Wrist fusion in patients with severe quadriplegic cerebral palsy

Pediatric Spastic Wrist Contractures Can Be Well Managed With Wrist Arthrodesis

BACKGROUND

Severe spastic wrist contractures secondary to cerebral palsy (CP) or alike can have significant implications for patient hand function, hygiene, skin breakdown, and cosmesis. When these contractures become rigid, soft tissue procedures alone are unable to obtain or maintain the desired correction. In these patients' wrist arthrodesis is an option-enabling the hand to be stabilized in a more functional position for hygiene, dressing, and general cosmesis, though are patients satisfied?

METHODS

All children who had undergone a wrist arthrodesis for the management of a severe wrist contracture at Shriners Hospital, Portland between January 2016 and January 2021 were identified (n=23). A chart review was undertaken to obtain data-demographic, operative, clinical, and radiographic. All patients were then contacted to participate in 2 patient-reported outcome questionnaires (74% response agreement), a numerical rating scale (NRS), based on the visual analog scale (VAS) and the disability analog scale (DAS). Results were assessed with the aid of descriptive statistics, means and percentages with the primary focus of determining overall patient satisfaction with the procedure.

RESULTS

Twenty-three patients were included in the review, and 74% took part in the prospective survey. Included were 10 patients with hemiplegia, 4 with triplegia, 7 with quadriplegia, 1 with a diagnosis of Rhett syndrome, and 1 with a history of traumatic brain injury. All patients achieved radiologic union by a mean of 8 weeks, and 87% obtained a neutral postoperative wrist alignment. The NRS showed 88% of patients were highly satisfied with their results; specifically, 82% had an improved appearance, 53% improved function, 71% improved daily cares, and 65% improved hygiene. The postoperative DAS score averaged 4.7 of 12 indicating mild disability. When looking at how a patient's diagnostic subtype affected outcome results, patients with triplegia reported less improvement and greater disability on the NRS and DAS, averaging 9.5 (severe disability on the DAS). The GMFCS classification had less correlation with outcomes.

CONCLUSION

Wrist arthrodesis is a good option for the management of pediatric spastic wrist contractures, with limited complications and an overall high patient/carer satisfaction rate.

LEVEL OF EVIDENCE

Level IV-case series.

Total Wrist Fusion with an Intramedullary Device: A Single-Institution Series with a Minimum of One Year Follow-Up

Objective  The primary purpose of this study was to evaluate the functional and surgical outcomes of total wrist fusion (TWF) following the use of a locked intramedullary nail (IMN). Methods  A single institution study was performed, which entailed in-person reexamination of 18 patients ( n  = 19 wrists), out of 35 eligible patients, who underwent TWF with an IMN from 2010 to 2017. For each patient, demographic, preoperative diagnosis, physical examination, wrist radiograph, and outcome questionnaire data were obtained. The questionnaires included the visual analog scale (VAS), quick disabilities of the arm, shoulder, and hand (QuickDASH), and Mayo Wrist Score assessments. In addition, complication and reoperation data for all TWFs with an IMN during the 2010 to 2017 period (35 patients, n _I  = 38 wrists) were noted. Results  In the 18 patients, age was 47.6 ± 13.9 years, 12 (63.2%) were female, and median follow-up was 150 weeks (range: 74-294). The VAS score was 0 ± 0 in 5 of 19 wrists with rheumatoid arthritis (RA) and 1.82 ± 2.78 in 14 of 19 wrists without RA. It was found that 21 of 38 wrists (55.3%) had an implant-related complication and 5 wrists (13%) underwent a reoperation due to the implant itself. Conclusions  To date, no sufficient data are present demonstrating a clear advantage of an IMN over dorsal plating for TWF at intermediate-term follow-up. Surgeons should be knowledgeable of the several potential complications of this IMN prior to its use for TWF. Level of Evidence  This is a Level IV, therapeutic study.

