Indications
End stage rheumatoid wrist
SLAC wrist
SNAC wrist
Kienbock's disease
Failed total wrist arthroplasty
Madelung's disease
Cerebral palsy
Brachial plexus injury
Rheumatoid wrist
SLAC wrist
SNAC wrist
Kienbock's disease
Options
Spanning dorsal plate
Non spanning dorsal plate - 3rd CMC sparing
Arthroscopic assist
Intramedullary devices
Spanning dorsal plate
Concept
Distal radius to third metacarpal
- fusion radiocarpal & midcarpal +/- fusion of 3rd carpometacarpal joint
- low profile and precontoured plate
- 15 degree dorsal angulation and slight ulna deviation to maximize grip strength
Dorsal plate
Technique
Vumedi wrist arthrodesis with dorsal plate video
Synthes LCP wrist fusion plate PDF
Dorsal midline incision
- release extensor retinaculum over 3rd extensor tendon
- cauterize PIN
- elevate 2nd and 4th extensor compartment
- vertical capsulotomy / arthrotomy
- expose radiocarpal / midcarpal joint
- remove articular surface with burr +/- bone grafr
- apply plate to distal radius and 3rd metarpal
Outcomes
Hazelwinkel et al J Wrist Surg 2020
- 215 wrist fusions
- 33% postoperative complication
- 19% reoperation at mean 7 months
- 7% symptomatic implants
- 5% implant failure
- 5% infection and wound complications
- 5% nonunion
- increased risk with smoking
CMC arthrodesis v plate bridging only
Rioux-Forker et al J Wrist Surg 2023
- 182 spanning wrist arthrodesis
- CMC arthrodesis in 139, CMC bridged only in 43
- increased hardware complications with CMC bridging only (67% v 22%)
- increased nonunion with CMC bridging only (12% v 3%)
Non spanning dorsal plate
Concept
Sparing 3rd carpo-metacarpal joint
- may reduce tendon rupture / 3rd metacarpal periprosthetic fracture
- ? indicated if CMC osteoarthritis
- ? non spanning increases nonunion rates
Technique
Medartis CMC sparing wrist fusion plate
Vumedi CMC sparing wrist fusion with short plate
Results
- 15 non CMC spanning to 11 CMC spanning wrist arthrodesis
- no nonunion
- 3 cases of tendon rupture / metacarpal fracture in spanning arthrodesis
- 3 hardware removals in non spanning arthrodesis
Arthroscopic wrist arthrodesis
Concept
Remove cartilage surfaces arthroscopically via radiocarpal and midcarpal portals
Percutaneous screw fixation
Intramedullary wrist arthrodesis
Concept
Intramedullar rod in distal radius
Intramedullary rod in 3rd metacarpal
Connected in middle with varying angles
Technique
Implate wrist arthrodesis nail
Implate wrist arthrodesis nail surgical technique
Results
Heifner et al J Wrist Surg 2023
- 32 wrist arthrodesis with locking IM nail
- union 94%
- 22% distal screw loosening
- 9% revision surgery (2/3 implant removal)