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C OPYRIGHT Ó 2011 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Five to Ten-Year Outcomes of the Universal

Total Wrist Arthroplasty in Patients with
Rheumatoid Arthritis
By Christina M. Ward, MD, Taften Kuhl, BS, and Brian D. Adams, MD

Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, Iowa City, Iowa

Background: Implant arthroplasty of the wrist offers pain relief with preservation of motion to patients with rheumatoid
arthritis, although few studies have investigated the long-term results of this procedure. The purpose of the present study
is to report the prospective results of total wrist arthroplasty with use of the Universal wrist prosthesis in a consecutive
series of patients with rheumatoid arthritis who were managed by a single surgeon.
Methods: Twenty-four wrist arthroplasties in twenty patients with rheumatoid arthritis were followed prospectively.
Nineteen wrists in fifteen patients were followed clinically and radiographically for a mean of 7.3 years (range, 5.0 to 10.8
years) after the index procedure. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH)
score, wrist range of motion, and standard radiographic findings.
Results: The average DASH score improved from 62 points preoperatively to 40 points at the time of the latest follow-up.
The mean wrist flexion and extension at the time of the latest follow-up were 42° and 20°, respectively, for a mean
improvement in the total flexion-extension arc of 14°. A total of nine wrists (45%) in eight patients underwent revision
surgery because of a loose carpal component at the time of the latest follow-up. One patient underwent wrist arthrodesis
because of recurrent wrist instability. Two additional wrists in two patients had radiographic evidence of carpal component
subsidence at the time of the latest follow-up. The implant survival rates at five and seven years for the original prosthetic
components were 75% and 60%, respectively.
Conclusions: The results for the Universal wrist prosthesis at a minimum of five years of follow-up include a high
rate of failure, most often because of carpal component loosening, resulting in revision of ten (50%) of twenty
wrists at the time of the latest follow-up (with the inclusion of one revision in a patient who died before five years).
Patients with a stable prosthesis maintained a functional range of motion and had improvement in patient-reported
outcome measures.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

R
heumatoid arthritis of the wrist can be debilitating, with stability, soft-tissue imbalance, and carpal component loosening
resultant interference with activities of daily living. have often led to poor outcomes. The early results associated
When nonoperative treatments such as splinting and with the first Universal wrist prosthesis (KMI, Carlsbad, Cal-
activity modification fail to relieve symptoms, surgical treatment ifornia) showed good survival rates and improvement in terms
is considered. Wrist arthrodesis provides a durable solution for of pain and disability4,5. However, to our knowledge, the long-
patients with severe wrist arthritis but sacrifices wrist motion1. term results associated with this implant in patients with rheu-
Decreased wrist motion is especially problematic for patients matoid arthritis have not been reported. The purpose of the
with bilateral wrist arthritis, multiple upper extremity joint in- present study was to prospectively evaluate the results of wrist
volvement, or those who require wrist mobility for special needs. arthroplasty with use of the Universal total wrist prosthesis in a
Wrist arthroplasty provides useful motion but historically has consecutive series of patients with rheumatoid arthritis after a
been associated with a high complication rate2,3. Prosthetic in- minimum duration of follow-up of five years.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors
or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to
provide such benefits from a commercial entity (KMI [Carlsbad, California]).

J Bone Joint Surg Am. 2011;93:914-9 d doi:10.2106/JBJS.H.01614

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Materials and Methods
T he present study was approved by our institutional review board, and
informed consent was obtained from all patients.
