Functional results of wrist arthrodesis

Abstracts

São analisados os resultados funcionais 51 artrodeses do punho em 49 pacientes, portadores de variadas patologias dessa região. Em todos os casos, a artrodese foi realizada com fixação interna rígida, usando placa e parafusos e o seguimento pós-operatório variou de 6 a 201 meses (média: 73 meses). Para a avaliação funcional foi empregado um método de subjetivo, baseado nas impressões dos próprios pacientes, e outro objetivo, através da análise das radiografias e de testes funcionais que simulam todo tipo de função do membro superior. A posição de fixação da artrodese foi de 14º de extensão e 8º de desvio ulnar, em média. Consolidação primária foi obtida em 50 (98%) punhos, num período médio de oito semanas, sendo que, no punho restante ocorreu pseudartrose, consolidada após re-operação com enxertia óssea. Houve melhora da intensidade e mudança do padrão da dor pré-operatória e todos os pacientes com atividade leve retornaram ao trabalho.. Houve perda relativa da força de preensão manual (61% do contralateral) e das pinças (cerca de 70% do lado contralateral), porém os testes funcionais apresentaram resultados considerados satisfatórios e concordantes com a literatura. Conclui-se que a artrodese do punho é um método aplicável a diversas patologias que impliquem em dor e instabilidade da articulação, que produz resultados consistentemente repetitíveis, sem afetar significativamente a função global do membro superior, apesar da relativa perda da força, a qual se deveu mais a fatores pré-existentes do que a artrodese em si.

Punho; artrodese; resultados funcionais

ARTIGO ORIGINAL

Functional results of wrist arthrodesis

Cláudio Henrique Barbieri^I; Nílton Mazzer^II; Valéria M. C. Elui^III; Marisa C. R. Fonseca^IV

^IChairman

^IIAssociate Professor

^IIIOcupational therapist

^IVPhysiotherapist

^{Correspondence}

SUMMARY

The functional results of 51 wrist arthrodesis carried out in 49 patients with different regional pathologies are analyzed. In all cases the arthrodesis was performed with rigid internal fixation with a dynamic compression plate; postoperative follow-up ranged from 6 to 201 months (average: 73 months). Both subjective and objective methods were used in the evaluation. The subjective method was based on the evaluation by the patients and the objective method on analysis of radiographs and functional tests simulating all different functions of the upper limb.

The arthrodesis was performed in 14º extension and 8º ulnal deviation, on average. Primary healing was obtained in 50 wrists (98%) in eight weeks on average. Pseudarthrosis was observed in one single case, and eventually healed after reoperation for bone grafting. All patients presented pain improvement, with a different pattern, as compared to the preoperative period and all of those with lighter activities resumed their previous occupation. Relative loss of grip strength (61% from normal) and digital pinch (70% from normal) were observed, but final results were considered as satisfactory on the functional tests, in accordance to the literature. It was concluded that wrist arthrodesis is applicable to a diversity of wrist pathologies which imply in pain and unstability, with easily reproducible results, without significantly affecting the global upper limb function, despite the relative loss of power, mainly due to the pre-existing factor.

Key words: Wrist; arthrodesis; functional results

INTRODUCTION

Functional use of the hand, either in strength or precision activities, is dependent on an stable and not painful wrist. Instability and pain result in prejudiced function and require some treatment, usually surgical⁽²¹⁾. Localized derangement of radio carpal joint may be treated by means of operative techniques involving ligamental reconstruction, limited intra carpal arthrodesis, and proximal line carpectomy, which bring different degrees of stability and pain relief, with the advantage of keeping some wrist mobility ^{(18, 22)}. Yet in severe instability and carpal arthrosis, and in cases where the previously mentioned procedures failed, total wrist arthrodesis has a room as a salvation procedure⁽⁶⁾.

Most frequent indications for total wrist arthrodesis are the restricted carpal pathologies (e.g. Kienböck's disease), and total carpal pathologies (e.g., post traumatic sequelae, rheumatoid arthritis and others) and extra carpal pathologies (e.g., neuromuscular diseases, periarticular soft tissue injuries, and tumoral ressections)⁽¹⁹⁾.

Many techniques were described for performing wrist arthrodesis, involving different fixation devices, as crossed wires, intramedullary wires, plates and screws, associated or not to bone grafting^(1,5). Each one of these methods brings inherent advantages and disadvantages, however, rigid internal fixation with plate and screws avoids the use of external splint during the healing period, allowing an early rehabilitation without risk of loosing the achieved corrections^{(2, 7,15,17)}.

