Wrist Arthrodesis: Review of Current Techniques

Peter J. L. Jebson, MD, and Brian D. Adams, MD

Abstract

Wrist arthrodesis is a well-established procedure that predictably relieves pain inserting the Steinmann pin into
and provides a stable wrist for power grip. Although a variety of techniques for the radius via the second or third
achieving a solid fusion have been described, the combination of rigid stabiliza- web space of the hand. In 1982,
tion with a dorsal plate and autogenous cancellous bone grafting results in a Feldon and co-workers9 described
high fusion rate and obviates the need for prolonged postoperative cast immobi- the use of two smaller Steinmann
lization. Successful results with dorsal plating with or without local bone graft pins inserted through the second
have recently been reported for patients with posttraumatic conditions. Rod or and third web spaces and between
pin fixation is an established procedure for patients with inflammatory arthritis the metacarpal shafts into the
or a connective tissue disorder; however, plate fixation for these conditions is medullary canal of the radius. This
becoming a more acceptable alternative. Complications are relatively common technique improved stability and
and range from minor transient problems to major problems, such as wound obviated the need for supplemen-
dehiscence, infection, extensor tendon adhesions, and plate tenderness, which tary staple or wire fixation. Viegas
may require implant removal. Preoperatively, patients should be assessed for et al10 recommended placing a sin-
the presence of carpal tunnel syndrome, distal radioulnar joint arthritis, or gle large Steinmann pin adjacent to
ulnocarpal impaction syndrome, which may become or remain symptomatic the base of the second metacarpal,
after arthrodesis. Wrist arthrodesis results in a high degree of patient satisfac- through the carpus, and into the
tion with respect to pain relief and correction of deformity. Patients are able to medullary canal of the radius. They
accomplish most daily tasks and activities by learning to adapt to, and compen- suggested that this insertion posi-
sate for, the loss of wrist motion. tion places the wrist in extension
J Am Acad Orthop Surg 2001;9:53-60 and ulnar deviation, thus improving
grip strength.
Proponents of intramedullary
rod or pin techniques have sug-
Since the original report by Ely in high rates of pseudarthrosis and gested a number of advantages.
1910, arthrodesis of the wrist has graft failure led to the use of inter- These include decreased operative
become a well-established recon- nal fixation devices to augment the time, simplicity, ability to perform
structive procedure for a number of arthrodesis.
upper extremity disorders. A vari- In 1965, Clayton6 described a tech-
ety of methods for achieving wrist nique for achieving wrist arthrod-
fusion have been described.1-5 The esis in patients with rheumatoid Dr. Jebson is Assistant Professor, Hand and
earliest techniques relied on cancel- arthritis. The technique involves Microvascular Surgery, Section of Orthopaedic
Surgery, University of Michigan Medical
lous or corticocancellous bone-graft the insertion of a single 3Ú 32-inch-
Center, Ann Arbor. Dr. Adams is Professor,
stabilization alone and varied with diameter Steinmann pin down the Division of Hand and Microsurgery, De-
respect to donor site; type, size, and third metacarpal shaft into the partment of Orthopaedic Surgery, University
shape of the graft; and method of medullary canal of the radius. The of Iowa Hospitals and Clinics, Iowa City.
graft insertion. Postoperative cast pin maintains alignment and stabil-
immobilization was required to ity after the placement of a dorsal Reprint requests: Dr. Jebson, Section of
Orthopaedic Surgery, University of Michigan
maintain wrist position until a solid corticocancellous bone graft. In
Medical Center, 1500 East Medical Center
fusion was achieved. Concerns re- 1971, Mannerfelt and Malmsten 7 Drive, TC2912, Ann Arbor, MI 48109-0328.
garding the inconvenience and modified the procedure by using a
morbidity of prolonged immobi- Rush rod reinforced with a staple. Copyright 2001 by the American Academy of
lization, the morbidity of extensive In 1973, Millender and Nalebuff8 Orthopaedic Surgeons.
bone grafting, and the unacceptably further modified the technique by