Between 1997 and 2001, twenty-one patients (twenty-five wrists) with
rheumatoid arthritis were managed with total wrist arthroplasty by a single
surgeon. All patients were prospectively enrolled in the present study and were
asked to return for follow-up at yearly intervals. One patient (one wrist) was
excluded because she had undergone a previous total wrist arthroplasty with a
Volz implant (Howmedica, Rutherford, New Jersey) at another institution. In
the remaining twenty patients, arthroplasty was performed on fifteen right and
nine left wrists. Fifteen procedures involved the dominant extremity. All pa-
tients were female. In order for a patient to be considered as a candidate for
wrist arthroplasty, there could be no history of infection in the wrist, no active
synovitis of the wrist, no loss of wrist extensor tendon function, no skin
problems overlying the wrist, and no need to routinely bear weight on the
upper extremities with a handheld device such as a cane, crutch, or walker.
Despite the destructive effects of rheumatoid arthritis, the distal carpal row had
to have sufficient preservation of bone stock to allow implantation of the carpal
component used for wrist arthroplasty. Distal carpal row bone loss in the form
of cysts or severe osteopenia may preclude secure fixation of this prosthetic
carpal component.
At the time of the latest follow-up, four patients (four wrists) had died.
Of those four patients, one patient (one wrist) had undergone conversion of the
wrist arthroplasty to a wrist fusion 2.2 years after the index procedure because
of recurrent implant instability. Because the final outcome for this implant
(revision) was known prior to the patient’s death, this patient was included in
the survivorship analysis. One patient (one wrist) declined to return for the
five-year follow-up. Minimum five-year radiographic and clinical data were
available for the remaining nineteen wrists (fifteen patients), and the mean
duration of follow-up for this group was 7.3 years (range, 5.0 to 10.8 years).
Surgical Technique
A single surgeon (B.D.A.) performed all procedures with use of the technique
5 terized by carpal collapse, ulnar translocation of the carpus, and osseous
described by Menon , with the exception of modification of the capsular flap as
described below. A longitudinal skin incision is made in line with the third
metacarpal. Starting in the sixth extensor compartment, the extensor retinac-
ulum is elevated as a radially based single flap. A broad, distally based, rect-
angular capsular flap is raised to expose the entire joint, including the distal
radioulnar joint.
The distal part of the radius and the distal part of the carpus are pre-
pared with use of the alignment and cutting guides, with minimal resection of
the distal part of the radius to better preserve the volar capsule. Trial radial and
carpal components are inserted, and their position is confirmed with fluo-
roscopy. The wrist is moved through a range of motion to assess soft-tissue
balance. A high-speed burr is used to remove any remaining joint surface
between the trapezoid, capitate, and hamate to facilitate intercarpal fusion.
Autogenous bone obtained from the partial carpal resection is used to augment
the intercarpal arthrodesis. The distal part of the ulna is resected. Sutures are
passed through drill holes in the ulna and are secured to the volar capsule to
stabilize the distal part of the ulna. The trial components are exchanged for the
final components. The radial component and the central stem of the carpal
component are fixed with cement. The carpal component is further secured
with two screws into the carpus. All implants were the first-generation Uni-
versal wrist prosthesis (KMI). During capsular closure, excessive tightness is
avoided to prevent loss of flexion. In some cases, either a portion of the extensor
retinaculum or an allograft (tensor fasciae latae) was used to augment a defi-
cient capsule due to inadequate length or thickness secondary to the rheu-
matoid arthritis. The radial wrist extensor and extensor pollicis longus tendons
remain superficial to the retinaculum, whereas the other dorsal tendons are
placed beneath the extensor retinaculum.
A subcutaneous suction drain is used for twenty-four hours. A bulky
gauze dressing incorporating a volar plaster wrist splint is applied. Strict ele-
vation of the hand and early digital motion are encouraged to reduce swelling
and the risk of tendon adhesions. If the wrist is stable on intraoperative ex-
F I V E T O T E N -Y E A R O U T C O M E S O F T H E U N I V E R S A L T O TA L W R I S T
A R T H R O P L A S T Y I N P AT I E N T S W I T H R H E U M AT O I D A R T H R I T I S
amination at the completion of implantation, the bandage is changed on the
second postoperative day and a removable custom plastic wrist splint is applied.
