Hand Surgery
1st Edition

Radiocarpal and Total Wrist Arthrodesis
Hermann Krimmer
In cases of severe arthritic damage to the radiocarpal or midcarpal joint where reconstructive procedures are excluded, salvage procedures are required. The principle of this treatment strategy consists of eliminating the destroyed articular surfaces by fusion. Total wrist fusion is the procedure with the longest history and is the most common treatment. Recently, motion-sparing procedures have become more popular. Limited wrist fusion is defined by fusing only the damaged or unstable areas while motion is maintained in the uninjured or stable regions of the joints. In cases of arthritic changes to the radiocarpal joint due, for example, to intraarticular fractures of the radius, the midcarpal joint may be preserved by limiting the fusion to the radioscapholunate joint, thereby maintaining useful mobility. The benefit of limited wrist fusion is well documented, and whenever suitable, this class of operation is preferred (1,2). However, in progressive stages of arthrosis involving the radiocarpal and midcarpal joint or in combination with severe malalignment of the carpus, total wrist fusion may be the best option.
Clinical Significance
The fundamental principle in the management of distal radial fractures consists of anatomic reduction of the fracture, thus restoring the congruity of the damaged articular surfaces. There has been significant progress made recently in the treatment of intraarticular fractures. Techniques such as arthroscopically assisted reduction and fixation by buttress plate design, which maintain reduction precisely and minimize the risk of secondary dislocation and posttraumatic arthrosis, have been shown to dramatically improve results. Despite efforts to achieve anatomic reductions in severely displaced comminuted fractures, residual displacement or chondrocyte death may compromise results, leading to posttraumatic degenerative disease (3).
Under these conditions, both the radiolunate and the radioscaphoid joints are involved, in contrast to the midcarpal joint, which is nearly always preserved. If significant shortening of the distal radius results, an additional factor of ulna impaction syndrome may result. The distal radioulnar joint may also be affected; if symptomatic, additional treatment may be necessary (Fig. 1).
Painful posttraumatic arthrosis of the radiocarpal joint is a common indication for further treatment. From the clinical point of view, patients often describe pain at the radial site of the wrist, often increasing with activity. Occasional swelling is noticed. Function is limited due to reduced grip strength, pain, and restriction of mobility. The goal for any treatment is a stable joint with maximally reduced pain and preferably with mobility, which is of great benefit from a functional point of view. The initial examination evaluates the painful area by palpating and checking the function of the wrist joint and comparing this with the radiologic findings. Additionally, grip strength should be recorded with a standard dynamometer as well as the arc of motion. Standard postero-anterior and lateral radiography usually reveals the damaged radiocarpal area. If in case of intraarticular incongruity, where reconstructive procedures such as correction osteotomy of the radius are contemplated, a computed tomography scan of the joint surface of the radius may prove helpful. It allows more accurate visualization of the subchondral bone architecture (Fig. 2). Finally, arthroscopy allows the most precise assessment of the joint surfaces.
The principle of radiocarpal arthrodesis was introduced by the discovery of spontaneous radiolunate fusion that resulted in a painless and functional wrist. Radiolunate arthrodesis as a surgical procedure was first reported by Chamay et al. to treat ulnar shift of the carpus in patients with rheumatoid arthritis (4). It has rarely been performed in patients with posttraumatic deformities of the wrist, and the results have not been clearly differentiated from rheumatoid cases (5). In nonrheumatoid patients, radiocarpal arthrodesis is indicated primarily for intraarticular malunion involving the radiolunate and occasionally the radioscaphoid joint. Another indication may be instability

of the entire carpus due to severe damage to the extrinsic radiocarpal ligaments.
FIGURE 1. Posteroanterior (A) and lateral (B) x-rays after intraarticular comminuted fracture of the radius in a 21-year-old man. Radiocarpal arthrosis and dorsal intercalated segment instability position of the lunate are evident.
Alternative Treatment Options
Nonoperative treatment methods are limited to immobilization, drug medication, or special pain therapy. Placing the involved wrist in a supportive splint may improve function by reduction or loss of mobility, thereby limiting pain. Antiinflammatory or pain drugs alone or in combination with immobilization are suitable to modulate pain. It is well recognized, however, that conservative measures in the face of symptomatic wrists with arthrosis fall short of successful outcomes over the long term.
FIGURE 2. Computed tomographic scan demonstrating damaged cartilage at the radiolunate and radioscaphoid fossa.
Wrist Denervation
Wilhelm first described the concept of eliminating pain in degenerative affections of the wrist joint by division of articular branches of sensory nerves (6). In 2001, he published his long-term experience with this procedure (7). One hundred eighty-seven patients were evaluated, and it was found that after 1.2 years, good and excellent results could be obtained in 81%. After 2.2 years, this percentage slightly decreased to 77.8%; after an average of 10.5 years, good results persisted in 62.5%. Similar results were found concerning grip strength, in which the initial improvement deteriorated with time. However, there was no differentiation according to the severity of the initial problem. In summary, wrist denervation represents a viable alternative for initial treatment. However, in severe cases, the improvements are limited and symptoms may rapidly recur.

