Total Wrist Arthroplasty vs Arthrodesis (Wrist OA Reconstruction)

The problem. End-stage wrist arthritis comes from rheumatoid arthritis, primary osteoarthritis or post-traumatic causes: SLAC or SNAC wrist, a malunited distal radius fracture, scaphoid nonunion, scapholunate dissociation and Kienbock's disease. When it has failed non-operative management it may need reconstruction, and the two principal operations are total wrist arthrodesis and total wrist arthroplasty.

Two opposite trade-offs. Because the operations trade in opposite directions, the choice is driven by patient factors (demand, occupation, bilaterality of disease, bone stock and quality) more than by the radiographic diagnosis.

Arthrodesis. Total wrist fusion is the durable, reliable option and the historical gold standard. It gives excellent, predictable pain relief and long-term durability, and the price is the permanent loss of wrist motion. Function is usually well preserved provided the contralateral wrist and the other ipsilateral joints (fingers, forearm rotation) move.

Arthroplasty. A total wrist replacement preserves motion, which matters for activities of daily living and personal care. Design has historically been difficult because of the complex wrist anatomy, with many early failures, but fourth-generation implants have improved durability. It is best suited to lower-demand patients who value motion.

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Who is fused. Arthrodesis is favoured, for its durable and predictable pain relief, in these situations:

• High-demand patients and manual workers
• Young, active patients
• Poor bone stock or soft tissues
• Infection
• As a salvage procedure

Who is replaced. Arthroplasty is favoured in lower-demand patients who want to retain motion, particularly:

• Bilateral wrist disease
• Rheumatoid arthritis with multiple affected joints, where preserving some wrist motion helps
• A contralateral wrist that is already fused

Counselling the limits. Total wrist arthroplasty is generally contraindicated for heavy manual labour and high-impact loading, which accelerate loosening, so adherence to activity limits is part of patient selection. The main mode of failure is component loosening, especially of the distal (carpal) component. Instability or dislocation, periprosthetic fracture and synovitis are the other complications.

The exit strategy. A failed arthroplasty can be converted to a total wrist arthrodesis, often with bone graft to fill the defect, as a reliable salvage. The conversion involves bone loss, but arthroplasty does not "burn bridges" in the way that might be feared.

Limited salvage comes first. In SLAC or SNAC wrist, scaphoid nonunion or Kienbock's disease the arthritis is initially confined to part of the wrist, so a limited, motion-sparing ladder comes before either total procedure. The option is chosen by which joints are spared:

• Wrist denervation (posterior and anterior interosseous neurectomy): a simple, motion-preserving option for pain in a patient who accepts ongoing degeneration
• Proximal row carpectomy (PRC): excises the proximal carpal row so that the capitate articulates in the lunate fossa; suits SLAC/SNAC with a preserved capitate head and lunate fossa
• Scaphoidectomy and four-corner fusion: for SLAC/SNAC where the capitate head is worn; removes the scaphoid and fuses the capitate, lunate, hamate and triquetrum
• Radioscapholunate fusion: a partial fusion for isolated radiocarpal arthritis, such as an intra-articular distal radius malunion, that preserves midcarpal motion

When the total procedures apply. Total arthrodesis or arthroplasty is reserved for pan-carpal disease, involving both the radiocarpal and the midcarpal joints, or for failed limited salvage. The same demand and bilaterality logic then chooses between them. The limited salvages are developed in proximal row carpectomy, four-corner fusion, SLAC wrist, SNAC wrist and Kienbock's disease.

How much motion is enough. Most activities of daily living are achievable within a relatively small arc, classically described as around 40 degrees of extension, 40 degrees of flexion and a combined 40 degrees of radioulnar deviation (Ryu). Palmer described an even smaller functional arc for everyday tasks, roughly 5 degrees of flexion to 30 degrees of extension. This is why losing wrist motion to a fusion is often well tolerated.

The position of fusion. A total wrist fusion is set in the position that optimises grip and function: around 10 to 15 degrees of extension with slight ulnar deviation (neutral or slight extension), the strongest position for power grip. Position and technique are detailed in wrist arthrodesis.

What arthroplasty preserves. A total wrist arthroplasty typically gives a functional but reduced arc, often in the region of 50 to 70 degrees of flexion-extension, enough for the tasks that a fused wrist makes awkward; the rheumatoid head-to-head below tests how reliably it does so. Implant designs, generations and the technique of replacement are covered in wrist arthroplasty.

The bilateral argument. The tasks a fused wrist most compromises are those needing wrist flexion: perineal and toileting care, and reaching into tight spaces. A patient with bilateral disease, or an already-fused contralateral wrist, gains the most from preserving motion on at least one side, which is exactly why arthroplasty is favoured there.

A recommendation to choose between two operations is only as good as the head-to-head data behind it, and the figure most often quoted for modern arthroplasty rests on a smaller base than its confident repetition suggests.

The single-implant figure. The widely quoted 81 percent survival at a mean of 11 years comes from a single retrospective series of 25 patients (26 wrists) with one implant. The surviving wrists had only moderate function scores (PRWHE 44, QuickDASH 41), even though 92 percent of patients said they were satisfied.

The registry picture. National registry data on 189 primary wrist replacements are more sobering and more generalisable: 78 percent survival at 5 years (95 percent CI 70 to 85) and 71 percent at 10 years (CI 59 to 80). Differences between designs are large, from 85 percent at 5 years for one prosthesis to 57 percent for another, so quote a range and name the implant rather than a single flattering number.

Head to head in the rheumatoid wrist. The most-cited systematic review compared 18 arthroplasty studies (about 500 procedures) with 20 fusion studies (over 800 procedures) in rheumatoid wrists. Fusion gave more reliable pain relief, arthroplasty had higher complication and revision rates, and satisfaction was high in both. Its sharpest finding is easy to miss: of 14 studies reporting motion, only three showed a mean active arc within the functional range, so the motion an arthroplasty preserves is not reliably the motion that makes a difference. The authors concluded that the data did not support widespread arthroplasty for the rheumatoid wrist.