Even resulting in a wrist that is stable and not painful, wrist arthrodesis is still controversial in relation to global function of the affected limb. For this reason, functional activity evaluation should be performed by means of a easily performable method, universally accepted, and involving both objective and subjective parameters, making easier result comparison thus being reproducible by any investigator^(4,10).

The objective of this study was to evaluate the efficacy of rigid internal fixation as a wrist arthrodesis method, and the global function of the upper limb after the arthrodesis healed.

MATERIAL AND METHODS

Between March 7^th, 1983 and June, 1999, 49 patients (51 wrists) underwent wrist arthrodesis using internal fixation by means of plate and screws. They were 29 males and 20 women, and age ranged from 18 to 70 years old (average: 42.06 years). Right side was involved in 51 wrists, and left in 23. In 26 cases, it was operated the dominant side.

The most important indication for arthrodesis was functional impairment, in 46 patients (93.87%), and pain on movements, observed in 36 patients (73.46%). Thirty patients (61.22%) had also pain at rest. Regarding the ethiology, total carpal pathology was predominant, including carpal colapse due to scaphoid fracture⁽⁷⁾, radiocarpal degeneration due to distal radius fracture⁽⁵⁾, systemic arthropaties⁽⁵⁾ and scapho-lunal disjunction⁽³⁾, with a total of 20 cases. Restrict carpal pathologies followed, involving exclusively Kiemböck's disease, with a total of 17. Last came extracarpal pathologies, with a total of 12 (Table 1).

Operative Technique

Under regional anesthesia of the brachial plexus (59%), or inhalatory general anesthesia (29%), or combined (12%), the affected wrist was approached through a dorsal longitudinal incision, opening the extensor retinaculum between 3^rd and 4^th tunnels. Articular capsule was as well longitudinally opened and retracted medially, ressecting the Lister tuberculus. Articular cartilage of radius, scaphoid, lunate and capitate were carefully removed, avoiding excessive removal of subcondral cancellous bone.

Rigid internal fixation was performed in 47 cases (92%) using a 3.5 mm dynamic compression plate (DCP), according to AO recommended technique^(8,15). Alternatively a 3.5 mm semi-tubular plate was used in four cases (8%). The plate was initially screwed to radius and after to the second metacarpal (7 cases) or to the third metacarpal (44 cases). Homologous bone grafting was used in 26 cases (51%), from anterior iliac crest (12), resected ulnal head (8) or radial distal extremity (6). Ulnal head was removed in 8 cases, due to degenerative changes associated to distal radio-ulnal joint, as reported in literature ⁽⁶⁾; alternativelly, Sauvé-Kapandji operation was performed in two other cases, in one with immediate diffuse degenerative wrist changes, and late in the other one, with ulno-carpal impact syndrome developed after wrist arthrodesis was performed ⁽¹⁴⁾.

Postoperative Follow-up

A cast splint was used until stitches were removed, around the tenth day, when physiotherapy was started moving fingers and elbow, and external immobilization abandoned after this period. Radiographic control was monthly performed until bone healing was documented. Removal of synthesis material was routinely performed in 11 cases (average 11.72 months) and due to chronic postoperative pain in 5 cases, ranging from 7 to 50 months after the arthrodesis was performed (average: 33.82 months), with a total of 16 cases of plate and screws removal (31.37%). Average follow-up of these patients was 73 months, ranging form 6 to 201 months.

Subjective Evaluation

Patients were requested to perform a subjective evaluation of the pain they had preoperatively, rating it according to scores 1 to 4 (1 - no pain; 2 - light and occasional pain; 3 - moderate pain; 4 - severe pain), and to compare it to eventual postoperative pain. Patients were as well questioned regarding their satisfaction, using a score system 1 to 3 (1- completely satisfied; 2 - partially satisfied; 3 - dissatisfied) and as if they returned or not to their usual professional activities.

Objective Evaluation

Preoperative radiographs were evaluated in all patients in antero-posterior and lateral aspects, regarding the following parameters: radio-carpal relation, radio-ulnal relation, carpal collapse, narrowing of articular space, articular surface erosion, and presence of osteophytes. In postoperative radiographs were evaluated fixation position of the wrist and time to bone healing.

Functional evaluation included the global finger grip strength and of the three digital pinches (pulp-pulp, lateral and three points), goniometry, and Jebsen and Buck-Gramcko functional tests, this last, specific for arthrodesis evaluation. Muscular strength tests were performed using a hand grip dynamometer* and a pinchmeter for the pinches**, with three alternated measurements, using contralateral limb as a reference for comparisons. In goniometry were comparatively evaluated: flexo-extension, radio-ulnal deviation and prono-suppination.

