Wrist Fusion - Callum Clark 24/7/2001

Definitions

Wrist Arthrodesis = Fusion of the radiocarpal, mid-carpal (+/- CMC) joints in the radio-central axis ( not including scapho-trapezial joint). No motion post-op.

Limited Wrist Arthrodesis or Intercarpal Arthrodesis = Fusion of certain carpal bones, sparing radiocarpal joint. Maximises post-op motion and strength. ?Delaying the inevitable?

Wrist arthrodesis – Indications

            Post-traumatic OA

            Rheumatoid

            SLAC wrist

            Infection

            Spastic deformity

            Flail wrist (to stabilise +/- tendon transfers)

            End stage Kienbock’s

            Failed Total joint arthroplasty

            Tumour resection

Techniques

Up to 1960s: Cortico-cancellous bone graft, usually from dorsal approach, with minimal or no fixation.

Smith-Peterson 1940: described ulnar approach and using ulna as BG.

Haddad and Riordian 1967: used radial approach, less wound and ext. tendon probs.

Long periods in POP

Up to 28% non-union

1960s and 70s: Use of Steinman pin or Rush nail as intra-medullary devices.

Clayton et al 1965: Steinman pin

Mannerfelt and Malmsten 1971: Rush nail

Millender and Nalebuff 1973: Rush nail in Rheumatoids

Only allows neutral position

Nail migration

Compromises MCPJ surgery

8% non-union

1979 Muller: Described using DCP dorsally in AO technique book.

Several studies; gradual swing away from POP post-op, more often use cancellous than cortico-cancellous BG, special AO/ASIF wrist fusion plate.

Negligible non-union

Proximal Row Carpectomy and fusion of radius to capitate, capito-hamate and 3 ^rd CMCJ, Liebold 1938, Louis et al 1984.

Some advantages: No need for iliac crest bone, reduced ulno-carpal impingement, but ? reduced grip strength with reduced carpal height.

Complications

Wound problems (dorsal approach)

Pseudarthrosis, non-union, mal-union

Scarring of ext tendons

Superficial radial nerve

OA (DRUJ, ulno-carpal joint, CMCJ)

Ulno-carpal impaction

Carpal Tunnel

Intrinsic contracture

Current Controversies

            Role of limited arthrodesis

Optimal position of fusion (consider POP trial)

            Fuse to 2 ^nd or 3 ^rd MC?

            Inclusion of CMC joints (most now include middle finger, but exclude index, for power grip)

            Which plate? (3.5mm DCP or titanium Synthes plate)

            When to use Proximal Row Carpectomy and fusion

            Surgical approach – 1 ^st , 2 ^nd or 3 ^rd compartments

            Release of dorsal interosseous compartments to prevent intrinsic tightness?

            Resecton of ulnar head