Total Wrist Arthroplasty vs Arthrodesis
- End-stage wrist arthritis - from rheumatoid arthritis, primary osteoarthritis, or post-traumatic causes (SLAC/SNAC wrist, malunited distal radius fracture, scaphoid nonunion, scapholunate dissociation, Kienbock's disease) - that has failed non-operative management may need reconstruction, and the two principal options are total wrist ARTHRODESIS (fusion) and total wrist ARTHROPLASTY.
- Total wrist ARTHRODESIS is the durable, reliable option and the historical gold standard: it gives excellent, predictable PAIN RELIEF and long-term durability and is preferred for HIGH-DEMAND patients and manual workers, younger active patients, those with poor bone stock or soft tissues, infection, and as a SALVAGE procedure; the cost is loss of wrist motion, but function is usually well preserved provided the contralateral wrist and the other ipsilateral joints (fingers, forearm rotation) move.
- Total wrist ARTHROPLASTY preserves wrist 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 - long-term series report implant survival around 80% at about 11 years with high patient satisfaction - and it is best suited to LOWER-DEMAND patients who value motion.
- The CHOICE is driven by PATIENT FACTORS more than the diagnosis: arthroplasty is favoured in lower-demand patients who want to retain motion, particularly with BILATERAL wrist disease or rheumatoid arthritis with multiple affected joints (where preserving some wrist motion helps), and especially if the contralateral wrist is already fused; arthrodesis is favoured in HIGH-DEMAND/manual workers, young active patients, those with inadequate bone/soft tissue, infection, or as salvage.
- COMPLICATIONS of total wrist arthroplasty include component (especially DISTAL/carpal component) LOOSENING, instability/dislocation, periprosthetic fracture, and synovitis; it is generally CONTRAINDICATED for heavy manual labour and high-impact loading, which accelerate loosening, so adherence to activity limits is part of patient selection.
- A key advantage in the algorithm is that a FAILED total wrist arthroplasty can be CONVERTED to a total wrist ARTHRODESIS (often with bone graft to fill the defect) as a reliable salvage - so arthroplasty does not 'burn bridges' in the way that might be feared, although the conversion involves bone loss; conversely, a fusion cannot be turned back into a moving joint, so the motion-preserving option, when appropriate, should be considered first in the right patient.
- “End-stage wrist arthritis (RA, OA, post-traumatic SLAC/SNAC, Kienbock): choose ARTHRODESIS (durable, reliable, high-demand/salvage - loses motion) vs ARTHROPLASTY (motion-preserving, 4th-gen ~80% survival - loosening/instability risks).
- “Choice driven by PATIENT FACTORS: arthroplasty for lower-demand wanting motion / bilateral disease / RA / contralateral fusion; arthrodesis for high-demand/manual workers, young active, poor bone, infection, salvage.
- “TWA NOT for heavy manual labour (loosening). Failed arthroplasty CONVERTS to arthrodesis (with graft); fusion is not reversible.
Durable, reliable pain relief - the gold standard for high-demand/manual workers, young active patients, poor bone/infection, and salvage. Cost: loses wrist motion.
Preserves motion (4th-gen ~80% survival) - for lower-demand patients wanting motion, bilateral disease/RA, or a contralateral fusion. Risks: loosening/instability; not for heavy labour.
The Decision: Arthrodesis vs Arthroplasty
End-stage wrist arthritis (RA, primary OA, or post-traumatic - SLAC/SNAC, malunited distal radius, scaphoid nonunion, Kienbock's) failing non-operative care needs reconstruction. Total wrist ARTHRODESIS is the durable, reliable historical gold standard, giving predictable pain relief and best suited to high-demand/ manual workers, young active patients, poor bone/soft tissue, infection and salvage - the cost is loss of wrist motion (usually well tolerated if the other wrist and joints move). Total wrist ARTHROPLASTY preserves motion; fourth-generation implants give around 80% survival at ~11 years with high satisfaction, and it suits lower-demand patients who value motion, bilateral disease, RA with multiple joints, or a contralateral fusion. The choice is driven by patient factors (demand, bilaterality, bone stock) more than the diagnosis. TWA risks loosening (especially the distal/carpal component) and instability and is not for heavy labour; a failed TWA converts to arthrodesis.
| Feature | Arthrodesis (fusion) | Arthroplasty (TWA) |
|---|---|---|
| Motion | Lost (fused) | Preserved |
| Durability / pain relief | Durable, reliable, predictable | Improved (4th-gen ~80% at 11y) but lower than fusion |
| Best for | High-demand/manual, young active, poor bone, infection, salvage | Lower-demand wanting motion, bilateral disease, RA, contralateral fusion |
| Main downside / failure | Loss of motion | Component (distal) loosening, instability, periprosthetic fracture |
| Heavy manual labour | Tolerated | Contraindicated (accelerates loosening) |
| Salvage / reversibility | Definitive (not reversible) | Failed TWA converts to arthrodesis (with graft) |
Selection, Outcomes & Salvage
- Favour arthrodesis in high-demand/manual workers, young active patients, poor bone stock or soft tissues, infection, and as salvage - for durable, predictable pain relief.
