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A-1132 Optimizing the Surgical Technique for difficult Wrist Arthroplasty Cases
Brian Adams, USA
Friday, June 15, 2018 · 9:41 a.m. · 25m 37s
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topic after the last topic um it seems quite mundane
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to um be talking about the details of
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over starter plastic which is a um certainly
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let's see how get there yet but challenge here don't know okay thank you very much for uh
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letting me come here and speak with you about uh some of the
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challenges i faced with the restart or plastic over the years
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and uh maybe give you a few tips and tricks on how to
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make this a procedure bit easier for you i think it is
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uh by definition a challenging operation and certainly um it's uh it has very
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uh i think specific and some people would say very limited indications
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but as we understand some of the pitfalls i think we can uh
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get more durable results um and consider expanding ever so slightly
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and cautiously the um uh uh the indications for the procedure and
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that's what i would like to talk to you about
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no united states we have less um implant systems available than
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a worldwide they're not all approve the united states
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you notice from the slide that there's a quite a few similarities between the different
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systems that uh are available i'm going to discuss um based on my um
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experience the um the program that i've been involved with which was the universal universal
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to it now the freedom wrist um but again you see some similarities
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what i'm going to try to present though is so where the commonalities are and how we can
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uh use those no matter which system uh you're going to be using for your patient
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these are the principal goals and i think sometimes we lose sight of these uh and
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i think each one of them are very important to get the optimum result
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you're trying to preserve as much capsule bone and the d. r. u. j. in a non rheumatoid
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uh you want to modify it ever so slightly is needed for the joy a joint and bony deformities
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don't forget to manage the soft tissue contract sure is another imbalances that uh maybe present
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because that may end up being one of your biggest problems down the road
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select the proper size of implant in order to achieve the
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motion instability that you really want to uh obtain
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you do need to worry about long term implant fixation that's uh
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basically our biggest problem i think is we look at longevity
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uh and uh the perform the precise closure uh and uh and i'll talk about that a bit more also
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so let's talk about the perfect world easy wrist as it comes in how do you manage that enough we can
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manage that properly then we can expand sort of our knowledge
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in our our techniques to the more challenging resistant
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so pretty operate planning like anything else is very important fall
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the surgical guide instructions are always remember that most
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surgeons uh don't even read it uh and have many read it the first time but then modified on
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their own i would suggest to you that very few people in this room to restore a starter plastic
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routinely so make sure that you're up on the systems
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uh nuances whatever it's specific sweater it's requirements
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use for asking me um liberally if you can to
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confirm where you're at to um avoid uh mistakes
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uh use the systems guides and and uh and i think they'll help
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you and most important allow enough time don't don't think this
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is an easy operation that you can just slip in at the end of your list uh as one more for the day
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so the exposure i think is one of the keys like anything else in surgery uh
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you need good access to the joint i think this is where people make mistakes
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and a and exposure should be versatile so you can manage the various deformities that might be present
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remember your closure is eventually going to after car so you want to retain the red
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neck along so you can use it for your uh benefit and the capsule
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so this is the reason why i prefer the e. i. a exposure that i've shown
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and um and that all allow you then to make a nice closure
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without inhibiting your motion because i think a lot of times it's talked about is wrist or the plastic doesn't give you
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the kind of motion that we're seeking and i think many times is because we're not doing the proper exposure
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had again we want to preserve the d. r. u. j. particularly in the non rheumatoid patient
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well what goes along with the exposure is also the asked the armies now and most of the
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systems that are available or trying to preserve as much of the bone as we possibly can
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so you wanna minimise the re section of the distal radius which
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preserves your ball wrist capsule and i think that's very key
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urine retain the on our side of the rest the best you can particular the t.
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f. c. and the sigmoid knowledge in as much of the overhead as you can
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and so that require some precise i'm re sections now with the freedom system
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which again is similar to the other systems i prefer the doors look uh uh justly based
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a dorsal capsule or flat broad uh to um uh obtain this sort of exposure
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uh so the most of the time the best up carpal cuts going to be through
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the proximal up for so the handmade which gives you the maximum kappa tate
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uh and some of this gay void and perhaps a residual amount of the track we term
00:05:05
but i think we found that in many cases we can actually sacrifice the track
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we term without really uh causing any problems with your ability of fixation or
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perhaps we might get in the pews a trick we chop i'm sorry a
00:05:18
piece of form impinge meant but uh that's not been proven for sure
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again they are re section of the radio should be minimise too but uh
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um retain the board capsule as well as the d. r. u. j.
