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Wrist osteoarthritis

VIEWS: 13 PAGES: 5

									Scandinavian Journal of Surgery 97: 305–309, 2008




Wrist osteoarthritis

s. C. talwalkar, M. J. hayton, J. K. stanley
Centre for Hand and Upper Limb Surgery, Wrightington Hospital for Joint Disease, Wigan,
Lancashire, U.K.



abstraCt

osteoarthritis of the wrist is one of the commonest conditions encountered in clinical
orthopaedic practice. this article looks at our approach to this problem including clinical
assessment, radiographic analysis and the management of wrist osteoarthritis.
Key words: Wrist; osteoarthritis; review; SLAC; arthrodesis; arthroplasty; carpectom



Osteoarthritis of the wrist is a common condition en-
countered in clinical practice (1) and can be broadly
divided into primary or secondary osteoarthritis. The
commoner secondary type of arthritis occurs in a
post- traumatic setting usually after significant frac-
tures around the wrist, particularly intra-articular
fractures of the radius, scaphoid fractures, non-unions
or secondary to ligament disruption of the wrist usu-
ally associated with subtle instability patterns (2).
These pathological processes lead to abnormal joint
loading resulting in altered wrist kinematics.
   Watson and Ballet described the SLAC pattern of
wrist arthritis (scapholunate advanced collapse),
where wrist arthritis occurs in a sequential manner
ultimately resulting in pancarpal arthritis (3). The
scaphoid flexes secondary to injury to the scapholu-
nate ligament with osteoarthritis developing over the       Fig. 1A. Comminuted intra-articular fracture of the lower end of
proximal pole of the scaphoid and the dorsal rim of         the radius.
the radius before spreading to the whole radioscaph-
oid joint and then beyond.
   Scaphoid fractures and a subsequent non-union
can lead to a progressive form of wrist arthritis. The
tip of the radial styloid is involved initially with sub-
sequent involvement of the proximal radioscaphoid
joint eventually culminating in pancarpal arthritis.
This is described as the SNAC pattern (scaphoid non
union advanced collapse).



Correspondence:
  S. C. Talwalkar, M.D.
  Centre for Hand and Upper Limb Surgery
  Wrightington Hospital for Joint Disease
  Appley Bridge
  Wigan, Lancashire, WN6 9EP U.K.                           Fig. 1B. Failure of fixation which eventually will lead to severe
  Email: stalwalkar@aol.com                                 osteoarthritis of the wrist.
306                                           S. C. Talwalkar, M. J. Hayton, J. K .Stanley FRCS




Fig. 2A. Dorsal synovitis secondary to wrist osteoarthritis.            Fig. 2B. Wrist osteoarthritis showing classical SLAC pattern with
                                                                        the radiolunate articulation preserved.




Fig. 3. Scapholunate dissociation showing osteochodral defect over      Fig. 4. Scaphoid non-union advanced collapse.
the scaphoid.




                                                                          Other less common causes of wrist arthritis would
                                                                        include avascular necrosis of the carpal bones as
                                                                        occurs in Kienbock’s or Preiser’s disease or due to
                                                                        congenital malformations such as Madelung’s defor-
                                                                        mity (4).



                                                                        ASSESSMENT

                                                                        A thorough history, physical examination and radio-
                                                                        logical assessment of the painful arthritic wrist is
                                                                        mandatory for a successful outcome. The history
                                                                        should include the age, the hand dominance, occupa-
                                                                        tion (plumbers, electricians, orthopaedic surgeons
                                                                        need some flexion and extension), racket sports (need
                                                                        flexion extension). Particular attention should be paid
Fig. 5. Kienbock’s disease with wrist osteoarthritis.                   to the functional needs of the patient.
                                                  Wrist osteoarthritis                                            307


   It is essential to clinically determine areas of maxi-     zation and the inclusion of autogenous bone (distal
mal tenderness and crepitus in order to localize the          radius or iliac crest) graft has produced fusion rates
pathology whether it is in the radiocarpal or ulnocar-        of between 93% to 100% (5, 6), plates narrower dis-
pal articulation or in the DRUJ (distal radioulnar            tally and smaller screws allow a better fit onto the
joint).                                                       third metacarpal.The ability of a wrist arthrodesis as
   Radiographs should be carefully assessed for the           a pain relieving measure is good. However, common
pattern of degenerate change including arthritis in           pitfalls include missed concomitant DRUJ and ulno-
the midcarpal joint as well as radioscaphoid and ra-          carpal problems (5, 7, 8). Special attention should be
diolunate arthritis. The capitate is described as the         made to prepare all joint surfaces with a technique
keystone of the wrist and represents the main articu-         we call in situ morcellisation. In this procedure bone
lation of the midcarpal joint. It is important to rule        rongeurs break up the carpal bones in situ and leave
out ulnar sided causes such as pisotriquetral osteoar-        them in place as an aggregate of bone fragments. The
thritis or ulnocarpal abutment.                               radial articular surface requires preparation with an
   It is important to pick a procedure which will cure        osteotome back to cancellous bone. The middle finger
the patient’s chief problem. The procedure should be          CMC joint should be specifically identified with di-
reliable and ideally should halt further progression          rect vision and confirmed under X-ray control. Once
of the arthritic process.                                     identified it should be morcellised as above. The mid-
   Biomechanical studies on the wrist have shown              dle finger CMC joint is important as a non-union at
that a midcarpal fusion will allow 50% to 67% of wrist        this site may allow movement and subsequent plate
motion. After a radiocarpal fusion only 40% of re-            failure particularly distally.
sidual motion remains, while following a proximal
row carpectomy, 50% to 70% of the carpal arc remains          Total wrist arthroplasty (TWA)
(1).
                                                              Total wrist arthroplasty has the advantage of pain
                                                              relief with preservation of movement. Implants have
MANAGEMENT                                                    been available for the last 30–40 years but over the
                                                              last few years modern two piece prosthesis that allow
CONSERvATIvE TREATMENT                                        solid fixation have gained popularity.
                                                                 Although the first generation Swanson implants
Pain relief using splint immobilization, analgesia and        provided good pain relief, long term data has shown
intra-articular steroid injections can provide some           a high incidence of implant failure (9). Newer gen-
improvement in function. However these tend to be             erations of articulated wrists have suffered with in-
temporary measures before definitive treatment.                stability problems. However, it is to be noted that
   Rigid splintage can be of benefit in demonstrating          TWA has been shown to maintain about 60% of the
to a patient the likely functional limitations a total        original arc of wrist motion (10). A lower demand
wrist fusion will entail. This will allow valuable in-        patient is ideal for this procedure as postoperative
formation to the patient as to whether certain activi-        activity restrictions may create problems for younger
ties will be possible following a fusion.                     active patients undergoing TWA. Patients who have
                                                              had wrist arthrodeses on one side and an arthroplasty
   SURGERy                                                    on the other prefer the TWA (11).
   Principles
                                                              Limited wrist fusion
   No movement:           Total wrist fusion
   Movement:              PRC                                 These procedures involve the fusion of some of the
                          Partial fusion                      carpal bones with the objective of preserving the por-
                          Total wrist replacement.            tion of the wrist not affected by arthritis.