Vol 9, No 1, January/February 2001 53

Wrist Arthrodesis
concomitant procedures at the
metacarpophalangeal joints in
patients with inflammatory arthri-
tis, short recuperation period, low-
ered cost compared with other
implants, and flexibility in posi-
tioning the wrist in the desired
amount of flexion or extension.
In 1972, Meuli 11 performed a
wrist arthrodesis with a dorsal plate
applied from the second metacarpal
to the radius. Manetta and Tavani12
recommended axial compression of
the radiocarpal joint and fixation of
the plate on the third metacarpal.
Wright and McMurtry13 reviewed
their experience with arthrodesis
with a 3.5-mm dynamic compres-
sion plate. Using a dorsal plate for
wrist arthrodesis was advocated as
a method of achieving immediate
rigid fixation that obviated the need
for postoperative cast immobiliza-
tion and avoided the complications
of hardware failure and pseudar-
throsis (Fig. 1). Although there
were high rates of fusion and sub-
Figure 1 Wrist arthrodesis performed
with the single-intramedullary-rod tech-
nique. The patient had a painful pseud-
arthrosis involving the scaphotrapezio-
trapezoid articulation. The rod is broken,
most likely the result of failure to include
the third carpometacarpal joint in the
fusion.
54
jective satisfaction with respect to
pain relief, several patients in their
series required plate removal be-
cause of tenderness and/or extensor
tendon irritation. In addition, precise
contouring of the plate into slight
wrist extension and ulnar deviation
was time-consuming and difficult
to achieve. A recent development
is the precontoured, low-contact,
dynamic-compression titanium
plate (Fig. 2), which was specially
designed for wrist arthrodesis.
Despite immediate rigid stabi-
lization with a dorsal plate and
advances in implant design, supple-
mentation of the fusion site with
autogenous cancellous bone graft
from the iliac crest continues to be
common practice. Significant donor-
site morbidity, including persistent
pain, hematoma formation, infec-
tion, and nerve injury, has led to the
use of alternative techniques, such
as obtaining bone graft from the
distal radius or fusion without bone
graft.14,15 Use of the iliac crest is
reserved for those patients with
poor bone quality or large defects.
Supplemental autogenous bone
grafting is usually not necessary for
patients with inflammatory arthritis.
Indications
The most common indication for
wrist arthrodesis is symptomatic
posttraumatic or degenerative arthro-
sis of the radiocarpal and midcarpal
joints that is severe and unrespon-
sive to conservative nonoperative
treatment and will not be improved
by a motion-saving procedure.
Additional indications include con-
ditions that cause destruction, insta-
bility, or contracture of the wrist
joint, such as the inflammatory
arthritides, infection, nerve palsy,
and paralytic, spastic, and connec-
tive tissue disorders, as well as bone
loss due to trauma or following
tumor resection. Wrist arthrodesis
is also indicated for the treatment of
Journal of the American Academy of Orthopaedic Surgeons
complex carpal instability problems
and salvage of a failed implant ar-
throplasty, proximal row carpectomy,
or limited intercarpal arthrodesis.
Performing bilateral wrist ar-
throdeses in the patient with in-
flammatory arthritis is controver-
sial. Patients with bilateral wrist
arthrodeses are believed to have
less dexterity and greater functional
compromise than those with an
arthrodesis of one extremity and
arthroplasty of the other. However,
there is disagreement with respect
to which extremity should be fused.
Arthrodesis of the nondominant
extremity and arthroplasty of the
dominant extremity has been advo-
cated. There is no consensus re-
garding optimal positioning when
arthrodesis is performed in both
extremities. Several authors recom-
mend the neutral position for the
dominant extremity and 5 to 10 de-
grees of flexion for the nondomi-
nant side.16,17 Brumfield and Cham-
poux18 recommend 10 degrees of
extension for both extremities.
Clayton and Ferlic19 recommend a
neutral position for both wrists.
Contraindications
Contraindications to wrist arthrod-
esis include a lack of adequate soft-
tissue coverage and the presence of
active wrist infection. Arthrodesis is
also contraindicated when motion-
preserving procedures are possible
means of preserving function.
Because of the technical require-
ments, wrist arthrodesis should
also be avoided for the skeletally
immature patient with open epiphy-
seal plates.
Surgical Technique Using
the Wrist Fusion Plate and
Local Bone Graft
This procedure can be performed
with the use of either brachial plexus
 Peter J. L. Jebson, MD, and Brian D. Adams, MD

