Abstract
Background Total wrist fusion can be elected to relieve pain in patients with osteoarthritis and rheumatoid arthritis. This study aimed to investigate the overall complications and the factors associated with reoperation and soft tissue complication after total wrist fusion.
Methods We retrospectively identified adult patients who underwent total wrist fusion using Current Procedural Terminology (CPT) codes, International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) and verified these by medical chart review. We included patients ( n = 215) who were treated at a single institutional system from January 1, 2002 to January 1, 2019. The mean age was 53.3 ± 15.0 years and the median follow-up was 6.1 years (interquartile range [IQR] =1.7–9.0). The most common indications for wrist fusion included inflammatory arthritis ( n = 66, 31%), degenerative arthritis ( n = 59, 27%), and posttraumatic arthritis ( n = 47, 22%). All wrist fusions were performed using a dorsal fusion plate or dorsal spanning plate, either with a local autograft ( n = 167, 78%), iliac crest autograft ( n = 2, 1.0%), allograft ( n = 7, 3.3%), a combination of both ( n = 16, 7.4%), or without a graft ( n = 23, 11%). We performed a multivariable logistic regression to evaluate factors associated with reoperation. In addition, we performed a similar analysis to identify the factors associated with soft tissue complication after total wrist fusion.
Results Forty-one (19%) patients underwent reoperation at a median of 6.9 months (IQR = 3.9–18). The indications included symptomatic implants ( n = 12, 27%), implant failures ( n = 8, 20%), infections ( n = 7, 17%), and nonunions ( n = 6, 15%). In multivariable analysis, total wrist fusion of the dominant hand (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.1–4.7, p = 0.033) was associated with a higher reoperation rate. Soft tissue complications occurred in 20 patients (9.3%) consisting of hematomas ( n = 8, 3.7%), observed blistering ( n = 5, 2.3%), and observed wound dehiscence ( n = 4, 1.9%). In multivariable analysis, smoking (OR: 2.5, CI: 0.95–6.4, p = 0.010) was independently associated with soft tissue complication after total wrist fusion. Seventy-two (33%) patients had a postoperative complication including symptomatic hardware ( n = 16, 7.4%), implant failure ( n = 11, 5.1%), infection ( n = 11, 5.1%), nonunion ( n = 8, 3.7%), and carpal tunnel syndrome ( n = 4, 1.9%).
Conclusion Roughly one-third (33%) of the patients undergoing total wrist fusion experience a postoperative complication and 19% of the patients underwent a reoperation. Total wrist fusion of the dominant hand results in higher reoperation rates. The risk of a soft tissue complication after total wrist fusion is increased in smokers.
Keywords: arthritis, arthrodesis, fusion
Total wrist fusion (TWF), also known as total wrist arthrodesis, can be elected to relieve pain in patients with osteoarthritis and rheumatoid arthritis. 1 2 3 4 Other nonpain related indications include cerebral palsy, brachial plexus injuries, mangled hands, and compartment syndrome without adequate wrist function.
Total wrist arthrodesis involves fusion of the carpus to the radius, preserving forearm rotation but eliminating wrist flexion–extension and radial–ulnar deviation. A variety of methods for achieving wrist fusion have been described, including the Mannerfelt and Malmsten technique, the Millender and Nalebuff technique, and using an AO wrist fusion plate. 5 6 7 8 9 To encourage bone union, different types of auto- and allografts can be used, including iliac crest bone autograft, ulna graft, olecranon graft, and radial graft. 4 Also free osseous flaps such as a medial femoral condylar flap and a vascularized fibula can be used for successful healing. 10 Recent studies have demonstrated that performing a TWF results in a high degree of patient satisfaction with mean Disabilities of the Arm, Shoulder and Hand (DASH) scores of 25 to 38. 11 12 13 14 15
However, Wei and Feldon reported an overall complication rate of 29% among 1,782 wrist arthrodeses, and a reoperation rate of 19%. 4 Nevertheless, little is known about the factors associated with reoperation in patients following TWF. Therefore, the aim of this study is to report the complications and the factors associated with reoperation and soft tissue complication after TWF.
