Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

There's only one final talk. Now, I know we've covered a lot of information. I'm gonna talk briefly about wrist arthroplasty. It's not a topic that you need to know much about. It's a bit of a controversial topic in hand and wrist surgery. It's not used that often as often as the other, um, procedures that we use around the wrist. But it's something that I think it's worth at least having a bit of knowledge about. Um, just so you have an idea of it. So, if it's ever brought up in the exam or anything like that, you've got, you've got something to go on. So it's only, it's only a short talk. I won't go too much in depth. I realize we've covered a lot today. Um, but we'll just go through a little sort of a brief overview on wrist arthroplasty. Ok. So as I said, it's gonna be a brief talk about wrist arthroplasty. Just, just covering some of the, the overview of the procedure itself and there are a couple of little controversies about it at the moment. So most of you all know, clearly this is not as popular as, uh, total hip replacements, total, knees, total shoulder replacements. There's not many centers that are doing this and east of England is pretty much just in south end and throughout the UK, there's a handful of centers that will be doing these procedures and there will be places like Derby and right, it's fairly low volume in terms of the numbers, which is why it's not quite as popular. Um And in the wrist, we have, we have really good alternatives. Our total wrist fusion works well for people, we've got good partial wrist fusions. We've got procedures such as the proximal row carpectomy, they generally have good outcomes. So that's what the wrist replacement is up against. You don't necessarily have the, the same um outcomes you in, in the other joints itself. Um fusing a hip or knee or a shoulder would be very much uh um an underused operation, quite a rare operation to be performed nowadays, even though it might have been used in the past with risk replacements as well. Previous generations of these have had problems, especially with cutting out instability and generally poor survivorship. So they haven't been that popular indications are pretty much what you'd expect. So, generalized wrist arthritis and for most authors, when you look at what they include, they tend to include people who've got pancarpal. So that's radiocarpal and midcarpal arthritis. If it's a more sort of isolated arthritis pattern, people has have got more of a tendency to use procedures such as the P RC and the, the partial wrist fusions. But it can be used in cases of osteoarthritis more commonly in the past, especially it's been rheumatoid arthritis and the inflammatory arthritis. Uh, patients that have had a, a wrist replacement can be used posttraumatic snaps, slacks and obviously, key box patients, we do this in patients where motion preservation is still required, but generally they have to be low function. There's some controversy with this, especially with the new mo Tec implant, I say from a year, it's been out for over 10 years. Um And some of the real um big pros of the mot say that they can perform this operation in higher functioning groups. But the general view across the most, the sort of the risk surgery community and across the literature is that this operation is fault for low function patients contraindications. Um As you can imagine, poor motor function, there's no point putting in a wrist replacement if you can't move the wrist afterwards, active sinusitis. As I've said, a lot of our patients that we we will do this in have inflammatory arthritis and with active sinusitis, people will have very poor bone quality and these, these implants will simply just cut out poor bone stock. You need somewhere to be able to put the implants in. Um So people who have very end stage arthritis with a lot of deformity may not be suitable for this. And as I've said we want low function patients. So it's contraindication in high demand patients. And it's also contra indicated in, in patients who may be low demand because of their inflammatory arthritis. But have a real reliance on weight bearing through the wrist using walking aids. They're probably not gonna be suitable patients for doing a wrist replacement and would probably benefit. I would have thought on a a most of these cases for a total risk fusion, a surgical technique. As you can imagine this, this varies between implants, but just to give you a quick flavor for what we, we would normally do, most of the implants were going through a dorsal approach. All in fact, all unwell all that I know of and the common approach to the dorsal aspect of the wrist is identifying E PL and opening up the third compartment. And we've talked about the the different compartments, especially just in Lucy's talk there. And then from the third compartment, you'll elevate the first and the second towards the radial direction and the 4th and 5th towards the ulnar direction away from the distal radius. And that'll give you access um to the distal radius and to the wrist joint itself. Often the at capsulotomy performed. But there may be various patterns of this. And for most of these implants, uh P RC is performed so the lunate will be excised. First of all, depending on the implant, it might just be the lunate all the rest of the proximal row at this point. But all the implants tend to use some form of jig to make the cuts like for using in a knee replacement after guide wire placement. And commonly the guide wires will