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Predicting Failure and Complications in Total Wrist Arthroplasty; review of a 40-year experience
Eric Wagner, MD; Kapil Mehrotra, MD; Marco Rizzo, MD
Mayo Clinic, Rochester, MN

Purpose: The objective of this study was to assess the results of our institution's 40 years of experience with primary total wrist arthroplasty, identifying factors associated with failures and complications.
Methods: We reviewed 425 total wrist arthroplasties with a minimum of 2-year follow-up over a 40-year period performed at our institution from 1974 to 2013. The mean age at surgery was 57 years, BMI 27, and 72% of patients were female. The average OR time was 185 minutes, while the average tourniquet time was 132 minutes. Surgical diagnoses included 22 (5%), osteoarthritis (OA), 375 inflammatory arthritis (88%), and 86 (7%) post-traumatic arthritis (PTA). There were 8 patients with a history of traumatic wrist instability. The implants in this study included Remotions (n=31), Biax (n=159), Volz (n=33), Meuli (n=138), Universal (n=7), and Swanson (n=57). Cement was used in 357 (84%), while 36 (8%) required bone graft.
Results: At a mean follow-up of 11 years (2-35), there were 110 (26%) revision surgeries performed at a mean 5.3 years postoperatively, while there was an additional 37 reoperations. Etiologies contributing to revision surgery include loosening (n=45), component fracture (n=11), infection (n=9), wrist instability (n=31), and other (n=26). The 5, 10 and 20-year survival rates were 84%, 74%, and 63%, respectively (Figure 1). The 10-year survival rates for the inflammatory arthritis (blue) and OA or PT (red) were 76% and 63% (p=0.06), respectively (Figure 1). The Remotion (HR 1.84, p=0.16), Meuli (HR 1.5, p=0.04), and Universal (HR 2.90, p=0.12) had slightly increased risks of revision surgery (Table 1). Patients with inflammatory arthritis had a slightly decreased risk of revision surgery (HR 0.63, p=0.10). There were 9 (2%) intraoperative complications involving a periprosthetic fracture, while postoperative complications included implant loosening (n=51), dislocations (n=46), recurrent subluxation (n=21) heterotopic ossification (n=7), deep infection (n=12), tendon/ligament injury (n=18), and wear (n=17). Of the 51 components with loosening, 46 had distal implant loosening. Dislocation rates were higher in the Meuli implants (p=0.03), while lower with the Swanson (p<0.01), and Remotion (p=0.01). Loosening rates were higher in older patients, as well as those receiving the Biax implant (p<0.01), but were lower in the Swanson and Remotion implants (p<0.02).
Summary Points: This series demonstrates a 74% 10-year and 63% 20-year implant survival after total wrist arthroplasty. Improved outcomes are seen in patients with inflammatory arthritis, while worse outcomes were associated with the Meuli, Universal, and Biax implants.

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