Wrist Arthrodesis

Indications

Wrist arthrodesis is performed to achieve pain relief and restore function in patients with severe wrist pathology. Indications include:

• Post-traumatic arthritis (e.g., following distal radius fractures or perilunate dislocations)
• Rheumatoid arthritis with severe wrist deformity and instability
• Osteoarthritis (primary or secondary) causing debilitating pain
• Kienböck’s disease (advanced stages) with collapse of the lunate
• Post-infectious arthritis causing joint destruction
• Severe wrist instability (e.g., due to chronic scapholunate ligament injury or SLAC/SNAC wrist)
• Failed wrist reconstruction procedures (e.g., proximal row carpectomy or partial wrist fusions)
• Brachial plexus injuries (in cases where wrist stability is needed for hand function)
• Spastic conditions (e.g., cerebral palsy) for functional positioning
• Salvage for tumors (after excision of bone malignancies involving the wrist)

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Contraindications

• Active infection at the wrist or systemic uncontrolled infection
• Noncompliance with postoperative immobilization and rehabilitation
• Inadequate bone stock for fixation (e.g., severe osteoporosis)
• Need for wrist motion in vocational or daily activities (consider motion-preserving alternatives like partial fusion)
• Poor soft tissue envelope (risk of wound complications)

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Preoperative Preparation

• Clinical evaluation: Assess wrist pain, deformity, and functional limitations
• Radiographic evaluation: X-rays (AP, lateral, oblique) to assess bone quality and alignment; CT scan may be useful for preoperative planning
• Medical optimization: Control of comorbid conditions (e.g., diabetes, rheumatoid arthritis)
• Patient counseling: Inform the patient about permanent loss of wrist motion, expected functional outcomes, and postoperative rehabilitation
• Surgical planning: Selection of appropriate fusion method (e.g., plate fixation, intramedullary fixation, or bone grafting if needed)

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Special Instruments, Positioning, and Anesthesia

Special Instruments

• Low-profile dorsal wrist fusion plate (locking or non-locking)
• Cortical and cancellous screws
• Power drill and burr for joint preparation
• Bone graft material (autograft from iliac crest or allograft)
• Oscillating saw and rongeurs
• Curettes for cartilage removal

Positioning

• Supine position with arm placed on a radiolucent hand table
• Tourniquet application on the upper arm for bloodless field
• Hand preparation: Sterile draping with antiseptic solution application

Anesthesia

• General anesthesia or regional anesthesia (supraclavicular or axillary brachial plexus block)

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Operative Technique & Approach

1. Dorsal Approach (Most Common)

• Incision:
  • A longitudinal dorsal incision over the third metacarpal base to the distal radius
  • Elevate skin flaps while preserving dorsal veins and subcutaneous tissue
• Exposure:
  • Identify and elevate the extensor retinaculum
  • Retract extensor tendons (extensor pollicis longus and extensor digitorum)
  • Expose the dorsal capsule and incise it longitudinally
• Joint Preparation:
  • Denude cartilage from radiocarpal and midcarpal joints using curettes, burrs, or an oscillating saw
  • Remove subchondral bone to expose bleeding cancellous bone
  • Pack bone graft (if used) into the prepared fusion bed
• Fixation:
  • Position the wrist in 10–15° of extension, slight ulnar deviation, and neutral pronation/supination
  • Place a low-profile dorsal wrist fusion plate over the radius, lunate, capitate, and third metacarpal
  • Secure the plate with locking screws in the radius and metacarpal
  • Ensure good compression across the fusion site with lag screws if needed
  • Confirm fixation with intraoperative fluoroscopy
• Closure:
  • Reapproximate the dorsal capsule
  • Repair the extensor retinaculum if possible to prevent tendon irritation
  • Subcutaneous and skin closure in layers

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Tips and Pearls

• Ensure adequate decortication of all fusion surfaces for better bone healing
• Position the wrist optimally for functional grip (10-15° extension, slight ulnar deviation)
• Use a precontoured plate to avoid excessive stress on the fusion site
• Avoid excessive compression on the dorsal soft tissues to prevent extensor tendon irritation
• Consider bone grafting in cases of poor bone quality or revision surgery

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What to Avoid

• Overextension (>20°) → Leads to difficulty with hand function (grip and pinch strength loss)
• Excessive shortening → Can cause altered biomechanics of the hand and elbow
• Leaving cartilage remnants → Impairs fusion and may lead to nonunion
• Soft tissue stripping → Avoid excessive periosteal damage to preserve vascular supply
• Improper plate positioning → Malpositioned plates can cause tendon irritation or impingement

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Postoperative Care Issues

• Immobilization:
  • Short arm splint for 1-2 weeks
  • Transition to a wrist immobilization orthosis for 6-8 weeks
• Weight-bearing restrictions:
  • No heavy lifting or weight-bearing for 8-12 weeks
• Rehabilitation:
  • Early finger and elbow range of motion
  • Gradual return to activities after radiographic fusion evidence (~3-4 months)
• Complications to Monitor:
  • Nonunion (risk factors: smoking, infection, poor fixation)
  • Extensor tendon irritation or rupture (if the plate is prominent)
  • Complex Regional Pain Syndrome (CRPS)
  • Hardware failure (if inadequate fixation is used)

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