total wrist arthroplasty -...

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Total Wrist ArthroplastyBrian D. Adams, MD

Although the wrist wasone of the first joints

treated by prosthetic replace-ment, the evolution of totalwrist arthroplasty has beenmuch slower than hip andknee arthroplasty. The lowerprevalence of symptomaticwrist arthritis and the avail-ability of other acceptabletreatments, such as limited orcomplete arthrodesis, havedampened the interest for thedesign and manufacturing ofwrist implants. In addition, thesmall size and complexity of

the wrist have been obstaclesto engineering. Small compo-nents place high demands onmaterials, resulting in morerapid wear and implant break-age. Attempts to simulate thenatural, multi-articulated wristand its normal motions usingcomplex designs, such as mul-tiple bearing surfaces, resultedin instability, loosening, andimplant breakage.1-3

Historical PerspectiveSwanson designed the first

wrist implant, having wide-spread commercial distributionin the United States. Theimplant was made of silicone,acting as a flexible spacer, withwrist motion resulting from acombination of implant flexi-bility and pistoning within themedullary canals of the radiusand metacarpal.4 Early results

generally were gratifying withgood pain relief and an accept-able range of motion; however,restoration of wrist height andhand balance was unpredictable.Longer follow-up revealed sub-sidence within the bone and a

high incidence of implant break-age, reaching 52% at 72 months(Figure 1).2,5,6 Silicone synovitis

became an important issue later,although the incidence waslower than with carpalimplants.7

Early articulated total wristprostheses incorporated bear-ings for joint motion, variousstem designs for fixation in theradius and carpus, and differentdegrees of constraint.8-14

From the Department of OrthopedicSurgery, University of Iowa, Iowa City,Iowa.

Dr Adams has a financial interestin KMI, Carlsbad, Calif.

Reprint requests: Brian D. Adams,MD, Dept of Orthopedic Surgery,University of Iowa, 200 Hawkins Dr,Iowa City, IA 52242.

With the advent of newer prosthetic designs, total wristarthroplasty provides a functional range of motion, betterwrist balance, reduced risk of loosening, and betterimplant stability.

Figure 1: Radiograph 5 yearspostoperatively reveals silicone wristimplant breakage.

Figure 2: Ulnar imbalance with aVoltz prosthesis.

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MARCH 2004 | Volume 27 • Number 3 279

Carpal component loosening,periprosthetic bone resorptionof the distal radius, and wristimbalance were serious prob-lems (Figure 2).11,13,14 In anattempt to reduce wrist imbal-ance and distal componentloosening, the Biaxial (DePuy,Warsaw, Ind), Trispherical(Osteonics, Allendale, NJ),revised Volz (Howmedica,Rutherford, NJ), and revisedMeuli (Sulzer OrthopaedicsLtd, Winterthur, Switzerland)were each designed to moreaccurately reproduce normalwrist kinematics. Early resultswere mixed, with persistentloosening, subsidence, andimbalance.15-20

Because distal component

loosening continued to plaguethe longevity of wrist replace-ment, in 1980, Menon devel-oped a new approach to implantfixation within the carpus.14,21

Previous designs relied on fixa-tion in the metacarpal canals,usually with cement, and wereassociated with a high inci-dence of loosening, metacarpalerosion, and implant penetra-tion. The distal component ofthe Universal total wrist system(Kinetikos Medical Inc [KMI],San Diego, Calif) is fixed by ashort central stem into the capi-tate and two deep-threaded

screws into the radial and ulnaraspects of the carpus. The fixa-tion is combined with an inter-carpal arthrodesis to providelong-term, solid bony support.Because the distal componentsupports the entire carpus,

proximal migration of the firstand fifth rays is prevented. Theradial component is inclined toreplicate the slope of the nor-mal distal radius. Soft-tissuebalancing can be adjusted byvariations in polyethylene sizes.

These design features offeredbetter wrist balance and morenormal load transfer. Theoblique osteotomy of the radiusand proximal osteotomythrough the carpus result inminimal bone resection and

The objective of totalwrist arthroplasty isto maintain wristmotion while relievingpain and correctingdeformity.

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wrist capsule preservation.Because the resection is limit-ed, more bone stock is availableto salvage the wrist by arthrode-sis if the prosthesis fails.

The articular surface of theUniversal distal component isshaped like a toroid (donut),which is intended to match thecontour of the proximal carpalrow.22 The long-term fixation ofthis prosthesis proved to be sub-stantially better than previousprosthetic designs. Dislocation,however, was a major problem,with a 9% frequency. Overallexperience with differentdesigns during the past three

and half decades strongly sug-gests specific criteria optimizeclinical results (Table).

