Total Wrist Fusion

Total wrist arthrodesis (TWA) is a highly effective surgical procedure used to address advanced wrist joint degeneration. It involves fusing the carpal bones to the distal radius, providing reliable pain relief, particularly for patients with severe conditions like rheumatoid arthritis, posttraumatic osteoarthritis, or cerebral palsy. While the procedure sacrifices wrist motion, it is particularly beneficial for patients who need pain relief and improved stability in the wrist but cannot benefit from other treatments, including total wrist arthroplasty.

How Common It Is and Who Gets It? (Epidemiology)

Total wrist arthrodesis is commonly performed on patients suffering from conditions like rheumatoid arthritis, posttraumatic osteoarthritis, and cerebral palsy. It is also a key salvage procedure for patients with failed wrist implants. Although wrist fusion leads to the loss of wrist motion, it is often the best option for individuals with severe wrist degeneration who are seeking pain relief and stability. Patients with conditions causing deformity, instability, or significant pain in the wrist are often the most suitable candidates.

Why It Happens – Causes (Etiology and Pathophysiology)

The primary reason for performing total wrist arthrodesis is to provide pain relief and functional stability for patients with degenerative or traumatic wrist conditions. In conditions like rheumatoid arthritis, the wrist joint becomes severely damaged, causing pain and deformity. Posttraumatic osteoarthritis develops after previous wrist injuries that lead to joint degeneration and instability. Wrist fusion can also be beneficial in cases of cerebral palsy and brachial plexus injuries, where the wrist’s range of motion is significantly compromised.

How the Body Part Normally Works? (Relevant Anatomy)

The wrist joint involves the articulation between the distal radius and the carpal bones. The carpal bones form a complex joint that allows for flexion, extension, radial deviation, and ulnar deviation. Wrist motion is critical for many daily activities, such as gripping, typing, and lifting objects. The loss of wrist motion following arthrodesis may limit these activities, but the fusion of the bones provides a stable, pain-free joint. The forearm’s rotation (pronation and supination) is preserved, which is a significant functional benefit for many patients.

What You Might Feel – Symptoms (Clinical Presentation)

Patients with advanced wrist degeneration experience chronic pain, stiffness, and loss of function. These symptoms are particularly pronounced in conditions like rheumatoid arthritis and posttraumatic osteoarthritis, where the wrist joint becomes deformed and painful. In addition to pain, patients may have difficulty with activities requiring wrist mobility, such as lifting, gripping, and fine motor tasks. A successful wrist fusion provides substantial pain relief and restores stability, even if wrist motion is lost.

How Doctors Find the Problem? (Diagnosis and Imaging)

Diagnosis of wrist joint degeneration involves a thorough clinical evaluation, including the patient’s history and symptoms. Imaging studies such as X-rays, MRI, and CT scans are crucial in assessing the extent of joint damage, deformity, and instability. In cases of posttraumatic osteoarthritis, X-rays can reveal joint space narrowing, bone spurs, and other signs of degeneration. MRI and CT scans provide more detailed images to assess soft tissue involvement and guide surgical planning.

Classification

Wrist joint degeneration and the need for arthrodesis can be classified based on the underlying condition:

• Rheumatoid Arthritis: Characterized by chronic inflammation and deformity of the wrist joint.
• Posttraumatic Osteoarthritis: Occurs after a wrist injury that leads to joint degeneration.
• Cerebral Palsy: May cause spasticity and deformities in the wrist, affecting function.
• Brachial Plexus Injuries: Result in impaired function or paralysis of the hand and wrist, which can benefit from wrist fusion.

Other Problems That Can Feel Similar (Differential Diagnosis)

Conditions like wrist tendonitis, carpal tunnel syndrome, or wrist sprains can present with symptoms similar to those of degenerative arthritis. A detailed physical examination, along with diagnostic imaging, helps distinguish between these conditions and identify whether wrist fusion is necessary.