The splint is removed two to three times daily for gentle active wrist motion
exercises. If wrist instability was evident intraoperatively, a plaster splint is
reapplied and is left in place for four weeks. After four weeks, the patient
advances to active wrist motion and begins using the hand for light activities of
daily living without the splint. Full use of the wrist without a splint is allowed
after eight weeks, except that lifting >10 lb (>4.5 kg) with this hand alone is
discouraged indefinitely. Patients may continue to use a splint as needed for
more strenuous activities.
Clinical Evaluation
Patients completed the Disabilities of the Arm, Shoulder and Hand (DASH)
questionnaire preoperatively, between one and two years postoperatively, and
at the most recent evaluation. The DASH questionnaire consists of thirty
items that address the degree of difficulty in performing certain tasks as well
as symptoms such as pain and stiffness. The DASH questionnaire is scored
from 0 to 100, with 0 representing a perfect score. Preoperative clinical ex-
amination included measurements of wrist flexion and extension, radial and
ulnar deviation, and pronation and supination with use of a hand-held go-
niometer. Range-of-motion measurements were repeated at each follow-up
visit.
Radiographic Evaluation
Preoperative posteroanterior and lateral wrist radiographs were evaluated
by the two authors (C.M.W. and T.K.) who did not perform the surgical
6
procedures. Each wrist was classified with use of the Simmen system .
Simmen Type I (‘‘ankylosis’’) is characterized by spontaneous ankylosis of
the intercarpal joints with or without radiocarpal fusion. Simmen Type II
(‘‘osteoarthritic’’) is characterized by moderate articular surface destruction
with associated subchondral sclerosis and occasional osteophytes, but no
evidence of destabilization. Simmen Type III (‘‘destabilization’’) is charac-
destruction.
Postoperative posteroanterior and lateral radiographs were analyzed for
evidence of carpal or radial component subsidence, osteolysis, intercarpal fu-
sion, and implant breakage. Osteolysis was indicated by progressive radiolu-
cency around the component. To our knowledge, there is not a standardized
method for defining carpal component subsidence. In order to quantify carpal
component subsidence for the purposes of the present study, we measured the
distance from the intersection of the central post with the baseplate of the carpal
implant to the base of the third metacarpal (Fig. 1-A). In some cases, the base of
the third metacarpal could not be consistently identified on sequential radio-
graphs. In those cases, the distance was measured to the base of the fourth
metacarpal. A decrease in this distance on sequential radiographs indicated
carpal component subsidence. The reliability of this measurement technique
has not been established.
Statistical Methods
A paired t test was used to compare preoperative and postoperative ranges
of motion and DASH scores. When comparing wrists with or without re-
vision surgery with regard to patient age, hand dominance, and preopera-
tive DASH score, a t test was used. For all analyses, the level of significance
was set at p < 0.05.
A Kaplan-Meier survivorship curve was created with use of data from
the nineteen wrists that had minimum five-year follow-up as well as the one
patient who had revision of the wrist before the time of death. The three
patients who died before a minimum of five years of follow-up and the one
patient who did not return for evaluation were excluded from the survivorship
analysis.
Source of Funding
We received no external funding for this study.
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Results (range, –20° to 32°) postoperatively (p = 0.45). The mean su-

Clinical Evaluation pination increased from 50° (range, 0° to 90°) preoperatively to

A t the time of the latest follow-up, ten wrist prostheses

(50%) in eight patients remained functional. In these
patients, the average DASH score improved from 62 points
(range, 42 to 80 points) preoperatively to 40 points (range, 18
to 72 points) at a mean of 14.5 months (range, eight to twenty-
four months) postoperatively and remained at 40 points (range,
18 to 80 points) at the time of the latest follow-up at a mean of
7.8 years after surgery.
There was no significant change in wrist flexion or ex-
tension, radial deviation, ulnar deviation, or forearm supination
between the preoperative and postoperative measurements.
