1

2011 British Editorial Society of Bone and Joint Surgery

Focus On
Avoiding fusion in
wrist arthritis
Advanced non-inflammatory arthritis of the wrist can lead to sig-
nificant disability. Traditionally, the treatment for arthritis of the
wrist which does not respond to either anti-inflammatory medi-
cation, splintage, steroid injections and time, would be a total
wrist fusion. However, wrist fusion substantially diminishes
function
1
and is usually avoidable. Two facts should prompt the
surgeon to avoid wrist fusion. First, arthritis rarely affects all the
joints of the wrist; secondly, there are now several movement-
sparing procedures which can give predictably good outcomes.
The history, examination and investigation of a patient with
non-inflammatory arthritis of the wrist, and who is a candidate
for surgery, should be directed towards one goal avoiding total
wrist fusion if possible.
This article describes the options available for surgical treat-
ment of arthritis of the wrist and emphasises the ways in which
the disability of total wrist fusion can be avoided.
Background
The wrist is a highly complex joint with articulations between the
distal radius and ulna and eight carpal bones. There are many
causes of arthritis of this joint, which include previous intra-
articular fracture, mid-carpal malalignment from a previous
distal radial fracture, interosseous ligament disruption, avascu-
lar necrosis and developmental abnormalities.
2
In many cases
there is no obvious cause.
Pancarpal arthritis is more likely to be seen with inflammatory
pathology such as rheumatoid arthritis but is less likely in non-
inflammatory degenerative arthritis. 'Isolated' osteoarthritis,
affecting just one or a few individual articulations, is more com-
mon. This delineation allows the surgeon to devise the most
appropriate surgical procedure in order to avoid wrist fusion, if
possible.
Historically, total wrist fusion was the standard procedure for
arthritis of the wrist from whatever cause, enhanced by the
technical ease of application for contoured plates (Fig. 1). This
aimed to reduce pain and allow a return to work. However, with
increasing interest in functional outcome after surgery, the
importance of preserving a small range of wrist movement to
allow activities of daily living such as perineal care, dressing
and combing hair, has become apparent.
3
This has encour-
aged growing support in favour of movement preservation, with
an increasing use of total wrist arthroplasty for pancarpal
arthritis, or limited intercarpal fusions for more focal degener-
ative disease.
4

Limited intercarpal arthrodesis
Many different techniques to secure union in intercarpal fusion
have been described; these include Kirschner wires (K-wires),
cannulated screws, bone staples and circular plates.
4-9
Many
combinations of intercarpal fusion have been undertaken since
Peterson and Lipscomb's description of available options in
1967.
10
The more commonly performed and reliable fusions are
scaphoid-trapezium-trapezoid (STT), radio-lunate, capitate-
hamate-lunate-triquetral (four-corner), and radio-scaphoid-lunate.
Scaphoid-trapezium-trapezoid fusion. This procedure (Fig. 2) is
used primarily to treat STT arthritis although has been proposed
as a solution for chronic scaphoid-lunate instability and Kien-
bock's disease.
4
It should be accompanied by a radial styloidec-
tomy, which allows an improved post-operative range of
movement.
2
K-wires may achieve high union rates (87%)
4
while
a post-operative range of movement of 62% of normal can be
expected.
2,4
However, there can be a high complication rate, with
Fig. 1
Radiograph of a total wrist fusion
using a contoured plate
2 T. CROOK, D. WARWICK
THE JOURNAL OF BONE AND JOINT SURGERY
49% of patients having persisting wrist pain.
4
Additionally,
altered wrist biomechanics and loading may explain the findings
of subsequent radio-scaphoid arthritis that occur in 23% of
patients after STT fusion.
11
Dissatisfaction with STT fusion is
common among patients and surgeons; however, there are alter-
natives. For example, excision of the very distal pole of the
scaphoid for STT arthritis. However, only a small amount should
be excised, and it should be avoided in those with pre-existing
hyperextension of the lunate, as the proximal row can extend into
a DISI deformity and thus cause secondary midcarpal
collapse.