be placed into the distal radius and into the third metacarpal via the capitate. A real problem that we have with wrist replacements is is a real lack of registry data. All the theories that we have and all the evidence we have is self reported, small series of patients, I'll cover a few of these in a minute. Um But the total wrist arthroplasty is not recorded on the N JR and only these two implants are on the ODP website when you look to find the ratings and these are the mot um implants which have been out for a few years now, but there have been a whole array of other implants that have been used previously. So II think personally this is a, this is a big issue with wrist replacements and something that, that needs to be addressed. As I said, the older designs have had all sorts of problems with cutting out and instability. So we've now arrived at what we call the fourth generation designs. So these are modern implants. They have a porous coating, especially on the distal radius and the the the distal stem as it goes up into the carpus and they rely on bony ingrowth rather than cement because cement hasn't, hasn't really worked to be quite honest in the, in, in the older implants. Um And the previous implants would have had fixation into the metacarpals and been relying on that. Whereas these fourth generation designs rely on fixation into the carpus. And then there's usually a screw that goes into the index metacarpal. So that's what they found on the biomechanical studies that's more likely to give them stability. So, implants you may have heard are the remotion, the universal to and the freedom. So the first implant here that you can see with the picture and the X ray is the remotion and the one to the right of the slide is the universal two which has now been superseded by the freedom. And I'll mention that in a moment. So I if you are going to mention wrist replacements, I try to avoid getting into that conversation during your exam. But probably the freedom is one of the implants that you would mention has been the sort of the newer design and the freedom itself has superseded the universal too. But if we look at the universal too, cos it's been a very uh widely used implant is relatively widely used over the last sort of nearly 20 years or so. And um a big series and this goes to show how big the series actually are for wrist replacements. You can imagine how many hip and knee arthroplasties are performed in the country. Every year. This was a series from Glasgow, um over eight years and it was 48 wrists in 46 patients, um with a mean of 63.5 years. And as you can see, for, for most of their patient group, the vast majority of these are inflammatory arthritis patients. But you can also see this is a minimum three years follow up which a as we know is not great in terms of um, implant data. And we certainly would be very wary about using hip and knee replacements that only had a minimum of three years days for most people would want something with a little bit. We'd be looking for things with o depth ratings of 10 years or more. However, they did find looking at all their patients that the dash scores did improve, significantly range of movement was maintained. You see, it's, it's not normal and most of the, the literature will say that it was never going to improve beyond what these patients already have, but it will maintain some range of motion. However, 24 of these 48 implants displayed loosening. And as I've said, this is quite a short follow up and six of these were revised for the loosening. Overall, there were 13 complications including acute median neuropathy, loosening, tender, rupture, periprosthetic joint infection and wound infection. Interestingly, median neuropathy has been described if the bone cuts that are taken when you implant the uh the wrist arthroplasties, the bone cuts are not, not um not big enough. So what ends up happening is you, you basically jack out the joint and you stretch the median nerve that can be an acute problem. However, for this series, this was not the cause. And what they found is when they did the carpal tunnel decompressions is that there was a build up of sinusitis which just actually penetrated the var capsule and irritated the nerve that way. So in this um group 48 risks, there were seven revisions overall. And as I said, six were revised for losing and one was for pain. So overall, there's a 21% reoperation rate which is quite high. Now, the freedom uh title was Arthroplasty has taken over from the Universal two and there has been a a series from writing and published um quite recently and for this one, there's no medium or long term data series. So again, this is a short term series from writing some 13 implants in 12 patients. One of these patients wasn't included, vast majority of these were female and vast majorities with rheumatoid arthritis with a mean of 59 years. So it's only a mean three years follow up. So again, it's not, it's not great data for the implant in terms of follow up. Um And in these, in this group of 12 that were followed up, one case was revised, they talked about carpal lucency in a third of these patients. Um And there was uh another great talk at the recent B SSH, which was actually looking at well how significant this is in wrist arthroplasty. And this is a question that's really up in the mo up in the air at the moment with wrist arthroplasty, that lucency is something that's quite commonly seen. But they, they can't, there's a lot of these patients who are um clinically doing very well but have lucency