The arthritic wrist. II - The degenerative wrist: Indications for different surgical treatments

Service de Chirurgie Orthopédique 1 et 2, Unité de Chirurgie de la Main, Hôpital Trousseau, CHRU de Tours, 37044 Tours cedex, France.
Orthopaedics & Traumatology Surgery & Research (Impact Factor: 1.26). 06/2011; 97(4 Suppl):S37-41. DOI: 10.1016/j.otsr.2011.03.007
Source: PubMed


For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined.

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Available from: Dominique Le Nen
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    ABSTRACT: Treatment of failures after prior wrist surgeries with major articular destruction is challenging. In most cases, total wrist fusion is the only possible salvage procedure. We propose a new interposition arthroplasty with a pyrocarbon implant called Amandys. A total of 16 patients, 14 men and 2 women, with a mean age of 56 years were operated on for a failure of wrist surgery performed previously, with an average time lapse of 12 years. The prior surgeries were partial wrist arthrodesis in seven cases, silicone implant interpositions in five cases, advanced Kienböck disease (Lichtman IV) treatment in two cases, proximal row carpectomy in one case, and an isolated scaphoidectomy in one case. A prospective study with clinical and radiological evaluation was performed with a mean follow-up of 24 months (6 to 41 months). Pain and function showed significant improvement. The mean pain score decreased from 7 of 10 to 4 of 10, postoperatively. The mean grip strength was 19 kg (53% of the contralateral side), and the mean range of motion in flexion extension was 68 degrees. Mean strength and range of motion did not change significantly with the operation. The mean QuickDASH (Disability Arm Shoulder and Hand) score decreased from 59 of 100 to 39 of 100. The mean Patient-Rated Wrist Evaluation decreased from 57 of 100 to 33. Two patients (12.5%) required revision for implant repositioning. No dislocation or subsidence of the implant was noted. Pyrocarbon interposition arthroplasty is a new option for treatment of advanced wrist destruction. Preliminary short-term results suggest that it may be a reliable alternative to total wrist fusion. The level of evidence of this study is IV (therapeutic case series).
    No preview · Article · Aug 2012
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    ABSTRACT: Post-traumatic, arthritic or degenerative destruction of the midcarpal and radiocarpal joints are difficult to treat. A new arthroplasty with a free interposition pyrocarbon implant, Amandys(®), is proposed for the treatment of extensive destruction of midcarpal and radiocarpal joints. Preliminary results are reported. The prospective series included 25 patients, 15 males and 10 females with a mean age of 60. The indications were degenerative, post-traumatic or rheumatoid destruction of the wrist. Sixty percent of the patients had already had surgery on their wrist before the operation. The mean follow-up was 24months. Three patients had a reoperation: two for a repositioning of the implant and one for a styloidectomy. At the last follow-up, the mean grip strength was 16kg (51% of the contralateral side), the mean range of motion in flexion-extension was 68°. Mean strength and range of motion did not change significantly with the operation. Pain and function showed significant improvement. The mean pain score decreased from 6.7/10 to 3.7/10 postoperatively. The mean PRWE score decreased from 61/100 to 32/100.The mean QuickDash score decreased from 63/100 to 36/100. Ninety-six percent of the patients were satisfied or very satisfied. No dislocation or subsidence of the implant was noticed. This minimally invasive pyrocarbon interposition increases the possibilities for the treatment of extensive articular destructions of the wrist. Indications must be limited to a well-aligned wrist with competent capsuloligamentous structure. This new arthroplasty is a reliable alternative to other surgical options, which are more radical or invasive such as total arthrodesis or total wrist prosthesis.
    No preview · Article · Aug 2012 · Chirurgie de la Main
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    ABSTRACT: Purpose Proximal row carpectomy is a well-established technique for the management of wrist arthritis; however, patient selection and long-term durability of proximal row carpectomy is still a matter of controversy. Hence, we conducted a systematic review of the English literature to determine the best evidence on long-term outcomes following proximal row carpectomy. Methods A MEDLINE search using the term "proximal row carpectomy" was performed. A total of 192 studies were identified. All studies with 10 or more years of follow-up were included in the review. Data extracted included patient demographics, indications for surgery, previous surgery, outcome assessment, and information on complications and failures. Results A total of 147 patients from six studies met the inclusion criteria and were included in the study. The majority of patients were male and involved in manual labor. There was no significant difference between the preoperative and long-term postoperative motion. The weighted mean for postoperative grip strength was 68.4% compared with the contralateral side. Disabilities of the arm, shoulder, and hand; patient-rated wrist examination; and Mayo wrist scores were comparable to those reported for four-corner arthrodesis. There were 21 failures (14.3%) requiring re-operation. Failures were not associated with a specific preoperative diagnosis but distributed among patients with Kienböck disease, scaphoid nonunion advanced collapse, and scapholunate advanced collapse arthritis. Conclusions This systematic review confirms the long-term durability of proximal row carpectomy when used for the treatment of wrist arthritis. Although radiocapitate arthritis develops over time in most patients, the clinical significance of this finding is undetermined and does not necessarily correlate with failure of proximal row carpectomy. Poorer long-term outcomes are likely to result in patients engaged in heavy manual labor, whereas better outcomes may be obtained in patients undergoing proximal row carpectomy for trauma or earlier-stage Kienböck disease.
    No preview · Article · Nov 2012
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