A B

Figure 2 A, The three plate options: the standard-bend (top), short-bend (middle), and straight plates (bottom). The precontoured titani-
um plates are manufactured by Synthes USA (Paoli, Pa). B, Note the low profile, tapered end, and built-in fusion angle of 10 degrees of
dorsiflexion in the standard-bend and short-bend plates.

block or general anesthesia. If iliac-
crest bone graft is required, general
anesthesia is usually necessary, al-
though on occasion local anesthesia
and a brief period of sedation may
be used for that portion of the pro-
cedure. Under tourniquet control, a
straight incision is made from
the distal third of the index finger–
middle finger interosseous space
across Lister’s tubercle and over the
radial shaft to the proximal border
of the abductor pollicis longus mus-
cle. Full-thickness skin flaps are ele-
vated, with care taken to protect the
cutaneous nerves and dorsal veins.
The third dorsal compartment of the
extensor retinaculum is opened, and
the extensor pollicis longus muscle
and tendon are retracted radially.
The second and fourth dorsal com-
partments are elevated subperiosteal-
ly in the radial and ulnar directions,
respectively. The dorsal aspect of
the third metacarpal is exposed by
sharply incising and elevating the
periosteum, with care taken to avoid
damaging the adjacent interosseous
muscles.
The incision is deepened proxi-
mally to expose the third carpo-
metacarpal, capitolunate, and ra-
diocarpal articulations. Distraction
is applied to the hand, and the ar-
ticular surfaces of the third car-
pometacarpal, capitolunate, radio-
scaphoid, and radiolunate joints
are denuded to cancellous bone
(Fig. 3, A). Articular cartilage may
be removed with a curette and/or
a rongeur. Alternatively, a burr
may be used, particularly for scle-
rotic bone. The triquetrohamate,
capitohamate, and scaphotrapezio-
trapezoid surfaces are similarly
prepared for fusion if symptomatic
arthritic involvement is identified
on preoperative radiographs or
clinical examination. Lister’s tuber-
cle is removed, and the dorsal sur-
faces of the scaphoid, lunate, and
capitate are decorticated to provide
a flat surface for plate application
(Fig. 3, B).
Cancellous bone graft is harvested
from within the distal metaphyseal
region of the radius through a corti-
cal window created 2 cm proximal
to the distal radial articular surface
and radial to the intended plate
position. One centimeter of sub-
chondral and metaphyseal bone
should be preserved during harvest-
ing of the graft. Bone graft is inserted
into the prepared joint spaces that
will lie beneath the plate.
The appropriate plate type is then
selected. If the AO wrist arthrod-
esis system is used, there are three
choices of plates. A standard-bend
plate is used in larger individuals.
A short-bend plate is used in small-
stature patients and in those with a
failed proximal-row carpectomy. A
straight plate is used in patients
with unusual wrist anatomy or a
severely deformed joint or when a
large intercalary bone graft is nec-
essary.
Proper plate position and align-
ment should be confirmed before
screw insertion. The plate is fixed
to the third metacarpal shaft with
three 2.7-mm bicortical screws.
Alternatively, the plate may be
fixed to the second metacarpal to
position the wrist in slight ulnar
deviation, thus enhancing power
grip. The holes must be drilled
exactly from dorsal to volar in the
sagittal plane; otherwise, rotational
malalignment of the middle finger
will occur when the plate is se-
cured to the radius. The holes
should also be drilled in the mid-
line of the metacarpal to optimize
screw fixation and to prevent meta-
carpal fracture. The plate should
be properly seated and secured as

Vol 9, No 1, January/February 2001 55

Wrist Arthrodesis

Before decortication

After plate application

Always fused Figure 3 A, Joint surfaces to be included in the fusion.

