PART III WRIST
chapter
14  Arthroplasty and Arthrodesis of
the Wrist
John Stanley
A pain-free, stable wrist joint is essential for normal function
of the hand. Pain arising from the wrist will, through
the spinal reflex, inhibit the function of the forearm muscu-
lature, thereby effectively reducing its power and leading to
weakness of grasp. This response to pain is not a conscious
act and is governed by involuntary responses not under vol-
untary control. The same mechanism applies when a wrist is
unstable; thus, an unstable wrist will similarly be character-
ized by weakness of grasp. Intermittent pain and instability
result in an unreliable grasp that can fail capriciously and
without warning. In addition to pain and instability may
be added the problems of restricted range of motion and
deformity, which may have an added adverse impact on
function.32
In practice one sees patients with pain at the wrist level
from a number of causes. Primary osteoarthritis of the wrist
is relatively uncommon and is exemplified by degenerative
changes at the scaphotrapeziotrapezoid (STT) joint. More
commonly, arthritis ensues after simple trauma, instability,
dislocations, or inflammatory arthritis and less commonly as
a result of cerebral palsy,79 penetrating wounds, gunshot
wounds, infection,25 and chondrolysis. On occasion, giant cell
tumors require excision and wrist reconstruction with
arthrodesis as the desired outcome.75,111
Treatment of a painful, unstable, degenerate, or stiff wrist
is the province of the hand and upper limb surgeon, and a
variety of surgical procedures are available within the sur-
geons’ armamentarium. The choice of treatment depends on
the cause and the pattern of the effects of the causative
pathology. The procedures available may be grouped into
two principal treatment options, namely, wrist arthrodesis,
partial8,13,118,122,124 or total,* and wrist arthroplasty,4,15,17,23,41
although metaphyseal decompression (forage)47 and partial
neurectomy15 are lesser used procedures.
The aim of any treatment is to provide a pain-free, stable,
and functional wrist, and each individual patient will have a
pattern of problems that guide the surgeon toward the appro-
priate treatment for that individual. In the author’s experi-
ence, some patients cannot tolerate the loss of range of
motion engendered by total wrist arthrodesis133 and will
*See references 1, 3, 7, 26, 42, 43, 66, 71, 132, 138.
therefore press for a motion-preserving procedure.76 There-
fore, careful assessment of the patient’s needs and require-
ments, as well as the patient’s approach to the problem, must
be considered.
Because the normal wrist enjoys considerable range of
motion, loss of any of that range of motion is perceived as
creating an impairment that may give rise to a disability.
However, a number of studies have been performed to
examine the requirements for wrist motion for a variety of
normal activities, and it is clear that most of the activities of
daily living can be performed with quite a restricted range
of motion of the wrist.
Palmer and colleagues suggested that the functional range
of wrist motion is 30 degrees of extension, 5 degrees of
flexion, 15 degrees of ulnar deviation, and 10 degrees of
radial deviation; these values were derived from a study in
which they evaluated 52 standardized tasks involving activi-
ties of daily living and some aspects of work.81 Brumfield
and Champoux found that in performing 15 activities of daily
living, 10 degrees of wrist flexion was required and 35
degrees of wrist extension was used.9 A later study by Ryu
and his group evaluated a smaller number of activities of
daily living and identified that there was an ideal range of
motion that they described as 60 degrees of extension, 54
degrees of flexion, 17 degrees of radial deviation, and 40
degrees of ulnar deviation.94,95 They do go on to say that the
majority of hand placement and range of motion tasks that
were studied in their project could be accomplished with
70% of maximum range of wrist motion—40 degrees each
of wrist flexion and extension and 40 degrees of combined
radial and ulnar deviation. Nelson demonstrated with use of
a splint to mimic stiffness that 123 activities of daily living
could be performed successfully with limited motion consist-
ing of 5 degrees of flexion, 6 degrees of extension, 7 degrees
of radial deviation, and 6 degrees of ulnar deviation.78 This
probably represents considerable coping strategies, compen-
satory motion of the shoulder and elbow, and modification
of activity by the individuals in the study. Their study does
quite clearly identify that although good range of motion is
of great value, only a small arc of motion in each direction
is required to maintain independence of existence. However,
for quality of life it is essential to have a greater range than
429
PART that described by Nelson simply because much of life is
III dealing with hobbies, pastimes, and work, and these activities
may require a specific range of motion that must be consid-
14  ered when assessing individual patients for treatment. More
recently, Franko and co-workers highlighted the issues sur-
Wrist
rounding the capacity of volunteers to adapt and compromise
to limitations of wrist motion.32 In their study, severe restric-
tion of wrist motion with the use of splints gave rise to only
a modest impairment in function of the wrist in activities of
daily living. However, when some motion was allowed, there
was a significant improvement in the ease of performance of
the same tasks and a significant improvement in the range of
tasks that could be performed. This highlights the general
need of patients to have some movement at the wrist but
that the range required will be different from individual to
individual.
Therefore, when patients seek advice and treatment for a
painful, unstable wrist, it is important to identify not only the
impairment that is present but also the net effect of that
impairment on functional ability because this will be unique
to the individual patient and will have a very great effect on
the choice of surgical procedure. Thus, with a good history
one can identify the patient’s particular activities that are
now inhibited by the painful or unstable wrist so that the
correct choice of a motion-preserving procedure, such as
limited arthrodesis or arthroplasty, or a motion-ablating pro-
cedure, such as arthrodesis, can be made. Similarly, the
patient’s age and occupation may well be a significant factor
in the decision-making process with regard to the choice
between arthroplasty and arthrodesis.76 Preoperative assess-
ment of the patient must include a detailed physical examina-
tion and a full radiographic assessment to determine the
residual bone stock and pattern of the disease. Additional
investigations may be needed to identify the underlying
pathology, for example, whether the condition is due to an
inflammatory or degenerative disease process, as well as
identification of any comorbidity that might prejudice the
outcome of any surgical procedure. Preoperative assessment
should score function, disability, and pain to facilitate mea-
surement of the outcome of the intervention. An important
element of the preoperative assessment is an evaluation of
the capacity of the patient’s willingness and ability to comply
with the appropriate postoperative instructions and the
therapy program that accompanies it, and such evaluation is
essential to a successful outcome for most surgical procedures
involving the wrist.
PREOPERATIVE ASSESSMENT
This process therefore consists of four discrete elements.
1. Identification of the impairment or loss of faculty. Impair-
ment is defined as the parameters that can be measured
and include range of motion, grip strength, deformity, and
stability.
2. Assessment of the pain, which by definition is a symptom,
and therefore no objective measurement can be made.
The closest that we can approach assessment of this aspect
of the patients’ problem with some degree of reliability is
through a visual analog scale, and therefore a visual
430
analog chart of the pain should be scored for pain at rest
and pain with activity.
3. The effect on an individual of the limitations generated
by the loss of faculty and the pain is defined as disability.
This identifies the areas of the activities of daily living that
are affected and the areas of significant difficulty within
patients’ lives that they wish to resolve.
4. Radiographic assessment to determine the range of pro-
cedures that are possible as defined by residual bone stock
and the pattern of degenerative changes.
Physical Examination of the Wrist
Examination of the wrist is necessary to establish the base­
line values of movement, strength, deformity, and stabil-
ity.57,109,118,125,130 In addition, visual inspection will allow the
examining physician to observe local swelling, scars, evi-
dence of current or previous infection, and the patient’s
reaction to movement or provocative stressing of the joint or
joints. The associated physical signs of inflammatory joint
disease may well be apparent, and this must include the
stigmata of inflammatory joint disease, as well as the scaly
patches and nail changes caused by psoriasis. A patient with
psoriasis must be warned of the Koebner phenomenon,134 in
which acute psoriatic plaques may develop along the length
of the scar engendered by the surgery. The presence of vas-
culitis or active rheumatoid disease is a contraindication to
any surgery until the condition is controlled.
Radiographic Evaluation
The standard posteroanterior, oblique, and lateral views
should be the basis for the initial radiographic examination.
Gross changes can be seen on these three standard views with
the shoulder held at 90 degrees of abduction, the elbow at
90 degrees of flexion, and the hand placed flat on the radio-
graphic plate.37 This gives a reproducible posteroanterior
view in neutral rotation with the beam centered over the
capitate and including the distal radioulnar joint (DRUJ).
Marked changes, as seen in the scapholunate advanced col-
lapse (SLAC) pattern of arthritis, the scaphoid nonunion
advanced collapse (SNAC) pattern, and carpal coalitions, are
easily identified.18 STT arthrosis may be associated with
deposition of calcium pyrophosphate (Figure 14.1A and B),
and in this condition the radiolunate joint may well be
involved. Less obvious and more difficult to assess is arthrosis
between the capitate and the lunate and between the head
of the hamate and the lunate. In these circumstances, the
so-called six-shot series37 includes a posteroanterior view of
the wrist in full radial and full ulnar deviation, which is valu-
able in identifying elements of instability with scapholunate
gapping. An anteroposterior grip view completes the series
and can magnify carpal collapse, scapholunate diastasis, and
whether there is impingement between the hamate head and
the hamate facet on the lunate (Figure 14.2A to C).114
Specific x-rays are indicated by the history and examina-
tion and, if indicated, should include, for example, a pisotri-
quetral skyline view (a lateral view with the wrist in 10
degrees of supination) (Figure 14.3) to exclude osteoarthritis
of this joint, which can coexist with other areas of arthritis
in the wrist and, if not identified, can give rise to residual
symptoms that may overshadow any improvement after
other surgery.

A B
Figure 14.1  A, Scaphotrapeziotrapezoidal arthrosis may be just localized to one hand, although the majority of patients suffer
from bilateral disease. B, The association with calcium pyrophosphate deposition disease is obvious in this patient with calcific
changes in the triangular fibrocartilage complex.
COMMON RADIOGRAPHIC
PATTERNS OF DISEASE
Osteoarthritis
In osteoarthritis, a common pattern of the progression of
degenerative change has been defined by Watson and Ballet
as the SLAC pattern (Figure 14.4).126 Similarly Cooney and
associates described the SNAC pattern (Figure 14.5).21
Rheumatoid Arthritis
Because the variable picture seen in the inflammatory
arthropathies such as rheumatoid arthritis does not lend itself
to either of these classifications, surgically based guidance
was therefore developed in our unit. The Wrightington clas-
sification of rheumatoid wrist radiographs was set down as a
guide when considering the surgical possibilities based on the
pattern of joint damage and residual bone stock.45
The Conservative Wrist
In general in the early stages of rheumatoid disease, x-rays
may show minor erosions (here between the scaphoid and
capitate), but no significant bone loss or ligament injury and
normal joint spaces. In these circumstances, simple synovec-
tomy with disease-modifying drugs, splintage, and other
measures may be all that is required. This would be called
the conservative wrist (Figure 14.6A).
The Restorative Wrist
As the disease progresses, localized loss of joint space
becomes apparent in the radiocarpal joint (see Figure 14.6B).
There may be secondary changes consisting of translation
and translocation of the carpus. Provided that the midcarpal
joint is well preserved, these patients are suitable for radiolu-
nate13,99 or radioscapholunate fusion.35,101
The Reconstructive Wrist
Progression of the disease can lead to widespread loss of the
joint surface, including the midcarpal joint, but if the bone
stock is preserved, the surgical choices are total wrist replace-
ment or total wrist arthrodesis (see Figure 14.6C).
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The Salvage Wrist
When the wrist has been so damaged by the disease process
that bone stock has been significantly lost, the only surgical
procedure that is reasonably reliable is arthrodesis, and this
is often the only practical course of action. Particular atten-
tion should be paid to the lateral x-ray of the wrist; it may
show significant volar subluxation of the lunate, which will
give rise to some difficulties in reducing the wrist and could
precipitate carpal tunnel syndrome as the wrist is relocated
and realigned (see Figure 14.6D).
SURGICAL TECHNIQUES
Partial Wrist Fusions
History of Limited Wrist Arthrodesis
 Peterson and Lipscomb, 1967: Intercarpal arthrodesis83
 Chamay et al., 1983: Radiolunate arthrodesis13
 Watson and Ballet, 1984: Surgical correction of the SLAC
wrist126
84
 Pisano et al., 1991: Scaphocapitate (SC) arthrodesis
 Minamikawa et al., 1992: The ideal sagittal scaphoid angle
for STT and SC arthrodesis72
 Calandruccio et al., 2000: Capitolunate fusion with exci-
sion of the scaphoid and triquetrum11
Much effort has gone into determining the most appropriate
intercarpal arthrodesis for a given condition, and there is a
wide range of opinion on the best option for particular pat-
terns of disease and the pathology. The choices are laid out
in the following sections.*
Radiolunate Fusion8,13,104
Indications
Localized degenerative change secondary to rheumatoid
arthritis is the most common cause of isolated radiolunate
*See references 24, 36, 40, 49, 62, 89, 116, 121.
431
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Wrist

A B

C
Figure 14.2  A, This radiograph of a wrist under axial load clearly demonstrates scapholunate dissociation but is also suggestive
of hamolunate impingement. B, This cadaveric specimen demonstrates hamolunate impaction, which can occur and may
compromise radiolunate and radioscapholunate arthrodesis. C, The most appropriate investigation is magnetic resonance
imaging, which shows significant bone edema at the tip of the hamate.

arthritis (Figure 14.7A and B). The indications for radiolu-

nate fusion are volar translation, carpal translocation, and
localized radiolunate arthritis, commonly seen in patients
with rheumatoid arthritis but also noted in those with die
punch fractures within the lunate fossa. This latter injury
causes a disorder of normal mechanics, scapholunate disso-
ciation, flexion of the scaphoid, and ultimately, degenerative
arthritis. Frequently, an ulnar abutment syndrome will
accompany the situation because of subsidence of the lunate
within the lunate fossa, and there may be associated damage
to the DRUJ. This complex injury can be improved by radio-
lunate fusion, provided that carpal height is restored.