Universal2 Total WristIntroduced in 2002, the

Universal2 Total Wrist System

(KMI) includes the positivefeatures of the first generationUniversal prosthesis alongwith several enhancementsand changes consistent withthe specifications listed in theTable. Using both computermodeling techniques and labo-ratory testing, an elliptical-shaped distal articular surfacewas designed to create an opti-mum balance between motionand stability. The shape pro-vides consistent congruity andcentralization of the contactarea on the polyethylene overthe entire range of prostheticmotion. The result is low

stress and wear on the polyeth-ylene and better articular sta-bility without creating a fullyconstrained joint (Figure 3).22

The shape also allowed abroad anteroposterior articularsurface dimension for addi-

tional stability, including thepotential for early active rangeof motion.

Beaded porous coating isapplied to the radial and carpalcomponents for possible fixa-tion by osseous integration.Uncemented fixation is thuspossible when consideredappropriate by the surgeon.The articular surfaces are off-set volarly relative to the stemsto improve wrist extension,further increase stability, andbetter match the cut surface of

the radius for close capsulehealing around the implant.The radial component stem isminimally flared to preservethe biologically active meta-physeal bone for osteointegra-tion. It also is long and straightto obtain an initial mechanicalpress fit. An option to preservethe distal ulna exists, which ismore relevant in the non-rheumatoid patient forimproved strength and reduced

morbidity. Logical and effi-cient instrumentation ensuresaccuracy and reproducibility.

IndicationsThe objective of total wrist

arthroplasty is to maintainwrist motion while relievingpain and correcting deformity.Patients who are afflicted byarthritis within multiple upperextremity joints and those withspecific needs or desires havethe greatest need for maintain-ing wrist motion. Patients with

rheumatoid arthritis who havebilateral wrist arthritis andelbow and shoulder involve-ment are good candidates.Studies have found that indi-viduals who have had a wristfusion on one side and totalwrist arthroplasty on the otherprefer the arthroplasty.23 Basicactivities of daily living suchas perineal care, fastening but-tons, combing hair, and writ-ing are made easier if some

Figure 3: Articular contact area of toroid versus ellipsoid shape. In flexion andextension, contact area rapidly declines for the toroidal shape, whereas thecontact area remains constant through motion for the elliptical shape.

TABLE

Specifications for the Optimum Total Wrist Prosthesis

Distal Component FixationPrimarily within carpus (avoid metacarpal canals)Intercarpal fusion (solid foundation for component)Uncemented (porous coated in-growth/screws)

ArticulationBroad (resists imbalance)Ellipsoidal (balance of constraint and contact area)Semi-constrained (resists dislocation/early motion)

Proximal ComponentReplicate radius (optimizes motion and load transfer)Minimize bone resection (preserves soft-tissues)Uncemented (porous coated in-growth, press-fit)

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To be considered for total wrist arthroplasty,patients should have a functional hand, activewrist extensor power, adequate bone stock,and no infection.



wrist motion is preserved.24,25

Patients with post-traumatic ordegenerative osteoarthritismay also be candidates fortotal wrist arthroplasty if theyare willing to comply with

permanent activity restric-tions.

To be considered for totalwrist arthroplasty, patientsshould have a functional hand,active wrist extensor power,adequate bone stock, and noinfection. Total wrist arthro-plasty is contraindicated inrheumatoid patients with high-ly active synovitis, as the riskof loosening is substantiallyincreased. Young activepatients and individuals withhigh physical demands are notgood candidates.26,27

Preoperative PlanningPatients with rheumatoid

arthritis should have a full pre-operative evaluation includingthe cervical spine. Total hip or

knee replacement should beperformed prior to wristarthroplasty to prevent weightbearing on the wrist prosthesis.Wrist replacement may be per-formed before or after shoul-

der or elbow surgery but priorto hand surgery to improvehand balance and optimizerehabilitation of the digits. Toreduce the risk of infection andwound healing problems, tem-porarily stopping medicationssuch as methotrexate and otherimmune-modulating medica-tions should be consideredafter consultation with arheumatologist. Decreasing oreliminating nonsteroidal anti-inflammatory agents for atleast 10 days preoperativelyand 5 days postoperatively isrecommended to reduce therisk of bleeding complications.

Radiographic assessment ofbone quality, erosions, carpalcollapse, carpal ulnar transla-tion, volar subluxation, and the

distal radioulnar joint will pre-pare the surgeon for potentialtechnical difficulties. Implantsize and alignment within thebones can be predicted usingradiographic templates. In the

posteroanterior view, the radialcomponent should not extendbeyond the edge of the radialstyloid. The carpal componentshould not extend �2 mm over

the margins of the carpus at theosteotomy. In general, thesmaller implant should beselected when decidingbetween two sizes.

