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Wrist arthroplasty with a new generation of prostheses in patients with rheumatoid arthritis
Wrist Arthroplasty With a New Generation of Prostheses in Patients With Rheumatoid Arthritis Sebastian Radmer, MD, Reimer Andresen, MD, Martin Sparmann, MD, Berlin, Germany The function of the wrist is frequently considerably impaired by early destruction in patients with rheumatoid arthritis. The aim of endoprosthetic arthroplasty is to restore functional use and provide freedom from pain. In our study a newly developed, uncemented wrist prosthesis was implanted in 30 patients (24 women and 6 men) with advanced destruction of the wrist. This wrist prosthesis is a hydroxyapatite-coated cobalt– chrome prosthesis with a titanium coating of the articular surfaces. The radial component has an articular surface inclination of 10° toward the ulna, and the carpal component, which is anchored with its tip in the distal carpal bones and third metacarpal bone, has a double articular surface with a radial inclination of 10°. At the 18-month follow-up visit, the following parameters were examined: x-ray, grip strength, range of motion, and the patient’s subjective satisfaction. Good improvement of function was found in 92% of the patients; 87% were free of pain. Eighty-eight percent of the patients rated the outcome of surgery as good. If the indication is accurately diagnosed, this wrist prosthesis can markedly improve function, which in turn leads to high patient acceptance. Various salvage procedures remain open because of the minimal loss of bone stock and the uncemented implantation of the prosthesis. (J Hand Surg 1999;24A:935–943. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Joint prosthesis, prosthesis design, rheumatoid arthritis, treatment outcome, wrist joint surgery.
In patients with rheumatoid arthritis, the joint of the upper extremities most often affected is the wrist. Destruction occurs at an early stage, with painful restriction of mobility, loss of strength, and impairment of the muscular equilibrium between extensors and flexors.1,2 In addition to functional loss, the From the Department of Rheumatic Surgery, Specialist Clinic for Rheumatology, Immanuel Hospital, Berlin, Germany; and the Department of Radiology and Nuclear Medicine, Behring Municipal Hospital, Academic Teaching Hospital, Free University of Berlin, Berlin, Germany. Received for publication July 21, 1998; accepted in revised form April 30, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Sebastian Radmer, MD, Department of Rheumatic Surgery, Specialist Clinic for Rheumatology, Immanuel Hospital Berlin, Koenigstr. 63, D-14109 Berlin, Germany. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A05-0011$3.00/0
visible deformities lead to aesthetic and thus social problems. Arthrodesis of the wrist has been used successfully for many years for stabilization and pain reduction, but leads to a loss of radiocarpal mobility.3 As an alternative, endoprosthetic replacement of the wrist has been performed since the early 1970s with the aim of reducing pain while maintaining or improving wrist function.2 The extent to which total wrist arthroplasty implant with the anatomic physiologic wrist prosthesis represents a satisfactory procedure for rheumatic patients is reported on the basis of objective criteria and subjective results obtained from a retrospective study.