12
Radio-scapho-lunate fusion . A radio-scapho-lunate fusion
(Fig. 3) is considered for patients in whom isolated radiocarpal
arthritis is present but who have a normal midcarpal joint. This is
typically seen after previous fractures of the distal radius. When
combined with excision of the distal pole of scaphoid, 50% of the
normal range of movement of the wrist can be preserved.
13
Radio-lunate fusion. This procedure (Fig. 4) was originally
described by Chamay for patients with rheumatoid arthritis. The
aim was to address the tendency of the rheumatoid proximal
carpal row to slide ulnarwards and into supination. Other indica-
tions now include traumatic ulnar translation, radiocarpal incon-
gruity after fracture of the lunate fossa, static volar intercalated
segment instability (VISI) and dynamic midcarpal instability.
14,15
Only a small series features in the literature although this
reports acceptable rates of union (12/14 cases).
16
Radio-lunate
fusion is not currently recommended for Kienbock's disease,
with Tambe et al. demonstrating a 50% failure rate in this cohort
of patients.
14
The lunate-radius distance must be preserved
after decortication, which usually requires interposition of a cor-
tical bone block.
Fig. 2
Radiograph of a scaphoid-trapezium-trapezoid (STT) fusion
Fig. 3
Radiograph of a radio-scapho-lunate fusion
Fig. 4
Radiograph of a radio-lunate fusion
AVOIDING FUSION IN WRIST ARTHRITIS 3
Scapho-luno-capitate fusion. Scapho-luno-capitate (SLC) fusion
is indicated in patients with VISI deformity, non-union of a
scaphoid fracture, scapholunate instability, Kienbock's disease,
or in patients with isolated midcarpal arthritis.
2,4
Fusions which
cross the midcarpal row produce the greatest restriction
approximately 60% of post-operative movement. However, it is
also suggested that the larger the surface area of the arthro-
desis, the higher the fusion rates. This is reflected in the low non-
union rate of 12% reported for this procedure.
4
Technical consid-
erations include reduction of the scapholunate joint before
formal arthrodesis; the use of dorsal plates or K-wires has been
described.
17
As with STT fusion, concurrent radial styloidectomy
is recommended in order to improve radial tilt and flexion.
Proximal row carpectomy and scaphoid excision with
capitate-hamate-lunate-triquetral (four-corner) fusion . Proxi-
mal row carpectomy (PRC) (Fig. 5) and scaphoid excision with a
capitate-hamate-lunate-triquetral, or four-corner fusion (4CF)
(Fig. 6) are the more commonly undertaken procedures for degen-
erative changes affecting the proximal carpal row. The typical
indication for these procedures is osteoarthritis of the radius-
scaphoid joint which can occur primarily but which may follow
scaphoid non-union, fracture of the scaphoid fossa of the radius,
or an interosseous ligament rupture of the scapholunate joint.
Plain radiographs, CT arthrography and a possible wrist
arthroscopy are used to determine which joint surfaces are pre-
served and which are degenerate. If the lunate-capitate articula-
tion shows arthritis then a PRC is contraindicated. If the lunate-
radius articulation shows arthritis then both a PRC and a 4CF are
contraindicated. If the capitate-lunate joint is degenerate then a
PRC is contraindicated and a 4CF is performed. If both the
lunate-radius and lunate-capitate of surfaces are preserved,
then the choice is either a PRC or a 4CF.
A PRC is technically easier to perform, as there is no need for
metalwork and no need for bone fusion. However, a 4CF is tech-
nically more difficult although has several theoretical advan-
tages. For example, it will allow locking of the wrist during grip in
those who require resistance to torque, such as might occur
during twisting and gripping, whereas the PRC will not. A 4CF
also preserves carpal height and maintains the original congru-
ity of the central and ulnar thirds of the carpus. However, for a
PRC, incongruency between the proximal pole of the capitate
and the lunate fossa will cause point loading and theoretically
increase the risk of radiocapitate arthritis. Despite the theoreti-
cal advantages of 4CF, no difference has been found in clinical
follow-up studies.