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and you can see here by setting up by retaining that you can see on this um
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x. ray that you can actually maintain than the short and long revealed in a ligaments
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uh and and the side view again uh we're just trying to create a flat surface uh with
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the systems um maintaining that and you're saying that whether it be a taurus starter plastic
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or as a i have me arthur plastic which i think is an
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now a growing indication for some of the more active patients
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you have to understand what particular wrist system you're using and you want to um recognise where that
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system should be so that you can place the
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arthur plastic in a position to optimise is
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the joint alignment in in most cases what you're trying to do is restore the natural wrist
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um i access the motion which is through the key a head of the kappa tape
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and then that will restore the balance of the soft issues uh both the capsule and must feel tenderness
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so you can see here how there is some shift in the preemptive status of the rest
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uh and that can be corrected with proper component align it
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back to the natural longitudinal axis of the rest
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and again it for him the arthur plastic we're trying to achieve the same thing so that
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the natural restraint emotion hopefully um uh less uh problems with him pension that might occur
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the implant sizing i think is often under stressed uh but i think it's very important again to
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achieve the proper range of motion ah and uh to obtain the best a bony fixation
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but also about some of our biggest challenges are an axial height uh of for
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the rest and preserve the d. r. u. j. as i keep mentioning
00:07:11
so using this case is an example for a stage working box disease
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well we can look at um what should be the alignment for the at
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least for the freedom or system which i think shares with other systems
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particular you wanna be in the centre axis of the cabot take that's where
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our maximum uh optimal fixation can occur in the just the component
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uh and then the second i think a touch uh most important place
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for achieving good fixation is through the proximal poll the handmade
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so by knowing where those two um uh anatomical um positions are then
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you can uh really modify and and select your proper an implant
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and particularly that will drive the uh proximal portion then for a retain the d. r. u. j.
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yeah long term care ability a certain our biggest problems i think one of the problems uh it is
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again uh not recognising that we're dealing with the multiple uh it
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a bone joint and we want to turn it into a to bone join if we can one of
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the ways to do that is alberto you'd show this many years ago and then j. man and
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his with the proper inner carpal fusion and i think that that does achieve and uh
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i i a lower risk of just a component loosening and there's um uh and
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and maybe adding um inner carpal fusion i'm sorry by adding a um a locking screws
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we may uh in in prove our inner carpal fusion and therefore longterm durability
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so this is often i think i forgot the part of forgotten part of the operation uh
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'cause it's at the end of the procedure uh but i would recommend that uh
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you don't uh belittle this and that you actually uh recognise its importance and certainly are
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shown that in some of the long term uh in in my patient the population
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and here you can see an example that were in six months there's nice a
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fusion that's taken place underneath the carpal a plate i and i think
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uh with the locking screws maybe that helps maybe it's not necessary but certainly
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i'm getting the in a couple fusion i think can be helpful
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the closure i think it's important that we've created a closure
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that uh provides the kind of stability we want
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mostly implants have inherent stability so that maybe isn't the the biggest factor
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but over tightening the capsule can certainly limit motion and that's why
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i again prefer a a broad base flap that can be
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allow you to lengthen and you can even augment that if needed and i'll come back to that in a moment
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so what about when we're not in a perfect world which is most of the cases that we're going to actually consider restart the plastic
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we need a bit more property planning will probably going to need to modify
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the procedure a bit more than what uh that surgical guide might say
00:09:51
we're going to need to use for us could be more frequently to confirm what we're doing is is working to our advantage