Methods
After Institutional Review Board approval, we retrospectively identified patients who underwent TWF using Current Procedural Terminology (CPT) codes and International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) ( Appendix 1 ). All relevant hand surgery encounters from January 1, 2002 to January 1, 2019 at a single institutional system in the Northeastern United States were verified by manual chart review ( n = 343). We included all adult patients who had a primary TWF performed at one of the institutional hospitals. We excluded patients who underwent partial or limited wrist arthrodesis such as a four-corner fusion, radiolunate fusion, or radioscaphocapitate fusion ( n = 85), had a traumatic ( n = 15) or oncologic ( n = 6) indication for wrist fusion, had a failed wrist arthroplasty ( n = 12), and patients where fixation was performed using an intramedullary rod ( n = 9) or with Kirschner wires ( n = 1) ( Fig. 1 ). Eight (3.7%) patients underwent bilateral wrist fusions and only the first wrist fusion was included in analyses. We analyzed a total of 215 patients.
Fig. 1.
Flowchart of patient inclusion. CPT, Current Procedural Terminology codes, ICD-9 and ICD-10, International Classification of Diseases, Ninth and Tenth Revision.
Appendix 1
CPT codes:
25800: Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion); without bone graft
25805: Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion); with sliding graft
25810: Arthrodesis, wrist joint (including radiocarpal and/or ulnocarpal fusion); with iliac or other autograft (includes obtaining graft)
ICD-9 procedure codes:
81.25: Carporadial fusion
ICD-10 procedure codes:
0RGN0ZZ: Fusion of Right Wrist Joint, Open Approach
0RGN07Z: Fusion of Right Wrist Joint with Autologous Tissue Substitute, Open Approach
0RGN0KZ: Fusion of Right Wrist Joint with Nonautologous Tissue Substitute, Open Approach
0RGP0ZZ: Fusion of Left Wrist Joint, Open Approach
0RGP07Z: Fusion of Left Wrist Joint with Autologous Tissue Substitute, Open Approach
0RGP0JZ: Fusion of Left Wrist Joint with Synthetic Substitute, Open Approach
A manual chart review was performed to collect data regarding patient- and surgical characteristics. In some patients there was missing data on the duration of surgery ( n = 90, 42%), immunosuppressive use ( n = 10, 4.7%), hand dominance ( n = 46, 21%), the metacarpal used for distal fixation ( n = 17, 7.9%), the number of distal screws ( n = 16, 7.4%), the number of proximal screws ( n = 16, 7.4%), smoking status ( n = 12, 5.6%), race ( n = 8, 3.7%), plate angle ( n = 7, 3.3%), or plate type ( n = 6, 2.8%), as this was not reported in the medical chart or radiographs were not accessible. The postoperative complications recorded included infection, nonunion, soft tissue complication, stress fracture, carpal tunnel syndrome, tenosynovitis, intrinsic contracture, extensor tendon rupture, and finger stiffness. Finger stiffness was defined as persistent postoperative stiffness of a finger reported by the treating physician in the medical chart. A reoperation was defined as any unplanned additional surgery of the wrist following wrist fusion. A soft tissue complication was defined as any soft tissue complication and included postoperative infections. Follow-up time was defined as the time from surgery to last clinical visit recorded in medical charts.
Study Population
We included 215 patients who underwent a TWF. The majority of the patients were male ( n = 118, 55%) and the mean age was 53 ± 15 years. The median follow-up was 6.1 years (interquartile range [IQR] =1.7–9.0). Indications for TWF included inflammatory arthritis ( n = 66, 31%), degenerative arthritis ( n = 59, 27%), posttraumatic arthritis ( n = 47, 22%), spastic wrist deformity ( n = 37, 17%), and other ( n = 6, 2.8%). The group of “other” consisted of two (0.93%) patients with a distal radius fracture nonunion, two patients (0.93%) with a dysfunctional limb (either plexopathy or following compartment syndrome), one patient with distal radioulnar joint instability (0.47%), and one (0.47%) patient with complex regional pain syndrome following distal radius malunion ( Table 1 ). At least one prior wrist surgery had been performed in 95 (44%) patients, including 29 (14%) proximal row carpectomies, 22 (10%) wrist arthroscopies, and 15 (7.0%) prior carpal tunnel releases among others ( Table 2 ).
