arthrodesis of the wrist joint: a follow-up study of sixty cases
TRANSCRIPT
Scand J Plast Reconstr Surg 5: 120-123, 1971
ARTHRODESIS OF THE WRIST JOINT
A Follow-up Study of Sixty Cases
Kurt Rechnagel
From the Department of Hand Surgery (Head: K . Bang Rasmussen and L. Zachariue), Orthopaedic Hospital, Copenhagen, Denmark
(Submitted for publication March 13, 1971)
Abstract. 60 wrist fusions were performed, during the period 1962-68. The indications for operation were pain, contracture or the need of stabilization. The standard technique was ulnar approach, resection of the ulnar head and insertion of a bone graft, in most cases from the iliac crest. In cases of cerebral palsy the radius was shortened and inserted into the carpal bones. With a few exceptions all the patients were relieved of their pain. In the cases of osteoarthritis 17 patients (out of 22) went back to normal work. Four are not working because of other diseases. In cerebral palsy the improvement is al- most only cosmetic. The bone graft from the iliac crest is considered superior to the ulnar graft since the latter resulted in 4 failures (out of 14 grafts) whereas the former (31 grafts) were all successful. In 12 patients there was no carpometacarpal fusion, but as these patients had almost no complaints it seems unnecessary to include the base of the metacarpals in the operation.
MATERIAL AND METHODS In 58 patients, 23 women and 35 men, 60 wrist arthrodeses were performed during the period 1962-6 8.
The decisive symptoms for operation were pain (in rheumatoid arthritis, malacia of the lunate bone, and osteoarthritis following fractures), con- fractures (particularly in spastic conditions) or the need of stabilization in paralysis of the upper ex- tremity (in poliomyelitis and lesions of the brachial plexus).
The different diseases in the 60 cases can be divided into the following main groups:
degenerative arthritis 22 rheumatoid arthritis 17 tuberculous arthritis 1 neurologic disorders 20
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The first three groups comprise primary changes in the wrist; in the last group the wrist was primarily normal without anatomical changes.
The operative technique varied to some extent. Thus in the cases of severe spastic contracture it was necessary to make a shortening to prevent in- creased tension of the flexor tendons when the hand is brought into the normal position. In these cases the radius was cut short, shaped like a chisel and inserted into the carpal bones (Fig. 1).
However, the standard technique is: ulnar ap- proach, resection of the ulnar head and insertion of a bone graft (Fig. 2). This technique was used in 75% of the operations:
standard technique 47 insertion of radius 12 chips + K-wire 4
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The total of 63 operations include three re- operations in cases of non-union, which will be discussed in the following. In the last 4 cases the conditions were so complicated after comminuted fractures, that it was impossible to fix a proper bone graft, and in these cases the fixation was performed with Kirschner-wire.
In most cases (31) a graft from the iliac crest was used, and in 14 cases the graft was taken from the resected ulna (Seddon, 1952). Post- operative treatment was plaster for 3 months.
At the operation the hand is placed in 20-25" dorsiflexion and slight ulnar deviation, but at the follow-up there is a variation from 40' dorsi- flexion down to neutral position. In bilateral cases
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Fig. 1 . Arthrodesis with shortening in cases with spastic contracttire.
of rheumatoid arthritis the one hand was inten- tionally placed in slight volarflexion for functional reasons, and all patients were satisfied with the position of the hand.
The majority of operations did not cause any complications, but of course some have occurred.
The most dramatic complication developed in a 51-year- old man who had suffered from increasing swelling, stiff- ness and pain in his left wrist for 12 months prior to hospitalisation. The X-ray (Fig. 3) showed destruction
Fig. 2. Anchylosis after the standard procedure using a bone graft (Bunnell, 1956).
Fig . 3. Tuberculous arthritis.
and osteoporosis, and the radiologist mentioned the possibility of specific infection, although he found i t more likely to be rheumatoid arthritis. As puncture of the wrist joint did not show any bacteria, wrist fusion was performed, but 5 days postoperatively he rather suddenly developed a severe shock. He had a miliary tuberculosis and was in an Addison-crisis. Treatment with cortisone, transfusions and tuberculostatic drugs improved his very poor condition. No local complications resulted and the wrist fusion was solid after the usual 3 months. He is now back to normal work, but his story prompts us to bear in mind that specific infections still do occur.
The other complications were local. Three cases with skin necrosis healed after skin-grafting. One case had a carpal tunnel syndrome after the operation, but decompression-operation 14 days after the fusion was followed by complete relief.
