| Wrist Arthrodesis: Review of Current Techniques Peter J. L. Jebson, MD, and Brian D. Adams, MD |
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Wrist arthrodesis is a well-established procedure that predictably relieves pain and provides a stable wrist for power grip. Although a variety of techniques for achieving a solid fusion have been described, the combination of rigid stabilization with a dorsal plate and autogenous cancellous bone grafting results in a high fusion rate and obviates the need for prolonged postoperative cast immobilization. Successful results with dorsal plating with or without local bone graft have recently been reported for patients with posttraumatic conditions. Rod or pin fixation is an established procedure for patients with inflammatory arthritis or a connective tissue disorder; however, plate fixation for these conditions is becoming a more acceptable alternative. Complications are relatively common and range from minor transient problems to major problems, such as wound dehiscence, infection, extensor tendon adhesions, and plate tenderness, which may require implant removal. Preoperatively, patients should be assessed for the presence of carpal tunnel syndrome, distal radioulnar joint arthritis, or ulnocarpal impaction syndrome, which may become or remain symptomatic after arthrodesis. Wrist arthrodesis results in a high degree of patient satisfaction with respect to pain relief and correction of deformity. Patients are able to accomplish most daily tasks and activities by learning to adapt to, and compensate for, the loss of wrist motion. Since the original report by Ely in 1910, arthrodesis of the wrist has become a well-established reconstructive procedure for a number of upper extremity disorders. A variety of methods for achieving wrist fusion have been described. The earliest techniques relied on cancellous or corticocancellous bone-graft stabilization alone and varied with respect to donor site; type, size, and shape of the graft; and method of graft insertion. Postoperative cast immobilization was required to maintain wrist position until a solid fusion was achieved. Concerns regarding the inconvenience and morbidity of prolonged immobilization, the morbidity of extensive bone grafting, and the unacceptably high rates of pseudarthrosis and graft failure led to the use of internal fixation devices to augment the arthrodesis. In 1965, Clayton described a technique for achieving wrist arthrodesis in patients with rheumatoid arthritis. The technique involves the insertion of a single 3/32-inch diameter Steinmann pin down the third metacarpal shaft into the medullary canal of the radius. The pin maintains alignment and stability after the placement of a dorsal corticocancellous bone graft. In 1971, Mannerfelt and Malmsten modified the procedure by using a Rush rod reinforced with a staple. In 1973, Millender and Nalebuff further modified the technique by inserting the Steinmann pin into the radius via the second or third web space of the hand. In 1982, Feldon and co-workers described the use of two smaller Steinmann pins inserted through the second and third web spaces and between the metacarpal shafts into the medullary canal of the radius. This technique improved stability and obviated the need for supplementary staple or wire fixation. Viegas et al recommended placing a single large Steinmann pin adjacent to the base of the second metacarpal, through the carpus, and into the medullary canal of the radius. They suggested that this insertion position places the wrist in extension and ulnar deviation, thus improving grip strength. |
| Figure 1 Wrist arthrodesis performed with the single-intramedullary-rod tech-nique. The patient had a painful pseud-arthrosis involving the scaphotrapezio-trapezoid articulation. The rod is broken, most likely the result of failure to include the third carpometacarpal joint in the fusion. |
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Proponents of intramedullary rod or pin techniques have suggested a number of advantages. These include decreased operative time, simplicity, ability to perform concomitant procedures at the metacarpophalangeal joints in patients with inflammatory arthritis, short recuperation period, lowered cost compared with other implants, and flexibility in positioning the wrist in the desired amount of flexion or extension. In 1972, Meuli11 performed a wrist arthrodesis with a dorsal plate applied from the second metacarpal to the radius. Manetta and Tavani12 recommended axial compression of the radiocarpal joint and fixation of the plate on the third metacarpal. Wright and McMurtry reviewed their experience with arthrodesis with a 3.5-mm dynamic compression plate. Using a dorsal plate for wrist arthrodesis was advocated as a method of achieving immediate rigid fixation that obviated the need for postoperative cast immobilization and avoided the complications of hardware failure and pseudarthrosis (Fig. 1). Although there were high rates of fusion and subjective satisfaction with respect to pain relief, several patients in their series required plate removal because of tenderness and/or extensor tendon irritation. In addition, precise contouring of the plate into slight wrist extension and ulnar deviation was time-consuming and difficult to achieve. A recent development is the precontoured, low-contact, dynamic-compression titanium plate (Fig. 2), which was specially designed for wrist arthrodesis.
