Wrist Arthrodesis Technique

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

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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.
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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.

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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
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