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.
From January 2000 to March 2004 16 thumbs after total avulsion-amputation were replanted in our hospitals. In 15 cases this was successful. In one case the thumb was lost 28 hours after replantation. Mostly the amputation was in the region of the first phalanx or the IP-joint of the thumb. In all cases our operative procedure for this form of amputation was the reconstruction of the vessels with vein grafts after the osteosynthesis and the reconstruction of the tendons. The donorsite region for the grafts was in 12 cases the dorsal forefoot and in 4 cases the distal forearm. In none of these cases there was the possibility of reconstructing both arteries. Mostly only an anastomosis for one artery and one vein could be done. For none of these patients it was possible to reconstruct the nerves primarily. Until now transphers of neurovascular skinislands of longfingers, free nerve transplantations with coaptations to the proximal stump of the injured nerve, free nerve transplantations with coaptations to the trunk of the median nerve or in one case an end-to-side coaptation have been performed to achieve a resensibility of the thumbs. In one case a patient rejected an operative nervereconstruction, because a sprouting of the proximal stump of the injured nerve lead to a (reduced) sensibility of the thumb. In 4 cases a therapy to achieve a resensibility has so far not been carried out. After replantations of injured thumbs necroses of the skin in different kinds were noticed. In 4 cases secondary skinreconstructions were necessary. All 15 successful replanted thumbs achieved very good results concerning function, strength and patient’s satisfaction. Our results don’t agree with the mostly bad results after total avulsionamputations mentioned in literature. We think that the replantation after total avulsionamputation of the thumb has a high chance of being successful and can achieve very good longtime results.
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.