Shortening wrist arthrodesis using a Rush pin in adult spastic wrist: A series of 15 cases

In spastic patients, shortening wrist arthrodesis (SWA) is indicated in cases of severe fixed flexion contracture. At present, the most commonly used technique is dorsal plate osteosynthesis. Ideally, fixation with smaller hardware volume farther from the tendons would limit postoperative tendon irritation and reoperation rates for hardware removal. The objective of our study was to evaluate the efficacy of Rush pin SWA in adults. A retrospective study included all patients with a central neurological impairment, undergoing SWA using a Rush pin inserted through the head of the third metacarpal, and with at least 6 months' follow-up. Attainment of preoperative objectives was evaluated by Global Assessment of Response to Treatment (GART, ranging from -4 to +4) and, for functional objectives, the House score and the Frenchay Arm Test. Consolidation and any degenerative changes in the third metacarpophalangeal joint were assessed on X-ray. Fifteen patients were included, with a mean follow-up of 13 months (range, 6-29). In general, the preoperative objectives were attained: mean GART score was 2.7 (range, 1-4). Functional objectives were attained in 3 of the 11 patients followed up (27%). In all cases, the arthrodesis had healed at a mean 74 days (range, 39-102). Three had hardware removed after consolidation; 1 experienced discomfort at the head of the third metacarpal. Rush pin arthrodesis is an interesting alternative to plate arthrodesis in the management of severe wrist flexion contracture in spastic patients. It gives satisfactory results with regard to preoperative objectives and is not associated with complications. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Wrist Arthrodesis in Children With Cerebral Palsy

Wrist treatment in spastic cerebral palsy includes splints, botulinum toxin, tendon transfers, tendon lengthening, capsular liberations, and arthrodesis. A well-indicated wrist arthrodesis corrects deformity improving function and cosmetic appearance in patients with fixed deformities. It is indicated in patients with cerebral palsy, older than 12 years with a fixed deformity in wrist flexion. We report 11 clinical cases with the wrist arthrodesis with a plate of 3.5 with 2.7 mm by dorsal approach and technical resources to minimize the complications of tendon irritation and dorsal discomfort. We present an illustrative clinical case. It is a known procedure, its execution must be careful to avoid complications.

Total Wrist Arthrodesis: Indications and Clinical Outcomes

Total wrist arthrodesis remains an important technique in the surgical armamentarium of upper extremity surgeons. The procedure has evolved over time but continues to provide reliable pain relief at the expense of wrist motion. It is indicated for management of a wide variety of upper extremity conditions, including rheumatoid arthritis, posttraumatic osteoarthritis, cerebral palsy, and brachial plexus injuries, and as a salvage technique after failed implant arthroplasty. Recent studies demonstrate high levels of patient satisfaction and good functional outcomes after bilateral wrist fusion. Compared with total wrist arthroplasty, total wrist arthrodesis provides more reliable pain relief with lower rates of complications, but further studies are needed to compare functional outcomes and cost-effectiveness.

Wrist arthrodesis in adolescents with cerebral palsy

Twenty adolescents with severe spastic deformities of the wrist (Zancolli type 3) and poor function on the House score were operated on between 2009 and 2014, and included in this retrospective cohort study. All were treated by wrist arthrodesis combining a proximal row carpectomy, curetting of the distal radius in order to imbed the capitate and a dorsal locking plate. The primary endpoint was improvement in the House score. Secondary endpoints included pre- and postoperative wrist flexion deformity, bone union, patient satisfaction regarding appearance and complications. The mean follow-up was 22 months. The mean age at the time of surgery was 16.2 years. Additional soft-tissue release was necessary in eight wrists. The mean House score improved significantly from 0.9 to 2.7. Average flexion deformity improved significantly from 66° to 10°. Bony union was achieved in all patients within 6 months. Four of the 20 patients required hardware removal because of fixed extension of the middle metacarpal. Wrist arthrodesis combining proximal row carpectomy with the use of a dorsal locking plate is a safe and reliable technique to improve function and appearance.

LEVEL OF EVIDENCE

IV.