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Wrist Arthritis – Motion Sparing Salvage
Wrist Arthritis – Motion Sparing Salvage Warren C. Hammert, MD University of Rochester Medical Center January 23, 2015 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Disclosure Nothing to disclose DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Wrist Arthritis Multiple etiologies Post traumatic (SLAC/ SNAC) Idiopathic/ Primary osteoarthritis (STT, midcarpal) Inflammatory Altered kinematics, resulting in pain and stiffness DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Wrist Arthritis Nonoperative Treatment Multiple procedures Dependent on underlying pathology, affected joints Most result in some loss of motion and grip strength Predictable pain relief DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Goal Pain free, stable and functional wrist Ideal motion – E/F = 60/60, RD/ UD = 20/40 Functional motion – 30-35/ 5-10, 5/10 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Case Example DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Case Example 41 y/o RHD restaurant owner SLAC Wrist reconstruction in 2007 Never had complete pain relief Dorsal central pain with flexion/ extension Pain to lesser degree with forearm rotation Pain with axial load across RC joint DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Case Example E= 25 F= 5 R= 10 U= 15 P= 60 S= 75 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Total Wrist Arthroplasty Indications Disabling pain Radiocarpal and midcarpal arthritis Low demand patient Patient accepting of lifetime restrictions/ limitations Contra-indications High demand patients Regular dependence on walking aids Absent motor control of wrist Poor bone quality Instability and unmanageable synovitis DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Arthroplasty Greater experience in Europe than US, particularly for non RA patients Several implant designs Newer designs require less bony resection for carpal component Survival rates approach 90% in some series Technically demanding operation Patient selection is important DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Outcomes Limited to level IV reports Most in RA with short F/U Increasing use in non RA patients Motion often similar to pre op Pain improved Revision surgery is common High patient satisfaction DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Denervation Wilhelm described in 1966 – total wrist denervation – greatest chance of success, but at risk of loss of proprioception Partial denervation – may be less predictable, but avoids multiple incisions and extensive dissection – selective denervation of most pain generating regions Single dorsal incision – Berger 1998 – AIN/ PIN DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Indications Pain/ Arthritis / Instability not amenable to nonoperative treatment Patients not willing to sacrifice motion Limited recovery time DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Preoperative Procedure Diagnostic local anesthetic injection blocking PIN/ AIN Measure pain and grip strength pre and post injection Should have substantial increase in grip strength (10%) and improvement in pain Allow patient to function that day and record any improvement with activities Repeat DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Procedure Hofmeister et al, Hand 2006 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Evidence Limited – retrospective series Pain relief variable Improvement in grip strength No change (loss) in motion Does not change underlying pathology, so may not be a definitive procedure DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Reconstructive Procedures Must be willing to trade loss of motion for pain relief Specific procedure dependent on joints involved Radioscaphoid, midcarpal (SLAC, SNAC) Radiolunate – posttraumatic following DRF, RA, Kienbock's STT – idiopathic or associated with thumb CMC DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION SLAC/ SNAC SLAC SNAC Treatment is same for advances stages of SLAC and SNAC arthritis Arthritis and Arthroplasty. Eds. Chhabra and Isaacs DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Radial Styloidectomy Early stages Temporary relief Resect 3-4 mm, preserve RSC ligament DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION SNAC – Distal Scaphoid Excision Malerich et al, JHS 2014 19 patients – 15 year F/U Motion improved 65% and grip improved 75% 2 failures – PRC and Total Arthrodesis Asymptomatic midcarpal arthritis Ruch and Papadonikolakis, JHS 2006 13 patients, Increase F/E= 230/290 6 patients increased RL angle Can improve motion May result in DISI Ruch and Papadonikolakis. JHS 2006 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Midcarpal Joint Preserved PRC vs Scaphoid excision and limited wrist fusion Comparative studies indicate procedures are roughly equivalent Variety of diagnoses and outcomes lumped together DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Midcarpal Joint Preserved PRC slightly better motion, but radiographic degeneration at long term follow up Limited arthrodesis – technically more demanding, potential for non/ delayed union and hardware issues Wrist motion – avg 65-70% Grip strength – avg 80% Mulford et al, Systematic Review of PRC vs Four Corner Fusion JHS E, 2009 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION PRC – Key Points Preferred in older and lower demand patients Inspect head of capitate Consider capsular interposition flap if early changes Preserve RSC ligament DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Technique Dorsal longitudinal incision Distally based capsular