Treatment Options

Non-Surgical Care

In mild to moderate cases of wrist arthritis or injury, conservative treatments such as rest, splints, anti-inflammatory medications, physical therapy, and steroid injections may be sufficient. However, when these treatments fail and pain and functional limitations persist, surgical intervention such as total wrist arthrodesis is considered.

Surgical Care

Total wrist arthrodesis is performed by fusing the carpal bones to the distal radius, which eliminates motion at the wrist joint. The procedure involves careful dissection and preparation of the bones, followed by stabilization using pre-contoured plates, screws, or pins. This technique reduces pain and provides a stable wrist for functional activities. Total wrist arthroplasty, an alternative procedure, involves replacing the damaged joint with an artificial implant but may not offer the same level of pain relief in cases of severe arthritis.

Total Wrist Arthrodesis Versus Total Wrist Arthroplasty

A significant area of ongoing debate in the orthopedic community is the comparison between total wrist arthrodesis and total wrist arthroplasty (TWA). While both procedures aim to relieve pain and restore function, they differ in terms of outcomes and complications. In patients with rheumatoid arthritis, total wrist arthrodesis generally provides more reliable pain relief and fewer complications compared to arthroplasty, which is associated with higher rates of revision and failure.

Studies comparing the two procedures have shown that total wrist arthrodesis is more cost-effective, with a lower risk of complications. However, wrist arthroplasty may offer functional advantages for some patients, particularly in terms of wrist motion. For instance, Nydick et al. found that patients who underwent arthroplasty had better scores on the Patient-Rated Wrist Evaluation (PRWE) compared to those who had wrist arthrodesis. Despite this, the decision between arthrodesis and arthroplasty must be based on individual patient needs, preferences, and functional goals.

Recovery and What to Expect After Treatment

Postoperative care includes immobilization of the wrist for several weeks to allow the bones to fuse. Patients are typically advised to avoid heavy lifting and extreme wrist movements during the healing period, which may take 3 to 6 months. Rehabilitation is essential to regain forearm and hand strength and function. Most patients experience significant pain relief, though they may need to adjust to the loss of wrist motion.

Possible Risks or Side Effects (Complications)

While total wrist arthrodesis is a highly successful procedure, it is not without risks. Possible complications include:

• Nonunion: Where the bones fail to fuse, requiring additional surgery.
• Ulnocarpal impaction: Caused by improper alignment during the fusion, leading to further damage to the wrist.
• Carpal tunnel syndrome: Compression of the median nerve due to changes in wrist alignment.
• Extensor tenosynovitis: Inflammation of the tendons that may develop after fusion.
• Infection: As with any surgery, there is a risk of infection at the surgical site.

Long-Term Outlook (Prognosis)

The prognosis for patients undergoing total wrist arthrodesis is generally excellent, with most patients experiencing significant pain relief and improved function. While the loss of wrist motion can limit some activities, the stability and pain-free function provided by the fusion allow many patients to resume normal daily tasks. The ability to perform tasks requiring forearm rotation remains intact, which is a significant functional benefit.

Out-of-Pocket Costs

Medicare

CPT Code 25800 – Total Wrist Arthrodesis: $174.38
CPT Code 25447 – Total Wrist Arthroplasty: $190.71

Under Medicare, 80% of the approved amount for these procedures is covered once the annual deductible has been met. The remaining 20% is typically the patient’s responsibility. Supplemental insurance plans—such as Medigap, AARP, or Blue Cross Blue Shield—usually cover this 20%, leaving most patients with little to no out-of-pocket expenses for Medicare-approved wrist surgeries. These supplemental plans work directly with Medicare to ensure full coverage for the procedure.

If you have secondary insurance—such as Employer-Based coverage, TRICARE, or Veterans Health Administration (VHA)—it serves as a secondary payer once Medicare processes the claim. After your deductible is satisfied, these secondary plans may cover any remaining balance, including coinsurance or any uncovered charges. Secondary plans typically have a modest deductible, ranging from $100 to $300, depending on the policy and network status.

Workers’ Compensation
If your wrist condition requiring surgery is work-related, Workers’ Compensation will fully cover all treatment-related costs, including surgery, hospitalization, and rehabilitation. You will have no out-of-pocket expenses under an accepted Workers’ Compensation claim.