Technique for Radiolunate Fusion

Figure 14.3  If not recognized preoperatively, pisotriquetral
arthrosis can be painful, irritate the ulnar nerve in the canal of
Guyon, and detract from an otherwise successful surgical wrist
procedure.
432
Preparation of the bone surface is sometimes awkward and
time-consuming because of the nature and shape of the
lunate and the radial fossa, the presence of eburnation of
subchondral bone in osteoarthritic patients, and distortion of
the anatomy as seen in rheumatoid disease (Figure 14.8).
There is a requirement to ensure that the lunate is restored

Figure 14.4  Scapholunate advanced collapse pattern of arthrosis
of the wrist. Localized arthrosis of the scaphoid fossa begins at
the styloid tip (stage I), proceeds to the proximal scaphoid fossa
(stage II), and is followed by capitolunate arthrosis (stage III). The
lunate may fall into dorsiflexion (dorsal intercalated segment
instability [DISI]) and the scaphoid into flexion as seen here, but
the integrity of the radiolunate articulation is preserved until late
in the process.
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Wrist: Arthroplasty and Arthrodesis of the Wrist
Figure 14.5  Scaphoid nonunion advanced collapse (SNAC)
pattern of arthrosis of the wrist. Degenerative changes develop in
the distal segment of the scaphoid (stage I), and the proximal
segment is spared.56 As in this case, excision of the proximal pole
of the nonunited scaphoid will precipitate a combination of
instability and SNAC. The scaphocapitate joint deteriorates in
stage II.
433
PART
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Wrist

A B

C D
Figure 14.6  A, The conservative wrist. Integrity of the ligament and joint surfaces characterizes this phase of the disease,
although erosions may be seen. B, The restorative wrist. The secondary arthrosis is principally confined to the lunate fossa and
suggests that radiolunate fusion is an appropriate option. In this radiograph, the presence of translocation and radioscaphoid
arthritis indicates that radioscapholunate fusion is the preferred option. C, The reconstructive wrist. Bony stock is well preserved,
although all joints are significantly affected, thus giving the opportunity to consider wrist replacement as an option. D, The
salvage wrist. Very poor bone stock remains, and with marked bone loss, arthrodesis remains the most likely choice, although
each case must be taken on its merits.

434

A
B
Figure 14.7  A, Radiolunate arthritis and carpal translocation may
be corrected by radiolunate fusion. B, Nature’s own solution to
the problem of inflammatory arthritis is spontaneous bony
ankylosis.
to its anatomic height, and this involves the use of iliac crest
bone graft or ulnar head bone graft if available and sufficient.
Fixation can be accomplished with Kirschner wires, staples,
miniature pin plates, blade plates, or screws. Headless can-
nulated or other compression screws passed through the
dorsal horn of the lunate can also be used to achieve rigid
fixation (Figure 14.9A and B).
AUTHOR’S PREFERRED METHOD OF
RADIOLUNATE ARTHRODESIS
The wrist is exposed through a standard longitudinal incision
approximately 8 cm long in line with the third metacarpal
and bisected by the radiocarpal joint line (Figure 14.10A
and B). The flaps are raised deep to the superficial fascia to
preserve the vessels and cutaneous nerves while obtaining an
excellent view of the extensor retinaculum. At this point
Lister’s tubercle is identified by palpation, and the extensor
retinaculum is opened over the third compartment just to the
ulnar side of Lister’s tubercle while taking care to not damage
PART
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Wrist: Arthroplasty and Arthrodesis of the Wrist
Figure 14.8  Volar subluxation of the lunate in a patient with
inflammatory joint disease creates a new, more proximal pseudo-
lunate fossa. This accentuates the supination deformity of the
carpus and causes profound collapse of the scaphoid. Isolated
radiolunate fusion in this patient would not be indicated.
the extensor pollicis longus (EPL). The digital extensor
tendons contained within the fourth compartment are raised
in the envelope created by the extensor retinaculum super-
ficially and the capsule of the wrist on the deep surface. This
prevents specific damage to the extensor tendons. The pos-
terior interosseous nerve can be identified lying to the ulnar
side of Lister’s tubercle, and a centimeter should be excised
to prevent tethering of this nerve, which may be extremely
painful when flexing the wrist.64 The wrist capsule is incised
longitudinally along the capitate–third metacarpal axis. The
fourth compartment tendons are contained within the tube
formed by the extensor retinaculum and the dorsal capsule
of the carpus, and displacing them to the ulnar side allows
identification of the capitolunate and radiolunate joints. The
capitolunate joint should be inspected; if it is degenerated,
one would have to consider a full wrist arthrodesis. If the
midcarpal joint is intact, the radiolunate joint is identified and
the cartilage of the lunate fossa and the proximal lunate
surface is denuded from the bone with curets, rongeurs, and
limited use of a bur. A graft is taken from the area deep to
Lister’s tubercle if carpal height is maintained. However, if
carpal height should need to be restored, a corticocancellous
bone graft is taken from the iliac crest with a trephine through
a small incision. The ulnar head, if it has been removed as
part of the procedure, may also be fashioned into a suitable
graft (Figure 14.11A and B). This yields a corticocancellous
435
PART
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14  After preparation of the bone surface and grafting, tempo-
Wrist
A translocation.
Interposition
graft
Staple
B unnecessarily.
Figure 14.9  A, Crossed screws are used here as the construct,
the ulnar head has been replaced, and it is imperative that
adequate clearance between the lunate graft and the implant be
maintained to minimize the potential for the development of an
ulna abutment syndrome. B, Staples may provide a simpler
method of fixation. (B, Copyright Elizabeth Martin.)
graft that may be shaped so that it can be inserted to restore
carpal height, particularly if a die punch fracture has previ-
ously occurred (Figure 14.12).
In a patient with a dorsal intercalated segment instability
(DISI) deformity, this must be corrected to achieve proper
balance of the remaining carpus. Fixation of the lunate in
extension during either radiolunate arthrodesis, capitolunate
fusion, or four-corner fusion will predictably result in loss of
extension. To correct the extended lunate, I fully flex the
wrist and pass a 0.062-inch Kirschner wire through the dorsal
aspect of the radius into the repositioned lunate. When the
wrist is brought back to neutral flexion-extension, the lunate
is in the correct position as seen in the sagittal view (Figure
14.13A to C). Gentle manipulation of the wrist into exten-
436
sion stretches the anterior capsule, and this process can be
repeated through two or three iterations. Extension of the
wrist is then improved and arthrodesis can be completed.
rary fixation with Kirschner wires through the distal dorsal
aspect of the radius into the lunate with the lunate in neutral
rotation allows the position to be checked with intraopera-
tive radiographs or fluoroscopy. Careful assessment of the
midcarpal joint should be performed to rule out hardware
penetration. A cannulated headless bone screw can then be
inserted along the wire. If the lunate does not lend itself
readily to fixation with Kirschner wires through the dorsal
horn, consideration can be given to removal of the proximal
pole of the triquetrum. This maneuver reveals the ulnar
aspect of the lunate and allows a Kirschner wire or headless
bone screw to be inserted through the lunate into the radius
from the ulnar side. This ensures extremely good fixation,
may increase range of motion, and also helps prevent
Pitfalls
1. Failure to appreciate that the posterior interosseous nerve
can be damaged during the course of the dissection and
give rise to limitation of motion because of traction on the
neuroma. If there is any doubt about the status of the
posterior interosseous nerve, it should be identified proxi-
mally and 1 cm of the nerve excised with appropriate
diathermy of the posterior interosseous artery. This will
prevent problems of neuroma of the tethered posterior
interosseous nerve.64
2. Fusion of the lunate in an excessively dorsiflexed position
(DISI). This restricts the range of motion in flexion con-
siderably, and a neutral or 10-degree dorsiflexed position
of the lunate in relation to the radius is essential.
3. Failure to restore carpal height leading to a permanently
flexed scaphoid, thereby restricting range of motion
4. Violation of the capitolunate joint by wires from the
radius into the lunate.
Postoperative Management
Use of a bulky dressing for 10 to 14 days with the hand
elevated whenever possible allows the swelling to subside. A
short arm cast immobilizes the wrist for a period of 5 to 6
weeks. At that point, early rehabilitation should be restricted
to using the dart thrower’s motion only, namely, radial devia-
tion and extension to ulnar deviation and flexion. This pre-
vents excessive forces acting on the radiolunate arthrodesis.
After a further period of 4 weeks, full mobilization can take
place, provided that radiographs confirm the presence of
union. Strengthening exercises for finger motion should start
early. At 3 months it is appropriate to leave patients free of
splintage, but avoidance of contact sports for 2 to 3 addi-
tional months is recommended. Excessive attempts to mobi-
lize the midcarpal joint can result in an increased risk for
nonunion.
Net Analysis of the Literature
Essentially, an approximately 10% nonunion rate58 and a
reduction in range of motion by half in flexion and extension
are reported.

B
Figure 14.10  A single dorsal incision allows wide exposure of the dorsum of the wrist through the third dorsal compartment
(A) and deep to the fourth extensor compartment (B), thereby maintaining the “extensor tube.”
CRITICAL POINTS: RADIOLUNATE ARTHRODESIS
Indications
 Isolated cases of radiolunate arthritis, which usually
arise as a result of localized die punch fractures or
from rheumatoid arthritis
 Instability of the proximal row of the carpus in
translation
 Failed soft tissue reconstruction of scapholunate
dissociation80,116,121,131
Contraindications
 The presence of significant degenerative changes in
the midcarpal joint
Radiographic Evaluation
 Assessment of the preoperative x-rays is essential to
ensure that the midcarpal joint is free of any
degenerative changes, there is no residual
degenerative arthritis in the DRUJ or pisotriquetral
joint, and the DRUJ is stable.
Pearls
 Maintain the fourth compartment “tube” intact to
allow early mobilization.
 Ensure that the posterior interosseous nerve has not
been damaged distally and excise it proximal to the
radiocarpal joint if it has. Injury to the posterior
interosseous nerve (which may be intact but tethered
in scar tissue) is an important cause of postoperative
pain when the wrist is flexed.
 Reduction of the lunate extension is very important;
therefore, for reduction, fully flex the wrist, drive a
Kirschner wire through the distal radius into the
PART
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14 
Wrist: Arthroplasty and Arthrodesis of the Wrist
lunate, and then extend the wrist to reduce the lunate
to the remainder of the carpus.
 During the procedure, temporary fixation of the lunate
to the radius followed by intraoperative radiographs
helps identify whether adequate height has been
achieved and whether the position of the lunate is not
excessively extended with regard to the capitate and
radius. In addition, the lunate must be placed so that
it comes to lie underneath the capitate, not to the
ulnar side of it.
 Excision of the proximal part of the triquetrum
can provide easier access for screw fixation if there
has been significant ulnar translocation of the
lunate.
 Restoration of carpal height is important in post-
trauma cases and to a lesser extent in rheumatoid
patients.
Expectations
 There will be permanent loss of some range of motion
that is generally on the order of or slightly less than
half the range of a normal wrist.
 Full recovery may take a period of 9 to 12 months to
learn to adapt to the new situation, and coping
strategies may be developed in conjunction with the
hand therapist.
 Not all pain will be relieved, and aching will usually
occur after heavy use.
 There is a risk for deterioration over time with the
development of degenerative changes within the
midcarpal joint. This may require further surgery in the
future.
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B
Figure 14.11  A, If the ulnar head is carefully excised as part of
the procedure, it can, in many circumstances, be sufficient graft
to perform radiolunate or radioscapholunate arthrodesis. B, The
head is held in a gauze sponge and the anterior, posterior, and
medial surfaces are removed with an oscillating saw sequentially.
The remaining cortical bone on the distal face provides a strong
structural element for the graft.

C
Figure 14.13  A, The wrist is fully flexed and a smooth 1.1-mm
Kirschner wire is inserted into the distal radius to fix the lunate in
neutral to slight flexion. If the wrist is moved into ulnar deviation
and flexed before transfixion, the maneuver reduces both the
translocation and flexion deformities. B, When the wrist is
brought into neutral, the position of the lunate remains reduced
and the capitate is in appropriate alignment with the lunate. C, A
joystick in the lunate facilitates proper reduction of the lunate
posture before transfixion.

Figure 14.12  The size of the graft will often allow restoration of
carpal height and is sufficiently robust to permit screw or staple
fixation.