One case with post-traumatic dystrophy de- veloped this condition after a severely com- minuted fracture of the radius. After treatment he went back to work, but because of persisting pain in the injured wrist fusion was performed. This was followed by a flare-up of the dystrophy. After blocs and later a sympatectomy (Smitwick) he went back to work again with a solid and painless wrist.
RESULTS 55 of the 60 operations have been followed-up. Three were untraceable and 2 patients have died.
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122 K . Rechnagel
The follow-up period is on average 3 years 10 months, varying from 7 years 5 months down to 8 months.
There were four cases of non-union. They were all carried out with ulnar graft. The three of them were re-operated with a new graft from the iliac crest, and after this study they were solid after the usual three months. The fourth case of non- union was partially solid between the radius and lunate bone (Fig. 4), and because this patient had no pain further treatment was not required.
Most of the patients had no pains, but 4 patients with rheumatoid arthritis still had some pain in the operated wrist. Two of these only felt the pain when using the hand. Six other patients mentioned some slight pain during work, but not to such an extent that they wanted any further treatment. All the other patients had no pain.
Many authors emphasize that the graft in wrist fusion has to reach the base of the second and third metacarpal bone (Butler, 1949; Haddard & Riordan, 1967). In this follow-up study I have found 12 cases where both the X-ray and the clinical examination indicate no carpometacarpal fusion. Only 2 of these patients had some slight pain during work, the others had no pains, This may justify the conclusion, that it is not necessary to include the base of the metacarpals in the fusion.
Only a few of the patients with rheumatoid arthritis are working full time and none of the patients with cerebral palsy. But this of course is not due to the wrist-operation.
In cerebral palsy there is almost only cosmetic improvement. In only 1 case did the function of the fingers improve after the operation. Two of the spastic children emphasized that it was easier to put the hand through the sleeve after the opera- tion, and this may also be called a slight functional improvement.
But the most important point is to evaluate the working capacity after the fusion in the patients with local wrist-disease, i.e. the group with osteo- arthritis following fractures and malacia of the lunate bone, a total of 22 patients. 17 of these are back at work, 4 are out of work as a result of other diseases and one has not been traced.
To complete this follow-up study, it must be mentioned that in no case was the supination or the pronation of the forearm less than prior to the operation. In the group with degenerative arthritis Scand J Plast Reconstr Surg 5
Fig. 4 . Union only between the radius and the lunate bone. This condition was painless,
these movements are normal, as are the finger movements. In cases of rheumatoid arthritis there seems to be some improvement of the function of the hand, but it is impossible to make a real evaluation of the function of the fingers because of the progression of the disease itself in the individual finger joints.
CONCLUSION This follow-up study confirms the established fact that wrist-fusion relieves pain where other treat- ment has failed.
In cerebral palsy one can expect only cosmetic improvement, very seldom slight functional im- provement. But to some of these patients even cosmetic improvement is of great importance.
In degenerative arthritis one may expect con- siderable functional improvement, and the patient stands a fair chance of returning to normal work.
As to the operative technique, it seems that the iliac graft is superior to the ulnar graft, since there were four failures of the ulnar graft; none of the iliac. Furthermore, the carpo-metacarpal fusion seems to be unnecessary, as patients with this condition did not have any complaints.
REFERENCES Bunnell, St. 1956. Surgery of the hand, 3rd ed., p. 325.
Lippincott, Philadelphia.
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Butler, A. A. 1949. Arthrodesis of the wrist joint. Amer
Frackelton, W. H. 1952. Wrist arthrodesis. Amer SOC
Haddard, R. J. & Riordan, D. C. 1967. Arthrodesis of the
Schwartz, S. 1967. Localized fusion at the wrist joint.
J Surg 78, 625.
Siirg Hand 25-6.
wrist. J Bone Joint Surg (Amer.) 49 A , 5 .
J Bone Joinf Sirrg (Amer.) 49 A, 8.
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Seddon, H. J. 1952. Reconstructive surgery of the upper extremity. Report of the second poliomyelitis con- ference, p. 226. Lippincott, Philadelphia.
Smith-Petersen, M. N. 1940. A new approach to the wrist joint. J Bone Joint Surg (Amer.) 22, 122.
Stjernsward, J. & Wetzenstein, H. 1964. Arthrodesis of the wrist joint. Acta Orfhop S c a d 35: 1 , 87.
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