Pisiform Impingement After Total Wrist
Sean T. Johnson, MD, Amar Patel, MD, Ryan P. Calfee, MD,
Arnold-Peter C. Weiss, MD
From the Department of Orthopaedics, Brown Medical School, Rhode Island Hospital, Providence, RI.
We present a 64-year-old woman with rheumatoid arthritis who developed increasing pain
3 years after a total wrist arthroplasty. The pain was localized over the ulnar side of the wrist
secondary to erosion of the pisiform. Pisiform excision resulted in a resolution of the
symptoms. When placing a carpal component, which includes a base plate as part of its
design, care should be taken to avoid any overhang of the implant edge into the pisotriquetral
joint. (J Hand Surg 2007;32A:334–336. Copyright © 2007 by the American Society for
Surgery of the Hand.)
Key words: Pisiform, rheumatoid, wrist arthroplasty complication, impingement.
ent designs of total wrist implants currently are avail-
able, each with specific advantages and disadvan-
tages. Outcomes using these systems have been
encouraging, with Menon1reporting 88% excellent
pain relief using the original design. Dislocations
complicated the early wrist implant designs; how-
ever, the newest versions include modifications to
maximize joint stability and implant fixation.2A
painful wrist arthroplasty may result from distal ulnar
instability, implant loosening, dislocation, fracture,
or infection. We report a patient with postoperative
impingement of the pisiform on the volar aspect of
the implant at the carpal component edge.
otal wrist arthroplasty has evolved to become
a reasonable treatment option for the severely
degenerative rheumatoid wrist. Several differ-
A 64-year-old woman presented to our institution
with long-standing, progressively worsening pain
and deformity in the left nondominant wrist second-
ary to rheumatoid arthritis. In August 2003, she had
an uncemented total wrist arthroplasty and a Darrach
procedure using an implant (Universal 2 implant;
KMI, Carlsbad, CA). After surgery she had symp-
tomatic distal ulna instability for which she had an
eventual transfer of half of the flexor carpi ulnaris,
followed by allograft dermis (AlloDerm, LifeCell
Corp., Branchburg, NJ) wrapping to her distal ulna
stump with resolution of symptoms.
At the 2-year follow-up examination, the patient’s
wrist range of motion was 55° of extension, 15° of
flexion, 15° of ulnar deviation, 10° of radial devia-
tion, 90° of pronation, and 85° of supination. Grip
strength reached 60% of the nonoperated side. Sub-
jectively, she had no pain with the left wrist and was
very satisfied with its function.
Approximately 3 years after the index procedure she
presented with worsening pain (8 of 10) localized on
the volar, ulnar aspect of the wrist. A posteroanterior
radiograph showed a well-positioned total wrist implant
(Fig. 1). The lateral radiograph showed excellent im-
plant alignment, but some shape change to the pisiform
oblique, fluoroscopic examination confirmed pisiform
impingement on the implant carpal component edge. A
diagnostic injection of 1% lidocaine adjacent to the
pisiform provided temporary relief.
The pisiform was excised surgically through a
curvilinear, longitudinal volar incision. During sur-
gery the pisiform was noted to have a groove and
erosion on the articular surface opposite the edge of
the carpal component base plate (Fig. 3). The pisi-
form appeared to impinge directly onto the edge of
the carpal component. No histologic examination
was performed, despite the presence of metallic wear
debris. At the first 2-week postoperative follow-up
examination, the patient noted complete resolution of
pain at the ulnar side of the wrist and maintained the
preoperative range of motion.
The Journal of Hand Surgery
Treating the symptomatic rheumatoid wrist presents
many challenges. In the advanced disease state, the
surgeon may offer either arthrodesis or arthroplasty.
Until recently, arthrodesis offered the most reliable
treatment for pain relief because of the high compli-
cation rate for older wrist arthroplasty implant de-
signs; however, the literature now indicates higher
fourth-generation implants in the rheumatoid popu-
lation.3Rheumatoid patients also perform activities
of daily living with more ease after arthroplasty when
compared with those treated with wrist arthrodesis.4
The 2 primary complications after total wrist ar-
throplasty are soft-tissue imbalance and loosening of
the distal portion of the prosthesis.5Early metal and
polyethylene arthroplasty designs were fraught with
complications, with rates ranging from 15% to 53%
across series.6Second- and third-generation wrist
implants were designed specifically to minimize
loosening and to provide a more stable, anatomically
shaped articulation; however, these designs still ex-
perienced a 9% to 14% dislocation rate.1,7In 2002,
the fourth generation of wrist implants was intro-
duced (Universal 2 implant), which offered further
improvement on initial designs with emphasis on
limiting bony resection, implant stability, and more
accurate restoration of radial tilt.2Other manufactur-
ers have followed with similar design parameters
using a carpal component that contains fixation
screws and a base plate (Small Bone Innovations,
Morrisville, PA). Any total wrist implant that uses a
resection plane in the carpus through the capitate
head region and a base plate on the carpal component
appears to have a risk for pisiform impingement on
the base plate if the base plate is sized incorrectly
(uncovered by bone) or malaligned (shifted ulnarly
within the remaining carpus).
Total wrist arthroplasty complications include in-
fection, hematoma, soft-tissue imbalance, disloca-
Figure 1. Postoperative, posteroanterior radiograph showing
excellent position of a total wrist arthroplasty implant. A
white arrow highlights the area of potential pisiform/carpal
base plate impingement.
Figure 2. Postoperative lateral radiograph shows a well-
aligned implant and suggests some contour change of the
pisiform opposite the carpal base plate (white arrow).
Figure 3. Intraoperative photograph shows a groove worn in
the pisiform articular surface and surrounding wear debris.
Johnson et al / Pisiform Impingement
tion, implant loosening, implant failure (silicone im- Download full-text
plants), and distal radius fracture.8,9We found no
mention of pisiform-derived complications in the lit-
erature. In 2004, Adams2published a review of wrist
arthroplasties that included early results with a rede-
signed implant (Universal 2, KMI, Carlsbad, CA). In
a series of 25 patients, he reported excellent fixation,
functional range of motion, and pain relief in all
patients; however, 5 patients experienced mild ulnar-
sided wrist discomfort. There was no further expla-
nation or specific diagnosis given for this pain.
Ulnar-sided wrist pain after complete distal ulnar
excision in conjunction with total wrist arthroplasty
should not be expected unless distal ulnar stump
instability develops. The patient presented in this
article shows another potential source of ulnar-sided
pain related to pisiform impingement on the carpal
base plate. Surgeons should take care to examine the
carpal base plate size and alignment during total
wrist arthroplasty to ensure that pisiform impinge-
ment does not occur. If intraoperative evidence of
potential impingement exists, concomitant excision
of the pisiform at the index procedure seems war-
Received for publication September 12, 2006; accepted in revised form
December 22, 2006.
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
Corresponding author: Arnold-Peter Weiss, MD, 2 Dudley St, Suite
200, Providence, RI 02905; e-mail: firstname.lastname@example.org.
Copyright © 2007 by the American Society for Surgery of the Hand
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The Journal of Hand Surgery / Vol. 32A No. 3 March 2007