First results of arthroplasty of the wrist by Swanson's implant. Twenty-five cases

Total wrist arthroplasty: A review

Total wrist arthroplasty was first performed over a hundred years ago. However, it did not prove a viable option until the late 1960s with the advent of the Swanson implant. Since then there have been many advances. The changes in design, and their rationale, are discussed in this article. The latest implants, the advances made and the indications for surgery are addressed.

Hand surgery in rheumatoid arthritis: state of the art and suggestions for research

OBJECTIVE

The role of surgery in the clinical management of patients with rheumatoid arthritis (RA)-associated hand dysfunction is still a subject of controversy. The efficacy of surgery in RA-associated hand dysfunction is assessed through an exhaustive review of published studies.

METHODS

A high-sensitivity search strategy was used to identify in MedLine and CENTRAL original studies related to hand and wrist surgery in RA patients. We selected articles including at least two adult RA patients which evaluated clinical outcomes through an observational or experimental design. Eligible studies were evaluated by standardized criteria. Two investigators independently used a pre-defined form to extract data about patient population, intervention, follow-up and clinical outcomes. Disagreements were discussed and resolved.

RESULTS

One hundred and ninety-six papers met inclusion criteria. Only five were randomized trials, while most studies followed an observational design, often of poor quality. As such, we could not pool data for statistical analysis; however, we were still able to provide a best evidence synthesis. A positive trend suggesting the efficacy of total carpal arthrodesis and metacarpophalangeal arthroplasty in reducing pain and improving function seemed to emerge from the published studies.

CONCLUSIONS

Despite recent advances in medical treatment, surgery still plays a role in the clinical management of RA-associated hand dysfunction. However, the majority of the available studies showed methodological flaws that prevented a clear definition of both surgical indications and criteria for choosing any specific procedure. Suggestions for further investigations are also provided.

Total wrist arthroplasty with Destot prostheses in patients with posttraumatic arthritis

PURPOSE

To analyze the functional and radiologic results after Destot arthroplasty, a wrist prosthesis designed for posttraumatic arthritis, and to define the indications for the use of the implant.

METHODS

Using the Meuli point score system, 28 Destot total-wrist arthroplasties in 25 patients with stage 2 or 3 scaphoid nonunion advanced collapse and scapholunate advanced collapse were evaluated for 12 to 96 months after surgery.

RESULTS

The overall ratings of the study group were excellent in 17 cases, good in 6, fair in 1, and poor in 4. Eighty-four percent showed improved range of motion and grip strength. Four patients experienced postoperative complications. No imbalance or dislocation was noted after surgery.

CONCLUSIONS

The Destot implant seems to be a good solution to restore functional range of motion after posttraumatic wrist arthritis when arthrodesis is required by nonmanual laborers older than 50 years of age.

[Development of surgical indications in the treatment of rheumatoid wrist. Report on experience based on 603 surgical cases, 1968-1994]

The author relates his experience in surgical treatment of the rheumatoid wrist based on a consecutive series of 603 cases operated from 1968 to 1994. His therapeutic indications have changed over the years after a retrospective study of the long-term results. He distinguishes conservative surgery, which combines dorsal synovectomy and relaxation stabilisation of the wrist (also called surgery of the dorsal wrist) from total arthrodesis and arthroplasty of the wrist. The results of conservative surgery after a follow-up of more than five years confirm that the disease continues in spite of synovectomy. Furthermore, relaxation stabilisation using soft tissue (extensor retinaculum and tendon transfer) is not sufficient to stabilise the wrist. Most of the time, this has to be completed by a partial radiocarpal arthrodesis. This is indicated when the carpus shows a medial translation or early in potentially progressive forms (Larsen Stage 1). In advanced forms conservative surgery consisting of partial radiocarpal arthrodesis is only indicated when the midcarpal joint appears functional after dynamic radiological examination. The author used the Swanson implant to perform 70 arthroplasties from 1973 to 1988. Long-term results show a large number of complications, which increased progressively with time. The Swanson implant was therefore abandoned in 1988. In 12 cases operated from 1979 to 1984 wrist arthroplasty was performed using Jackson's technique which consists of resection-interposition of a silastic sheath. This technique was also abandoned in 1984 due to the variable and unpredictable results obtained. At the present time, the author:-does not perform arthroplasties; increasingly completes surgery of the dorsal wrist by radiolunate arthrodesis;-has noted an increase in indications for total wrist arthrodesis. He emphasizes the importance of long-term evaluation of surgical results in rheumatoid arthritis.

Arthroplasty of the rheumatoid wrist with Swanson implant. Long-term results and complications

Seventy-five patients with Steinbrocker stage III et IV rheumatoid wrists underwent arthroplasty with Swanson implant. Sixty-two implants were reviewed at 5 years postoperatively. Functional criteria, namely pain, mobility and grip proved satisfactory in 66% of cases. Radiological examination revealed 23% radial implant fractures, 50% dislocated or fractured ulnar implants and 29% foreign body synovitis. This high rate of complication is disappointing given the encouraging initial results, and leads us to reconsider the appropriateness of such surgery in severe cases of rheumatoid wrist.

Combined radiocarpal arthrodesis and midcarpal (lunocapitate) arthroplasty for treatment of rheumatoid arthritis of the wrist

Arthroplasties for the wrist with rheumatoid arthritis are usually revised for the articulation between radius and carpus. The midcarpal joint is disregarded although it remains structurally better preserved and is therefore better suited for the preservation of stable motion. When the midcarpal surfaces are satisfactory, a radio-scapho-lunate fusion, accompanied by a midcarpal synovectomy, is an excellent procedure. When the midcarpal surfaces, particularly the head of the capitate, are also destroyed, the tendency has been to either perform a pan-arthrodesis, or to insert a wrist endo-prosthesis. For these severely unstable and destroyed wrists, a stabilization of the radiocarpal joint by arthrodesis, combined with preservation of motion at the midcarpal level by resection of the damaged head of the capitate and its replacement with a small implant has been done. This procedure has allowed all patients to retain a functional range of motion and to experience satisfactory relief of pain.

The surgical treatment of the rheumatoid wrist. Current perspectives

The authors stress the prevalence and severity of wrist involvement in rheumatoid disease. Improved knowledge of aetiopathogenesis and deformities had led to identification of the importance of the distal consequences on the digital joints of decentralization of the wrist. Synovectomy retains an important place at the onset of the disease. This may be completed by stabilization procedures (tendon transfer and partial arthrodesis). At the advanced stage of the disease, arthroplasty is currently overtaking arthrodesis. Interposition arthroplasty, with its rare indications, is now well developed. Although the solution of the future, arthroplasties lack sufficient follow up in terms of their results. The Swanson implant offers limited mobility but ensures freedom from pain and a good wrist axis. The ideal treatment of the rheumatoid wrist is oriented towards early conservative surgery and later, at an advanced stage, towards arthroplasty, the ideal technique of which remains to be discovered.