Wrist Arthrodesis 

Updated: Mar 25, 2019
Author: John J Walsh, IV, MD; Chief Editor: Harris Gellman, MD 

Overview

Background

Arthropathy and resulting arthritis of the wrist give rise to pain, which in turn leads to disability and decreased function of the upper extremity.[1]

The articulation afforded the hand by the wrist is important for mobility, strength, and dexterity. The pain produced by arthropathy of the wrist causes the patient to use a wrist splint to decrease pain. However, loss of mobility due to splinting is only part of the problem. The pull of the finger and wrist flexors and extensors exerts considerable force on the many intercarpal joints. Pain produced by bone-on-bone contact is compounded by the pressure exerted in active motion, and the result is reluctance of the patient to perform active motion.

Pathophysiology and etiology of wrist arthropathy

Joint arthropathy resulting in wrist arthritis is nearly identical to arthropathy in other joints, including the hip and knee. The principal problem is loss of articular cartilage between the carpal bones and/or the metacarpal and distal radius. The major difference is the fact that the wrist is not normally a weightbearing joint.

Causative factors for wrist arthropathy include, but are not limited to, the following:

Wrist arthrodesis is also indicated for stabilization of the wrist when combined with tendon transfers, for correction of wrist deformities in patients with spastic hemiplegia, and for salvage of unsuccessful wrist arthroplasty.

The various etiologies notwithstanding, the common pathway of disease includes the following:

  • Destruction of articular cartilage
  • Formation of osteophytes
  • Loss of the normal joint interval
  • Formation of degenerative subchondral cysts

Bone-on-bone contact produces reactive bone formation in the subchondral area and eventually results in eburnation (sclerosis) of the contacting bone surfaces. Pressure and abrasion irritate afferent nerves in the substance of the bone. Inflammation is either a result of the primary etiology (eg, rheumatoid arthritis or gout) or can be a result of synovial irritation. Prostaglandins and cytokines are generated as a result of inflammation, causing pain and decreased mobility of the wrist.

Epidemiology of wrist arthropathy

No comprehensive epidemiology data for wrist arthropathy are reported in the literature. However, Watson and Ballet reviewed 4000 wrist radiographs for evidence of arthritis (eg, joint space narrowing, osteophyte formation, subchondral reactive bone formation, or subchondral cyst formation).[2] Of these 4000 radiographs, 210 (5.3%) had unequivocal radiographic changes consistent with wrist arthritis. The scapholunate advanced collapse (SLAC) pattern was most prevalent, noted in 120 (57% of pathologic joints) of the 210 radiographs.

In this study, triscaphoid arthritis (ie, scaphoid, trapezoid, and trapezium) was found in 14% of affected wrists.[2] Non-scaphoid-related arthritis was found in only 3% of affected wrists. The radiolunate joint was almost never affected. Note that this population did not include wrist arthritis due to inflammatory arthropathy.

Treatment of wrist arthropathy

The goal of arthrodesis for painful arthritis is to prevent motion by obtaining bony consolidation of worn joint surfaces and thereby remove the pain generated in the joint. In addition, wrist arthrodesis can be beneficial in providing a more functional hand and upper extremity in patients with deforming spastic hemiplegia.

The earliest wrist arthrodesis procedures consisted of decortication and combinations of corticocancellous bone grafts keyed into accurately cut slots and keyways. Immobilization of the wrist was required postoperatively to ensure adequate healing.

Later, the use of percutaneous pin fixation allowed for decreased reliance on external immobilization. Steinmann pins were also employed as internal splints in an attempt to provide more rigid fixation. The development of internal fixation with plates and screws revolutionized wrist arthrodesis and almost completely eliminated the need for external immobilization.[3]

Currently, state-of-the-art total wrist arthrodesis employs the use of a specifically designed dynamic compression plate, which allows rigid fixation with larger screws proximally and smaller screws distally to reduce the risk of fracturing the metacarpals. Limited intercarpal arthrodeses still employ combinations of Kirschner wires (K-wires), screws, staples, and structural bone grafting. Specialty plate and screw constructs have been designed for use in both limited and total arthrodesis of the wrist.[4]

Indications

Arthrodesis of the wrist joint is indicated in degenerative joint disease and instability associated with restricted and painful range of motion (ROM). Further indications are unsuccessful reconstruction, partial arthrodesis, or arthroplasty, with or without total joint replacement.[5]

Total wrist fusion still represents the main treatment for severe posttraumatic disorders of the wrist due to long-standing scaphoid nonunion advanced collapse (SNAC), SLAC (see the images below), and occasionally posttraumatic arthritis secondary to distal radius fractures.

