Abstract
Purpose
Total wrist fusion (TWF) is a reliable surgical procedure for wrist arthritis. Options include: arthrodesis of the third carpometacarpal (CMC) joints (third CMC joint fusion); bridging the third CMC joint without fusion (third CMC joint bridging); or using a nonspanning plate (third CMC joint sparing). The review aimed to evaluate and compare these techniques regarding grip strength and complications.
Methods
A systematic review searched MEDLINE, Embase, and Scopus databases. Observational studies and randomized controlled trials investigating dorsal plate TWF were included. Meta-analysis was conducted using Stata (version 18). Grip strength was defined as long-term (12+ months) postoperative kilogram force in the operative hand expressed as percentage of contralateral hand and analyzed using a random-effects meta-analysis. The Freeman–Tukey transformation was applied to stabilize the estimates of variance, and complications were analyzed using a random-effects meta-analysis of single proportions. Subgroup analysis was performed for early/intermediate (0–30 months) and delayed (30+ months) follow up.
Results
Sixteen studies were identified, including 786 wrists. Mean follow up was 5.4 years. Only six studies reported grip strength as an outcome measure. To permit statistical analysis, the third CMC joint fusion and third CMC joint bridging groups were combined (termed third CMC joint spanning) and compared against the third CMC joint sparing group, revealing no significant difference in mean grip strength (74% vs 64%). Between 0 and 30 months, there was no statistically significant difference in complication rate (third CMC joint fusion = 24%, third CMC joint bridging = 16%, and third CMC joint sparing = 14%). Beyond 30 months, there was a higher rate of complications in the third CMC joint bridging group than in the third CMC joint fusion group (50% vs 20%). Longer-term follow-up data were not available in the third CMC joint sparing group. There was no significant difference in the union rates between groups (96% to 97%).
Conclusions
There is a higher rate of complications with a third CMC joint bridging technique than the third CMC joint fusion technique. Early outcomes of third CMC joint sparing techniques appear equivalent but longer-term data are still required.
Type of study/level of evidence
Therapeutic I.
Key words: Carpometacarpal joint, Complications, Grip strength, Total wrist arthrodesis, Total wrist fusion
Total wrist fusion (TWF) is an established procedure for eliminating pain while sacrificing movement across degenerative joints. The first technique for wrist arthrodesis was published by Steindler1 in 1918 who described wrist stabilization in children with spastic hemiparesis and polio. Today, the most common indications for TWF include osteoarthritis, posttraumatic and rheumatoid arthritis, avascular necrosis, and scapholunate and scaphoid nonunion advanced collapse, with patients generally achieving good pain relief and satisfactory levels of function.2, 3, 4
The traditional approach to TWF focuses on five joints: radiolunate, radioscaphoid, lunocapitate, scaphocapitate, and the third carpometacarpal (CMC) joint. However, controversy remains as to the need to include the third CMC joint, brought about primarily by concern over complication.2,5,6 If the fusion plate does not lie perfectly in the sagittal plane, the third CMC joint screw may induce rotational deformity. Rarely, the capitate screw may protrude into the carpal canal. In addition, nonunion and subsequent implant failure are also recognized to occur most frequently around the third CMC joint.5,7
The advancement of implant technology, allowing lower profile plates with the capacity for multiple locking screws, has enabled manufactures to design short, third CMC joint sparing plate options. These aim to avoid the controversy of the third CMC joint by fixing onto the capitate and distal carpal row, leaving the third CMC joint undisturbed. Theoretically, the reduced plate length associated with this third CMC joint sparing technique may correspond to reduced plate-related complications, such as implant fatigue, fracture, and extensor tendon synovitis.7 However, there is a concern around the rigidity of internal fixation provided by third CMC joint sparing plates compared with that of the traditional third CMC joint fusion or third CMC joint bridging techniques.8
Although experimental carpal kinematic research provides valuable insights into the biomechanical consequences of TWF, there is a paucity of research to explain the potential consequences of the third CMC joint sparing technique both in a laboratory or clinical setting, resulting in an understandable apprehension among the orthopedic community.9
The aim of this review was to examine and synthesize existing literature surrounding wrist arthrodesis, specifically regarding the management of the third CMC joint. We will evaluate the comparative efficacy of TWF using the techniques of third CMC joint fusion (a dorsal wrist plate fixed to the metacarpal with preparation of the third CMC joint surfaces), third CMC joint bridging (a dorsal wrist plate fixed to the metacarpal without violation of the third CMC joint), and third CMC joint sparing (a dorsal wrist plate fixed to the distal carpal row without violation of the third CMC joint). We will specifically assess grip strength at least 12 months following surgery and the incidence of complications. Grip strength was selected as the primary comparator as it is traditionally reported in wrist fusion papers and correlates well with clinical outcomes.
