The aim of this work is to present a clinical case of wrist arthroplasty failure due to chronic infection and try to discuss and draw a therapeutic approach (algorithm) for similar cases taking in consideration the degree of osteolysis, the presence of detachment and inherent instability and the condition of the soft tissues. The authors report a case of an individual, male, 58 years old, manual worker, that appears with pain and inflammatory signs on right wrist arthroplasty, with fistulous track. The revison procedure was performed in 2 stages: the first stage revision consisted on removal the implant, debridement and interposition of cement spacer with antibiotics and immobilization, the second stage revision a radio-metacarpal arthrodesis with plate and interposition of autologous graft harvested. The improvement of the implants in recent years have contributed to the increasing use of arthroplasty as a treatment option with good results. Although it presents itself with an attractive option in terms of future functional capabilities, arthroplasty remains with some risks and have a higher rate of complications in the medium and long term than fusion, so the selection of patients should be careful. The main problem of wrist arthroplasty revision is due to bone stock loose to promote fusion and the shortening after implant removal. At 1,5 years follow-up, we denote a higher patient satisfaction, without pain, radiological fusion and 28 points in DASH score. The success of wrist arthroplasty depends on careful patient selection, careful preoperative planning, rigorous technique and an appropriate program of functional rehabilitation. The wrist arthrodesis can always be seen as an ultimate salvation procedure in the treatment of failure of wrist arthroplasty, either a mechanical or infectious failure

Introduction. Total Wrist Arthroplasty (TWA) for Rheumatoid Arthritis (RA) of wrist allows pain relief and preservation of the movements. Aims. The aims of current study were to evaluate outcomes of Universal-2® TWA at a tertiary centre. Methods. This was a retrospective review of case notes of 92 Universal-2® wrist replacements performed from 2003 to 2009. There were 63 female and 14 male patients. Ten patients had bilateral wrist replacements. There were 5 patients lost to follow-up and 2 patients died at 2 and 4 years following TWA, due to un-related causes. The available literature related to Universal implant was also reviewed. Results. The indication was RA in 83 wrists, 3 had severe osteoarthritis and one had post-traumatic arthritis following scaphoid fracture. Mean age was 60 years (26 to 86 years) and mean follow-up of 51 months (13 to 94 months). Post-operatively pain relief was achieved in 91.2% and patient satisfaction was 86%. Movements were preserved with mean dorsiflexion of 23. o. and palmarflexion of 21. o. An interim study of 34 patients showed VAS pain score improved from 5.4 to 1.7 and DASH score improvement of 14 points. Radiologically, intercarpal fusion was noted in 85% of the cases. Minor complications included; joint stiffness (10%, n=14), wrist pain (9%, n=8) and superficial infection in 2 cases (2.3%). Major complications were revision of wrist arthroplasty in 4.7% (n=4) and 3.5% salvage arthrodesis (n=3). Conclusion. Pain relief and patient satisfaction following wrist arthroplasty was consistently high in our series. The incidence of major complications was 8.1% in this study, compared to the literature review which shows rates of 12% for Universal-2® TWA and up to 50% in earlier Universal® implant. Universal-2® Wrist Arthroplasty is recommended for pain relief and preservation of function. Further studies are required particularly focusing on Carpal component loosening and long term outcomes

The December 2015 Wrist & Hand Roundup360 looks at: Fuse or replace? The index PIPJ; A solution for the unstable DRUJ at last; Anatomical reconstruction in place of arthroplasty?; The Welsh ‘fight bite’; Does surgeon empathy improve results?; Regional or local for wrist analgesia; The evidence for wrist arthroplasty; FPL rupture a hidden problem?; Deciding on surgery in the distal radius; Composing that paper in hand surgery

The June 2014 Wrist & Hand Roundup360 looks at: aart throwing not quite as we thought; two-gear, four-bar linkage in the wrist?; assessing outcomes in distal radial fractures; gold standard Swanson’s?; multistrand repairs of unclear benefit in flexor tendon release; for goodness’ sake, leave the thumb alone in scaphoid fractures; horizons in carpal tunnel surgery; treading the Essex-Lopresti tightrope; wrist replacement in trauma? and radial shortening reliable in the long term for Kienbock’s disease

Aims

Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review.