The inclusion of optional joints into the arthrodesis is based
Optional on the presence of deformity or arthritis on preoperative
examination or radiographs. B, Lister’s tubercle is os-
teotomized. The dorsal aspects of the third carpometacarpal
joint, scaphoid, capitate, and lunate are decorticated.
A

far proximally as possible on the
metacarpal shaft to avoid irritation
of the overlying extensor tendons
by the distal edge of the plate. An
additional 2.7-mm bicortical screw
is placed into the capitate. The
plate is fixed to the radius with
four fully threaded 3.5-mm screws
placed in bicortical fashion. The
fusion mass is compressed by
drilling the radial-shaft screw holes
eccentrically away from the wrist
joint.
Appropriate plate position and
screw lengths are confirmed with
intraoperative radiographic imag-
ing. Wound closure is performed
over a suction drain. The distal por-
tion of the plate is covered with the
dorsal hand fascia and periosteum
if possible. The capsule may also
be covered over the plate; alterna-
tively, a distally based slip from
one of the wrist extensor tendons
may be used. The extensor pollicis
longus is transposed above the
extensor retinaculum as the third
dorsal compartment is closed. The
tourniquet is deflated, and hemosta-
sis is obtained. Skin closure is per-
formed with nonabsorbable suture
placed in interrupted horizontal-
mattress fashion to facilitate ever-
sion of the wound edges. A soft,
bulky dressing is applied.
Postoperatively, the patient is
encouraged to elevate the extremity
and perform active and passive dig-
ital range-of-motion exercises. Su-
tures are removed at 10 to 14 days,
and a volar forearm-based splint is
applied. Only light activities are
permitted. Strengthening exercises
are begun 6 weeks after surgery.
Splinting is discontinued at 6 to 8
weeks, and full unrestricted use of
the extremity is usually permitted
by 10 to 12 weeks postoperatively
when healing is complete and radio-
graphs confirm successful fusion.
Figure 4 illustrates a case of wrist
arthrodesis performed with the cus-
tom plate in a patient with post-
traumatic arthritis.
Surgical Technique Using
an Intramedullary Rod
Exposure of the distal radius and car-
pus is performed through a dorsal
longitudinal incision, as described
for the dorsal-plate technique. In
the patient with inflammatory ar-
thritis, it is particularly important to
handle all skin flaps gently, to pre-
serve dorsal veins, and to maintain
thick skin flaps. The skin flaps and
subcutaneous tissue are elevated
from the extensor retinaculum,
which is incised longitudinally over
the sixth compartment. The remain-
ing compartments are released in an
ulnar-to-radial direction, preserving
the broad, radially based retinacular
flap for transposition of all or a por-
tion of the retinaculum beneath the
extensor tendons.
A longitudinal wrist capsulotomy
is made, followed by exposure of
the radiocarpal and intercarpal
joints. A complete radiocarpal and
intercarpal synovectomy is per-
formed. Articular cartilage from
the radiocarpal, intercarpal, and
midcarpal joints is removed. Con-
comitant procedures involving the
extensor tendons and the distal
radioulnar joint (DRUJ) are per-
formed as indicated. If the distal
ulna is excised, the resected bone
may be morcellized and used as
bone graft. In patients with post-

