Hand Surgery
1st Edition

74
Principles of Limited Wrist Arthrodesis
Arnold-Peter C. Weiss
Osteoarthritis of the wrist is a common malady that is seen in multiple age groups. Rheumatoid arthritis of the wrist is far less common, although it is seen frequently in patients with advanced disease. In both conditions, if the degenerative changes have spread throughout the carpus and radiocarpal joint, treatment is generally directed to arthrodesis of the entire wrist, thus providing a stable, pain-free wrist, or total wrist arthroplasty, which eliminates pain but allows some functional arc of motion (1,2,3 and 4). In certain patients, the arthritis pattern only affects a few of the intercarpal wrist joints or a portion of the radiocarpal joint, if it has not gotten to the stage in which it affects all of the joints throughout the wrist (5). In these patients, limited arthro-desis of the wrist can provide a pain-free, stable wrist construct and still can preserve some motion through the intact joints (6,7,8 and 9). The basic understanding of how to evaluate patients clinically and radiographically to stage the most appropriate type of procedure and highlights of the technical caveats of undertaking limited wrist arthrodesis are detailed in this chapter.
BASIC PRINCIPLES
Surgical treatment for the reconstruction of the wrist via intercarpal or radiocarpal arthrodesis hinges on the ability to eliminate motion by arthrodesis of the offending joints or by undertaking surgical elimination of the offending joints to reduce pain. The ultimate goal is to try to preserve as much motion as possible while simultaneously eliminating pain that is related to the joints that have focal arthritis. A careful radiographic evaluation of each of the joints that provides motion to the wrist is essential, and the surgeon needs to understand the different arthrodesis options that are available, given the particular radiographic pattern that is present.
Expected motion outcome after limited wrist arthrodesis is relatively predictable based on experimental cadaver studies of simulated arthrodesis and long-term follow-up studies of specific arthrodeses that were performed for various problems (10,11,12,13,14 and 15). Overall, any fusion that involves the midcarpal joint generally allows a postoperative range of motion from one-half to two-thirds of normal. Arthrodesis that involves the radiocarpal joint and that preserves motion through the midcarpal joint generally provides a postoperative range of motion of one-third to one-half of normal motion. These postoperative motion expectations should be discussed with the patient to select the treatment option that is ideal for the patient’s particular situation and to place reasonable expectations on what can be expected from the surgery on a long-term basis. Surgical treatment options that maintain the most congruent, normal joint articulation that is possible provide the most predictable long-term outcomes with respect to pain relief and maintenance of motion (5,9).
ANALYSIS OF RADIOGRAPHS
In general, well-performed posteroanterior and lateral radiographs of the wrist provide sufficient information to accurately gauge which limited arthrodesis would be the most appropriate for any specific patient. Occasionally, with significant osseous overlap or osteophyte formation, a computed tomography scan of the wrist may provide additional information that can help differentiate between two close surgical options. The most important three joints to examine on standard radiographs are the radioscaphoid, the radiolunate, and the head of the capitate in its articulation with the proximal row (Fig. 1). Radioscaphoid arthritis is one of the earliest types of arthritis and is seen in numerous conditions, including scaphoid nonunion and long-term scapholunate ligament disruption (9,16). Frequently, the entire radioscaphoid joint becomes involved, and significant pain and deformity are noted. For successful treatment at this stage, elimination of the entire scaphoid or, in some cases, fusion of the scaphoid to the radius is required to eliminate pain. The radiolunate joint is one of the last areas of the wrist to see degenerative changes. It is frequently
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used for many surgical reconstructive procedures and becomes the main articulation in patients who undergo four-corner arthrodesis, capitolunate arthrodesis, and proximal row carpectomy. Except in cases of posttraumatic arthritis after distal radius fractures, it is unlikely to see significant degenerative changes in the radiolunate joint, therefore allowing its frequent use to maintain motion in many patients (17,18 and 19). The head of the capitate is the main articulation for the midcarpal joint. It is of importance in a proximal row carpectomy, in which it is one of the main articulating surfaces with the radiolunate joint, and it should also be examined carefully to determine whether fusion of the capitate within the arthrodesis is required (20). Frequently, in moderate to severe stages of degenerative change in the wrist, the capitate head shows deterioration and loss of articular congruity. In these patients, treatment should be directed at incorporating the head of the capitate within the fusion mass, thus eliminating any potential pain from abnormal motion at this joint.
