Mid-Carpal Hemiarthroplasty

S.W. Wo l f e , E. Ja n g (Ne w Yo r k ), G. Pa c k e r (So u t h e n d -o n -s e a , UK), J.J. Cr i s c o (Pr o v i d e n c e , RI)

Historical Perspective these procedures has been demonstrated to halt the progression of arthritis, but each has been demonstrated to provide Wrist arthritis, whether caused by trauma, symptomatic relief of pain and return to instability, or inflammatory arthropathy, is functional activities, often for prolonged one of the most common conditions periods [9]. treated by hand surgeons. The manage­ ment of wrist arthritis varies with the Arthrodesis eliminates arthritic joints, severity and etiology of the pathology, and as such, is a more permanent with the common goal of achieving pain- solution. Total arthrodesis has long been free function. The progressive nature of a mainstay in the surgical treatment of arthritis dictates that while any number severe wrist osteoarthritis because of its of conservative treatments may be relative ease of execution, durability of effective in relieving symptoms, continued symptom relief, and predictability of loading of an arthritic joint will result in long-term results [10, 11]. While total the need for further intervention. In wrist fusion results in predictable relief of patients with painful and dysfunctional pain, the inevitable loss of motion may arthritic wrists who have failed conserva­­ result in an undesired loss of functionality tive management, surgical interventions [11, 12]. Furthermore, total arthrodesis is are generally grouped into one of three contraindicated in the patient with severe surgical categories: ablation, arthrodesis, rheumatoid arthritis involving multiple or arthroplasty. Each option has a unique joints, for whom wrist motion may be set of advantages and disadvantages. necessary for proper upper extremity function. The trade-off between pain and Ablative procedures remove arthritic motion that is achieved by total arthro­ components of the failing carpus, in an desis makes the procedure ideal for attempt to mitigate symptoms and slow patients with severe wrist arthritis and the progression of arthritis. Examples otherwise normal upper extremity joints, include: open or arthroscopic debride­ whose higher activity level might tradi­ ment and synovectomy [1], posterior tionally preclude total wrist arthroplasty. interosseous neurectomy or wrist denervation [2-4], radial styloidectomy Limited arthrodesis offers the patient an [5], distal scaphoidectomy [6, 7], and ability to preserve some wrist motion, 1 proximal row carpectomy [8]. None of while eliminating specific arthritic joints. Ar t h r o p l a s t i e s r a d i o -c a r p i e n n e s

A number of limited intercarpal fusions cations have diminished the enthusiasm have been proposed to treat the varied with which the technique was originally presentations of wrist arthritis. Scaphoid described [20-26]. Problems caused by excision and four-corner fusion (4CF) has silicone synovitis resulted in Swanson’s gained favor as an alternative to proxi­ original silicone implants being replaced mal row carpectomy (PRC) in treating by metallic implants, but the metallic advanced-stage scapholunate and implants suffered from their own issues scaphoid nonunion advanced collapse of instability and distal component failure (SLAC and SNAC), due to the preservation [27-29]. Early reports demonstrated a of carpal height and maintenance of the dis­concerting incidence of aseptic congruent native radiolunate joint. Single loosening of the distal component, parti­ cohort studies suggest a decreased cu­larly in cases of inflammatory arthritis, tendency for arthritic progression and and often requiring reoperation [23, 29]. revision surgery in the arthrodesis group Furthermore, while one of the proposed when compared to proximal row carpec­ benefits of total wrist fusion was the tomy, though no longterm prospective availability of total wrist arthroplasty as a studies have been performed [13, 14]. salvage procedure, many complications For either option, wrist motion is cons­ during the conversion to total arthrodesis trained because the important midcarpal have been reported [30]. “dart-thrower’s arc” [15, 16] is largely eliminated, and compensatory motion of Although newer implants offer improved the elbow and shoulder may ensue. designs that result in “less devastating Radioscapholunate arthrodesis is an complications”, the issues surrounding attractive surgical option that preserves the distal component of total wrist repla­ carpal height as well as the critical mid­ cements have still not been completely carpal motion necessary for physiological resolved [24, 31, 32]. As a result, the motion of the wrist, but is largely confined proce­dure has not matched the wide­ to isolated arthritis of the radiocarpal spread acceptance gained by its joint, and complications including non­ counterpart procedures in the hip, knee, union, midcarpal arthritis, and hamate- and shoulder. lunate impaction syndrome have been reported [17, 18]. Rationale for wrist Total wrist arthroplasty was first described Hemiarthroplasty in 1973 by Swanson, as an alternative to wrist fusion for patients who have specific Many of the issues surrounding total needs or desires to maintain wrist motion wrist arthroplasty have been localized to [19]. At a time when total joint arthroplasty problems caused by the distal com­ was rapidly establishing itself as the ponent. Loosening of the distal implant is dominant reconstructive procedure in likely due to a combination of the thin large joints, wrist arthroplasty seemed to medullary canals found in the metacarpal be a desirable alternative for the subset bones, and the high moments expe­ of patients with severe wrist arthritis. rienced by the wrist joint during activities of daily living. In addition, traditional 2 Despite the positive characteristics of designs of total wrist arthroplasty resect total wrist arthroplasty, reports of compli­ a significant portion of the distal radius, Mid-Ca r p a l He m i a r t h r o p l a s t y