438
Scaphocapitate Arthrodesis73
Indications
SC fusion is considered a relatively equal alternative to STT
fusion for stabilization of the scaphoid. Accordingly, indica-
tions include dynamic or rotatory subluxation of the scaphoid
(RSS), persistent symptomatic predynamic instability, non-
union of the scaphoid, Kienbock’s disease,38,49 and midcarpal
instability. It is particularly advantageous with chronic scaph-
oid nonunions to address the instability, as well as expand
the area of bone healing from distal to proximal scaphoid to
capitate.
Most authors believe that there are no significant loading
differences between SC and STT fusion. Watson thinks that
better motion is achieved with STT fusion than with SC
fusion. Laboratory study by Meyerdierks and colleagues
revealed less loss of flexion-extension after SC fusion (19%)
than after STT fusion (23%).70 Another study simulating
limited intercarpal arthrodesis by Douglas and associates
found no significant difference. After both STT and SC fusion
there is diminished joint reactive force at the radiolunate and
capitolunate joints. The amount of restriction of motion very
much depends on proper reduction of the scaphoid to a posi-
tion between 30 and 57 degrees of flexion with respect to
the radius.24
Contraindications
Contraindications, as in STT fusion, include any abnormality
of the radioscaphoid joint that would be susceptible to
increased degeneration and symptoms because of the altered
or increased loading through the radioscaphoid joint after SC
fusion. Similarly, STT degenerative changes would be a con-
traindication to SC fusion.
Fixation
Fixation can be accomplished with Kirschner wires, staples,
screws, or plate and screws (Figure 14.14). Safe hardware
insertion requires identification and protection of the radial
artery and the dorsal sensory radial nerve branches. Pro-
vided that normal intercarpal spacing is maintained by decor-
ticating only the dorsal 75% of the articular surfaces and by
packing the resultant space with bone graft, compression
screws may be used between the scaphoid and capitate to
hold the scaphoid in a 40- to 50-degree radioscaphoid angle.
AUTHOR’S PREFERRED METHOD OF
SCAPHOCAPITATE ARTHRODESIS
The wrist is exposed through a longitudinal incision from
Lister’s tubercle to the base of the index metacarpal. The
dorsal sensory radial nerve branches are protected. The
capsule is exposed between the extensor carpi radialis brevis
(ECRB) and extensor carpi radialis longus (ECRL) tendons
and opened in a “T” fashion. Both the radioscaphoid and
capitolunate joints are protected. The radiocarpal joint is
inspected to confirm that the radioscaphoid joint has normal
cartilage. One or two provisional Kirschner wires are placed
into the distal scaphoid and advanced to the SC joint surface
with use of a drill guide to protect the radial artery and the
dorsal sensory radial nerve branches from being caught up
in the Kirschner wire rotation. Reduction of the scaphoid is
required when instability of the scaphoid exists. It is not
usually necessary in most patients with Kienbock’s disease,
PART
III
14 
Wrist: Arthroplasty and Arthrodesis of the Wrist
Graft
Figure 14.14  Scaphocapitate fusion with staples. Normal space
between the scaphoid and capitate is maintained by preserving
the volar 25% articulation of both bones. (Copyright Elizabeth
Martin.)
however. Similarly, if the lunate is tilted dorsally, this angula-
tion must be corrected to ensure normal alignment of the
fused capitate. For reduction, the proximal scaphoid pole is
depressed and the distal pole of scaphoid elevated with a
0.062-inch Kirschner wire “joystick,” supplemented as
needed with a large skin hook applied around the distal
scaphoid. Correct capitolunate posture can be restored by the
application of a palmar-directed load on the capitate until the
lunate is restored to its normal tilt.
The provisional Kirschner wires are advanced into the
capitate, and reduction to a 40- to 50-degree radioscaphoid
angle is confirmed by fluoroscopy with the wrist in neutral
alignment. Excessive scaphoid extension will impede radial
deviation and extension. Any adjustments in scaphoid posi-
tion are made before decortication of the joint surfaces. The
dorsal 80% of the SC joint is then decorticated down to
cancellous bone, including the dorsal apposing edges. Care is
taken to avoid penetration of the capitolunate joint. Cancel-
lous bone graft is harvested through a cortical window made
just proximal to Lister’s tubercle and is packed into the fusion
space. Two staples 15 mm wide and 10 or 13 mm deep are
inserted by power across the SC joint (see Figure 14.14).
Alternatively, one or two headless bone screws may be
placed along the Kirschner wires after predrilling and con-
firming the depth with fluoroscopy. Care must be taken to
not close the normal intercarpal spacing with the compres-
sion screws. The provisional Kirschner wires are removed
and the capsule closed with 3-0 braided absorbable suture.
The skin is closed with subcuticular 3-0 monofilament poly-
propylene, followed by Steri-Strips. The hand and wrist are
immobilized with a noncompressive short arm bulky dressing
and thumb spica splint.
439
PART Postoperative Management
III
At 10 days, the sutures are removed and a short-arm thumb
spica cast is applied. At 8 weeks, radiographs are checked,
14  and if satisfactory, a short arm wrist splint is applied for
intermittent protection. Active range of motion is initiated.
Wrist
Strengthening is usually deferred until 10 to 12 weeks
postoperatively.
Postoperative Expectations
Range of motion should approximate 50% to 60% of the
opposite side. Although SC fusion in the laboratory decreases
flexion-extension motion by 12.8%36 to 18%,24 greater losses
are seen clinically. Sennwald and Ufenast reported a flexion-
extension arc of 62 degrees.98 Viegas and associates reported
range of motion 50% of the opposite side.121 Grip strength
will be approximately 80% of the opposite side; Pisano and
co-workers reported 74% of the opposite side,84 and
Sennwald and Ufenast documented 83% of the opposite
side.98 Nonunion rates should be similar between STT and
SC fusion. By combining the results of several series of SC
fusion, a 13% to 18% incidence of nonunion has been
noted.58 By meta-analysis of the literature, a 6% to 28%
incidence of nonunion can be expected with a 95% confi-
dence interval.
CRITICAL POINTS: SCAPHOCAPITATE ARTHRODESIS
Indications
 Dynamic or static RSS
 Chronic scaphoid nonunion
 Kienbock’s disease
Preoperative Evaluation
 Evaluate scaphoid stability with the Watson scaphoid
shift test.
 Obtain a supinated anteroposterior radiograph to
evaluate the scapholunate joint for increased gap and
to be sure that the radioscaphoid and STT joints are
free of degenerative changes.
 Obtain a lateral radiograph to evaluate the
scapholunate angle.
 Obtain a hyperpronated anteroposterior radiograph to
evaluate the STT joint.
Pearls
 Preserve the volarmost cartilage surfaces between the
scaphoid and lunate to maintain normal anatomic
relationships.
 It is easier to reduce the scaphoid before
decortication.
Technical Points
 Protect the radial sensory nerve branches and radial
artery by using a small drill guide during Kirschner
wire placement.
 Confirm by fluoroscopy or radiographs proper
reduction of the scaphoid to a 40- to 50-degree
radioscaphoid angle. Separate lunate reduction is not
required.
Pitfall
 Avoid overreduction (extension greater than 50
degrees) of the scaphoid, which will limit motion,
particularly radial deviation and extension.
440
Postoperative Care
 The initial dressing should be bulky but
noncompressive to avoid postoperative pain. Apply a
short-arm thumb spica splint.
 At 10 days, apply a well-molded short-arm thumb
spica cast.
 At 8 weeks, check radiographs and initiate active range
of motion exercises.
Expectations
 Fifty percent to 60% range of motion in comparison
to the opposite wrist
 Eighty percent grip strength
 Fifteen percent nonunion rate
 Minimum 4-month recovery time before sports
participation
Athletic Participation
Athletic use of the involved extremity is precluded for at
least 8 weeks. Nonloaded use is allowed at 8 weeks. Full
use and any exposure to sudden force should be avoided
for at least 10 to 13 weeks after surgery. Patients should
not expect strong, relatively symptom-free wrist
performance until at least 4 months after surgery.
What I Tell My Patients
Patients are advised that they will lose 40% to 50% of
wrist motion but should still have a very functional arc. It
is possible that they may experience postoperative
transient tingling over the dorsoradial aspect of the wrist
or hand, which will resolve over time. Although the wrist
will never feel “normal,” almost all patients will feel
improvement and regain 70% to 80% of grip strength.
Patients are strongly advised to discontinue smoking
preoperatively. Nonunion is unlikely but can occur in
15% of cases, particularly in patients who smoke.
Radioscapholunate Arthrodesis
Indications
 Proximal row destruction, most commonly seen in post-
traumatic cases in which there has been extensive intra-
articular damage, but also after chondrolysis, infection, or
inflammatory arthritis.
 Preservation of midcarpal motion while dealing with the
painful radiocarpal motion
Contraindications
 Patients who have active infection
 Destruction of the distal radius with significant deformity
 Degenerative changes in the midcarpal joint
AUTHOR’S PREFERRED METHOD
OF TREATMENT
Through a central longitudinal dorsal incision, full-thickness
skin flaps are raised to identify the extensor retinaculum.
Lister’s tubercle is identified and an incision made in the
extensor retinaculum in a line between the third and fourth
compartments. The fourth compartment is raised as a tube
by dissection of the fourth compartment and the dorsal
capsule from the dorsal aspect of the wrist and carpus. The
EPL tendon is dislocated from its groove. Lister’s tubercle is
 lems of using Kirschner wires or cannulated screws.101 They PART
reported successful use of 2.4-mm distal radial plates to III
provide locking plate stabilization of their radioscapholunate
fusions. Nagy and Büchler identified two patients who
14 
exhibited secondary midcarpal degenerative joint disease.77

Wrist: Arthroplasty and Arthrodesis of the Wrist

Hamate-lunate impaction syndrome can occur in patients
with a type II lunate110 and may be secondary to activities
that require frequent flexion and ulnar deviation (see Figure
14.2B).114 Treatment of hamate-lunate impaction syndrome
is amputation of 2 to 3 mm of the tip of the hamate head,
which can be performed at the same time as radioscapholu-
nate fusion. This causes no instability in the wrist and can
ensure that hamate-lunate impaction syndrome does not lead
to pain and the late development of midcarpal degenerative
joint disease.

CRITICAL POINTS: RADIOSCAPHOLUNATE ARTHRODESIS

Figure 14.15  Example of radioscapholunate fusion. The diseased
ulnar head has been excised and prepared in this case as the two
grafts that are necessary to achieve restoration of carpal height
and to ensure that the lunate is neutral in flexion and extension.
Normally, it is our practice to excise the distal 20% of the
scaphoid initially and then check during the dart thrower’s range
of motion that clearance is adequate. Further excision can be
done until the surgeon is comfortable with the range of motion.
Similarly, excision of the triquetrum follows the same principle.
removed with an osteotome. The ECRB and ECRL are then
retracted to the radial side, and the capsule is raised from the
Indications
 Radioscaphoid or radioscapholunate joint arthritic
deformity after distal radial intra-articular fractures
 Rheumatoid arthritis with relative sparing of the
midcarpal joint
Preoperative Evaluation
 Computed tomography can be very helpful as an
adjunct to the standard x-rays to identify the nature of
the midcarpal joint and in particular identify the
presence or absence of a type II lunate facet.
Pearls
 There must be complete absence of degenerative joint

Lister’s tubercle to the styloid process. Inspection of the
midcarpal joint to ensure that there is adequate cartilage on
the surface is the first prerequisite of this procedure. Any
malalignment of the proximal row must be corrected by
reduction of the lunate into the neutral position and reduc-
tion of the scaphoid into 45 degrees of radioscaphoid flexion,
as determined by image intensification. The articular surfaces
are then excised down to cancellous bone. The space is filled
with bone graft, which may be taken from the distal radius
through a small defect created by removal of Lister’s tubercle
(Figure 14.15). Once the graft is in situ and the positions are
satisfactory, Kirschner wires are driven across from the
radius to the scaphoid and from the radius to the lunate.
Although memory metal staples can be used for this purpose
and can be helpful in obtaining compression, positioning of
the staples is crucial. Once reduction and fixation for the
arthrodesis have been achieved, range of motion should be
checked. Because the scaphoid is fixed at 45 degrees of
flexion, flexion-extension may be limited and radial devia-
tion is particularly limited. The resultant motion is almost
entirely in the dart thrower’s plane of radial extension to
ulnar flexion. Therefore, I prefer to excise the distal pole of
the scaphoid to enable further radial deviation,35,43 and sepa-
rately, Pervaiz has recommended removal of the triquetrum
to enable unimpeded ulnar deviation of the wrist.82
Complications
Shin and Jupiter commented on the problems of nonunion
after attempted radioscapholunate arthrodesis and the prob-
disease within the midcarpal joint.
 A 2- to 3-mm amputation of the impacting part of the
head of the hamate must be performed if there is a
significant type II joint on the lunate.
 A 2.4-mm locking plate across the radiocarpal joint is a
reliable method of fusion.97
 The fourth compartment should be raised as a tube by
subperiosteal dissection and the EPL dislocated toward
the radial side.
 Partial osteotomy of the tubercle of Lister and raising
the flap from the radial side preserve the EPL pulley
mechanism.
 Displacement of the ECRB and ECRL to the radial side
gives adequate exposure.
 Excision of the distal pole of the scaphoid should be
performed to allow free radial deviation of the wrist.
 Decortication of the posterior two thirds of the
scaphoid, lunate, and radius preserves longitudinal
alignment and length, and the area can be grafted
quite readily. The use of a rongeur is most helpful in
preparing the surfaces.
64
 Any doubt about posterior interosseous nerve injury
should lead to excision of a centimeter of the posterior
interosseous nerve, proximal to the distal radiocarpal
joint.
Pitfalls
 Failure to recognize that a type II lunate is preventing
full ulnar deviation of the midcarpal joint and therefore
that excision of the proximal tip of the hamate is
necessary
Continued