18,19
The outcomes for the two procedures
PRC and 4CF are similar with satisfactory results in carefully
selected patients. Approximately 80% of grip strength and 60%
of the arc of movement are maintained post-operatively.
2

Both PRC and 4CF are performed through a dorsal
approach. Great care is taken to preserve the volar radiocarpal
ligaments in order to prevent post-operative ulnar translation
of the carpus.
2,18
A 4CF involves excision of the scaphoid followed by decortica-
tion and fusion of the capitate, hamate, lunate and triquetrum.
The lunate must be reduced to a neutral position before arthro-
desis. Methods of fixation include K-wires, headless screws and
dorsal circular plates. Some studies have suggested that higher
rates of non-union may be associated with the use of circular
plates; however, advocates argue that results are satisfactory in
expert hands.
20
Impingement of the plate during wrist extension
can be avoided by adequately recessing the plate beneath the
dorsal lunate cartilage.
2,21
Fig. 5
Radiograph of a proximal row carpectomy.
Fig. 6
Radiograph of a capitate-hamate-lunate-triquetral (four-corner) fusion.
4 T. CROOK, D. WARWICK
THE JOURNAL OF BONE AND JOINT SURGERY
Pancarpal arthritis
In patients for whom pancarpal arthritis is present, the options
for surgical treatment are a total wrist fusion or a total wrist
arthroplasty.
Total wrist arthroplasty. Total wrist arthroplasty (TWA) (Fig. 7)
seeks to maintain a range of movement that allows the activities of
daily living to be performed. Most experience with this procedure
has involved patients with rheumatoid arthritis. In this situation,
multiple joints are often affected, including the contralateral wrist.
For patients who have previously undergone a wrist fusion followed
by a contralateral TWA, the wrist replacement is preferred.
22
Fur-
thermore, in one outcome study, 100% of patients would have
undergone a second procedure to restore wrist movement after a
previous arthrodesis.
23
Total wrist arthroplasty has evolved signifi-
cantly over the past thirty years and important lessons have been
learned from early implant failures and design errors. It is now gen-
erally accepted that several key design features are required. Min-
imal bone resection of the distal radius enables preservation of the
carpal ligament attachments, enhancing both wrist proprioception
and stability.
24
The articulation should be a semi-constrained,
broad and ellipsoid in shape.
25
The distal fixation should aim to be
within the carpus, rather than using metacarpal fixation as was
seen in earlier designs. The use of an associated distal row inter-
carpal fusion enables a broad base of support for the distal com-
ponent.
26
Uncemented prostheses, with screws to augment their
initial fixation, is recommended as the best method of implant fix-
ation.
24
Preservation of the distal radioulnar joint and ulnar head is
desirable, given the catastrophic instability that can be associated
with excision of the ulnar head.
Patient selection is critical to the success of TWA. Patients
with osteoarthritis typically have good bone stock, good soft-
tissue quality, and good alignment of the wrist.
26
It is essential
that such patients understand the implications of TWA. Perma-
nent modification of activities is required, specifically avoiding
impact-loading activities such as tennis and only allowing inter-
mittent lifting of objects over 10lbs in weight. Although these
modifications can maintain wrist movement, they may also
make the implant less appealing to younger patients with their
higher physical demands. Typically, after TWA one might expect a
60 arc of movement for flexion and extension
26,27
although
there are presently no long-term results for the most modern
designs. This is particularly relevant in respect of implant subsid-
ence, wear of the polyethylene liner and deposition of debris.
Consequently, TWA should be seen as an experimental option
for pancarpal arthritis, albeit one that offers significant promise
and normally satisfactory early outcomes. Patient consent must
carefully cover this issue.