Materials and Methods
Study design
This systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews in accordance with the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and the Quality of Reporting of Meta-analyses guidelines.10 It was registered on the International Prospective Register of Systematic Reviews.
Literature search and inclusion criteria
Two independent reviewers searched the Embase, Scopus, and MEDLINE databases (A.K. and M.L.S.). Eligible original research articles including clinical trials and observational research (cohort studies, case-control studies and case series) were reviewed. Articles were included on the basis of investigating TWF with a dorsal wrist plate, specifying whether the third CMC joint was included in the fusion. Indications for TWF included osteoarthritis, rheumatoid arthritis, avascular necrosis, scapholunate and scaphoid nonunion advanced collapse, posttraumatic arthritis, brachial plexus injury, and tetraplegia.
Wrist fusion techniques were classified as follows. Third CMC joint sparing was defined as the use of a short dorsal wrist plate fixed to the distal carpal row without violation of the CMCJ3 capsule. Third CMC joint bridging was defined as the use of a dorsal wrist plate crossing the third CMC joint with fixation onto the metacarpal but without the use of a CMCJ screw or preparation of the CMCJ3 surfaces. Third CMC joint fusion was defined as the use of a dorsal wrist plate fixed to the metacarpal with a third CMC joint screw and/or preparation of the third CMC joint surfaces with the goal of fusion.
Where appropriate, for the purpose of analysis, third CMC joint bridging and third CMC joint fusion cases were combined into one group, termed third CMC joint spanning. Of note, this was performed to improve the statistical power of the results.
Primary outcome measures of interest included postoperative grip strength at minimum 12 months postoperative (defined as kilogram force in operative hand expressed as a percentage of the contralateral hand) and complications. For papers that gave absolute values of grip strength, a calculation was carried out based on this raw data to derive a percentage for uniformity and ease of analysis.
Exclusion criteria
Articles describing limited wrist fusion or TWF with alternative techniques were excluded. Articles not in English, literature reviews, case reports, and gray literature were excluded.
Statistical analysis
Subgroups were created based on each wrist fusion technique as well as follow-up period. Follow-up periods were defined as early (0–30 months) and late (greater than 30 months), with subgroup analyses performed on each group.
Meta-analysis was conducted using Stata (version 18), and the Freeman–Tukey transformation used to stabilize estimates of variance. A random-effects meta-analysis of single proportions created in Stata was used to analyze the incidence of complications after each wrist fusion technique, and the mean grip strength after each technique. Heterogenous data that could not be appropriately analyzed by statistical methods were processed as a narrative review.
Quality assessment and bias
Qualitative validity assessment was appraised using the Grading of Recommendations Assessment, Development, and Evaluation guidelines.11 These outline a focus on the constructs of inconsistency, imprecision, publication bias, and indirectness. Qualitative risk of bias assessment was undertaken with a focus on the following constructs: confounding, selection bias, data analysis, bias because of measurement of outcome variables, and bias because of missing outcome data. Bias assessment was conducted either alongside data extraction or immediately after so as not to inadvertently affect the selection of the studies. No studies were excluded from the analysis based on their risk of bias assessment alone.
Results
Characteristics of included studies
The Preferred Reporting Items for Systematic Reviews and Meta-Analysis process for identifying studies is outlined in Figure 1. From 231 articles identified through the literature search, 16 studies were included, representing a total of 786 wrists. Across all studies, the mean follow up was 5.4 years. Table 1 summaries the characteristics of included studies.3,4,8,9,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23
Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement of search results. Flow diagram outlining the inclusion and exclusion of articles identified from the literature search.
Table 1.