Wrist motion is achieved primarily via rotation at the radiocarpal and midcarpal joints. The contribution of each carpal bone to total range of motion has been previously investigated, although there is no consensus regarding the influence of each structure to global wrist motion. The objective of this comprehensive in-vitro biomechanical study was to determine the kinematics of the capitate, scaphoid and lunate during unconstrained simulated wrist flexion-extension. In addition, this study examined the effect of motion direction (i.e. flexion or extension) on the kinematics and contribution of the carpal bones. Seven fresh frozen cadaveric upper limb specimens (age: 67±18 yrs) were amputated mid-humerus, and the wrist flexors/extensors were exposed and sutured at their musculotendinous junctions. Each specimen was mounted on a wrist motion simulator in neutral forearm rotation with the elbow at 90° flexion. Passive flexion and extension motion of the wrist was simulated by moving a K-wire, inserted into the third metacarpal, through the flexion/extension motion arc at a speed of ∼5 mm/sec under muscle tone loads of 10N. Carpal kinematics were captured using optical tracking of bone fixated markers. Kinematic data was analysed from ±35° flexion/extension. Scaphoid and lunate motion differed between wrist flexion and extension, but correlated linearly (R‸2=0.99,0.97) with capitate motion. In wrist extension, the scaphoid (p=0.03) and lunate (p=0.01) extended 83±19% & 37±18% respectively relative to the capitate. In wrist flexion, the scaphoid (p=1.0) and lunate (p=0.01) flexed 95±20% and 70±12% respectively relative to the capitate. The ratio of carpal rotation to global wrist rotation decreased as the wrist moved from flexion to extension. The lunate rotates on average 46±25% less than the capitate and 35±31% less than the scaphoid during global wrist motion (p=0.01). The scaphoid rotates on average 11±19% less than the capitate during wrist flexion and extension (p=0.07). There was no difference in the contribution of carpal bone motion to global wrist motion during flexion (p=0.26) or extension (p=0.78). The capitate, lunate and scaphoid move synergistically throughout planar motions of the wrist. Our study found that both the scaphoid and lunate contributed at a greater degree during wrist flexion compared to extension, suggesting that the radiocarpal joint plays a more critical role in wrist flexion. Our results agree with previous studies demonstrating that the scaphoid and lunate do not contribute equally to wrist motion and do not function as a single unit during planar wrist motion. The large magnitude of differential rotation observed between the scaphoid and lunate may be responsible for the high incidence of scapholunate ligament injuries relative to other intercarpal ligaments. An understanding of normal carpal kinematics may assist in developing more durable wrist arthroplasty designs

