Long-term outcomes of the Universal 2 total wrist replacement: revision and loosening at 10 years and beyond

Customized Metal 3D Printed Total Wrist Prosthesis in the Treatment of Severely Destroyed Wrist: Design Rationale and Clinical Applications

OBJECTIVE

Severe destruction of the wrist joint after trauma, disease, or iatrogenic causes can lead to significant bone defects and deformities, limiting the options for surgeries. Bespoke 3D-printed metal prostheses were designed and used for four patients. This study aimed to describe the design rationale and report the clinical outcomes.

METHODS

Between 2022 and August 2024, we followed up on four patients with significant bone defects and deformities caused by various factors, who opted against arthrodesis. These patients were treated with customized 3D-printed prostheses replacements. All cases underwent assessment through clinical and radiological examinations, evaluating parameters including passive range of motion (ROM) of the wrist, grip strength, VAS of pain, and functional scales such as the Mayo score, Patient-Rated Wrist Evaluation (PRWE), and Quick Disabilities of the Arm, Shoulder, and Hand (quick DASH) score. A paired t-test was conducted to compare pre- and postoperative outcomes.

RESULT

The mean follow-up period lasted 11.9 ± 6.7 months (range 6-18 months). All patients reported satisfying pain relief and enhanced function. The average ROM was 23.3° ± 5.7° of extension and 27.0° ± 18.6° of flexion. The average VAS score of pain was 1.5. The mean Mayo score, PRWE, and Quick DASH were 60.0, 31.5, and 28.3, respectively. No complications such as loosening, dislocation, or infection were observed during the follow-up period.

CONCLUSIONS

Customized 3D-printed prosthetic replacements for severely destroyed wrists can provide good functional outcomes with a higher satisfaction rate.

LEVEL OF EVIDENCE

IV.

Total Wrist Arthroplasty With a New Design: 20 Cases With 8-Year Follow-Up

PURPOSE

Total wrist arthroplasty (TWA) is an established motion-preserving alternative to arthrodesis in the treatment of wrist arthritis, but post-TWA complications requiring additional surgery remain an issue. A new TWA design has been proposed. The purpose of this study was to report the outcome of a cohort study of 20 patients who underwent surgery using the new TWA design.

METHODS

Patients were assessed before surgery and at 1, 2, and 8 years after surgery for visual analog scale (VAS) pain scores, wrist range of motion, hand grip strength, and patient-reported outcome measures (PROMs). Radiographic examination was conducted for evidence of prosthetic loosening. Reasons for revision were analyzed.

RESULTS

In total, 24 reoperations were performed, including 12 revisions in 6 patients. Patient-reported outcome measures improved significantly at the 2-year follow-up compared with preoperative values. Hand grip strength, wrist extension, and VAS pain scores improved significantly at the 2-year follow-up. No radiographic loosening of the components was observed, but backing out of the carpal screws was noted in 16 of the 20 cases.

CONCLUSIONS

The new TWA resulted in improved VAS pain scores, PROMs, wrist extension, and hand grip strength. The high frequency of reoperation is a concern, and modification of the implant is needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-term outcomes of the Universal 2 total wrist arthroplasty

Aims

The Universal 2 total wrist arthroplasty (TWA) aims to alleviate wrist pain and restore function. This study investigates the survival time, revision rate, complication rate, and performs radiological analysis on Universal 2 TWAs in the long term.

Methods

Forty-seven Universal 2 TWA in 45 patients were performed between 2006 and 2014. Patient satisfaction, DASH score, complications, revision rate and radiological analysis of the TWA were recorded.