Total wrist arthrodesis. Arthrodesis of the wrist remains the
traditional treatment for pancarpal osteoarthritis in young
active patients. The goal of surgery is to relieve pain and pro-
vide a stable base for power grip. In rheumatoid arthritis with
erosive collapse of the wrist, simple fusion with a pin can give
reliable results (Fig. 8). The use of pre-contoured dorsal wrist
plates is now widespread. This allows fusion of the wrist in 10
to 15 of extension and slight ulnar deviation, which optimises
grip strength.
2
Fusion rates of 95% to 100% can be
expected.
2,28,29
Total wrist arthrodesis historically appeared to
provide satisfactory post-operative outcomes.
30
However, with
Fig. 7
Radiograph of a total wrist arthroplasty
Fig. 8
Radiograph of a wrist fusion using a Steinmann pin
AVOIDING FUSION IN WRIST ARTHRITIS 5
the advent of better functional outcome criteria, the desirabil-
ity of wrist fusion has been challenged. Although most patients
are satisfied with pain relief and their ability to return to
employment, there are substantial functional limitations.
These include difficulty with perineal care and working in con-
fined spaces where the shoulder and elbow are unable to com-
pensate for the lack of wrist movement.
31
When bilateral wrist
arthrodeses are required, the non-dominant wrist should be
fused in 5 to 10 of flexion in order to allow for perineal care.
As with all surgical procedures, careful pre-operative counsel-
ling of patients is required to ensure patients have a realistic
expectation of the likely outcome.
30

Conclusion
Osteoarthritis of the wrist is common and has a significant effect
on the activities of daily living. Careful surgical planning is
required in order to provide the most appropriate treatment to
enable satisfactory pain relief while maintaining adequate func-
tion. Historically, the emphasis has been orientated more
towards arthrodesis as a means of offering predictable pain
relief. However, with the evolution of new designs of wrist arthro-
plasty as well as the satisfactory outcomes for limited, partial
arthrodeses, the surgical options for arthritis of the wrist now
require careful consideration.
Timothy Crook BM FRCS(Tr & Orth)
SpR in Orthopaedics, Southampton University Hospitals
David Warwick MD BM FRCS FRCS(Orth) EDHS
Hand Wrist and Elbow Unit, Southampton University Hospitals
Correspondence to: David Warwick, Reader in Orthopaedic Surgery,
University of Southampton, Southampton, SO16 6UY, United Kingdom
Email: davidwarwick@handsurgery.co.uk
References
1. Field J, Herbert TJ, Prosser R. Total wrist fusion: a functional assessment. J Hand
Surg 1996;21:429-33.
2. Weiss KE, Rodner CM. Osteoarthritis of the wrist. Review article. J Hand Surg
2007;32A:725-46.
3. Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion: a biome-
chanical study. J Hand Surg 1995;10A:39-46.
4. Siegel JM, Ruby LK. A critical look at intercarpal arthrodesis: Review of the litera-
ture. J Hand Surg 1996;21A;717-23.
5. Watson HK, Weinzweig J, Guidera PM, Zeppieri J, Ashmead D. One thousand
intercarpal arthrodeses. J Hand Surg 1999;24A:307-15.
6. Larsen CF, Jacoby RA, McCabe SJ. Non-union rates of limited carpal arthrodesis:
a meta-analysis of the literature. J Hand Surg 1997;22A:66-73.
7. Benkeddache Y, Gottesman H, Fourrier P. Multiple stapling for wrist arthrodesis
in the non-rheumatoid patient. J Hand Surg 1984;9A:256-60.
8. Shindle MK, Burton KJ, Weiland AJ, Domb BG, Wolfe SW. Complications of cir-
cular plate fixation for four-corner arthrodesis. J Hand Surg 2007;32B:50-3.
9. Chung KC, Watt AJ, Kotsis SV. A prospective outcome study of four-corner wrist
arthrodesis using a circular limited plate fusion for stage II scapholunate advanced
collapse wrist deformity. Plast Reconstr Surg 2006;11:433-42.