Modified Proximal Row Carpectomy (Die-Punch Technique)
Although proximal row carpectomy is considered an acceptable treatment for radioscaphoid arthrosis, it is not suitable in cases of radiolunate arthrosis. Foucher described a technique in which the lunate is fused in an “inset” manner in the lunate fascia, described as a die-punch technique (8). Resecting the scaphoid and triquetrum results in maintenance of mobility. In a series of four cases, significant improvement of mobility and grip strength resulted. However, no long-term results of larger cohorts have been reported.
Total wrist arthrodesis represents the ultimate salvage technique for painful wrist arthrosis. It sacrifices mobility completely, and outcome studies using self-reporting scoring systems have revealed significant disability from the patient’s point of view. Additionally, in several cases, the lack of elasticity of the wrist joint may exacerbate pain in other areas around the wrist. Finally, total wrist fusion does not guarantee a pain-free result. However, in progressive stages of arthrosis with damage to the midcarpal joint and lack of extrinsic ligamentous support or in situations of failed partial arthrodesis, total wrist arthrodesis represents the most reliable procedure (9).
Surgical Technique
Regional or general anesthesia is required. I begin the procedure under tourniquet control through a slightly oblique incision on the dorsum of the wrist. The branches of the superficial radial nerve and dorsal ulnar nerve and the dorsal veins are preserved, and the retinaculum is identified. The third extensor compartment is incised, and the retinaculum is subperiosteally elevated to the radial and ulnar side, opening the second and fourth compartments (Fig. 3). At the radial border of the fourth compartment, the posterior interosseous nerve is excised. The radiocarpal joint is entered through a transverse incision of the joint capsule. To better visualize the joint, the dorsal rim of the radius may be trimmed with an oscillating saw. Typically, obvious destruction of the radiolunate and radioscaphoid joint surfaces is seen, sometimes in combination with rupture of the scapholunate ligament (Fig. 4). Under these conditions, radioscapholunate arthrodesis is performed. Only in the case of preserved scapholunate ligament and radioscaphoid cartilage might radiolunate arthrodesis be considered an alternative (10). With a slightly curved rongeur, the cartilage and subchondral bone are removed from the scaphoid and lunate fossae of the radius (Fig. 5). By hyperflexing the wrist, the lunate and scaphoid are prepared in the same way to expose cancellous bone. At the ulnar border of the radius, three 1.6-mm Kirschner wires are inserted such that only thin tips are visible through the deteriorated distal radius. One Kirschner wire should fix the scaphoid in the long axis, and the others should secure the lunate. The position of the lunate should be in neutral extension or