Wrist arthrodesis. Stage III scapholunate advanced Wrist arthrodesis. Stage III scapholunate advanced collapse (SLAC) wrist. Patient desired motion-preserving procedure.
Wrist arthrodesis. Sequence of degenerative change Wrist arthrodesis. Sequence of degenerative changes in scapholunate advanced collapse (SLAC) wrist arthritis pattern.

Specific indications for radiocarpal arthrodesis include the following:

  • Posttraumatic osteoarthrosis of the radiocarpal joint and midcarpal joints as commonly observed following chronic scapholunate dissociation complex fractures
  • A previous more limited arthrodesis that was unsuccessful, 
  • An unsuccessful total-joint or previous arthroplasty of the radiocarpal joint
  • Paralysis of the wrist or hand with potential for reconstruction involving the use of wrist or finger motions for tendon transfer
  • Reconstruction following segmental tumor resection, infection, or traumatic segmental bone loss of the distal radius and carpus
  • Adolescent spastic hemiplegia with wrist flexion deformity
  • Rheumatoid arthritis [6]

Midcarpal fusion has become increasingly more popular because it preserves ROM. However, whether the preserved motion is of real benefit from the patient's point of view is questionable, because complete pain relief is rare following this type of limited wrist fusion. Midcarpal fusion is preferable to total wrist fusion for treatment of progressive carpal collapse (eg, SLAC or SNAC).[7, 8] Currently, patients with occupations or interests that require intricate use of their hands are believed to have better outcomes with limited arthrodeses because of the preservation of motion.[9]

Subtotal arthrodesis is not recommended for patients with rheumatoid wrist joints or those engaged in hard manual labor, because the functional results are only negligibly better than those obtained with total arthrodesis. Limited wrist arthrodesis is the surgical fusion of selected bones of the wrist. In each case, the extent of the fusion is determined by the extent of the disease process.

Limited wrist arthrodesis is an alternative to complete wrist fusion when a localized area of degenerative change or instability in the carpus is present. It relieves pain while still allowing some range of motion.[10] Biomechanical alterations do occur following limited intracarpal fusions. Subtotal arthrodeses of the wrist are indicated for painful arthritis involving one or two radiocarpal or intracarpal joint surfaces, stabilization of carpal collapse deformities, failed ligament reconstructions or repairs, or bone tumors with partial carpal involvement.[11]

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while attempting to eliminate pain. Selective fusion of specific carpal bones can be used in persons with degenerative arthritis, rotatory subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienböck disease, and congenital synchondrosis or partial fusion of specific carpal joints.[12]

The need for fusion of the capitate, lunate, triquetrum, and hamate is still unclear. Evidence suggests that there may be an improved ability to reduce the capitate on the lunate and a lower rate of nonunion when the triquetrum and scaphoid are excised and the only fusion surfaces are localized between the capitate and lunate. Migration of the screws can be an issue with this technique.[13, 14]

Contraindications

A contraindication for wrist arthrodesis is an open distal radial physis. Severe trauma to the wrist and physis might require epiphysiodesis and, therefore, allow for fusion.

A relative contraindication is an elderly patient with a sedentary lifestyle, especially if the targeted wrist is the nondominant wrist. In this situation, an arthroplasty may be more suitable.

Other contraindications include the following:

  • Quadriparetics who use their motors for modified grasp and transfer techniques
  • Neurologic diseases or injury causing major sensory deprivation in the hand
  • Advanced rheumatoid disease where stabilization techniques are more suitable than formal arthrodesis

Technical Considerations

Procedural planning

One surgical treatment not involving arthrodesis is particularly useful in the SLAC wrist. The treatment involves partial denervation of the wrist through division of the anterior and posterior interosseous nerves at the level of the wrist through a small dorsal incision, as described by Berger.[15]  This does not affect the articular changes directly but can reduce symptoms to allow arthrodesis to be postponed or avoided.

The surgical technique depends mainly on the quality of bone substance and degree of joint degeneration. Differences between fusion types include the type of bone graft and osteosynthesis being used.