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| Figure 2 The three plate options: the standard-bend (top), short-bend (middle), and straight plates (bottom). The precontoured titanium plates are manufactured by Synthes USA (Paoli, Pa). Note the low profile, tapered end, and built-in fusion angle of 10 degrees of dorsiflexion in the standard-bend and short-bend plates. |
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Despite immediate rigid stabilization with a dorsal plate and advances in implant design, supplementation of the fusion site with autogenous cancellous bone graft from the iliac crest continues to be common practice. Significant donor site morbidity, including persistent pain, hematoma formation, infection, and nerve injury, has led to the use of alternative techniques, such as obtaining bone graft from the distal radius or fusion without bone graft. Use of the iliac crest is reserved for those patients with poor bone quality or large defects. Supplemental autogenous bone grafting is usually not necessary for patients with inflammatory arthritis Indications The most common indication for wrist arthrodesis is symptomatic post-traumatic or degenerative arthrosis of the radiocarpal and midcarpal joints that is severe and unresponsive to conservative nonoperative treatment and will not be improved by a motion-saving procedure. Additional indications include conditions that cause destruction, instability, or contracture of the wrist joint, such as the inflammatory arthritides, infection, nerve palsy, and paralytic, spastic, and connective tissue disorders, as well as bone loss due to trauma or following tumor resection. Wrist arthrodesis is also indicated for the treatment of complex carpal instability problems and salvage of a failed implant arthroplasty, proximal row carpectomy, or limited intercarpal arthrodesis. Performing bilateral wrist arthrodeses in the patient with inflammatory arthritis is controversial. Patients with bilateral wrist arthrodeses are believed to have less dexterity and greater functional compromise than those with an arthrodesis of one extremity and arthroplasty of the other. However, there is disagreement with respect to which extremity should be fused. Arthrodesis of the nondominant extremity and arthroplasty of the dominant extremity has been advocated. There is no consensus regarding optimal positioning when arthrodesis is performed in both extremities. Several authors recommend the neutral position for the dominant extremity and 5 to 10 degrees of flexion for the nondominant side. Brumfield and Champoux recommend 10 degrees of extension for both extremities. Clayton and Ferlic recommend a neutral position for both wrists. Contraindications Contraindications to wrist arthrodesis include a lack of adequate soft tissue coverage and the presence of active wrist infection. Arthrodesis is also contraindicated when motion-preserving procedures are a possible means of preserving function. Because of the technical requirements, wrist arthrodesis should also be avoided for the skeletally immature patient with open epiphyseal plates. Surgical Technique Using the Wrist Fusion Plate and Local Bone Graft This procedure can be performed with the use of either brachial plexus block or general anesthesia. If iliac crest bone graft is required, general anesthesia is usually necessary, although on occasion local anesthesia and a brief period of sedation may be used for that portion of the procedure. Under tourniquet control, a straight incision is made from the distal third of the index finger-middle finger interosseous space across Lister's tubercle and over the radial shaft to the proximal border of the abductor pollicis longus muscle. Full-thickness skin flaps are elevated, with care taken to protect the cutaneous nerves and dorsal veins. The third dorsal compartment of the extensor retinaculum is opened, and the extensor pollicis longus muscle and tendon are retracted radially. The second and fourth dorsal compartments are elevated subperiosteally in the radial and ulnar directions, respectively. The dorsal aspect of the third metacarpal is exposed by sharply incising and elevating the periosteum, with care taken to avoid damaging the adjacent interosseous muscles. The incision is deepened proximally to expose the third carpometacarpal, capitolunate, and radiocarpal articulations. Distraction is applied to the hand, and the articular surfaces of the third carpometacarpal, capitolunate, radioscaphoid, and radiolunate joints are denuded to cancellous bone (Fig. 3A). Articular cartilage may be removed with a curette and/or a rongeur. Alternatively, a burr may be used, particularly for sclerotic bone. The triquetrohamate, capitohamate, and scaphotrapezio-trapezoid surfaces are similarly prepared for fusion if symptomatic arthritic involvement is identified on preoperative radiographs or clinical examination. Lister's tubercle is removed, and the dorsal surfaces of the scaphoid, lunate, and capitate are decorticated to provide a flat surface for plate