   APPROACHES                                                 1. STT fusion (scaphotrapezio-trapezoid fusion)
   1. Longitudinal incision in line with the third            This is a common site of arthritis particularly in
      metacarpal: based on the third dorsal com-              women. The approach is through a small transverse
      partment with a T incision over the capsule.            incision and includes a radial styloidectomy. On an
   2. Ligament sparing approach preserving por-               average 65% of normal motion is regained postop-
      tions of the dorsal intercarpal ligaments and           eratively (1). Saffar (12) describes calcium pyrophos-
      radiocarpal ligament.                                   phate dihydrate deposition (CPDD) disease in the
   3. Transverse incisions are useful in limited              wrist which has radiographic features including soft
      wrist arthrodeses.                                      tissue calcification, joint space narrowing, bone scle-
                                                              rosis, subchondral cyst formation without osteophyte
Total wrist arthrodesis                                       formation, and large intraosseous geodes with Trian-
                                                              gular fibrocartilage calcification. Frequently found
This is the standard surgical treatment for patients          and isolated scaphotrapezio-trapezoid (STT) arthritis
with severe wrist arthritis with widespread involve-          is specific for CPDD. Distal radioulnar (DRUJ), iso-
ment of all the carpal bones. The use of pre-contoured        lated midcarpal joint and pisotriquetral joint involve-
plates has reduced the need for long term immobili-           ment also occur.
308                                           S. C. Talwalkar, M. J. Hayton, J. K .Stanley FRCS




                                                                        Fig. 8. Proximal row carpectomy with fusion of the first CMC
                                                                        joint.




Fig. 6. STT joint osteoarthritis.                                       2. Scapho(luno)capitate fusion
                                                                        This is used for patients with scapholunate instability
                                                                        and with midcarpal degenerative joint disease. The
                                                                        SL joint needs to be accurately reduced prior to fu-
                                                                        sion and a styloidectomy is done to prevent impinge-
                                                                        ment. Overall 33–50% of normal range is preserved
                                                                        after this procedure (13).

                                                                        3. Four corner fusion (capitate-lunate-hamate-
                                                                           triquetrum) arthrodesis.
                                                                        The pattern of arthritis in the SLAC wrist often al-
                                                                        lows the radio-lunate joint to be preserved for a lon-
                                                                        ger time than the other articulations. As described by
Fig. 7A. Circular plate fixation for four-corner fusion of the wrist.    Watson (3, 14) the four corner fusion involves com-
                                                                        plete excision of the scaphoid with an arthrodesis of
                                                                        the remaining carpus, i.e. the capitate, lunate, hamate
                                                                        and the triquetrum. Fixation can be provided with
                                                                        the help of dorsally based circular plates or k wires.
                                                                        Dorsal circular plates have been popular in the past.
                                                                        Several studies have shown them to be inferior to
                                                                        traditional methods of fixation due to a higher rate of
                                                                        non-union and dorsal impingement (15–18).

                                                                        4. Proximal row carpectomy (PRC)
                                                                        This procedure involves removal of the entire proxi-
                                                                        mal carpal row, i.e. the scaphoid, lunate and the tri-
           B                                                            quetrum. A pre-requisite for offering this procedure
                                                                        is that the capitate should be unaffected by the ar-
                                                                        thritic process. It provides an excellent salvage pro-
                                                                        cedure for the wrist. It can be performed either
                                                                        through a transverse or a longitudinal incision and
                                                                        the bones of the proximal carpal row are removed. It
                                                                        is crucial to preserve the volar radioscaphocapitate
                                                                        ligament as it prevents ulnar translation of the capi-
                                                                        tates off the distal radius. This ligament is at risk
                                                                        during the excision of the scaphoid. 80% of normal
                                                                        grip strength and 60% of normal motion is preserved.
                                                                        Over a period of time radiocapitate changes develop;
          C
                                                                        younger patients seem to be more prone to develop-
Figs 7B and 7C. Radiographs of patient with circular plate fixation      ing this pattern of secondary degenerative change
for four-corner fusion.                                                 (19, 20).
                                                          Wrist osteoarthritis                                                        309


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