The aim is to create a stable joint in an acceptable functional position. The position of arthrodesis depends on the patient's needs. A neutral position is generally accepted in patients with rheumatoid arthritis, whereas slight wrist extension and ulnar deviation are preferred in patients with degenerative joint disease.[16, 17, 18, 19]  A stable osteosynthesis with plate fixation is reliable and allows early rehabilitation.

The use of internal fixation has decreased the need for prolonged immobilization in a cast postoperatively and has improved outcomes. Historically, single or multiple screws have been used to hold a cortical bone graft in place in the dorsal aspect of the wrist. The use of a single K-wire to supplement immobilization in a cast has also been described. A technique described for use in patients with rheumatoid arthritis uses a single permanent Steinmann pin advanced retrograde from the third metacarpal into the medullary canal of the radius.

A later modification of this method was the addition of a Rush rod with supplementary staple fixation, eliminating the need for postoperative immobilization in a cast. In fact, the results of a modification of this technique reported by Millender and Nalebuff support the finding that immobilization in a plaster cast is not imperative after wrist arthrodesis in patients with rheumatoid arthritis when internal fixation is used.[20]  This technique has also been used for arthrodesis of wrists in individuals with posttraumatic disorders.

Other methods of internal fixation included the use of multiple staples without an intramedullary pin and the technique of placing a pin from the thenar eminence into the medullary canal of the radius without exposing the wrist.

The use of dorsal placement of a nine-hole plate from the second metacarpal to the radius with an additional corticocancellous autogenous iliac crest bone graft was first described in 1972. Later, Larsson described a similar technique that used a six-hole self-compressing plate.[21]  By the early 1980s, a larger eight-hole 3.5-mm dynamic compression plate was advocated to provide more appropriate rigid fixation.

Currently, a specifically designed wrist arthrodesis plate is available, which combines a 3.5-mm dynamic compression plate proximally and a 2.7-mm dynamic compression plate distally. (See Technique.) This combination AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) wrist arthrodesis plate allows improved and stable fixation by using larger screws in the distal radius and reduces the risk of metacarpal fracture and fragmentation by using smaller 2.7-mm screws into the metacarpal.

Application of this wrist fusion plate yields a high rate of fusion when bone graft is used and, in comparison to other wrist arthrodesis techniques, yields a more predictable rate of fusion.[22]  Three versions of the AO/ASIF wrist fusion plate are available: short carpal bend, long carpal bend, and straight plate. All versions use three 2.7-mm metacarpal screws, one 2.7-mm capitate screw, and four 3.5-mm radius screws.

The use of corticocancellous bone graft from the iliac crest is still advocated to augment the site of the arthrodesis for appropriate osseous consolidation. Slot grafts and onlay grafts create the added physical integrity of corticocancellous grafts. However, data have been reported showing that cancellous bone alone is sufficient for fusion when used with fixation. This has facilitated harvesting cancellous bone from the distal radius, eliminating the need for iliac crest bone graft harvest when limited amounts of graft are needed.

The performance of proximal row carpectomy in conjunction with total wrist arthrodesis in patients with rheumatoid arthritis has been described, with a view to simplifying the arthrodesis and rendering an iliac bone graft unnecessary. In a study by Pham et al, the combination of total wrist arthrodesis with proximal row carpectomy was reliably and reproducibly beneficial, and no adverse effects related to loss of carpal height were reported.[23]

Limited intercarpal arthrodesis can be achieved by either onlay corticocancellous grafts or interpositional cancellous grafts performed through a dorsal exposure. In an attempt to preserve motion, various limited arthrodeses of the carpus have been described. Although these procedures are technically demanding, successful results may be expected, especially in conditions of carpal instability.

The decision as to which carpal bones are to be fused depends on the location and type of pathology. Kienböck disease (AVN of the lunate) can be treated by fusing the radial aspect of the carpus. A scaphotrapeziotrapezoidal (STT) arthrodesis stabilizes the carpus and unloads the central column of the wrist.[24]  Scapholunate dissociation resulting from rupture of the scapholunate ligament can also be treated with STT fusion.