The mean wrist flexion-extension arc increased from 48°
(range, 15° to 95°) preoperatively to 62° (range, 30° to 90°)
postoperatively. The mean flexion increased from 32° (range,
15° to 55°) preoperatively to 42° (range, 30° to 55°) postop-
eratively (p = 0.06). The mean extension increased from 16°
(range, 0° to 40°) preoperatively to 20° (range, –20° to 45°)
postoperatively (p = 0.46). The mean radial deviation changed
minimally, from 6° (range, –10° to 18°) preoperatively to 8°
(range, 0° to 35°) postoperatively (p = 0.80). The mean ulnar
deviation was 15° (range, 0° to 40°) preoperatively and 17°
71° (range, 40° to 90°) postoperatively (p = 0.12). The mean
pronation increased significantly from 54° (range, 0° to 90°)
preoperatively to 83° (range, 60° to 90°) postoperatively (p =
0.04). The increase in pronation and supination was likely a
result of distal ulnar resection.
Radiographic Evaluation
On preoperative radiographs, nine of the twenty-four wrists
were classified as Simmen Type I; five, as Type II; and nine, as
Type III. Preoperative radiographs could not be located for
one patient.
At the time of the latest follow-up, intercarpal fusion was
seen in all ten wrists with retained functional prostheses. Five of
the ten wrists that were treated with revision had radiographic
evidence of intercarpal fusion prior to the revision. In the
wrists that were not treated with revision, radiographic changes
at the time of the latest follow-up included carpal component
subsidence and osteolysis (one wrist), osteolysis without sub-
sidence (one wrist), and carpal component subsidence without
osteolysis (one wrist). There was no radiographic evidence of
implant breakage or radial component subsidence.

Fig. 1-A Fig. 1-B

Figs. 1-A, 1-B, and 1-C Case 4 (see Appendix). Fig. 1-A Posteroanterior radiograph of the left wrist and hand, made three months after wrist
arthroplasty. The black arrows denote the start and end points of the measurement used to quantify carpal component subsidence. Note the
lack of fusion between the capitate and the hamate. Fig. 1-B Posteroanterior radiograph, made three years after the index procedure, demon-
strating that the carpal component has subsided so the distance between the baseplate and the base of the third metacarpal has decreased
substantially.
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Fig. 1-C
Posteroanterior radiograph, made two years after carpal component
revision with bone-grafting, showing that the prosthesis has remained
stable.
Complications
Short-term complications included wound-healing problems
(17%; four of twenty-four wrists) and persistent prosthetic
instability (4%; one of twenty-four wrists). Superficial skin
necrosis or delayed superficial wound-healing occurred in
four patients (four wrists; 17%), but all lesions healed with
dressing changes. There were no deep or periprosthetic in-
fections. Recurrent prosthetic dislocation occurred in one
wrist. Dislocation was first identified two months postoper-
atively and recurred despite closed reduction and casting. The
patient underwent carpal component revision two months
after the index procedure, but redislocation recurred and
was treated with wrist arthrodesis 2.2 years after the index
procedure.
Revision Surgery
Nine patients (ten wrists) underwent a total of twelve surgical
revision procedures (see Appendix). One prosthesis (Case 1)
was revised to a wrist arthrodesis because of recurrent insta-
bility. That patient died of an unrelated cause 2.2 years after
the index procedure. In the group of nineteen wrists with a
minimum of five years of follow-up, nine prostheses (in eight
patients) had revision surgery because of carpal component
loosening (Figs. 1-A, 1-B, and 1-C). The mean time to revi-
sion surgery for carpal component loosening was 5.5 years
(range, 2.7 to 9.3 years). Prior to revision, four of the eight
F I V E T O T E N -Y E A R O U T C O M E S O F T H E U N I V E R S A L T O TA L W R I S T
A R T H R O P L A S T Y I N P AT I E N T S W I T H R H E U M AT O I D A R T H R I T I S
patients had developed painful swelling of the wrist. Revision
surgery revealed polyethylene wear, metallosis, and carpal
component loosening in all of the wrists. There was no evi-
dence of gross radial component loosening in any wrist at the
time of revision, although resorption under the tray of the
radial component often prompted revision of the distal radial
component. With inclusion of the patient who died, ten
(50%) of twenty prostheses had been revised by the time of
the latest follow-up. The survival rates of the original implant
at five and seven years were 75% (fifteen of twenty) and 60%
(twelve of twenty), respectively (Fig. 2). Two of the wrists with
carpal component loosening were revised to wrist arthrodeses
3.5 and 5.3 years following wrist arthroplasty with use of
Steinmann pins and demineralized bone matrix for grafting.