recentered if ulnar translocation is present. Cancellous bone from the iliac crest is packed into the space between lunate, scaphoid, and radius, and the Kirschner wires are advanced into the scaphoid and lunate. Care is taken to avoid overadvancing the wires into the midcarpal joint. (Fig. 6). To improve wrist mobility, Garcia Elias recommends excision of the distal pole of the scaphoid (10a).
FIGURE 3. Slight oblique incision at the dorsum of the wrist opening the third and fourth extensor compartments.
FIGURE 4. Destroyed articular surfaces of the radioscaphoid and radiolunate joint.
FIGURE 5. Decortication of the radius, the scaphoid, and the lunate with a rongeur.
FIGURE 6. The radiocarpal space is filled with cancellous bone. After realignment of the carpus, the Kirschner wires are inserted.
Care must be taken to be certain that the Kirschner wires are not advanced into the carpal tunnel to avoid the risk of injuring nerve or tendon structures. After verifying proper placement of the hardware and position of the bones, the Kirschner wires are bent and cut down directly to the radial cortex to avoid any disturbance of the extensor tendons (Fig. 7). The retinaculum is reattached, leaving the extensor pollicis longus tendon subcutaneously (extraretinacular) (Fig. 8).
In cases of an ulnar plus condition due to radial shortening, the radiocarpal space may be overcorrected, thereby balancing the carpus and the ulna in a more neutral variance, preventing ulna impaction. If, however, a damaged distal radioulnar joint is present, shortening or resection of the ulna head may be considered.
FIGURE 7. The Kirschner wires are bent near to the cortex of the radius.
FIGURE 8. The extensor retinaculum is closed, leaving the extensor pollicis longus tendon subcutaneously.
Postoperatively, the extremity is immobilized in a fore-based thumb spica cast for 8 weeks. Patients are instructed in active finger range-of-motion exercises on the first postoperative day. After radiographic confirmation with bony consolidation, the midcarpal joint is included in active and passive physiotherapy. Kirschner wire removal is optional (Fig. 9).
In an attempt to optimize postoperative range of motion and midcarpal stability, the capsulotomy may be modified to conform to the ligament-splitting technique (11). Although cancellous bone graft has been the historical choice and remains a viable source of good bone, alternatives have been developed. Included are autogenous sources from the olecranon and proximal tibial metaphysis, allograft cancellous bone, and a number of bone substitutes. Fixation alternatives include staples, interosseous headless screws, and plate fixation. Surgeons are encouraged to use the techniques that they are most familiar with and that have yielded the best results in their hands.
Major complications of radiocarpal arthrodesis include pseudarthrosis, tendon adherence, and insufficient pain relief (12). With the use of Kirschner wires and cancellous bone of the iliac crest, we have achieved a high union rate of 94% (13). We regard the use of plates for this procedure as unnecessary, as the union rate is even less and the complication rate with regard to tendon adherence is higher (12). Rigid fixation with the use of compression screws in a cannulated design proved to be difficult because of the thin cortices of the carpal bones. When the Kirschner wires are inserted at the ulnar border of the radius and countersunk into the cortex, the risk of tendon adherence is minimized and removal remains an option. Insufficient pain relief has to be localized and treated separately. In our experience,

residual pain is most commonly found around the distal radioulnar joint.
FIGURE 9. A,B: On postoperative x-ray, the distal part of the scaphoid is resected (see Fig. 1 for the preoperative x-rays). A: Posteroanterior view. B: Lateral view.
Clinical Results
Two reports are available of uniform groups dealing with radiolunate and radiocarpal arthrodesis used for treatment of posttraumatic conditions. In 1991, Sturzenegger and Buchler presented their results of 14 patients who underwent radioscapholunate arthrodesis due to painful radiocarpal arthrosis after comminuted fractures of the distal radius (14). Stabilization was achieved in the majority by means of a 3.5-mm AO T-plate and corticocancellous bone graft from the iliac crest. In addition to the radioscapholunate arthrodesis, nine patients underwent supplementary procedures to the distal radioulnar joint. Average follow-up was 23.8 months. They reported significant pain relief, with 7 out of 14 patients pain-free, four suffering slight discomfort, and three reporting pain during daily activities. No patient complained of pain at rest. Range of motion was reported as an average 30 degrees of extension and 17 degrees of flexion, with grip strength averaging 49.4% relative to the unaffected side.
To evaluate long-term results, Nagy and Buchler reassessed these patients, with an average follow-up period of 8 years (12). Five patients were reoperated on to convert to a total wrist fusion because of symptomatic nonunion or early progressive arthritis of remaining joint surfaces. Two wrists were still symptomatic. Ultimately, satisfactory results of radioscapholunate fusions were maintained in seven cases. It was found that outcomes were worse with an increasing number of prearthrodesis operations. The high nonunion rate was attributed to technical factors.
In 1996, Saffar reported a series of 11 patients with symptomatic distal radial intraarticular malunions limited to the radiolunate joint (10). All were treated by radiolunate arthrodesis. For fixation, a sliding graft technique from the distal radius or corticocancellous graft harvested from the iliac crest with fixation by two screws was used. Average follow-up was 28.5 months, and union was achieved in 10 out of 11 cases. Pain decreased from continuous or present at light work to absent or slight in all cases. The range of motion averaged 33 degrees of flexion, 39 degrees of extension, 17 degrees of radial deviation, and 29 degrees of ulnar deviation. The average postoperative strength was 57% of the contralateral uninjured side. With an increased number of patients, Saffar confirmed these results in 2001 (15).
Our results of radiocarpal arthrodesis after comminuted fractures of the distal radius were published by Beyermann et al. (13). Eighteen patients were reexamined, and the follow-up ranged from 6 to 66 months. Nonunion occurred in one case, which was successfully treated by a second bone graft. Radiologic examination revealed bony consolidation in all cases at follow-up, and there were no major signs of degenerative arthrosis in the midcarpal joint. Postoperative


