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Wrist Arthrodesis

- Indications:
    - painful or unstable wrist joint w/ advanced destruction due to OA, RA, post traumatic arthritis, SLAC wrist, spastic flexion
              contracture, degenerative scaphoid non-union, unsuccessful wrist arthroplasty, and Keinbock's dz;
    - this procedure is more beneficial for young, active pts or middle aged pts, but not for elderly pts;

- PreOp Considerations:
    - in the rheumatoid wrist note that application of a dorsal plate increases the chances of dorsal wound dehiscence;
    - ulnocarpal impaction
          - if preoperative radiographs demonstrate abutment between between the distal ulna and the triquetrum in addition to loss of
                     supination, then consider the need for radial lengtening w/ bone graft;
    - bone grafting:
          - cancellous bone grafting (iliac or local) is sufficient when there is no significant loss of carpal bone stock nor cyst formation;
          - cortico-cancellous bone grafting may be indicated w/ severe bone resorption or significant cyst formation
                      (however, complication rate is higher);
    - ROM of other joints:
          - remember that the elbow and shoulder joints will have to compensate for loss of wrist motion;

- Dorsal Approach to the Wrist:
    - w/ severe deformity, consider wider exposure to the first dorsal compartment inorder to allow excision of the radial styloid;
    - individual carpal bones and distal radius are exposed w/ wrist hyperflexion;
    - articular cartilage is removed w/ rongeur;
    - proximal row carpectomy:
           - consider performing a proximal row carpectomy procedure so that the proximal capitate and hamate are fused into the distal
                      radial surface;
           - the proximal row carpectomy is especially indicated for patients with ulnar positive varience, because it eliminates
                      common occurence of ulnotriquetral impingement following arthrodesis;
           - after proximal carpal row is excised, the carpi can be used as bone graft;
           - the standard fusion technique then procedes on, using the standard fusion plate;
           - references:
                  - Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis.   
                  - Wrist arthrodesis in post traumatic arthritis: a comparison of two methods.   
    - fusion:
           - most surgeons prefer not to fuse the index CMC joint;
           - whether to fuse the long CMC joint remains controversial (sparing the joint allows it to participate in power grip);
           - ref: AO-wrist arthrodesis: with and without arthrodesis of the third carpometacarpal joint. 
    - intrinsic compartment release:
           - it has been observed that intrinsic tightness in the of the index and long digits is a frequent complication of wrist fusion,
                     and may be related to occult compartment syndrome;
           - to manage this potential problem, consider releasing the dorsal fascial compartments;
    - ulnar head:
           - in RA consider resection of the ulnar head, and then using it for bone graft;

- Position of Arthrodesis:
    - w/ non RA wrist, 10 deg of dorsiflexion is ideal because its allows position for power gripping;
           - maximum grip is generated in 35 deg of dorsiflexion but this interferes with ADL's;
    - in pts w/ RA (see RA wrist), neutral or flexed position is more desirable;
           - position of 5-10 deg of ulnar deviation is perferred in order to counter balance zig zag collapse and ulnar drift;
    - note that despite the usual recommendations, some patients will prefer slightly more flexion or extension in the wrist;
           - if possible, consider casting the wrist before surgery in extension and the neurtral position to determine which position is
                        more comfortable for the patient;
    - reference:
           - The relationship between wrist position, grasp size, and grip strength

- Methods of Fixation:
    - pin Fixation:
           - in the report by Rehak DC, et al (2000), the authors compared use of pin fixation vs 3.5 mm reconstruction plate;
                  - wrists showed a tendency for migration into volar flexion (3-6 deg) from the initial intra-operative position;
    - 3.5 mm reconstruction plate:
           - in the report by Rehak DC, et al (2000), the authors compared use of pin fixation vs 3.5 mm reconstruction plate;
                  - technique involved placement of the extensor retinaculum beneath the extensor tendons;
                  - 3-4 screws are placed in the distal radius and two screws are placed in metacarpal, and if possible one screw in capitate;
                  - wrists had an average 5 deg of extension and 5 deg of ulnar deviation; 
           - A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist.
    - synthes plate:
           - 8 hole titanium, w/ 2.7 mm screws inserted into the distal 4 holes, and 3.5 mm holes in the proximal 4 holes;
           - in order to have the wrist in 10 deg of dorsiflexion, a contoured plate is necessary;
           - often the dorsal articular lip will have to be sculpted and Lister's tubercle will have to be removed in order to achieve a flat
                      bed for the plate;
           - most often the plate is applied to the long metacarpal so that 3 cortical screws can be inserted into the metacarpal and 4
                   screws in the radius (often a screw will also be inserted into the capitate)
                   - in some cases, the plate will be attached to the index metacarpal, if this optimizes the wrist position (for ulnar deviation)
                               or if it optimizes plate fit;
                   - in some cases, the plate must be placed obliquely across the dorsal radial surface inorder to get the optimal amount of
                               ulnar deviation;

- Wound Closure:
    - consider detaching the ECRB insertion and then moblizing it over the plate and incorporating it into the capsular closure (this may
               help prevent wound dehicience;

- Post Op:
    - Volar splint for 2 weeks;
    - unionn is usually achieved by 3 months;
    - plate is not removed unless it causes symptoms;

- Case Example:

- Complications:
    - extensor tenosynovitis most common complication and is related to prominent plate and screws;
    - intrinsic contracture;
    - carpal tunnel syndrome;
    - non union of the CMC joint;
    - RU joint instability:
    - ulno-carpal abutment:
           - reference:
                 - Ulnocarpal abutment after wrist arthrodesis.

High re-operation and complication rates 11 years after arthrodesis of the wrist for non-inflammatory arthritis

Wrist arthrodesis in paralyzed arms of children.

Wrist arthrodesis in rheumatoid arthritis. A comparison of two methods of fusion.

An in vitro analysis of wrist motion: the effect of limited intercarpal arthrodesis and the contributions of the radiocarpal and midcarpal joints.

Arthrodesis of the Wrist for Post Traumatic Disorders
Complications following AO/ASIF wrist arthrodesis

Long-Term Follow-Up Study of Radiocarpal Arthrodesis for the Rheumatoid Wrist.