Table 1. Study population.
| Variables | All patients |
|---|---|
| ( n = 215) | |
| Age, mean (SD), years | 53 (15) |
| Male sex, n (%) | 118 (55) |
| Diabetes mellitus, n (%) | 18 (8.7) |
| Oral immunosuppressive use, n (%) n a | 59 (27) |
| Smoking, n (%) n b | 36 (18) |
| Wrist fusion dominant hand, n (%) n c | 94 (44) |
| Prior wrist surgery, n (%) | |
| 0 | 120 (55) |
| 1 | 38 (18) |
| >1 | 57 (27) |
| Indication wrist fusion | |
| Inflammatory | 66 (31) |
| Degenerative arthritis | 59 (27) |
| Posttraumatic arthritis | 47 (22) |
| Spastic contractures | 37 (17) |
| Other | 6 (2.8) |
| Race, n (%) d | |
| Caucasian | 181 (87) |
| African American | 12 (5.8) |
| Hispanic | 10 (4.8) |
| Other | 4 (1.9) |
| Surgical characteristics | |
| Duration surgery, mean (SD), minutes e | 86 (45) |
| Concomitant surgery at time of wrist fusion, n (%) | 162 (75) |
| Graft, n (%) | |
| Autograft only | 169 (79) |
| Local | 167 (78) |
| Iliac crest | 2 (1.0) |
| Allograft only | 7 (3.3) |
| Allograft and autograft | 16 (7.4) |
| No graft | 23 (11) |
| Plate angle, n (%) f | |
| Angled | 177 (85) |
| Bend | 31 (15) |
| Plate type, n (%) g | |
| DCP | 3 (1.4) |
| LC-DCP | 26 (12) |
| LCP | 178 (83) |
| Spanning plate LCP | 2 (0.9) |
| Distal fixation, n (%) h | |
| MC 2 | 1 (0.5) |
| MC 3 | 197 (100) |
| Distal screws, n (%) i | |
| 2 | 6 (3.0) |
| 3 | 62 (31) |
| 4 | 131 (66) |
| Proximal screws, n (%) i | |
| 2 | 1 (0.5) |
| 3 | 59 (30) |
| 4 | 139 (70) |
Abbreviations: DCP, dynamic compression plate; LCP, locking compression plate; MC 2, index metacarpal; MC 3, middle metacarpal; SD, standard deviation.
n = 10.
n = 12.
n = 46.
n = 8.
n = 90.
n = 7.
n = 6.
n = 17.
n = 16.
Table 2. Previous surgeries.
| All patients | |
|---|---|
| Surgery type | ( n = 215) |
| PRC, n (%) | 29 (14) |
| Arthroscopy, n (%) | 22 (10) |
| ORIF, n (%) | 15 (7.0) |
| CTR, n (%) | 15 (6.9) |
| Implant removal, n (%) | 13 (6.1) |
| Debridement, n (%) | 13 (6.1) |
| FCA, n (%) | 12 (5.6) |
| Darrach, n (%) | 8 (3.7) |
| Extensor tenosynovectomy, n (%) | 8 (3.7) |
| Compartment release, n (%) | 3 (1.4) |
| Extensor tendon transfer, n (%) | 3 (1.4) |
| PIN/AIN neurectomy, n (%) | 2 (0.9) |
| Hand/wrist tendon release, n (%) | 2 (0.9) |
| Radius fracture fixation, n (%) | 2 (0.9) |
| Open biopsy, n (%) | 2 (0.9) |
| Neurolysis, n (%) | 2 (0.9) |
| Unknown, n (%) | 1 (0.5) |
| Reconstruction wrist ligaments, n (%) | 1 (0.5) |
Abbreviations: AIN, anterior interosseous nerve; CTR, carpal tunnel release; FCA, four corner arthrodesis; ORIF, open reduction internal fixation; PIN, posterior interosseous nerve; PRC, proximal row carpectomy.
Surgical Technique
A dorsal fusion plate or dorsal spanning plate was used in all TWFs, either with a local autograft ( n = 167, 78%), iliac crest autograft ( n = 2, 1.0%), allograft ( n = 7, 3.3%), a combination of both ( n = 16, 7.4%), or without a graft ( n = 23, 11%). Local autograft included bone harvested from the radius, ulna, or carpus. The majority of the patients underwent concomitant surgery at time of wrist ( n = 162, 75%), including 85 (40%) concomitant posterior interosseous nerve (PIN) neurectomies, 31 (14%) carpal tunnel releases, and 30 (14%) Darrach procedures ( Table 3 ). In most patients, a bent/angled plate ( n = 177, 85%), with mostly four distal screws ( n = 131, 66%) and four proximal screws ( n = 139, 70%), was used. Except for one patient, all patients had distal fixation to the third metacarpal ( n = 200). Arthrodesis of the third carpometacarpal (CMC) joint was performed in 24 (11%) patients. Surgeries were performed by 15 surgeons and seven surgeons performed more than 10 surgeries accounting for 87% of the TWFs performed.
