Assessing Periprosthetic Bone in Total Wrist Arthroplasty: The Validity of DXA.

INTRODUCTION: Dual-energy X-ray absorptiometry (DXA) can measure bone mineral density (BMD) around joint arthroplasties. DXA has never been used in total wrist arthroplasties (TWA). We investigated (1) whether BMD differs between 2 TWAs implanted in the same cadaver forearm, (2) the effect of forearm rotation and wrist extension on measured BMD around TWA in a cadaver, and (3) the precision of DXA in a cadaver and patients. METHODOLOGY: One ROI around the distal and 1 and 3 ROIs (ROI1-3) around the proximal component were used. Ten DXA scans were performed on forearm and femur mode convertible to orthopedic knee mode without arthroplasty, with ReMotion, and with Motec TWA in one cadaver forearm. Ten scans with 5° increments from 90°-70° pronation and 0°-20° extension, were performed with Motec. Precision was calculated as coefficient of variation (CV%) and least significant change (LSC%) from cadaver scans and double examinations with femur mode converted to orthopedic knee mode in 40 patients (20 ReMotion, 20 Motec). RESULTS: BMD was higher in all Motec than corresponding ReMotion ROIs (p < 0.05). BMD changed with 10° supination in the distal ROI and ROI1, and with 5° extension in the distal ROI (p < 0.05). In the cadaver the orthopedic knee mode was more precise than the forearm mode in 3 Motec ROIs (p < 0.05). In patients CV was 2.21%-3.08% in the distal ROI, 1.66%-2.01% in the proximal ROI, and 1.98%-2.87% with 3 ROIs. CONCLUSIONS: DXA is feasible for BMD measurement around the proximal component using the orthopedic knee mode, but not the distal component of TWA.

Five- to 10-Year Prospective Follow-Up of Wrist Arthroplasty in 56 Nonrheumatoid Patients.

PURPOSE: The goal of the study was to evaluate the clinical and radiological outcomes of a cementless wrist arthroplasty with minimum 5-year follow-up in nonrheumatoid patients. METHODS: Fifty-seven (40 male) patients with end-stage arthritis changes received an uncemented ball-and-socket total wrist arthroplasty (Motec Wrist). Function was evaluated before surgery and at yearly follow-ups. Visual analog scale at rest and activity, quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), active range of motion (AROM), and grip-strength were recorded. Standardized radiographs were taken to assess osteolysis, loosening, and subsidence. RESULTS: Fifty-six patients were followed for a mean of 8 years (SD, 2 years). Eight wrists were reoperated with arthrodesis (4) or a new arthroplasty (4) owing to distal component loosening (3), infection (2), pain/fixed malposition (2), or proximal and distal component loosening (1). One radiocarpal dislocation was reduced closed and remained stable. Improved QuickDASH score and visual analog scale pain score both at rest and during activity were found at the last follow-up, as well as increased AROM (97° vs 126°) and grip strength (21 kg vs 24 kg). The radiological follow-up demonstrated loosening in 2 wrists. Thirty-five patients were working at surgery (17 manual labor) and 27 (11 manual labor) at follow-up. The 10-year Kaplan-Meyer survival of the implants was 86% for revision for any cause; 2 additional arthroplasties are loose (but not revised), giving a survival rate of 82% if these are revised prior to 10 years of observation. CONCLUSIONS: An uncemented total wrist arthroplasty can provide long-lasting unrestricted hand function in young and active patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Long-Term Outcomes of Wrist Arthroplasty Using the ReMotion™ Implant in Non-inflammatory Wrist Pathology.

Background: Wrist arthroplasty is increasingly offered to patients with symptomatic wrist arthritis as an alternative to wrist arthrodesis. The purpose of this study was to present our outcomes with the ReMotion™ wrist arthroplasty in a consecutive series of patients with wrist arthritis from non-inflammatory conditions. Methods: Thirteen (eight women, nine dominant wrists) patients, 68 (44-85) years of age with advanced radiocarpal arthritis due to SLAC/SNAC (11) and Kienbock disease (2) had a ReMotion™ (Stryker, Michigan, USA) wrist arthroplasty implanted, and were prospectively followed for 7 (4-9) years. The outcome measures included patient-rated wrist and hand evaluation (PRWHE) score, disabilities of the arm, shoulder and hand questionnaire (QuickDASH) score, visual analogue pain score (0-10) on the radial and ulnar aspect of the wrist at rest (VASrR/VASuR) and activity (VASrA/VASuA), active wrist range of motion (AROM) including flexion, extension, ulnar and radial deviation, pronation and supination and grip and key-pinch strength measured preoperatively and at yearly follow-ups by independent hand therapists. Results: Six patients had ten re-operations during the follow-up including four revisions to a new arthroplasty. Four were considered loose at follow-up. A significant reduction in PRWHE (63 to 12), radial pain at activity (6 to 1) and increased pronation (85° v 90°) was observed. Conclusions: We found a high complication and reoperation rate, two out of 13 had no complications or reoperations. The ReMotion™ arthroplasty should be used with caution in non-inflammatory wrist patients and the patients followed closely. A high reoperation and revision rate can be expected, and surgeons familiar with revision arthroplasty procedures should perform the surgery. Level of Evidence: Level II (Therapeutic).