441
PART
CRITICAL POINTS: RADIOSCAPHOLUNATE
III ARTHRODESIS—cont’d
14   Dissociative volar intercalated segment instability (VISI)
 Failure to adequately excise the distal pole of the
scaphoid
Wrist
 Violation of the capitolunate joint
 Failure to recognize ulna abutment between the ulnar
head and triquetrum
Expectations
 Seventy-degree arc of flexion-extension, 35-degree arc
of radioulnar deviation
 Thirty percent nonunion rate
 Incomplete relief of pain
 Nine- to 12-month recovery
 Possible late-onset midcarpal degenerative changes
Postoperative Care
As is standard for any fusion, initial immobilization in a
bulky dressing for 10 to 14 days with the hand elevated
whenever possible allows the swelling to subside. At 10
to 14 days a short arm cast that allows finger and thumb
motion is applied for 4 to 6 weeks. Once union is
confirmed at 6 to 8 weeks, therapy is commenced with 1
to 2 weeks of dart thrower’s motion, followed by 4 weeks
of additional flexion-extension and radial-ulnar deviation
exercises. Strengthening exercises with avoidance of
heavy activities are then initiated for 4 to 6 weeks, and
no contact sports are permitted for 4 to 5 months
postoperatively.
What Patients Should Be Told
There will be restricted range of motion, as identified by
Garcia-Elias and colleagues.34 The overall arc of flexion-
extension should be approximately 70 degrees with 15
degrees of radial deviation and 20 degrees of ulnar
deviation. Nagly and associates documented an average
postoperative range of motion of 32 degrees of flexion,
35 degrees of extension, 14 degrees of radial deviation,
and 19 degrees of ulnar deviation.76 There is a nonunion
rate of 30%.58 Recovery occurs over a period of 9 to 12
months, and then not all pain will be relieved. Patients
should be warned that they are at risk for midcarpal
arthritis because of the altered wrist biomechanics.
Scapholunate Arthrodesis
Because motion of the scaphoid varies from individual to
individual, the results of scapholunate arthrodesis are unpre-
dictable. In the hypermobile group of patients, the scaphoid
will pronate and flex considerably with a small amount of
translation. At the other extreme, the scaphoid does not flex
or pronate in radial deviation.22 In patients with hypermobile
scaphoids, scapholunate arthrodesis is contraindicated. Non-
union rates are high, the ability to achieve union is low, and
the results are unpredictable. With a 60% nonunion rate, this
procedure has not really been proved to be satisfactory
treatment.
Lunotriquetral Arthrodesis46,52
Indications
 Painful partial coalition of the lunotriquetral joint
 Symptomatic triquetrolunate dissociative instability
442
Contraindications
 Patients with midcarpal arthritis
 Nondissociative ulnar midcarpal instability
AUTHOR’S PREFERRED METHOD OF
LUNOTRIQUETRAL ARTHRODESIS
A longitudinal dorsal wrist incision is used. The lunotrique-
tral joint is approached through the fifth dorsal extensor
compartment, and the extensor digiti minimi is dislocated
toward the radial side. The triquetrum is identified through
a longitudinal capsular incision, and the fourth compartment
is raised subperiosteally off the distal radius to identify the
lunotriquetral interval. The interval is prepared with osteo-
tomes and a rongeur. Distal radius bone graft may be taken
by elevating Lister’s tubercle and using the same incision or
a separate small transverse incision overlying the second
compartment. The fusion site is packed with bone graft
while maintaining intercarpal spacing. Temporary 0.045-inch
Kirschner wire fixation confirms the reduction and appropri-
ate alignment. The Kirschner wire may be used to guide the
cannulated drill or reamer to prepare for the insertion of a
single cannulated headless bone screw; this can give rise to
substantial compression of the joint, which is then usually
stable. If there are any doubts about stability, a percutaneous
Kirschner wire can be inserted in addition and cut flush with
the triquetrum and left in situ.
Postoperative Management
As with any limited wrist arthrodesis, healing requires 5 to
6 weeks of immobilization. At this point the patient may be
mobilized gently with flexion-extension exercises and initia-
tion of grip-strengthening exercises. If the x-rays show satis-
factory union, more powerful activities can be started at 8
weeks, and at 12 weeks the patient should be satisfactorily
recovered, but heavy activities and contact sports should be
avoided for 4 to 5 months.
Pearls
Because the effect of lunotriquetral fusion is unpredictable,
temporary stabilization of the joint with a headless bone
screw can be performed percutaneously through a small stab
incision while taking care to avoid the dorsal branch of the
ulnar nerve. After inserting a Kirschner wire and confirming
its position with fluoroscopy, a cannulated drill and tap are
used, followed by insertion of a headless bone screw across
the joint (Figure 14.16). The patient can then “try out” the
fusion for the next 4 to 6 weeks; if successful, then as a defi-
nite open procedure, the screw can be loosened, the joint
prepared, bone graft inserted, and the screw recompressed.
Failure of the temporary fixation to improve the patient’s
symptoms indicates that the screw should be removed and
the status quo be re-established. Further consideration about
management of the instability and pain needs to be made.
Pitfalls
The major problem occurs during the introduction of percu-
taneous wires from the ulnar side. The dorsal branch of the
ulnar nerve is highly vulnerable at this point, and injury
may give rise to a neuroma of this nerve associated with

Figure 14.16  Headless bone screws are ideal for triquetrolunate
(TL) fusion. A trial of TL fusion can be performed by percutaneous
insertion of a TL screw.
disturbance of sensation on the dorsal/ulnar aspect of the
hand. This complication causes considerable distress to
patients and significantly detracts from any positive benefit
of this procedure. To avoid this problem, a small skin incision
should be made as is practiced in arthroscopy of the wrist,
blunt dissection performed down to the triquetrum, and a
drill sleeve used to protect the soft tissues.
Preoperative x-rays in full ulnar deviation and full axial
compression of the forearm should identify whether there is
abutment between the ulnar head and the triquetrum. Ulnar
impaction may be the cause of lunotriquetral instability;
it may also be a cause of significant pain. Treatment
involves an isolated or combined wafer procedure29 or
ulnar-shortening osteotomy.
What Patients Should Be Told
There is a nonunion rate of 30%,58 there will always be loss
of 30% to 40% range of motion, the results are somewhat
unpredictable, and recovery takes 9 to 12 months. The pain
may not be entirely relieved.
Triquetrohamate Fusion
Rao and Culver reported an almost 50% failure rate in pro-
viding relief of symptomatic midcarpal instability with tri-
quetrohamate fusion88; therefore, this operation is not
recommended. The author’s experience mirrors that of these
authors.
Scaphotrapeziotrapezoidal Fusion
Indications
The presence of degenerative arthrosis localized to the STT
joint is often associated with calcium pyrophosphate deposi-
tion disease. Primary osteoarthritis of this joint is not uncom- PART
mon. Painful radial deviation and pain on gripping and when III
performing heavier tasks are the usual complaints made by
patients with STT arthritis, and failure of conservative mea-
14 
sures and corticosteroid injection is the indication for surgical
Wrist: Arthroplasty and Arthrodesis of the Wrist
intervention. STT arthrodesis (called triscaphe arthrodesis
by Watson124) is also indicated for selected cases of dynamic
or static RSS, persistent symptomatic predynamic RSS
with instability, nonunion of the scaphoid, Kienbock’s
disease,38,49,127,129 scapholunate dissociation,124 midcarpal
instability, and congenital synchondrosis of the STT joint.
Contraindications
Contraindications primarily include radiographic narrowing
or degenerative change of the radioscaphoid joint, which will
become increasingly degenerative and symptomatic after the
increased load transfer associated with STT fusion.
Preoperative evaluation should include radiography of the
STT joint with full ulnar deviation views and full radial devia-
tion views to identify whether the scaphoid moves. If the
scaphoid is highly mobile, as characterized by considerable
flexion and pronation during radial deviation, an STT fusion
condemns patients to painful radioscaphoid subluxation each
time that they move into radial deviation. In this case, one
should consider some form of either interpositional arthro-
plasty or excisional arthroplasty rather than arthrodesis.
Similarly, if there is substantial gap formation at the STT joint
on full ulnar deviation that closes on radial deviation, there
may be chronic bone loss involving the distal pole of the
scaphoid. These patients have less satisfactory results with
arthrodesis than do those with no appreciable gapping on
ulnar deviation. The group with appreciable gapping has
significant impairment of postoperative motion in the author’s
experience and seems to be better served by excision of the
distal pole of the scaphoid.35
AUTHOR’S PREFERRED METHOD OF
SCAPHOTRAPEZIOTRAPEZOID FUSION
The STT joint is approached through a 4-cm transverse dorsal
wrist incision just distal to the radial styloid. The dorsal veins
and branches of the superficial branch of the radial nerve are
preserved. The radial styloid is exposed through an incision
in the capsule, and the distal 5 mm is removed with a rongeur.
A transverse incision in the dorsal capsule is then made, and
the radioscaphoid joint is inspected. If significant degenera-
tive disease is found here, the procedure of choice is proximal
row carpectomy (if the capitate has a healthy articular
surface) or SLAC reconstruction (if both the scaphoid fossa
and head of capitate show degenerative wear).
The distal aspect of the extensor retinaculum is then
opened along the EPL and the STT joint approached through
a transverse capsular incision between the ECRL and ECRB
tendons. The entire articular surfaces of the scaphoid, trape-
zium, and trapezoid are then removed with a rongeur while
taking care to remove the proximal half of the trapezium-
trapezoid articulation only. It is mandatory that the subchon-
dral hard cancellous bone also be removed and the softer
cancellous surfaces exposed. The dorsal cortex of the trape-
zium and trapezoid is likewise removed to broaden the
surface area for fusion. The volar lip of the scaphoid is decor-
ticated by inserting a dental rongeur deep into the joint and
443
PART
III TZM TZD
14 
Wrist
Figure 14.17  These diagrammatic representations of the preparation and positioning of the scaphoid highlight the requirement
of ensuring that the scaphoid must lie in a flexed position at 45 to 55 degrees to the long axis of the radius before insertion of
the Kirschner wires. S, scaphoid.
levering the handle distally. Cancellous bone graft is then
harvested from the distal radius at Lister’s tubercle. Two
0.045-inch Kirschner wires are driven percutaneously from
the distal aspect of the dorsal trapezoid proximally into the
prepared space without crossing it. The first, radially posi-
tioned Kirschner wire is passed to the point of just touching
the surface of the scaphoid. The second, ulnarly positioned
Kirschner wire is passed proximally to the point of entering
the scaphotrapezoid space. The wrist is then placed in full
radial deviation and 45 degrees of dorsiflexion while the
scaphoid tuberosity is reduced by the surgeon’s thumb to
prevent overcorrection of the scaphoid (Figure 14.17). A
5-mm spacer, usually the handle of a small instrument, is
placed into the scaphotrapezoid space to maintain the origi-
nal external dimensions of the STT joint, and the radial
Kirschner wire is driven into the scaphoid while avoiding
placement into the radioscaphoid joint. The spacer is then
removed, and the ulnar Kirschner wire is similarly driven
into the scaphoid. After pinning, the scaphoid should lie at
approximately 55 degrees of flexion relative to the long axis
of the radius when seen from the lateral view. This ensures
optimal radioscaphoid congruity and maximizes postopera-
tive range of motion. It is not necessary to correct any abnor-
mal rotation of the lunate. Excessive extension of the scaphoid
will limit the motion obtained after surgery. Cancellous bone
is then densely packed into the spaces between the scaphoid,
trapezium, and trapezoid. The pins are cut beneath the skin
level, and the wrist capsule and extensor retinaculum are
simply realigned without suturing. The skin incisions are
closed with a single-layer subcuticular monofilament suture.
The postoperative dressing consists of a bulky noncompres-
sive wrap incorporating a long arm plaster splint. The hand
is placed in a protected position with the wrist in slight exten-
sion and radial deviation, the forearm neutral, and the elbow
at 90 degrees.
Postoperative Management
Maximum initial immobilization is mandatory for these
small-bone fusions. Three to 5 days after surgery, the bulky
dressing is removed and a long-arm thumb spica cast applied.
The proximal carpal row is easily immobilized by casting the
444
45˚
forearm and arm, but it is difficult to adequately maintain the
position of the distal carpal row. Therefore, the metacarpo-
phalangeal (MP) joints of the index and middle fingers are
flexed to 80 to 90 degrees and included in the long arm cast
and the interphalangeal joints are left free. Four weeks post-
operatively, the long arm cast and skin sutures are removed.
A short-arm thumb spica cast is applied for an additional 2
to 3 weeks. In patients older than 55 years, 3 weeks in a long
arm cast followed by 3 weeks in a short arm cast may be
sufficient. Six weeks postoperatively, the short arm cast is
removed and radiographs are obtained. If radiographic evi-
dence of union is seen, the pins are removed in the office and
the patient is referred for hand therapy for full wrist mobili-
zation. A splint may occasionally be used for an additional
1 or 2 weeks if there is any doubt about the status of bone
healing.
Alternative Techniques
Staples
Power-inserted staples can simplify the fixation process and
prevent complications related to Kirschner wire irritation and
possible infection. After provisional fixation in appropriate
position with Kirschner wires, staples are driven by power
across the scaphotrapezial and scaphotrapezoid joints. The
provisional Kirschner wires can then be removed. Postopera-
tive care is as outlined earlier.
Screw Fixation
The STT joint should be reduced and provisionally held by
two guide wires and checked under fluoroscopy. Length is
measured and an appropriate-length cannulated screw can be
inserted over each wire.
What Patients Should Be Told
Watson has reported excellent functional results and pain-
free, stable wrists after STT arthrodesis. After 4 to 6 weeks
of hand therapy, the average range of motion is usually 50%
to 70% of that of the contralateral normal wrist; it increases
to an average of 80% by 1 year after surgery. Grip strength
has averaged 90% of that of the unaffected wrist. Long-term
radiographic follow-up has revealed only rare instances of

Figure 14.18  Early stage III SLAC wrist as seen on a radiograph.
The prolonged scaphoid flexion and the deepening radial erosion
force the lunate into extension, which becomes very difficult to
reduce because of an associated anterior capsular contracture.
Reduction, however, is essential to permit extension of the wrist,
which after a four-corner fusion, occurs solely at the radiolunate
articulation.
progressive radioscaphoid or intercarpal degenerative
changes and just in patients who had some evidence of
disease in these joints at the time of surgery.124 It is important
to avoid radial styloid impingement because this can give rise
to postoperative pain; styloidectomy is thus an important
element in the procedure.93 The nonunion rate is greater than
20%. There will always be some loss of range of motion,
which is somewhat unpredictable. Recovery takes 9 to 12
months, and pain relief may not be complete.
Not all authors report similar successful results after STT
arthrodesis. Kleinman and Carroll reported a 52% complica-
tion rate in 47 wrists monitored for 10 years and highlighted
the need for precise positioning of the fused scaphoid.55
Reconstruction of Wrists with Scapholunate
Advanced Collapse (Scaphoid Excision,
Capitate-Lunate-Hamate-Triquetrum Fusion)
The SLAC126 and SNAC20 patterns of arthritis spare the
radiolunate articulation, and therefore capitate-hamate-
lunate-triquetrum arthrodesis (the four-corner fusion with
scaphoid excision) has become the procedure of choice, par-
ticularly if the midcarpal joint is arthritic.54,56,120,128,131 Exci-
sion of the scaphoid must include stabilization of the
remaining carpus to prevent gross instability, and this is
achieved effectively either through arthrodesis of the capi-
tate, lunate, triquetrum, and hamate or by capitolunate
fusion alone. Capitolunate arthrodesis reduces the area of
cancellous bone exposed and may be less reliable than four-
corner fusion.
Indications
The presence of degenerative changes in the radioscaphoid
joint and the midcarpal joint identifies the pattern as SLAC
wrist stage III (Figure 14.18). If the capitolunate joint is pre-
served, proximal row carpectomy is an alternative to four-
corner fusion and has the same or improved outcome.19,48,63,115,137
Scaphoid nonunion or avascular necrosis of the scaphoid with
the SNAC pattern of arthritis may lead to significant symp- PART
tomatic wrist arthritis, and four-corner fusion is an option.100 III
Contraindications
14 
The lunate fossa must be intact and free of disease such as
Wrist: Arthroplasty and Arthrodesis of the Wrist
crystalline or inflammatory arthropathy for four-corner
fusion or capitolunate fusion to succeed.
AUTHOR’S PREFERRED METHOD OF
TREATMENT: SCAPHOID EXCISION AND FOUR-
CORNER FUSION
A longitudinal incision is made in the line of the third meta-
carpal. The extensor retinaculum is incised over the third
compartment, and the fourth and second compartments are
exposed over the carpus. Posterior interosseous neurectomy
must be performed by excising a 1-cm segment of the nerve
proximal to the dorsal rim of the radius. The capsule is
incised transversely at the level of the capitolunate joint. The
ECRL is retracted radially and the ECRB retracted ulnarly to
extend the capsulotomy more radially for exposure of the
scaphoid. The scaphoid is removed with a rongeur. The
palmar radioscaphocapitate and long radiolunate ligaments
are protected. Visual inspection of the lunate and the lunate
fossa must confirm intact articular cartilage. The remaining
cartilage and subchondral bone are removed from the sur-
faces of the capitate, distal lunate, hamate, and distal trique-
trum until a broad cancellous surface is obtained. Bone graft
is harvested from beneath Lister’s tubercle. Next, 0.045-inch
Kirschner wires are percutaneously pre-set through the capi-
tate, hamate, and triquetrum so that they line up with the
more proximal lunate. A fourth wire is passed into the tri-
quetrum directed toward the capitate. Cancellous graft is
packed into the deep interval between the capitate and
lunate. The most important step in this procedure is to reduce
the dorsiflexed position of the lunate in relation to the radius.
A Kirschner wire inserted into the dorsal lunate is used as a
joystick for reduction. With the lunate reduced into neutral
alignment or very slight extension, the capitate is translated
ulnarward to center it with the lunate in the coronal plane.
The pre-set Kirchner wires are then passed across the capi-
tolunate, capitohamate, triquetrocapitate, and triquetrolu-
nate joints under fluoroscopic guidance (Figure 14.19A). The
intervals between the bones are packed with cancellous bone
harvested from the distal radius. We prefer at this point to
insert cannulated headless self-tapping bone screws over the
Kirschner wires to compress the fusion site. The wires are
removed, and passive range of movement is recorded. The
capsule is closed, the retinaculum repaired, the subcutaneous
tissues approximated, and the skin closed with subcuticular
suture.
Postoperative Management
(Kirschner Wire Fixation)
The extremity is immobilized in a bulky conforming dressing
and a short arm splint in 20 degrees of extension. At 3 to 5
days the soft dressing is removed and a short arm cast applied.
The fingers are left free for exercises. At 5 weeks after
surgery the patient is assessed clinically and radiographically,
a lightweight removable splint is applied, and remedial exer-
cises are commenced. In patients younger than 55 years, a
more cautious approach consisting of the application of a
445
PART
III
14  between the capitate and hamate, a second between the
Wrist
A nique. The bones are provisionally held by Kirschner wires,
B
Figure 14.19  A, Kirschner wires fixing a four-corner fusion.
B, Diagram of staple fixation. (Copyright Elizabeth Martin.)
long arm cast for the first 5 weeks may be indicated. When
cannulated compression screws are used, the period of casting
may be shortened by a week or two to enable gentle range
of motion exercises.
Alternative Methods of Fixation
In recent years a number of internal fixation devices have
been designed and applied to limited wrist fusion in an
attempt to provide more rigid fixation.
Staple Fixation
Power fixation devices have facilitated placement of staples
with both improved accuracy of placement and improved
446
biomechanical properties.6,99 The capitate, lunate, hamate,
and triquetrum are prepared as described earlier and provi-
sionally held with Kirschner wires. One staple is placed
hamate and triquetrum, and a third between the lunate and
capitate (see Figure 14.19B). Staples measuring 13 mm wide
and 10 mm deep are normally chosen.
Screw Fixation
The development of headless compression screws has facili-
tated internal fixation of carpal bones by the ability to bury
the screw within the carpus. Several manufacturers have
designed appropriate headless cannulated screws. Screw fixa-
tion affords the opportunity for initiation of earlier range
of motion because more reliable and rigid fixation can be
achieved.
Circular Plate Fixation
The surgical approach is as described in the preceding tech-
and intervals between the joints are denuded of cartilage. A
circular rasp is centered over the fusion area and advanced
by power or hand to a point flush or below the dorsal surface
of the carpal bones. This creates abundant cancellous surfaces
and provides further visualization for additional removal of
cartilage between the four bones. Autogenous cancellous
bone graft from the distal radius is packed between each of
the four bones within the rasped defect. The circular plate is
aligned to allow maximum screw placement in each of the
four bones. If the plate is properly aligned, two screws can
be placed in each bone. A holder/drill guide is used to main-
tain proper alignment of the plate, and self-tapping screws
are sequentially placed after predrilling. Tightening of the
screws imparts compression to the four bones. An additional
screw is placed in each of the bones as space allows. Proper
placement is assessed by intraoperative fluoroscopy and stan-
dard anteroposterior and lateral radiographs (Figure 14.20A
and B).14 Additional bone graft may be packed within the
central portion of the four-corner region through the plate.
Plate fixation may enable earlier range of motion, but several
recent studies have noted a higher nonunion rate and hard-
ware complications with circular plate fixation.51,102,119
Scaphoid Excision with
Capitolunate Arthrodesis
Stabilization (fusion) of the midcarpal joint for reconstruction
of a SLAC wrist can also be achieved by isolated capitolunate
fusion (Figure 14.21A and B).5,11,50,53 Because there is no
theoretical difference in motion between the two options,
four-bone fusion has been recommended to enlarge the
fusion surfaces and improve the rate of union. With the avail-
ability of more rigid methods of fixation, isolated capitolu-
nate fusion has been used as a simpler procedure that requires
only limited bone graft, which can be obtained from the
excised scaphoid. Screw fixation permits earlier initiation of
range of motion. Some authors recommend triquetral exci-
sion at the time of capitolunate fusion.
Total Wrist Arthrodesis
When the wrist has been so damaged by the disease process
that significant bone stock has been lost, the only surgical
 PART
III
14 

Wrist: Arthroplasty and Arthrodesis of the Wrist

A B
Figure 14.20  A and B, Radiographs demonstrating successful four-corner fusion. Use of a circular plate is effective in holding the
four bones together, but the plate must be recessed to prevent dorsal impingement of the plate by the dorsal lip of the radius.
Excessive recession of the plate diminishes the area of contact between the bones, and this is a matter of clinical judgment. Note
the fracture of one of the more radial screws.

B
A

Figure 14.21  A, Excision of the scaphoid and localized capitolunate fusion fixed with headless bone screws. B, Excision of the
scaphoid and triquetrum occasionally requires an additional capitohamate arthrodesis in the small group of patients with a
mobile capitohamate joint. (Copyright Elizabeth Martin.)

procedure that is reasonably reliable is arthrodesis, and this  Ely, 1920: Arthrodesis for tuberculosis25
is often the only practical course of action. Particular atten-  Gill, 1923: Devised a method of corticocancellous grafting
tion should be paid to the lateral x-ray of the wrist; it may to provide stability138
show significant volar subluxation of the lunate, which will  Smith-Peterson, 1939: Described an ulnar approach with
give rise to some difficulties in reducing the wrist and could distal ulnar excision103
27
precipitate carpal tunnel syndrome as the wrist is relocated  Evans, 1955: Wedge arthrodesis
and realigned.
Plates, Wires, and Staples
History of Wrist Arthrodesis60,62,88,96,97,106,113,135  Wood, 1967: Introduced a modification of the Gill tech-
 Steindler,1918: Wrist arthrodesis for stabilization in nique involving compression wire fixation138
patients with polio and spastic hemiparesis107  Larsson, 1974: AO plating
59

447
PART
III
14 
Wrist
Figure 14.22  Introduction of intramedullary pins through the
head of the third metacarpal is rapid and effective fixation for
radiocarpal arthrodesis.
 Benkeddache et al., 1984: Multiple staples6
 Hastingset al., 1993/1996: Modified AO plate with
compression42
Intramedullary Fixation
 Robinson and Kayfetz, 1952: Intramedullary rods in rheu-
matoid patients92
 Clayton, 1965: Outlined techniques without fixation in
rheumatoid patients15
 Mannerfelt and Malmsten, 1971: Introduced the Rush pin
technique67
 Millender and Nalebuff, 1973: Popularized the use of a
Steinmann pin and sliding graft71
AUTHOR’S PREFERRED METHOD OF TOTAL
WRIST ARTHRODESIS
Precontoured plates may be used for total wrist arthrodesis
in patients with degenerative arthrosis and inflammatory
arthritis but with good bone stock. For patients with signifi-
cant bone loss because of inflammatory joint disease, the
technique first described by Ferlic and Clayton30 and further
popularized by Millender and Nalebuff71 uses a Steinmann
pin inserted down the third metacarpal shaft and into the
radius (Figure 14.22). The technique is both technically
simple and effective.
This technique is not without potential complications since
the third MP joint will have to be violated. In addition,
because these patients have multijoint involvement, it is
likely that surgery to replace the third MP joint will be
required as a result of the rheumatoid joint disease. The
Steinmann pin may be difficult to countersink, and if there
is a failure of union of the third carpometacarpal (CMC) joint,
448
Figure 14.23  Three lengths of pins in two diameters for
placement in the third metacarpal shaft are shown here. The
introducer and countersink driver are also demonstrated.
continued motion at the third CMC joint may cause the pin
to work loose and migrate distally. For these reasons, some
surgeons prefer to place the pin retrogradely through the
carpus and out the second intermetacarpal web space. The
pin can then be redirected in an antegrade fashion down
the shaft of the radius. The intermetacarpal pin position
places the hand in a slightly ulnar-deviated position, which
is advantageous mechanically.
To counteract these problems and to improve secure intra-
medullary fixation, the Wrightington unit has developed a
specialized instrument kit consisting of modified pins, a
driver, and a countersink driver (Osteotec Ltd,, Christchurch,
Dorset, UK).105 The tip of the pins has a flat cutting edge with
a chip breaker so that it may be used as a drill when mounted
on a hand drill piece. There are a variety of sizes and lengths
(Figure 14.23). Preoperative radiographs must be assessed to
identify the diameter of the third metacarpal so that that the
correct size and length of pin can be chosen. The wrist joint
is opened through a dorsal incision in the midline, and the
extensor retinaculum is opened longitudinally through the
fifth extensor compartment and reflected to the radial side of
the second compartment. Extensor tenosynovectomy is per-
formed as necessary. The dorsal capsule is then detached
from the distal radius and reflected distally. Posterior interos-
seous neurectomy is routinely performed. The wrist joint is
then flexed and adhesions broken down with a blunt dissec-
tor. The presence of volar subluxation of the lunate and a
large anterior shelf should be excluded (Figure 14.24); if
present, the shelf should be excised. Failure to recognize its
presence and to remove the shelf may result in postoperative
median nerve compression and symptoms of acute carpal
tunnel syndrome. The joint is then mobilized and reduced if
necessary. Relocation of the scaphoid and the lunate into
their anatomic positions is often very difficult or impossible;
however, this can be remedied at the time of driving the pin
across the carpus and radius. Commencing 1 to 2 cm proxi-
mal to the articular surface of the radius and extending to
the third CMC joint, the dorsal two thirds of the radius,
including the articular surface, and the carpus, including the
base of the third metacarpal bone, are morselized with a
rongeur. The bone is usually osteoporotic and easy to
morselize.
A stab incision is made over the dome of the metacarpal
head while the MP joint of the third finger is kept fully flexed.