Jebsen test involves a series of daily life tasks simulation, such as writing, feeding and taking objects like cards, small objects, light and heavy. Percentual score is obtained from pattern values obtained in control studies by the author. Buck-Gramcko test performs an objective evaluation of arthrodesis, as seen in (Table 2).

RESULTS

From the 49 patients who underwent wrist arthrodesis, 32 returned for interview and underwent a postoperative functional analysis (Table 3). For the remaining 17 patients, who did not return for the evaluation, arthrodesis result was evaluated by the files and radiographs.

Subjective Evaluation

An overall improvement of the pain, both in intensity and pattern, was observed. However, from the 20 cases with preoperative severe or moderate pain (62.5%), 6 (27.27%) had the same pattern and intensity level after the surgery according to subjective information. On the other side, the number of patients without pain or with light pain changed from 12 (37.5%) to 26 (81.2%).

Complete or partial satisfaction was obtained in 31 patients (96.8%). Reason for dissatisfaction, in the only case that reported such, was pain due to plate loosing, leading to indication for a surgical revision of the arthrodesis.

Heavy duty workers, such as sugar cane croppers, stone masons or plumbers, couldn't go back to their usual professional activities, mostly due to lack of hand grip strength and pain when under effort. However, pain clearly appeared in activities requesting prono-suppination, barely appearing in axial efforts. Yet patients with lighter activities returned to usual work with no restriction (65.62% of the total).

Objective Evaluation

Evaluation of preoperative radiographs of the 49 patients (51 wrists) evidenced intracarpal arthrosis, mainly between scaphoid, lunate and capitate in 29 cases (59.18%). Carpal collapse was screened in wrists with Kienböck's disease (Figures 2 and 3) or scaphoid pseudarthrosis, by means of carpal height method of MacMurtry⁽⁴⁾, and found in 14 cases of the 24 wrists with those pathologies (58.33%). Degeneration of distal radio-ulnal joint or the presence of the "ulna minus" variation was found in 3 cases. Were also found reduction of radio-carpal space in 29 cases (59.18%) and presence of osteophytes in 25 cases (51.02%).

Radiographic analysis demonstrated that the arthrodesis position was in average in 14.2° extension (range 0° to 32°), and 8.7° ulnal deviation (range: 0° to 22°) (Figure 3). Time to bone healing was in average 8.16 weeks, ranging form 6 to 16 weeks.

Hand grip strength was, in average of 61.21% of normal contralateral side, ranging from 7.2 to 100%, being the lesser values observed in extracarpal pathologies, mainly neuromuscular (average: 52.27%). Pinches strength was slightly higher than hand grip, being in average 64.11% for lateral pinch, 71.66% for pulp-pulp and 71.40% for three point pinch, in comparison to contralateral side.

In goniometry, a prono-suppination deficit was found, with an average of 75.58° pronation, and 64.77° suppination, however not configuring functional impairment for daily activities.

Under Jebsen method functional evaluation, it was found that function of wrists that underwent arthrodesis was in average 50.73% of the pattern percentile determined by the author, while in normal wrists was 70.75%, representing a relative average function of 71.70% in operated wrists. Individual evaluation of the tasks may be seen in (Figure 1).

In Buck-Gramcko test, average final rate was 6.79, equivalent to a satisfactory result. Separated evaluation, by pathology demonstrated that extracarpal pathologies, restricted carpal pathologies and total carpal pathologies, reached the scores 5.12 (satisfactory), 7.33 (good) and 8.00 (good), respectively.

Complications

Five patients presented superficial infection of surgical wound, were treated with antibiotics and healing was achieved without need of surgical débridement. One patient had carpal tunnel syndrome after the arthrodesis, which was resolved by flexor retinaculum liberation. Three patients needed to be submitted to arthrodesis revision, due to loosening of synthesis material, plate fracture and pseudarthrosis. Five patients had chronic post operative pain, making necessary to remove the plates and screws.

DISCUSSION

Wrist mobility loosening consequent to arthrodesis leads some surgeons to consider this procedure as the last treatment for a series of intra-articular and extra-articular conditions. However, the disability produced by wrist arthrodesis may be compensated, or alleviated, since the patient has normal shoulder, elbow, forearm and hand^(3,9).

