Total Wrist Arthroplasty: An International Perspective.

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

Ulnar Head or Total Distal Radioulnar Joint Replacement, Isolated and Combined with Total Wrist Arthroplasty: Midterm Results.

Purpose Various implants have been described for ulnar head replacement (UHR) or for total replacement of the distal radioulnar joint (DRUJ). Many series are small and few reports on mid- or long-term results. This study is primarily aimed to report on the midterm results after ulnar head only and total DRUJ replacement using the uHead in the treatment of painful disorders of the DRUJ. The secondary aim of the study was to eventually assess the combination of UHR and total wrist arthroplasty (TWA). Materials and Methods We included 20 consecutive patients in whom an UHR with the uHead was performed at our institution between February 2005 and March 2017. There were 6 men and 14 women with mean age of 59 years (range: 36-80 years). The mean follow-up time was 5 years (range: 2-15 years). Data were recorded prospectively before operation and at follow-up examinations and entered in a registry. The patients were followed-up at 3 and 6 weeks and 3, 6, and 12 months postoperatively and thereafter annually. In five cases, the uHead was implanted simultaneously with a Remotion TWA. In four cases, a Remotion TWA had been implanted previously. Kaplan-Meier survival analysis was used to estimate the cumulative probability of remaining free of revision. A nonparametric Wilcoxon's signed-rank test was used for comparing data not normally distributed (qDASH [quick disabilities of the hand, shoulder, and arm] scores), and the paired parametric Student's t -test was used for normally distributed data (pain and visual analogue scale [VAS] scores, range of motion, and grip strength). Significance was set at a p -value of less than 0.05. Results Pain, grip strength, and the function improved significantly. Pain after surgery decreased with 50 points on the VAS score scale of 100, from 66 (mean), preoperatively (range: 16-97) to 16 (mean; range: 0-51), postoperatively, while grip strength nearly doubled from 12 KgF (mean; range: 4-22), before to 21 KgF (mean; range: 6-36), after the surgery. Patients function measured with qDASH scores improved from 56 (mean; range: 36-75), preoperatively to 19 (mean; range: 4-47), postoperatively. Wrist extension, flexion, and ulnar and radial deviation did not change to a clinically or statistically significant extend, neither did supination nor pronation improved after surgery. While three UHRs were revised early because of pain problems and/or unsatisfactory forearm rotation in two cases and infection in one, 17 had an uncomplicated postoperative course and these patients were satisfied with the results of the surgery at all the follow-ups. Due to limited number of cases, the calculation of significance in comparing combined cases with UHR only cases was abandoned. Conclusion Ulnar head arthroplasty (uHead) showed significant improvement in pain, grip strength, and the function of the patients with a painful disability of the DRUJ, without impairment on mobility on the midterm follow-up. The overall implant survival over the time and the complication rate was acceptable.

The Rotoglide™ total replacement of the first metatarso-phalangeal joint. A prospective series with 7-15 years clinico-radiological follow-up with survival analysis.

BACKGROUND: The Rotoglide total replacement of the MTP-1 joint. 15 years survival analysis. The purpose of this prospective study was to evaluate the long-term performance clinico-radiographically of an uncemented three-component total replacement for the first metatarso-phalangeal joint (MTP-1) used for hallux rigidus (primary osteoarthritis grades 3 and 4). The follow-up was median 11.5 years (7-15). METHODS: The AOFAS forefoot score was used preoperatively and at follow-up. Radiographs were taken weight-bearing in the AP-projection and in tip-toe standing in the lateral view. Arthrosis in the sesamoid junction, prosthetic loosening, subsidence (of prosthesis as well as sesamoids), and dorsiflexion were measured, recorded and subjected to multiple variance analysis. Survival analysis was performed for 15 years. MATERIAL: Ninety implants in 80 patients (53 women and 27 men); median age 58 (41-76) were evaluated. RESULTS: Six patients representing seven prostheses in situ had died from unrelated reason. The median preoperative AOFAS increased significantly from 40 to 95. The median gain was 45. Four replacements (4.4%) were extracted for other reasons than loosening. No aseptic loosenings were recorded. The survival rate at 15 years was 91.5% (83-100). Multiple variance analysis showed that arthrosis in the metatarso-sesamoid junction correlated with reduced AOFAS score. CONCLUSION: The prosthesis has stood the test of time; the results justify its further use.