No-Fault Insurance
If your wrist condition is the result of a motor vehicle accident, No-Fault Insurance will cover all medical and surgical expenses, including arthrodesis and arthroplasty procedures. The only possible out-of-pocket cost may be a small deductible depending on your individual policy terms.

Example
George, a 59-year-old patient with severe wrist arthritis, underwent total wrist arthrodesis (CPT 25800) and later total wrist arthroplasty (CPT 25447). His estimated Medicare out-of-pocket costs were $174.38 for the arthrodesis and $190.71 for the arthroplasty. Since George had supplemental insurance through AARP Medigap, the 20% that Medicare did not cover was fully paid, leaving him with no out-of-pocket expenses for either surgery.

Frequently Asked Questions (FAQ)

Q. How long does it take to recover from total wrist arthrodesis?
A. Recovery typically takes 3 to 6 months. During this period, the wrist is immobilized, followed by gradual rehabilitation to restore forearm and hand function.

Q. Will I regain full function of my wrist after arthrodesis?
A. Total wrist arthrodesis provides significant pain relief and stability but results in the permanent loss of wrist motion. However, patients typically regain functional ability in the forearm and hand.

Q. What are the risks of total wrist arthrodesis?
A. The main risks include nonunion (failure of the bones to fuse), complications with wrist alignment, and nerve compression, such as carpal tunnel syndrome.

Clinical Insight & Recent Findings

A recent study compared the outcomes of total wrist arthroplasty (TWA) and total wrist fusion (TWF) in patients with symptomatic end-stage wrist arthritis. The study found no significant differences in patient-reported outcomes, pain levels, grip strength, or functional scores between the two procedures at up to 24 months postoperatively.

Both groups showed improvement in disability and pain, with patients undergoing TWF reporting better pain relief, especially during loading. However, wrist motion was significantly better preserved in the TWA group, indicating that TWA may offer some advantages in certain functional activities.

Despite this, the overall outcomes were similar, suggesting that TWF remains a viable treatment option. These findings challenge the widespread use of TWA as a superior method over TWF for wrist arthritis. (“Study of total wrist arthroplasty vs fusion – See PubMed.“)

Who Performs This Treatment? (Specialists and Team Involved)

Total wrist arthrodesis is typically performed by orthopedic surgeons specializing in hand or upper extremity surgery. The procedure may require a multidisciplinary team, including physical therapists and rehabilitation specialists, to ensure optimal recovery.

When to See a Specialist?

You should see a specialist if you experience chronic wrist pain, limited motion, or instability due to arthritis, injury, or deformity. If conservative treatments fail to provide relief, surgical intervention such as wrist arthrodesis may be necessary.

When to Go to the Emergency Room?

Emergency care is necessary if you experience severe pain, swelling, or visible deformity in the wrist following an injury. In the postoperative period, seek immediate care if you experience signs of infection, such as increased redness, swelling, or fever.

What Recovery Really Looks Like?

Recovery after wrist arthrodesis involves a period of immobilization followed by physical therapy. Most patients can resume daily activities, although they must adjust to the loss of wrist motion. Forearm rotation and hand function are typically preserved.

What Happens If You Ignore It?

Ignoring advanced wrist degeneration can lead to chronic pain, instability, and further loss of function. Total wrist arthrodesis offers a solution for patients whose condition has not improved with conservative treatments.

How to Prevent It?

Preventing wrist degeneration involves managing underlying conditions like rheumatoid arthritis and protecting the wrist from repetitive trauma. Early intervention and lifestyle modifications can reduce the risk of severe arthritis and deformities.

Nutrition and Bone or Joint Health

Maintaining healthy bones and joints through a balanced diet rich in calcium and vitamin D supports wrist health and may help slow the progression of degenerative conditions like arthritis.

Activity and Lifestyle Modifications

After total wrist arthrodesis, patients should gradually return to normal activities, avoiding extreme wrist movements. Occupational modifications may be needed for individuals whose jobs involve repetitive or heavy wrist use.