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and we have to modify the um systems guides uh when needed because it may not work
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in every case and you can't be in a hurry or it's not gonna go well
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so there's lots of things that can going to contribute to defer uh difficulties and i think the
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joint surfaces were probably ready for we know there's going to be radius and carpal rotations
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carpal displacements can be a bit a bit more of a problem in channels than we might not recognise initially
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and remodel laying can really for all our orientation off so be aware of that
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other things it can be challenging our radius mel unions in the post traumatic group
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that may uh change the alignment of the axis of the radius uh as well
00:10:38
as it may actually impede our ability to put in the uh implants
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so for instance in this case where there wasn't probably a accurate rappers are are recognition uh what was
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going on in the rest and uh this is um one of my cases where uh in
00:10:55
the all or compile i'm sorry the carpet component was uh put in
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that with too much positioning our our say not proper positioning
00:11:02
within the kappa tate and so it shifted to the older side you can see then we didn't capture on the radio side
00:11:08
so alignment can be thrown off by this pretty um a
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a pretty operative deformity as a as shown here
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but the biggest challenge i think that we face is axial collapse we need room to get these implants in
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and that we need to modify the technique in order to uh i i get the
00:11:27
implant in in the proper way without sacrificing the soft tissue so axial collapse
00:11:32
i think is our biggest concern and the one where you need
00:11:35
the most properly planning you need to create enough space
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you cannot sacrifice dust billy that's our problem see what i
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maintain the carpets the best you can so you wanna
00:11:45
it reset more radius but not too much a little bit goes a long way for losing these wrists up
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and if you get nothing more from my presentation is remember
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don't sacrifice this tilly sacrifice proximity to create space
00:11:59
um and that made that require the sacrifice some of the distal
00:12:03
all no i prefer away for re section so that i'd
00:12:06
uh can retain the easy use up she's i can retain the parts of the t. f. c. c. and so forth
00:12:12
uh so um you but uh you can choose what works best for you
00:12:18
in this case uh you can see there's some changes in the um on the radius uh that uh we're
00:12:24
not totally recognise at the time of the surgery and the preamp replanting but you have to be
00:12:29
ready for those in here you can see their summer rotations are some healing within the of a just
00:12:33
a radius you recogniser some mel union here everywhere so you need to find the can now
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um and uh maybe shift the implant in slightly as was done here
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in the semi arthur plaster to her in order to put it
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in in uh in the proper position you can see the lateral film shows that it does fall the long axis of the radius
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just a radius million is gonna even be a higher um a difficulty as
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you can see in this case where there's substantial a deformity with
00:13:02
uh the typical changes that we see and in this case uh i've
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written this up in the journal of of a wrist surgery
00:13:09
his um i've uses now several times and i think it's a good
00:13:13
bail out uh that's not in any of the surgical guides
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and that is you can actually use the opposite side implant an asymmetric um
00:13:20
system and put it in upside down so this preserves the boulder capsule
00:13:25
it allows you then still the cover that just a radius and get
00:13:28
a nice closure uh without uh doing honesty ah to me
00:13:33
other mechanisms that i think we can do a utilise uh that uh been very helpful
00:13:38
for to me are these patients with the ball or sub workstation the typical rheumatoid
00:13:43
where we acted to preserve the polar caps o. can be more challenging and hear what we want is nice access to the joint
00:13:49
uh and we can uh peel off of our capsule so we can retain it
00:13:53
and then we'd have to remove that of all or lip of the radius otherwise they'll be up
00:13:58
a impinge men of the of the tendons isn't maybe even irritation the median or afterwards
00:14:04
and uh uh okay usually only the repair the capsule back to the radius
00:14:09
fortunately we don't have as much of a rheumatoid deformity group um uh to
00:14:14
uh as as challenges but these are the maximum challenging patience i think
00:14:18
in as a group uh when i look back at my group uh we needed to do
00:14:23
a fifty percent of my patience required some sorta tendon lengthening in soft tissue rebalancing
00:14:28
so in the greater deformities particular in the door so capsule the tendons
00:14:32
be ready to do that and you may need to augment
00:14:35
one of my favourite techniques for augmenting of the all three the polar caps o. torso
00:14:40
capsule and the red neck and misuse of tense or fashion lotta our craft
00:14:44
and that's worked well for me but they'll be other options for you that you might wanna use yell
00:14:51
what i see more and more questions come across is the patients that have
00:14:55
that prior surgeries and these are probably the most challenging of all because
00:14:59
you have to deal with scar tissue uh and other things but the these are the categories i think that are
00:15:04
the biggest challenges and that is the ball last obviously the p. r. c. of four quarter fusion retained
00:15:10
implants that may get in the way of where you this stems would go in the screws go for both
00:15:15
the proximal end the just the components potentially if you're going to remove them you may have been lost
00:15:20
so was then they're going to be enough bone to support your implants you're
00:15:24
obviously this is the maximum uh probably might have like a p.
