2 The procedure

2.1 Indications and current treatments

2.1.1 Wrist arthritis can result from rheumatoid arthritis, osteoarthritis, trauma or sepsis. It can cause pain, stiffness and swelling.

2.1.2 Conservative management includes the use of analgesics, non-steroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs or steroid medication. If these are inadequate, surgical treatments such as proximal row carpectomy, limited or partial carpal fusion, or total wrist arthrodesis can be used.

2.2 Outline of the procedure

2.2.1 Total wrist replacement aims to create a stable, pain-free joint with a functional range of movement.

2.2.2 The procedure is performed under either general or regional anaesthesia, usually with the use of a tourniquet. A dorsal approach is made to the wrist, and bone is removed from both sides of the joint using jigs. The prosthetic components are then implanted into the bones and may be further fixed with screws before the bearing surface is attached onto the ends of these components. Fluoroscopy may be used to confirm positions of the implants. Postoperatively, the wrist may be immobilised to promote healing, followed by physical therapy and mobilisation.

Sections 2.3 and 2.4 describe efficacy and safety outcomes which were available in the published literature and which the Committee considered as part of the evidence about this procedure. For more details, refer to the Sources of evidence.

2.3 Efficacy

2.3.1 A non-randomised controlled trial of 51 patients comparing wrist implant (27 wrists) with arthrodesis (24 wrists) reported no statistically significant difference in wrist function.

2.3.2 In a case series of 19 patients (22 wrists), mean disabilities of the arm, shoulder and hand (DASH) score improved from 46.0 points at baseline to 32.1 points at 12-month follow-up (p < 0.05).

2.3.3 A case series of 30 patients (32 wrists) reported a significant improvement in range of motion in all directions, apart from radial deviation, after 20 months. A case series of 27 patients (29 wrists) reported improvement in some movements at 4-year follow-up. Pain was significantly reduced (p ‚ȧ 0.002).

2.3.4 A case series of 25 patients (28 wrists) reported pain as absent in 72% (18/25), moderate in 20% (5/25) and severe in 8% (2/25) of patients 47 months after the wrist implant. Another case series reported pain relief in all 25 patients, although 20% (5/25) reported mild discomfort on the ulnar side (follow-up period not stated).

2.3.5 The Specialist Advisers considered key efficacy outcomes to include long-term pain relief, range of motion, functional movement and prosthesis survival.

2.4 Safety

2.4.1 The non-randomised controlled trial of 51 patients reported superficial wound complications in 22% (6/27), joint instability in 15% (4/27) and persistent paraesthesia in 4% (1/27) of patients.

2.4.2 In four case series, wrist implant dislocation occurred in 16% (5/32), 14% (3/22), 0% (0/25) and 0% (0/28) of wrists. Joint loosening was reported in 16% (5/32), 10% (3/29), 0% (0/25) and 0% (0/28) of wrists.

2.4.3 In the non-randomised controlled trial, hardware-related fracture occurred in 0% (0/27) and 4% (1/24) of patients in the implant and arthrodesis groups, respectively.

2.4.4 In the case series, implant complications or errors in implantation occurred in 32% (8/25), 19% (5/27) and 12% (3/25) of patients, and in 27% (6/22) of wrists.

2.4.5 The Specialist Advisers considered key safety outcomes to include rates of infection, dislocation, loosening, stiffness and neurovascular complications. Additional theoretical events include tendon rupture, periprosthetic fracture and complex regional pain syndrome.

2.5 Other comments

2.5.1 The Committee saw evidence on several different implants, some of which have been withdrawn. The implant design continues to evolve.

2.5.2 Most of the evidence seen by the Committee related to patients with rheumatoid arthritis.

2.5.3 The Committee noted that the National Joint Register intends to enable data collection on total wrist replacement in the future.