Psychometric properties of two questionnaires in the context of total wrist arthroplasty.

INTRODUCTION: Patient-rated outcome measures are frequently used to assess the results of total wrist arthroplasty, but their psychometric properties have not yet been evaluated in this group of patients. The purpose of our study was to assess the psychometric properties of the Danish Quick Disabilites of Arm Shoulder and Hand (QuickDASH) and Patient-rated Wrist Evaluation questionnaires in patients with total wrist arthroplasty. METHODS: In a prospective cohort of 102 cases, we evaluated the QuickDASH. Furthermore, in a cross-sectional study and a test-retest on a subgroup of the patients, we evaluated the Patient-rated Wrist Evaluation. RESULTS: Internal consistency and reproducibility were very high (Cronbach's alpha 0.96/0.97; Spearman's rho 0.90/ 0.91; intraclass coefficient 0.91/0.92), and there were no floor or ceiling effects. The responsiveness of the QuickDASH was high (standardised response mean 1.06 and effect size 1.07). The construct validity of both scales was confirmed by three a priori formulated hypotheses: a moderate, negative correlation of scores with grip-strength; a moderate, positive correlation with pain and a very weak or no correlation with mobility. Rheumatoid patients scored significantly higher on the QuickDASH than other patients did. The scores of both questionnaires were very closely related. CONCLUSION: Both questionnaires are valid and equivalent for use in patients with total wrist arthroplasty. FUNDING: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. TRIAL REGISTRATION: not relevant.

Favorable results after total wrist arthroplasty: 65 wrists in 60 patients followed for 5­9 years.

BACKGROUND AND PURPOSE: During the past 40 years, several attempts have been made with total wrist arthroplasty to avoid fusion in severely destroyed wrists. The results have often been disappointing. There is only modest clinical documentation due to the small number of patients (especially non-rheumatoid cases) and short follow-up times. Here we report a multicenter series using a third-generation implant with a minimum follow-up time of 5 years. METHODS: In 2012, data were retrieved from a registry of consecutive wrist operations at 7 centers with units specialized in hand surgery, between 2003 and 2007. The wrists had been reviewed annually and analysis was done on the latest follow-up data. RESULTS: 60 patients had been operated (5 bilaterally), 5 wrists had been revised, and 52 were available for follow-up (with the revised cases excluded). The pain scores, QuickDASH scores, ulnar flexion, and supination for the whole group were statistically significantly better at follow-up. There were no statistically significant differences between the rheumatoid and the non-rheumatoid patients except for motion, which was better in the non-rheumatoid group. The motion obtained depended on the preoperative motion. Implant survival was 0.9 at 5-9 years. INTERPRETATION: The clinical results in terms of pain, motion, strength, and function were similar to those in previous reports. The implant survival was 0.9 at 9 years, both in rheumatoid and non-rheumatoid cases, which is an important improvement compared to the earlier generations of total wrist arthroplasty.

Can total wrist arthroplasty be an option in the treatment of the severely destroyed posttraumatic wrist?

Background Severely destroyed posttraumatic wrists are usually treated by partial or total wrist fusion or proximal row carpectomy. The indications for and longevity of total wrist arthroplasty (TWA) are still unclear. Case Description The aim of this study was to analyze a series in which one last-generation total wrist arthroplasty was used as a salvage procedure for wrists with severe arthritis due to traumatic causes. The data were prospectively recorded in a web-based registry. Seven centers participated. Thirty-five cases had a minimum follow-up time of 2 years. Average follow-up was 39 (24-96) months. Pain had improved significantly at follow-up, mobility remained unchanged. The total revision rate was 3.7%, and the implant survival was 92% at 4-8 years. Literature Review Very few studies have described specific results after TWA in posttraumatic cases and almost none using classical "third-generation" implants. The number of cases and the follow-up in the published series are small. Clinical Relevance Although painful posttraumatic wrists with severe joint destruction can be salvaged by partial or total fusion, we found that, evaluated at short- to midterm, total wrist arthroplasty can be an alternative procedure and gives results that are comparable to those obtained in rheumatoid cases. Level IV Case series.