application (Fig. 3B). Cancellous bone graft is harvested from within the distal metaphyseal region of the radius through a cortical window created 2 cm proximal to the distal radial articular surface and radial to the intended plate position. One centimeter of subchondral and metaphyseal bone should be preserved during harvesting of the graft. Bone graft is inserted into the prepared joint spaces that will lie beneath the plate. The appropriate plate type is then selected. If the AO wrist arthrodesis system is used, there are three choices of plates. A standard-bend plate is used in larger individuals. A short-bend plate is used in small-stature patients and in those with a failed proximal row carpectomy. A straight plate is used in patients with unusual wrist anatomy or a severely deformed joint or when a large intercalary bone graft is necessary. Proper plate position and alignment should be confirmed before screw insertion. The plate is fixed to the third metacarpal shaft with three 2.7-mm bicortical screws. Alternatively, the plate may be fixed to the second metacarpal to position the wrist in slight ulnar deviation, thus enhancing power grip. The holes must be drilled exactly from dorsal to volar in the sagittal plane; otherwise, rotational malalignment of the middle finger will occur when the plate is secured to the radius. The holes should also be drilled in the mid-line of the metacarpal to optimize screw fixation and to prevent meta-carpal fracture. The plate should be properly seated and secured as far proximally as possible on the metacarpal shaft to avoid irritation of the overlying extensor tendons by the distal edge of the plate. An additional 2.7-mm bicortical screw is placed into the capitate. The plate is fixed to the radius with four fully threaded 3.5-mm screws placed in bicortical fashion. The fusion mass is compressed by drilling the radial-shaft screw holes eccentrically away from the wrist joint.
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Before Decortication Figure 3A Joint surfaces to be included in the fusion. The inclusion of optional joints into the arthrodesis is based on the presence of deformity or arthritis on preoperative examination or radiographs. |
| Figure 3B Lister’s tubercle is osteotomized. The dorsal aspects of the third carpometacarpal joint, scaphoid, capitate, and lunate are decorticated. |
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Appropriate plate position and screw lengths are confirmed with intraoperative radiographic imaging. Wound closure is performed over a suction drain. The distal portion of the plate is covered with the dorsal hand fascia and periosteum if possible. The capsule may also be covered over the plate; alternatively, a distally based slip from one of the wrist extensor tendons may be used. The extensor pollicis longus is transposed above the extensor retinaculum as the third dorsal compartment is closed. The tourniquet is deflated, and hemostasis is obtained. Skin closure is performed with nonabsorbable suture placed in interrupted horizontal mattress fashion to facilitate eversion of the wound edges. A soft, bulky dressing is applied. Postoperatively, the patient is encouraged to elevate the extremity and perform active and passive digital range-of-motion exercises. Sutures are removed at 10 to 14 days, and a volar forearm-based splint is applied. Only light activities are permitted. Strengthening exercises are begun 6 weeks after surgery. Splinting is discontinued at 6 to 8 weeks, and full unrestricted use of the extremity is usually permitted by 10 to 12 weeks postoperatively when healing is complete and radiographs confirm successful fusion. Figure 4 illustrates a case of wrist arthrodesis performed with the custom plate in a patient with post-traumatic arthritis. Surgical Technique Using an Intramedullary Rod Exposure of the distal radius and carpus is performed through a dorsal longitudinal incision, as described for the dorsal plate technique. In the patient with inflammatory arthritis, it is particularly important to handle all skin flaps gently, to preserve dorsal veins, and to maintain thick skin flaps. The skin flaps and subcutaneous tissue are elevated from the extensor retinaculum, which is incised longitudinally over the sixth compartment. The remaining compartments are released in an ulnar-to-radial direction, preserving the broad, radially based retinacular flap for transposition of all or a portion of the retinaculum beneath the extensor tendons. A longitudinal wrist capsulotomy is made, followed by exposure of the radiocarpal and intercarpal joints. A complete radiocarpal and intercarpal synovectomy is performed. Articular cartilage from the radiocarpal, intercarpal, and midcarpal joints is removed. Concomitant procedures involving the extensor tendons and the distal radioulnar joint (DRUJ) are performed as indicated. If the distal ulna is excised, the resected bone may be morcellized and used as bone graft. In patients with post-traumatic or degenerative arthritis, the fusion site is