wrist motion averaged 24 degrees of extension, 23 degrees of flexion, 9 degrees of radial deviation, and 16 degrees of ulnar deviation. Average grip strength improved from 31.9 to 51.1 kPa. Pain relief based on a visual analog scale was significant, with 30 points less on average, demonstrating minimal pain at rest (6 points) and slight pain during activity (33 points) postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) score showed 25.7 points on average, reflecting some residual disability but at a significantly lower level than total wrist arthrodesis (Fig. 10).
FIGURE 10. A,B: Eleven months after intraarticular fracture of the radius with arthrosis of the radiocarpal joint and palmar dislocation of the entire carpus. C,D: Treatment by radioscapholunate fusion and realignment of the carpus.
Radioscapholunate fusion is the preferred treatment in destroyed radiocarpal joints. It provides significant pain relief and improvement of grip strength by maintaining motion. Preferably, cancellous bone from the iliac crest should be used to balance exactly the variance between radius and ulna to prevent ulna impaction syndrome and to achieve a high union rate. If additional damage of the distal radioulnar joint is present, procedures should be considered to resect the ulna (16,17). Radiolunate fusion may be considered as an alternative only when the scapholunate ligament and the radioscaphoid joint are not injured and one can anticipate an improved final arc of motion (10,13). Resecting the distal pole of the scaphoid as part of a radio-scapholunate arthrodesis may improve motion but remains to be proved in a large series of patients.
Clinical Significance and Indication
A stable and sufficiently pain-free wrist remains the goal for surgical treatments of posttraumatic degenerative arthrosis. Historically, total wrist fusion has been regarded as the most predictable treatment concept, with the belief that it results in complete pain relief and only limited functional disability (16,18). However, the medical literature only infrequently documents the result of total wrist fusion in a way that addresses the patient’s subjective impression after total wrist arthrodesis. Recently, several reports have been published demonstrating significant disability using the DASH self-reporting scoring system (19,20). The results were similar at different institutions, and the superiority of motion-sparing procedures could be documented (1,2). If no articular cartilage with congruent joint mobility is available and motion-sparing procedures are excluded, one has to keep in mind that wrist fusion is well established historically and typically results in significant pain relief and overall upper extremity functional improvement.
Technical Aspects
Many techniques have been described to accomplish total wrist arthrodesis. The use of large Steinmann pins was preferably performed in rheumatoid cases. Under posttraumatic conditions, the application of rigid plating techniques allows early recovery without external constraints and leads to a high union rate. Standard compression plates do not contour to the curvature of the carpus. This typically leads to irritation of the extensor tendons and may restrict wrist position. The Synthes wrist fusion plate avoids many of the potential complications of plate irritation due to the low profile of the plate in the distal region over the metacarpals. Another advantage is the precontoured shape, which provides compression over the carpus and results in slight extension of 15 to 20 degrees of the fused wrist without need for any plate manipulation. The source and type of bone graft have varied among different techniques, most favoring corticocancellous bone from the iliac crest. Weiss and Hastings demonstrated that with the use of a low-profile preshaped plate technique, a 100% fusion rate could be achieved with local bone graft from the radius, avoiding a second incision at the iliac crest (21). Patients presenting with large osseous defects or with poor-quality bone should still be considered as candidates for augmentation of their arthrodesis with bone graft from the iliac crest. Controversy remains regarding

the necessity of inclusion of the third carpometacarpal joint in the fusion (22,23). I believe that because the Synthes plate is not routinely necessary, the third carpometacarpal should be included in the fusion to improve stability and to prevent painful secondary changes.
FIGURE 11. Straight incision over the dorsum of the wrist exposing the extensor retinaculum.
FIGURE 12. The retinaculum and the wrist capsule are subperiosteally detached.
FIGURE 13. The dorsal rim of the radius is resected and the carpus decorticated.
Surgical Technique
Under tourniquet control, a straight incision is created over the dorsum of the wrist, starting at the proximal part of the third metacarpal and ending at the distal fourth of the forearm. The subcutaneous nerves and veins are preserved, and the retinaculum is identified (Fig. 11). The third extensor compartment is incised, the tendon is reflected radially, and the retinaculum is subperiosteally detached to the radial and ulnar side, opening the second and fourth compartment. At the radial border of the fourth compartment, the posterior interosseous nerve is excised. The wrist capsule is opened by creating two flaps based proximally at the radial side and distally at the ulnar side, opening the wrist like a window (Fig. 12). This guarantees suturing the capsule over the plate as a deep layer to protect the tendons.
The dorsal rim of the radius is resected, and the dorsal carpus is decorticated (Fig. 13). The intercarpal joints are decorticated to exposed cancellous bone, including the radiolunate, the radioscaphoid, and the capitolunate joints. The third carpometacarpal joint is identified, and the dorsal aspect is removed with a rongeur. The AO wrist fusion system consists of three plates. A long version is appropriate for larger hands and the short version for smaller hands. The long and shorter precontoured versions require removal of the dorsal cortex of the distal radius. A straight version provides stabilization for interposition of corticocancellous bone graft for replacement of large carpal defects caused by trauma or tumor.
FIGURE 14. The carpal joints are packed with cancellous bone graft.
FIGURE 15. The AO wrist fusion plate in place.
The joints to be fused are packed with cancellous bone graft either from local source or iliac crest, and the appropriate plate is positioned over the third metacarpal (Fig. 14). The first screw is placed in the third metacarpal using the middle hole and making certain that the screw passes directly dorsal to palmar in the sagittal plane between the ulnar and radial margins of the third metacarpal. The plate then is aligned over the dorsal aspect of the radius, and one 3.5-mm screw is inserted. The position of the plate and