Materials and Methods In 30 consecutive rheumatoid arthritis patients (24 women and 6 men) with an average age of 49.3 years (range, 29 – 67 years), arthroplasty was performed The Journal of Hand Surgery 935
936 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
for advanced wrist destruction (x-ray morphologic stage according to Larsen III–V).4 Severe soft tissue destruction (eg, rupture of the extensor tendons) is a contraindication for implantation of this device. The only absolute contraindication to wrist arthroplasty is infection. It may be performed in the presence of very advanced destructive arthritis with severe loss of bone stock; even volar subluxation or osteoporosis are not contraindications. All the patients were implanted with an uncemented anatomic physiologic wrist prosthesis (Fig. 1), which is a hydroxyapatitecoated cobalt– chrome prosthesis with a titanium coating of the articular surfaces. The prosthesis is composed of 2 components. The radial component has an articular surface inclination of 10° toward the ulna and the carpal component, which is anchored with its tip in the third metacarpal bone and the distal carpal bones, has a mobile bearing surface with a radial inclination of 10°. This shape and inclination adapts the adjustment of the proximal carpal bones in the normal range of motion. The radial component is made in 4 sizes; the carpal component is available in one standard size. The surgical approach is made using an S-shaped cutaneous incision running from the radial to the distal side along the tendon of the long extensor tendon of the thumb, diagonally across the wrist cavity to the ulnar extensor tendon of the wrist, up to approximately 2 cm proximal to the ulnar head. After dissecting the subcutaneous layer while preserving the cutaneous veins, the extensor retinaculum is exposed and detached radially. The opening thus begins in the fifth extensor tendon compartment. An extensive synovectomy of the extensor tendons is then performed, the posterior interosseus nerve is resected, and Lister’s tubercle is removed to prevent any obstruction to articulation for the extensor tendons after the later reconstruction of the extensor retinaculum over the prosthesis. The radioulnar joint is then opened, preserving the collateral ligament apparatus, and the ulnar head is resected. The capsule is dissected distally in the direction of the thumb, exposing the distal midcarpal joint. The lunate bone and parts of the scaphoid bone and hamate bone can now be resected. The capitate bone is opened using an awl; the awl is inserted in the direction of the third metacarpal bone until the base plate has been opened and the tip is positioned in the transition to the middle third of the bone (Fig. 2). The saw gouge is placed on the awl and resection is performed 90° to the horizontal instrument, which should be positioned in the proximal third of the
Figure 1. The anatomic physiologic wrist prosthesis used for uncemented implantation is a hydroxyapatite-coated cobalt– chrome prosthesis with a titanium coating of the articular surfaces.
capitate bone to reconstruct the carpal height. A special hole gouge is then used to complete the distal implant bed. The radial medullary space is opened centrally with an awl and extended by bone compression. The final preparation of the radial implant bed is performed with a medullary gouge (Fig. 3) so that the dorsal and palmar implant edges are consistent with the bone margin. The radial component is inserted into the prepared implant bed, followed by the carpal component.
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 937
Figure 2. Dissection and preparation of the carpal implant bed using a special awl. The tip comes to rest in the base of the third metacarpal bone.
After repositioning, the wrist capsule is closed. Additional stabilization of the dorsal wrist capsule is achieved by reconstruction of the extensor retinaculum palmarly to the extensor tendons. In unstable radioulnar joints and for active correction of alignment, a partial transfer of the tendon of the short radial extensor muscle of the wrist to the tendon of the ulnar extensor muscle of the wrist can be performed directly at the carpal attachment.
After surgery the wrist is immobilized in a thermoplastic splint for 4 weeks and physiotherapy exercises of the fingers and active pronation and supination movements are applied beginning on the first postoperative day. The 18-month follow-up examination included the following parameters: standardized x-ray control in 2 planes for assessing osteointegration and lucent lines around the implants as well as subsidence and shift, carpal height ratio according
938 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
Figure 3. Dissection and preparation of the radial implant bed using a bone-compressing medullary gauge.
to Youm and Flatt5 (normal, 0.54 6 0.03), measurement of grip strength in kilopascals (1 kPa 5 103N/ m2) using a grip meter, and determination of wrist mobility (range of motion). The patients were asked to rate their pain as none, moderate, and severe. Finally, the patient’s subjective satisfaction with the surgical procedure was evaluated by a questionnaire to determine whether they were very satisfied, satisfied, or dissatisfied with the outcome of the procedure.