on the X ray. And the significance of this is not quite yet defined. Again, wrist movement was preserved but not significantly improved. And these patients are all low demand patients, they're provided with effective pain relief, but they're low demand and it keeps some wrist movement. The motc is the, the sort of slightly different implant as I showed you a picture of that um earlier, I'll just just nip back just so you can um remember it. So as you can see, it's a ball and cup design. Now, the the thicker stem goes into the distal radius and the thin stem goes up to the capitate into the third metacarpal and it just acts as a ball and socket joint in the middle of the wrist. Importantly, this can't be used on rheumatoid patients. And that's because the stability isn't there that if patients have poor soft tissues, their wrist will be completely unstable with, with a ball and socket joint. So these are, these are limited to the noninflammatory patients. And the recommendation from the designers of this implant is that people should be doing 10 a year for the first two years. And most of the literature will tell you that there's a learning curve for total risk arthroplasty. Now, personally, I don't see anywhere near this number of patients in my clinic who I think would be suitable for wrist replacement. I may see one or two a year um and some years zero. So that's why really the these patients have to be sent to somebody who's doing a higher volume and shouldn't, people should not be doing these just once or twice a year. Now, there was a, a Multicenter International Series which reported 10 years of data and that's uh 100 and 76 motx in 100 and 59 patients, 100 and 71 including the final analysis. The MOEC as I've showed in the previous picture, there was two implants, one's metal on metal, one's metal on poly and they didn't find any significant differences in complications or revisions between the articulations. Interestingly because of the previous issues that have happened. Metal on metal is not available in the States. And the mean follow up is 5.8 years for this. And that's yeah, we'll talk, we're talking about reported follow ups between 18 months and 12 years. So again, for implants for arthroplasty, that's not not a massive follow up. But as you can see from the series short data. But in five years that the Kaplan my survivability code looks fairly reasonable. But if we look at the overall complications, there were 33 complications in this group and six of them, they felt to be avoidable. So again, we're talking about learning curves here, 30 of them potentially avoidable and seven were unpreventable. So again, these are, these are uh implants that have a relatively high risk of uh complication and maybe a lot of that is attributed to the fact that people might not be doing huge numbers of these. And this was uh a systematic review now from nearly 10 years ago by David Joe who's um currently a consultant up in Norwich. Um and that systematic review which gets quoted on a lot of talks about um wrist arthroplasty shows that the total wrist arthroplasty will, will preserve some motion. But it's important you're not giving people, you couldn't promise to give people more motion than they already have functional scores generally improved. However, complications were higher compared to arthrodesis. Careful, careful patient selection is required and there was no good evidence at that time to support widespread use. And I think from the, looking at the literature that the same, the situation remains the same 10 years later. C as I said, overview of wrist arthroplasty, just so you've got some knowledge about it, but generally these are low numbers, it's a low number procedure and it should be done in select centers to ensure a reasonable volume. And that's the girth principles that we all know from the rest of orthopedics. It's known that there's a learning curve associated with these implants. Patient selection is crucial. And even though some people may say that they can deal with higher function, uh higher functioning patients. The the general consensus at the moment is that patients undergoing this should be low function and really registry data is required, we should have these on the NJ R and we should have um um compulsory outcomes reported for these so that we can collect real data and and see who these implants would be good for. And it may be possible in the future that we get to use these more as implants improve. But at the moment, they still um they still um require very careful patient selection. And for the vast majority of patients that we see with end stage risk, arthritis, a fusion, APR C or a, a partial carpal fusion is gonna be the, the option that we go for. OK. Any questions about that, it's a bit of a whiz through and I don't do wrist replacements myself. So I don't claim to be an expert on them, but generally that is the consensus at the moment. Um um So just remember if you're going into the um don't jump in with wrist replacement as one of the one of your answers straight away, but have a an awareness of it because if it does get brought up, you want to be able to say something about it. Ok. Well, if that's no more questions, then we'll close the session, obviously, thanks to all our speakers that we've had over the last three sessions. Um Mr Hopkinson Wooley, Mr Johnson, Lucy Mailing Maria, um and Mia of course, um and all you guys who've helped out Alex and Charlie for helping run the sessions. Um And hopefully I'll see some of you guys next week in Cambridge.