Subjective evaluation of the studied cases demonstrated that wrist arthrodesis was efficacious for reducing pain intensity and changing its pattern. However, in 6 cases (18.75%) pain persisted in daily activity, what was reported by other authors ⁽²²⁾, who found recurrence of pain in 5.6% of their cases and by ^(12,13), with 11% of pain recurrence. Besides this, patients' satisfaction with the method is high, reaching 96.8% among our patients, who related it to pain improvement, wrist stability and adequate hand positioning. On the other hand, despite the high index of satisfaction, only 65.2% of the patients returned to their previous professional activity, even those considered as light. Patients working in heavy duties didn't go back to their jobs, particularly prejudiced by pain on pronation and suppination efforts.

Position of the arthrodesed wrist was extension (average: 14.2°) and ulnal deviation (average 8.7°), within the adequate range for most of professional activities and allowing a better hand grip strength according to biomechanical studies^{(11,13,16,20)}. In the case of bilateral arthrodesis, one of the wrists was fixed in extension and the other one in neutral position, making easier to perform some activities, such as private hygiene, for example.

Healing rate was of 98%, and the only case which evolved to pseudarthrosis was resubmitted to surgery, getting to heal. Average time to bone healing of the arthrodesis was 8.16 weeks, which is in accordance with the reported in literature^(2,17). It is worthy to remind that it is very difficult to access exactly the time for healing of the arthrodesis, because the constitution of the involved bones, mostly cancellous, and the presence of the plate, constitute themselves as obstacles for a good observation of the healing area. There was also no significant difference between results of a rigid fixation, with a DCP plate, or a more elastic one with a semi-tubular plate, what opposes to the anterior observation, that healing time as slightly longer with the last one⁽²⁾.

Goniometry demonstrated that no important commitment of elbow or shoulder due to surgical procedure occurred. Only in patients with extra-carpal pathologies, such as neuromuscular ones, it was found a significant impairment of prono-suppination, in a deficiency inherent to the disease itself.

Grip strength was reduced in almost all patients, with an average of 61.21% of the strength of contralateral normal hand, however with a very wide range, since it was normal (100%) in at least one patient, while it was almost null (7.2%) in another one, with extracarpal neuromuscular disease, the group of patients with worst functional results. Jebsen's test⁽¹⁰⁾ revealed that the overall functional performance was of 71.70% of contralateral side, while Buck-Gramcko's⁽⁴⁾ reached an average of 6.79 points, again the worst performance for extracarpal diseases. Obviously the deficiency in these cases was caused by the pathology and not by the arthrodesis. Yet, in the item personal satisfaction, all patients were unanimous to say that a functional improvement was achieved, or, at least, there was no worsening.

Complication rate was high in this set of cases. So, five had superficial infection which however resolved with specific treatment. A probable predisposing factor to superficial infection is the superficiality of the procedure and the plate, placed almost subcutaneously. Another probable factor is that the surgery was performed by training residents, what makes the surgery longer and increases tissue manipulation, as these events characterize the beginning of the learning curve. As experience increases, these factors trend to reduce their importance.

Surgical revision was necessary in three cases presenting complications linked to fixation leading to non healing. In these cases, it was always detected a technical mistake, also included in the learning procedure of residents, still not skilled in the surgery, and in the particularities of transarticular fixation, mainly regarding adequate preparation of the surfaces to be arthrodesed. In this case, again, the incidence of these complications should subside as a doctors become more experienced.

Carpal tunnel syndrome happened in one case, probably due to the sudden change in position of the wrist, partially flexed, to an extension of 20°. This is an unexpected and as well unpredictable, since it was found in only one case, which however had a good evolution after the median nerve was surgically released.

Five patients requested the plate to be removed. This is, as a matter of fact, the reason of frequent complaints of the patients, either for aesthetics, since the plate is visible under the skin, or for problems caused by minor traumas over it. The probable solution of this problem would be a specially designed plate for wrist arthrodesis recently introduced by AO in Brazilian market.

CONCLUSIONS

Nevertheless a relatively high incidence of complications was found, probably due to inexperience of some of the surgeons, the conclusion from the analysis of the cases here presented is that wrist arthrodesis with a rigid internal fixation is an efficient procedure, which is easy to be performed, with encouraging functional results, bringing satisfaction to the patients, however with very precise indications. This surgery, however, should not be indicated before other therapeutic possibilities were evaluated.

