Overview of Wrist Arthrodesis

Wrist arthrodesis, also known as wrist fusion, is a medical procedure that stops movement in the wrist joint by joining, or fusing, the radius bone in the arm to the small bones in the wrist, called the carpal bones. The main reason to perform this procedure is to relieve pain. It’s used in situations where the wrist has become very damaged, either through diseases like advanced arthritis, fractures, or severe injuries to the ligaments. This option is typically chosen when other treatment methods haven’t been able to reduce the patient’s discomfort.

There are different ways to perform a wrist arthrodesis. It can involve fusing all of the wrist joint or just parts of it. Types of partial wrist fusion include: scapholunate fusion, four-corner fusion with scaphoid removal, scapho-trapezoid fusion, scaphocapitate fusion, and radio-lunate fusion. Regardless of whether the fusion is total or partial, the aim is to reduce pain and maintain as much wrist function as possible. In this text, we’re specifically talking about total wrist fusion where the entire wrist joint is immobilized.

Anatomy and Physiology of Wrist Arthrodesis

The wrist joint has three parts: the distal radioulnar joint, the radiocarpal joint, and the intercarpal joint.

The distal radioulnar joint links the end of the ulna, one of the bones in your forearm, with a little notch on the radius, the other bone in your forearm. It helps your forearm twist and turn, a movement we know as pronation (when your palm faces down) and supination (when your palm faces up). Lister’s tubercle, a small bump on the radius, can be felt on the upper side of your wrist. It helps guide the tendon for one of the thumb’s extensor muscles and is also a reference point for surgeries.

The radiocarpal joint connects the end of your radius to your wrist bones. The part of your wrist on the side of your little finger only occasionally connects with the ulna, depending on how your wrist is moved. The protective layer around the radiocarpal joint is thin and flimsy on the upper surface and is continuous with the softer, connecting parts between the wrist bones. It’s strengthened by many ligaments.

There are eight wrist bones, arranged in two rows. The closer row to your arm has, from the thumb to the little finger: the scaphoid, lunate, triquetrum, and pisiform. The pisiform bone does not connect with the radius. The row closer to your fingers has the trapezium, trapezoid, capitate, and hamate, which then connect to the bones of your hand.

The “Poirier’s space” is a soft part of the wrist, it is located at a part of the wrist where a bone called capitate is present. It can flex or extend, and it is susceptible to injury, like dislocation of a nearby bone. The wrist also has many ligaments, tendons that help in flexing and extending, nerves and arteries.

The wrist can move in three ways: bending and straightening, side-to-side, and twisting. Most of the bending comes from the mid carpal joint, while most of the straightening comes from the radiocarpal joint. For the side-to-side movement, the mid carpal joint helps more with the side towards the thumb, while both the radiocarpal and mid carpal joints work equally for the side towards the little finger. The twisting movement happens at the connections between the radius and ulna.

The end of the radius carries most of the load of the wrist, while the ulna carries a smaller fraction, which shows how each part contributes to the functioning of your wrist.

Why do People Need Wrist Arthrodesis

If you’re experiencing pain or instability in your wrist, you might be dealing with wrist arthritis. It can originate from many different reasons and it’s the main reason people end up needing a medical procedure called wrist arthrodesis. The usual culprit for wrist arthritis is something called the scapholunate advanced collapse, or SLAC, which affects a specific part of your wrist. The second most common type is scaphotrapezial-trapezoidal arthrosis, and it’s noticed in about 40% of wrist X-rays.

There are other types of wrist arthritis too, but their incidence usually depends on where the injury occurred. These include the scaphoid nonunion advanced collapse (SNAC), distal radio-ulnar joint arthrosis, and pisotriquetral arthrosis.

Arthritis itself can come about for many reasons. It could just be due to the wear and tear of ageing (degenerative), or could be because of an injury (post-traumatic). The latter includes conditions like SLAC, SNAC, wrist fractures, or injuries to the brachial plexus, a group of nerves in your arm. Wrist arthritis can also be inflammatory, like in rheumatoid arthritis, a condition where your immune system attacks your own body’s cells, or due to congenital disorders like Madelung’s deformity. There’s also idiopathic arthritis, where the cause is unknown, as well as arthritis that comes after wrist conditions like Kienbock disease (when the lunate bone in your wrist doesn’t get enough blood) or Preiser disease (similarly, the scaphoid bone gets less blood).