Results Clinical Evaluations Before surgery all the patients complained of severe pain and a marked reduction in function of the hand. The average range of motion was extension, 13° (minimum, 235°; maximum, 40°; SD, 11°); flexion, 24° (minimum, 25°; maximum, 60°; SD, 14°); pronation, 65° (minimum, 15°; maximum, 90°; SD, 14°); supination, 57° (minimum,
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 939
210°; maximum, 85°; SD, 19°); radial deviation, 3° (minimum, 220°; maximum, 10°; SD, 7°); and ulnar deviation, 18° (minimum, 5°; maximum, 30°; SD, 6°) (Table 1). In 28 of the 30 patients (92%) there was good improvement in range of motion. After 18 months, the average mobility was as follows: extension, 33° (range, 5° to 50°; SD, 11°); flexion, 35° (range, 25° to 65°; SD, 9°); pronation, 88° (range, 83° to 90°; SD, 3°); supination, 84° (range, 75° to 90°; SD, 4°); radial deviation, 7° (range, 0° to 15°; SD, 3°); and ulnar deviation, 16° (range, 5° to 25°; SD, 4°) Table 1, Fig. 4). The mean grip strength improved in all patients from a preoperative value of 18 kPa (range, 5– 45 kPa; SD, 12 kPa) to a postoperative value of 29 kPa (range, 10 – 65 kPa; SD, 13 kPa), although there were great interindividual fluctuations due to the hand deformities that were also present.
Radiographic Evaluation The preoperative x-ray images showed far-advanced destruction of the wrist (Larsen stage III–V)4 and the carpal height ratio was markedly reduced (0.31). In the follow-up x-rays there were no signs of loosening in these patients after 18 months; the carpal height ratio was on average 0.52 and was thus within the normal range.
Subjective Outcome The symptoms of pain were markedly improved; 26 of the patients (87%) rated their pain as none and 4 (13%) complained of moderate pain; no patients complained of severe pain. Twenty-six of the patients (88%) were satisfied or very satisfied with the result; 4 (12%) were subjectively dissatisfied with the result. Twenty-five (84%) of the patients said they would undergo the procedure again.
Complications The prosthesis became dislocated 4 months after surgery in one patient due to increasing soft-tissue
destruction. In another patient, a prosthesis infection occurred 7 months after surgery due to a dog bite. In both cases, the prosthesis was removed and a Mannerfelt arthrodesis of the wrist was performed. In an additional case, a patient suffered a dislocation of the carpal component. In this patient a stable condition was achieved by means of revision surgery and arthrodesis of the wrist was not necessary (Figs. 5, 6). A wound-healing disorder occurred in 2 of the patients that was cured by conservative measures. There were no deep wound-healing disorders.
Discussion A stable and pain-free wrist is essential for proper functioning of the hand and is therefore the most important goal of surgical intervention. This goal is difficult to achieve in rheumatoid patients due to the generally far-advanced deformity and destruction of the bone and soft tissue structures. Various forms of wrist arthrodeses (eg, Mannerfelt arthrodesis, Chamay arthrodesis, plate arthrodesis) have been the treatment of choice to date.1,6 The first total wrist replacement was performed in 1890 by Gluck in Berlin.7 To improve the functional outcome, various total wrist endoprostheses have been developed and implanted over the past few years with varying success. To achieve a good postoperative result, pain reduction, correction of the deformity, and improvement or maintenance of mobility accompanied by sufficient stability should be achieved by implantation of a prosthesis. Another requirement is preservation of sufficient bone stock for arthrodesis or implantation of a revision prosthesis,6,14,15 which was necessary in 2 of our patients. An additional early complication is dislocation of the carpal component, which we found 4 months after surgery due to incorrect primary implantation. Meuli16 found that the greatest number of complications occurred during the first postoperative year; an incorrect surgical
Table 1. Pre- and Postoperative Range of Motion (Degrees) Preoperative
18 mo Postoperative
Motion
Mean
SD
Min
Max
Mean
SD
Min
Max
Extension Flexion Supination Pronation Radial Deviation Ulnar Deviation
13 24 57 65 3 18
11 14 19 14 7 6
235 25 210 15 220 5
40 60 85 90 10 30
33 35 84 88 7 16
11 9 4 3 3 4
5 25 75 83 0 5
50 65 90 90 15 25
940 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
Figure 4. The x-ray images taken after surgery show the correct seating of the anatomic physiologic wrist prosthesis and good function for (A) dorsal extension and palmar flexion as well as for (B) radial and ulnar deviation.