supplemented with cancellous bone harvested from the distal radius or iliac crest. There are several acceptable methods of pin or rod placement. The single-Steinmann-pin technique of Millender and Nalebuff and the duarod technique of Feldon demonstrate the principles of this approach. Millender-Nalebuff Technique With this technique, the wrist is palmar-flexed, and the intramedullary canal of the distal radius is carefully entered with a pointed awl or large curette. A Steinmann pin is advanced into the radius manually or with a power drill. The size of the pin is sequentially increased until the largest possible pin that can be accommodated by the radial shaft is identified. This pin is drilled in a proximal-to-distal direction through the carpus until it exits through the second or third intermetacarpal space dorsally. The pin is then withdrawn distally, the hand is reduced on the wrist, and the pin is advanced proximally into the previously prepared medullary canal of the radius. The pin is countersunk beneath the skin into the intermetacarpal space with a bone tamp. Because the pin is not bent, the wrist is subsequently fused in a neutral flexion-extension position. Alternatively, if concomitant meta-carpophalangeal joint implant arthroplasties are to be performed, the Steinmann pin can be placed down the third metacarpal shaft after resection of the metacarpal head. The pin should be sufficiently countersunk to avoid interfering with subsequent implant placement. Feldon Dual-Rod Technique Instead of a single large Steinmann pin, two smaller (3/32- to 7/64-inch-diameter) pins are inserted dorsally across the carpus into the second and third intermetacarpal spaces. The pins may be bent before or after insertion to obtain the desired degree of wrist extension and ulnar deviation. The pins are cut short and impacted beneath the skin. In both methods, the capsule is reapproximated, and the radially based extensor retinacular flap is transposed beneath the extensor tendons. If there is a tendency toward bowstringing, one half of the retinaculum can be placed over the tendons. The tourniquet is released, and hemostasis is obtained. The skin is closed, and a sterile dressing is applied, followed by a short plaster arm cast or splint immobilization.
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| Figure 4 A, B, C, D AP (A) and lateral (B) radiographs of the wrist demonstrate the scapholunate advanced collapse (SLAC) pattern of arthritis, with narrowing of the radioscaphoid joint and midcarpal arthritis. Posteroanterior (C) and lateral (D) radiographs 10 weeks after wrist arthrodesis performed with a titanium custom wrist fusion plate and local bone graft |
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Postoperative management is similar to that used after arthrodesis with a dorsal plate with one exception. Following suture removal, the wrist is immobilized in a short arm cast for 6 weeks. The decision to discontinue immobilization is based on radiographic confirmation of successful arthrodesis. Capitate-Radius Arthrodesis An alternative technique for achieving radiocarpal arthrodesis in patients with a severe flexion deformity of the wrist due to congenital or acquired spastic deformities of the upper extremity has been reported by Louis et al. The technique involves excision of the proximal 80% of the scaphoid, the entire lunate and triquetrum, and a portion of the hamate. A trough is created in the subchondral region of the distal radius to facilitate seating of the denuded proximal pole of the capitate. The hand is positioned in neutral or slight palmar flexion and ulnar deviation, and the fusion site is augmented with Kirschner wires, transfixing staples, or a dorsal plate as needed. Concomitant sectioning, lengthening, or transfer of wrist and digital flexor tendons may be needed to allow satisfactory positioning of the hand. Postoperatively, plaster cast immobilization is maintained until there is clinical and radiographic evidence of union. The advantages of the capitate-radius arthrodesis include the intrinsic stability created by excision of the proximal carpal row and insertion of the capitate into the radius and the elimination of autogenous bone grafting. In addition, the shortening accommodates the contracted volar wrist and digital flexor tendons. The cosmetic appearance of the severely flexed extremity is significantly improved after capitate-radius arthrodesis. However, functional improvement is dependent on the preoperative diagnosis, functional abilities, and the severity of spasticity. Comparative Results In one retrospective series of 89 consecutive patients who had undergone wrist arthrodesis for a post-traumatic disorder, patients treated with dorsal-plate fixation were compared with those treated with various other techniques. In the former group, fusion was more successful (98% versus 82%) and occurred earlier (average, 10.3 weeks versus 12.2 weeks postoperatively). When performed in patients with post-traumatic or degenerative conditions, dorsal-plate