- Favour arthroplasty in lower-demand patients who value motion, bilateral wrist disease, RA with multiple affected joints, or where the contralateral wrist is already fused (retaining some motion on one side helps daily function/personal care).
- Counsel on TWA limits: no heavy manual labour/high-impact loading (accelerates loosening); the main failure is distal/carpal component loosening, with instability and periprosthetic fracture also seen.
- Salvage: a failed total wrist arthroplasty converts to a total wrist arthrodesis (often with bone graft); a fusion is definitive and cannot be reversed - so consider the motion-preserving option first in the right patient."
The wrist-reconstruction decision should be driven by the patient - their demand, occupation, bilaterality of disease and bone quality - rather than the radiographic diagnosis alone, because the two operations make opposite trade-offs. Arthrodesis gives the most durable, reliable pain relief and is the right choice for a high-demand manual worker, a young active patient, poor bone or infection, and as salvage, but it permanently removes wrist motion. Arthroplasty preserves motion and has improved markedly with modern implants, but it must not be offered to a heavy manual labourer and carries a real rate of distal-component loosening and instability. Crucially, a failed arthroplasty can be salvaged by conversion to a fusion, whereas a fusion cannot be turned back into a moving joint - so in an appropriate lower-demand patient who values motion, the motion-preserving option deserves first consideration, with the patient counselled on the activity limits and the conversion pathway if it fails.
Evidence & Key Studies
Long-term results of a fourth-generation total wrist arthroplasty (Universal 2)
- The Universal 2 total wrist implant had 81% implant survival at a mean 11-year follow-up, with 92% of patients (very) satisfied.
- Five implants failed and were converted to total wrist arthrodesis (distal component loosening in 3, recurrent luxation in 1, recurrent synovitis in 1) at a mean of 9.2 years.
- Distal component loosening was the main failure mode, and conversion to arthrodesis was the salvage.
Total wrist arthroplasty - indications and state of the art
- Total wrist arthroplasty was historically accompanied by many failures (and rejected by most surgeons) because of the complex wrist anatomy, but newer concepts have established it as more than an individual-case option, with expanded, standardised indications.
- In 162 patients (41% rheumatoid arthritis, the rest osteoarthritis/post-traumatic causes), QuickDASH and pain improved and grip increased; range of motion decreased in rheumatoid patients but increased in others, with an average complication rate of 3.7% and no implant removals requiring secondary arthrodesis.
- Modern total wrist arthroplasty can be an equivalent treatment option in appropriately selected patients.
According to PubMed, the long-term survival (81% at 11 years) and high satisfaction of a fourth-generation total wrist implant, with distal-component loosening as the main failure mode and conversion to arthrodesis as salvage, come from the cited Zijlker series; the historical difficulty and failure of total wrist arthroplasty, its improvement with newer concepts, and the outcomes across rheumatoid and osteoarthritic/post-traumatic patients (improved function/grip, ROM decreased in RA but increased in others) from the cited Nicoloff study. The arthrodesis-versus-arthroplasty indications (demand, bilaterality, bone, RA vs OA), the motion-versus- durability trade-off, and the irreversibility of fusion are standard, well-established teaching. (See also our SLAC/SNAC Wrist and Wrist Arthrodesis topics.)
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“How do you decide between total wrist arthrodesis and arthroplasty for end-stage wrist arthritis?”
“What are the complications and salvage options for total wrist arthroplasty?”
Mnemonics & Memory Aids
WRIST
Hook:WRIST: Which patient (demand), Rheumatoid/bilateral -> arthroplasty, Industrial/manual -> arthrodesis, Survival ~80% (loosening), Transfer back impossible (fusion definitive).
The problem
- End-stage wrist arthritis: RA, primary OA, post-traumatic (SLAC/SNAC, malunion, scaphoid nonunion, Kienbock)
- Failed non-operative care -> reconstruction
- Two options: arthrodesis (fusion) vs arthroplasty
Arthrodesis (fusion)
- Durable, reliable, predictable pain relief (historical gold standard)
- High-demand/manual, young active, poor bone, infection, salvage
- Cost: loss of wrist motion (usually well tolerated); definitive/irreversible
Arthroplasty (TWA)
- Motion-preserving; 4th-gen survival ~80% at 11y, high satisfaction
- Lower-demand wanting motion, bilateral disease, RA, contralateral fusion
- Not for heavy manual labour; main failure = distal/carpal component loosening (also instability, periprosthetic fracture)
Decision & salvage
- Driven by patient demand/bilaterality/bone, not diagnosis alone
- Failed TWA converts to arthrodesis (with graft)
- Fusion cannot be reversed - consider motion-preserving option first in the right patient