When a Person Should Avoid Wrist Arthrodesis

There aren’t any hard and fast rules about who should not undergo this procedure. However, if a patient decides they don’t want the procedure, or if they are allergic to the material used in the implant, they should avoid it. In some cases, they might be better off with a different operation like a full joint replacement instead of a wrist fusion.

The choice of which operation to undergo should be a discussion between the patient and the doctor. This decision will take into account their age, what they need their wrist to do, and the health issue that’s affecting the wrist.

Equipment used for Wrist Arthrodesis

A wrist fusion surgery kit, which can be supplied by various medical equipment companies, includes all the needed tools and devices for the surgery. The devices used in the operation are generally made of stainless steel or titanium, and come in different shapes and sizes to fit each patient’s unique requirements and to maximize the effectiveness of the surgery.

The pre-shaped plates, which usually have a 15-degree bend to match the curve of the back of the wrist, play a key role in the operation. These plates can be further shaped during the operation to fit the patient’s specific anatomy. However, it’s important to avoid bending these plates where the holes are located or bending them repeatedly in different directions, as doing so can weaken the plates.

The screws used can vary in size, most commonly 2.3 mm, 2.7 mm, and 3.5 mm, and can either securely lock into place or move slightly, depending on which parts of the plate they are inserted into.

Sometimes, the surgeon may choose to use bone grafts during the operation. This could either be directly taken from the patient or obtained from a tissue bank, depending on what is best for the patient and the surgeon’s personal preference.

Image intensifiers, which help provide a clear image of the wrist, are commonly used during the operation. As a result, it’s necessary for the patient and the medical team to wear appropriate protective gear.

Tourniquets, which are devices used to control blood flow, might also be used during the surgery. These are put on at the start of the procedure and released before the wound is closed to make sure any bleeding areas are detected.

Other devices that might be used during this wrist fusion surgery include a suction device, which removes fluids from the surgical area, and diathermy, a tool that uses heat to stop bleeding or cut through tissue.

Who is needed to perform Wrist Arthrodesis?

The team that performs the surgery is made up of several key people. The head of the team is the orthopedic surgeon, a specialist doctor trained in treating problems related to the bones and muscles. Supporting the surgeon are a surgical assistant, a scrub nurse, and other staff members. These are all skilled medical professionals who help ensure the surgery goes smoothly.

Another necessary part of the team is the anesthetic team. These are the medical experts who will make sure you stay asleep and don’t feel any pain during the surgery. An operating theatre practitioner helps the anesthetic team and the rest of the surgical team with their duties.

Almost always during this type of surgery, special machines called image intensifiers are used to help the surgeon see inside your body more clearly. This is why someone called a radiographer is also part of the team. These are the folks who know everything about operating these machines. Sometimes, if the equipment allows, the surgeon may even directly control some smaller image machines.

In some cases, the surgeon might invite representatives from the companies that make the surgical equipment to be present during the operation. They’re there to provide any help or guidance needed about using the equipment. This all helps to ensure that the surgery is as successful and safe as possible.

Preparing for Wrist Arthrodesis

Before any surgical procedure, it’s important to thoroughly check the patient’s condition. In the case of arthritis, doctors will carry out a full set of x-rays to understand how far the arthritis has advanced and how much bone is left. Sometimes, extra tests might be needed to figure out the exact type of arthritis, like inflammatory or degenerative arthritis, and if there are any other health issues that need to be considered.

The procedure is generally done under general anesthesia, which means the patient is put into a deep sleep and won’t feel anything during surgery. The anesthetic team can also provide a nerve block before surgery. This method helps to manage pain after the procedure. At the end of the surgery, a local anesthetic, which numbs a specific area of the body, can also be injected depending on how complex and long the surgery was. This helps in relieving pain after surgery.

When getting ready for the procedure, patients will be laid flat on their backs (known as the supine position) on a standard operating table. The arm that’s affected by arthritis is placed on a separate table that’s attached to the main operating table and can be seen clearly on an x-ray. The patient’s shoulder is positioned at the edge of the operating table. Tourniquets, which are devices used to stop blood flow, may be applied if needed.

Antibiotics are often given before the procedure to prevent infections. However, the best type of antibiotics to use can vary, so this should be confirmed with the local hospital guidelines.

How is Wrist Arthrodesis performed

The approach mentioned here is just a reference; different surgeons may follow slightly different methods based on their preference or experience.

After the patient has been anesthetized and prepared for surgery, a pressure device known as a tourniquet is placed and secured in position (if needed).

