[Wrist arthrodesis with a fixed-angle, "low-profile" fusion plate without carpometacarpal joint fixation]

S Köhler, K Koch, A Arsalan-Werner, I M Mehling, J Seegmüller, H Krimmer, Michael Sauerbier
Operative Orthopädie und Traumatologie 2017 September 12

OBJECTIVE: Total wrist arthrodesis to improve functional use of the hand by reducing pain and increasing grip strength.

INDICATIONS: Painful destruction of the radio- and midcarpal joints.

CONTRAINDICATIONS: Analgesia and satisfactory hand function after motion-preserving surgical or conservative treatment. Chronic joint infection.

SURGICAL TECHNIQUE: Posterior approach to the wrist. Removal of articular surfaces destroyed all the way down to cancellous bone. Filling of defects with cancellous bone graft taken from distal radius or iliac crest. Osteosynthesis with fixed-angle wrist fusion plate without carpometacarpal (CMC) III joint fixation.

POSTOPERATIVE MANAGEMENT: Below-elbow cast for 2 weeks. Immediate active motion fingers exercises. X‑ray control 6 weeks postoperatively. Gradual increase of normal hand use in daily life after bony consolidation.

RESULTS: Total wrist arthrodesis was performed using a fixed-angle fusion plate without CMC III joint fixation in 28 patients (21 men, 7 women). A follow-up of 14/28 patients was performed at a mean of 21 (3-39) months postoperatively. Grip strength improved from 14 (0-38) kg preoperatively to 22 (12-40) kg postoperatively. The average postoperative DASH score was 40 (6-72) points. Pain measured with the VAS scale (0-10) improved from an average of 7 (3-10) points preoperatively to 2 (0-6) points postoperatively. Overall, 13/14 patients were satisfied with the treatment; 26/28 patients achieved primary bony consolidation. Postoperative complications found in 9 of 28 patients: 2 nonunion, pain in the CMC II (n = 3) or III (n = 1) joints, 2 screw breakage, 1 postoperative bleeding and 1 infection. Both cases of nonunion healed after plate removal, re-osteosynthesis with a straight wrist arthrodesis plate, bridging the CMC III joint, and a bone graft from the iliac crest. All patients with CMC II joint pain were pain-free after removal of the protruding screw. One patient had chronic pain in the CMC III joint despite plate removal. In the 2 cases with screw breakage, no issues caused. In one patient, after primary bony consolidation, removal of the plate was performed for extensor tenolysis and not as a result of the broken screw. In the second patient, removal of the plate after primary bony consolidation was unnecessary as the patient was pain-free in the area of the broken screw, yet a protruding screw in the CMC II joint cavity was removed.

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