Characteristics of Included Studies
| Author (y) | Title | Technique | Wrists | Follow-up |
|---|---|---|---|---|
| Briotti et al12 (2022) | Wrist arthrodesis using the Medartis carpometacarpal joint sparing plate | Third CMC joint sparing | 23 | 17 Mo |
| Knie et al13 (2023) | Long-term results after total wrist fusion | Third CMC joint bridging | 71 | 11 Y |
| Rioux-Forker et al14 (2023) | The effect of 3rd carpometacarpal arthrodesis in the outcomes of total wrist fusion using modern plate technology | Third CMC joint bridged and fusion | 182 | 10 Y |
| Roulet et al15 (2023) | Total arthrodesis for non-rheumatoid wrists: outcomes at 5 and 20 years of follow-up | Third CMC joint bridging | 37 | 5 Y |
| Rodríguez-Nogué et al16 (2022) | Results of the total wrist arthrodesis with contoured plate in a series of 41 wrists with median follow-up of 6 years | Third CMC joint fusion | 41 | 6 Y |
| Smith et al3 (2022) | Long-term functional outcomes after total wrist arthrodesis | Third CMC joint bridging | 36 | 10 Y |
| Bozon et al17 (2022) | Wrist shortening arthrodesis with volar plate in a dorsal position for spastic wrist contracture | Third CMC joint bridging | 28 | 2 Y |
| Hernekamp et al4 (2019) | Low-profile locking-plate vs. the conventional AO system: early comparative results in wrist arthrodesis | Third CMC joint sparing and bridging | 20 | 4 Y |
| Owen et al18 (2016) | Factors predictive of patient outcome following total wrist arthrodesis | Third CMC joint fusion | 77 | 6 Y |
| Berling et al8 (2015) | Hardware-related complications following radiocarpal arthrodesis using a dorsal plate | Third CMC joint bridging and fusion | 122 | 2 Y |
| Koch et al19 (2019) | Grip strength following total wrist arthrodesis using the same hand as reference: a prospective study | Third CMC joint bridging | 22 | 2 Y |
| Ozer et al20 (2010) | Clinically successful total wrist fusion using cancellous bone allograft | Third CMC joint fusion | 15 | 18 Mo |
| Houshian et al21 (2001) | Wrist arthrodesis with the AO titanium wrist fusion plate: A consecutive series of 42 cases | Third CMC joint fusion | 42 | 23 Mo |
| Taii et al22 (2018) | Wrist arthrodesis in rheumatoid arthritis using an LCP metaphyseal locking plate versus an AO wrist fusion plate | Third CMC joint bridging | 16 | 4 Y |
| Kohler et al23 (2017) | Wrist arthrodesis with an angle-stable “low-profile” plate without carpometacarpal fusion | Third CMC joint sparing | 28 | 21 Mo |
| Rancy et al9 (2017) | Non-spanning Total Wrist Arthrodesis with a Low-Profile Locking Plate | Third CMC joint sparing and fusion | 26 | 5 Y |
Summary table outlining the 16 studies included in the review. Columns separated into first author, year of publication, title of study, wrist fusion technique (spared, bridged, fused), number of wrists, and follow-up period.
Bias
Bias because of selection of participants was most common, with 11 articles deemed to be at high risk of bias. There were four studies with a high risk of confounding bias and two at high risk because of measurement of outcome variables, resulting from uncertainty regarding the method of grip strength and complication reporting. Bias because of attrition or missing outcome data was observed in one study, with five studies at unclear risk of missing outcome data. Figure 2 summarizes the risk of bias assessment.
Figure 2.
Risk of bias assessment for all included studies. Qualitative assessment of bias identified in each included article, with a focus on confounding bias, selection bias, bias introduced through the statistical methods, measurement bias, and bias because of missing outcome data. Green: low risk of bias, and red: high risk of bias. Blank squares indicate uncertainty of assessment.
Grip strength
Pertinent results are summarized in Table 2. Only six studies reported grip strength as an outcome measure. To permit statistical analysis, the third CMC joint fusion and third CMC joint bridging groups were combined (termed third CMC joint spanning) and compared with the third CMC joint sparing group (Fig. 3). At 12 months, third CMC joint spanning techniques were associated with a mean grip strength of 74% of that of the contralateral side compared with 64% in the third CMC joint sparing group; however, this difference did not reach statistical significance (P = .61). Longer-term comparative analyses of grip strength were not possible because of insufficient follow up in available studies.
Table 2.