Table 3. Concomitant surgeries.
| All patients | ||
|---|---|---|
| Surgery type | ( n = 215) | % |
| PIN neurectomy, n (%) | 85 | 40 |
| CTR, n (%) | 31 | 14 |
| Darrach procedure, n (%) | 30 | 14 |
| Ulna hemiresection arthroplasty, n (%) | 25 | 12 |
| Tendon transfer hand/wrist, n (%) | 20 | 9.3 |
| PRC, n (%) | 18 | 8.4 |
| Distal radial ulnar joint hemiarthroplasty, n (%) | 16 | 7.4 |
| Neuroma excision, n (%) | 4 | 1.9 |
| Sauvé-Kapandji procedure, n (%) | 2 | 0.9 |
| Radius fracture fixation, n (%) | 2 | 0.9 |
| Wrist contracture release, n (%) | 1 | 0.5 |
Abbreviations: CTR, carpal tunnel release; PIN, posterior interosseous nerve; PRC, proximal row carpectomy.
Statistical Analysis
Categorical data was presented as frequencies and percentages, continuous data as means and standard deviations or as median and IQR. To evaluate the factors associated with reoperation, we used the Fisher's exact test for dichotomous and categorical variables and the Student's t -test for age, which was normally distributed. In addition, we performed a similar analysis to identify the factors associated with soft tissue complication after TWF. We included all explanatory variables with a p < 0.1 in a multivariable logistic regression model to identify independent factors associated with reoperation. Significance was set at 0.05 for all tests. All analyses were performed with Stata (StataCorp. College Station, TX).
Results
Reoperation
A total of 41 (19%) patients underwent reoperation at a median of 6.9 months (IQR = 3.9–18); these were performed for symptomatic implants ( n = 12, 27%), implant failures ( n = 8, 20%), infections ( n = 7, 17%), and nonunions ( n = 6, 15%) ( Figs. 2 , 3 and Table 4 ). Among the patients with implant failure, two patients underwent implant removal for broken screws, two patients underwent implant removal for implant loosening, and one patient underwent implant removal for a broken and loose implant. One patient had soft tissue incompetence with an exposed plate; this patient underwent implant removal and primary skin closure. Among the patients who had implant failure, two patients underwent implant removal with revision arthrodesis; the remaining ( n = 6) had the implant removed as the fusion was mature. Among the patients with an infection, two patients underwent irrigation and debridement, two patients underwent washout and vacuum-assisted closure, and three patients underwent implant removal alone. Among the patients with nonunion, two patients underwent implant removal and revision arthrodesis with a plate and local autograft, one patient underwent implant removal and revision arthrodesis with a plate and allograft, and one patient underwent implant removal and revision with two radiocarpal screws and local autograft ( Figs. 4 and 5 ). One patient had nonunion of the scaphotrapezial and third CMC joint and had a revision with a plate, allograft, and local autograft with concomitant partial excision of the ulna. One patient had nonunion but, based on their preference, underwent implant removal and PIN neurectomy without rearthrodesis. All revision arthrodeses achieved bony union ( Table 5 ).
Fig. 2.
Kaplan–Meier survival curve for reoperation after total wrist fusion.
Fig. 3.
X-rays of patient with ( A ) total wrist fusion for degenerative arthritis, ( B ) stress fracture after 4 months, ( C ) 10 months after implant removal and open reduction and internal fixation.
Table 4. Indications of reoperations.
| Indications | Reoperations ( n = 41) |
|---|---|
| Symptomatic implant, n (%) | 12 (27) |
| Implant failure, n (%) | 8 (20) |
| Infection, n (%) | 7 (17) |
| Nonunion, n (%) | 6 (15) |
| Ulnar impaction, n (%) | 2 (4.9) |
| Incorrect size hardware, n (%) | 1 (2.4) |
| Stress fracture, n (%) | 1 (2.4) |
| Difficulty with flexion, n (%) | 1 (2.4) |
| Adhesions of the tendons to the plate, n (%) | 1 (2.4) |
| Removal hardware without indication, n (%) | 1 (2.4) |
| Extensor tendon rupture, n (%) | 1 (2.3) |
Fig. 4.
X-rays of patient with ( A ) total wrist fusion for posttraumatic arthritis, ( B ) nonunion after 6 months of follow-up, ( C ) 1 month after revision of total wrist fusion with two screws.