Figure 14.24  If the lunate is translated in the palmar direction,
fusion in situ carries the risk of pin perforation into the flexor
aspect of the forearm. Reducing the lunate to the radius without
excision of the anterior shelf risks postoperative median nerve
compression. The presence of marked arterial calcification
indicates that excessive manipulation should be avoided.
The tip of the pin mounted on a hand drill or a low-speed
power driver is introduced through a small stab incision over
the third metacarpal head with the third MP joint flexed to
90 degrees. The pin engages within the cartilage and then
through the subchondral bone into the shaft of the third
metacarpal and is then drilled down the shaft of the third
metacarpal and through the isthmus. Once the pin is into the
carpus itself, the drill can be removed and the driver applied
(Figure 14.25), which allows the pin to be manipulated. The
metal handheld driver is partly cannulated so that the pin can
be controlled during alignment of the metacarpal with the
radius. The pin can then be directed to engage within the
distal radius and tapped with a small mallet to properly
engage within the radius for approximately 5 to 6 mm. With
the driver still engaged over the pin, the radius and the third
metacarpal are brought into axial alignment. The driver is
then tapped with a mallet and the pin driven into the radius.
The driver is removed and approximately 2.5 cm of pin
remains visible at the MP joint. The countersink driver is then
engaged (Figure 14.26A) and the pin driven into the shaft of
the metacarpal. The countersink driver is graduated in 5-mm
markings, and 15 mm is sufficient impaction to prevent the
pin from backing out. In general, a single pin is all that
is required unless there has been significant loss of bone, in
which case two-pin fixation may be necessary (see Figure
14.26B). Rotational stability must be checked, and if there is
any rotational movement, an additional 3-mm pin may be
introduced through the second metacarpal head or through
the second-third metacarpal interspace. This latter technique
reduces the risk of the pins converging and jamming and the
potential for fracture of the radius, carpus, or both. As an
PART
III
14 
Wrist: Arthroplasty and Arthrodesis of the Wrist
A
B
Figure 14.25  A, After the posterior two thirds of the articular
surface of the radius and carpus are morselized, the pin is
introduced through the third metacarpal head with the MP joint
fully flexed and driven through the diaphysis with a slow-speed
motorized or hand drill. Emergence of the tip of the pin into the
prepared carpus allows removal of the drill and application of the
driver, which now controls pin direction. B, The tip of the pin is
then advanced and manipulated into the prepared distal surface
of the radius by using light blows on the driver with a mallet.
alternative, a staple may be used to prevent rotation. Mor-
selization of the carpus generates adequate bone stock to
stimulate the healing process for fusion. If the ulnar head has
been excised, it can be converted to a corticocancellous graft
to lay on the surface of the radius and carpus (Figure 14.27A
and B). I prefer to include the third CMC joint as part of the
fusion mass.
Wrist Arthrodesis after Failed Total
Wrist Arthroplasty
This technique can also be used to recover from a wrist
replacement that has failed. In these circumstances there is
considerable loss of bone substance, and our preferred tech-
nique involves the use of morselized femoral head allograft
that has been prepared with a bone mill. The implants and
cement, if present, are removed and the absence of infection
confirmed. After three passages through the bone mill (to
make the size of the fragments appropriate for the radius and
carpus), the allograft femoral head is introduced into the
defect and impact-grafted into the distal radius and into the
defect within the carpus with bone tamps. Two pins are used
for the second and third metacarpals to lock the carpus and
hand in alignment with the radius. Any remaining gap may
be filled with autologous bone from iliac crest if thought to
be necessary.
449
PART
III CRITICAL POINTS: RHEUMATOID WRIST ARTHRODESIS
14  Indications
 Pan-carpal arthrosis of the radiocarpal and midcarpal
joints
Wrist
 Failed previous partial fusion
 Failed total joint or previous arthroplasty
42
 Significant bone loss of the distal radius and carpus
15,66
 Other inflammatory arthritis/deformity
A  Insufficient removal of the anterior shelf
B to achieve wrist arthrodesis. This was updated in 1982 by
Figure 14.26  A, Once a stable construct is achieved, the driver is
removed and the countersink tool is applied into the dimple at
the base of the pin, which is driven into the metacarpal for a
distance of approximately 12 inch. B, Two pins can be used if a
single pin fails to prevent rotational stability.
A B
Figure 14.27  The extraperiosteal excised ulnar head can be used as a corticocancellous graft. A, The head is opened into a graft
with a narrow bone rongeur. B, The softer bone of a rheumatoid patient is ideal for this technique. The periosteum holds the
fragments together, and the graft remains a viable supplement to the main morselization of the carpus and distal radius.
450
Pearls
 Carefully assess preoperative carpal tunnel symptoms
and perform a concomitant release, even for mild
symptoms.
 Decorticate the dorsal 80% of the third CMC joint.
 Remove the ulnar head in one piece if indicated for
additional source of graft.
 Morselize the dorsal two thirds of the scaphoid, lunate,
capitate, and all of the radial articular surface,
including the distal dorsal rim.
 When there is significant ulnar translation, remove part
of the radial styloid to facilitate realignment of the
wrist.
 Remove the anterior lunate fossa shelf if present.
Pitfalls
 Acute carpal tunnel syndrome
 Pain from incomplete fusion of the third CMC joint
 Insufficient countersinking of the pin past the isthmus
of the third metacarpal
Postoperative Care
 Immobilize the hand and wrist in a bulky dressing and
splint for 10 days.
 Protect against excessive use with a removable short
arm splint until 6 weeks postoperatively.
 At 6 weeks discontinue the splint.
 At 8 weeks begin strengthening.
Total Arthrodesis for Primary and Secondary
Osteoarthritis of the Wrist
Technique for Wrist Fusion (Method of the AO
Hand Study Group)
In 1974 the AO manual recommended dorsal compression
plate fixation of the radiocarpal joint with iliac bone grafting
Heim and Pfeiffer44 and recommended by Wright and
McMurtry in 1983.136 The technique was further modified
and an integrated implant system developed by the AO Hand
Study Group. A standard longitudinal incision is begun in the
mid-metacarpal area and centered between the second and

Figure 14.28  The extensor retinaculum is incised over the EPL
tendon. (Copyright Elizabeth Martin.)
third metacarpals (see Figure 14-10A). The incision passes
across Lister’s tubercle and ends over the dorsum of the distal
radius just proximal to the muscle belly of the adductor pol-
licis longus. The radial side of the incision is raised as a flap
directly off the dorsal surface of the retinaculum and contains
the superficial branch of the radial nerve. The dorsum of the
retinaculum is opened by incising the third compartment
(EPL) (Figure 14.28). The EPL is mobilized from the com-
partment proximally and distally and transposed radially.
The distal radius is exposed subperiosteally, and the longitu-
dinal incision in the periosteum is extended distally through
the capsule out to the radial base of the third metacarpal. A
1- to 2-cm portion of the posterior interosseous nerve is
excised just proximal to the articular surface of the radius.
The insertion of the ECRB is subperiosteally elevated by
scalpel dissection and reflected radially. An incision is made
in the interosseous fascia on the radial side of the third meta-
carpal. The dorsal surface of the third metacarpal is exposed
without disturbing the intrinsic musculature on either side. A
scalpel blade is used to elevate the two flaps of capsule from
the carpus. The second dorsal compartment is elevated sub-
periosteally from the radius and reflected radially with its
underlying capsule. The fourth extensor compartment is
elevated subperiosteally from the radius and reflected with
its underlying capsule ulnarly over to the DRUJ (see Figure
PART
III
14 
Wrist: Arthroplasty and Arthrodesis of the Wrist
Figure 14.29  Posteroanterior and lateral radiographs of a wrist
after arthrodesis with a contoured plate and preservation of the
proximal row. A less contoured plate can be used if the proximal
row is chosen to be removed.
14.10B). The second and fourth dorsal tendinous compart-
ments are not entered. The DRUJ is left undisturbed unless
distal ulnar resection is needed for degenerative arthritis. To
allow flat apposition of the plate on the radius, Lister’s tuber-
cle is removed with an osteotome. The dorsal cortices of the
base of the third metacarpal and the carpal bones are removed
to give excellent visual access to all the joints to be included
in the fusion. In most instances I now perform total wrist
fusion with proximal row carpectomy, which results in radio-
capitate-metacarpal fusion.65 This simplifies the fusion, mini-
mizes the need for graft, and avoids potential ulnocarpal
impingement. The proximal carpal row is excised, and these
bones are morselized for bone graft. The articular cartilage
and subchondral bone are removed down to cancellous bone
from the distal radius, capitate, proximal hamate, and third
CMC joints. In the past, a large corticocancellous bone graft
was recommended for wrist arthrodesis to provide stability,
as well as osteogenesis.45,46 Cortical bone is not necessary
when a contoured plate (Figure 14.29) is used, but if used,
the low-contour fit of the plate will be compromised. A
purely cancellous graft is incorporated faster and has been
shown to be associated with lower donor site morbidity.43
Additional cancellous bone can be harvested from within the
distal radius through a cortical window made radial to the
intended plate position and 1.5 to 2 cm proximal to the wrist
joint (Figure 14.30). All joints to be fused are packed with
cancellous bone before plate fixation. In the rare instances in
which local bone graft is judged inadequate, I prefer cancel-
lous bone harvested from the olecranon or from a window
in the superior aspect of the iliac crest without stripping it of
its musculature. A titanium low-contact dynamic compres-
sion plate (LCDCP) facilitates fusion; different plate sizes are
available with short or longer bends depending on whether
the proximal row is retained or excised. A straight version is
451
PART
III
14 
Wrist
used when large segmental carpal traumatic or tumor defects
require corticocancellous intercalary graft replacement.
These plates do not need contouring and position the wrist
in neutral extension. If precontoured plates are not available,
a straight 3.5-mm LCDCP may be similarly contoured to
follow the dorsal radius, carpal sulcus, and dorsal third meta-
carpal. In small individuals, a nine-hole, 3.5-mm reconstruc-
tion plate is optimal. In persons with extremely small hands,
a 2.7-mm reconstruction or 2.7-mm semitubular plate may
be required.
The plate is affixed to the third metacarpal with 2.7-mm
screws while taking care to ensure central drilling in its
narrow isthmus. The distal metacarpal hole is drilled first to
enable fine-tuning of the position. Accurate alignment of the
plate in the dorsal midline of the metacarpal is essential to
avoid malrotation and maximize grip strength potential.85
The remaining metacarpal screws are drilled and placed.
Next, a 2.7-mm cancellous screw is placed in the capitate. If
there is space between the plate and the capitate, the capitate
may be lagged up against the plate, and a shorter screw than
measured is required to avoid volar screw penetration into
the carpal canal. The hand is then aligned with the forearm,
and the capitate is manually compressed into the decorticated
distal radius. With the plate aligned over the radius and the
hand properly oriented, the second most distal screw in the
radius (chosen because it lies in cortical bone) is drilled with
a 2.5-mm bit in compression mode and a 3.5-mm cortical
screw inserted. The remaining radius holes are filled in no-
compression mode.
Closure
A small suction drain is routinely used and brought out
proximally. The retained radial and ulnar flaps of the previ-
ously opened third (EPL) compartment are used to close the
capsule over the plate to the extent possible. The EPL is left
transposed radially out of Lister’s canal so that it does not
touch the plate other than proximally.
Postoperative Management
A bulky short arm dressing incorporating a volar plaster
splint is applied. At week 2 this is converted to a light com-
452
Figure 14.30  Cancellous graft is harvested from the
distal radius through a window created by excision of
Lister’s tubercle.
pressive dressing or sleeve, and the wrist is supported with
a wrist immobilization splint, which serves to remind the
patient and others that a surgical procedure has been done;
it does not support or protect the plate. Full active use of the
hand and digits is allowed, but resistance or lifting is limited
to 1 kg. The splint is discontinued at 6 weeks. Full use of the
hand is allowed by the 10th week. Radiographic healing is
to be expected by 8 to 10 weeks.
CRITICAL POINTS: PLATE FIXATION FOR
WRIST ARTHRODESIS
Indications
 Pan-carpal arthrosis of the radiocarpal and midcarpal
joints
 Failed past limited arthrodesis
 Failed total joint or previous arthroplasty
 Paralysis of the wrist or hand (with the potential for
using functioning tendons for transfer)74,106
 Reconstruction after segmental tumor resection,
infection, or traumatic segmental bone loss of the
distal radius and carpus26,75
 Inflammatory arthritis with good bone stock
43
Pearls
 Carefully assess the preoperative carpal tunnel
symptoms and perform a concomitant release, even
for mild symptoms.
 Decorticate the dorsal 80% of the third CMC joint.
 Remove the dorsal distal radius for improved plate fit.
 Harvest a distal radius metaphyseal bone graft and
apply to the fusion site.
 Removal of the proximal row simplifies fusion and
avoids ulnocarpal impingement.
 In a patient with rheumatoid arthritis and ulnar
translation, remove part of the radial styloid to
facilitate realignment of the wrist.
Technical Points
 Transpose the EPL.
 Excise the proximal row.
 Decorticate the third CMC joint, capitate, proximal
hamate, and distal radius.