and as such, shift the wrist’s center of arthroplasty was combined with a rotation proximally. This alteration of proximal row carpectomy. wrist kinematics thus increases the moment on the distal component, poten­ Satisfactory outcomes were reported at tially contributing to distal component one and two years of followup, with relief loosening and pullout. This subtle shift in of pain in both patients. Range of motion the dynamic structure of the wrist joint in both patients was sufficient to meet results in significant changes in the Palmer’s definition of a functional wrist (a kinematics, soft tissue envelope, and minimum of 5° flexion, 30° extension, 10° musculotendinous forces of the wrist, radial deviation, and 15° ulnar deviation) which may lead to degenerative arthritis [34]. With the caveat that both patients or impaired motion. These precautions had good bone stock and soft tissue surrounding total wrist arthroplasty quality, Boyer went on to recommend the converge to impose strict activity procedure as a viable option for carefully restrictions on patients undergoing the selected patients who would otherwise procedure, as well as limitations on only be eligible for complete wrist fusion, eligibility for the procedure. As a result, but had specific needs or desires for although total wrist arthroplasty theore­ preserved range of motion. tically preserves motion of the wrist, the complications caused by the distal com­ Three months later, two small patient ponent impose a number of constraints series were presented at the 2010 on patient activity. International Wrist Investigators Work­ shop (IWIW), separately by Culp and As a result, a number of surgeons began Adams. Culp reported the results of a investigating the possibility of implanting retrospective review of 16 wrist hemi­ just the proximal component of a total arthroplasty patients, at a range of wrist arthroplasty in order to avoid failure 4 months to 2.5 years followup, performed of the distal component. The first for the treatment of rheumatoid arthritis, description of the use of wrist hemi­ SLAC wrist, or Kienböck’s disease. All arthroplasty was published by Boyer et patients reported being “satisfied” with al. in June 2010, as a case report on two the outcomes of surgery, which included patients [33]. One patient was a 36-year a 22% mean increase in mean grip old woman with a 15-year history of strength, a noticeable decrease in pain, rheumatoid arthritis affecting both wrists and continued clinical and radiographic and refractory to splinting and steroid stability. Only one reoperation was injections, while the other was a 52-year required, a wrist capsulectomy to relieve old man with a 1.5-year history of stiffness [35]. persistent osteoarthritis. Both patients had specific desires to retain motion in Adams et al. combined a biomechanical the wrist. Both patients had personally study and a patient series to evaluate the experienced the loss of motion caused proximal hemiarthroplasty procedure. A by alternative treatments and requested study of 8 cadaver specimens utilized a motion-preserving procedure instead. radio-opaque markers in the capitate As a result, the two patients opted for a and radius to assess the alignment of the limited procedure wherein implantation wrist radiographically following hemi­ 3 of the radial component of a wrist arthroplasty and proximal row carpec­ Ar t h r o p l a s t i e s r a d i o -c a r p i e n n e s