Wrist motion is achieved primarily via rotation at the radiocarpal and midcarpal joints. The contribution of each carpal bone to total range of motion has been previously investigated, although there is no consensus regarding the influence of each structure to global wrist motion. The objective of this comprehensive in-vitro biomechanical study was to determine the kinematics of the capitate, scaphoid and lunate during unconstrained simulated wrist flexion-extension. In addition, this study examined the effect of motion direction (i.e. flexion or extension) on the kinematics and contribution of the carpal bones. Seven fresh frozen cadaveric upper limb specimens (age: 67±18 yrs) were amputated mid-humerus, and the wrist flexors/extensors were exposed and sutured at their musculotendinous junctions. Each specimen was mounted on a wrist motion simulator in neutral forearm rotation with the elbow at 90° flexion. Passive flexion and extension motion of the wrist was simulated by moving a K-wire, inserted into the third metacarpal, through the flexion/extension motion arc at a speed of ∼5 mm/sec under muscle tone loads of 10N. Carpal kinematics were captured using optical tracking of bone fixated markers. Kinematic data was analysed from ±35° flexion/extension. Scaphoid and lunate motion differed between wrist flexion and extension, but correlated linearly (R^2=0.99,0.97) with capitate motion. In wrist extension, the scaphoid (p=0.03) and lunate (p=0.01) extended 83±19% & 37±18% respectively relative to the capitate. In wrist flexion, the scaphoid (p=1.0) and lunate (p=0.01) flexed 95±20% and 70±12% respectively relative to the capitate. The ratio of carpal rotation to global wrist rotation decreased as the wrist moved from flexion to extension. The lunate rotates on average 46±25% less than the capitate and 35±31% less than the scaphoid during global wrist motion (p=0.01). The scaphoid rotates on average 11±19% less than the capitate during wrist flexion and extension (p=0.07). There was no difference in the contribution of carpal bone motion to global wrist motion during flexion (p=0.26) or extension (p=0.78). The capitate, lunate and scaphoid move synergistically throughout planar motions of the wrist. Our study found that both the scaphoid and lunate contributed at a greater degree during wrist flexion compared to extension, suggesting that the radiocarpal joint plays a more critical role in wrist flexion. Our results agree with previous studies demonstrating that the scaphoid and lunate do not contribute equally to wrist motion and do not function as a single unit during planar wrist motion. The large magnitude of differential rotation observed between the scaphoid and lunate may be responsible for the high incidence of scapholunate ligament injuries relative to other intercarpal ligaments. An understanding of normal carpal kinematics may assist in developing more durable wrist arthroplasty designs

Introduction: Darrach’s procedure is indicated for conditions were the distal radio-ulnar joint movement is painful or restricted. The procedure may be indicated at the time of wrist arthrodesis. Darrach’s procedure is not without complications and revision surgery may be indicated. Aims: To determine the success rate following wrist arthrodesis and whether Darrach’s procedure correlates to revision surgery. Methods: A retrospective case note review was performed of a consecutive series of patients who underwent wrist arthrodesis between 1991 and 2002 at our institution; performed by a single surgeon. Results: 73 patients underwent wrist arthrodesis. 39 were female and 34 male. The indications for wrist arthrodesis were rheumatoid disease, osteoarthritis, carpal instability and failed wrist arthroplasty. Successful arthrodesis was achieved in 82% (60/73) of patients, where revision arthrodesis was defined as the end point. 25% (18/73) patients underwent Darrach’s procedure at the time of their primary arthrodesis. 25% (15/60) of the patients whose primary arthrodesis was successful underwent concomitant Darrach’s procedure. 23% (3/13) of patients who underwent revision arthrodesis had undergone concomitant Darrach’s procedure during their primary arthrodesis. 77% (10/13) patients who underwent revision arthrodesis did not undergo Darrach’s procedure at the time of their primary arthrodesis. Of these 10 patients, 3 (30%) of them underwent concomitant Darrach’s procedure during revision arthrodesis. Conclusion: Wrist arthrodesis in our institution is comparable with that of published literature. The incidence of Darrach’s procedure at the time of primary wrist arthrodesis is 25%. There is a small increase to 30% in the number of patients who require Darrach’s procedure at the time of revision arthrodesis, which is not statistically significant