Summary of Key Results
| Third CMC Joint Spared | Third CMC Joint Bridged | Third CMC Joint Fused | P Value | |
|---|---|---|---|---|
| Grip strength | 64% | 74% | .61 | |
| Union rate | 96% | 97% | 97% | NA |
| 0–30 mo postop complication rate | 14% | 16% | 24% | .64 |
| >30 mo postop complication rate | NA | 52% | 25% | .01 |
| Hardware removal rate | 8% | 23% | 8% | NA |
Summary table comparing key result differences in grip strength and complications among the third CMC joint sparing, third CMC joint bridging, and third CMC joint fusion groups.
NA, not available.
Figure 3.
Grip strength across included studies. Pooled results of mean grip strength expressed as percentage of contralateral side after spanning and sparing wrist fusion technique.
Complications
The full list of complications reported can be viewed in Table 3. Removal of hardware was not deemed a complication in unto itself but rather was considered to occur in response to a complication. As such, it is dealt with separately.
Table 3.
Complication reporting terminology used variably within included studies
| Complication reporting Terminology | ||||||
|---|---|---|---|---|---|---|
| Tendinopathy Tendonitis Tenosynovitis Tendon impingement Tendon pain Tendon adhesion |
Plate prominence Plate impingement Plate irritation Plate fracture Plate breakage Plate loosening |
Screw fracture Screw breakage Screw prominence Screw loosening Loosening of osteosynthesis material Screw rupture |
Neuroma Carpal tunnel syndrome Complex regional pain syndrome Pain |
Hematoma Postoperative bleeding Hematoma at iliac crest graft site |
Distal radioulnar joint pain TFCC pain Ulnar sided wrist pain |
Superficial infection Deep infection Infection at iliac crest Periprosthetic fracture Wound dehiscence |
Table displaying the variable terminology used within included articles when discussing complications.
TFCC, triangular fibrocartilage complex.
Overall, the most common complications appeared to be hardware related, followed by tenosynovitis and neuroma. There was, however, significant variability in complication reporting standards, the terms used and detail as to how these were defined and managed (Table 3). As such, we have been unable to determine the incidence of specific complications but instead combined the data to give an overall complication prevalence. In the early to intermediate follow-up period (0–30 months), the prevalence of complications after third CMC joint fusion was 24% (95% confidence interval [CI], 0.01–0.41) compared with 16% after third CMC joint bridging (95% CI, 0.09–0.25) and 14% after third CMC joint sparing techniques (95% CI, 0–0.45). However, this difference was not statistically significant (P = .64; Fig. 4). After 30 months, there was a significantly higher rate of complication in the third CMC joint bridging cohort than in the third CMC joint fusion (52% vs 20%, respectively; P = .01; Fig. 5). Insufficient detail was provided in the papers to determine if complication profile varied between the early and late periods or between constructs.
Figure 4.
Complications after TWF ≤30 months follow-up. Pooled results of all complications after each wrist fusion technique with follow up between zero and 30 months follow-up. The overall rate of complications was 18% (95% CI, 10%–28%).
Figure 5.
Complications after TWF >30 months follow-up. Pooled results of all complications after each wrist fusion technique after CMC bridging and CMC fusion technique. The overall rate of complications was 35% (95% CI, 20%–53%). Results of wrist sparing technique could not be included because of insufficient follow-up of studies.
Hardware removal
In line with higher complication rates, hardware removal was also most frequent in the third CMC joint bridging group at 23% overall compared with 8% in both the third CMC joint sparing and third CMC joint fusion groups. The most common reasons attributed for hardware removal were tendon irritation (described as tenosynovitis or tendinopathy), discomfort, infection, periprosthetic fracture, revision fusion, neuroma management, other unrelated surgery, as well as simple patient choice. Timing of removal was not clearly stated. The high variability in reporting and reasoning behind hardware removal precluded meaningful meta-analysis.
Union
Union rates appeared equivalent among the 3 techniques at 97%, 97% and 96% for third CMC joint fusion, third CMC joint bridging and third CMC joint sparing cohorts, respectively. It was notable, however, that the definition of union and time to union was not clearly stipulated in any paper, nor was the site of nonunion when it occurred, whether radiocarpal, midcarpal, or CMC.