tomy. Radioulnar alignment remained midcarpal motion and the important within 2.2mm on posteroanterior radio­ “dart-thrower’s arc” of motion [16]. By graphs and within 4.7mm on lateral replacing the proximal carpal row instead images during radial/ulnar deviation and of resecting and resurfacing the radius, a flexion/extension, respectively. In a replacement for the midcarpal joint consecutive series of 13 patients under­ articulation is created. This is an important going hemiarthroplasty for osteoarthritis distinction from the traditional radiocarpal or rheumatoid arthritis, the corresponding replacement of total wrist arthroplasty parameters were found to remain within and is attractive from a kinematic 3.9mm and 2.5mm [36]. standpoint. The ellipsoidal shape of traditional total wrist bearing surfaces, Taken together, the results of these while offering mobility separately in the studies suggest that proximal wrist flexion-extension and radio-ulnar de­ hemiarthroplasty represents a potential viation planes, is incapable of enabling improvement upon total wrist arthroplasty the coupled dart-thrower’s motion. or wrist arthrodesis, with early studies Reconstruction of a midcarpal prosthetic demonstrating good radiographic stabi­ articulation theoretically has the potential lity in addition to potential improvements for increased cartilage longevity of the in grip strength, pain reduction, and native midcarpal cartilaginous surface by clinical stability. The technique is easier preserving a congruent articulation and to execute than a total wrist arthroplasty emulating normal midcarpal kinematics. or arthrodesis, and both options are Further, restoration of the normal carpal potentially still available after a hemi­ height restores normal capsuloligamen­ arthroplasty should a revision be tous relationships and approximates the required. wrist’s native center of rotation.

Conception of Midcarpal Design Considerations Hemiarthroplasty Any wrist prosthesis or implant design While wrist hemiarthroplasty successfully specifically for midcarpal hemiarthroplasty addresses the problems caused by the must satisfy a number of functional distal component of a total wrist arthro­ requirements to ensure that the patient’s plasty, the alteration of wrist kinematics activities of daily living are not further remains an issue. The proximal implants limited by the treatment imposed. Efforts of total wrist arthroplasties were not should be made to preserve the principal designed to accommodate this new use, motion of the wrist, the so-called dart- and as a result, cannot fully replicate thrower’s motion, in any technique that midcarpal wrist motion. aims to restore functional motion of the wrist. This coupled motion — which In 2006, the senior authors filed a U.S. comprises an elliptical envelope oriented patent application for a “midcarpal hemi­ along an oblique axis from extension/ arthroplasty,” to replicate the complex radial deviation to flexion/ulnar deviation articular structure formed by the proximal — is crucial during both high-strength 4 carpal row. The implant was conceived and high-dexterity activities involving the with the goal of enabling preservation of wrist [16, 37, 38]. Implant designs that Mid-Ca r p a l He m i a r t h r o p l a s t y

can reproduce this motion are hypo­ It is important to replicate the unique thesized to allow for greater functionality geometry of the midcarpal joint in the of the wrist during a wide variety of design of a prosthesis intended for use in activities. hemiarthroplasty (fig. 1). A design that

Fig. 1: Radiographs demonstrating the use of a prosthesis specifically designed to ac- commodate the anatomy of the distal carpal row. This 41-year old male active right- hand dominant male was treated for severe radiocarpal arthritis (A, B) using a midcar- pal hemiarthroplasty implant, and followup radiographs were obtained one year after surgery (C, D). Note the preservation of carpal height with the use of a midcarpal he- miarthroplasty. The patient was able to resume golfing on a regular basis 12 weeks 5 post-operation. Ar t h r o p l a s t i e s r a d i o -c a r p i e n n e s

minimizes wear and stress on the distal carpal row should allow for smoother motion of the wrist joint, decreased articular cartilage wear, and reduced risk of implant loosening or failure. In particular, throwing and sporting activities demand that the proximal implant be designed with a geometry that limits translation and shear stress between the proximal and distal components.