technique was the cause of these cases as well. The main long-term complication is loosening of the carpal component, as reported by Cobb and Beckenbaugh17 and Lorei et al.18 Despite the relatively high rate of complications compared with other total ar-
throplasties, such as of the knee or hip, the subjective satisfaction of the patients is high.3 The wrist function of the other 28 patients was very good after 18 months. The range of motion is comparable with the results reported by Ferlic and
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 941
Figure 5. Anteroposterior and lateral views obtained 6 months after implantation show a dislocation of the carpal component from the base of the third metacarpal bone in the (A) ulnar and (B) palmar direction.
Clayton8 for the CFV prosthesis, and by Cobb and Beckenbaugh17 for a biaxial wrist prosthesis. The follow-up period in our study, however, was approximately equivalent to that in Ferlic and Clayton’s8 study and considerably shorter than in Cobb and Beckenbaugh’s17 study. As expected, range of motion is better than after implantation of the Swanson prosthesis.12,19,20 With regard to pain reduction and improvement in strength, there is no major difference from other prosthesis models reported in the literature.9 –11,16 Although the range of motion was only slightly improved after prosthesis implantation, there was a marked improvement in function, which can be explained primarily by the pain reduction achieved.17 The x-rays obtained 18 months after surgery did not reveal any evidence of loosening of the proximal or distal prosthesis components, and the car-
pal height ratio was unchanged compared with the x-rays obtained directly after surgery. It is recognized that in a small patient population 18 months is a relatively short follow-up period for total joint replacement arthroplasty; although the lack of loosening is impressive, the follow-up period is too short to accept this finding as the final outcome with the prosthesis. The best postoperative outcome is achieved in patients in whom the surrounding soft tissue structures remain intact, as for other wrist arthroplasties.8 Like other types of prosthesis, the anatomic physiologic wrist prosthesis is not entirely suitable for heavy work and lifting. In such cases, wrist arthrodesis is preferred.6 Patient acceptance is very high if the indication is accurately diagnosed. Due to the minimal bone resection involved, there is room for various alternative procedures.
942 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
Figure 6. After revision surgery with change of the carpal component, correct seating of the prosthesis can be seen in these (A) anteroposterior and (B) lateral views.
References 1. Mannerfelt L. Total arthrodesis of the wrist. Rheumatology 1992;17:116 –121. 2. Swanson AB. Flexible implant arthroplasty for arthritic disabilities of the radiocarpal joint: a silicone rubber intramedullary stemmed flexible hinge implant for the wrist joint. Orthop Clin North Am 1973;4:383–394. 3. Gellman H, Hontas R, Brumfield RH Jr, Tozzi J, Conaty JP. Total wrist arthroplasty in rheumatoid arthritis: a long term clinical review. Clin Orthop 1997;342:71–76. 4. Larsen A, Dale K, Eck M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol 1977;18:481– 491. 5. Youm Y, Flatt AE. Kinematics of the wrist. Clin Orthop 1980;149:21–32. 6. Murray PM. Current status of wrist arthrodesis and wrist arthroplasty. Clin Plast Surg 1996;23:385–394.
