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 Several of the implants have been modified or withdrawn.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.

Diagnostic and treatment recommendations for recurrent or persistent symptoms after trapeziectomy: a Delphi study.

The aim of this Delphi study was to provide a diagnostic and treatment algorithm for patients with persistent or recurrent symptoms after trapeziometacarpal joint resection arthroplasty. Three Delphi rounds were conducted in which surveys were sent to 182 experienced hand surgeons worldwide. Responses were received from 140 participants. A consensus threshold was set at 67% agreement. Diagnostic tools and treatment approaches for six common revision scenarios achieved consensus. Radiographs are appropriate as primary (97%) and CT scans as secondary (76%) diagnostic tools. For scaphometacarpal impingement, 67% of respondents agreed that revision interposition is appropriate, with 93% recommending autologous tendon for the interposition. Additional suspension was considered appropriate by 68% of the participants. The diagnostic and treatment algorithm can help the surgeon to identify the reason for persistent symptoms after trapeziometacarpal joint resection arthroplasty and to choose an appropriate treatment strategy.Level of evidence: V.

Revisions after trapeziometacarpal joint resection arthroplasty: A systematic literature review.

BACKGROUND: The aim of this systematic literature review was to describe current indications and interventions for revisions after trapeziometacarpal joint (TMJ) resection arthroplasty. METHODS: The literature search was conducted by an experienced librarian in the Medline, EMBASE, Cochrane Library, Web of Science and Scopus databases. We included all articles that investigated any TMJ arthroplasty procedure in which the trapezium was completely resected and if any subsequent revision procedure including joint-related and soft-tissue surgeries was mentioned. Two independent reviewers selected the articles and were involved in data extraction. RESULTS: Sixty-two articles reporting on 5,284 operated thumbs and 434 revision surgeries were included. We extracted 24 indications for revision and 31 revision techniques. Most revisions were performed because of subsidence/impingement of the first metacarpal bone (n=194 thumbs) followed by unspecified pain (n=53), metacarpophalangeal joint problems (n=28) and scaphotrapezoidal osteoarthritis (n=17). Eleven treatment strategies were found for subsidence/impingement of the first metacarpal, the most frequent being revision of the existing interposition using autologous tendon (n=46) and soft tissue interposition with distraction pinning (n=28). CONCLUSIONS: There are a wide variety of indications and even more surgical techniques described in the literature to treat persisting or recurrent pain after TMJ resection arthroplasty. Currently, there is no uniform treatment guideline available how to diagnose and treat such cases. Therefore, the results of this literature review will form the basis for a Delphi study aiming to develop recommendations for the diagnosis and treatment of persistent / recurrent pain after TMJ resection arthroplasty. LEVEL OF EVIDENCE: IV.

Total Wrist Arthroplasty: An International Perspective.

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

The Conservative Treatment of Some Hand and Carpal Fractures.

In recent decades, there has been a trend toward increased use of operative treatment of hand fractures. However, internal stabilization with wires or open reduction and internal fixation of the phalanges and the metacarpals carries a risk of surgical complications that can be avoided by using appropriate conservative treatment. In this article, some hand fractures that can be managed safely without surgery are discussed. In conclusion, when facing a fracture in the hand, the first consideration is whether the fracture can be treated nonoperatively and not which operative treatment is most appropriate. This applies to both displaced and undisplaced fractures.

Challenging the dogma: severely angulated neck fractures of the fifth metacarpal must be treated surgically.

Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the validity of these threshold values. Eighteen prospective comparative studies on operative and/or conservative treatment options in adults were included. None of the studies demonstrated any correlation between the residual or initial angulation and the clinical results despite accepting more severe angular deformities. Closed reduction and immobilization without internal fixation improved the palmar angle by 5° to 9° in three studies and 29° in a fourth. Operative treatments compared with non-reducing conservative treatments showed no benefit of the surgery other than aesthetic issues. The synthesis of this review indicates that 90% of fractures of the metacarpal neck with apex angulation up to 70° can be treated successfully with a functional metacarpal brace without reduction. Disability of the Arm, Shoulder and Hand questionnaire scores <10 are uniformly reported. I modified my own practice accordingly a decade ago to treating these fractures conservatively regardless of the palmar angulation, except in patients with exceptional demands or other fracture deformities.