Both wrists had clinical and radiographic evidence of fusion
one year after the arthrodesis procedure. A third wrist un-
derwent arthrodesis with a Synthes wrist fusion plate 9.3 years
after the index procedure. Less than one year of follow-up was
available for this patient. Two wrists underwent revision of the
carpal component and wrist capsule supplementation with
allograft fascia lata at 2.9 and 3.1 years after the index pro-
cedure. One of these implants was stable at the time of the
latest follow-up (Figs. 1-A, 1-B, and 1-C). The other wrist
underwent a third procedure 5.3 years after the revision, with
removal of the carpal component and fascia lata allograft
interposition.
Five wrists had insufficient carpal bone stock to support a
revision carpal component. These wrists underwent removal of
the carpal component, bone-grafting of the carpal defect with
use of allograft corticocancellous chips mixed with deminer-
alized bone matrix, and insertion of rolled allograft fascia lata
as an interposition between the carpus and the radial compo-
nent at an average of 6.7 years (range, 4.2 to 8.3 years) after the
index procedure. In two of these wrists, the radial component
was revised to a Universal 2 component (Integra LifeSciences,
Plainsboro, New Jersey) because of bone resorption around the
radial component. Despite resorption beneath the distal ar-
ticular surface of the radial implant, all implants were well fixed
in the radial shaft at the time of surgery. The stable radial
component was retained in the remaining three wrists. The
wrist capsule was carefully closed and the wrist was immobi-
lized in a cast for two to three months after the interposition
procedure. The salvage procedure alleviated pain but led to re-
duced wrist extension, decreased strength, and a resting posture
in some ulnar deviation.
There was no significant difference between the ten
revised and ten nonrevised wrists in terms of age at the time
of surgery (p = 0.92), Simmen classification (p = 0.62),
dominance (p = 0.86), or preoperative DASH score (p = 0.56).
At the time of the latest follow-up, ten of ten wrists with a
functional prosthesis had radiographic evidence of intercar-
pal fusion. Of the nine wrists that were revised because of
carpal component loosening, four did not have radiographic
evidence of intercarpal fusion at the time of revision. There
was no significant difference between these two groups (p =
1.0).
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Fig. 2
Kaplan-Meier survivorship curve for the Universal wrist prosthesis.
Discussion
W rist arthroplasty offers pain relief with preservation of
motion in patients with severe rheumatoid arthritis of the
wrist. Compared with patients who are managed with wrist
arthrodesis, those who are managed with wrist arthroplasty have
less difficulty with personal hygiene and fine dexterity that re-
quires wrist flexion7. Just a few degrees of wrist motion can result
in substantially increased digit positioning in space3. Most pa-
tients with a wrist arthroplasty on one side and a wrist ar-
throdesis on the contralateral side prefer the wrist on the side of
the arthroplasty8. Unfortunately, wrist arthroplasty has resulted
in a high number of complications and implant failures. A recent
meta-analysis of wrist arthroplasty and wrist arthrodesis in pa-
tients with rheumatoid arthritis demonstrated an overall com-
plication rate of 30% for wrist arthroplasty and 17% for wrist
arthrodesis1. In our series of patients with rheumatoid arthritis,
50% of implants had failed by the time of the latest follow-up.