CRITICAL POINTS: PLATE FIXATION FOR
WRIST ARTHRODESIS—cont’d
 Place graft in the third CMC joint.
 Fix the plate to the metacarpal firstthrough the most
distal screw hole.
 Align the plate with the metacarpal and fix the first
and second screws.
 Fix the capitate.
 Reduce the wrist and fix the plate to the radius in
compression mode.
 Add additional graft from the dorsal distal aspect of
the radius and excised carpal bones to the fusion area.
Pitfalls
 The drill hole through the metacarpal portion of the
plate must be in the sagittal plane. If not, the plate will
lie rotated on the metacarpal. Subsequent radius
fixation will cause rotational deformity of the third
metacarpal.
 If the capitate does not contact the undersurface of the
plate and is lagged up to the plate, the screw may end
up being too long and protrude into the carpal canal.
Check screw length with fluoroscopy.
 If non–self-tapping screws are used, be careful to avoid
excessive penetration of the tip through the
metacarpal, which may injure the deep motor branch
of the ulnar nerve as it crosses radially.
Postoperative Care
 Immobilize the hand and wrist in a bulky dressing and
splint for 10 days.
 Then protect against excessive use with a removable
short arm splint until 6 weeks postoperatively.
 At 6 weeks discontinue the splint.
 At 8 weeks begin strengthening.
 Allow full use at 10 weeks.
Athletic Participation
 Patients are given a 5-lb weight limit for the first 8
weeks.
 Full use is allowed after 10 weeks as symptoms allow.
Complications
A union rate of nearly 100% can be expected when using a
precontoured compression plate and local bone graft. Larsson
reported a 0% nonunion rate in 23 cases,59 and Weiss and
Hastings also had a 0% nonunion rate in 28 patients with a
plate and local bone graft.132 When partial nonunion occurs,
it most commonly occurs at the third CMC joint (Figure
14.31). With stabilization of the radiocarpal and midcarpal
joints, stress may be concentrated distally, and micromotion
can lead to fibrous union. Prevention depends on careful and
complete decortication of the dorsal 80% of the third CMC
joint down to cancellous bone. Although some authors have
advised against attempts to formally include the third CMC
joint in the fusion, subsequent plate removal is then manda-
tory to prevent hardware loosening or fatigue fracture. When
not included in the fusion, the second and third CMC joints
may be at risk for the later development of symptomatic
degenerative changes.7 Standard 3.5-mm plates have been
reported to have hardware complication rates of 19%, the
majority at the metacarpal level. The incidence of plate
PART
III
14 
Wrist: Arthroplasty and Arthrodesis of the Wrist
Figure 14.31  Failure to achieve sound arthrodesis at the third
carpometacarpal joint in an active individual may give rise to
loosening of the plate from the metacarpal as shown here, with
subsequent painful swelling and diminished function.
removal for tenderness has been 12%.42 The lower-profile
precontoured wrist fusion plate uses smaller 2.7-mm screws
distally at the metacarpal level and has tapered edges, and
the screws are recessed flush with the dorsal plate surface.
With use of this lower-profile plate, symptoms requiring
implant removal are rare. The incidence of carpal tunnel
syndrome after AO plate fusion is between 3.6%42 and
10.5%.43 The surgeon must carefully assess for preoperative
carpal tunnel symptoms that may become symptomatic post-
operatively. Ideally, the three-dimensional architecture of
the carpal canal should not be altered significantly by fusion.
Postoperative carpal tunnel symptoms will require carpal
tunnel release in 67%.43 Although wrist fusion is generally
predictable in providing pain relief, unexplained pain can
persist despite successful fusion. This is most commonly seen
in patients who have previously undergone multiple failed
surgical procedures. When this is the case, selective wrist
nerve blocks may be indicated to determine whether wrist
denervation would be helpful.10 A 0% to 3.5% incidence of
DRUJ pain can occur after fusion.16,133 In a series of 85 wrist
fusions, new pain in the DRUJ was seen in just one case and
resolved after injection of the joint with 1 mL of betametha-
sone. Plate fixation of the radius to the third metacarpal
usually “radializes” the wrist and protects against impinge-
ment of the distal end of the ulna and carpus. Ulnocarpal
abutment can occur when there is a discrepancy between the
combined height of the radius and radial carpus and that of
the ulna and ulnar part of the carpus.33,112 When the surgeon
chooses to maintain and incorporate the proximal row into
the fusion, visual and radiographic means must be used to
ensure that the triquetrum does not interfere with the distal
end of the ulna. If insufficient space exists between the distal
ulna and the triquetrum, the triquetrum should be excised
(see Figure 14.29). Ulnar abutment is obviated if the proxi-
mal row has been excised.
What Patients Should Be Told
Most patients experience significant swelling requiring bed
rest and strict hand elevation. Patients are told that they will
453
PART be immobilized in a bulky dressing for 10 days followed by
III a removable splint until 6 weeks postoperatively and that
they can expect a 98.5% union rate. Although full use is
14  allowed at 10 weeks, they will not feel really adapted until
6 months after surgery. Complete pain relief cannot be guar-
Wrist
anteed if they have undergone multiple previous surgeries.
Grip strength will take a year to plateau and will approxi-
mate 72% of normal.42 Bolano and Green found no signifi-
cant difference in grip strength between fusion with retention
of the proximal row and fusion with excision of the proximal
row.7 Patients should expect a 6-month learning/adaptation
period to the fusion. Ninety-two percent of tasks will be
performed in a normal manner without undue delay. The
greatest functional problems will be perineal care, lifting a
glass or can from a low table, and horizontal use of a screw-
driver. Further surgery for plate removal is unlikely with the
low-profile precontoured plates.
Total Wrist Replacement
Although total wrist arthrodesis yields significant pain relief,
stability, and power grasp, immobility of the wrist now
requires compensatory motion of the elbow and shoulder to
accurately place the hand in space and more particularly to
allow the thumb, index finger, and middle finger to perform
fine activities with precision. Therefore, loss of wrist motion
can give rise to significant dysfunction in occupational, self-
care, and recreational activities.32,78 However, the individual
patient’s capacity to adapt, compromise, and develop coping
strategies, coupled with support and assistance from family
members, requires careful assessment and counseling to
ensure the proper choice of surgical reconstruction. In
individual patients a decision has to be made whether to
preserve motion at the expense of some residual pain or to
remove motion and improve the pain considerably. For some
patients the choice is very easy and obvious; for others, loss
of mobility of the wrist may be associated with difficulties
with the shoulder and elbow, as seen in patients with inflam-
matory arthritis. Many patients with a wrist arthrodesis
report significant impairment in the finer dextrous activities,
although they learn to cope. In our practice, patients who
have undergone wrist arthrodesis on one side and wrist
replacement on the other prefer the wrist replacement to the
wrist fusion and state that they find preservation of some
motion of considerable importance, particularly in activities
of daily living.74
Normal wrist motion is accomplished by a complex interac-
tion of multiple articulations involving the radius, ulna, and
carpal bones. Total wrist arthroplasty cannot duplicate this
intricate system, but it can potentially produce a stable, pain-
free joint with a functional range of motion. Achieving a
functional and durable outcome requires appropriate patient
selection, preoperative planning, and accurate surgery.
Because arthroplasty poses greater risks than arthrodesis
does, low-demand patients with special needs or desire for
wrist motion are the best candidates. Recently, patients with
degenerative arthritis are seeking to have replacement rather
than fusion as they gain greater awareness of the surgical
options. Careful patient selection is critical to a good outcome,
and caution is advised when advising patients with high
demands and perhaps unrealistic expectations.
454
History of Total Wrist Arthroplasty90,91
 Gluck, 1891: Ivory implant for tuberculosis of the wrist28
108
 Swanson, 1972: Flexible-hinge silicone arthroplasty
 Voltz, 1976: AMC/Voltz prosthesis, a highly constrained
implant123
69
 Meuli, 1980: The Meuli implant, a ball-and-socket design
4
 Guepar, 1986: The first distal screw fixation device
 Menon, 1998: Universal I, screw fixation of the distal
component into the second metacarpal and hamate68
 Clayton et al., 1988, The CFV wrist, a reverse-polarity
implant30
31
 Figgie et al., 1990: Trispherical wrist
61
 Legré et al., 1994: Destot prosthesis
 Beckenbaugh, 1996: Biaxial wrist, ingrowth fixation into
the radius and third metacarpal17
86
 Radmer et al., 1999: ATW/APH prosthesis
 Adams, 2001: Universal II (Integra Life Sciences, Plains-
boro, NJ), change in design to reduce the risk for
dislocation2
 Rozing, 2003: RWS implant
87
 Palmer et al., 2005: Maestro (Biomet Orthopaedics,
Warsaw, IN), a design with alignment with the lunate fossa
 Gupta, 2005: Re-Motion (Small Bone Innovations, Mor-
risville, PA), an implant with 10 degrees of pronation-
supination of the components41
Swanson, in the late 1960s/early 1970s, developed a flexible-
hinge silicone arthroplasty of the wrist,108 similar to the suc-
cessful MP joint implants. Patients initially had extremely
good results with a high level of pain relief and functional
range of motion. Although the early results were encourag-
ing, it became apparent over time that balance of the wrist
was an important issue. Failure of the implant at its distal
stem, when inserted into the carpus and third metacarpal,
was a common feature, with loss of the ulnar shoulder (Figure
14.32) of the implant. This frequently occurred in association
with ulnar deviation of the wrist and caused significant func-
tional problems, and a number of implants had to be removed
(Figure 14.33). The long-term results of Swanson arthro-
plasty31 showed that those that survived and were well bal-
anced continued to give good pain relief, although a gradually
decreasing range of motion. It has recently been recom-
mended by the group in Zurich that for very low-demand
elderly patients with inflammatory arthritis, use of a Swanson
flexible-hinge implant may still be considered.54 However,
the development of metal-on-plastic hip replacements
encouraged many to attempt to reproduce this success at the
wrist joint, and a number of implants were designed, includ-
ing the early Voltz,123 Meuli,69 and Guepar group implants.4
Subsequently, the Mayo clinic introduced the biaxial wrist.17
All these implants had their particular foibles with difficulty
in balancing the wrist. In 1998, Menon presented the first
reports of the ellipsoid Universal I wrist design, which is
composed of a metallic radial component and a polyethylene
carpal component fixed to a metal carpal base plate.68 The
implant was a departure from the normal distal stem and
cement fixation and instead relied on screw fixation in the
second and fourth metacarpals and a central peg in the capi-
tate. The particular design of this implant was attractive, and
a number of these procedures were performed. The Univer-
sal I results as reported by Menon,68 however, identified a