Results

Mean follow-up was 11.7 years (range 2.5-17.6 years). There was significant improvement in post-operative DASH score (mean 58.3, SD 13) compared to preoperative DASH scores (mean 33, SD 20, p < 0.001). At latest follow-up, 65 % of patients would undergo the procedure, a reduction from 87 % at mid-term follow-up. On radiological analysis, 26 wrists had lucencies of at least one component. Complications occurred in 18 wrists (38 %). Eleven TWA (23 %) were revised at a mean 7.3 years post-operation (range 2.0-13.7 years). Mean survival of the implant was 13.6 years (12.2-15.0 years 95 % CI). Kaplan-Meier analysis identified no significant differences in survivorship between inflammatory arthritis (13.2 years, 11.5-14.9 years 95 % CI) and osteoarthritis (12.9 years, 11.0-14.8 years 95 % CI, p = 0.39).

Conclusion

At long-term follow-up, the Universal 2 TWA can produce significant improvements in DASH scores and good satisfaction rates. However, a significant number of implants showed radiological loosening, with a high associated complication and revision rate. Patients should be adequately counselled on these risks pre-operatively.

Outcome Assessments for the Rheumatoid Hand

Rheumatoid arthritis profoundly affects hand function and quality of life. Standardized outcome measures are lacking, hindering comparison between studies. Clinical assessment traditionally relies on performance-based tests like range of motion, grip, and the Jebsen-Taylor Hand Function Test, crucial for evaluating treatment effects, especially surgery. Patient-reported outcome measures have gained significance in assessing post-surgery results, with tools like Cochin Hand Disability Scale and Michigan Hand Outcomes Questionnaire proving effective. However, generic instruments and disease-specific ones also play roles in follow-up. Combining objective measures with patient-reported outcomes is essential for comprehensive evaluation and postoperative care in rheumatoid hand patients.

Long-term results and explant analysis of the ReMotion total wrist arthroplasty

The ReMotion wrist replacement has good short- to medium-term survival with an acceptable complication profile as we previously reported in a cohort of patients with rheumatoid arthritis. We now report the long-term results of the same cohort and details of explant analysis of revisions undertaken for aseptic loosening. A total of 16 wrists were reviewed. Seven prostheses remain in situ with no obvious signs of wear or radiological loosening at a mean follow-up of 15.5 years. Three wrists had been revised: one for infection and two for aseptic loosening. Five patients (six wrists) died 2-9 years after operation from unrelated causes. Explant analysis demonstrated relatively minor wear compared with the published results of the Universal-2 prosthesis. We hypothesize that this may be explained by differences in polyethylene sterilization and prosthetic design. The ReMotion wrist replacement has favourable long-term results in patients with rheumatoid arthritis with a 16-year survival rate of 78%-86%.Level of evidence: IV.

Complications after total wrist arthroplasty

We reviewed the incidence and management of complications after total wrist arthroplasty, as reported in the literature, with so-called fourth-generation implants and other recent designs. While early intraoperative and postoperative complications, including fractures, tendon lacerations, infection, nerve compression, tendonitis, stiffness and chronic regional pain syndrome, had an acceptable incidence, late complications, such as periprosthetic osteolysis and implant loosening, occurred more frequently. Implant survival at 10 years was in the range of 70%-80% in most publications. Several of the implants have been modified or withdrawn. Instability and dislocation were frequent after a pyrocarbon spacer. Failed arthroplasties can be salvaged by revision arthroplasty or total wrist arthrodesis. Revision arthroplasty has a lower survival rate than primary arthroplasty and does not clearly offer important significant advantages over total wrist arthrodesis in terms of patient-reported outcome measures. Further development of prosthetic design, new materials and more knowledge on patient-related risk factors are needed.

Total wrist arthroplasty: commentary and opinions

Total wrist arthroplasty (TWA) is gaining interest as a management option for wrist arthritis. This review article summarizes the current evidence base for TWA, focusing on the performance and survivorship of fourth-generation implants. These appear to offer satisfactory patient-reported outcomes and survivorship over the medium term, but heterogeneity between implants and patient populations complicates data interpretation. We discuss issues facing TWA practice, including surgical competency, volume, implant development and stewardship. We acknowledge the need for further research on this topic and highlight a number of questions that need answering.