If degenerative changes are evident in the radioscaphoid articulation, then a scaphoid excision and a four-corner (ie, lunate-triquetrum-capitate-hamate) arthrodesis is necessary.[25, 26, 27, 28, 13]  It has been suggested that capitolunate arthrodesis may be an alternative to four-corner fusion for SNAC wrists with osteoarthritis.[14]

Outcomes

Wrist arthrodesis results in a high degree of patient satisfaction with respect to pain relief and correction of deformity.[29] Patients are able to accomplish most daily tasks and activities by learning to adapt to and compensate for the loss of wrist motion. After wrist arthrodesis, patients adapt to their fused wrists but still have difficulty with some activities, such as getting the hand into tight places, heavy lifting, and positioning the hand for some specific activities. However, satisfactory postoperative function appears to depend more on pain relief than on residual motion.[30]

Wrist arthrodesis, either pancarpal or limited, is considered the primary surgical alternative in patients with most end-stage arthritic conditions of the wrist. The pancarpal arthrodesis is a predictable durable alternative to a variety of posttraumatic, degenerative, or neoplastic conditions of the wrist. However, some authors report that complications may be prevalent. This procedure may also be modified and applied to the destroyed rheumatoid wrist.

Overall, selection of fixation mode depends on bone quality.[31] With the current wide array of surgical alternatives, the surgeon must consider each case carefully and select the procedure that best applies to each particular situation. Furthermore, the surgeon must educate the patient on the limitations of each procedure.

Solid fusion, pain relief, and satisfactory functional results can be achieved after wrist arthrodesis. Prerequisites for obtaining such results are as follows[32] :

  • First, the patient's upper extremity level of function and range of motion of all other joints of the extremity must be assessed preoperatively, and wrist and hand deformities must be addressed radiographically
  • Second, during surgery, rigid fixation should be obtained and wrist deformity should be corrected
  • Third, a postoperative rehabilitation program should include range of motion of other joints, muscle strengthening, and functional activities

In a population-level analysis comparing proximal row carpectomy and partial wrist arthrodesis for treatment of chronic wrist arthritis, Rahgozar et al determined that the rate of conversion to total wrist arthrodesis and the associated direct cost were significantly higher with the latter than with the former.[33]

In a study aimed at investigating the long-term rate of secondary surgical procedures (including conversion to total wrist arthrodesis) in 123 patients who underwent proximal row carpectomy (n = 62) or four-corner arthrodesis (n = 61), Williams et al found that at a mean follow-up of 8.2 years, the two operations were comparable in terms of patient-reported outcomes and total wrist arthrodesis conversion rates.[34]  However, those in the four-corner arthrodesis group were significantly more likely to undergo secondary operations.

 

Periprocedural Care

Preprocedural Planning

History and physical examination

The history is simple and specific. The patient reports pain in one or both wrists. He or she may recall a history of trauma to the affected wrist or have a related diagnosis such as rheumatoid arthritis[35]  or gout. The patient's pain is usually progressive and, at the time of presentation to an orthopedic surgeon, has already been treated conservatively. The pain is usually exacerbated with use and relieved with rest and nonsteroidal anti-inflammatory drugs (NSAIDs). The patient may have swelling and stiffness associated with the wrist pain.

Preoperatively, patients should be assessed for the presence of carpal tunnel syndrome, distal radioulnar joint arthritis, or ulnocarpal impaction syndrome, which may become or remain symptomatic after arthrodesis.

On physical examination, painful range of motion of the wrist is present. Soft-tissue swelling or an effusion may be noted around the wrist. Provocative testing of the carpus may reveal instability or laxity of the intercarpal ligaments. The patient usually has decreased range of motion of the wrist due partly to a mechanical block and partly to pain.

Laboratory studies

Preoperative laboratory work should include studies that predict healing ability, such as prealbumin, albumin, and absolute lymphocyte count. Prealbumin results should be above 18 mg/dL for normal wound healing. The absolute lymphocyte count should be greater than 1500/μL for normal wound healing. Blood loss is not of great concern, and cross-matched blood is not generally required.

Imaging studies

Radiography

Preoperative radiography, including anteroposterior [AP], lateral, oblique, and clenched-fist views, should be obtained. (See the images below.) Radiographs of the wrist reveal changes consistent with arthropathy and arthritis. The standard three views of the wrist should identify the intracarpal and intercarpal joints with arthrosis. Radiographs should be examined for the following:

  • Loss of joint intervals
  • Subchondral reactive bone formation
  • Subchondral cysts
  • Osteophyte formation
Wrist arthrodesis. Posteroanterior wrist radiograp Wrist arthrodesis. Posteroanterior wrist radiograph demonstrating marked radiolunate degenerative joint disease. Either radioscapholunate fusion or total wrist fusion is appropriate treatment.
Wrist arthrodesis. Lateral wrist radiograph depict Wrist arthrodesis. Lateral wrist radiograph depicting marked wear in radiocarpal articulation.