FIGURE 1. Careful radiographic assessment should be undertaken. The main joints to examine are the radioscaphoid, the radiolunate, and the head of the capitate. Secondary joints are the scaphotrapeziotrapezoid joint and the distal radioulnar joint.
SURGICAL EXPOSURES
Skin exposure can use a limited dorsal transverse incision or a more extensile longitudinal or T-shaped incision to expose the retinaculum and, ultimately, the dorsal wrist. With patients who have specific focal areas of arthritis that require a small area of local fusion [e.g., the scaphotrapeziotrapezoid (STT) joint], a limited dorsal transverse incision can provide adequate exposure without significant soft tissue dissection (21,22,23,24 and 25). Additional advantages of limited dorsal transverse incisions include their excellent appearance postoperatively and the relatively limited soft tissue dissection, whereas disadvantages include a difficulty in extending the incision for exposure in the event of unforeseen surgical issues. For small, as well as large, fusion areas, a longitudinal or T-shaped incision can be used for the skin surfaces with multiple different incisions that are being used to extend through the retinaculum and capsule to the carpus. The extensor pollicis longus (EPL) tendon can be transposed out of the third dorsal compartment, and an interval between the second and fourth compartments is opened, exposing the dorsal carpus (Fig. 2) (3). Longitudinal
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capsular incisions do disrupt the transverse intercarpal and radiocarpal ligaments, potentially resulting in greater postoperative scar formation even with anatomic reapproximation. Alternatively, a ligament-sparing dorsal exposure can provide excellent visualization of the entire carpus, while maintaining capsular incisions in line with the dorsal wrist ligaments and allowing easier closure and the likelihood of less postoperative scar formation (Fig. 3) (26,27 and 28). Lister’s tubercle is almost always removed to provide a flat surface from which a distal radius bone graft can be obtained to be used during the arthrodesis itself.
FIGURE 2. A,B: Dorsal exposure of the wrist allows release of the third compartment from which the extensor pollicis longus (EPL) tendon can be transposed radially, exposing Lister’s tubercle. Removal of Lister’s tubercle allows access to the distal radius for bone graft harvest. During layered closure, the EPL tendon is left transposed radially, therefore lying over the second compartment distally.
FIGURE 3. Dorsal exposure to the deep structures of the wrist can use ligament-sparing techniques. Two flaps can be fashioned, one that isolates the vast majority of the dorsal carpus (A) and a second on the ulnar base (B) that is a triangular form that can access the lunotriquetral joint, as well as the triangular fibrocartilage complex (TFCC).
TECHNICAL TIPS
  • Maintain precise capsular incisions by using a no. 15 blade, which maintains the integrity of the capsule and allows a careful and strong repair during closure. The use of dissecting scissors to explore the capsule can shred some of the soft tissues, thus resulting in the inability to get excellent suture “bites” during closure.
  • Attempt to preserve all of the extrinsic and intrinsic ligaments of the wrist that are not affected directly by the procedure itself. Many of the extrinsic ligaments of the wrist are required for long-term stability of limited wrist arthrodesis. The radioscaphocapitate (RSL) ligament and the long radiolunate ligament provide antitranslational stability to the carpus after four-corner arthrodesis with scaphoid excision for degenerative changes that are seen in scaphoid nonunion advanced collapse and scapholunate advanced collapse (27,28). In addition, the intrinsic ligaments can provide additional stability to the fusion mass in the immediate postoperative period, if their sacrifice is not required by the procedure that is selected.
  • Careful attention to the sensory branches of the radial and ulnar nerves is essential during exposure of the dorsal wrist, regardless of the technique that is used. Injury to these nerves, especially the sensory branch of the radial nerve, can impart significant postoperative discomfort and dysesthesias in the patient and can make an otherwise successful limited wrist arthrodesis less than satisfactory. The sensory branch of the radial nerve fibers is extremely sensitive to any type of traction trauma, and a careful “no-touch” technique should be attempted to prevent dysesthetic symptoms postoperatively.
  • Limited denervation of the carpus is also helpful in eliminating postoperative pain. The distal branches of the posterior interosseous nerve can be easily seen in the floor of the fourth compartment, and, generally, a 1-cm segment can be resected, providing some denervation to the proximal carpus itself.