Discussion
There remains debate in the literature around the preferred technique for TWF.7,8 The traditional approach of incorporating the radiocarpal, midcarpal, and CMC joints into the fusion construct has seen alterations, which include bridging the third CMC joint 3 without joint preparation as well as sparing the third CMC joint by ending the wrist fusion construct at the distal carpal row.
Our systematic review has demonstrated comparable grip strength outcomes and overall complication rates among the 3 techniques in the first 30 months following surgery. However, beyond 30 months, use of a third CMC joint bridging technique is associated with a statistically significant increase in complication rate at 52% compared with 20% using a third CMC joint fusion technique. Third CMC joint bridging was also associated with a higher rate of hardware removal than the other techniques (23% vs 8% vs 8%). However, the high variability in reporting detail as well as the inconsistency in terminology used, precluded our ability to isolate a specific complication or group of complications driving this difference.
Roulet et al15 reported that persistent micromotion in the third CMC joint bridging group leads to osteolysis at the bone-screw interface, as well as metalware fatigue, debris formation, tenosynovitis, and pain, often leading to a need for hardware removal. However, when specifically investigating persistent pain in the third CMC joint bridged wrist, focusing their research question on its potential causes, Knie et al13 were also unable to reliably identify any attributable radiological or anatomical cause, despite several clinical tests and extensive statistical investigation. Our review corroborates these findings and emphasizes the need for future research to use clear, defined, and consistent terminology in their reporting such that accurate meta-analysis can be completed.
Our finding of study heterogeny and the low quality of available data has been a consistent feature within our analysis and was also been recognized in the recent systematic review by Owen et al,24 who also investigated inclusion of the third CMC joint in wrist fusion constructs. They found a pooled complication rate of 16%, but instead found no difference between techniques. They highlight study heterogeneity and a resultant low confidence in their findings. We suspect that their differing result of equivalent complications between groups, compared with that of our own findings, occurred because of their decision to include all methods of wrist fusion and thus spread their analysis across an even greater number of studies, adding further complication and heterogeneity to their data.
The association of third CMC joint bridging techniques with long-term complications would suggest that if still opting for such as technique, it may be prudent to remove the hardware at an early stage, rather than waiting for it to become necessary because of complication. This was also recommended in the seminal study by Nagy et al7 in 2002 that found that of 34 patients who had received a third CMC joint bridged TWF and subsequent plate removal, 33 remained asymptomatic and satisfied with their outcome. It adds further reassurance that Knie et al13 also found patients in this group were still generally satisfied and achieved good clinical outcomes despite the additional surgery. We believe that this likely reflects the relative importance of preserved or improved grip strength on patient experience, over and above the negative impact of a further surgery. Grip strength recorded as a percentage of the uninjured side has been found to demonstrate a strong independent positive correlation with outcome scores, and we found this to be equivalent across all fusion techniques, highlighting the overall reliability of TWF as a procedure.25
The obvious progression of this argument, given that the third CMC joint sparing plates also achieved equivalent grip strength outcomes, would be to suggest that this would be preferential to avoid the necessity of this further surgery. The available evidence demonstrates positive early outcomes with equivalent union rates and low early complication profiles similar to that of other techniques; however, at present, we lack the long-term follow-up data to recommend this technique conclusively.4,9,12,23 It would make sense, however, that given third CMC joint bridging patients seem to do well following plate removal, those who have a similar final wrist position with preservation of third CMC joint motion but avoid the second procedure of metalwork removal could expect to do as well or better over the longer term.7
There are of course limitations to this work. As discussed, current literature consists largely of small, single-center retrospective observational studies with significant heterogeneity in reporting standards. Consequently, we were not able to perform a complete meta-analysis and as such our results cannot be used to conclusively determine whether bridging, fusing, or sparing of the third CMC joint has a statistically significant benefit in terms of grip strength or avoidance of complication, despite the statistical inference we have seen. In addition, baseline patient characteristics were not included in the analysis because of the lack of demographic data reporting among included studies and inconsistencies in patient recruitment and outcome measurement, which further contribute to the heterogeneity of available data. This highlights the need for further clinical and biomechanical research investigating patient outcomes and implant dynamics after TWF and in particular the need to standardize reporting of complications and outcomes to permit future meta-analyses of combined data.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
Acknowledgments
The authors would like to acknowledge Prof John McGeachie for reviewing the manuscript.
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