The Modified Clayton-Mannerfelt Arthrodesis of the Wrist in Rheumatoid Arthritis: Operative Technique and Report on 93 Cases
Schulthess Clinic, Orthopedics Upper Extremities/Hand Surgery, Zurich, SwitzerlandThe Journal of hand surgery (Impact Factor: 1.67). 05/2013; 38(5):999-1005. DOI: 10.1016/j.jhsa.2013.02.029
Arthrodesis of a painful and destroyed wrist is one of the key operations in patients with rheumatoid arthritis. Clayton is given credit for the first description of an operative technique of wrist arthrodesis by means of an intramedullary Steinmann pin. Mannerfelt popularized this technique by using a Rush pin and additional fixation with staples. The aim of the present article is to give a detailed description of the operative technique used in our hospital. Over a period of 13 years, 104 modified Clayton-Mannerfelt arthrodeses were performed in 87 patients with rheumatoid arthritis. Ninety-three wrists were reviewed clinically and radiographically. The patients had high fusion rates and a reliable reduction in preoperative pain, with a low rate of complications. The pin technique is more versatile than standard wrist arthrodesis plates, and the wrist can be positioned according to the needs of the patient. This technique seems to be a good alternative to conventional wrist arthrodesis using an arthrodesis plate in wrists destroyed by rheumatoid arthritis, even in situations with difficult bone stock. In most cases, it is not necessary to remove the hardware.
- "If the 11 reviews (such as this one) and the 11 papers in an issue devoted to the rheumatoid wrist and elbow [Hand Clin 2011;27(1)] are excluded, 52 articles remain [16–67]. These papers deal with the following topics: methodology for clinical review, particularly the validity of the DASH and Quick-DASH scores in RA , their good correlation with the DAS-28 , the importance of the ICFDH , and the best follow-up tools: visual analog scale for pain, Grippit's device for strength, Grip Ability Test (GAT), DASH score and Canadian Occupational Performance Measure (COPM) ; surgery of extensor tendons ruptures: predictive role of extensor carpi ulnaris (ECU) palmar dislocation on the occurrence of finger extensor tendon ruptures , comparative results of grafts and tendon transfers , predictive outcome factors ; surgery of the distal radioulnar joint: total resection  or hemiresection of the ulnar head  , Sauvé-Kapandji procedure, either the original  or modified version (908 rotation of ulnar head) , and its beneficial effect on carpal instability , advantage of systematic stabilization of the ulnar stump with the ECU , prosthetic arthroplasty ; surgery of the radiocarpal and midcarpal joints: arthroscopic synovectomy  , radiolunar     , radiolunar and radioscapholunar arthrodesis , total wrist arthrodesis  , prosthetic arthroplasty: universal  , biaxial  or ReMotion clinical  or biomechanical  study, comparison of the costs of conservative management, prosthetic arthroplasty and arthrodesis ; advantages and disadvantages of arthrodesis and arthroplasties according to surgeons and rheumatologists ; surgery of the metacarpophalangeal joints: influence of swan-neck and boutonniere deformities on arthroplasty results , cutaneous risks , clinical results, either in isolation     or compared to those of non-operated patients  , importance of esthetics on patient satisfaction , comparison of classic silicone implants and spacers without stems made of PLDLA  ; management of proximal interphalangeal joints with reducible swan-neck     or boutonniere  deformity; infectious risks: no statistically significant increase in the risk of postoperative infection when biologics and/or methotrexate are discontinued (3.2%) or continued (5.1%), leading the authors to continue biologics and/or methotrexate treatment perioperatively ; indications for surgery based on the surgeon's, rheumatologist's and physiotherapist's opinions   . "
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ABSTRACT: Introduction: Wrist arthrodesis offers high success rates in patients with rheumatoid arthritis; however, loss of residual mobility may cause unnecessary disability. This makes wrist denervation an appealing alternative. However, there is a distinct lack of patient-reported outcome measure studies comparing these two procedures. The aim of this study was to report any change in function, pain and satisfaction following wrist arthrodesis compared to denervation in a single surgeon series of rheumatoid patients. Patients and methods: The results of 16 wrist arthrodesis in 15 patients and 14 partial (PIN) wrist denervations in 13 patients were compared with a mean follow-up period of 39 and 22 months, respectively. The primary outcome measures were the same for both groups and included the validated patient-rated wrist evaluation questionnaire and a satisfaction questionnaire. Results: Wrist arthrodesis significantly improved the mean total pain and functional outcome scores by 54 and 36 %, respectively, at the time of follow-up. Wrist denervation patients also reported significant improvements of 44 and 42 % in total pain and functional outcomes, respectively; 87 % reported being very satisfied with their wrist arthrodesis procedure compared to 78 % in the denervation group. No statistically significant difference in response between the groups was observed in this series of patients. Conclusions: Both procedures enjoyed favourable results amongst patients with excellent satisfaction outcomes. PIN denervation is a simple procedure with low complication rates and we therefore consider it a valid alternative to more difficult treatment options, such as partial or total wrist arthrodesis.
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ABSTRACT: We studied a technical modification of Mannerfelt's total wrist fusion technique in a series of 19 wrists. A fully intramedullary technique without dorsal carpal fixation was used to protect the extensor tendons. Two intramedullary Rush pins without dorsal staples were used during the arthrodesis procedure. Nineteen rheumatoid arthritis wrists (2 bilateral cases) were reviewed with a mean follow-up of 4.9 years (range 2-10 years). Clinical outcomes were assessed using the VAS pain scale, DASH-score and wrist strength measurements. Wrist fusion was assessed on AP and lateral X-rays of the wrist. The position of the carpal Rush pin entry points and distal hook orientation were also assessed. Pain was 8.9 preoperatively and 1.1 at the last follow-up with 95% patients satisfied. Mean DASH-score was 46.9 points. The pinch strength was 79% and the grip strength was 68% of the contralateral wrist. Carpal height, carpal anterior subluxation and ulnar deviation were stable at the last follow-up. All of the wrists were in straight position and no extensor tendon ruptures were noted. Fusion was complete in all cases within 6 to 12 weeks, except in one case. The technical modification proposed in the current study -intraosseous fixation only- appears to be a good alternative to Mannerfelt's original technique. Every case treated with this modified technique had good functional results and none required pin removal.
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