7. Ritt MJPF, Stuart PR, Naggar L, Beckenbaugh RD. The early history of arthroplasty of the wrist: from amputation to total wrist implant. J Hand Surg 1994;19B:778 – 782. 8. Ferlic DC, Clayton ML. Results of CFV total wrist arthroplasty: review and early report. Orthopedics 1995; 18:1167–1171. 9. Figgie MP, Ranawat CS, Inglis AE, Sobel M, Figgie HE III. Trispherical total wrist arthroplasty in rheumatoid arthritis. J Hand Surg 1990;15A:217–223. 10. Lirette R, Kinnard P. Biaxial total wrist arthroplasty in rheumatoid arthritis. Can J Surg 1995;38:51–53. 11. Meuli HC, Fernandez DL. Uncemented total wrist arthroplasty. J Hand Surg 1995;20A:115–122. 12. Stanley JK, Tolat AR. Long-term results of Swanson silastic arthroplasty in the rheumatic wrist. J Hand Surg 1993;18B:381–388.
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 943 13. Volz RG. The development of a total wrist arthroplasty. Clin Orthop 1976;116:209 –214. 14. Ferlic DC, Jolly SL, Clayton ML. Salvage for failed implant arthroplasty of the wrist. J Hand Surg 1992;17A:917–923. 15. Rettig ME, Beckenbaugh RD. Revision total wrist arthroplasty. J Hand Surg 1993;18A:798 – 804. 16. Meuli HC. Total wrist arthroplasty: experience with a noncemented wrist prosthesis. Clin Orthop 1997;342:77–83. 17. Cobb TK, Beckenbaugh RD. Biaxial total-wrist arthroplasty. J Hand Surg 1996;21A:1011–1021.
18. Lorei MP, Figgie MP, Ranawat CS, Inglis AE. Failed total wrist arthroplasty: analysis of failures and results of operative management. Clin Orthop 1997;342:84 –93. 19. Clayton ML, Ferlic DC, Dennis DA, Jolly SL. Arthroplasty of the wrist: review of Volz and Swanson wrist arthroplasty. Rheumatology 1992;17:186 –197. 20. Jolly SL, Ferlic DC, Clayton ML, Dennis DA, Stringer EA. Swanson silicone arthroplasty of the wrist in rheumatoid arthritis: a long-term follow-up. J Hand Surg 1992;17A: 142–149.
In patients with rheumatoid arthritis, the joint of the upper extremities most often affected is the wrist. Destruction occurs at an early stage, with painful restriction of mobility, loss of strength, and impairment of the muscular equilibrium between extensors and flexors.1,2 In addition to functional loss, the From the Department of Rheumatic Surgery, Specialist Clinic for Rheumatology, Immanuel Hospital, Berlin, Germany; and the Department of Radiology and Nuclear Medicine, Behring Municipal Hospital, Academic Teaching Hospital, Free University of Berlin, Berlin, Germany. Received for publication July 21, 1998; accepted in revised form April 30, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Sebastian Radmer, MD, Department of Rheumatic Surgery, Specialist Clinic for Rheumatology, Immanuel Hospital Berlin, Koenigstr. 63, D-14109 Berlin, Germany. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A05-0011$3.00/0
visible deformities lead to aesthetic and thus social problems. Arthrodesis of the wrist has been used successfully for many years for stabilization and pain reduction, but leads to a loss of radiocarpal mobility.3 As an alternative, endoprosthetic replacement of the wrist has been performed since the early 1970s with the aim of reducing pain while maintaining or improving wrist function.2 The extent to which total wrist arthroplasty implant with the anatomic physiologic wrist prosthesis represents a satisfactory procedure for rheumatic patients is reported on the basis of objective criteria and subjective results obtained from a retrospective study.
