Total Wrist Replacement: State of the Art, Challenges and Pitfalls: A Comparative Review

Abstract

Background Total wrist replacement (TWR) as motion-preserving procedure continues to be critically discussed in the literature, although the complication rates have been significantly reduced with the current 3rd generation designs compared with older types. Possible reasons for this are often also a lack of knowledge about the currently available evidence, the complication management, and the lack of practical experience by the surgeons. Methods Based on an extended review of literature and own experience, the aim of this article is to give practicable insights for the clinician on: (1) biomechanical fundamentals, (2) differences in design, survivorship and functional outcome between the recent types, (3) possible pitfalls, and (4) failures and salvage options. Results The goal of TWR is that the overall wrist motion is maintained respectively improved despite it works with a locked midcarpal joint. Regarding survivorship and functional outcome the Maestro is (was) being superior over all other types that is (was) based on features in design. There is no scientific evidence as to why the Maestro was withdrawn from the marketplace by the company. For assessment of instability and/or impingement the use of dynamic radiographs is recommended. The problem of TWR is unchanged failure of the carpal components primarily based on mechanical dysbalance, and secondarily followed by metal and/or polyethylene wear, but surgical revision of asyptomatic periprosthetic osteolysis without safe radiagraphic signs of loosening is only required in not more than 20% of cases. For a failed TWR, revision TWR or conversion to total wrist arthrodesis are viable salvage options. Conclusions The knowledge about recent evidence and features in design of the available types, exact assessment of radiographic findings, presence of technical skills by the surgeons, and observance of the patient's expectations are the basic requirements for a successful TWR.

The Crucial Role of Locking Screws in Total Wrist Arthroplasty: Should We Always Revise or Not?

“…5 B), first reported by Schmidt in 2017. 7 It is also noteworthy that a typical ulnar-sided impingement between the implant components is described for the Universal2. 10

Figure 6 A A 10-year follow-up after primary combined replacements.

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“…However, despite the superiority of Maestro both in terms of survivorship and functional outcome over all other third-generation TWA types (or fourth-generation types when declaring the silicone implants as first type), this implant was withdrawn from the marketplace in 2018, suggesting that the implant was no longer profitable for the company. 7

Figure 4 A On the left is the required explantation of a first Maestro type device. The carpal component has sunk due to the migration of the tip of the capitate peg into the third carpometacarpal joint (yellow arrow), and both nonlocking screws have subsequently migrated (circles).

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“…5 A). 7 , 9 10 Micromotions may arise from the preexisting mechanical imbalance of implants and iatrogenic-related issues, such as incorrectly aligned implants or ligamentous instabilities ( Fig. 6 B).…”

“…Considering all third-generation TWA types, revision becomes necessary in no more than 20% of cases with first Maestro type demonstrating superiority at the 10-year follow-up (survivorship with revision in 93% and nonrevision in remarkable 90% despite detectable radiographic signs of PPO). 7 , 10 Revision is only required if the PPO becomes symptomatic in combination with evident radiographic signs of loosening, such as dislocation or sinking of the carpal or radial components, with or without screw migration or breakage ( Figs. 4 A, 6 B).…”