56 Journal of the American Academy of Orthopaedic Surgeons


traumatic or degenerative arthritis,
the fusion site is supplemented
with cancellous bone harvested
from the distal radius or iliac crest.
There are several acceptable
methods of pin or rod placement.
The single-Steinmann-pin technique
of Millender and Nalebuff8 and the
dual-rod technique of Feldon9 dem-
onstrate the principles of this ap-
proach.
Millender-Nalebuff Technique
With this technique, the wrist is
palmar-flexed, and the intramedul-
lary canal of the distal radius is
carefully entered with a pointed
awl or large curette. A Steinmann
pin is advanced into the radius
manually or with a power drill.
The size of the pin is sequentially
increased until the largest possible
pin that can be accommodated by
the radial shaft is identified. This
pin is drilled in a proximal-to-distal
direction through the carpus until
A B
Figure 4 AP (A) and lateral (B) radiographs of the wrist demonstrate the scapholunate advanced collapse (SLAC) pattern of arthritis,
with narrowing of the radioscaphoid joint and midcarpal arthritis. Posteroanterior (C) and lateral (D) radiographs 10 weeks after wrist
arthrodesis performed with a titanium custom wrist fusion plate and local bone graft.
Vol 9, No 1, January/February 2001
Peter J. L. Jebson, MD, and Brian D. Adams, MD
it exits through the second or third
intermetacarpal space dorsally.
The pin is then withdrawn distally,
the hand is reduced on the wrist,
and the pin is advanced proximally
into the previously prepared med-
ullary canal of the radius. The pin
is countersunk beneath the skin
into the intermetacarpal space with
a bone tamp.
Because the pin is not bent, the
wrist is subsequently fused in a
neutral flexion-extension position.
Alternatively, if concomitant meta-
carpophalangeal joint implant ar-
throplasties are to be performed, the
Steinmann pin can be placed down
the third metacarpal shaft after
resection of the metacarpal head.
The pin should be sufficiently coun-
tersunk to avoid interfering with
subsequent implant placement.
Feldon Dual-Rod Technique
Instead of a single large Stein-
mann pin, two smaller (3Ú32- to 7Ú64-
C D
inch-diameter) pins are inserted
dorsally across the carpus into the
second and third intermetacarpal
spaces. The pins may be bent be-
fore or after insertion to obtain the
desired degree of wrist extension
and ulnar deviation. The pins are
cut short and impacted beneath the
skin.
In both methods, the capsule is
reapproximated, and the radially
based extensor retinacular flap is
transposed beneath the extensor
tendons. If there is a tendency to-
ward bowstringing, one half of the
retinaculum can be placed over the
tendons. The tourniquet is released,
and hemostasis is obtained. The
skin is closed, and a sterile dressing
is applied, followed by a short plas-
ter arm cast or splint immobili-
zation.
Postoperative management is
similar to that used after arthrode-
sis with a dorsal plate with one
exception. Following suture re-
57
Wrist Arthrodesis
moval, the wrist is immobilized in a
short arm cast for 6 weeks. The de-
cision to discontinue immobiliza-
tion is based on radiographic con-
firmation of successful arthrodesis.
Capitate-Radius
Arthrodesis
An alternative technique for achiev-
ing radiocarpal arthrodesis in pa-
tients with a severe flexion defor-
mity of the wrist due to congenital
or acquired spastic deformities of
the upper extremity has been re-
ported by Louis et al.20 The tech-
nique involves excision of the prox-
imal 80% of the scaphoid, the entire
lunate and triquetrum, and a por-
tion of the hamate. A trough is cre-
ated in the subchondral region of
the distal radius to facilitate seating
of the denuded proximal pole of the
capitate. The hand is positioned in
neutral or slight palmar flexion and
ulnar deviation, and the fusion site
is augmented with Kirschner wires,
transfixing staples, or a dorsal plate
as needed. Concomitant sectioning,
lengthening, or transfer of wrist
and digital flexor tendons may be
needed to allow satisfactory posi-
tioning of the hand. Postopera-
tively, plaster cast immobilization
is maintained until there is clinical
and radiographic evidence of union.
The advantages of the capitate-
