Wrist Arthroplasty Where are we now? Brian D Adams, MD Professor Orthopedic Surgery Baylor College of Medicine 72 y/o male, retired, no walking aides, minimal stressful activities, who has left, non-dominant wrist pain. No DMARDs or steroids. Right wrist fusion Poll the Audience 1. Wrist denervation 2. Radioscapholunate fusion 3. Arthrodesis 4. Total wrist replacement 1
Priorities Technical ease Risk Rehabilitation Pain relief Strength Motion Comparative Outcomes Patients prefer arthroplasty over arthrodesis Goodman & Millender 1980 Volz 1984 Vicar & Burton 1986 Kobus & Turner 1990 Figgie, et al 1990 Functional ROM of the Wrist (Maximum, Used, Required) Brumfield (1984) 10 F 35 E Palmar (1985) 5 F 30 E 10 RD, 15 UD Ryu (1991) 54 F 60 E 17 RD, 40 UD satisfactory 40 F 40 E 10 RD, 30 UD Nelson (1992) 5 F 6 E 7 RD, 6 UD 30 Flexion and 30 Extension 2
Design Challenges for a Wrist Implant Distal carpal row Proximal carpal row TFCC Radius Wrist axis of motion center of rotation is in capitate head Kinetics of Wrist Wrist and digital flexor forces must be resisted 3
Deformity & Associated Problems ligament attenuation erosion of volar rim bony shelf forms USA experience Swanson 1967 Silicone hinge Meuli 1972 Ball and socket Volz / CFV 1973 Dorsopalmar track Figgie & Ranawat 1977 Track and hinge Beckenbaugh 1982 Ellipsoidal Menon 1990 Toroid, screws Adams 2004 Uncemented, stable Gupta 2006 Mobile bearing Palmer & Strickland 2008 Distal Modularity Adams 2014 Anatomic articulation Universal Prosthesis 1990 4
14 years post operative Universal total wrist Optimizing the Design Distal Component Fixation Within carpus (avoid metacarpals) Intercarpal fusion (solid foundation) Uncemented (screws) Locking screws to increase fixation Articulation Unlinked (reduce stress of bone fixation) Broad (resists imbalance) Semi-constrained (resist dislocation) Proximal Component Replicate radius Minimize bone resection Uncemented (in-growth, press-fit) Intercarpal fusion to create two-bone joint 5
General Indications OA, SLAC, post-traumatic, & rheumatoid combined radiocarpal / midcarpal arthritis low demand, elderly patient patient recognizes lifetime limitations General Contra-indications high demand patient regular dependence on walking aides absent motor control of wrist poor bone stock previous surgical fusion if wrist extensors have been sacrificed Specific Contraindications severe active bony erosion 6
Example Cases rheumatoid arthritis old scaphoid nonunion SNAC wrist 7
post-traumatic arthritis old distal radius fx Kienbock s disease 8
Conversion for total wrist fusion Post-traumatic arthritis 9
Failed Proximal Row Carpectomy (PRC) Conversion from Failed Proximal Row Carpectomy (PRC) PA Obl Failed Four Bone Fusion Lat 10
PA Obl Lat Conversion from Failed Four Bone Fusion 17 of 21 pts had rheumatoid arthritis UNI 2 11
19 of 21 pts had rheumatoid arthritis 83 of 92 pts had rheumatoid arthritis 64 year old calligrapher with pseudogout and post-traumatic arthritis Minimal preop wrist motion 5 year post op 12
Massey Flossie On-growth fixation in osteopenia at 5 years Poly exchange, debridement, and bone allografting 6 six years post op 1 year after poly exchange Freedom Wrist Arthroplasty System Evolving Design for Expanding Indications 13
Proper placement to optimize loading and balance Minimize radius resection to preserve capsule & DRUJ Minimize radius resection to preserve capsule & DRUJ 14