00:15:28
r. c. for our re storing and the joint height a way with
00:15:32
the soft tissue problems and then there may be partial few asians
00:15:35
uh or complete fusion see even in which case your surgical guides are probably not gonna help you near as much and
00:15:41
you may have to do some of this uh on your own with a more and more of an art form
00:15:46
so the classical challenges in the p. r. c. conversion where i think the most questions come about
00:15:53
and again uh creating enough space for the implant is one of our biggest challenges
00:15:58
uh preserving the kappa tate um a is is our goal
00:16:02
uh preserving the d. r. u. j. if we can as our secondary goal and then our last challenge is what
00:16:08
we do about the uh the fact left by this cave wait if if we think that's necessary to fill
00:16:14
well one of the uh tracks that are a couple the tricks i've learned over
00:16:17
the years for this group because it is a growing group of indications
00:16:20
is by putting the m. plant in a slightly tilted another word of flatter angle
00:16:26
um you don't need to a performance much re section of the distal radius on the older side another which you
00:16:32
can still preserve the d. r. u. j. potentially and you can put the implant in more proximal a
00:16:38
again you have to worry about preserving the board capsule so you may need to
00:16:41
peel it away a little bit more but it still can be retained
00:16:46
if you need to fill the gap where the skate void was by respecting this radius properly you can then
00:16:51
use that a bone graft uh to fill in from the radius to the gap for this gave way
00:16:58
or ah oh well we don't use our so that no
00:17:02
real inflation our goal is obviously early regular motion
00:17:06
what we want to our demise the asked you integration as hard as for the noise um
00:17:11
yeah so i i think it's important to reduce the stress on the
00:17:14
rest for about eight weeks before you let them do their activities
00:17:19
doubt just close with we also need to be able to have some sort
00:17:23
of bail out if you will for um the failed toll rest
00:17:27
we know that that has a a risk we know what can happen uh and i think out
00:17:32
not having the proper a long long term plan uh is probably an appropriate for patients
00:17:39
i don't have time to discuss all the techniques for revision our trip
00:17:42
last the i think it's probably a whole discussion in itself
00:17:46
but in those cases where there's not enough bone stock available for revision then
00:17:50
i think our only option then is the conversion to a taurus fusion
00:17:54
uh the technique um i've written up that i think still works uh well uh and
00:17:59
is probably the easiest of all the procedures is to use an inter cleary
00:18:03
oh i'll graph which avoids the uh the morbidity of an autograph
00:18:08
and i think you can be done with um a can sell us femoral head telegraphed um
00:18:13
releasing the dorsal play whether or not you need to use a bone a stimulant to
00:18:18
help 'em speed up the healing i don't know but i have in most cases
00:18:22
uh so here's the uh sort of the typical um patient where you can see there's good incorporation
00:18:27
uh of the uh ally craft over time uh i now use a locking plate
00:18:32
when needed because i think these can take a uh several months to heal
00:18:36
uh in fortunately um uh the losing rate for these plates is actually very very low
00:18:43
so um i would like to thank michelle for a of inviting
00:18:47
me here um uh it's better fun ride with a
00:18:49
restart or blast the and visit him you run around with your m. g. or his m. g. it's a
00:18:54
lot of fun uh and uh again i don't want to make it sound like we started last isn't easy procedure
00:19:01
but i think as we learn more more of the techniques
00:19:04
uh to help uh get a more predictable result
00:19:08
that we can expand the indications we shouldn't be as afraid of restart the plastic is
00:19:12
we were many years ago certainly i was uh and i'm more comfortable with that
00:19:17
i agree with what we shall presented yesterday when uh he
00:19:20
talked about his life experiences that it should be
00:19:23
i thought about carefully uh but uh in the proper
00:19:27
patient with lower demands um and uh preferably elderly
00:19:32
oh and recognising their lifetime limitations that uh you can get some a nice results
00:19:37
yeah he said he would have it done in his own wrist but i can tell you is
00:19:40
building this sidewalk that goes from is a summer home all the way to the uh
00:19:44
to the c. i. think i'm not too sure i'm not sure who's gonna carry those
00:19:47
rocks for you michelle if you're gonna have a restart the plastic but uh maybe
00:19:51
you can invite me back well thank you all for uh putting up with me
00:19:54
um i'll be happy to answer any questions
00:19:57
how right on time i think
00:20:07
oh
00:20:13
yeah i heard is a question so he says uh by had much um experience or a
00:20:19
success with impacting grafting and i'm assuming you're meeting for room potentially revisions or potentially