10. Peterson HA, Lipscomb PR. Intercarpal arthrodesis. Arch Surg 1967;95:127-34.
11. Minami A, Kato H, Suenaga N, Iwasaki N. Scaphotrapeziotrapezoid fusion: long-
term follow-up study. J Orthop Sci 2003;8:319-22.
12. Corbin C, Warwick D. Midcarpal instability after excision arthroplasty for scapho-
trapezial-trapezoid (STT) arthritis. J Hand Surg 2009:34:537-8.
13. Garcia-Elias M, Lluch A, Ferreres A, Papini-Zorli I, Rahimtoola ZO. Treatment
of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and dis-
tal scaphoidectomy. J Hand Surg 2005;30A:8-15.
14. Tambe A, Farhan A, Trail I, Stanley J. Is radiolunate fusion a viable option in
advance Kienbock disease? Acta Orthop Belg 2007;73:598-603.
15. Garcia-Elias M. The non-dissociative clunking wrist: A personal view. J Hand Surg
2008;33:698-711.
16. Halikis MN, Colello-Abraham K, Taleisnik J. Radiolunate fusion: The forgotten
partial arthrodesis. Clin Orthop 1997;341:30-35.
17. Walsh EF, Manuel JLM, Weiss APC. Scapho-lunate-capitate fusion for scapholu-
nate ligament injuries. Atlas Hand Clin 2003;8:279-85.
18. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal Row Carpectomy vs
Four Corner Fusion for Scapholunate (Slac) or Scaphoid Nonunion Advanced Collapse
(Snac) Wrists: A systematic review of outcomes. J Hand Surg 2009;34:256-63.
19. Vanhove W, De Vil J, Van Seymortier P, Boone B, Verdonk R. Proximal row
carpectomy versus four-corner arthrodesis as a treatment for SLAC (Scapholunate
Advanced Collapse) wrist. J Hand Surg 2008;33:118-25.
20. Kendall CB, Brown TR, Millon SJ, Rudisill LE, Sanders JL, Tanner SL. Results
of four-corner arthrodesis using dorsal circular plate fixation. J Hand Surg
2005;30A:903-7.
21. Vance MC, Hernandez JD, DiDonna ML, Stern PJ. Complications and outcome of
four-corner arthrodesis: circular plate fixation versus traditional techniques. J Hand
Surg 2005;30A:1122-27.
22. Vicar AJ, Burton RI. Surgical management of the rheumatoid wrist - fusion or artho-
plasty. J Hand Surg 1986;11A:790-7.
23. Adey L, Ring D, Jupiter JB. Health status after total wrist arthrodesis for post-trau-
matic arthritis. J Hand Surg 2005;30A:932-36.
24. Gupta A. Total wrist arthroplasty: a review paper. Am J Orthop 2008;37(8 Suppl):12-16.
25. Grosland NM, Rogge RD, Adams BD. Influence of articular geometry on prosthetic
wrist stability. Clin Orthop 2004;412:134-42.
26. Anderson MC, Adams BD. Total wrist arthroplasty. Hand Clin 2005;21:621-30.
27. Menon J. Universal total wrist implant: experience with a carpal component fixed
with three screws. J Arthroplsty 1998;13:515-23.
28. Wright CS,McMurtry RY. AO Arthrodesis in the hand. J Hand Surg. 1983;8:932-35.
29. Hastings H II, Weiss APC, Quenzer D, Wiedeman GP, Hanington KR, Strick-
land JW. Arthrodesis of the wrist for post-traumatic disorders. J Bone Joint Surg
[Am] 1996;78-A:897-902.
30. Hayden RJ, C PA, Jebson PJL. Wrist arthrodesis. Hand Clin 2005;21:631-40.
31. Weiss APC, Hastings H. Wrist arthrodesis for traumatic conditions: a study of plate
and local bone application. J Hand Surg 1995;20:50-56.