Patients in our study in whom the implant did not fail
maintained a functional range of motion of the wrist. Perfor-
mance of most activities of daily living requires a relatively
modest wrist flexion-extension arc of 35° and a radial-ulnar
deviation arc of 25°9. The mean postoperative flexion-extension
arc in the present series was 62° (range, 30° to 90°), and only
one of our patients had a flexion-extension arc of <35°. The
mean postoperative radial-ulnar deviation arc in our patients
was 25° (range, 15° to 40°). There was a significant increase
in pronation postoperatively, but there was no significant im-
provement in wrist flexion or extension, radial deviation, ulnar
deviation, or supination postoperatively. The average flexion-
F I V E T O T E N -Y E A R O U T C O M E S O F T H E U N I V E R S A L T O TA L W R I S T
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extension arc of 62° and the average radial-ulnar deviation arc of
25° are similar to previously reported results with this prosthesis3.
Despite the theoretical advantages of wrist arthroplasty,
enthusiasm for this procedure has been tempered by reports of
early complications, with few reports of long-term results. Early
silicone wrist replacements were prone to breakage and osteol-
ysis10. Later nonanatomic designs such as the Meuli wrist prosthesis
have been affected by wrist imbalance, resulting in substantial
ulnar deviation and prosthesis dislocation in 8% of patients11.
Early failures of previous prostheses prompted changes
in design to improve wrist stability. The Universal prosthesis
has a large articular surface area designed to resist wrist im-
balance. Nevertheless, Menon reported that volar dislocation
(prevalence, 14%) was the most common complication in his
series of patients who were managed with the Universal pros-
thesis5. One of our patients experienced wrist instability and
was ultimately managed with revision to a wrist arthrodesis.
Carpal component loosening has been a common mode
of failure of previous wrist prostheses11,12 and was the most
commonly encountered complication in our series. Nine wrists
(45%) in eight patients underwent revision secondary to carpal
component loosening, and an additional two patients had ra-
diographic evidence of carpal component subsidence. After a
mean duration of follow-up of 6.7 years, Menon reported that
thirty-four of thirty-seven Universal wrist prostheses remained
in place, for a 92% survival rate5. None of his patients had
evidence of carpal component loosening at the time of the latest
follow-up, whereas 45% of the wrists in our study had a revi-
sion because of loose carpal components. Menon emphasized
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the importance of achieving intercarpal fusion ‘‘to [form] a
solid bony support for the carpal component and [reduce] the
chance of loosening by decreasing the toggle.’’5 A higher rate of
intercarpal fusion may have contributed to the lower carpal
loosening rate in that study, as Menon reported radiographic
evidence of intercarpal fusion in his patients but did not supply
specific numbers5. The patients in our study who had carpal
component loosening were less likely to have radiographic evi-
dence of intercarpal fusion than those who had stable prostheses,
although this difference did not reach significance.
Carpal component failure, metallosis, and polyethylene
wear debris were always seen at the time of revision surgery. A
finite-element computer model has shown that the toroidal ar-
ticulation of the Universal implant is subject to low contact areas
and high peak pressures when moved even small degrees from the
neutral position of the wrist13. Such motion in vivo could explain
the high rate of polyethylene wear. In the absence of a solid in-
tercarpal fusion, wear particles could more easily migrate distally
and contribute to osteolysis and carpal component loosening.
To address the problems of polyethylene wear and carpal
component loosening, the next generation of the Universal
prosthesis (the Universal 2 prosthesis) utilizes an ellipsoidal ar-
ticulation rather than the toroidal articulation seen in the first
Universal prostheses. Although the change in shape may appear
subtle, in a finite-element model, the ellipsoidal articulation
resulted in lower peak contact pressures and greater implant
stability than the toroidal articulation did13. In addition, the
central stem of the Universal 2 carpal component has a porous
coating to promote osseointegration. In what we believe to be the
only published study of this implant14, the failure rate was much
lower than that in our series. In that study, van Winterswijk and
Bakx reported carpal component loosening in one of seventeen
wrists after twenty to seventy-four months of follow-up.
