It's a pleasure coming here again this year to speak on wrist fusion. Well, the indications have been discussed by some of my colleagues earlier and I won't go over that. But basically, this is thought to be an end-stage solid. If everything else has gone wrong, what can you do to fuse the wrist in totality? It gives excellent pain relief, in my opinion. They get excellent function because they can now load the wrist, they've got a solid post that they can use. But obviously, at the expense of any motion in the flexion, extension, radial and under-deviation plane. I still use a pre-contoured 30 degree angulated plate. But there's more modern locking plates now that don't seem to need to cross the third CMC joint. And we'll discuss that. The 30 degree angulation improves grip strength. The only slight downside to this was a boxer that I had had a chronic wrist injury and he wanted to return to boxing. I put a straight plate in him because he didn't want to be 30 degrees extended because he'd be slapping. So we put a straight plate on him and he returned to professional boxing. And this is the more modern locking plate that doesn't traverse the third CMC joint. And we'll discuss that, whether that's indicated or not. So here we go, the patient wants to have a solid wrist and are happy with the loss of flexion and extension. And whenever you bring up the concept of a total wrist fusion with patients, they're absolute in horror. They feel as though their life is going to end. But certainly, it's worth giving them the names of cooperative patients. Go and see a hand therapist to talk it through them. And usually, most patients are really, really happy with this. But it is one of those operations that the patients initially, when you do broach the subject with them, they feel as though their life is over and their wrist is over. Which I guess that's why we're doing their wrist is over. And so what I will do is ask them to go and see my therapist. I will ask them to speak to some of my patients. And occasionally, I will give them a trial by rigid block splint. And that's useful for a couple of months, just to let them go out into their everyday activities to see what they can do. And more importantly, what they can't do. And it's surprising how many patients come back and say, you know what? That was pretty good. It's, you know, the splint itself got in the way. But if that wasn't there, I think I can do most things now. So if we just look at the technique, if any of the patients got any preoperative carpal tunnel symptoms, nerve conduction studies are positive. It's certainly worse prophylactically releasing the carpal tunnel. Either at the same time, what I try and do is I release that early. And then six to eight, 12 weeks later, when the wound's completely healed, I'll then do a carpal tunnel decompression. Midline incision, third compartment released. And the EPL is exteriorized. Retinacular retraction and inverted T-capsulotomy. Here we go. We go down through the third compartment. The incision, if you're using an AO plate, it's really quite long, actually. You need to be more or less the whole way along the metacarpal and then down onto the radius. So there's the third compartment. That's released and EPL is exteriorized at the closure. And then I perform an inverted T-capsulotomy. And with the long limb of the T going along the third metacarpal. And I dissect that so I know exactly where the third metacarpal is and my plate will sit perfectly on the metacarpal plate and not angulated or deviated. I take off Lister's tubercle. I perform an oblique slide osteotomy, taking away the dorsal, probably third of the distal radius with an osteotome. Always passing the osteotome from proximal to distal. You don't want to do this from distal to proximal because you may propagate up the radial shaft and that would become a very bad day. So I use that then as bone graft. I mush that up and I can impact into the fusion site. And what I perform is an inside tube morselization. I will just put a ronger into the radiocarpal and I'll just smash everything up and leave it all inside tube. So I sometimes take it all out, smash it all up and put it back in. Particular care and attention is to the distal radial articular surface which I will excise and then I'll put some sagittal cuts into the radius just to increase the bone mass area for bone to leak out and give a fusion. And I've not had any particular problem with this whatsoever. My inside tube morselization technique is quite scary when you first see it and I'm fixing it distally along the third metacarpal shaft, approximately along the radius. So I really don't mind what happens in the middle. Now if you're obviously using one of the more modern locking plates you need some solid bone to fix. So that's my technique if I do go on to the more modern locking plates. So the third CMC joint, in my practice I actively find it. I take away 80% of it. I leave that volar bridge and I bone graft into that area. If you don't fuse the third CMC joint you do need to remove the plate and once bone union has occurred at a year, 18 months or so. So in my practice it just takes me two minutes just to go up to the third CMC joint, excise the CMC joint and pack some really nice bone graft into that. And here we go. Fusion with a pre-contoured AO plate. You can see there's different screw sizes just because the metacarpal is smaller than the radius. That's the first screw that I put on, the distal one. Central, confirm it on the image intensification to ensure that you're nice and straight and then put a proximal screw on. And I use fluoro all the way through this procedure just to ensure that all the articular surfaces are removed. And in particular the volar rim of the radius has to be removed. And that's often a very solid concrete bolt nut, volar ulnar area of the radius. Post-operatively, they do swell and so I will put them into a splint and a very loose bandage just to allow them, if they need to swell, they can swell in that. And so certainly there's no rigid compression at all. So what does the literature say? I was quite surprised really reading this because in my practice I'm really happy with the wrist fusions. Hill Hastings, who's popularized the AO plate, looked at 90 wrists and certainly found that his plate was superior both in fusion rates and also in complications rates. Jeremy Fields looked at 20 wrist fusions and there were 45 complication rates but only four of those needed further surgery. They did the Jebson score which recorded poor function. But I think this is as a consequence of rheumatoid patients with poor hand function anyway and reduced range of finger movement. So when I've looked at all the literature, what do you need to tell your patients? Well you can tell your patient if you use the model plates, either a bridging, pre-contour plate or a locking plate, you've got a near 100% fusion rate. So we are going to get you to heal. It does take 10 to 12 weeks for that fusion to occur. So be careful when you're doing that. And it'll take you up to a year for things to fully settle for your wrist and for your forearm to adapt to its new position. Grip strength, 72% and only 15% of patients need plate removal. So I don't routinely take plates out unless you haven't taken the third CMC joint out and then you will need to do that. So there are still some answers. Can you return to boxing? So that was a question for me about a year ago and I did a fusion with a straight fusion plate and he's gone to a back to the professional ranks. Golf, can you return to golf? There's anecdotal case series where the occasional patient has returned to golf. Certainly with your non-dominant side, you probably can because you either keep that straighter or your dominant side is the wrist that you'll cock and you probably won't be able to do a wrist fusion. So I'll be interested if anyone has fused a wrist that has gone back to playing golf. So thanks for your attention. Has anyone got a wrist fusion that's returned to golf? Was that dominant or non-dominant? Yeah. I need every help I can get, so I may list myself. So if you've got a plate across there, there'll be micro movement at the third CMC joint if you don't fuse it. And with time, that micro movement that's occurring underneath the plate will just lift the plate off and it's well reported in the literature. So you either fuse the CMC joint and then you can leave the plate in or if you haven't touched the CMC joint, you take the plate out.

wrist fusion

pain relief

limited wrist motion

plate options

patient education