Fig. 5.
X-rays of patient with ( A ) total wrist fusion for inflammatory arthritis, ( B ) nonunion after 10 months of follow-up, ( C ) 2 months after revision of total wrist fusion with plate.
Table 5. Type of reoperation stratified by indication.
| Indication reoperation | Reoperation | |
|---|---|---|
| Symptomatic implant ( n = 12) | Implant removal | 9 (75) |
| Implant removal + extensor tenolysis | 2 (17) | |
| Implant removal + CTR | 1 (8.3) | |
| Implant failure ( n = 8) | Implant removal | 6 (75) |
| Implant removal + revision arthrodesis with plate and local autograft | 2 (25) | |
| Infection ( n = 7) | Implant removal | 3 (43) |
| Irrigation + debridement | 2 (29) | |
| Washout and vacuum assisted closure | 2 (29) | |
| Nonunion ( n = 6) | Implant removal + revision arthrodesis with plate and local autograft | 2 (33) |
| Implant removal + revision with two radiocarpal screws and local autograft | 1 (17) | |
| Implant removal + extensor tenolysis + PIN | 1 (17) | |
| Implant removal + revision arthrodesis with plate and allograft | 1 (17) | |
| Revision with plate + allograft+ local autograft+ partial excision of ulna | 1 (17) | |
| Ulnar impaction ( n = 2) | Resection pisiform + resection triquetrum | 1 (50) |
| Total ulnar prosthesis + pisiform excision | 1 (50) | |
| Incorrect size hardware ( n = 1) | Replacement of four distal radius screws | 1 (100) |
| Stress fracture ( n = 1) | Implant removal + ORIF | 1 (50) |
| Difficulty with flexion ( n = 1) | Implant removal + extensor tenolysis | 1 (100) |
| Adhesions of the tendons to the plate ( n = 1) | Implant removal + extensor tenolysis | 1 (100) |
| Removal hardware without indication ( n = 1) | Implant removal | 1 (100) |
| Extensor tendon rupture ( n = 1) | Darrach + extensor tendon transfer | 1 (100) |
Abbreviations: CTR, carpal tunnel release; ORIF, open reduction internal fixation; PIN, posterior interosseous nerve.
In bivariate analysis, TWF of the dominant hand (26 vs. 14%, p = 0.037) and prior wrist surgery (27 vs. 13%, p = 0.008) was associated with higher reoperation rates and concomitant PIN neurectomy (11 vs. 25%, p = 0.013) was associated with lower reoperation rates ( Table 6 ). In multivariable analysis, TWF of the dominant hand (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.1–4.7, p = 0.033) was associated with a higher reoperation rate ( Table 7 ).
Table 6. Factors associated with reoperation after total wrist fusion.
| Patient without | Patients with | ||
|---|---|---|---|
| Variable | Reoperation ( n = 174) | Reoperation ( n = 41) | p -Value |
| Age, mean (SD), years | 54 (15) | 50 (14) | 0.10 a |
| Male sex, n (%) | 94 (80) | 25 (20) | 0.73 b |
| Diabetes mellitus, n (%) | 14 (78) | 4 (22) | 0.76 b |
| Oral immunosuppressive use, n (%) n a | 51 (86) | 8 (14) | 0.25 b |
| Smoking, n (%) n b | 25 (69) | 11 (31) | 0.065 b |
| Wrist fusion dominant hand, n (%) n c | 70 (74) | 24 (26) | 0.037 b |
| Prior wrist surgery, n (%) | 69 (73) | 26 (27) | 0.0080 b |
| Indication wrist fusion, n (%) | 0.29 b | ||
| Inflammatory | 58 (88) | 8 (12) | |
| Degenerative arthritis | 44 (75) | 15 (25) | |
| Posttraumatic arthritis | 38 (81) | 9 (19) | |
| Contractures | 30 (81) | 7 (19) | |
| Other | 4 (67) | 2 (33) | |
| Race, n (%) d | >0.99 b | ||
| Caucasian | 146 (81) | 35 (19) | |
| Other | 21 (81) | 5 (19) | |
| Duration surgery, mean (SD), minutes e | 86 (41) | 86 (61) | 0.96 a |
| Concomitant surgery at time of wrist fusion, n (%) | 132 (81) | 30 (19) | 0.69 a |
| Concomitant PIN neurectomy, n (%) | 76 (89) | 9 (11) | 0.013 b |
| Graft, n (%) | 0.20 b | ||
| Autograft | 140 (83) | 29 (17) | |
| Other | 34 (74) | 12 (26) | |
| Plate angle, n (%) f | >0.99 b | ||
| Straight | 25 (81) | 6 (19) | |
| Angled | 142 (80) | 35 (20) | |
| Plate type, n (%) g | 0.63 b | ||
| LCP | 144 (81) | 34 (19) | |
| Other | 24 (77) | 7 (23) |
Abbreviations: LCP, locking compression plate; PIN, posterior interosseous nerve; SD, standard deviation.