Operative Technique A dorsal longitudinal inci-

sion is made over the wrist inline with the third metacarpal,extending proximally from itsmidshaft. The skin and subcu-taneous tissue are elevatedtogether off the extensor reti-

naculum, with care to protectsensory branches of the radialand ulnar nerves. The extensorcarpi ulnaris compartment isopened along its volar margin

and the entire retinaculum iselevated radially to the septumbetween the first and secondextensor compartments. Anextensor tenosynovectomy isperformed if needed. Theextensor carpi radialis brevismust be intact or reparable and

Figure 6: Radial cutting block applied to resect thearticular surface at the proper angle. (Reprintedwith permission from Adams BD. Total wristarthroplasty. Semin Arthroplasty. 2000; 11:72-81.Copyright © 2000. Elsevier Inc.)

Figure 4: Exposure of the distal radius and carpusthrough a radially based retinacular flap and distallybased capsular flap. Figure 5: Guide rod placed toalign cutting block and broach for radius resection.(Reprinted with permission from Adams BD. Totalwrist arthroplasty. Semin Arthroplasty. 2000; 11:72-81. Copyright © 2000. Elsevier Inc.)

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Wrist replacement may be performed beforeor after shoulder or elbow surgery but priorto hand surgery to improve hand balance andoptimize rehabilitation of the digits.



the extensor carpi radialislongus should be functional.

The dorsal wrist capsule israised in continuity with thedorsal distal radial ulnar joint

capsule and periosteum overthe distal 1 cm of the radius asa distally based rectangularflap. The sides of the flap are

made in the floors of the firstand sixth extensor compart-ments. The brachioradialisand first extensor compart-ment are elevated subpe-

riosteally from the distal sty-loid (Figure 4). The wrist isfully flexed to expose thejoint. Synovectomies of theradiocarpal and distal radioul-

nar joints are performed whenneeded. If the distal radioul-nar joint is arthritic or the dis-tal radius is severely eroded,

the distal ulna is resectedthrough its neck.

The radial alignment rod ofthe instrument set is insertedthrough a hole 5 mm below

the dorsal rim of the radiusand just radial to Lister’stubercle. Fluoroscopy con-firms central placement of therod in the canal (Figure 5).The guide bar and cuttingblock are mounted on the rodand positioned to remove onlythe articular surface (Figure6). Pins are inserted throughthe block and the osteotomy iscompleted. The guide rod isreinserted and the appropriatesize broach is mounted on therod. Aligning the broach withsigmoid notch and dorsal rimof the radius, the broach is dri-ven into the radius until itscollar becomes flush with the

cortex (Figure 7). A trial radi-al component is inserted.

The scaphoid and triquetrumare temporarily pinned if theyare mobile to facilitate the car-

pus osteotomy. The lunate isexcised by sharp dissection orrongeur. Using the drill guide, ahole is made in the center of thecapitate. The guide bar and cut-ting block are inserted and posi-tioned to resect the proximal 1mm of the hamate, a smallamount of the capitate head, andapproximately half of thescaphoid and triquetrum (Figure8). The trial component isinserted and the screw holes aremade using the drill guide(Figure 9). The trial screws andradial and poly trial compo-nents are inserted. The pros-thesis typically is stable andshould demonstrate approxi-

Figure 7: Broaching the radius. (Reprinted withpermission from Adams BD. Total wrist arthroplasty.Semin Arthroplasty. 2000; 11:72-81. Copyright © 2000.Elsevier Inc.) Figure 8: Carpal cutting block forresection through the capitate head, scaphoid waist,and midtriquetrum. (Reprinted with permission fromAdams BD. Total wrist arthroplasty. SeminArthroplasty. 2000; 11:72-81. Copyright © 2000.Elsevier Inc.)

The prosthesis typically is stable and shoulddemonstrate approximately 35° of flexionand 35° of extension with modest tightnessat full extension.

Figure 9: Carpal component placement. (Reprinted withpermission from Adams BD. Total wrist arthroplasty. SeminArthroplasty. 2000; 11:72-81. Copyright © 2000. Elsevier Inc.)

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mately 35° of flexion and 35°of extension with modesttightness at full extension. Ifsoft-tissue tension is tight, it isadjusted by step-cut tendonlengthening of the wrist flex-ors or further resection of theradius. If tension is insuffi-cient, the palmar joint capsulemay need to be repaired to therim of the distal radius or athicker polyethylene may berequired.

Prior to implanting the finalprosthesis, three horizontal 3-0polyester mattress sutures areplaced through small boneholes along the dorsal rim of thedistal radius for eventual cap-sule closure. If the ulnar headwas resected, sutures also areplaced through the dorsal neck.The articular surfaces areremoved from the triquetrum,capitate, hamate, scaphoid, andtrapezoid and previously resect-ed bone is packed in the spacesto achieve an intercarpalarthrodesis. The final implantsare impacted in place and thescrews are inserted tightly.The capsule repairs to com-pletely enclose the implants.The extensor retinaculum isrepaired, leaving the extensorcarpi radialis longus and bre-vis and the extensor pollicislongus superficial.