REFERÊNCIAS BIBLIOGRÁFICA

Work performed at Hand and Upper Limb Surgery Service and Microsurgery from Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP

• 1. Abbot, L. C., Saunders, J. B. deC. & Bost, F. C.: Arthrodesis of the wrist with the use of grafts of cancellous bone. J. Bone Joint Surg. 24: 883-898, 1942.
• 2. Barbieri, C. H., La Banca Jr., J. & Sakashita, A. F.: Artrodese de punho com fixação interna rígida. Rev. Bras. Ortop. 22(6): 155-162, 1987.
• 3. Barbieri, C. H., Mazer, N., Kfuri Jr., M., Nishimura, M. T. & Elui, V. M. C.: Artrodese do punho com fixação interna rígida: avaliação funcional. Rev. Bras. Ortop. 29(6):411-415, 1994.
• 4. Buck-Gramcko, D. & Lohmann, H.: Compression arthrodesis of the wrist; in Tubiana, R. (ed.). The Hand (V. 2), Philadelphia, W. B. Saunders, 1981, p.723.
• 5. Campbell, C. J., Keokarn, T.: Total and subtotal arthrodesis of the wrist. J. Bone Joint Surg. 46A: 1520-1533, 1964.
• 6. Craigen, M. A. C. & Stankley, J. K.: Distal ulnar instability following wrist arthrodesis in men. J. Hand Surg. 20B: 155-158, 1995.
• 7. Field, J., Herbert, T. J. & Prosser, R.: Total wrist fusion. J. Hand Surg. 21B: 429-433, 1996.
• 8. Heim, U. & Pfeiffer, K. M.: Small fragment set manual. Technique recommended by the ASIF group (2^nd ed.). Berlin, Heidelberg, New York, Springer-Verlag, 1982, p.143.
• 9. Hoppenfeld, S.: Physical examination of the spine and extremities. New York, Appleton-Century-Crofts, 1970, p.88-89.
• 10. Jebsen, R. H., Taylor, N., Trischmann, R. B., Trotter, M. J. & Howard, L. A.: An objective and standardized test of hand function. Arch. Phys. Med. Rehab. 50: 311-319, 1969.
• 11. Kraft, G. H. & Detels, P. L.: Position of function of the hand. Arch. Phys. Med. Rehab. 53: 272-275, 1972.
• 12. Larsson, S. E.: Compression arthrodesis of the wrist: a consecutive series of 23 cases. Clin. Orthop. 99: 146-153, 1974.
• 13. Leighton, R. K. & Petrie, D.: Arthrodesis of the wrist. Can. J. Surg. 30: 115-116, 1987.
• 14. Mazzer N., Barbieri C. H., Martins M. M. P., Souza A. G.: Tratamento dos desarranjos da articulação radio-ulnal distal pela técnica de Sauvé-Kapandji. Resultados preliminaries. Acta Ortop. Bras. 9(1): 12-20, 2001.
• 15. Müller, M., Allgöwer, M., Schneider, R. & Willenegger, H.: Manual of internal fixation (3^rd ed.), Berlin, Springer-Verlag, 1991, p.232.
• 16. Pryce, J. C.: The wrist position between neutral and ulnar deviation that facilites the maximum power grip strength.. J. Biomech. 13: 505-511, 1980.
• 17. Sagerman, S. D. & Palmer, A. K.: Wrist arthrodesis using dynamic compression plate. J. Hand Surg. 21B: 437-441, 1996.
• 18. Taleisnik, J.: Subtotal arthrodesis of the wrist joint. Clin. Orthop. 187: 81-88, 1984.
• 19. Van Gemert, J. G. W. A.: Arthrodesis of the wrist. A clinical, radiographic and ergonomic study of 66 cases. Acta Orthop. Scand., Suppl. 210, V. 55, 1984.
• 20. Volz, R. G., Lieb, M. & Benjamin, J.: Biomechanics of the wrist. Clin. Orthop. 149: 112-117, 1980.
• 21. Weiss, A-P. C. & Hastings, H.: Wrist arthrodesis for traumatic conditions: a study of plate and local bone graft application. J. Hand Surg. 20A: 50-56, 1995.
• 22. Zachary, S. V. & Stern, P. J.: Complications following AO-ASIF wrist arthrodesis. J Hand Surg, 20A: 339-344, 1995.

Correspondence to

Hand and Upper Limb Surgery and Microsurgery Service

Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP

Campus Universitário

14048-900 Ribeirão Preto SP BRASIL

Publication Dates

• Publication in this collection
  21 Sept 2005
• Date of issue
  Mar 2002

History

• Accepted
  27 Nov 2001
• Received
  06 Apr 2000