Figure 14.32  Imbalance of the wrist aggravated by ulnar
translation of the common extensor tendons resulted in a high
attrition rate of the silicone implant with consequent deterioration
in function.
significant dislocation rate, and it became apparent that
design modifications were required. The Universal II implant
restored the normal radial inclination of the distal radius and
altered the shape and conformity of the implant with a sub-
sequent reduction in the instability rate to 1% to 2%.39
Further developments and designs have recently been intro-
duced, but no long-term clinical results are yet available for
these innovations. A new design from Gupta41 and further
designs are being considered in Europe as well.
Preoperative Evaluation
Clinical Examination
Examination must include an accurate range of active and
passive motion, most particularly to determine whether there
is subluxation or dislocation of the carpus and whether the
DRUJ is stable. The status of the flexor and extensor tendons
of the wrist and hand must be assessed. Functional assess-
ment of the patient should be performed and a detailed
history taken of the patient’s activities, including home cir-
cumstances, hobbies, and pastimes. Patients who live alone
have no one to assist them with important activities of daily
living. Some patients with a sedentary occupation can have
quite high-demand leisure activities that are a balance to
their lives. Joint-preserving procedures should be considered
in a patient who finds a trial period of splint immobilization
unacceptable.
Surgical Technique (Universal II Implant)
The dorsal aspect of the wrist is exposed through a longitu-
dinal central incision with reflection of the extensor retinacu-
PART
III
14 
Wrist: Arthroplasty and Arthrodesis of the Wrist
Figure 14.33  Excised silicone wrist arthroplasty. Note the implant
wear.
lum and extensor tendons of the fourth compartment toward
the ulnar side and reflection of the third and second compart-
ments to the radial side. A segment of the posterior interos-
seous nerve can be excised just proximal to the radiocarpal
joint at the discretion of the surgeon. The distal radius is
identified, and the dorsal capsule of the radiocarpal joint is
defined and raised (Figure 14.34A and B). Two methods can
be used for this: raising the capsule either in two distally
based flaps with an inverted “T” incision or as an ulnar-based
flap by raising the dorsal radiolunotriquetral ligament from
the rim of the radius, incising along the distal edge of the
dorsal intercarpal ligament fibers, and detaching them on the
radial side and leaving them attached to the hamate and
triquetrum on the ulnar side. The object of preserving the
capsule is to provide cover for the implant and to place a
layer of tissue between the implant and the extensor tendons.
The proximal half of the scaphoid, the lunate, and the trique-
trum is excised. During proximal scaphoid excision and
sizing of the carpal component, it is helpful to temporarily
pin the distal scaphoid to the distal carpal row. The distal
radius is examined for bone loss, particularly in the lunate
fossa. A central guide pin is introduced through the dorsal
radial quadrant of the radius 5 mm below and in line with
Lister’s tubercle. This is then checked on the image intensifier
to ensure that it is correctly located parallel to the cortices
in both the sagittal and coronal planes. Introduction of a
cutting guide along the central pin allows the radial cutting
guide to be located and fixed with temporary Kirschner
wires. Removal of the central pin allows the radial guide to
be checked for position with intraoperative radiographs. The
distal radius is then cut and removed (Figure 14.35). Reinser-
tion of the medullary guide pin allows introduction of the
cannulated reamers, and reaming of the shaft can proceed
(Figure 14.36A and B). A trial radial component of the
appropriate size is then inserted. Having completed prepara-
tion of the radius, preparation of the distal component may
be performed.
A Kirschner wire is introduced through the head of the
capitate and into the third metacarpal with use of the wire
guide. This again is checked on the intensifier to ensure that
its placement within the third metacarpal and the capitate is,
455
PART
III
14 
Wrist

Figure 14.34  The incision is along the line of the third metacarpal and may be extended proximally and distally to facilitate
exposure of the wrist. A, The fourth compartment is raised as for wrist fusion. The second compartment must be raised as
shown. When the retinaculum has been raised in this manner, it can be passed deep to the ECRL, ECRB, and EPL and, with a
hemostat, can be used to maintain radial displacement of the radial-side tendons to facilitate the exposure. B, The dorsal capsule
is raised as shown. (Copyright Elizabeth Martin.)

Figure 14.35  The cutting guide temporarily held in

place by Kirschner wires after removal of the
intramedullary guide rod. If a satisfactory position is
achieved, as seen on intraoperative radiographs, the
distal radial articular surface can be excised with an
oscillating saw.

in fact, aligned in both the sagittal and coronal planes (Figure
14.37A and B). A cannulated drill is introduced along the
guide wire and drilled to the appropriate depth as marked
on the drill. The wire and drill are removed and the distal
alignment guide is placed in the drill hole. The cutting guide
is placed on the alignment guide and temporary Kirschner
wires are inserted through the cutting guide (Figure 14.38).
The position is checked with a radiograph. With the cutting
guide in place, the appropriate amount of capitate head,
residual scaphoid, and if necessary, part of the hamate is
456
removed. The distal trial implant is then inserted after
removal of the guides (Figure 14.39). The metacarpal align-
ment guide is placed on the second metacarpal to guide
introduction of the screws through the plate and into the
second metacarpal. A similar process allows introduction of
the screw into the hamate by alignment with the fourth
metacarpal guides (Figure 14.40). The screw must be in the
hamate but must not cross the fourth CMC joint (which is
mobile). The polyethylene central component is then attached
(Figure 14.41), and range of motion and stability are assessed.

B passed through to the third metacarpal. B, The position of the
Figure 14.36  A, With the guide pin reinserted, the medullary
canal can be reamed. B, The trial radial component is then
inserted.
It is particularly important to assess axial distraction to
ensure that there is no excessive laxity within the joint that
would encourage dislocation. The distal component has
modular sizes so that appropriate tension can be attained.
However, if the component is too large and prevents exten-
sion, a smaller component should be inserted. If this is not
possible, 2 mm must be removed from the distal radius.
When satisfied with the sizing, the trial components can be
removed and the final components implanted. The compo-
nents may be inserted with or without cement. It is important
to complete an intercarpal fusion of the distal row bones for
support of the carpal component plate. After confirmation of
adequate range of motion, particularly in extension, the
wounds are closed, the capsule is closed, and the extensor
tendons are examined. Provided that the common extensors
are suitably centralized and aligned, closure of the superficial
fascia and skin is all that is required. If there is a tendency
PART
III
14 
Wrist: Arthroplasty and Arthrodesis of the Wrist
A
B
Figure 14.37  A, A Kirschner wire is inserted into the capitate and
Kirschner wire must be assessed with intraoperative radiographs
or fluoroscopy.
for the tendons to lie to the ulnar side of the long axis of the
implant, they should be centralized to properly balance the
implant (see later).
The patient is immobilized in plaster for a period of 2
weeks for wound healing. The sutures are removed at 2
weeks, at which time early controlled motion in the form of
flexion-extension and some radial-ulnar deviation is allowed.
Over a period of 3 months, wrist range of motion recovers
and plateaus.
Centralization of the Extensor Tendons
Centralization is achieved by performing a hemitransection
of the ECRL proximally, raising a strip to its insertion on the
base of the second metacarpal, and threading it deep to the
ECRB and the common extensor tendons.12 This should not
include the extensor digiti minimi. The strip of ECRL is then
taken superficial to the extensor digitorum communis and
457
PART
III
14 
Wrist
Figure 14.39  The distal implant must lie in contact with the cut
surface of the capitate, scaphoid, and triquetrum, and the central
stem of the implant should remain within the body of the
capitate.
woven through the ECRB. The loop that has been generated
allows centralization of the extensor tendons (Figure 14.42).
This is very often necessary in a rheumatoid patient when
preservation of the tube of the fourth compartment is not
always possible and when extensor tenosynovectomy may
be necessary.
Other Prostheses
A number of total wrist prostheses are available. With most
prostheses, the distal component is fixed in much the same
way as the Universal II. However, there is a 10-degree axial
rotation of the carpal component of the “Re-Motion” (Small
Bone Innovations, Morrisville, PA) (Figure 14.43) to allow
458
Figure 14.38  The distal cutting guide is held with
two Kirschner wires and the position checked and
adjusted if necessary.
Figure 14.40  Seating of both components is followed by placing
the trial screws into the second metacarpal and hamate.
some degree of intercarpal supination and pronation. The
Universal II components do not have the capacity to absorb
carpal rotation, and many rheumatoid patients rely on some
degree of intercarpal pronation-supination to accommodate
for poor forearm rotation. In addition, the articular rims of
the radius are preserved during preparation and placement
of the Re-Motion implant so that the capsular attachments
are preserved. The range of motion to be expected is 20
degrees of flexion, between 30 and 40 degrees of extension,
and an arc of motion of 25 degrees of radial and ulnar devia-
tion. It is possible that marked distortion of the distal radius
articular surface, as seen on occasion in rheumatoid arthritis,
may make seating of the Re-Motion radial component more
difficult.
The Maestro (Biomet Orthopaedics, Warsaw, IN) (Figure
14.44) implant is designed to mimic proximal row carpec-
tomy and depends on replacement primarily of the capitate
 PART
III
14 

Wrist: Arthroplasty and Arthrodesis of the Wrist

A B
Figure 14.41  A, A trial central polyethylene bearing surface is then placed. B, Verification with radiographs.

Figure 14.42  Use of half of the extensor carpi radialis longus

(ECRL) tendon to align and stabilize the common extensor
tendons is achieved by harvesting part of the tendon proximally
to distally and leaving the tendon strip attached distally. The strip
of tendon is then taken deep to the common extensors and
woven into the remaining ECRL to create an open loop. The Figure 14.43  The “Re-Motion” total wrist replacement (Small
tension in this loop is judged to be correct when the common Bone Innovations, Morrisville, PA).
extensors are aligned with the longitudinal axis of the implant.
Similarly, the extensor carpi ulnaris (ECU) tendon is brought up to
the dorsum by bringing the extensor retinaculum deep to the should be meticulous and cutting guides used to ensure accu-
tendon. The free edge of the retinaculum is then brought over
racy of bone preparation. Repeated intraoperative radio-
the ECU tendon and sutured to itself under appropriate tension to
realign the tendon dorsally. graphs are important to ensure correct alignment to minimize
the risk for early and midterm mechanical failure.

head; articulation is achieved with a polyethylene proximal

component seated in the radius. The capitate component has CRITICAL POINTS: UNIVERSAL II WRIST ARTHROPLASTY
been suggested as a hemiarthroplasty in rheumatoid patients.
The early results are very encouraging,23 but as always with Indications
 Pan-carpal arthrosis of the radiocarpal and midcarpal
all implants, some failures are inevitable,20 and the patient
joints in patients with low demand
and treating physician should be aware of the potential risks
associated with implant arthroplasty. Surgical technique Continued

459
PART
III
14   Cement fixation is an option.
Wrist
Figure 14.44  The Maestro total wrist replacement (Biomet
Orthopaedics, Warsaw, IN).
CRITICAL POINTS: UNIVERSAL II
WRIST ARTHROPLASTY—cont’d
 Failed past limited arthrodesis
 Rheumatoid wrist arthritis and other inflammatory
arthritis/deformity with radiocarpal ulnar translocation
instability
 SLAC pattern of arthritis in older low-demand patients
 Avascular necrosis of the carpal bones
Pearls and Technical Points
 Carefully assess for preoperative carpal tunnel
symptoms and perform a concomitant release, even for
mild symptoms.
 Template the preoperative radiographs to guide
selection of the appropriate implant size.
 In the event that it is difficult to raise a continuous
capsuloperiosteal tube containing the fourth
compartment tendons for adequate exposure (see
Figure 14.10), the fourth compartment extensor
retinaculum can be released and taken off the tendons
and the tendons allowed to be retracted to the ulnar
side.
 It is very important to see the entire distal end of the
radius when opening the capsule, and on occasion the
extensor tendons can interfere with such visualization.
 Expose the distal radius and free the first compartment.
 Removal of the proximal row and the proximal half of
the scaphoid and part of the triquetrum exposes both
the distal radius and the distal row of the carpus.
 Check the alignment of the guide pin within the radius
in the sagittal and coronal planes on intraoperative
radiographs.
 Measure three times; cut once.
 In rheumatoid arthritis with ulnar translation, remove
part of the radial styloid to facilitate realignment of the
wrist.
 Check the insertion of the radial component with
radiographs.
 Check alignment of the carpal guide with radiographs.
 Preparation of the distal row includes very accurate
placement of the central peg and accurate placement
of the screws.
460
 Intercarpal arthrodesis is essential to ensure stability of
the distal component.
 The range of motion to aim for is 40 degrees of
extension, 20 degrees of flexion, 10 degrees of radial
deviation, and 15 degrees of ulnar deviation.
Pitfalls
 Overstuffing the joint causes significant restricted
range of motion.
 Failure to remove and deal with the anterior lunate
fossa lip can lead to acute carpal tunnel syndrome if
the wrist is then relocated into its normal position.
 A very large lunate fossa defect gives rise to poor
support of the implant of whatever type.
 Extreme palmar subluxation of the carpus on
preoperative lateral radiographs and rupture of the
radial and ulnar wrist extensor tendons are
contraindications to total wrist arthroplasty.
 On completion of surgery, an x-ray must be taken
before closure to ensure that there is no likelihood of
ulnar abutment between the head of the ulna and the
implant on the radius.33,117 If there is, a wafer type29 of
procedure can be performed, and in a rheumatoid
patient one may consider distal ulnar excision.105
Postoperative Care
 Immobilize for 3 to 5 days in a bulky conforming
dressing.
 Immobilize in a splint for 10 to 14 days.
 Begin an active supervised gentle exercise program for
4 to 6 weeks with a rest splint used between exercise
periods for comfort.
 At 6 to 8 weeks, increase mobilization but permanently
avoid repeated forceful activities (hammering, etc.)
and avoid heavy manual work and contact sports.
 Further postoperative care includes encouraging
patients to develop the appropriate range of motion
for their lifestyle by encouraging them to perform tasks
at an early stage in a planned, progressive, and
purposeful fashion with a structured rehabilitation
program of activities.
Joint Protection
 Advice regarding avoidance of stressful and staccato
activity is crucial for long-term survival of the implants.
What Patients Should Be Told
The results of wrist replacement for a patient with
inflammatory arthritis are very good for pain relief, but
attempts at restoration of a normal range of motion are
undesirable because this increases the risk of dislocation.
The range to be expected is 25 to 35 degrees of
extension and 30 to 40 degrees of flexion, 10 degrees of
radial deviation, and 15 degrees of ulnar deviation;
however, these ranges can be highly variable. For
patients with severe rheumatoid disease, the outcome in
terms of range of motion may be less predictable, but
the motion obtained is of great value in improving the
capacity for activities of daily living.32 The recovery
period after the acute surgical phase is 6 to 8 weeks, but
the wrist will continue to improve for up to 1 year after
implantation of the prosthesis. The midterm (1 to 5
years) risk for instability of the implant is reported to be
15%.74 The loosening rate is dependent on time and the
level of activity. No long-term results are available for use
of the Universal II implant in patients with osteoarthritis.
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