The surgeon prepares the skin at the site of the operation by applying antiseptic solution and places sterile drapes to cover the area. An incision (cut), around 8 cm long, is made along the back of the wrist between two specific areas, known as the third and fourth extensor compartments. A bony point known as Lister’s tubercle helps the surgeon identify where to make the incision.

Next, the soft tissues are carefully separated without damaging the nerve branches of the radial nerve found beneath the skin. A tendon known as the extensor policis longus tendon becomes visible and can be moved to the side (laterally).

The surgeon then longitudinally splits ligaments – bands of tissue that connect bones, known as the dorsal radiocarpal and dorsal intercarpal, which frees the cover, or “capsule”, of a joint from the radius bone near the styloid process.

The surgeon then carefully removes the articular cartilage, the smooth tissue at the end of bones that helps them move easily, from the radiocarpal and intercarpal joint surfaces. The surgeon removes the outer layer of the bone (decorticate) from the back of the scaphoid, lunate, capitate, and 3rd carpometacarpal joint. At this stage, bone graft, which is a surgical procedure that uses transplanted bone to repair and rebuild diseased or damaged bones, can be harvested from the distal radius or iliac crest and placed into the gaps at the fusion zone. Instead of personal bone graft (autograft), donor bone (allograft) can also be used. The distal radioulnar joint is usually left untouched.

The surgeon then puts a Kirschner wire (K wire), a thin metal pin used to hold bone fragments together, through the distal radius’s articular surface and the lunate. The surgeon adjusts the wrist position and advances the K wire through the joint. The doctor uses an image intensifier, a device that provides real-time X-ray imaging, to check the position of the lunate and the K wire.

Next, the surgeon puts on a surgical plate. A pre-shaped dynamic compression plate or a standard 3.5mm dynamic compression plate can be shaped and placed on the back of the radius and the third metacarpal bone.

The screws are put in, starting from the most distant hole on the third metacarpus and heading towards the nearest hole on the distal radius. The order of screw insertion could vary based on the surgeon’s preference and technique, with some choosing to insert the first screws into the carpal bones before the metacarpal bones.

Once all screws are inserted, the surgical area is thoroughly cleaned, and the tourniquet is deflated. Any sources of bleeding are sealed using a technique called diathermy, which uses heat produced by electric current.

The surgeon then closes the surgical incision, beginning with the joint’s capsule using dissolvable stitches. The surgeon repairs the extensor retinaculum, a band that holds down the tendons that straighten the wrist, fingers, and thumb, and moves the extensor pollicis longus tendon underneath the skin.

The subcutaneous layer, the layer of tissue beneath the skin, is closed with absorbable stitches, and a dressing is applied over the wound as chosen by the surgeon.

Depending on the surgeon’s preference, a volar brace or a short arm cast may be applied at the end of the surgery which can be removed once the wound is healed.

After the operation, early finger movement is recommended. However, patients are typically advised not to put weight on the operated arm for 8 to 12 weeks post-surgery.

Possible Complications of Wrist Arthrodesis

This particular medical procedure could lead to complications in up to 20% of cases. However, these complications are usually minor and can vary widely. Here are some of the possible issues that could happen:

1. Hematoma formation: Hematoma is a fancy word for a bruise or swelling that happens because of blood gathering in one area.

2. Nerve injury or dysfunction: This has been reported in around 35% of cases. In 10% to 25% of cases, damage to the median nerve might cause carpal tunnel syndrome (which can lead to numbness, tingling, and weakness in the hand). During this procedure, the highest risk of injury appears to be for the nerves at the back of the hand and the nerve that gives feeling to your thumb and the back of your hand.

3. Vascular injury: This means an injury to your blood vessels. If this happens, a team of vascular surgeons would be involved in the procedure to address the issue.

4. Infection: Some people may have a higher risk of getting an infection after surgery. This includes older people, those with weak immune systems, and people who have kidney disease or diabetes. People who smoke also have a higher risk. The chance of getting an infection can be lowered by giving preventative antibiotics before surgery.

5. Nonunion: This is when the bone fails to heal after a fracture. If you’re still having wrist pain after surgery, doctors might suspect nonunion and could take some X-rays to check further. However, the chance of nonunion is pretty low considering over 90% of such fractures heal fine.

6. Tendon injury: Specifically, the tendon that helps you straighten your thumb can be injured, due to its location near the surface of the skin. In rare cases, the tendons that bend your fingers and thumb can also get hurt.