flap DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Technique Evaluate head of capitate Preserve RSC ligament Interposition flap if desired DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION PRC - Outcomes F/E arc = 65-75% Grip strength = 80% Progressive radiographic arthritis, but does not always correlate with symptoms Long term outcomes (>20 years) demonstrate reasonable pain relief and function in 2/3 of patients (Wall et al) Series are from multiple diagnoses – SLAC, SNAC, Preiser’s, Kienbock’s, OA DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION PRC Outcomes Wall et al, JHS 2013 17 wrists in 16 patients, minimum 20 yr f/u SLAC (5), SNAC (5), Kienbock’s (7) 11 wrists - no further surgery 6 wrists – radiocarpal arthrodesis Avg time 11 yrs (8 mos-20 yrs) 10/11 remained satisfied with min change in motion and strength No correlation between radiographic changes and satisfaction Higher risk of failure for age < 40 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Limited Wrist Arthrodesis Scaphoid excision and limited arthrodesis CHLT vs CL Triquetral excision Excision has produced comparable clinical results, but theoretically may increase contact pressures across the RL joint Concerns for screw migration DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Midcarpal Arthritis - Key Points Technically demanding Capitate and lunate should be collinear and AP and lateral Correct lunate extension – pin RL if necessary Triquetrum? Bone graft Fixation - headless cannulated screws, dorsal circular plates, k wires, staples DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Technique Dorsal incision Ligament sparing capsulotomy Scaphoid excision Preparation for arthrodesis DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Dorsal approach Ligament sparing capsulotomy DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Outcomes Similar to PRC 65-70% motion (100 less than PRC) 80% grip strength Complications greater than PRC Nonunion Hardware Mulford et al, Systematic Review of PRC vs Four Corner Fusion JHS E, 2009 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION ??Triquetrum?? Calandruccio et al, JHS 2000 14 wrists at 28 mos for SLAC wrists E/F = 52%/ 45%, R/U = 38%/ 51% Grip 71% 2 nonunion DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION ??Triquetrum?? Gaston et al, JHS 2009 57 patients with SLAC/ SNAC with limited wrist arthrodesis (CL vs CHLT) 34 patients (16 CL, 18 CHLT) with avg f/u 35.5 months (4-110) 12/16 of CL fusion had triquetrum excised Triquetral excision made it easier to correct lunate extension Bone graft 8/16 CL and all CHLT Additional procedures – radial styloidectomy, CTR, CuTR, PIN neurectomy, CMC arthroplasty in both groups DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION ??Triquetrum?? Gaston et al, JHS 2009 CL had 100 less wrist motion – F/E (p=0.0477) No significant differences between groups for other motion, grip strength, pain VAS, DASH Higher nonunion rate CHLT (11-0%) Fixation – CL – screws/ CHLT – kwires-9, screws 6, staple 1 Screw migration was a problem in both groups – higher in CL group (not statistically significant) Revision surgeries (5/16 CL, 6/18 CHLT) DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION ??Triquetrum?? Cohen et al, JHS 2012 Biomechanical study – 10 cadavers Triquetral excision - ulnar carpal pressures decrease significantly in RU motion Triquetral excision alters load and kinematics, but No significant differences in RL contact pressure with or without triquetrum DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Radiocarpal (Radiolunate) Arthritis RSL Fusion Berkhout et al JHS E 2010 Cadaver study comparing RSL fusion + distal scaphoid excision + triquetral excision Distal scaphoidectomy + Triquetrectomy = 88% F/E and 98% R/U DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Flexion-Extension DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Radial-Ulnar Deviation DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Technique Bone graft Stabilization K wires T plates Circular plate Cannulated screws DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Fixation Isaacs et al, JHS 2008 Circular and T plates Average load to failure not statistically different Failure load 58% higher for circular plate DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Distal Scaphoid Excision Garcia-Elias et al JHS 2005 DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Outcomes Garcia Elias, JHS 2005 16 patients – 37 months Complete pain relief 10 patients F=320, E=350, R=140, U=190 Progressive midcarpal arthritis in 2 pts DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Back to Patient Grip strength pre/post local block Pre = 26/ 38, Post = 40/42 Repeated 2 weeks later Pre = 28/38, Post = 42/40 Based on increase in strength and decreased pain, plan for AIN/ PIN neurectomy DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Case Example DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Case Example Early substantial improvement in pain (0-10) preop 8, early post op 3 Incision healing well and maintained motion DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Case Example May not be a definitive procedure Does not address the underlying cause Does preserve motion and does not “burn bridges” DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION AIN/ PIN Neurectomy Key Points: Check grip strength and pain before and after anesthetic injections on 2 separate occasions Should see increase in strength (10%) and decrease in pain to consider surgery DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION Thank You DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION
