (Table 1). The patients were examined clinically and radiographically 2 and 8 weeks, and at an average of 1.7 (range 0.5–3.4) years, postoperatively (Table 1). The severity of the articular damage was assessed on the plain radiographs using the classification of Larsen et al. (1977), and most showed severe grade IV or V changes with palmar subluxation of the radiocarpal joint (Table 1). The carpal height index (CHI) (Youm et al., 1978) and the ulnar translocation index (UTI) (Youm et al., 1978) were measured to quantify the pre-operative wrist deformity and the post-operative alignment. The post-operative position of the fused wrist was determined by measuring the angle between the long axis of the radius and that of the third metacarpal on the anteroposterior (ulnar/ 563
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THE JOURNAL OF HAND SURGERY VOL. 27B No. 6 DECEMBER 2002
Table 1FPatients and the outcome of wrist fusion Patients 1
2
Objective results
Age (years)
Side
Follow-up (years)
Duration of RA (years)
Larsen grade
Fusion
M
69 61
M
71
F F
41 34
F F
63 40
F F F F
33 70 49 75
F F F F F F F
59 50 52 66 47 45 67
3.4 2.8 3.2 0.5 3.0 2.5 2.8 2.5 0.5 2.2 2.0 0.5 1.8 1.6 1.6 1.5 1.0 1.3 1.0 1.0 1.0 1.0 0.5 0.5
Over 20
F
R L L R R L R R L R R L R L R R L L R L R R R R
III III IV IV V V III V V III IV IV V IV III IV IV III IV IV V IV III IV
Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Sex
Over 20 10–20 10–20 Over 20 Over 20 5–10 10–20 Over 20 5–10 Over 20 5–10 Over 20 5–10 Over 20 Over 20 0–5 10–20
Position Ulnar deviation 41 41 21 31 121 11 51 211 181 131 161 271 181 321 71 121 101 21 01 21 31 71 131 61
Subjective results
Extension
Pain score3
Functional score4
Satisfied overall5
Satisfied with position of the fusion
91 31 201 121 01 51 41 111 91 21 251 121 31 221 91 121 101 41 21 31 11 51 111 41
0 3 0 1 1 0 1 0 0 1 0 4 0 1 0 0 0 0 0 0 1 1 1 1
300 160 330 260 30 300 170 320 320 190 200 100 200 270 140 320 320 160 190 150 230 150 340 310
9 5 9 8 4 9 7 8 10 4 9 4 8.5 5 8 10 10 9 8 8 8 6 10 9
Yes Yes Yes Yes Yes Yes No No Yes Yes No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
1 F = Female, M = Male; 2L = Left, R = Right; 30 = no pain, 1 = slight, intermittent pain, 3 = disturbing, intermittent pain, 4 = disturbing, continuous pain; 4Function of the hand: significantly improved = 325–420, moderately improved = 210–325, moderately impaired = 105–210 and significantly impaired = 0–105 points; 5Score =1–10.
sutured together to form an X-shaped structure (Fig 2), which enhanced compression within the wrist joint. The radial flap of the extensor retinaculum was placed under the finger extensor tendons, so as to form a gliding surface, and the wound was closed. The wrist was immobilized in a plaster cast for 2–3 weeks postoperatively, and a Hexalites splint was worn for a further 6–7 weeks. Mobilization of the elbow and the fingers was started immediately post-operatively with physiotherapy supervision.
RESULTS Solid bony union was achieved in 21 of 24 wrists (Fig 3). Clinical and radiographical nonunion of the left wrist of a 40-year-old woman required re-operation: in this case the SR-PLLA rod had migrated into the medullary canal of the radius. The arthrodesis was then stabilized with Kirschner wires and the wrist fused uneventfully. Another patient had radiographical and clinical nonunion of the radiocarpal and one intercarpal joints, but did not require re-operation. No complications other than nonunion occurred. The mean pre-operative carpal height index was 0.36 (range 0.11–0.49) and post-operatively, it was 0.39
(range 0.19–0.56), reflecting correction of wrist subluxation. The mean pre- and post-operative ulnar translocation indices were both 0.24 (pre-operative range, 0.03–0.49: post-operative range, 0.05–0.40), but the UTI improved by 0.02–0.24 in ten of the 12 patients with severe pre-operative ulnar translocation (UTIo0.25). The average position of the fusion was with 81 (range 121 to 321) ulnar deviation and 81 (range 41 to 251) extension (Table 1). Satisfactory pain relief was observed in all but two wrists (both with nonunion) (Table 1), and the overall satisfaction with the outcome of surgery was high (mean 8: range 4–10) (Table 1). Two of the dissatisfied patients had nonunions and the other had bilateral fusions and found the stiffness of both wrists uncomfortable. The maximum improvement was achieved in 0–6 months in 12 wrists, 6–12 months in eight wrists and 12–18 months in two wrists. Two wrists with short follow-up were still recovering at their 6-month follow-up appointments. Seven patients wished that their wrists had been fused 1–10 years earlier. Older patients were more satisfied with the position of fusion than younger ones (Po0.001), and patients with fusions in near-neutral radio-ulnar deviation were more satisfied than those in greater ulnar deviation (Po0.05). Three patients were dissatisfied with the position of the
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565
Table 2FEvaluation of the functional outcome by assessing the patients’ ability to perform daily tasks, modified by Jebsen et al. (1969) Activities of daily life testing criteria Personal care/hygiene examination Combing hair Fastening and unfastening a button Perineal care Brushing the inside of the teeth Brushing the outside of the teeth Tying the shoelaces Diet/food preparation examination Turning a faucet on and off Pouring from a pitcher Drinking from a glass Using a knife Using a fork Unscrewing and screwing of a jar lid Turning a spatula Occupational/Miscellaneous examination Using a hammer Using a screwdriver Opening a door by a handle Turning a key Standing up from a seated position whereby force is placed upon the wrist Driving a car Signing one’s name Using a broom
Fig 1 Arthrodesis of the right wrist of a patient with rheumatoid arthritis. The finger extensor tendons have been retracted. The joint surfaces have been resected, and the self-reinforced polyL-lactide rod (arrow pointing) is seen before implantation within the radius and capitate.
Scoring: easier post- than pre-operatively = 20 points; no change = 10 points; more difficult post- than pre-operatively = 0 points. Maximum score = 420 points. The function of the hand was considered clearly improved if the score was 325–420, moderately improved if 210–325, moderately impaired if 105–210 and clearly impaired if 0–105 points.
Table 3FEvaluation of the personal satisfaction of the patients on the outcome of the wrist arthrodesis (Weiss et al., 1995) The patient reviews these questions on personal satisfaction Are you satisfied with the fused wrist? What activities can’t you do with this wrist that you used to do? Do you wish that you had had the fusion surgery earlier? Would you prefer a different position of the fused wrist? How long did it take for the wrist to attain maximum improvement after fusion? The patient then, on a scale from 1 to 10 (10 = excellent), rates the wrist after the fusion in terms of overall function and pain relief
wrist which caused functional difficulties with tasks such as working on a computer and reaching up for objects from high shelves. One patient was dissatisfied with the appearance of the fused wrist. Nine patients found that some activities were impossible to perform after the fusion, especially picking up small objects from the floor. The subjective ADL functional scores showed that the function of the hand for daily life activities improved significantly or moderately in 12 arms, but was
Fig 2 Diagram of the arthrodesis, and the tenodesis of the extensor carpi radialis longus and extensor carpi ulnaris tendons.
moderately impaired in ten and significantly impaired in two. The patients with the high functional scores were more satisfied than those with low functional scores (Po0.001).
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THE JOURNAL OF HAND SURGERY VOL. 27B No. 6 DECEMBER 2002
Fig 3 Arthrodesis of the left wrist of a 52-year-old woman. (a, b) Pre-operative anteroposterior and lateral views; (c, d) anteroposterior and lateral views showing solid bony union 1 year post-operatively.