Maintaining the anatomy of the distal radioulnar joint (DRUJ) by preserving as much of the distal radius as possible is an important consideration in wrist prosthetic design. Motion at the DRUJ will benefit from the preservation of the articular surfaces of the distal radius as well as the critical bony origins of the Fig. 2: KinematX Midcarpal Hemiarthroplasty. palmar and dorsal arms of the radioulnar Note the cobalt-chromium articulating surface, ligaments. designed to create a near-acetabular joint with the distal carpal row. The stem is coated with a The KinematX Midcarpal Hemiarthroplas­ grit-blasted bony ingrowth, designed to impro- ved fixation within the distal radius. ty (Extremity Medical, Parsippany, NJ) is designed to meet these requirements. It is constructed of cobalt-chromium, and is coated with a grit-blasted bony Indications and Contraindications ingrowth designed to improved fixation. Three sizes allow for accurate canal fill Wrist hemiarthroplasty is indicated for and recreation of normal capsule- the treatment of painful radiocarpal ligamentous tension. The component’s arthritis that remains symptomatic and nearly acetabular articulation with the limits functionality, despite adequate distal carpal row is achieved by a nonsurgical management. Midcarpal computer-aided design utilizing aggre­ hemiarthroplasty is preferred over arthro­ gated computer tomography of 20 desis in cases in which an active lifestyle normal wrists (fig. 2). The monobloc, and/or the presence of shoulder or elbow proximal carpal row replacement is easy arthritis leads the patient to request to insert with minimal soft tissue disrup­ preservation of wrist range of motion for tion and instrumentation. By minimizing optimal upper extremity function. The bony removal of the distal radius, the etiologies of arthritis for which hemi­ subchondral plate remains intact and arthroplasty is indicated include arthritis provides increased support for the secondary to SLAC or SNAC wrist, post- prosthesis. traumatic radiocarpal osteoarthritis,

6 Mid-Ca r p a l He m i a r t h r o p l a s t y

distal radial articular malunion, Kienböck’s The third dorsal compartment is opened disease, and potentially, inflammatory as the extensor pollicis longus tendon is arthritis. The ideal patient for wrist hemi­ freed from its sheath and transposed arthroplasty is one in which the midcarpal radially. The first and second extensor articular cartilage is preserved. compartments are then elevated radially in a subperiosteal fashion. Hemiarthroplasty is contraindicated in patients with active inflammatory wrist A transverse capsular incision is made synovitis, or those with a recent or remote near the CMC joint, and a large proximally history of infectious arthritis. Significant based rectangular capsule-ligamentous bone loss and instability or severe flap is raised, with a wafer of the osteoporosis may also preclude the use triquetrum being lifted in continuity with of a prosthesis due to the risk of the capsule in order to preserve the component loosening. Effective function insertions of the dorsal radiocarpal and of a hemiarthroplasty may be prevented dorsal intercarpal ligaments. The by severe articular cartilage wear from posterior interosseous nerve may be inflammatory arthropathy, or instability preserved in this approach in order to created by compromise of capsulo­ improve wrist proprioception at the ligamentous sleeve. Caution should also surgeon’s discretion [39, 40]. be used in patients with extensor tendon disruption, as this may indicate attrition The proximal row is then excised in its of critical ligamentous support and affect entirety. Helpful instruments include a the soft tissue balance across the threaded 3.5mm Schanz pin, which can prosthetic articulation [21]. It remains be utilized as a “joystick” to assist in unclear how much midcarpal arthrosis, carpal bone excision, and curved peri­ particularly narrowing and/or degenera­ osteal elevators to divide capsular attach­ tive changes of the capitolunate joint, is ments. It is critically important to retain acceptable before midcarpal hemi­ the extrinsic palmar ligaments and main­ arthroplasty is contraindicated. tain pristine midcarpal articular surfaces.

