What Are the Risk Factors and Complications Associated With Intraoperative and Postoperative Fractures in Total Wrist Arthroplasty?

Abstract

Background Total wrist arthroplasty (TWA) can relieve pain and preserve some wrist motion in patients with advanced wrist arthritis. However, few studies have evaluated the risks and outcomes associated with periprosthetic fractures around TWAs. Questions/purposes (1) What is the risk of intraoperative and postoperative fractures after TWAs? (2) What factors are associated with increased risk of intraoperative and postoperative fracture after TWAs? (3) What is the fracture-free and revision-free survivorship of TWAs among patients who sustained an intraoperative fracture during the index TWA? Methods At one institution during a 40-year period, 445 patients underwent primary TWAs. Of those, 15 patients died before 2 years and 5 were lost to followup, leaving 425 patients who underwent primary TWAs with a minimum of 2-year followup. The primary diagnosis for the TWA included osteoarthritis ([OA] 5%), inflammatory arthritis (90%), and posttraumatic arthritis (5%). Indications for TWA included pancarpal arthritis combined with marked pain and loss of wrist function. The mean age of the patients was 57 years, BMI was 26 kg/m 2 , and 73% were females. Six different implants were used during the 40-year period. Mean followup was 10 years (range, 2-18 years). Results Intraoperative fractures occurred in nine (2%) primary TWAs, while postoperative fractures occurred after eight (2%) TWAs. After analyzing demographics, comorbidities, and surgical factors, intraoperative fractures were found to be associated with only age at surgery (hazard ratio [HR], 1.10; 95% CI, 1.03-1.20; p = 0.006) and use of a bone graft (HR, 5.80; 95% CI, p = 0.03). No factors were found to be associated with increased risk of postoperative fractures; specifically, intraoperative fracture was not associated with subsequent fracture development. The 5-, 10-, and 15-year KaplanMeier survival rates free of postoperative fracture were 99%, 98%, and 95%, respectively. The 5-and 10-year revision-free survival rates after intraoperative fracture were 88% and 88%, respectively, compared with 84% and 74% without an intraoperative fracture (p = 0.36). Furthermore, the survival-free of revision surgery rates for aseptic distal loosening at 5 and 10 years were 88% and 88%, respectively, compared with 93% and 87% without a fracture (p = 0.85). Conclusions Intraoperative fractures occur in approximately 2% of TWAs. These fractures do not appear to affect long-term implant survival or risk of fracture. Patient age and the need for bone graft were the only factors in the risk of intraoperative fractures. Postoperative fractures also occur in 2% of TWAs, but often result in revision surgery.

CORR Insights®: High Survivorship and Few Complications With Cementless Total Wrist Arthroplasty at a Mean Followup of 9 Years

“…The current study by Gil and colleagues showed a reasonable survivorship of 77.7% at 15 years, which is consistent with other comparable recent studies that show an improved survivorship of the latest generation of implants [1][2][3][5][6][7][8]. Perhaps if this pattern of finding increased longevity and minimal complications continues to be reported, the data will serve as a counterclaim for the many steadfast skeptics.…”

A critical appraisal to the decision by the company Zimmer Biomet to withdraw the MaestroTM Wrist Reconstructive System from the marketplace

“…In the literature, there are no evident scientific data with the use of all third generation TWA types (including the Maestro TM Total Wrist/WRS!) that support the necessity of cementation at time of its primary insertion (Figure 1A-C, Figure 5A-B, Figure 11A-E), cementation is only recommended primarily in patients with poor bone stock (rheumatoid arthritis, advanced stage of osteoporosis) (Figure 2A-B, Figure 7) or in cases of revision TWA, and cementation does not decrease the risk of intraor postoperative periprosthetic fracture [2][3][4][5][6][7][8][9][10][11][12][13]16,17,[59][60][61][62][63]. Noted that for metacarpophalangeal implants it has been observed a higher risk of intraoperative periprosthetic fractures when using cementation than implants which are inserted in a non-cemented manner [64].…”

"Off label" use of the ReMotionTM total wrist for treatment of advanced stage of post-traumatic pancarpal wrist osteoarthritis: Report of two cases and review of literature

“…Periprosthetic fracture, observed with our second patient, can be a concern. Occurrence has been reported in approximately 2% of all TWAs independently of its intra-or postoperative occurrence observed at an average of 7.9 years after TWA, and for intraoperative occurrence only age was found to be a risk factor [61]. Non-displaced fractures can be treated by splinting, however, in order to achieve early stability for movement of the wrist, cementation and/or internal fixation are the methods of choice [62,63].…”