n = 10; using Student's t -test
n = 12; using Fisher's exact test
n = 46
n = 8
n = 90
n = 7
n = 6
Table 7. Logistic regression. Factors associated with reoperation after total wrist fusion.
| Variable | OR | SE | 95% CI | p- Value |
|---|---|---|---|---|
| Smoking | 1.9 | 0.81 | 0.80–4.4 | 0.15 |
| Concomitant PIN neurectomy | 0.45 | 0.20 | 0.19–1.1 | 0.077 |
| Prior wrist surgery | 2.0 | 0.80 | 0.92–4.4 | 0.08 |
| Wrist fusion dominant hand | 2.2 | 0.84 | 1.1–4.7 | 0.033 |
Abbreviations: CI, confidence interval; OR, odds ratio; PIN, posterior interosseous nerve; SE, standard error.
Note: All explanatory variables with a p < 0.1 were included in multivariable analysis.
Soft Tissue Complications
Soft tissue complications occurred in 20 patients (9.3%) consisting of hematomas ( n = 8, 3.7%), observed blistering ( n = 5, 2.3%), and observed wound dehiscence ( n = 4, 1.9%). In bivariate analysis, diabetes mellitus (24 vs. 6.3%, p = 0.012) was associated with soft tissue complication after TWF ( Table 8 ). In multivariable analysis, smoking (OR: 2.5, CI: 0.95–6.4, p = 0.010) was independently associated with soft tissue complication after TWF ( Table 9 ).
Table 8. Factors associated with soft tissue complication after total wrist fusion.
| Variable | Patients without soft tissue complication ( n = 190) | Patients with soft tissue complication ( n = 25) | p -Value |
|---|---|---|---|
| Age, mean (SD), years | 53 (15) | 54 (19) | 0.70 a |
| Male sex, n (%) | 103 (87) | 15 (12) | 0.67 b |
| Diabetes mellitus, n (%) | 12 (67) | 6 (33) | 0.012 b |
| Oral immunosuppressive use, n (%) n a | 51 (86) | 8 (14) | 0.64 |
| Smoking, n (%) n b | 28 (78) | 8 (22) | 0.055 |
| Arthrodesis dominant hand, n (%) n c | 84 (89) | 10 (11) | 0.83 |
| Prior wrist surgery, n (%) | 86 (91) | 9 (9.5) | 0.40 |
| Indication wrist fusion, n (%) | 0.57 | ||
| Inflammatory | 59 (89) | 7 (11) | |
| Degenerative arthritis | 54 (92) | 5 (8.5) | |
| Posttraumatic arthritis | 41 (87) | 6 (13) | |
| Contractures | 30 (81) | 7 (19) | |
| Other | 6 (100) | 0 | |
| Race, n (%) d | 0.75 | ||
| Caucasian | 160 (89) | 21 (12) | |
| Other | 24 (92) | 2 (7.7) | |
| Duration surgery, mean (SD), minutes e | 84 (45) | 99 (45) | 0.25 |
| Concomitant surgery at time of wrist fusion, n (%) | 141 (87) | 21 (13) | 0.34 |
| Concomitant PIN neurectomy, n (%) | 74 (87) | 11 (13) | 0.67 |
| Graft, n (%) | 0.44 | ||
| Autograft | 151 (89) | 18 (11) | |
| Other | 39 (85) | 7 (15) | |
| Plate angle, n (%) f | 0.77 | ||
| Straight | 27 (87) | 4 (13) | |
| Angled | 156 (88) | 21 (12) | |
| Plate type, n (%) g | 0.55 | ||
| LCP | 158 (89) | 20 (11) | |
| Other | 26 (84) | 5 (16) |
Abbreviations: LCP, locking compression plate; PIN, posterior interosseous nerve; SD, standard deviation.
n = 18; using Student's t-test
n = 12; Using Fisher's exact test
n = 35
n = 8
n = 92
n = 7
n = 6
Table 9. Logistic regression. Factors associated with soft tissue complication after total wrist fusion.
| Variable | OR | SE | 95% CI | p- Value |
|---|---|---|---|---|
| Diabetes mellitus | 4.3 | 2.4 | 1.4–13 | 0.063 |
| Smoking | 2.5 | 1.2 | 0.95–6.4 | 0.010 |
Abbreviations: CI, confidence interval; OR, odds ratio; SE, standard error.