"Remotion" total wrist arthroplasty: preliminary results of a prospective international multicenter study of 215 cases.

This study reports the current results of an international multicenter study of one last generation total wrist arthroplasty (TWA) ("ReMotion," Small Bone Innovation, Morristown, PA). The two first authors (G.H. and M.B.) built a Web-based prospective database including clinical and radiological preoperative and postoperative reports of "ReMotion" TWA at regular intervals. The cases of 7 centers with more than 15 inclusions were considered for this article. A total of 215 wrists were included. In the rheumatoid arthritis (RA; 129 wrists) and nonrheumatoid arthritis (non-RA; 86 wrists) groups, there were respectively 5 and 6% complications requiring implant revision with a survival rate of 96 and 92%, respectively, at an average follow-up of 4 years. Within the whole series, only one dislocation was observed in one non-RA wrist. A total of 112 wrists (75 rheumatoid and 37 nonrheumatoid) had more than 2 years of follow-up (minimum: 2 years, maximum: 8 years). In rheumatoid and non-RA group, visual analog scale (VAS) pain score improved by 48 and 54 points, respectively, and QuickDASH score improved by 20 and 21 points, respectively, with no statistical differences. Average postoperative arc of wrist flexion-extension was 58 degrees in rheumatoid wrists (loss of 1 degree) compared with 63 degrees in non-RA wrists (loss of 9 degrees) with no statistical differences. Grip strength improved respectively by 40 and 19% in rheumatoid and non-RA groups (p = 0.033). Implant loosening was observed in 4% of the rheumatoid wrists and 3% of the non-RA wrists with no statistical differences. A Web-based TWA international registry was presented. Our results suggest that the use of the "ReMotion" TWA is feasible in the midterm both for rheumatoid and non-RA patients. This is a significant improvement compared with the previous generation TWA. The level of evidence for this study is IV.

[Validation of questionnaire for conditions of the upper extremity]. / Validering af spørgeskema ved lidelser i overekstremiteten.

INTRODUCTION: DASH stands for Disability of the Arm, Shoulder and Hand and is a questionnaire developed in the US that can be used for assessment of patients with disability in the upper extremities. On the basis of the answers provided, a numerical DASH score can be calculated that reflects the patient's subjective evaluation of his or her disability. DASH would be of use for all upper-limb disorders and is appropriate for both acute and chronic disorders of either traumatic or non-traumatic aetiology. We present a study in which DASH has been used in a group of patients with a variety of conditions in the upper extremity. The aim was to evaluate the reproducibility of the scoring of Danish patients and to evaluate whether the questionnaire was useful in Danish clinical practice. MATERIAL AND METHODS: A total of 83 patients joined the study, 72 of these with hand-related conditions and ten with shoulder problems. The patients included were all in a stable stage of their disease, which typically was chronic, and they were invited to answer the questionnaire in connection with a medical examination preceding surgery or at the final ambulatory visit after treatment had been given. RESULTS: A total of 54 of the patients met all criteria concerning delays and responsiveness. The DASH scores of the first and second test were numerically close with an intra-class coefficient of 0.85. Cronbach's alpha was 0.96, indicating that the subtests were internally consistent. Spearman's correlation coefficient was overall 0.9 and, thus, there was a strong correlation between the first and the second response. CONCLUSIONS: The study reveals a good reproducibility of the DASH questionnaire. DASH scoring is stable and reliable and useful in a Danish patient population.