  • In general, transposition of the EPL tendon is desirable to avoid any secondary problems from the distal radius bone graft site, which generally goes through Lister’s tubercle (3). By transposing the EPL tendon radially, leaving it transposed on closure, and removing Lister’s tubercle, excellent quality bone graft can be obtained,
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    and no possibility of EPL impingement on a roughened Lister’s tubercle occurs postoperatively.
  • Be certain that any hardware that is used for fixation during the arthrodesis does not impinge dorsally or volarly during clinical range of motion. One should check this intraoperatively with range of motion as well as by using mini fluoroscopic examination to ensure that no hardware penetration has occurred volarly. The use of mini fluoroscopic examination intraoperatively with motion ensures that impingement does not occur in joints that are not being fused.
LIMITED WRIST ARTHRODESIS
Limited wrist arthrodesis involves the local fusion of a portion of the carpus while maintaining motion through another area of the carpus that is not affected by the arthritis itself (8). After radiographic examination for the area of focal arthritis, surgical treatment can be undertaken to fuse the joints that are affected by the degenerative changes themselves, while allowing motion to occur at the remaining wrist joints that are unaffected by arthritis. Because the wrist has complex articulations that provide its overall function, some motion is always lost owing to partial wrist arthrodesis. However, the maintenance of perfect congruity of the remaining joints that provide motion can provide long-term pain relief and the lack of further secondary degenerative changes. Although iliac crest cancellous bone grafting is certainly appropriate, most limited wrist arthrodeses can be safely performed by using cancellous bone graft that is taken from the distal radius and by salvaging some cancellous bone from any individual carpal bones that are excised. Bone graft substitutes are probably not, in and of themselves, able to predictably obtain a successful arthrodesis at this juncture without some significant cancellous bone graft being placed, as well. Undoubtedly, the use of bone growth factors and other stimulatory compounds will increase in the future and may eventually eliminate the need for cancellous bone grafting to achieve stable, limited wrist arthrodesis.
Basic Arthrodesis Principles
  • Take down at least one-half of the joint surfaces that are involved in the arthrodesis, leaving a small portion of the volar joint intact to preserve carpal spacing and to maintain appropriate carpal reduction (Fig. 4).
  • Denude all degenerative surfaces down to good cancellous bone graft, removing any hard, subchondral bone that might inhibit predictable arthrodesis.
  • Use high-quality autogenous cancellous bone graft, which should be packed very tightly into the spaces that are being fused to provide some intrinsic stability and maximum osteogenic potential.
  • Use the most rigid fixation method possible for the arthrodesis that is being undertaken to allow earlier range of motion and decreased overall stiffness during the postoperative period.
  • During the postoperative period, and especially when undertaking therapy, sequential radiographs can provide valuable information regarding fusion rate, as well as any potential problems of inappropriate motion at the arthro-desis site.
  • Always attempt to reduce any carpal bones that are out of position (e.g., the lunate in a dorsal intercalated segment instability alignment) to their normal position before provisional fixation and ultimate stable fixation (Fig. 5). Frequently, one can use a 0.062-in. Kirschner wire as a joystick to reduce the lunate, which is the bone that is affected most often, into its normal alignment, thus reconstituting carpal height and preventing secondary impingement due to a malpositioned arthrodesis.
FIGURE 4. Denudation of cartilage and hard subchondral bone should be taken down to the cancellous level at the site that is being fused. Good-quality autogenous graft is then packed into the interstices. A portion of the volar joint is maintained to allow maintenance of carpal spacing.
FIGURE 5. Any abnormal alignment of the carpus needs to be reduced before arthrodesis. The most frequent abnormal alignment involves the lunate in a distal intercalated segment instability (DISI) pattern (A). One can use a free Kirschner wire (k-wire) as a joystick to move the lunate out of DISI (B). Alternatively, one can use a “through-the-radius” technique (C) with flexion of the wrist, which brings the lunate out of DISI, and then can pin, in that position, the lunate via the dorsal distal radius. When the hand is then brought back into extension, the lunate is generally reduced.
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FIGURE 6. Radioscapholunate arthrodesis with optional excision of the pole of the distal scaphoid.