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PA Lat 72 y/o male, retired, no walking aides, minimal stressful activities, who has left, non-dominant wrist pain. No DMARDs or steroids. Right wrist fusion Poll the Audience 1. Wrist denervation 2. Radioscapholunate fusion 3. Arthrodesis 4. Total wrist replacement 17
PA Lat Thank You 18
2 years post operative 19
6/1/2015 Wrist Arthritis: PRC & Wrist Arthrodesis Mark Baratz Dept. of Orthopedics UPMC Pittsburgh, PA baratzme@upmc.edu The Challenge Relieve pain Preserve motion For some, a little is a lot 50 degree arc allows 80% of ADL s 1
6/1/2015 Options PRC Limited wrist fusion Implant arthroplasty PRC Typically performed when: Head of capitate healthy Lunate fossa healthy Results good in patients > 35 years old Radiographic evidence of OA @ 10 years Clinical outcome better that x-rays Variation on the Theme 2
6/1/2015 Case Presentation A 69 year old male with SNAC wrist Wants to golf Has midcarpal arthritis Joint space narrowing & sclerosis PRC with capsular interposition Salomon and Eaton 96 3
6/1/2015 PRC Dorsal Capsular Interposition Hughes, Towsen and Baratz ASSH 00 Results: Cadaver Study Towsen, Hughes, Baratz ASSH 00 PRC PRC+DCI Degrees : p=0.001 Flexion Extension Radial Deviation Ulnar Deviation Results Clinical Study Degrees 100 80 60 40 20 PRC PRC + DCI 0 Flexion Extension Total Arc of Motion 4
6/1/2015 Results - Clinical 12 years later Pain free 60 o arc of motion Still golfing at 81! How bad can the arthritis be? 36-year old iron worker with wrist pain after trauma 5
6/1/2015 2 years later 4 corner (CLTH) fusion Scaphoid left in wrist Pain, weak, stiff Exam Wrist motion: 10 dorsiflexion 25 palmar flexion Grip strength: right 40 left 110 6
6/1/2015 4 years; working as iron worker 7
6/1/2015 So Wrist motion improved from: 35 to 115 degrees Grip 40 lbs to 70 lbs Pain is now intermittent; but still working as heavy laborer Clinical results 37 patients with PRC + interposition 28 available with average 5 yr. f/u I: 23 mild to moderate mid-carpal djd II: 5 advanced mid carpal and/or radiolunate DJD Group I Motion 88 to 91 VAS 2 Dash 18 20/23 back to work 2 revision surgery Group II Motion 62 to 78 VAS 1 DASH 6 All back to work 8
6/1/2015 A cautionary tale PRC with minimum 15 year f/u Ali et al. Hand 2012 61 patients Questionaire Av. f/u 19.8 years Motion unchanged from pre-op DJD appears @ 2 years 74% unhappy 85% required daily pain meds 20% had fusion 9
6/1/2015 Wrist Arthrodesis Chronic right wrist pain Long-standing RA Wrist arthrodesis with sliding radial graft Baratz et al. ASSH 91 10
6/1/2015 Rehak, Casper, Baratz et al. Orthopedics 2000 11
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6/1/2015 Outcome? Wagner et al JHS 2015 Bilateral fusions 13 patients Av. 14 year f/u 11/13 inflammatory arthritis 93% satisfied and would repeat But 7 revision procedures (54%!) 5 re-do 2 plate removals 13
Kienbock s Disease New Treatment Options William B. Geissler, M.D. Alan E Freeland Chair of Hand Surgery Professor and Chief Division of Hand and Upper Extremity Chief: Arthroscopic Surgery and Sports Medicine University of Mississippi Medical Center Kienbock s Disease First described by Peste Collapse lunate in cadaver dissections Robert Kienbock described x-rays changes Avascular necrosis of lunate Precise etiology unknown Kienbock s Disease Etiology unknown Lunate receives blood supply from volar/dorsal vessels In some individuals decreased vessel I-Pattern most at risk for necrosis 1