Other Complications
Seventy-two (33%) patients had a postoperative complication and 28 (13%) patients had more than one complication resulting in a total of 100 postoperative complications. The postoperative complications included symptomatic hardware ( n = 16, 7.4%), implant failure ( n = 11, 5.1%), infection ( n = 11, 5.1%), nonunion ( n = 8, 3.7%), and carpal tunnel syndrome ( n = 4, 1.9%) ( Table 10 ).
Table 10. Complications.
| All patients | |
|---|---|
| Complications | ( n = 215) |
| Soft tissue complication, n (%) | 20 (9.3) |
| Symptomatic implants, n (%) | 16 (7.4) |
| Implant failure, n (%) | 11 (5.1) |
| Infection, n (%) | 11 (5.1) |
| Tenosynovitis, n (%) | 10 (4.7) |
| Nonunion, n (%) | 8 (3.7) |
| Other complications, n (%) | 7 (3.2) |
| Finger stiffness, n (%) | 5 (2.3) |
| Carpal tunnel syndrome, n (%) | 4 (1.9) |
| Ulnar impaction, n (%) | 3 (1.4) |
| Intrinsic contracture, n (%) | 2 (0.9) |
| Incorrect size hardware, n (%) | 1 (0.5) |
| Extensor tendon rupture, n (%) | 1 (0.5) |
| Stress fracture, n (%) | 1 (0.5) |
| Total | 100 |
Discussion
This study evaluated the postoperative complications and the factors associated with reoperation and soft tissue complication following TWF in 215 patients with a median follow-up of 6.1 years. One-third of patients had a postoperative complication. Reoperations were performed in 19% of patients, mostly for symptomatic implants. Six reoperations were performed for nonunion. A TWF of the dominant hand was associated with a higher reoperation rate. Soft tissue complications occurred in 9.3% of patients and were associated with smoking.
The results of this study need to be interpreted in light of its limitations. First, a manual chart review was performed to collect data; therefore, our analysis was dependent on the accuracy of the data recording. A second limitation is that patients could be missed as a result of miscoding. Another limitation was how to define follow-up: either time from surgery to the database query or time from surgery to the last clinical note in the database. We defined the follow-up time as the time from surgery to last clinical visit recorded in medical charts considering that this would minimize the loss of follow-up from patients who switched hospitals within our institutional system. Also, as with all retrospective studies, there is missing data regarding a small portion of surgical procedure and patient characteristics.
At least 33% of the patients had one postoperative complication and 19% underwent a reoperation. The most common complications were soft tissue complications (9.3%) and symptomatic implants (8.8%). These reoperation and complication rates are similar to prior studies: Reigstad et al included 76 patients who underwent TWF for noninflammatory arthritis and reported that 46 (61%) patients developed complications, resulting in 65 reoperations. They reported that the most frequent complication was pain over the plate/breakage (42%) followed by nonunion (4%). 16 Rauhaniemi et al included 115 patients with rheumatoid arthritis who underwent a TWF. Among these patients, 18 had postoperative complications and 9 underwent a reoperation. Three patients had a revision for nonunion, two patients had a revision for broken Rush pins, and two had a revision for a superficial wound infection. 17 In this study, five patients had persistent postoperative finger stiffness. Persistent postoperative finger stiffness was defined as finger stiffness that was still present during the last follow-up at the orthopaedic hand surgery department.