wrist is verified clinically and radiographically. If no changes have to be made, the plate is fixed distally with the 2.7-mm screws. Proximally, one or two screws can be placed in compression with the low-contact dynamic compression plate drill guide. Finally, a 2.7-mm screw is inserted into the capitate (Fig. 15).
FIGURE 16. The wrist capsule is sutured over the plate.
FIGURE 17. The retinaculum is closed, leaving the extensor pollicis longus subcutaneously.
The dorsal wrist capsule is closed over the plate and the retinaculum sutured, leaving the extensor pollicis longus tendon in a subcutaneous extraretinacular course (Figs. 16 and 17). A protective splint is worn for 4 to 6 weeks until union is achieved. Active range of motion of the digits to prevent adherence of the extensor or flexor tendons is started from the first postoperative day, in addition to elbow and shoulder range-of-motion exercises.
Three major problems have been identified as inherent to total wrist arthrodesis: occurrence of nonunion at the wrist or carpometacarpal joint; adherence of tendons with restricted mobility; and persisting pain in the distal radioulnar joint. Nonunion has been shown to be a frequent complication, occurring in up to 19% and requiring repeated surgery (24). With the change to compression plates, the incidence of nonunion has decreased significantly to rates below 8% (19,25). The use of the low-profile and contoured AO plate has made it possible to achieve a 100% union rate using local bone graft (21). To prevent restriction of mobility of the fingers, physiotherapy immediately after the operation is mandatory. Tendon adherence and irritation frequently occurred with the regular plates, requiring removal of the plate combined with tenolysis. Due to the low-profile design in the distal part and precontoured shape, removal of the AO plate is optional and necessary only in rare cases, with a rate of 4% in our own series (19). Problems around the ulnar head caused by damage of the distal radioulnar joint, painful instability, or ulna plus variance are best treated by hemiresection arthroplasty (16). In cases of persisting painful instability after a salvage procedure at the ulna head, we have solved the problem by implanting an ulna head prosthesis in three cases (26).
Clinical Results
Overall, the satisfaction rate of total wrist arthrodesis is reported as high. Advantages such as pain relief and improved grip strength are attributed to total wrist fusion, but the disadvantages such as functional impairment, social limitations, and postoperative quality of life must be considered individually (27,28). One report using the DASH self-reporting scoring system found significant disability and functional impairment in patients with total wrist arthrodesis, with a ranking of 51 points (20). In a study of 64 patients after total wrist arthrodesis, we found similar results, with the DASH scores averaging 46 points. However, the vast majority of the patients were satisfied and would have undergone the procedure earlier if they had known the final result (19). In our comparative study of total wrist arthrodesis (41 patients) versus four-bone fusion (97 patients) for treatment of posttraumatic carpal collapse, the overall satisfaction rate was similar in both groups (84% and 86%, respectively). The traditional wrist score, however, as well as the DASH score revealed significant superiority of the four-bone fusion based on similar pain relief and functional benefit due to the preserved mobility (1). In progressive radiocarpal and midcarpal arthrosis, inflammatory arthritis, complete loss of carpal ligamentous support with dislocation of the carpus, as well as failed previous operative treatments or failed motion-preserving procedures, total wrist arthrodesis still represents the most reliable surgical option (Fig. 18).

FIGURE 18. A,B: Scapholunate advanced collapse wrist with progressive carpal collapse and ulnar translocation. C,D: Treatment by total wrist arthrodesis with the AO wrist fusion plate.

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