The radial articular surface is then Surgical Technique exposed by wrist flexion and palmar translation of the distal row using a thin Routine skin preparation and upper retractor placed under the volar lip of the extremity draping is conducted after the radius. A power elliptical rasp (fig. 3) is administration of preoperative prophy­ then used to remove all articular cartilage lactic antibiotics, anesthesia, and from the lunate and scaphoid facets of tourniquet control. A universal dorsal the distal radius, smoothing the inter- incision is utilized, 4-5cm in length over facet ridge to create a concave and the wrist, in line with the third metacarpal. matching subchondral plate surface for Thick subcutaneous skin flaps are the implant. It is important to preserve elevated off the extensor retinaculum, the volar and dorsal capsuloligamentous and the retinaculum incised just radial to attachments originating on their respec­ Lister’s tubercle and reflected ulnarly. tive lips of the radius. 7 Ar t h r o p l a s t i e s r a d i o -c a r p i e n n e s

The implant is then press-fit or cemented, depending on the surgeon’s preference. Repair of the retinaculum, leaving the extensor pollicis longus tendon trans­ posed superficial to the retinaculum, is recommended. Routine closure is performed according to the individual surgeon’s preference, and a volar plaster wrist splint is applied in neutral position. Early mobilization of the shoulder, elbow, forearm, digits, and thumb is initiated immediately, and discontinuation of the splint at the first return visit for suture removal. A supervised program of progressive wrist range of motion exercises is prescribed at this time (flexion/extension, radial and ulnar deviation, pronation/supination, dart- throwing motion and circumduction), with strengthening being introduced at 6-8 weeks from the time of surgery. Full Fig. 3: Power elliptical rasp used in conjunction activity is usually permitted at 8 weeks, with midcarpal hemiarthroplasty. A power ellip- tical rasp (A) is used to remove all articular car- with no permanent activity restrictions tilage from the lunate and scaphoid facets of the (contingent on return of full strength). distal radius (B). The power rasp obliterates the inter-facet ridge, leaving a smooth, concave sub- chondral plate surface that matches the curvatu- re of the implant. Complications

The general risks of implant arthroplasty also apply to wrist hemiarthroplasty: wound healing problems, infection, hematoma, joint stiffness, nerve or Precise placement of a guidewire in the tendon injury, intraoperative fracture, and center of the radial canal is confirmed late loosening or subsidence. Early with PA and lateral fluoroscopic views. A experience indicates that overall risk of starter hole in the radius is centered aseptic loosening is less than that of total about the guide wire, and enlarged with wrist arthroplasty, but longer-term studies specialized “box cutting” instruments or are required. Potential complications a power burr. The canal is then broached specific to the wrist include extensor to the templated implant size. Trial adhesions, wrist instability, carpal impin­ placement of the implant is then gement, and the development of performed, followed by articulation of symptomatic midcarpal arthrosis over the wrist and a preliminary assessment time. The extent to which these potential of stability and wrist motion. At this complications may affect the long-term 8 stage, laxity is preferable to undue outcomes of midcarpal hemiarthroplasty tension. remains to be seen. Mid-Ca r p a l He m i a r t h r o p l a s t y