Particular attention should be paid to joints that are not going to be fused, such as the distal radioulnar joint and the thumb, index, ring, and small finger carpal-metacarpal joints. Pain from arthropathy in these joints is not affected by fusion and can lead to suboptimal outcome. Contralateral wrist radiography can be used to assess ulnar variance of the pathologic side. Standard radiography with three views of the wrist (AP, lateral, oblique) is necessary to determine which of the carpal articulations is involved and the extent of any such involvement.

Scaphoid view radiography should be obtained to determine whether an occult nonunion of the scaphoid exists.

The clenched-fist view stresses the intercarpal ligaments and may reveal an incompetent scapholunate ligament. Failure to address this problem at operation results in the failure of a scaphotrapeziotrapezoidal (STT) fusion.

Computed tomography

On the rare occasions when plain radiography appears to be inadequate to identify all of the bony pathology accurately, computed tomography (CT) of the wrist can be helpful by exposing malalignment of bony columns and underlying arthropathy.

Patient Preparation

Smoking cessation prior to surgery is critical and should be addressed early in the preoperative planning. The operative extremity should be confirmed with the patient and marked in the holding area by the operating surgeon.

Monitoring & Follow-up

The dressing is removed 10-14 days postoperatively, and the sutures are removed if the surgical site is healed. Although some authors have questioned the need for postoperative immobilization of the wrist after using a compression fusion plate, most postoperative courses include either a removable plastic wrist splint or short-arm cast for at least 6 weeks postoperatively.

Loss of mobility is of great concern; accordingly, occupational hand therapy is started for range of motion of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints as soon as the dressing is removed. However, weightbearing is restricted until radiographic and clinical evidence of fusion is noted. An Isotoner glove can be used to control edema in the hand. Radiographs of the wrist generally are obtained at 3 and 6 weeks, and then every 3 weeks until fusion is obtained.

The internal stabilization in subtotal wrist arthrodesis and in older methods of total wrist arthrodesis generally does not provide the rigid mechanical integrity provided by the Synthes plate. Therefore, postoperative immobilization with a well-constructed splint and later a short arm cast is required. Care should be taken to allow for motion at the MCP, PIP, and DIP joints. Postoperative care in these situations is similar to that with the Synthes plate, except that the wrist is kept strictly immobilized in a cast until fusion. After fusion, physical therapy is continued to regain partial motion in the wrist.

 

Technique

Approach Considerations

Generally, by the time a patient with wrist arthropathy presents to an orthopedic surgeon, most conservative medical therapies have been attempted. The mainstay of medical treatment is nonsteroidal anti-inflammatory drugs (NSAIDs). Combined with physical and occupational therapy and activity modification, NSAID therapy can provide a lasting level of pain relief and should be attempted before arthrodesis is considered.

Mechanical bracing also can be efficacious by reducing the amount of movement through the wrist. Specific treatments aimed at disease modification may be indicated for diseases such as rheumatoid arthritis and gout.

Combined intra-articular injection of corticosteroids and a local anesthetic can alleviate pain, but the pain almost always recurs. Caution must be observed if corticosteroid treatment is to be employed in the rheumatoid joint. The added attritional effects of the corticosteroids combined with weakness of tendons due to inflammation and mechanical stress establish the potential for rupture.

Current methods and surgical technique for total wrist arthrodesis provide relatively good outcomes and are not controversial. However, there remains some controversy surrounding wrist and carpal arthroplasty and subtotal arthrodesis.

The goal of subtotal arthrodesis of the wrist is to provide a stable and pain-free joint, with preservation of a limited but useful range of motion. Reported experiences indicate that the available mobility of the remaining joints that are not fused tends to increase with time and use of the extremity, and accelerated wear of these joints has not been a problem. The main point at issue concerns which carpal bones should be fused.

Wrist arthroplasty is still in its infancy. Wrist arthroplasty has been reported to have high rates of subsidence and loosening, but functional results have been acceptable. Conversion to total wrist arthrodesis is a potential salvage option for failed arthroplasty, but it is technically demanding and requires block autograft for spanning defects left by the resected implant.