Ulna Length Hulten Act Chir Scand 76: 121. 1928 Ulnar variance Neutral 51% Negative 23% Correlated 18 of 23 patients with Kienbock were ulnar negative in series Gelberman» J Hand Surg 5: 272-278.1980 Relationship of ulnar variance to Kienbock D Hoore» J Hand Surg 19:229-231. 1994 No relationship in 125 wrists Nakamura» Acta Orthop Scand 64: 207-211. 1993 Ulnar variance occurs equal in general population and Kienbock Lichtman Classification Stage I : Normal radiographs, MRI + Stage II : Sclerosis on radiographs Stage IIIA: Lunate collapse, normal carpal alignment Stage IIIB: Lunate collapse, Loss carpal height Stage IV: Radiocarpal arthritis Bain and Begg Arthroscopic Classification Grade 0 - Articular surface functional Grade 1 one nonfunctional surface Grade 2 A: proximal lunate articular surface Lunate facet of distal radius B: Proximal lunate surface Distal lunate surface Grade 3: 3 nonfunctional articular surface Grade IV: 4 nonfunctional surfaces 2
Kienbock s Disease Multiple treatment options based on radiograph staging Joint leveling procedures Vascular procedures Partial fusions Proximal row carpectomy Pyrocarbon replacement Total Wrist fusion Joint Leveling Radial shortening osteotomy Vascularized Bone Grafting Stage 1, II, IIIA Ulnar Negative Joint Leveling Trumble» J Hand Surg 11A: 88-93. 1986 90% reduction lunate strain First 2mm shortening Greater than 4mm no changes in load Hori» J Orthop Trauma 8:107-110. 1994 Decreased load Radial shortening 45% Scaphocapitate fusion 12% Capitate shortening with hamate fusion 66% Capitate-hamate fusion no change 3
Keinbock s Disease Keinbock s Disease Keinbock s Disease 4
Stage I, II, IIIA Ulnar Negative Vascularized Procedures Hori J Hand Surg 4:23-33.1979 8 of 9 pts improved Buchler» J Hand Surg BR 19: 466-478. 1994 33% retained correction at 2 years 50% fair/poor results Moran» J Hand Surg 31A: 705-710.2006 60% showed vascularization by MRI 98% pain relief Capitate Shortening Capitate Hamate Fusion Radial Osteotomy Stage I,II, III A Ulnar Positive Madelung s and Kienbock Radial Osteotomy 5
Radial Osteotomy Results Capitate Shortening Osteotomy Hanel et al» Atlas Hand Clin 4: 45-58 1999 Remarkable results 1 year ROM/Strength plateaued at 1 year Almquist» Hand Clin 9: 505-512.1993 80% grip strength 83% satisfaction rate Stage III B Salvage Options STT fusion Watson» J Hand Surg 10: 179-187.1985 46% excellent results 32% good results Proximal Row Carpectomy De Smet» J Hand Surg Br 30: 585-587. 2005 No pain 13 Moderate 3 Severe - 5 Scapho-capitate Fusion Pyrocarbon Lunate Replacement 6
Pyrocarbon Lunate Replacement Indication Stage 3B Advantages Does not burn any bridges Can always do PRC Can always do partial fusion Can always do total wrist fusion Pyrocarbon Lunate Replacement Indication: Stage 3B Disadvantages Technically challenging Control of lunate rotation Dislocation Radiographs 7
Technical Pearls Utilize the correct size 5 options Control rotation of the scaphoid ECRB transfer Reinforce dorsal capsule Pyrocarbon Lunate Replacement Surgical Technique Video Pyrocarbon Lunate Replacement Controversial Does not burn bridges Use for correct indication Stage 3B High patient satisfaction ROM similar to PRC or scaphocapitate fusion Not indicated in Stage 4 8
www.geisslermd.com Lunate Shape Zapico» Universidad de Valladoid 1966 Relationship of lunate shape and variance Type 1 lunate In ulnar negative patients Type 2 & 3 Rectangular and in neutral and positive patients Type 1 weakest configuration 9