Hand Surgery Department Poznan University of Medical Sciences Piotr Czarnecki
Arthroscopic debridement, bone excision MP, PIP, total wrist replacement PIP, CMC fusion partial wrist fusion proximal row carpectomy Thumb CMC joint replacement Total wrist fusion Wrist denervation
Similar indications as trapeziectomy but good height of trapezium no ST joint degeneration (ex. Eaton stage IV) Still results similar as trapeziectomy (some better in functional tests) Surgeon and patient feeling that joint is preserved (replaced)
BioPro modular Biomet ARPE MEMOMETAL Ivory Small Bone Innovations Braun-Cutter Elektra
looks like small hip mostly noncemented, hydroxyapatite metal on poliethylene modular: different neck sizes and offset retentive or nonretentive cup dorsal or volar approach usually faster and nicer than trapeziectomy splint for 4-6 weeks
7-15% complication rate (in the beginning learning curve) 10 years survival rate 93% faster and better pain relief, function, grip strength, range of motion resection arthroplasty 10% bad results in elderly and >20% in younger Regnard PJ. Electra trapezio metacarpal prosthesis: results of the first 100 cases. J Hand Surg Br. 2006 Ulrich-Vinther M, Puggaard H, Lange B.: Prospective 1 -year follow-up study comparing joint prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis. J Hand Surg Am. 2008
65-year-old women with advanced degenerative changes and slight subluxation
6 weeks post op 3 months postop
3 months postop
implant failure: acetabulum loosening, dislocation, perforation and fracture of trapezium, CRPS possible conversion to trapeziectomy with suspensionplasty after implant removal sometimes dislocation not symptomatic!
advanced wrist atrhritis and degeneration salvage procedure heavy workers brachial plexus injuries, MPS, spasticity still the advantage of total wrist replacement in cases of arthritis is hard to proof
dorsal approach removal of chondral/subchondral layers include CM joints? plate trial dedicated plate, custom shaped graft placement allografts, autografts, bone substitutes fixation with compression
posttraumatic arthritis and flexion contracture DRUJ changes but asymptomatic short bend plate
heavy manual worker, 20-0-20 deg. motion preserved
custom plate bending resection of distal radius and ulna titanium plates are more susceptible for breakage during bending and in time
Fusion PRC different indications! Acta chir belg, 2005, 105, 626-630 Outcome of two Salvage Procedures for Posttraumatic Osteoarthritis of the Wrist : Arthrodesis or Proximal Row Carpectomy L. De Smet, I. Degreef, J. Truyen, F. Robijns
5 year follow-up
Percentage operated Total wrist fusion vs. replacement with Universal implant 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% patient satisfaction pain limiting function complications fusion Universal criteria Murphy et al / Wrist Arthroplasty Versus Arthrodesis The Journal of Hand Surgery / Vol. 28A No. 4 July 2003
plate/screw loosening or breakage nonunion approx. 1% residual pain infection extensor tendinitis
not commonly used advanced changes but patient needs motion and refuses fusion (older surgeon, taxi driver) rather partial than complete diagnostic injection before surgery Need some research about consequences (proprioception, degeneration advancement)
Arthritis pattern fracture of radius fracture of scaphoid arthritis Kienböck's disease rheumatoid disease chronic instability congenital malformation and arthritis
USN SRN PIN AIN LCN PIN and AIN and include radial or ulnar side depending on symptoms
60-year-old general surgeon AVN of lunate many years ago almost full range of motion degenerative changes confirmed in arthroscopy limited denervation of PIN, AIN pain decrease from 7/10 to 3/10 increasing in the summer when working in the garden
Wilhelm,8 1966 21 partial 19% 16 Geldmacher et al,9 1972 24 complete, 8 partial 75% No data Buck-Gramcko,10 1974 5 complete, 26 partial 35% 28 Buck-Gramcko,11 1977 30 complete, 165 partial No data 48 Helmke et al,29 1977 54 complete 28% 37 Stegemann et al,28 1980 26 complete 88% 30 Rostlund et al,12 1980 9 complete None 24 Martini et al,13 1983 33 complete/partial 54% 24 Ekerot et al,14 1983 48 complete/partial None 28 Dellon,2 1985 29 partial None 35 Foucher et al,15 1992 50 complete 40% 48 Buck-Gramcko,16 1993 61 complete/partial 77% 74 Ishida et al,17 1993 17 complete, 12 partial 41% 51 Ferreres et al,18 1995 22 complete, 30 partial None 65 Grechenig et al,19 1998 22 complete 27% 50 Foucher et al,20 1998 50 complete None 60 Weinstein and Berger,4 2002 19 partial None 30 80% success rate 84% success rate 13% no pain, 55% slight pain 26% complete, 43% partial 83% positive 81% positive 89% improvement 84% success rate 56% pain relief 90% improvement 72% improvement 76% very or remarkably satisfied 24% satisfied Complete better than partial 77% satisfied 74% pain relief 80% pain relief, 85% satisfied 761 (sum) 75% improvement (mean)
many options for treatment arthritis solution has to be customed for the patient symptoms and situation (work, sport, demands, age) still classical surgery (fusion, reconstruction, excision) doesn t seems to be replaced by joint replacement (complications, cost) despite possible advantage for the patient (hard to proove)
Hand Surgery Department Poznan University of Medical Sciences