Wrist Hemiarthroplasty for Acute Irreparable Osteoporotic Distal Radius Fractures (DRF) in the Elderly: Preliminary Study

Introduction Freeland was the first to coin the term “irreparable DRF” in a series of young patients treated with early wrist arthrodesis. There is currently no definition of irreparable DRF in the osteoporotic elderly population.

Roux was the first to publish a series of “centrally impacted DRF” in an elderly population treated with wrist hemiarthroplasty. To the best of our knowledge.e this is the only paper related to this topic

The purpose of this paper was to provide a reproducible definition of an irreparable DRF in the elderly and to report on a series of elderly patients with irreparable DRF treated with wrist hemiarthroplasty.

Materials and Methods We used six criteria included in the PAF classification to define irreparable DRF in the elderly: AO type “C” fracture, osteoporotic bone, high extra- and intra-articular displacement scores, circumferential comminution, distal fracture line, and impacted fracture.

To be included in this prospective study the patients had: (1) to present with an irreparable DRF according to the above criteria; (2) be classified as “2-2” according to the PAF classification system, that is, nondependant elderly patient with disease and limited (but not minimal) functional needs.

A total of 14 patients (14 wrists) all female, average age 74 years (64 to 87) were included in this prospective study between April 2011 and May 2014.

The radial component of the Remotion TWA was used in 12 cases. A newly designed wrist hemiarthroplasty for fracture (“Cobra” implant, Lepine) was used in two cases. (The senior author and Lyon university have a conflict of interest concerning this new implant). A stabilized ulnar head resection was used in conjunction with the wrist implant in 12 of 14 wrists. The ulnar head could be kept intact in two cases.

A total of 11 patients had more than six months of follow-up (average 19–maximum 39) and their results are presented.

Results No postoperative infections or implant dislocations were observed. One patient was reoperated on for a lack of active ulnar deviation and a tendancy to radial inclination 18 months after the index procedure. She sustained extensor tenolysis, and ECRL was transferred to ECRB proximal to the extensor retinaculum. She felt a significant early improvement at eight weeks postsurgery. At follow-up, the average VAS pain was 1/10. Active pronation and supination were respectively 68° and 73° on average. Active wrist extension and flexion were respectively 27° and 26° on average. The average grip strength (Jamar Dynamometer) was 9,5 kg. Radiologically, there were no nonunions and bone healing around the distal part of the implant was obtained in all wrists.

Conclusion In our experience, ORIF with volar plate, for what we call “irreparable osteoporotic DRF,” is technically difficult and doomed to failure (secondary displacements, secondary tendon ruptures, etc.). There is, currently, no one-stage, satisfactory treatment for these elderly, but still somewhat active, patients. The concept of prosthetic replacement for irreparable fractures in the elderly is widely accepted for hip, shoulder, and elbow joints.

In 2011, Roux proposed a massive wrist hemiarthroplasty for complex, “centrally impacted” DRF in the elderly. In the present study: (1) we propose a combination of six criteria to reproducibly define irreparable DRF in the elderly. (2) We also report a small preliminary series of wrist hemiarthroplasties with encouraging results at short-term follow-up.

Further experience is necessary to validate the concept and the newly designed implant.