radius arthrodesis include the in-
trinsic stability created by excision
of the proximal carpal row and in-
sertion of the capitate into the ra-
dius and the elimination of autog-
enous bone grafting. In addition,
the shortening accommodates the
contracted volar wrist and digital
flexor tendons. The cosmetic ap-
pearance of the severely flexed ex-
tremity is significantly improved
after capitate-radius arthrodesis.
However, functional improvement
is dependent on the preoperative
diagnosis, functional abilities, and
the severity of spasticity.
58
Comparative Results
In one retrospective series of 89
consecutive patients who had un-
dergone wrist arthrodesis for a
posttraumatic disorder, patients
treated with dorsal-plate fixation
were compared with those treated
with various other techniques.14 In
the former group, fusion was more
successful (98% versus 82%) and oc-
curred earlier (average, 10.3 weeks
versus 12.2 weeks postoperatively).
When performed in patients with
posttraumatic or degenerative con-
ditions, dorsal-plate fixation and
autogenous bone grafting results in
highly reliable fusion rates, ranging
from 93% to 100%.13,21,22 Preliminary
data demonstrate similar success
with the use of the specially de-
signed low-profile precontoured
plate and local bone graft.22
Most of the patients reported in
the literature who have had wrist
arthrodesis with dorsal-plate fixa-
tion had diagnoses of degenerative,
posttraumatic, or neurologic condi-
tions. There are very few studies
involving patients with inflamma-
tory arthritis. In the largest series
of rheumatoid patients with a wrist
arthrodesis performed with a dorsal
plate, successful union occurred in
all 23 patients.23 The arthrodesis was
performed with a self-compressing
six-hole plate applied on the sec-
ond metacarpal. In the series of
Zachary and Stern,24 all 5 patients
with inflammatory arthritis had a
successful wrist arthrodesis with
the dorsal-plate technique. How-
ever, all three failures in the series
of Wright and McMurtry13 occurred
in patients with rheumatoid arthri-
tis. Similarly, Bracey et al25 reported
a nonunion rate of 17% after wrist
arthrodesis performed with a dor-
sal T-plate in patients with rheu-
matoid arthritis. In one patient, the
arthrodesis was performed after
failure of a cemented wrist prosthe-
sis. The other failure occurred after
a postoperative infection. Because
Journal of the American Academy of Orthopaedic Surgeons
of plate prominence, the higher
rates of nonunion, delicate skin, and
osteoporotic bone, and the greater
risk of infection, the intramedullary-
rod technique remains an accept-
able and popular alternative for
patients with inflammatory ar-
thritis.
Satisfactory results have also
been reported when wrist arthrod-
esis is obtained with intramedullary
fixation. 6-8,26 However, these re-
ports predominantly involved pa-
tients with rheumatoid arthritis. In
Clayton’s original report,6 all 5 pa-
tients with rheumatoid arthritis had
a successful fusion. Mannerfelt and
Malmsten7 reported successful wrist
fusion using a Rush pin and staple
in all but 1 of their 43 rheumatoid
patients. The same technique was
used in 1 patient with a congenital
deformity and 5 patients with a
posttraumatic or neurologic disor-
der; however, their outcome was
not reported.
In the series of Millender and
Nalebuff,8 all but 2 of the 60 rheu-
matoid patients (70 arthrodeses)
had a successful fusion with a
Steinmann pin supplemented with
a staple or single Kirschner wire.
Postoperatively, up to 5 months of
immobilization in a long or short
arm cast was necessary. Clendenin
and Green 27 reported successful
union in all but 1 of their 12 pa-
tients in whom arthrodesis was
performed with the technique of
Millender and Nalebuff. Vahvanen
and Tallroth 26 reported a 100%
fusion rate in 38 patients with
rheumatoid arthritis (45 wrists) in
whom arthrodesis was performed
with a single Rush pin. In the only
series of nonrheumatoid patients
in whom arthrodesis was per-
formed with a modification of the
Millender-Nalebuff intramedullary
technique, all 10 patients (7 with
posttraumatic arthritis, 2 with
Kienböck disease, and 1 with pso-
riatic arthritis) achieved solid
fusion.10