Bilateral carpal pilon-type fractures due to clenched fist trauma: a case report.

Background: Multiple carpal fractures or fracture dislocations can be devastating to the wrist. Despite anatomical reduction and ligament reconstruction, reduced function and arthrosis is often observed. Simple fractures without ligament injuries often fare well if anatomy is restored and the fracture heals. Case Description: A 17-year-old autistic man presented with pilon-type bilateral fractures of the carpals after crashing his bicycle in a car with clenched fists around his bicycle handlebars. He had a displaced scaphoid, minimal displaced capitate and an undisplaced hamate fracture on the left side and an undisplaced scaphoid and displaced two-part capitate fracture on the right side. The fractures were reduced and stable fixation with screws performed. He was immobilized for 2 weeks and allowed early active motion. At 8 weeks the fractures had healed, and he obtained good function. At final follow-up after 6 months his nearest of kin reported excellent function, he had returned to his preinjury activity level. Range of motion and grip-strength was excellent and symmetrical. Radiographs and CT scans revealed healed fractures in anatomical position, no sign of ligament injuries, carpal instability or arthrosis. Conclusions: Multiple carpal fractures are not necessarily prone to reduced wrist function, pain and arthrosis, even in bilateral cases. If the ligaments are intact, stable fixation obtained and early mobilization obtained the fractures reduced and stable fixation obtained excellent hand and wrist function can be obtained.

15-20 Year Follow-up After Wrist Arthroplasty Surgery - Revisiting the Development and Introduction of a New Prototype Concept for Total Wrist Arthroplasty.

Background: Wrist arthroplasties have not achieved clinical outcomes comparable to those of shoulders and knees, being offered low-demand patients due to a high failure rate. In the 90s, there were no wrist arthroplasties available for high-demand patients. An experimental setup for the development of a new wrist arthroplasty intended for all wrist patients were done. A long-term final follow-up to evaluate the performance of the experimental arthroplasty was performed. Methods: A novel uncemented modular wrist prosthesis with conical threaded fixation, metal-on-metal coupling and ball-and-socket articulation was developed. In an experimental study, eight patients (7 men, 53 years of age) were operated between 2001 and 2003, to treat non-inflammatory primary or secondary osteoarthritis. Published mid-term results (7-9 years) demonstrated satisfactory function, but two arthroplasties were converted to arthrodesis due to infection. Results: At final follow-up 15-20 years after primary surgery, the remaining six patients still had a wrist arthroplasty (in three the original) in situ. The clinical results were good. Low pain (median = 0), Quick Disability of Arm, Shoulder and Hand (QDASH median 11) and Patient Rated Wrist and Hand Evaluation (PRWHE median = 14) scores were reported. Wrist active range of motion (AROM) was 64% and grip strength 86% compared to the opposite side. None regretted choosing arthroplasty knowing the outcome. Conclusions: Despite technical errors and the implementation of an incomplete prototype, this new concept for arthroplasty has demonstrated promising long-term fixation, a stable articulation with good range of motion, satisfactory function and pain reduction in high-demand patients. Level of Evidence: Level IV (Therapeutic).

A randomized controlled trial comparing two modern total wrist arthroplasties : improved function with stable implants, but high complication rates in non-rheumatoid wrists at two years.

AIMS: To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour. METHODS: A total of 40 patients suffering from non-rheumatoid wrist arthritis were enrolled in a randomized controlled trial comparing the ReMotion and Motec TWAs. Patient-rated and functional outcomes, radiological changes, blood metal ion levels, migration measured by model-based radiostereometric analysis (RSA), bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA), complications, loosening, and revision rates at two years were compared. RESULTS: Patient-Rated Wrist and Hand Evaluation (PRWHE) scores, abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire scores, and pain improved similarly and significantly in both groups. Wrist motion improved significantly in the Motec group only, and forearm rotation in the ReMotion group only. Cobalt (Co) and chromium (Cr) blood ion levels were significantly higher in the metal-on-metal (MoM) Motec group than in the metal-on-polyethylene (MoP) ReMotion group. Mean total translation was 0.65 mm (95% confidence interval (CI) 0.26 to 1.12) and 0.27 mm (95% CI 0.14 to 0.47) for the ReMotion carpal and radial components, and 0.32 mm (95% CI 0.22 to 0.45) and 0.26 mm (95% CI 0.20 to 0.34) for the Motec metacarpal and radial components, respectively. Apart from dorsal and volar tilts, which were significantly higher for the radial ReMotion than for the Motec component, no significant differences in absolute migration occurred. BMD around the radial components never returned to baseline. Almost one-third of patients required reoperation due to complications. Two ReMotion implants were revised to Motec TWAs due to carpal component loosening, and three Motec MoM articulations were revised to metal-on-polyether ether ketone due to painful synovitis. CONCLUSION: Both implants provided matched function and were stable at short-term follow-up, but with a high complication rate. This procedure should be restricted to specialist centres undertaking prospective analysis until its role is clarified.Cite this article: Bone Joint J 2022;104-B(10):1132-1141.