Radioscapholunate Arthrodesis
Patients who have severe distal radius fractures, subsequent degenerative joint disease throughout the radiocarpal joint that involves the entire joint surface, and yet a well-maintained midcarpal joint are ideal candidates for an RSL arthro-desis (17,18 and 19) (Fig. 6). Rigid fixation of the scaphoid, lunate, and radius can be provided by using powered staples or a Spider plate (Kinetikos Medical Inc., San Diego, CA) to provide the best possible rigid fixation. Without excision of the distal scaphoid pole, one can expect approximately one-third of the normal motion to occur, but this can be increased to approximately one-half of normal motion with excision of the distal one-half of the scaphoid.
Radiolunate Arthrodesis
Radiolunate arthrodesis is most commonly performed in rheumatoid arthritis to prevent ulnar translation of the carpus and to maintain overall alignment of the carpus and metacarpals with the forearm axis (29,30,31 and 32) (Fig. 7). Long-term results have shown some degradation of the radiolunate arthrodesis with subsequent translation, but successful outcomes can be obtained for relatively long periods of time. The use of radiolunate fusions in osteoarthritic patients is far less common, although, in certain cases in which extrinsic ligament disruption has occurred, this particular arthrodesis may provide some overall support. Fixation can be generally obtained with powered staples, individual screws, or a mini Spider plate.
Scaphotrapeziotrapezoid Arthrodesis
Although far less common than the thumb carpometacarpal arthritis, degenerative changes at the STT joint can cause focal pain (21,22,23,24 and 25) (Fig. 8). The use of a small transverse incision, with distal radius autogenous bone graft, generally provides adequate exposure. Fixation can be obtained with multiple Kirschner wires or a mini Spider plate, and the overall predictability of fusion rate is high. Radial styloidectomy should always be performed to prevent secondary impingement problems and radial-sided wrist pain. Average range of motion is approximately two-thirds of normal.
FIGURE 7. Radiolunate arthrodesis.
Scaphocapitate Arthrodesis
Scaphocapitate arthrodesis is usually performed for scapholunate instability problems (33,34) (Fig. 9). Its overall
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mechanical characteristics are similar to those seen with an STT arthrodesis. The procedure is rarely used for arthritic changes. Fixation can be obtained by multiple methods by using multiple Kirschner wires, powered staples, or mini Spider plate fixation.
FIGURE 8. Scaphotrapeziotrapezoid (STT) arthrodesis, which should be accompanied by a radial styloidectomy.
FIGURE 9. Scaphocapitate arthrodesis, which should be accompanied by a radial styloidectomy.
Four-Corner Arthrodesis
Four-corner arthrodesis, which involves the capitate, lunate, hamate, and triquetrum, is most commonly performed as a reconstruction for wrists with scapholunate advanced collapse or scaphoid nonunion advanced collapse (9,35,36 and 37) (Fig. 10). One must ensure that full reduction of the lunate is undertaken before arthrodesis to prevent any dorsal impingement on wrist extension. A large Kirschner wire joystick is generally used to accomplish lunate reduction. Provisional fixation with a few Kirschner wires is generally required. Overall fixation can use multiple Kirschner wires, powered staples, headless screws, or a Spider plate. The use of a Spider plate for fixation of four-corner fusion is ideal, because it provides immediate rigid fixation, circumferential compression, and a lack of any potential impingement problems and eliminates sensory nerve irritation during the postoperative period. One can expect approximately 50% to 60% of the normal motion. Motion generally plateaus at 6 to 9 months postsurgery.
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Scapholunocapitate Arthrodesis
Scapholunocapitate arthrodesis is commonly used for large scapholunate ligament tears that involve significant diastasis of the scaphoid and lunate yet without the presence of degenerative changes at the radioscaphoid joint (37,38) (Fig. 11). Excellent pain relief can be obtained with this procedure, although motion loss can, on occasion, be significant. A radial styloidectomy is almost always performed to decrease overall impingement potential with wrist motion. During radial styloidectomy, care must be undertaken to preserve the extrinsic-stabilizing ligaments of the wrist. Postoperative motion range of one-third to one-half of normal wrist motion can be expected.
FIGURE 10. Four-corner arthrodesis, which should be accompanied by scaphoid excision in patients who have radioscaphoid arthritis (generally those with scapholunate advanced collapse or scaphoid nonunion advanced collapse wrist). For patients with midcarpal instability, an in situ four-corner arthrodesis can be performed, leaving the scaphoid intact.
FIGURE 11. Scapholunocapitate arthrodesis. Radial styloidectomy should generally be performed with this procedure.
FIGURE 12. Lunotriquetral arthrodesis.