Materials and Methods In 30 consecutive rheumatoid arthritis patients (24 women and 6 men) with an average age of 49.3 years (range, 29 – 67 years), arthroplasty was performed The Journal of Hand Surgery 935
936 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
for advanced wrist destruction (x-ray morphologic stage according to Larsen III–V).4 Severe soft tissue destruction (eg, rupture of the extensor tendons) is a contraindication for implantation of this device. The only absolute contraindication to wrist arthroplasty is infection. It may be performed in the presence of very advanced destructive arthritis with severe loss of bone stock; even volar subluxation or osteoporosis are not contraindications. All the patients were implanted with an uncemented anatomic physiologic wrist prosthesis (Fig. 1), which is a hydroxyapatitecoated cobalt– chrome prosthesis with a titanium coating of the articular surfaces. The prosthesis is composed of 2 components. The radial component has an articular surface inclination of 10° toward the ulna and the carpal component, which is anchored with its tip in the third metacarpal bone and the distal carpal bones, has a mobile bearing surface with a radial inclination of 10°. This shape and inclination adapts the adjustment of the proximal carpal bones in the normal range of motion. The radial component is made in 4 sizes; the carpal component is available in one standard size. The surgical approach is made using an S-shaped cutaneous incision running from the radial to the distal side along the tendon of the long extensor tendon of the thumb, diagonally across the wrist cavity to the ulnar extensor tendon of the wrist, up to approximately 2 cm proximal to the ulnar head. After dissecting the subcutaneous layer while preserving the cutaneous veins, the extensor retinaculum is exposed and detached radially. The opening thus begins in the fifth extensor tendon compartment. An extensive synovectomy of the extensor tendons is then performed, the posterior interosseus nerve is resected, and Lister’s tubercle is removed to prevent any obstruction to articulation for the extensor tendons after the later reconstruction of the extensor retinaculum over the prosthesis. The radioulnar joint is then opened, preserving the collateral ligament apparatus, and the ulnar head is resected. The capsule is dissected distally in the direction of the thumb, exposing the distal midcarpal joint. The lunate bone and parts of the scaphoid bone and hamate bone can now be resected. The capitate bone is opened using an awl; the awl is inserted in the direction of the third metacarpal bone until the base plate has been opened and the tip is positioned in the transition to the middle third of the bone (Fig. 2). The saw gouge is placed on the awl and resection is performed 90° to the horizontal instrument, which should be positioned in the proximal third of the
Figure 1. The anatomic physiologic wrist prosthesis used for uncemented implantation is a hydroxyapatite-coated cobalt– chrome prosthesis with a titanium coating of the articular surfaces.
capitate bone to reconstruct the carpal height. A special hole gouge is then used to complete the distal implant bed. The radial medullary space is opened centrally with an awl and extended by bone compression. The final preparation of the radial implant bed is performed with a medullary gouge (Fig. 3) so that the dorsal and palmar implant edges are consistent with the bone margin. The radial component is inserted into the prepared implant bed, followed by the carpal component.
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 937
Figure 2. Dissection and preparation of the carpal implant bed using a special awl. The tip comes to rest in the base of the third metacarpal bone.
After repositioning, the wrist capsule is closed. Additional stabilization of the dorsal wrist capsule is achieved by reconstruction of the extensor retinaculum palmarly to the extensor tendons. In unstable radioulnar joints and for active correction of alignment, a partial transfer of the tendon of the short radial extensor muscle of the wrist to the tendon of the ulnar extensor muscle of the wrist can be performed directly at the carpal attachment.
After surgery the wrist is immobilized in a thermoplastic splint for 4 weeks and physiotherapy exercises of the fingers and active pronation and supination movements are applied beginning on the first postoperative day. The 18-month follow-up examination included the following parameters: standardized x-ray control in 2 planes for assessing osteointegration and lucent lines around the implants as well as subsidence and shift, carpal height ratio according
938 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
Figure 3. Dissection and preparation of the radial implant bed using a bone-compressing medullary gauge.
to Youm and Flatt5 (normal, 0.54 6 0.03), measurement of grip strength in kilopascals (1 kPa 5 103N/ m2) using a grip meter, and determination of wrist mobility (range of motion). The patients were asked to rate their pain as none, moderate, and severe. Finally, the patient’s subjective satisfaction with the surgical procedure was evaluated by a questionnaire to determine whether they were very satisfied, satisfied, or dissatisfied with the outcome of the procedure.
