CPT® Code 25446

1. Indications

The procedure is indicated for the following conditions:

• Severe Arthritis - Patients with advanced osteoarthritis or rheumatoid arthritis affecting wrist function.
• Trauma - Individuals who have sustained significant wrist injuries that compromise joint integrity.
• Degenerative Joint Disease - Conditions leading to the deterioration of the wrist joint, resulting in pain and loss of mobility.
• Failed Previous Wrist Surgery - Patients who have had unsuccessful prior surgical interventions on the wrist.

2. Procedure

The procedure involves several critical steps to ensure successful arthroplasty with prosthetic replacement:

• Step 1: Incision A midline incision is made over the posterior aspect of the wrist, extending from the distal forearm to the proximal metacarpal region. This incision provides access to the wrist joint and surrounding structures.
• Step 2: Joint Exposure The radiocarpal joint and distal radioulnar joint (DRUJ) are carefully exposed. The retinaculum is released starting from the ulnar border and extending to the radial border, allowing for better access to the joint.
• Step 3: Nerve Protection The radial and ulnar nerves are protected using vessel loops to prevent any nerve damage during the procedure.
• Step 4: Resection of Carpal Bones The dorsal aspect of the joint capsule is elevated as a single layer, and part or all of the carpal bones are resected using an oscillating saw to prepare for the prosthetic components.
• Step 5: Distal Radius Preparation A guide is placed over the distal radius to determine the amount of bone to be removed. The distal radius is then excised using a bone saw or osteotome.
• Step 6: Sizing and Trial Component Placement The remaining portion of the distal radius is sized, and a trial radial component is placed to assess fit and alignment.
• Step 7: Stabilization of Carpal Bones Any remaining carpal bones are stabilized with Kirschner wires to maintain their position during the procedure.
• Step 8: Drill Hole Creation A drill hole is created in one of the remaining carpal bones or, if all carpal bones have been resected, in the third metacarpal bone. This hole is essential for centering the hand over the radial component of the total wrist prosthesis.
• Step 9: Trial Carpal Component Placement A trial carpal component is secured to the remaining carpal bones or the metacarpals, allowing for evaluation and necessary adjustments.
• Step 10: Final Component Placement The final prosthetic components are then tamped into place, ensuring a secure fit within the wrist joint.
• Step 11: Stabilization and Closure Sutures are placed through the triangular fibrocartilage to stabilize the prosthetic components. The dorsal aspect of the joint capsule is returned to its normal position and repaired with sutures. Finally, the retinaculum and overlying soft tissues and skin are repaired in layers to complete the procedure.

3. Post-Procedure

Post-procedure care involves monitoring the surgical site for signs of infection and ensuring proper healing. Patients are typically advised on rehabilitation exercises to restore mobility and strength in the wrist. Follow-up appointments are essential to assess the integration of the prosthetic components and to make any necessary adjustments to the rehabilitation plan. Pain management strategies may also be implemented to enhance recovery.