Progressing arthrosis and a high conversion rate 11 (4-19) years after four corner fusion.

Four corner fusion (4CF) is a limited wrist arthrodesis offered to patients with painful wrists due to scaphoid non-union advanced collapse (SNAC) or scapho-lunate advanced collapse (SLAC). A retrospective study of 42 wrists (in 36 patients), operated with 4CF using K-wires and autologous bone graft followed up after 11 (4-19) years was performed, 25 were male and mean age at surgery was 51 (22-71) years. During the follow-up period, 13 wrists were converted to total wrist arthrodesis or wrist arthroplasty, and one is scheduled for conversion (14/42, 33%) due to non-union (3), DISI and progressing arthrosis (7) or progressing arthrosis (4). Non-union was seen in 3/42 (93%) wrists, all were later converted. At the final follow-up, the patients reported residual pain, VAS = 15 and 36 at rest and activity, respectively, and QDASH/PRWHE = 32 and 31, respectively. Active range of motion (AROM) was 38% and grip-strength was 76% compared to the uninjured side. Degenerative changes were seen in 88% on CT scans at follow-up. 4CF renders an acceptable pain reduction and function in the majority of patients, but increased degeneration and a high number of conversions after a longer follow-up time is concerning.

Satisfactory function 12 years after triscaphoid arthrodesis for chronic scapholunate ligament injury.

Scapholunate ligament (SLL) injury represents a hazard to the wrist and the treatment of these injuries has been the focus of much debate. We performed a long-term follow (>10 years) of triscaphoid arthrodesis for symptomatic chronic SLL injuries in 10 (8 men) patients 37 (22-49) years of age. All arthrodesis healed. One patient was converted to total wrist arthrodesis during the follow-up period, and three had minor additional surgeries. At final follow-up, the patients had reduced active range of motion (AROM, 55%) and grip strength (85%) compared to the opposite side, but reported low Quick Disability of Arm, Shoulder and Hand (QDASH) (11), Patient-Rated Wrist and Hand Evaluation (PRWHE) (25) and visual analog scale (VAS) pain scores (0 and 10 at rest and activity). Radiographs found minimal degenerative changes in four patients, while CT scans demonstrated changes in seven patients, in three of these scaphoid was subluxed on the rim of the radius. The patients working prior to surgery were working at follow-up. A triscaphoid arthrodesis for SLL renders a functional wrist function in most patients for many years and has postponed more extensive surgery like total wrist arthrodesis or wrist arthroplasty. The patients are still young, and the degenerative changes seen especially on CT scans warrants attention.

High precision and accuracy of model-based RSA for analysis of wrist arthroplasty.

Radiostereometric analysis (RSA) is a method for measuring micromotion in joint arthroplasties. RSA has never been used in total wrist arthroplasties. We evaluated: (i) the precision of model-based RSA in total wrist arthroplasties measured in a phantom model and in patients; (ii) the number of bone markers necessary to ensure the precision; and (iii) the accuracy of model-based RSA in a phantom model. Reverse engineered models of radial and carpal/metacarpal components of two wrist arthroplasties (ReMotion® and Motec®) were obtained by laser scanning. Precision and accuracy of each arthroplasty were analyzed with regards to translation and rotation along the three coordinate axes. Precision was analyzed in 10 phantom and 30 clinical double examinations for each arthroplasty, and was expressed by a repeatability coefficient. The precision of different numbers and configurations of bone markers in the phantom model were compared. Accuracy was tested in a phantom model where the implants were attached to a micrometer, and was defined as the mean difference between measured and true migration. In the phantom model the precision for translations ranged from 0.03 to 0.14 mm and for rotations from 0.18 to 1.52°. In patients the precision for translations ranged from 0.06 to 0.18 mm, and for rotations from 0.32 to 2.18°. Less than four bone markers resulted in inferior precision. Accuracy ranged from -0.06 to 0.04 mm, and from -0.38 to -0.01°. Y-rotations could not be obtained from the Motec® due to rotational symmetry about the longitudinal axis. We conclude that model-based RSA in total wrist arthroplasties is precise, accurate, and feasible to use for clinical evaluation of micromotion in wrist arthroplasties. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3053-3063, 2018.