Total Wrist Arthrodesis with a Custom 3D Cage Plate and Periosteal Flap for Salvage of a Failed Wrist Arthroplasty

Abstract Salvage of a failed wrist arthroplasty can be challenging, requiring management of large bone defects, periprosthetic infection, metallosis, and osteolysis. A durable salvage operation is conversion to wrist arthrodesis, which can provide a stable, pain-free wrist with preservation of tendon function. We present a case of massive osteolysis after a failed fourth-generation wrist arthroplasty, which was converted to a wrist arthrodesis using a custom 3D-printed titanium cage and augmentation with a free medial femoral condyle periosteal flap. A 44-year-old female with juvenile rheumatoid arthritis presented with progressive pain and deformity 14 years after total wrist arthroplasty. In the first-stage extensive osteolysis and metallosis was encountered requiring tenosynovectomy, implant removal and insertion of a cement spacer. In the second stage, a custom 3D titanium cage–plate construct was filled with morselized femoral head allograft and fixed to the native metacarpals and radius with an onlay-free vascularized medial femoral condyle periosteal flap. Computed tomography confirmed bony union was achieved at 6 months with excellent flexor and extensor tendon function and a patient-rated wrist evaluation pain score of 12/50 at 16 months. Wrist arthrodesis following failed wrist arthroplasty has traditionally been achieved using femoral head allografts and iliac crest bone grafting with standard dorsal wrist fusion plates. Custom 3D titanium cage implants with allograft have been described in reconstruction of bone defects after tumor resection, trauma, and in arthrodesis. Recalcitrant upper extremity nonunions and failed wrist arthrodesis have been treated with free medial femoral condyle periosteal flaps. Custom 3D titanium cage–plate constructs with allograft bone grafting allows reconstruction of the failed wrist arthroplasty to wrist arthrodesis providing a durable solution to complex bone defects. Augmentation with a free medial femoral condyle periosteal flap provides a highly vascularized, osteogenic layer, which aids bony fusion.