Arthrodesis of Wrist

During the operation, it is important to perform a close inspection of the condition of the articular surfaces and interarticular ligaments. Preoperative radiographs and clinical examination may not accurately identify all of the intercarpal joints with significant arthroplasty and/or laxity. Significant pathology in adjacent joints may lead to subtotal arthrodesis to total arthrodesis. Carpal instability in joints not fused must be addressed adequately.

In addition, inspection of the extensor tendons may reveal tenosynovitis and possibly impending rupture. Performing an arthrodesis and ignoring tendinopathy is a mistake. The use of the Synthes compression plate can lead to shortening of the carpus and result in ulnar impingement, which should be addressed at the time of fusion. Arthritis of the distal radioulnar joint must also be recognized, and it can be managed surgically by resection of the distal ulna and extensor carpi ulnaris tenodesis stabilization of the distal ulna site.

Traditionally, the approach to the wrist for arthrodesis is dorsally between the third and fourth dorsal compartments (see the images below). The third dorsal compartment houses the extensor pollicis longus tendon, and the fourth dorsal compartment houses the extensor digitorum communis and extensor indicis proprius tendons.

Wrist arthrodesis. Radiograph of patient after wri Wrist arthrodesis. Radiograph of patient after wrist fusion. No distal ulnar resection was necessary in this case.
Wrist arthrodesis. Lateral view following wrist fu Wrist arthrodesis. Lateral view following wrist fusion demonstrating dorsiflexion provided by plate.

A straight longitudinal incision is centered over the distal radioulnar joint extending distally over the third metacarpal. Care should be taken to avoid transecting the cutaneous sensory branches of the superficial radial nerve, which are directly radial to the incision. The dorsal wrist capsule and extensor retinaculum are opened sharply between the third and fourth dorsal compartments and are sharply elevated with care taken not to injure the underlying tendons.

The extensor pollicis longus tendon is elevated radially over the Lister tubercle, and the tubercle is removed. The tendon of the third compartment is retracted radially, and the tendons of the fourth compartment are retracted ulnarly. Cancellous bone graft can be obtained from the distal radius just radial to the Lister tubercle.

The dorsal intercarpal ligaments are opened sharply, and the articular surfaces that are to be fused are decorticated. Bone graft is placed between the decorticated bone ends. The dorsal prominence of the distal radius, lunate, capitate, and proximal third metacarpal most likely will have to be resected to allow the compression plate to lie flat against the carpal bones (see the image below). Failure to perform this step may result in distraction of the carpal bones when the plate is applied.

Wrist arthrodesis. Intraoperative view after plate Wrist arthrodesis. Intraoperative view after plate application. Portions of distal radius and dorsal capitate have been resected to allow proper plate fitting.

A lag screw through the radioscaphoid joint can be helpful in preventing ulnar deviation and ulnar impaction syndrome. The dorsal capsule and extensor retinaculum are closed, and then the overlying skin is closed (see second image below).

Wrist arthrodesis. Retinaculum split and repaired Wrist arthrodesis. Retinaculum split and repaired to avoid tendon attrition by plate and prevent bow-stringing.

In total wrist arthrodesis, the joints that are critical to fuse are the following:

  • Radioscaphoid
  • Radiolunate
  • Scaphocapitate
  • Capitate-lunate
  • Capitate-trapezoid
  • Third carpometacarpal (CMC)

The compression plate is sized and applied to provide at least six cortices of fixation at the third metacarpal and distal radius. Fusion of the ulnar-side joints (ie, lunotriquetral, capitate-hamate, triquetrum-hamate) is advised only if significant arthrosis of these joints is present at the time of surgery.

Subtotal wrist arthrodesis operations are exposed in a similar fashion, with the exception that the incision is not extended distally over the third metacarpal. The joints to be fused are similarly decorticated and grafted. The joints can be stabilized with the use of lag screws, plates, K-wires, Steinmann pins, interosseous wires, or a combination of these. (See the images below.)