fixation and autogenous bone grafting results in highly reliable fusion rates, ranging from 93% to 100%. Preliminary data demonstrate similar success with the use of the specially designed low-profile precontoured plate and local bone graft. Most of the patients reported in the literature who have had wrist arthrodesis with dorsal-plate fixation had diagnoses of degenerative, post-traumatic, or neurologic conditions. There are very few studies involving patients with inflammatory arthritis. In the largest series of rheumatoid patients with a wrist arthrodesis performed with a dorsal plate, successful union occurred in all 23 patients. The arthrodesis was performed with a self-compressing six-hole plate applied on the second metacarpal. In the series of Zachary and Stern, all 5 patients with inflammatory arthritis had a successful wrist arthrodesis with the dorsal-plate technique. However, all three failures in the series of Wright and McMurtry occurred in patients with rheumatoid arthritis. Similarly, Bracey et al reported a nonunion rate of 17% after wrist arthrodesis performed with a dorsal T-plate in patients with rheumatoid arthritis. In one patient, the arthrodesis was performed after failure of a cemented wrist prosthesis. The other failure occurred after a postoperative infection. Because of plate prominence, the higher rates of nonunion, delicate skin, and osteoporotic bone, and the greater risk of infection, the intramedullary-rod technique remains an acceptable and popular alternative for patients with inflammatory arthritis. Satisfactory results have also been reported when wrist arthrodesis is obtained with intramedullary fixation. However, these reports predominantly involved patients with rheumatoid arthritis. In Clayton's original report, all 5 patients with rheumatoid arthritis had a successful fusion. Mannerfelt and Malmsten reported successful wrist fusion using a Rush pin and staple in all but 1 of their 43 rheumatoid patients. The same technique was used in 1 patient with a congenital deformity and 5 patients with a posttraumatic or neurologic disorder; however, their outcome was not reported. In the series of Millender and Nalebuff, all but 2 of the 60 rheumatoid patients (70 arthrodeses) had a successful fusion with a Steinmann pin supplemented with a staple or single Kirschner wire. Postoperatively, up to 5 months of immobilization in a long or short arm cast was necessary. Clendenin and Green reported successful union in all but 1 of their 12 patients in whom arthrodesis was performed with the technique of Millender and Nalebuff. Vahvanen and Tallroth reported a 100% fusion rate in 38 patients with rheumatoid arthritis (45 wrists) in whom arthrodesis was performed with a single Rush pin. In the only series of nonrheumatoid patients in whom arthrodesis was performed with a modification of the Millender-Nalebuff intramedullary technique, all 10 patients (7 with posttraumatic arthritis, 2 with Kienböck disease, and 1 with psoriatic arthritis) achieved solid fusion. Functional Outcome Wrist arthrodesis results in high subjective patient satisfaction with respect to pain relief and correction of deformity. Grip strength, digital range of motion, and fore-arm rotation do not significantly change from preoperative values. Improvements in pinch and grip strengths have been reported following wrist arthrodesis in patients with osteoarthritis, but not in those with rheumatoid arthritis. In a recent study assessing the functional capabilities of patients after unilateral wrist arthrodesis performed for a variety of post-traumatic conditions, most tasks and daily activities could still be performed, but required adaptation and modification by the patient. The most difficult tasks were perineal care, manipulating the hand in tight spaces, and activities that required forceful pronation and supination with a simultaneous strong grip. Manual laborers have difficulty crawling, pushing, carrying, and using tools, particularly a hammer, because of the loss of wrist extension. Interestingly, maximum improvement in function did not occur for an average of 14.5 months after arthrodesis. Most patients returned to their original occupation with some job modification, such as lifting restrictions. In the retrospective study of Hastings et al, those patients in whom arthrodesis had been performed with a dorsal plate returned to work earlier than those in whom arthrodesis had been performed with various other methods. Complications Complications after wrist arthrodesis occur regardless of the technique used. However, review of the literature suggests that plate fixation is associated with a lower incidence. Hastings et al reviewed the data on 89 patients with 90 wrist arthrodeses performed for various post-traumatic disorders. In 56 patients (57 wrists), arthrodesis was performed with plate fixation. In 33 patients (33 wrists), the arthrodesis was performed with a variety of other methods. In 28 of these 33, arthrodesis was performed with an onlay corticocancellous bone graft temporarily