Wagner Eric R, Srnec Jason J, Mehrotra Kapil, Rizzo Marco
Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
Clin Orthop Relat Res. 2017 Nov;475(11):2694-2700. doi: 10.1007/s11999-017-5442-2. Epub 2017 Jul 7.
Total wrist arthroplasty (TWA) can relieve pain and preserve some wrist motion in patients with advanced wrist arthritis. However, few studies have evaluated the risks and outcomes associated with periprosthetic fractures around TWAs.
QUESTIONS/PURPOSES: (1) What is the risk of intraoperative and postoperative fractures after TWAs? (2) What factors are associated with increased risk of intraoperative and postoperative fracture after TWAs? (3) What is the fracture-free and revision-free survivorship of TWAs among patients who sustained an intraoperative fracture during the index TWA?
At one institution during a 40-year period, 445 patients underwent primary TWAs. Of those, 15 patients died before 2 years and 5 were lost to followup, leaving 425 patients who underwent primary TWAs with a minimum of 2-year followup. The primary diagnosis for the TWA included osteoarthritis ([OA] 5%), inflammatory arthritis (90%), and posttraumatic arthritis (5%). Indications for TWA included pancarpal arthritis combined with marked pain and loss of wrist function. The mean age of the patients was 57 years, BMI was 26 kg/m, and 73% were females. Six different implants were used during the 40-year period. Mean followup was 10 years (range, 2-18 years).
Intraoperative fractures occurred in nine (2%) primary TWAs, while postoperative fractures occurred after eight (2%) TWAs. After analyzing demographics, comorbidities, and surgical factors, intraoperative fractures were found to be associated with only age at surgery (hazard ratio [HR], 1.10; 95% CI, 1.03-1.20; p = 0.006) and use of a bone graft (HR, 5.80; 95% CI, 1.18-23.08; p = 0.03). No factors were found to be associated with increased risk of postoperative fractures; specifically, intraoperative fracture was not associated with subsequent fracture development. The 5-, 10-, and 15-year Kaplan-Meier survival rates free of postoperative fracture were 99%, 98%, and 95%, respectively. The 5- and 10-year revision-free survival rates after intraoperative fracture were 88% and 88%, respectively, compared with 84% and 74% without an intraoperative fracture (p = 0.36). Furthermore, the survival-free of revision surgery rates for aseptic distal loosening at 5 and 10 years were 88% and 88%, respectively, compared with 93% and 87% without a fracture (p = 0.85).
Intraoperative fractures occur in approximately 2% of TWAs. These fractures do not appear to affect long-term implant survival or risk of fracture. Patient age and the need for bone graft were the only factors in the risk of intraoperative fractures. Postoperative fractures also occur in 2% of TWAs, but often result in revision surgery.
Level III, therapeutic study.
全腕关节置换术（TWA）可缓解晚期腕关节炎患者的疼痛并保留部分腕关节活动度。然而，很少有研究评估TWA周围假体周围骨折的风险及预后。
问题/目的：（1）TWA术后术中及术后骨折的风险是多少？（2）哪些因素与TWA术后术中及术后骨折风险增加相关？（3）在初次TWA术中发生骨折的患者中，TWA的无骨折及无翻修生存率是多少？
在一家机构的40年期间，445例患者接受了初次TWA。其中，15例患者在2年内死亡，5例失访，剩余425例接受初次TWA的患者进行了至少2年的随访。TWA的主要诊断包括骨关节炎（[OA]5%）、炎性关节炎（90%）和创伤后关节炎（5%）。TWA的适应证包括全腕关节炎合并明显疼痛和腕关节功能丧失。患者的平均年龄为57岁，体重指数为26kg/m，73%为女性。在40年期间使用了6种不同的植入物。平均随访时间为10年（范围2 - 18年）。
9例（2%）初次TWA术中发生骨折，8例（2%）TWA术后发生骨折。在分析人口统计学、合并症和手术因素后，发现术中骨折仅与手术时年龄（风险比[HR]，1.10；95%置信区间，1.03 - 1.20；p = 0.006）和使用骨移植（HR，5.80；95%置信区间，1.18 - 23.08；p = 0.03）相关。未发现与术后骨折风险增加相关的因素；具体而言，术中骨折与随后的骨折发生无关。术后无骨折的5年、10年和15年Kaplan - Meier生存率分别为99%、98%和95%。术中骨折后5年和10年的无翻修生存率分别为88%和88%，而无术中骨折的分别为84%和74%（p = 0.36）。此外，无菌性远端松动的无翻修手术生存率在5年和10年分别为88%和88%，无骨折的分别为93%和87%（p = 0.85）。
约2%的TWA术中发生骨折。这些骨折似乎不影响植入物的长期生存或骨折风险。患者年龄和骨移植需求是术中骨折风险的唯一因素。2%的TWA术后也会发生骨折，但通常会导致翻修手术。
三级治疗性研究。