The five-year survival of the implants in our series was
lower than that reported previously for the BIAX Total Wrist
System (DePuy Orthopaedics, Warsaw, Indiana)8,15 . Carpal
component loosening was the most common cause of failure
reported by Cobb and Beckenbaugh15, resulting in revision of
eight (13%) of fifty-seven biaxial wrist prostheses with an ad-
ditional six implants showing radiographic signs of loosening
References
1. Cavaliere CM, Chung KC. A systematic review of total wrist arthroplasty compared
with total wrist arthrodesis for rheumatoid arthritis. Plast Reconstr Surg. 2008;
122:813-25.
2. Adams BD. Complications of wrist arthroplasty. Hand Clinics. 2010;26:
213-20.
3. Radmer S, Andresen R, Sparmann M. Total wrist arthroplasty in patients with
rheumatoid arthritis. J Hand Surg Am. 2003;28:789-94.
4. Divelbiss BJ, Sollerman C, Adams BD. Early results of the Universal
total wrist arthroplasty in rheumatoid arthritis. J Hand Surg Am. 2002;27:
195-204.
5. Menon J. Universal Total Wrist Implant: experience with a carpal component fixed
with three screws. J Arthroplasty. 1998;13:515-23.
6. Zangger P, Kachura JR, Bogoch ER. The Simmen classification of wrist destruc-
tion in rheumatoid arthritis. Experience in patients with early disease. J Hand Surg
Br. 1999;24:400-4.
7. Murphy DM, Khoury JG, Imbriglia JE, Adams BD. Comparison of arthroplasty and
arthrodesis for the rheumatoid wrist. J Hand Surg Am. 2003;28:570-6.
F I V E T O T E N -Y E A R O U T C O M E S O F T H E U N I V E R S A L T O TA L W R I S T
A R T H R O P L A S T Y I N P AT I E N T S W I T H R H E U M AT O I D A R T H R I T I S
at the time of the latest follow-up after a minimum of two years.
Takwale et al. found radiographic evidence of loosening in
fourteen of sixty-three BIAX wrist prostheses after a minimum
duration of follow-up of only twelve months, resulting in re-
vision surgery in five wrists8. Symptomatic soft-tissue imbal-
ance was also noted in eleven wrists in the study by Takwale
et al.8, and seven wrists in the study by Cobb and Beckenbaugh
had radiocarpal subluxation or dislocation15.
A major limitation of the present study is the small
number of patients. Total wrist arthroplasty is not a common
procedure, and accumulating the large number of patients
necessary for detailed analysis of possible factors leading to
failure of a wrist arthroplasty prosthesis would likely require
the cooperation of multiple institutions.
In conclusion, wrist arthroplasty with use of the Uni-
versal prosthesis for the treatment of rheumatoid arthritis re-
sulted in a high rate of carpal component loosening. Our failure
rate was higher than previously reported for this prosthesis.
Carpal component loosening remains an obstacle to predict-
able good long-term survival of this implant in patients with
rheumatoid arthritis.
Appendix
A table showing the revision procedures performed on nine
patients (ten wrists) is available with the online version of
this article on our web site at jbjs.org. n
Christina M. Ward, MD
Department of Orthopaedic Surgery,
University of Minnesota,
Regions Hospital, 640 Jackson Street,
MS 11503L, St. Paul, MN 55101
Taften Kuhl, BS
Brian D. Adams, MD
Department of Orthopaedic Surgery and Rehabilitation,
University of Iowa, 200 Hawkins Drive,
01023 JPP, Iowa City, IA 52242.
E-mail address for B.D. Adams: brian-adams@uiowa.edu
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