Posted: Aug. 09, 2006
Osteoarthritis brought a world of pain to a 79 year old Houston woman. The breakdown and loss of cartilage in her joints led to two hip replacements and a knee replacement.
The intense pain in her left wrist became so severe, the joint often swelled up and kept her from sleeping.
Steroids and other medications were not working. Traditionally, doctors would recommend a joint fusion to ease the pain in her wrist. But fusions take away the ability to extend and flex the wrist. Combined with the patient's other joint limitations, a fusion would further decrease her range of motion, making it even harder to perform everyday tasks.
Dr. Evan Collins, an orthopedic surgeon at The Methodist Hospital, offered the patient an option: a total wrist replacement with a new improved implant and surgical technique that could maintain her wrist's flexing and extending abilities and eliminate the pain. Five weeks post surgery, the patient’s pain is significantly reduced and she feels much better.
"There's a trend to critically re-examine the role of total wrist replacements for arthritic problems," says Collins. "Traditionally the wrist has been an area where joint replacement has been frowned upon. But the implants and techniques have improved, and we’re starting to ask different questions. It's patient dependent and that's the key."
One of the most complex joints in the body, the wrist and its eight small carpal bones are connected to and control much of the movement in the forearm and hand. The smaller joints within the wrist all surrounded by articular cartilage and ligaments must be healthy and mobile to allow pain free and wide-ranging motion.
Once degenerative arthritis affects wrist cartilage, pain often surrounds the slightest movement and can interfere with the movement of other joints as well.
Bone fusions joining together what’s left of the wrist bones with pins, plates or grafts are successful in eliminating pain. Their main advantage is allowing patients to maintain their ability to lift and carry heavy items. Their main drawback, however, is the lack of movement in the repaired wrist.
"Most patients truly don't want their wrists fused," says Collins. "Imagine putting your wrist in a cast so it doesn't bend for the rest of your life. When you fuse a joint, you have to know that the other joints around it can compensate for the lack of motion."
Wrist replacements also have a major drawback: patients are advised to lift no more than 15 to 20 pounds for the rest of their lives. The big advantage to a total replacement, however, is that the implant restores strength and range of motion while taking away the pain.
Collins and his associate Dr. David Hildreth offer total wrist replacement surgery to arthritic patients who don't have to lift or carry heavy loads but want to maintain flexibility of their wrist joint. It also is offered to patients with inflammatory arthritis, rheumatoid arthritis and lupus. Age plays a factor in patient eligibility, he says.
"We don't know the longevity of the implant," Collins explains. "We hope it lasts 20 or 30 years. We want it to last for the rest of a patient's life." He and Hildreth currently work with a newer metal implant that better matches the body's anatomy. It lends itself to creating better soft tissue balances during surgery. In fact, Collins helped design some of the soft tissue exposures used with the device.
Like any joint replacement surgery, the first weeks after the replacement are tough for patients, who generally experience swelling and pain. The surgery itself requires an overnight hospital stay. Surgeons make an incision through the back of the wrist, move the protective tendons and open up the wrist joint area. They remove the bones necessary to make room for the implant, which is then joined to the existing hand and forearm bones with screws and cement.
The implant allows surgeons to straighten the joint to its original height, giving the wrist balance and stability. Patients are immobilized with a splint for a few days to let the swelling go down, then they're fitted with a cast for two to three weeks followed by a removable splint.
Risks include the potential for infection and nerve damage. All of the hand's blood vessels and nerves extend across the wrist, so surgeons must create a safe pathway to affix the implant. Loosening also is a risk with a total wrist replacement, and it's the main reason patients have weight restrictions on their artificial joint.
"Any complication from a total wrist replacement is certainly a bit more challenging than fusion complications," says Collins. "If these joints fail, we don't have a great salvage operation yet."
But all of that is quickly changing. As more and more surgeons test the newest wrist implants, their body of knowledge is growing and the devices and techniques become more effective. The day may come when wrist replacements performed in Europe for decades are as common as hip and knee replacements.
"The goal is to do a good job initially and have it last as long as possible," Collins explains. Many patients will continue to require wrist fusions based on their age, level of activity and desires. But there's a growing list of patients who may benefit from a wrist replacement.
"It is an option we're going to offer to more and more patients as we see the success of these newer implants continue to improve," Collins says. "Oftentimes in medicine we practice based on tradition. But if there's a viable option to fusing, I think most patients would want to consider it. We're supposed to offer as many choices to people as possible."