Wrist arthrodesis. Radioscapholunate fusion techni Wrist arthrodesis. Radioscapholunate fusion technique.
Wrist arthrodesis. Completed radioscapholunate fus Wrist arthrodesis. Completed radioscapholunate fusion.
Wrist arthrodesis. Position of dowel grafts for sc Wrist arthrodesis. Position of dowel grafts for scaphotrapeziotrapezoidal (STT) fusion (radial) and four-corner fusion (ulnar).
Wrist arthrodesis. Side-to-side range of motion af Wrist arthrodesis. Side-to-side range of motion after scaphotrapeziotrapezoidal (STT) fusion.
Wrist arthrodesis. Schematic emphasizing need for Wrist arthrodesis. Schematic emphasizing need for correct capitolunate alignment during four-corner arthrodesis.

Postoperative Care

In total wrist arthrodesis, the use of the Synthes 3.5 fusion plate has all but obviated the need for significant postoperative immobilization. A bulky hand dressing is applied with an incorporated volar plaster slab. Subtotal arthrodesis or total arthrodesis using methods other than the Synthes plate require significant postoperative immobilization. Most limited arthrodeses can be immobilized in a short arm cast; however, a scaphotrapeziotrapezoidal (STT) fusion should be treated with a short arm thumb spica cast.

As with any hand operation, the central postoperative management necessity is elevation of the extremity and local modalities to prevent postoperative edema.

Complications

Complications of total wrist arthrodesis are relatively common and range from minor transient problems to major problems (eg, wound dehiscence, infection, extensor tendon adhesions, and plate tenderness) that may necessitate implant removal.[36] Major complications include pseudarthrosis, deep wound infection, neuroma, and fracture of healed fusion. Minor complications are similar to other operations of the hand and include transient nerve palsy and superficial skin necrosis.[37]

A complication related to plate use is fracture at the ends of the fusion plate; therefore, some authors recommend removal of the plate after solid healing.[38] A recognized potential complication of using compression plating is the possibility of impingement between the ulnar head and the carpus. This occurs secondary to the relative shortening across the radiocarpal joint after bone is decorticated and joint-surface apposition is obtained. Carefully check for impingement intraoperatively; if it is present, treat it with some form of ulnar shortening (distal or diaphyseal).

Specific wrist fusion complications include the following:

  • Nonunion
  • Plate tenderness
  • Extensor/flexor tendon adhesions requiring tenolysis
  • Carpal tunnel syndrome
  • Iliac crest donor complications
  • Distal radioulnar joint pain or dysfunction
  • Wound-healing problems
  • Persistent unexplained pain
 

Questions & Answers

Overview

What is wrist arthrodesis?

How does the pathophysiology of wrist arthropathy differ from other joint arthropathies?

What causes wrist arthropathy?

What is the pathogenesis of wrist arthropathy?

What is the prevalence of wrist arthropathy?

What is the role of wrist arthrodesis in the treatment of wrist arthropathy?

When is arthrodesis indicated in the treatment of wrist arthropathy?

When is radiocarpal arthrodesis indicated in the treatment of wrist arthropathy?

When is midcarpal fusion indicated in the treatment of wrist arthropathy?

When is limited arthrodesis indicated in the treatment of wrist arthropathy?

What are the contraindications for wrist arthrodesis?

Which alternative treatments may allow wrist arthrodesis to be postponed or avoided?

What is the basis for surgical technique in wrist arthrodesis?

What are the reported outcomes of wrist arthrodesis?

Which factors increase the likelihood of positive results following wrist arthrodesis?

Periprocedural Care

Which clinical history findings are characteristic of wrist arthropathy?

What should be assessed in the preoperative evaluation of patients undergoing wrist arthrodesis?

Which physical findings are characteristic of wrist arthropathy?

What lab tests are included in the preoperative assessment for wrist arthrodesis?

What is the role of radiography in the preoperative assessment of wrist arthrodesis?

What is the role of CT scanning in the preoperative assessment of wrist arthrodesis?

What is included in patient preparation for wrist arthrodesis?

How are patients monitored following wrist arthrodesis?

Technique

What is the role of nonsurgical treatment for wrist arthropathy?

What is the role of surgery for wrist arthropathy?

How is wrist arthrodesis performed?

Which joints are fused in total wrist arthrodesis?

How does the performance of subtotal wrist arthrodesis differ from total wrist arthrodesis?

What is included in postoperative care following wrist arthrodesis?

What are the possible complications of total wrist arthrodesis?

What are the possible complications of wrist arthrodesis related to plate use?

What are the possible complications of arthrodesis related to wrist fusion?