Complications of distal radius fractures range from 20 to 30% and are consequence of injury or of treatment. Management of these complications must be individualised and the multitude of proposal treatments prove that this problem is controversial. Complications may involve soft tissue (tendon, nerve, arterial or fascial complication, reflex symphatetic distrophy) or bone and joint (malunion, nonunion, osteoarthritis). Tendon complications following distal radius fractures, range from minor adhesions to complete rupture. Peritendinous adhesions will become apparent after cast removal. Diagnosis is based on the limitation of the range of movement for individual fingers.This complication can be avoided with a proper cast technique allowing full range of motion to the digits. Treatment consists of rehabilitation techniques and only rarely, in severe cases, operative tenolysis may be a treatment of choice. Tendons may be entrapped either in the fracture site or in the distal radioulnar joint. Most common tendon entrapment are for extensor carpi ulnaris and extensor digiti minimi. If early recognition is made, open reduction with freeing the tendon must be the choice. Late diagnosis will require more complex tenolysis procedures. Tendon rupture may occur at the time of injury due to sharp fracture fragments. Diagnosis is based on identification of functional loss and, whenever possible, primary tendon suture is recommended. If the diagnosis is late the treatment is free tendon graft or tendon transfer. The late rupture of extensor pollicis longus is the most common possibility. Since it is not related with comminution or displacement of fracture it is possible that an ischemic mechanism is involved. Solutions are free tendon graft or the transfer of extensor indicis proprius. Direct tendon repair is not recommended after few weeks. Nerve complications. Careful neurological investigations demonstrated that nerve injuries associated with distal radius fractures are more common than it is believed. Median nerve is most frequently involved. Primary mechanisms of injury are: direct lesions due to fracture fragments, lesions related to forced manipulation and nonanatomical position of immobilization. Late injuries, occurring a long time after the fracture are more frequent and are related to carpal tunnel syndrome or paraneural adhesions. Carpal tunnel pressure could be measured and ethiologic factors must be identificated in order to establish the proper treatment, usually based on relise of carpal tunnel. Ulnar and radial neuropathy are less common and treatment may vary from cast removal to relise of Guyon’s canal. Vascular complications are uncommon, arise usually in relation with high energy trauma and the treatment is complex, involving different speciality surgeons. Some authors presented rare cases of entrapment of vasculare structures or radial artery pseudoaneurism after the use a volar plate. Compartment syndrome after distal radius fracture is rare and is likely to occur in young adults suffering a high energy trauma. Clinical diagnosis is based on the classical 5 “P’s” (pain, pallor, paresthesias, paralysis, and pulselessness) but treatment must start before all symptoms are present. Anytime when compartment syndrome is suspected, intracompartimental pressure must be measured. The treatment must start immediately and consist in removal of constrictive devices (bandage, cast) and fasciotomy. Indications for fasciotomy are intracompartmental pressure of 15–25mmHg in presence of clinical signs or over 25mmHg in absence of clinical signs. If there is doubt, it is better to perform an unnecessary fasciotomy than to wait until lesions becomes irreversible. Reflex sympathetic distrophy is described with many terms such as algodistrophy, cauzalgia, Sûdeck’s atrophy, shoulder-hand syndrome. Recently, the term complex regional pain syndrome was proposed to replace all the exiting synonyms. Despite many theories, the pathogeny of this disease is uncertain. The diagnosis is mainly clinical, based on presence of pain, trophic changes (atrophy, stiffness, edema) and functional impairment but plain x-ray demonstrating osteopenia and bone scintigraphy showing abnormal bone turnover may be helpful. Since the patogeny is unclear, the treatment is targeting the symptoms rather then the disease. Treatment must be individualized and may consist of: physical therapy of the hand, pain control with general or local drugs, corticosteroids, and symphatectomy. Prevention of reflex symphatetic dystrophy in the first days of a distal radial fracture is very important and include: prevention of the edema (elevation of the hand, early mobilization of fingers), decrease of pain, cast removal to relive pression, non-traumatic surgery. Malunion is the most common complication of distal radius fracture and it usually occurs after close treatment. The malalignament may be extraarticular or it may involve the joint (radiocarpal or distal radioulnar joint). Axial shortening and dorsal or radial malalignament are the most common. Clinical signs are wrist pain, loss of grip strength, limitation of wrist mobility. Osteoarthritis is likely to develop in both types of malunions. For extraarticular nonunions osteotomy is usually the treatment of choice. Many types of osteotomies have been proposed but the most commonly used are opening wedge osteotomy and Watson osteotomy. Intraarticular malunion is more difficult to treat and many surgical solutions have been proposed: intraarticular osteotomy, bone resections (styloid, anterior or posterior rim, radiolunate or radioscapholunate limited arthrodesis, proximal row carpectomy, wrist denervation, wrist arthroplasty, total wrist arthrodesis). Salvage procedures on the distal radioulnar joint may be resection of distal cubitus (Darrach) or Sauve-Kapandji technique. Nonunion is an extremely rare complication and is likely to occur in patients with multiple comorbid conditions such as diabetes, peripheral vascular disease or alcoholism. In most cases the initial treatment was close reduction and cast immobilization or external fixation. Diagnosis is based on the absence of radiographic signs of union at 6 months. Treatment must be individualized but basic options are reconstructive procedures or wrist arthrodesis. Reconstructive procedures consist of debridement of nonunion site, realignment with distractor, plate and screw fixation and iliac crest bone grafting. Since the bone is of poor-quality, new implants providing fixation in orthogonal planes may be useful. Usually, malalignement is present, so some authors recommend to take in to consideration the possibility to associate reconstructive procedures with additional techniques such as: dividing brachioradialis tendon, incision of the dorsal or volar joint capsule or Darrach operation in presence of severe shortening of the radius. Wrist arthrodesis should be chosen when the distal fragment has less then 5 millimeters of subchondral bone supporting the articular surface

