Total Wrist Replacement: State of the Art, Challenges and Pitfalls: A Comparative Review

Abstract

Background: Total wrist replacement (TWR) as motion-preserving procedure continues to be critically
discussed in the literature, although the complication rates have been significantly reduced with the
current 3rd generation designs compared with older types. Possible reasons for this are often also a lack
of knowledge about the currently available evidence, the complication management, and the lack of
practical experience by the surgeons.

Methods: Based on an extended review of literature and own experience, the aim of this article is to
give practicable insights for the clinician on: (1) biomechanical fundamentals, (2) differences in design,
survivorship and functional outcome between the recent types, (3) possible pitfalls, and (4) failures and
salvage options.

Results: The goal of TWR is that the overall wrist motion is maintained respectively improved despite
it works with a locked midcarpal joint. Regarding survivorship and functional outcome the Maestro is
(was) being superior over all other types that is (was) based on features in design. There is no scientific
evidence as to why the Maestro was withdrawn from the marketplace by the company. For assessment
of instability and/or impingement the use of dynamic radiographs is recommended. The problem
of TWR is unchanged failure of the carpal components primarily based on mechanical dysbalance,
and secondarily followed by metal and/or polyethylene wear, but surgical revision of asyptomatic
periprosthetic osteolysis without safe radiagraphic signs of loosening is only required in not more than
20% of cases. For a failed TWR, revision TWR or conversion to total wrist arthrodesis are viable
salvage options.

Conclusion: The knowledge about recent evidence and features in design of the available types, exact
assessment of radiographic findings, presence of technical skills by the surgeons, and observance of the
patient's expectations are the basic requirements for a successful TWR.