Treatment of Total Wrist Arthroplasty Dislocation; an analysis of 38 consecutive cases
Gregory R Anderson, MD; Eric R Wagner, MD; Nathan R Wanderman, MD; Marco Rizzo, MD
Mayo Clinic, Rochester, MN
Hypothesis:There remains a paucity of information regarding the treatment outcomes of dislocation after total wrist arthroplasties (TWA). This study's purpose was to assess the outcomes of surgical and nonoperative treatment modalities for TWA dislocations.
Methods:Out of 445 primary TWA arthroplasties collected in a single institution's total joints registry over a 35 year period, there were 38 (9%) acute dislocations that required intervention by a healthcare professional. The mean age was 56 (35-74), with 31 (82%) females. The diagnoses for the TWA dislocations included rheumatoid arthritis (n=36) or osteoarthritis/post-traumatic arthritis (n=2). The study analyzed dislocation treatment, subsequent procedures needed, pain scores and range of motion at last follow-up. Dislocation was defined as radiographic evidence of TWA prosthetic dislocation diagnosed and treated by a fellowship trained hand surgeon.
Results:Of the 38 dislocations, initial treatments included 31 closed reduction and splinting, 4 conversions to total wrist arthrodesis, and 3 soft tissue stabilization procedures involving open reduction and capsular tightening. Every patient initially treated nonoperatively or with soft tissue stabilization procedures alone failed management and experienced recurrent instability. Although 7 of these patients desired no further intervention, 22 patients treated nonoperatively and all 3 treated with soft tissue procedures eventually underwent revision TWA. Additionally, the other 2 treated nonoperatively were converted to arthrodesis. Ultimately, 6 patients underwent total wrist arthrodesis, while 25 underwent revision TWA. All 6 patients who underwent arthrodesis did not require further interventions, with none or mild pain at a mean 1.8 years (1-4) postoperative follow-up. Of the 25 revision TWAs, 5 (20%) experienced recurrent instability at a mean 3.6 months (1-14) postoperatively. At a mean follow-up 5 years (1-15), the 2 and 5 year survival-free of repeat instability after revision TWA for dislocation was 79% and 79%, respectively (Figure 1). No difference in repeat instability existed between the different implants utilized in the revision TWA (p=0.87). While a higher rate of repeat instability after revision TWA existed compared to fusion, it was not statistically significant (p=0.12).
Summary Points:Treatment of TWA dislocation, while a rare event, is technically challenging, with high rates of repeat instability. Nonoperative and soft tissue stabilization procedures fail to restore wrist articular stability. While revision arthroplasty leads to stable joints in 4 out of 5 patients, our series suggests arthrodesis as the most reliable definitive treatment option for these patients.
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