00:20:25
in somebody that has a press up a post traumatic where there's a bone loss in
00:20:30
the mid pappas is those would be the two indications that i would see um
00:20:34
in most cases of for me revisions have banned uh at
00:20:38
the stage where there's too much bone loss for
00:20:41
impassioned grafting and i typically would recommend and i know
00:20:45
we all think it's taboo to consider cement fixation
00:20:48
but certainly some of my longest term patience now that i've still been falling headband cemented and still
00:20:54
doing well so i'm not as fearful of using some and uh for the approximate component
00:21:00
uh and uh and i think if it's done uh it selectively
00:21:04
uh even for the just the component can be effective
00:21:07
never last i think crafting just early um can be very helpful and in that case
00:21:13
if they're still retained if you will kappa tape you can use i prefer
00:21:17
only to use autograph not telegraphed an impassioned grafting uh but um i've only done
00:21:23
it a few cases approximately and that's where there's been minimal bone loss
00:21:28
just one other question is are uh are you investigate 'cause i have a patient that has got
00:21:35
some proximal component loosening with are still wise just the dust or you might have versus
00:21:40
a fairly young um remote to wait i'm here and i'm out looked into seeing whether
00:21:47
or not it was possible to get a a a custom employer with a longer
00:21:51
stan made and it's not possible to do that in just curious why in new york
00:21:57
and other upper extremity implants with the exception of the fingers you can get a
00:22:02
longer stem option for a beige and how come up in the wrists none of the non it companies actually
00:22:08
uh have that as a custom option see it would seem to me that the longer stem
00:22:13
that are perhaps more a feel of that of that real baptists might be reasonable
00:22:20
oh optional though it's not very common i guess probably reason at all
00:22:25
yeah i i think you answered your own question there with the last sentence
00:22:29
and that is um how common is that that we would need
00:22:35
how how common it would be that we would need to sort of implant
00:22:39
is what drives the companies to um agreed to make these various different
00:22:44
implants custom implants is politically unites states uh become very difficult the f.
00:22:48
d. a. is put severe restrictions on custom implants so um uh
00:22:55
what we need is really a full system i totally agree with you with different options for
00:22:59
longer stems as revisions uh are considered rather than
00:23:04
conversion to a wrist um a fusion
00:23:07
so the main reason you you answered your own question is that
00:23:10
it's less common uh then what the um uh companies
00:23:14
would like to see if you will so that they would um see some sort of profit but i think
00:23:19
uh again as we all get more comfortable uh with um uh the
00:23:24
implant systems that we use and uh i can see durable results
00:23:28
uh then i think they'll be more uh interest in that i have to uh i do a lot
00:23:33
b. r. c.s and then my question is does understand is it technically more demanding or is it
00:23:40
results are worse after the proximal kept falling out that's a great
00:23:45
question no i think if you can achieve um a proper
00:23:48
uh i insertion of the a toll road starter blast the i
00:23:52
think the results are equally good if not even better
00:23:55
then some of the other ones i think four corner fusion is actually more difficult to convert
00:24:00
uh and to get a good result 'cause they tend to have more scarring that
00:24:03
a p. r. c. um i and so i i think as we um
00:24:09
find our results and and pool results and can publish them on on p. r. c.s i think we're gonna find
00:24:15
that they actually do quite well so so p. r. c. combined with its long like it last for long
00:24:21
use well i said last yellow fifteen seventeen years say cases active people
00:24:28
so if you received is also not bad we talked with the total joint replacements so so
00:24:35
it can be like recommendation to ooh oh it is to the other ice oh um
00:24:41
i'm not sure i totally understand up but i i'm a p. r. c.
00:24:44
fan also so i'm with you i would not i would not change
00:24:48
from doing my p. r. c. two as a pry i'm sorry to restart
00:24:52
the plastic is a primary procedure instead of a p. r. c.
00:24:56
i i misunderstood you i think what what i was trying to say is that what a p. r. c. fails
00:25:02
we still have another option rather than just going straight away to a
00:25:05
complete wrist fusion and and i think we can then go another
00:25:10
hopefully ten years uh with um wrist motion rather than going what they they
00:25:14
go together so it's not a conflict if you do your c. and
00:25:19
correct so it's good it's got use yes i think that's good news they don't you think
00:25:24
one of the most awesome usually that might happen around while people have their own