DISCUSSION Mannerfelt and Malmsten (1971) reported their results for wrist arthrodesis using a Rush pin and two metal staples. There are now several modification of this technique (Barbier et al., 1999; Kobus and Turner, 1990). Alternative fixation techniques, such as metal plate or screw fixation, have also been introduced (Howard et al., 1993; Pech et al., 1996; Rehak et al., 2000), and fusion rates of between 96% and 100%, have been reported, with the infrequent pseudo-arthroses
usually being asymptomatic (Rosen and Weiland, 1998). Other complications can occur after wrist arthrodeses with rates of up to 23% (Kobus and Turner, 1990; Rehak et al., 2000). These complications include poor wound healing, median nerve compression and symptoms due to the fixation device. Removal of metal pins, plates and screws because of migration or discomfort are relatively common (Howard et al., 1993; Kobus and Turner, 1990; Mannerfelt and Malmsten, 1971; Millender and Nalebuff, 1973; Pech et al., 1996; Rayan, 1986; Vicar and Burton, 1986).
WRIST ARTHRODESIS IN RA
The surgical technique in the present study was described by Juutilainen and Pa¨tia¨la¨ (1995). The bioabsorbale rod is made of PLLA, which degrades in the presence of water and living tissues over several years (Bo¨stman et al., 1995). The mechanism of degradation is mainly hydrolysis, and the carbon dioxide and water produced are excreted through respiration (Williams, 1981). Previous experimental and clinical studies suggest that PLLA is not toxic and is highly biocompatible (Bo¨stman and Pihlajama¨ki, 2000). The mechanical properties of PLLA implants are improved by self-reinforcement during manufacture (To¨rma¨la¨, 1992), and they are suitable for fixation of cancellous bone fractures and arthrodeses (Rokkanen et al., 2000). Juutilainen and Pa¨tia¨la¨ (1995) performed 18 wrist arthrodeses on patients with rheumatoid arthritis, and bony union was achieved in all their cases. The SR-PLLA rod was implanted longitudinally, within the radius and capitate and stabilized the arthrodesis in both the extensor–flexor and ulnar–radial planes. Tenodesis of the extensor carpi radialis longus and extensor carpi ulnaris tendons applies compression to the arthrodesis, and prevents dorsal subluxation of the distal ulna during rotation of the forearm. A plaster cast was used post-operatively to provide further rotational stability. In our study, one nonunion had to be revised, but the overall complication rate was low when compared with studies using other methods of fixation (Kobus and Turner, 1990; Rehak et al., 2000). Placement of the arthrodesis in slight extension and ulnar deviation has been suggested as ideal, allowing maximal function of the hand after wrist fusion (Barbier et al., 1999; Pryce, 1980; Ryu et al., 1991). Although the highest levels of satisfaction in our study were found in patients with slight ulnar deviation, the degree of extension did not influence patient satisfaction and the position of the wrist had no impact on the functional outcome. Older patients had higher levels of satisfaction, probably as their functional demands were less. Hand function subjectively improved in 12 wrists but deteriorated in ten. This may indicate that some patients are better able than others to adapt to stiffness of the wrist. Moreover, rheumatoid involvement of other joints of the upper limb may also affect the function of the hand, and this was not investigated in the present study. All but two patients (22 wrists) had satisfactory pain relief and all but three (21) were satisfied with their outcome, demonstrating that patients tolerate the restrictions caused by a stiff wrist provided it is painless. While arthroplasty of the wrist continues to have high failure and complication rates (Brase and Millender, 1986; Meuli and Fernandez, 1995), arthrodesis remains the best method of managing a rheumatoid wrist.
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Acknowledgements
Received: 19 September 2001 Accepted after revision: 26 April 2002 Nina Voutilainen, Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, P.O. Box 266 (Topeliuksenkatu 5), FIN-00029 HUS, Finland. Tel.: +358-9-4711; Fax +358-9-471 87481; E-mail:nina.voutilainen@hus.fi
This study was supported by The Research Foundation of Rheumatoid Diseases in Finland, The Cultural Foundation of Satakunta and The Academy of Finland.
r 2002 The British Society for Surgery of the Hand. Published by Elsevier science Ltd. All rights reserved. doi: 10.1054/jhsb.2002.0806, available online at http://www.idealibrary.com on