Sept. 22, 2017
Early-stage wrist arthritis can often be managed with medication, splinting and modification of activities. If these nonoperative treatments fail, wrist fusion has been the treatment of choice to alleviate pain and improve joint function. However, patients frequently report limitations after fusion involving daily activities that benefit from motion, such as perineal care and button fastening.
Wrist before and after replacement
X-rays show the wrist of a 64-year-old man before and after wrist replacement surgery at Mayo Clinic. A. Preoperative anteroposterior view. B. Preoperative lateral view. C. Postoperative anteroposterior view. D. Postoperative lateral view.
Orthopedic surgeons at Mayo Clinic in Rochester, Minnesota, offer the option of wrist replacement. Although performed less commonly than hip or knee replacement, wrist replacement can provide relief from pain and instability while preserving the range of motion needed for daily activities.
"Wrist replacement can be an option for patients who are reluctant to have a wrist fusion. At Mayo Clinic we are seeing increasing referrals for this procedure," says Marco Rizzo, M.D., a consultant in Orthopedic Surgery at Mayo Clinic's campus in Minnesota. "As a major center for orthopedic surgery, we have the volume of patients and range of surgical subspecialties to ensure skills and experience with wrist replacement."
Wrist replacement is most commonly performed on patients with rheumatoid arthritis, but it's also used to treat osteoarthritis and post-traumatic arthritis. Dr. Rizzo notes that the most suitable candidates are older patients who have pancarpal arthritis and who don't perform work that requires heavy lifting, which can diminish the longevity of the implant.
"Our short- and midterm outcomes in terms of pain relief and the maintenance of joint function are generally very good," he says. "The long-term outcomes unfortunately are not as strong as we would like. Additional surgery is often needed after about 10 years."
Preserving wrist function
According to an analysis by Dr. Rizzo and colleagues of data from the National (Nationwide) Inpatient Sample, wrist fusion was performed four times more frequently than wrist replacement from 2001 to 2010. The researchers' study, published in the August 2016 issue of Journal of Wrist Surgery, notes that the total complication rate was 10 percent among the 738 wrist fusions performed and 7 percent among the 199 wrist replacements.
The study further notes that newer wrist replacement systems have improved design and kinematics compared with those used before 2010. Designed to solve previous models' complications with loosening of the distal component, these newer implants are mainly uncemented and have porous titanium surfaces to allow for osseous integration. With this new technology, wrist replacement systems are being offered to patients who are reluctant to forgo wrist function.
"We have patients who come to us for evaluation for contralateral treatment after having fusion on one wrist," Dr. Rizzo says. "They express frustration with the limitations to movement in the fused wrist and are concerned about having a fusion in that other wrist. Patients who ultimately have wrist fusion on one side and wrist replacement on the other prefer the replacement."
Mayo Clinic has a rich history of innovations in wrist replacement, through studies conducted in the Mayo Clinic Motion Analysis Laboratory. Mayo Clinic hand surgeons designed one of the new wrist implants that is now available. In a retrospective comparative study published in the November 2012 issue of Journal of Wrist Surgery, Mayo Clinic researchers found that newer resurfacing implants, including the one designed at Mayo Clinic, provided good pain relief and functional motion, and had lower Disabilities of the Arm, Shoulder and Hand (DASH) scores than an earlier design.
At Mayo Clinic, evaluation for wrist replacement involves testing of active and passive motion, as well as a detailed history and assessment of the patient's daily activities, including pastimes and level of care at home. The duration of the wrist replacement system depends greatly on the physical demands placed on it.
"The temptation after wrist replacement is similar to having a set of new tires and wanting to give them a run up the highway," Dr. Rizzo says. "But I tell patients that they must go gently."
For more information
Melamed E, et al. Trends in the utilization of total wrist arthroplasty versus wrist fusion for treatment of advanced wrist arthritis. Journal of Wrist Surgery. 2016;5:211.
Cooney W, et al. Total wrist replacement: A retrospective comparative study. Journal of Wrist Surgery. 2012;1:165.