Early Outcomes weeks followup (range, 15-56 weeks), the mean Mayo wrist score increased The most comprehensive study of wrist significantly from 31.9 to 58.8 (p<0.05). hemiarthroplasty outcomes to date was The mean Disabilities of the Arm, Hand, performed by a single surgeon in London, and Wrist (DASH) score decreased UK, using the KinematX Midcarpal significantly from 47.8 to 28.8 (p<0.05), Hemiarthroplasty (Extremity Medical, with the index patient reporting a DASH Parsippany, New Jersey) over a followup score of 0 at one year followup. Five of period of 13 months [43]. the seven who were employed at time of surgery were able to return to their regular The average age of the nine patients was duties at work. 44 years (range, 23-74 years), with three male and six female patients. The The average range of motion (ROM) dominant hand was affected in six of the tended to increase (though this trend did nine, and seven were working at time of not reach statistical significance) when the surgery (none of which were in pre-operative assessments were com­ professions involving manual labor). The pared to latest follow up. Specifically, at indication for surgery was SLAC wrist in a mean of 31 weeks of followup, patients three patients, osteoarthritis of the wrist achieved a mean flexion-extension arc of in three, inflammatory arthritis in two, 79° (range, 30-130°, 53% of contralateral), and Kienböck’s disease in one. Two of radio-ulnar devia­tion arc of 23° (range, the patients presented with early 5-37°, 34% of contralateral), and grip midcarpal joint space narrowing. Prior strength 18.9kg (62% of contralateral). surgeries were attempted in two cases, a When the analysis was further stratified radial styloidectomy in one and a distal to exclude the two patients with ulnar arthroplasty in another. The average inflammatory conditions, ROM was found operative time required to perform the to increase significantly across all planes procedure was 49 minutes (range, 45-60 of motion (Table 2). minutes). The two patients with inflammatory Outcomes for all patients are reported conditions were found to have persistently below (Table 1). At an average of 31 low Mayo wrist scores (30 and 35), high

Table 1: Pre- and Post-Operative Data, All Patients [43]

Outcome Pre-Op Post-Op Significance Mayo Wrist Score 31.9 58.8 p=.006* DASH Score 47.8 28.7 p=.028* Flexion/Extension Arc (°) 64.6 79.3 p=.362 Radial/Ulnar Deviation Arc (°) 16.9 22.9 p=.262 Grip (kg) 16.1 18.9 p=.496 Grip (% of Contralateral) 56.3 61.7 p=.501 Includes all patients who underwent hemiarthroplasty, including both post-traumatic and inflammatory etiologies. Asterisks (*) indicate p<0.05. Data are reported as mean value. DASH = Disabilities of the Arm, Shoulder, and Hand 9 questionnaire, kg = kilograms. Ar t h r o p l a s t i e s r a d i o -c a r p i e n n e s

Table 2: Pre- and Post-Operative Data, Post-Traumatic Patients Only [43]

Outcome Pre-Op Post-Op Significance Mayo Wrist Score 35.0 67.5 p=.006* DASH Score 43.2 15.9 p=.006* Flexion/Extension Arc (°) 58.7 90.8 p=.039* Radial/Ulnar Deviation Arc (°) 13.3 24.7 p=.035* Grip (kg) 17.8 22.5 p=.217 Includes only those patients with post-traumatic etiologies for wrist arthritis, and excludes those patients with inflammatory etiologies. Asterisks (*) indicate p<0.05. Data are reported as mean value. DASH = Disabilities of the Arm, Shoulder, and Hand questionnaire, kg = kilograms.

DASH scores (66 and 68), low grip early results. While no definitive con­ strengths (8kg), and reduced motion (one clusions can be reached about the utility went on to require manipulation). The only of such implants as of yet, from a two complications in the series were need theoretical standpoint, the restoration of for manipulation in two patients. There physiological kinematics offered by were no cases of component loosening, proximal row implants are consistent no revisions, and no infections in the with the improved early outcomes 9 patients over a period of 13 months. demonstrated. The elimination of the distal component, whenever possible, should also reduce component-related Recommendations loosening, fracture, and cut-out. However, the concerns about the use of Hemiarthroplasty is a novel technique prostheses in cases of inflammatory that is still in its infancy, but early out­ arthritis have not yet been fully resolved, comes are encouraging. A newer and the indications and contraindications prosthetic design, incorporating design for the use of hemiarthroplasty continue considerations specific to emulation of to evolve with more collective experience the midcarpal joint, has led to promising with the procedure.

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