transfixed with Steinmann pins or Kirschner wires. Four patients had an onlay graft alone; the remaining arthrodeses involved intramedullary fixation without bone grafting. A 3.5-mm dynamic compression or reconstruction plate was used for plate fixation. Autogenous iliac crest bone graft was used in all but 1 of the 57 arthrodeses. Nonunion occurred in 2% of the arthrodeses performed with a plate, compared with 18% of the arthrodeses performed with other methods. Additional complications occurred in 51% of patients with plate fixation, compared with 79% of the patients in whom arthrodesis had been performed with alternative methods. Complications associated with plate fixation included extensor tendon adhesions or tenosynovitis, intrinsic muscle contracture, tenderness over the plate, poor wound healing, painful nonunion of the third carpometacarpal joint, and carpal tunnel syndrome. Fifty-nine percent of these complications required operative treatment. Complications associated with the alternative arthrodesis techniques included tendon adhesions, carpal tunnel syndrome, DRUJ pain, pin-track infection, and pin migration or breakage. Twenty-one percent of these complications required operative treatment. Complications related specifically to dorsal-plate fixation and iliac crest bone grafting were analyzed by Zachary and Stern. Although the union rate was 100%, there were a total of 82 complications in 50 of the 73 wrist arthrodeses. Approximately 80% of these complications resolved spontaneously or with nonoperative treatment. Nineteen patients required surgery, which most commonly involved plate removal because of prominence, loosening, or the development of a symptomatic bursa. Resection of the distal ulna was necessary in 3 patients and was recommended for 5 additional patients with symptomatic DRUJ arthritis or ulnar im-paction syndrome. Failure to identify or anticipate DRUJ problems in the wrist arthrodesis patient is a well-recognized source of postoperative dissatisfaction. Concomitant DRUJ disorders and the potential for "iatrogenic" ulnar impaction syndrome or compression of the median nerve in the carpal tunnel after wrist arthrodesis should be addressed preoperatively or intraoperatively, as these conditions may be aggravated, potentially compromising an otherwise successful arthrodesis. The management of extensor tendon irritation by the plate can be particularly challenging. Nonoperative treatment modalities include icing, nonsteroidal anti-inflammatory medication, and the judicious use of corticosteroid injections. Plate removal is reserved for patients with persistent, chronic symptoms. Removal is typically performed after successful arthrodesis. Some patients continue to have persistent symptoms despite plate removal. Although wrist arthrodesis with intramedullary fixation is relatively simple and safe, complications directly attributable to the various intramedullary devices do occur. Rod or pin migration with irritation of the surrounding tendons and skin necessitates bending of the pin, which makes subsequent implant removal difficult. Breakage of the rod or pin can be associated with pseudarthrosis. Fortunately, the incidence of these complications is low. Summary Wrist arthrodesis results in predictable pain relief and a high degree of patient satisfaction. Some adaptation and modification of functional activities is required, and certain tasks, such as perineal care, are difficult. The traditional technique of intramedullary rod or pin fixation is most applicable for patients with inflammatory arthritis or a connective tissue disorder. Plate fixation is indicated for patients with post-traumatic or degenerative arthrosis. The advantages of this type of fixation include immediate rigidity, thus permitting early postoperative rehabilitation with little or no immobilization. Wrist arthrodesis with dorsal-plate fixation and autogenous bone grafting is associated with higher fusion rates and a lower incidence of complications than the alternative techniques. Plate prominence may result in tenderness or extensor tendon irritation, necessitating removal. Recent developments in plate design and the use of local bone graft in selected patients may decrease morbidity and complications. However, there are as yet no data to suggest that use of the custom wrist fusion plate reduces the incidence of plate-associated complications or the need for plate removal. The custom plate is easier to use and was developed to theoretically reduce the incidence of complications. However, other factors, such as implant cost, patient size, bone quality, and clinical diagnosis, should be considered when selecting the appropriate implant type or method for wrist arthrodesis. Careful pre-operative clinical and radiographic evaluations are essential to detect the presence of other conditions, such as intercarpal arthritis, carpal tunnel syndrome, DRUJ arthritis, or ulnocarpal impaction, that may need to be treated at the time of wrist arthrodesis.
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