PostoperativeManagement

The postoperative dressingand plaster splint are removedon day 3 and a supervised exer-cise program is begun, includ-ing gentle active flexion, exten-sion, radial and ulnar deviation,pronation, supination, and digi-tal motion. Strengthening isadded at week 4. The patient is

advised against impact loadingof the wrist and repetitive force-ful use of the hand.

ResultsIn Menon’s first report of 37

Universal prostheses with amean follow-up of 6.7 years(range: 4-10 years), no casedemonstrated radiographic evi-dence of distal componentloosening.21 In a further fol-low-up study including 57implants, carpal componentloosening was not reported.28

Subsidence of the radial com-ponent was observed but wasnot progressive or sympto-matic. Similar to other prosthe-ses, the Universal implant pro-

vided consistently good painrelief (90%) and a functionalrange of motion. Average post-operative motion was 36°extension, 41° flexion, 7° radi-

al deviation, and 13° ulnardeviation. Dislocation was themost common complication,with 5 occurring in the first 37cases and a total of 6 among the57 cases in the later follow-up.

The initial higher incidence ofdislocation was partly attrib-uted to the lack of availabilityof different implant sizes andthicknesses of polyethyleneinserts at that time. In addition,Menon criticized himself forexcessive bone resection in hisearly cases. Modularity of thepolyethylene insert and multi-ple implant sizes helped reducethe incidence of dislocation inhis later experience.

A prospective study of 22Universal prostheses implantedby 2 surgeons with 1- to 2-yearfollow-up demonstrated resultssimilar to Menon’s. Patientsachieved an average of 41°flexion and 35° extension.29

Disabilities of the Arm,Shoulder, and Hand (DASH)outcome survey scoresimproved 24 points at 2 years.Three (14%) prostheses wereunstable and required furthertreatment; all 3 were in patientswith highly active rheumatoiddisease with severe wrist laxity.A further multicenter study of82 patients showed goodresults at 1- to 5-year follow-upwith equivalent outcomes ofmotion and patient satisfactionachieved by all surgeons.30

Dislocation continued to occurwith a 9% overall incidence.Distal component looseningoccurred in 4 patients, all ofwhom had persistently activesynovitis and failed to achieve

Figure 10: Postoperative radiograph of the Universal2 prosthesis.

Revision arthroplasty, arthrodesis, andresection arthroplasty are options forsalvaging a failed total wrist arthroplastydue to imbalance, loosening, or instability.

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an intercarpal fusion resultingin lack of solid bony implantsupport.

Early results with theUniversal2 prosthesis in 25patients (20 women and 5 men)operated by 2 surgeons, havebeen excellent. Twenty patientshad rheumatoid arthritis, 2post-traumatic arthritis, and 3osteoarthritis. All prostheseswere implanted uncemented.Results revealed excellent fixa-tion with an average of 37°flexion, 33° extension, 22°ulnar deviation, and 9° radialdeviation. Pain relief was ratedgood by all patients but mildulnar-sided wrist discomfortpersisted in 5 patients. Painrelief and motion often did notreach their maximum improve-ments for 6 months. AverageDASH scores improved 20%and Patient Related WristEvaluation scores improved35%. Radiographic implantloosening was not noted, but 1patient with osteopenia had 3mm of subsidence, whichplateaued. No dislocations orimplant loosening or revisionshave occurred (Figure 10).31 Anadditional surgeon surveyfound no reported dislocationsor revisions in �125 wristsimplanted in the United States.

DiscussionRevision arthroplasty, arthro-

desis, and resection arthroplastyare options for salvaging a failedtotal wrist arthroplasty due toimbalance, loosening, or insta-bility. Revision arthroplasty is anoption for aseptic loosening ifadequate bone stock exists or ifbone grafting is feasible. Thethickened capsule must be wide-ly released to allow wrist flexion

and extraction of the compo-nents. If substantial subsidence ispresent, lengthening of the wristflexors and extensor tendonsmay be required. Iliac crest bonegraft may be needed to filldefects and re-establish the basicarchitecture of the carpus.

When using the Universal2prosthesis for revision, the graftcan be transfixed to the remain-ing carpus using the carpal com-ponent fixation screws. The deci-sion to perform a revisiondepends on the integrity of thebone and soft tissues. Patientswith poor bone stock, inadequatecapsular tissue, or particulatesynovitis are not candidates forrevision arthroplasty. An estab-lished infection should be treatedby implant removal and primaryor delayed conversion to anarthrodesis.1,3,32

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