We found that TWF of the dominant hand was independently associated with a higher reoperation rate. Twenty-four (26%) patients who had TWF of the dominant hand underwent a reoperation compared with 17 (14%) patients who had a TWF of the nondominant hand. Among these patients, 11 (46%) patients had a reoperation for symptomatic implant. An explanation for this may be that patients tend to use their dominant hand more frequently and earlier postoperatively, resulting in a greater loading on the implant. 18
A PIN neurectomy appeared to have a potential relationship to a lower reoperation rate (OR: 0.45, 95% CI: 0.19–1.1, p = 0.077). Only nine patients with a concomitant PIN neurectomy had a reoperation, with the most frequent indication being nonunion ( n = 4, 5.1%), followed by infection ( n = 2, 2.6%), symptomatic implant ( n = 2, 2.6%), and exposed hardware ( n = 1, 1.3%). A notable observation was that only two patients with a PIN neurectomy underwent reoperation for a symptomatic implant. The PIN innervates the dorsal capsule so, in theory, neurectomy could reduce the pain patients experience in this area; alternatively, surgeons who perform a PIN neurectomy may perform a more thorough preparation of the fusion bed and an association may not be causal. 19 20 21 Similar findings were reported by van Hernen et al who found that performing an anterior interosseous nerve and/or PIN neurectomy at the time of proximal row carpectomy was associated with lower rates of conversion to wrist arthrodesis. 22 In addition, Wagner et al reported reduced pain, improved functional outcomes, and a higher rate of wrist joint preservation in patients with arthritis who underwent a proximal row carpectomy and a concomitant neurectomy procedure. 23 However, in our study, it may be argued that the PIN is denervated by performing the TWF itself.
In bivariate analysis, prior wrist surgery was associated with a higher reoperation rate (15 vs. 27%, p = 0.0080), but these associations were not independent predictors in multivariable analysis. O'Shaughnessy et al found that prior wrist surgery was associated with higher rates of revision surgery after wrist denervation. 24 Wagner et al reported that revision surgeries after bilateral TWF were more common in patients with prior surgeries. 25 Reigstad et al also found that prior wrist surgery was associated with reduced wrist function and higher pain scores. 16 It is not clear why prior surgery is associated with reoperation. This could represent a more difficult pathology, a poor capacity for healing or alternatively, this could reflect that some patients prefer operative intervention to address persistent symptoms.
In this study, the majority of the patients underwent TWF with a bent plate and had distal fixation on the third metacarpal. Arthrodesis of the third CMC joint was performed in 24 (11%) patients. Among these patients, one (4.2%) patient had a reoperation for hardware failure and one (4.2%) patient had a reoperation for a symptomatic implant. The literature on performing a concomitant arthrodesis of the third CMC joint is debated. Reigstad et al reported a lower reoperation rate among the patients who underwent arthrodesis of the third CMC joint. They state that arthrodesis of the third CMC joint should be performed in patients with good soft tissue and normal-sized hands. 16 On the contrary, Nagy et al reported that 20 (43%) patients developed nonunion among 47 patients who underwent arthrodesis of the third CMC joint with plate removal. Eleven (23%) of these were painful and required reoperation. They also reported that among 34 patients who underwent bridging of the third CMC joint, all but one (97%) remained free of pain after plate removal. They conclude that arthrodesis of the third CMC joint should not be performed at the same time of TWF. 26 We did not have adequate power in this study to make a conclusion regarding CMC fusion.
We found that smoking was independently associated with soft tissue complications after TWF. The adverse effects of smoking on soft tissue healing have often been described. 27 28 29 The vasoconstriction due to smoking leads to reduced blood flow to healing tissues. In addition, the macrophage and fibroblast activation is impaired increasing the risk of a surgical site infection. 30
Some of the findings of this study have been described previously. 16 17 However, this study provides new information on the results of total wrist fusion. First, our study describes the largest cohort of patients undergoing TWF to date. Second, all indications for TWF were included in our cohort compared with previous studies that described either patients with noninflammatory arthritis or patients with rheumatoid arthritis. 16 17 Finally, in this study, surgeries were performed by 15 different surgeons that result in a high degree of generalizability. Other studies report that the surgeries were performed by one or two surgeons. 13 15
In conclusion, this study provides data regarding the complications of TWF. Roughly one-third (33%) of the patients undergoing TWF experience a postoperative complication and 19% undergo a reoperation. TWF of the dominant hand results in higher reoperation rates. Based on the results of this series, patients with TWF on dominant hand and patients with prior wrist surgery should be counseled accordingly when considering wrist fusion. The risk of a soft tissue complication after TWF is increased in smokers.
Footnotes
Conflict of Interest N.C.C. reports personal fees from Flexion Medical, personal fees from Miami device Solutions, personal fees from DePuy Synthes, outside the submitted work. K.R.E. reports personal fees from Axogen, personal fees from Integra, personal fees from Checkpoint, outside the submitted work. J.L. reports personal fees from Axogen, outside the submitted work.
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