Total wrist arthrodesis (TWA) is a highly effective procedure frequently employed by orthopedic surgeons to address various upper extremity conditions. This surgical technique involves fusing the carpal bones to the distal radius, providing reliable pain relief, especially in patients suffering from advanced wrist joint degeneration. While this procedure sacrifices wrist motion, it is particularly beneficial for patients suffering from conditions like rheumatoid arthritis, posttraumatic osteoarthritis, and cerebral palsy, as well as those dealing with failed implant arthroplasties.
Indications for Total Wrist Arthrodesis
Total wrist arthrodesis is indicated for various wrist pathologies, including rheumatoid arthritis, posttraumatic osteoarthritis, spasticity disorders like cerebral palsy, and brachial plexus injuries. It is also considered a salvage technique for patients who have failed previous wrist arthroplasties. The procedure aims to provide effective pain relief for patients whose wrist joints are severely damaged, offering a functional, pain-free alternative when other options are less successful. Although the procedure results in the loss of wrist motion, it preserves forearm rotation, which is a significant functional benefit for many patients.
In rheumatoid arthritis, a condition where the wrist joint is often severely deformed and painful, wrist arthrodesis offers substantial improvement in terms of pain reduction and overall function. Similarly, in posttraumatic osteoarthritis, where previous injuries have led to joint degeneration, wrist fusion provides much-needed stability and pain relief. Brachial plexus injuries, which may cause paralysis or impaired function of the hand, also benefit from wrist arthrodesis as a way to optimize upper limb function.
The Evolution of the Technique
The roots of total wrist arthrodesis can be traced back to the 1970s when Mannerfelt and Malmsten first popularized the procedure. They introduced a technique that did not require external fixation, relying instead on a retrograde Rush pin and staples for stabilization. This innovation greatly simplified the procedure, allowing for successful fusion without the need for bone grafts from distant sites like the iliac crest. Over time, modifications have been made to improve the procedure’s efficacy, such as the introduction of Steinmann pins by Millender and Nalebuff in 1973, which enhanced the fixation process.
Later studies revealed higher rates of complications with some techniques, such as pseudarthrosis, which necessitated a second surgical intervention. In response, newer methods have incorporated compression plating and more advanced fixation techniques, which have improved outcomes. Today, modern wrist arthrodesis is typically performed using pre-contoured plates with locking or non-locking screws to provide rigid fixation and compression across the wrist joint, resulting in higher fusion rates and reduced complication rates.
Clinical Outcomes and Success Rates
Recent studies on total wrist arthrodesis have demonstrated excellent clinical outcomes, particularly in patients with rheumatoid arthritis and posttraumatic arthritis. A notable study by Kluge et al found that 98% of rheumatoid arthritis patients who underwent wrist arthrodesis achieved a successful fusion within 10 weeks, with minimal complications. Patients reported significant pain relief and improved function, with many stating they would choose the procedure again.
In cases of posttraumatic arthritis, total wrist arthrodesis also provides high levels of patient satisfaction, although some patients may perceive their disability from the reduced wrist motion as more significant than the actual functional loss. Despite this, the procedure remains a gold standard for managing degenerative arthritis and other severe wrist conditions.
Bilateral wrist arthrodesis, which involves fusing both wrists, has been shown to produce positive outcomes, despite concerns about functional limitations. A study by Wagner et al. demonstrated that 93% of patients were satisfied with the results, and 9 out of 13 patients returned to full-time work after undergoing bilateral wrist fusion. These findings suggest that bilateral wrist arthrodesis can provide significant long-term benefits for patients with severe arthritis or deformities in both wrists.
Complications and Challenges
Although wrist arthrodesis is a highly successful procedure, it is not without its risks. Major complications can include nonunion, ulnocarpal impaction, carpal tunnel syndrome, extensor tenosynovitis, and deep infections. Nonunion, where the bones fail to fuse, is one of the most common complications and may require additional surgery to achieve a successful fusion. Minor complications, such as superficial wound infections or transient carpal tunnel symptoms, are less frequent but still noteworthy.
Advancements in surgical techniques, such as the use of pre-contoured locking plates and improved fixation methods, have significantly reduced the risk of complications. However, careful planning and precise execution remain critical to minimizing risks and ensuring optimal outcomes.
Total Wrist Arthrodesis Versus Total Wrist Arthroplasty
A significant area of ongoing debate in the orthopedic community is the comparison between total wrist arthrodesis and total wrist arthroplasty (TWA). While both procedures aim to relieve pain and restore function, they differ in terms of outcomes and complications. In patients with rheumatoid arthritis, total wrist arthrodesis generally provides more reliable pain relief and fewer complications compared to arthroplasty, which is associated with higher rates of revision and failure.
Studies comparing the two procedures have shown that total wrist arthrodesis is more cost-effective, with a lower risk of complications. However, wrist arthroplasty may offer functional advantages for some patients, particularly in terms of wrist motion. For instance, Nydick et al. found that patients who underwent arthroplasty had better scores on the Patient-Rated Wrist Evaluation (PRWE) compared to those who had wrist arthrodesis. Despite this, the decision between arthrodesis and arthroplasty must be based on individual patient needs, preferences, and functional goals.
Conclusion
Total wrist arthrodesis remains an essential surgical procedure for patients suffering from advanced wrist joint degeneration. With its ability to provide effective pain relief and improve function in patients with conditions such as rheumatoid arthritis, posttraumatic osteoarthritis, and brachial plexus injuries, it continues to play a pivotal role in orthopedic surgery. Advances in surgical techniques and fixation methods have improved the outcomes of this procedure, reducing complication rates and enhancing patient satisfaction. However, further studies are needed to refine the indications, techniques, and long-term outcomes of total wrist arthrodesis, particularly in comparison to total wrist arthroplasty.