Results Clinical Evaluations Before surgery all the patients complained of severe pain and a marked reduction in function of the hand. The average range of motion was extension, 13° (minimum, 235°; maximum, 40°; SD, 11°); flexion, 24° (minimum, 25°; maximum, 60°; SD, 14°); pronation, 65° (minimum, 15°; maximum, 90°; SD, 14°); supination, 57° (minimum,
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 939
210°; maximum, 85°; SD, 19°); radial deviation, 3° (minimum, 220°; maximum, 10°; SD, 7°); and ulnar deviation, 18° (minimum, 5°; maximum, 30°; SD, 6°) (Table 1). In 28 of the 30 patients (92%) there was good improvement in range of motion. After 18 months, the average mobility was as follows: extension, 33° (range, 5° to 50°; SD, 11°); flexion, 35° (range, 25° to 65°; SD, 9°); pronation, 88° (range, 83° to 90°; SD, 3°); supination, 84° (range, 75° to 90°; SD, 4°); radial deviation, 7° (range, 0° to 15°; SD, 3°); and ulnar deviation, 16° (range, 5° to 25°; SD, 4°) Table 1, Fig. 4). The mean grip strength improved in all patients from a preoperative value of 18 kPa (range, 5– 45 kPa; SD, 12 kPa) to a postoperative value of 29 kPa (range, 10 – 65 kPa; SD, 13 kPa), although there were great interindividual fluctuations due to the hand deformities that were also present.
Radiographic Evaluation The preoperative x-ray images showed far-advanced destruction of the wrist (Larsen stage III–V)4 and the carpal height ratio was markedly reduced (0.31). In the follow-up x-rays there were no signs of loosening in these patients after 18 months; the carpal height ratio was on average 0.52 and was thus within the normal range.
Subjective Outcome The symptoms of pain were markedly improved; 26 of the patients (87%) rated their pain as none and 4 (13%) complained of moderate pain; no patients complained of severe pain. Twenty-six of the patients (88%) were satisfied or very satisfied with the result; 4 (12%) were subjectively dissatisfied with the result. Twenty-five (84%) of the patients said they would undergo the procedure again.
Complications The prosthesis became dislocated 4 months after surgery in one patient due to increasing soft-tissue
destruction. In another patient, a prosthesis infection occurred 7 months after surgery due to a dog bite. In both cases, the prosthesis was removed and a Mannerfelt arthrodesis of the wrist was performed. In an additional case, a patient suffered a dislocation of the carpal component. In this patient a stable condition was achieved by means of revision surgery and arthrodesis of the wrist was not necessary (Figs. 5, 6). A wound-healing disorder occurred in 2 of the patients that was cured by conservative measures. There were no deep wound-healing disorders.
Discussion A stable and pain-free wrist is essential for proper functioning of the hand and is therefore the most important goal of surgical intervention. This goal is difficult to achieve in rheumatoid patients due to the generally far-advanced deformity and destruction of the bone and soft tissue structures. Various forms of wrist arthrodeses (eg, Mannerfelt arthrodesis, Chamay arthrodesis, plate arthrodesis) have been the treatment of choice to date.1,6 The first total wrist replacement was performed in 1890 by Gluck in Berlin.7 To improve the functional outcome, various total wrist endoprostheses have been developed and implanted over the past few years with varying success. To achieve a good postoperative result, pain reduction, correction of the deformity, and improvement or maintenance of mobility accompanied by sufficient stability should be achieved by implantation of a prosthesis. Another requirement is preservation of sufficient bone stock for arthrodesis or implantation of a revision prosthesis,6,14,15 which was necessary in 2 of our patients. An additional early complication is dislocation of the carpal component, which we found 4 months after surgery due to incorrect primary implantation. Meuli16 found that the greatest number of complications occurred during the first postoperative year; an incorrect surgical
Table 1. Pre- and Postoperative Range of Motion (Degrees) Preoperative
18 mo Postoperative
Motion
Mean
SD
Min
Max
Mean
SD
Min
Max
Extension Flexion Supination Pronation Radial Deviation Ulnar Deviation
13 24 57 65 3 18
11 14 19 14 7 6
235 25 210 15 220 5
40 60 85 90 10 30
33 35 84 88 7 16
11 9 4 3 3 4
5 25 75 83 0 5
50 65 90 90 15 25
940 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
Figure 4. The x-ray images taken after surgery show the correct seating of the anatomic physiologic wrist prosthesis and good function for (A) dorsal extension and palmar flexion as well as for (B) radial and ulnar deviation.