There is an incidence of failures of total wrist arthroplasties. We review our experiences in revising total wrist implant arthroplasties to arthrodeses. The most common mode of failure of the arthroplasties in our series was metacarpal loosening with dorsal perforation of the stem. We used for the revision arthrodesis in all our cases tricortical iliac crest bone grafts and additional spongiosa transplants from this donor site region. In one case we used a vascularized iliac crest bone graft to bridge the bone defect because of a bad host quality of the recipient area. Fixation was achieved with plates and screws. Our average follow-up period was 28 month. 14 patients with 15 failed wrist implants were treated with this technique. 14 patients undergoing arthrodesis attained a solid painless fusion after a single operation. In one case a non-union with a loosening of the screws due to using a non-rigid plate was seen. In this case a revision was necessary to achieve a bone healing. All patients were pain free and achieved an increased grip strength after bony fusion. Arthrodesis after failed total wrist arthroplasty is a satisfactory salvage procedure even in cases with a bad quality of the recipient area. We recommend a rigid fixation technique to prevent non-unions

There is an high incidence of failures of total wrist arthroplasties. We review our experiences in revising total wrist implant arthroplasties to arthrodeses. The most common mode of failure of the arthroplasties in our series was metacarpal loosening with dorsal perforation of the stem. Loosening of the proximal stem, progressive mal-position of the wrist and other causes appeared. We used for the revision arthrodesis in all our cases tricortical iliac crest bone grafts and additional spongiosa transplants from this donor site region. In one case we used a vascularized iliac crest bone graft to bridge the bone defect because of a bad host quality of the recipient area. Fixation was achieved with plates and screws. Our average follow-up period was 32 month. 40 patients with 41 failed wrist implants (3 different types) were treated with this technique. 40 wrist undergoing arthrodesis attained a solid painless fusion after a single operation. In one case a non-union with a loosening of the screws due to using a non-rigid plate was seen. In this case a revision was necessary to achieve a bone healing. All patients were satisfied, pain free and achieved an increased pinch and grip strength after bony fusion (measured with Yamar-Vigorimeter). A persisting loss of carpal height was seen in all cases. Arthrodesis after failed total wrist arthroplasty is a satisfactory salvage procedure even in cases with a bad quality of the recipient area. We recommend a rigid fixation technique to prevent non-unions

The February 2013 Wrist & Hand Roundup³⁶⁰ looks at: to splint or not to splint; salvage of the unsalvageable; a close shave for malunions; a classic approach to malunion; diabetic carpal tunnel; capsulodesis; a wrist from a fibula; thumb-based osteoarthritis - a further opinion from the Editor-in-Chief.