Despite continued advances in implant design, the potential for complications and need for further surgery are significant following partial wrist arthroplasty (PWA) and total wrist arthroplasty (TWA), according to study data presented at the 2015 American Society for Surgery of the Hand (ASSH) annual meeting.

“Historically, the predominant indication for TWA has been wrist pain secondary to end-stage rheumatoid arthritis (RA),” Patrick M. Kane, MD, said. “However, improved implant design, along with increased public awareness and the desire for more function-preserving options, has led to greater interest in TWA and PWA for a wider audience. Yet, little mid- to long-term data exists on clinical outcomes, complications, or revision rates for currently available implants.”

Study design
Dr. Kane and his co-researchers retrospectively reviewed data on 100 patients (105 wrists) who had undergone distal radius hemiarthroplasty (DRH, n = 52), carpal hemiarthroplasty (CH, n = 6), or both (TWA, n = 47) at their institution between 2005 and 2014. DRH procedures were performed using either polyethylene (n = 13) or all-metal (n= 39) radial components up until 2010, after which a transition was made to strictly all-metal components.

Indications for surgery were primarily degenerative or post-traumatic arthritis in DRH and CH patients, and RA or other inflammatory arthropathies in TWA patients (Fig. 1). Additional patient demographics recorded included age, sex, BMI, handedness, and previous injury. The average patient follow-up was
2.6 years; the longest follow-up was 12.4 years. The study’s primary outcomes were postoperative complications and the need for revision surgery.

Findings, conclusions
The researchers reported similar postoperative complication rates in the three surgical groups, with an overall complication rate of 50.5 percent. Contractures and component failure accounted for the largest number of complications requiring further surgery (20 percent and 15 percent, respectively). The overall revision rate was 39 percent. The mean number of revisions performed per patient was 2.12; the average time from index surgery to the first revision was 20.76 months.

“Although the type of surgery did not have a significant effect on complication rates, it did play a role in the type or severity of complications,” Dr. Kane said. “The incidences of soft-tissue-type complications such as contracture were much higher (P < 0.001) in DRH patients (42.3 percent), compared to TWA patients (16.7 percent), while TWA patients had the highest incidence of component failure (24 percent) (P = 0.046) across all groups,” he explained.

“Similarly, although the transition to all-metal components for DRH did result in less implant failure, the overall complication rate was not significantly changed,” he said.

The underlying indications for surgery were also not significant in predicting risk for, or type of, complication.

Differences among the surgical groups with respect to superficial and deep infections were not significant, Dr. Kane noted. Superficial infections occurred in 7.1 percent of TWA patients and 7.6 percent of DRH patients; most resolved with oral antibiotics. Deep infections occurred in 4.7 percent of TWA patients and 3.8 percent of DRH patients; these were associated with a high number of medical comorbidities and multiple prior surgeries. All deep infections required removal of hardware, placement of an antibiotic spacer, and a prolonged course of intravenous antibiotics prior to a definitive surgery.

The authors admit that the study did have limitations, namely its retrospective design and absence of patient outcomes or satisfaction scores. Nonetheless, “As PWA and TWA continue to evolve as treatment options, they should be carefully examined with respect to both goals and patient/physician expectations,” Dr. Kane cautioned. “Patients should be extensively counseled on the potential for complications and an arduous treatment course if complications develop.”

Dr. Kane’s coauthors of “Wrist Arthroplasty: A Complicated Matter” are Michael Gaspar, MD; Jesse Lou, BA; Randall Culp, MD; and Sidney Jacoby, MD. The authors’ disclosure information can be accessed at http://www.aaos.org/disclosure

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

• Although PWA and TWA may provide significant pain relief for arthritic wrists, these procedures have a high incidence of postoperative complications, many of which require revision surgery.
• Patients should be counseled on the potential risks and complicated postoperative course of treatment.
• Certain patients, particularly those with multiple comordibities or poor skin quality, should be screened cautiously prior to PWA or TWA.

References:

1. Boeckstyns ME, Herzberg G, Merser S. Favorable results after total wrist arthroplasty: 65 wrists in 60 patients followed for 5–9 years. Acta Orthop. 2013 Aug;84(4):415-9.
2. Ward CM, Kuhl T, Adams BD. Five to ten-year outcomes of the Universal total wrist arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Am. 2011;93(10): 914-919.
3. Boyer JS, Adams B. Distal radius hemiarthroplasty combined with proximal row carpectomy: case report. Iowa Orthop J. 2010;30:168-173.
4. Culp RW, Bachoura A, Gelman SE, Jacoby SM. Proximal row carpectomy combined with wrist hemiarthroplasty. J Wrist Surg. 2012;1(1): 39-46. 17.
5. Nydick JA, Greenberg SM, Stone JD, Williams B, Polikandriotis JA, Hess AV. Clinical outcomes of total wrist arthroplasty. J Hand Surg Am. 2012;37(8): 1580-1584.