7. Tendon irritation from metal plates or failure of the metal works: The plate used in the surgery or the breaking of the metal works may cause irritation to your tendons.

8. Reflex sympathetic dystrophy: This is a rare condition that leads to chronic pain, usually in an arm or a leg.

9. Neuroma formation: Neuroma is a growth or tumor that could happen on your nerve tissue.

10. Distal radioulnar joint arthritis: This is a type of arthritis that affects the joint at the wrist.

11. Iliac crest donor complications: If the bone graft is harvested from your hip area (ilium), there can be complications like hematoma (bruising), infections, nerve injury, or prolonged discomfort.

12. Hardware complications: The screws and plates used in the surgery could break, loosen or fail.

What Else Should I Know About Wrist Arthrodesis?

When a person undergoes a total wrist fusion surgery, it often results in limited mobility of the affected wrist. This means they usually can’t bend or extend the wrist themselves, and their ability to grip things may be weakened. It’s important for patients to be aware of this, especially if the affected wrist is the one they use most.

This reduced wrist functionality can have a significant impact on a person’s daily tasks that involve the use of the hand or wrist. It can also affect their job, particularly if it requires active hand or wrist movements like typing or using a computer. Therefore, wrist fusion surgery is usually considered as a last resort, only advised for patients who haven’t found relief from any other treatments.

Despite the limitations, in the right individuals, the surgery has shown good results. Most patients are satisfied post-surgery, and their grip strength typically returns to 75% to 90% of what it was on the other side.

Frequently asked questions

1. What are the potential risks and complications associated with wrist arthrodesis? 2. How long is the recovery period after wrist arthrodesis surgery? 3. Will I be able to regain any wrist function after the procedure? 4. Are there any alternative treatment options for my wrist condition? 5. How long will the wrist fusion last and will I need any additional surgeries in the future?

Wrist Arthrodesis is a surgical procedure that fuses the bones in the wrist joint together. This procedure eliminates the movement in the wrist, which can significantly impact the functioning of the hand and arm. It can limit the ability to perform activities that require wrist movement, such as twisting, bending, and side-to-side motion.

The decision to undergo Wrist Arthrodesis is based on individual factors and the specific health issue affecting the wrist. It may be recommended if other treatment options have failed to provide relief or if there is severe pain, instability, or deformity in the wrist joint. Wrist Arthrodesis may be necessary to improve function and reduce pain in conditions such as arthritis, post-traumatic injuries, or failed previous surgeries. Ultimately, the decision to undergo Wrist Arthrodesis should be made through a discussion between the patient and their doctor, considering factors such as age, desired wrist function, and the specific health issue.

You should not get Wrist Arthrodesis if you decide you don't want the procedure or if you are allergic to the material used in the implant. In some cases, a full joint replacement might be a better option instead of wrist fusion, depending on factors such as age, wrist functionality needs, and the specific health issue affecting the wrist.

The recovery time for Wrist Arthrodesis can vary, but patients are typically advised not to put weight on the operated arm for 8 to 12 weeks post-surgery. Early finger movement is recommended, but full recovery can take several months. Complications such as hematoma formation, nerve injury or dysfunction, vascular injury, infection, nonunion, tendon injury, and tendon irritation from metal plates or failure of the metal works can occur, but they are usually minor and can be addressed by medical professionals.

To prepare for Wrist Arthrodesis, the patient should undergo a full set of x-rays to determine the extent of arthritis and bone condition. Antibiotics are often given before the procedure to prevent infections. The patient will be placed under general anesthesia or may receive a nerve block for pain management.

The complications of Wrist Arthrodesis include hematoma formation, nerve injury or dysfunction, vascular injury, infection, nonunion, tendon injury, tendon irritation from metal plates or failure of the metal works, reflex sympathetic dystrophy, neuroma formation, distal radioulnar joint arthritis, iliac crest donor complications, and hardware complications.

The symptoms that require Wrist Arthrodesis include pain and instability in the wrist, which can be caused by wrist arthritis. This can be due to various reasons such as scapholunate advanced collapse (SLAC) or scaphotrapezial-trapezoidal arthrosis. Other types of wrist arthritis may also require Wrist Arthrodesis depending on the location of the injury or the underlying cause.

There is no specific information provided in the given text about the safety of wrist arthrodesis in pregnancy. It is recommended to consult with a healthcare professional for personalized advice regarding the safety of any medical procedure during pregnancy.

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