Ulnar Head or Total Distal Radioulnar Joint Replacement, Isolated and Combined with Total Wrist Arthroplasty: Midterm Results.

Purpose Various implants have been described for ulnar head replacement (UHR) or for total replacement of the distal radioulnar joint (DRUJ). Many series are small and few reports on mid- or long-term results. This study is primarily aimed to report on the midterm results after ulnar head only and total DRUJ replacement using the uHead in the treatment of painful disorders of the DRUJ. The secondary aim of the study was to eventually assess the combination of UHR and total wrist arthroplasty (TWA). Materials and Methods We included 20 consecutive patients in whom an UHR with the uHead was performed at our institution between February 2005 and March 2017. There were 6 men and 14 women with mean age of 59 years (range: 36-80 years). The mean follow-up time was 5 years (range: 2-15 years). Data were recorded prospectively before operation and at follow-up examinations and entered in a registry. The patients were followed-up at 3 and 6 weeks and 3, 6, and 12 months postoperatively and thereafter annually. In five cases, the uHead was implanted simultaneously with a Remotion TWA. In four cases, a Remotion TWA had been implanted previously. Kaplan-Meier survival analysis was used to estimate the cumulative probability of remaining free of revision. A nonparametric Wilcoxon's signed-rank test was used for comparing data not normally distributed (qDASH [quick disabilities of the hand, shoulder, and arm] scores), and the paired parametric Student's t -test was used for normally distributed data (pain and visual analogue scale [VAS] scores, range of motion, and grip strength). Significance was set at a p -value of less than 0.05. Results Pain, grip strength, and the function improved significantly. Pain after surgery decreased with 50 points on the VAS score scale of 100, from 66 (mean), preoperatively (range: 16-97) to 16 (mean; range: 0-51), postoperatively, while grip strength nearly doubled from 12 KgF (mean; range: 4-22), before to 21 KgF (mean; range: 6-36), after the surgery. Patients function measured with qDASH scores improved from 56 (mean; range: 36-75), preoperatively to 19 (mean; range: 4-47), postoperatively. Wrist extension, flexion, and ulnar and radial deviation did not change to a clinically or statistically significant extend, neither did supination nor pronation improved after surgery. While three UHRs were revised early because of pain problems and/or unsatisfactory forearm rotation in two cases and infection in one, 17 had an uncomplicated postoperative course and these patients were satisfied with the results of the surgery at all the follow-ups. Due to limited number of cases, the calculation of significance in comparing combined cases with UHR only cases was abandoned. Conclusion Ulnar head arthroplasty (uHead) showed significant improvement in pain, grip strength, and the function of the patients with a painful disability of the DRUJ, without impairment on mobility on the midterm follow-up. The overall implant survival over the time and the complication rate was acceptable.

Current methods, outcomes and challenges for the treatment of hand fractures.

In treating hand fractures, we have to make a proper decision about conservative treatment versus surgical intervention and decide on individual surgical methods. This article reviews recent publications, technical advances, and outcome measures in treating metacarpal fractures, phalangeal fractures, complex fractures of the proximal interphalangeal joints, bony mallet fingers, and fractures of the thumb. My personal preferences and considerations are presented. At the end, the current challenges that hand surgeons are facing in treating frequent phalangeal and metacarpal fractures are discussed.

Functional outcomes after salvage procedures for the destroyed wrist: an overview.

The most widely used procedures for salvaging a destroyed wrist are four-corner arthrodesis, radiocarpal arthrodesis, proximal row carpectomy, total wrist arthrodesis, and total wrist replacement or resurfacing. The purpose of this article is to give an overview of the functional results obtained with the various salvage procedures and of the common methods for assessing the surgical outcomes. The outcomes are assessed by clinical measurements and scoring methods, but the actual functional status and well-being of the patients should be presented together with patient-reported outcomes. No salvage procedure can restore entirely full wrist function. Understanding indications, risks, and the outcomes of these procedures would favour a better decision for surgery and help choose the proper treatment from among the surgical options discussed with patients.