Lunotriquetral Arthrodesis
Lunotriquetral arthrodesis is most commonly used in patients who have lunotriquetral instability that is marked by pain and a volar intercalated segment instability deformity of the lunate (Fig. 12). Although the procedure can provide adequate pain relief and can stabilize the interval, the rate of successful arthrodesis is lower than the success rate that is seen with a four-corner arthrodesis. This finding is probably due to the small surface area of the joint being fused. Recently, it has been believed that soft tissue reconstruction procedures have provided better overall outcome with less loss of motion. Postoperative range of motion is approximately one-half of normal (39,40).
FIGURE 13. Multiple Kirschner wires are used to obtain arthrodesis in a four-corner fusion. (Reprinted with permission of Arnold-Peter C. Weiss.)
FIGURE 14. Multiple staples are used to obtain arthrodesis in a four-corner fusion. (Reprinted with permission of Arnold-Peter C. Weiss.)
FIXATION METHODS
Kirschner Wires
Kirschner wires are the most common method of orthopedic fixation (Fig. 13). They are inexpensive and easy to use and provide adequate fixation. Disadvantages include the requirement for prolonged cast immobilization, the need for removal, and problems related to the
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sensory branch nerve fibers that frequently impinge on the pins themselves. There is a risk for pin protrusion and pin tract infection. Initial stability is relatively good, and fusion rates are quite acceptable with this technique (41,42).
FIGURE 15. Spider and mini Spider plates that are specially designed for limited intercarpal arthrodesis. These plates can be used for nearly all of the intercarpal arthrodeses that have been described. (Reprinted with permission of Arnold-Peter C. Weiss.)
Staples
Standard staples, which are implanted with manual or power-driven devices, provide limited compression but do provide some stability (Fig. 14). Because these protrude, leaving a portion of the staple on the dorsal aspect of the carpus, they can easily impinge in wrist extension, and care must be taken to ensure that no impingement occurs. They are relatively easy to use, although their application in a multiplanar fashion can be challenging. Newer staples that provide a memory compression force may provide more optimal outcomes, although impingement problems are still an issue.
Headless Screws
Headless screws can provide good and stable compression across an arthrodesis site. A downside to this fixation method is that the screw generally needs to go through the joint surface, where range of motion occurs. Most often, more than one screw is required, and it can be challenging to place these screws in a nonparallel fashion. Nevertheless, with meticulous technique, excellent stability can be achieved in selected fusions.
Specialized Plates
Specialized plates have been recently designed that provide for the ability of rigid fixation of the carpal bones (Fig. 15). The Spider and mini Spider plates (Kinetikos Medical Inc.,
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San Diego, CA) were first introduced 3 years ago with an innovative design. The technique for providing a fusion by using this plate as well as the ability to recess the plate within the carpal bones that are being fused was originally described by the author. The plate allows for complete recessed application (so that no portion of the plate protrudes dorsally, thus eliminating potential impingement), rigid fixation with cancellous screws in the carpal bones that are being fused, the placement of autogenous bone graft through the center of the plate at the site of the fusion, and circumferential compression of the bones that are being fused when screw tightening occurs (Fig. 16). The plates are available in eight- and six-hole versions. The eight-hole version is ideally suited to four-corner and RSL arthrodeses, whereas the six-hole version is suited to scapholunocapitate, STT, and scaphocapitate fusions. The plates provide enough rigid fixation to allow earlier range of motion, compared to alternative forms of fixation. Fusion rates from two studies that involved limited wrist fusions reported a 100% fusion rate with the use of these plates (37).
FIGURE 16. After provisional fixation and exposure of the joints that are to be fused, a rasp is used to form the recessed cone into the carpal bones (A). Exposure of the joints is identified after rasping (B), and an additional portion of the joint should be taken down to allow the bone graft to be placed deeper within the joint surfaces. After ensuring that there is no protrusion of the Spider or mini Spider plate, a specially designed plate holder and drill guide is used to start placing screws (C). Successful placement of the Spider or mini Spider plate (D) allows a verification of range of motion in which no instability between the bones that are being fused should be seen. In addition, the extrinsic ligaments are easily visualized in this illustration and are found to be intact. E: A close-up of the Spider plate with its accompanying screws, followed by graft packing through the central hole. Posteroanterior (F) and lateral (G) radiographs demonstrate excellent fixation of a four-corner arthrodesis with the Spider plate.
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