technique was the cause of these cases as well. The main long-term complication is loosening of the carpal component, as reported by Cobb and Beckenbaugh17 and Lorei et al.18 Despite the relatively high rate of complications compared with other total ar-
throplasties, such as of the knee or hip, the subjective satisfaction of the patients is high.3 The wrist function of the other 28 patients was very good after 18 months. The range of motion is comparable with the results reported by Ferlic and
The Journal of Hand Surgery / Vol. 24A No. 5 September 1999 941
Figure 5. Anteroposterior and lateral views obtained 6 months after implantation show a dislocation of the carpal component from the base of the third metacarpal bone in the (A) ulnar and (B) palmar direction.
Clayton8 for the CFV prosthesis, and by Cobb and Beckenbaugh17 for a biaxial wrist prosthesis. The follow-up period in our study, however, was approximately equivalent to that in Ferlic and Clayton’s8 study and considerably shorter than in Cobb and Beckenbaugh’s17 study. As expected, range of motion is better than after implantation of the Swanson prosthesis.12,19,20 With regard to pain reduction and improvement in strength, there is no major difference from other prosthesis models reported in the literature.9 –11,16 Although the range of motion was only slightly improved after prosthesis implantation, there was a marked improvement in function, which can be explained primarily by the pain reduction achieved.17 The x-rays obtained 18 months after surgery did not reveal any evidence of loosening of the proximal or distal prosthesis components, and the car-
pal height ratio was unchanged compared with the x-rays obtained directly after surgery. It is recognized that in a small patient population 18 months is a relatively short follow-up period for total joint replacement arthroplasty; although the lack of loosening is impressive, the follow-up period is too short to accept this finding as the final outcome with the prosthesis. The best postoperative outcome is achieved in patients in whom the surrounding soft tissue structures remain intact, as for other wrist arthroplasties.8 Like other types of prosthesis, the anatomic physiologic wrist prosthesis is not entirely suitable for heavy work and lifting. In such cases, wrist arthrodesis is preferred.6 Patient acceptance is very high if the indication is accurately diagnosed. Due to the minimal bone resection involved, there is room for various alternative procedures.
942 Radmer, Andresen, and Sparmann / Wrist Arthroplasty in Rheumatics
Figure 6. After revision surgery with change of the carpal component, correct seating of the prosthesis can be seen in these (A) anteroposterior and (B) lateral views.
References 1. Mannerfelt L. Total arthrodesis of the wrist. Rheumatology 1992;17:116 –121. 2. Swanson AB. Flexible implant arthroplasty for arthritic disabilities of the radiocarpal joint: a silicone rubber intramedullary stemmed flexible hinge implant for the wrist joint. Orthop Clin North Am 1973;4:383–394. 3. Gellman H, Hontas R, Brumfield RH Jr, Tozzi J, Conaty JP. Total wrist arthroplasty in rheumatoid arthritis: a long term clinical review. Clin Orthop 1997;342:71–76. 4. Larsen A, Dale K, Eck M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol 1977;18:481– 491. 5. Youm Y, Flatt AE. Kinematics of the wrist. Clin Orthop 1980;149:21–32. 6. Murray PM. Current status of wrist arthrodesis and wrist arthroplasty. Clin Plast Surg 1996;23:385–394.
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