Functional Outcome
Wrist arthrodesis results in high
subjective patient satisfaction with
respect to pain relief and correction
of deformity.8,13,28 Grip strength,
digital range of motion, and fore-
arm rotation do not significantly
change from preoperative values.22
Improvements in pinch and grip
strengths have been reported fol-
lowing wrist arthrodesis in patients
with osteoarthritis, but not in those
with rheumatoid arthritis.13
In a recent study assessing the
functional capabilities of patients
after unilateral wrist arthrodesis
performed for a variety of post-
traumatic conditions, most tasks
and daily activities could still be
performed, but required adapta-
tion and modification by the pa-
tient. 28 The most difficult tasks
were perineal care, manipulating
the hand in tight spaces, and activi-
ties that required forceful prona-
tion and supination with a simulta-
neous strong grip. Manual laborers
have difficulty crawling, pushing,
carrying, and using tools, particu-
larly a hammer, because of the loss
of wrist extension. Interestingly,
maximum improvement in function
did not occur for an average of 14.5
months after arthrodesis.28 Most
patients returned to their original
occupation with some job modifica-
tion, such as lifting restrictions. In
the retrospective study of Hastings
et al, 21 those patients in whom
arthrodesis had been performed
with a dorsal plate returned to
work earlier than those in whom
arthrodesis had been performed
with various other methods.14
Complications
Complications after wrist arthrode-
sis occur regardless of the technique
used.27 However, review of the lit-
erature suggests that plate fixation
is associated with a lower incidence.
Vol 9, No 1, January/February 2001
Peter J. L. Jebson, MD, and Brian D. Adams, MD
Hastings et al21 reviewed the data
on 89 patients with 90 wrist arthrod-
eses performed for various post-
traumatic disorders. In 56 patients
(57 wrists), arthrodesis was per-
formed with plate fixation. In 33
patients (33 wrists), the arthrodesis
was performed with a variety of
other methods. In 28 of these 33,
arthrodesis was performed with an
onlay corticocancellous bone graft
temporarily transfixed with Stein-
mann pins or Kirschner wires. Four
patients had an onlay graft alone;
the remaining arthrodeses involved
intramedullary fixation without
bone grafting. A 3.5-mm dynamic
compression or reconstruction plate
was used for plate fixation. Autog-
enous iliac-crest bone graft was
used in all but 1 of the 57 arthrodeses.
Nonunion occurred in 2% of the
arthrodeses performed with a plate,
compared with 18% of the arthrod-
eses performed with other meth-
ods. Additional complications oc-
curred in 51% of patients with plate
fixation, compared with 79% of the
patients in whom arthrodesis had
been performed with alternative
methods. Complications associated
with plate fixation included exten-
sor tendon adhesions or tenosyn-
ovitis, intrinsic muscle contracture,
tenderness over the plate, poor
wound healing, painful nonunion
of the third carpometacarpal joint,
and carpal tunnel syndrome. Fifty-
nine percent of these complications
required operative treatment.
Complications associated with the
alternative arthrodesis techniques
included tendon adhesions, carpal
tunnel syndrome, DRUJ pain, pin-
track infection, and pin migration
or breakage. Twenty-one percent
of these complications required
operative treatment.
Complications related specifically
to dorsal-plate fixation and iliac-
crest bone grafting were analyzed
by Zachary and Stern.24 Although
the union rate was 100%, there
were a total of 82 complications in
50 of the 73 wrist arthrodeses.
Approximately 80% of these com-
plications resolved spontaneously
or with nonoperative treatment.
Nineteen patients required surgery,
which most commonly involved
plate removal because of promi-
nence, loosening, or the development
of a symptomatic bursa. Resection
of the distal ulna was necessary in
3 patients and was recommended
for 5 additional patients with symp-
tomatic DRUJ arthritis or ulnar im-
paction syndrome.
Failure to identify or anticipate
DRUJ problems in the wrist arthrod-
esis patient is a well-recognized
source of postoperative dissatisfac-
tion.17,24,27,29 Concomitant DRUJ dis-
orders and the potential for “iatro-
genic” ulnar impaction syndrome or
compression of the median nerve in
the carpal tunnel after wrist arthrod-
esis should be addressed preopera-
tively or intraoperatively, as these
conditions may be aggravated, po-
tentially compromising an otherwise
successful arthrodesis. The manage-
ment of extensor tendon irritation by
the plate can be particularly chal-
lenging. Nonoperative treatment
modalities include icing, nonsteroi-
dal anti-inflammatory medication,
and the judicious use of corticoste-
roid injections. Plate removal is re-
served for patients with persistent,
chronic symptoms. Removal is typi-
cally performed after successful ar-
throdesis. Some patients continue to
have persistent symptoms despite
plate removal.
Although wrist arthrodesis with
intramedullary fixation is relatively
simple and safe, complications
directly attributable to the various
intramedullary devices do occur.
Rod or pin migration with irritation
of the surrounding tendons and
skin necessitates bending of the pin,
which makes subsequent implant re-
moval difficult. Breakage of the rod
or pin can be associated with pseud-
arthrosis. Fortunately, the incidence
of these complications is low.6-8,26
59
Wrist Arthrodesis
Summary
Wrist arthrodesis results in pre-
dictable pain relief and a high de-
gree of patient satisfaction. Some
adaptation and modification of
functional activities is required, and
certain tasks, such as perineal care,
are difficult. The traditional tech-
nique of intramedullary rod or pin
fixation is most applicable for pa-
tients with inflammatory arthritis or
a connective tissue disorder.
Plate fixation is indicated for pa-
tients with posttraumatic or degen-
erative arthrosis. The advantages
of this type of fixation include im-
mediate rigidity, thus permitting
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