Creator: Dr. Mohammed hutaif
Published: 2026-04-12T14:37:32.884263+00:00

INTRODUCTION TO WRIST ARTHRODESIS

Total wrist arthrodesis is a highly reliable, definitive salvage procedure designed to provide a stable, painless wrist for patients suffering from advanced pan-carpal arthritis, severe post-traumatic arthrosis, paralytic deformities, and end-stage rheumatoid arthritis (RA). While motion-preserving alternatives such as partial wrist fusions and total wrist arthroplasty (TWA) exist, arthrodesis remains the gold standard for achieving predictable pain relief and restoring functional grip strength.

The technique popularized by Millender and Nalebuff is particularly advantageous in the rheumatoid population. It utilizes a stout intramedullary Steinmann pin for longitudinal stability, combined with supplemental rotational control. Crucially, this technique anticipates the progressive nature of rheumatoid disease by accommodating concurrent or future metacarpophalangeal (MCP) joint arthroplasties—a common necessity in the rheumatoid hand.

INDICATIONS AND PATIENT SELECTION

The decision to proceed with a total wrist arthrodesis must be carefully weighed against the patient's functional demands, bilateral upper extremity status, and the integrity of adjacent joints.

Primary Indications

Advanced Rheumatoid Arthritis: Characterized by severe carpal collapse, ulnar translocation of the carpus, and volar subluxation of the radiocarpal joint that is not amenable to soft-tissue reconstruction or arthroplasty.
Post-Traumatic Osteoarthritis: End-stage pan-carpal arthritis secondary to scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), or intra-articular distal radius fractures.
Neurologic Deficits: Spastic hemiplegia or brachial plexus palsies requiring a stable terminal post for upper extremity function.
Failed Previous Interventions: Salvage of failed partial carpal fusions, failed proximal row carpectomy (PRC), or failed total wrist arthroplasty.

💡 Clinical Pearl: Bilateral Disease

In patients with bilateral severe wrist arthritis (common in RA), the general consensus is to fuse one wrist in slight extension (10° to 15°) to maximize grip strength, and the contralateral wrist in neutral or slight flexion to facilitate perineal care and activities of daily living (ADLs). However, the Millender and Nalebuff technique inherently places the wrist in a neutral position due to the straight intramedullary trajectory of the Steinmann pin.

PREOPERATIVE PLANNING AND BIOMECHANICS

Biomechanical Considerations

The primary goal of wrist arthrodesis is to create a solid osseous column from the radius, through the carpus, to the third metacarpal. The third metacarpal is chosen as the distal anchor because it forms the central, immobile pillar of the hand alongside the capitate.

The Millender and Nalebuff technique utilizes a straight Steinmann pin. Because the pin traverses the medullary canal of the radius, the capitate, and the third metacarpal, it dictates a neutral alignment (0° of flexion/extension and 0° of radioulnar deviation). While slight extension is biomechanically optimal for maximum grip strength, neutral alignment is highly functional and significantly reduces the extensor tendon attrition often seen with prominent dorsal hardware in extended fusions.

Preoperative Optimization

Radiographic Evaluation: Standard posteroanterior (PA), lateral, and oblique radiographs are mandatory. Assess the degree of bone stock loss, carpal subluxation, and the medullary canal diameter of the radius and third metacarpal to template Steinmann pin sizing.
Rheumatologic Management: Coordinate with the patient's rheumatologist regarding the perioperative management of Disease-Modifying Antirheumatic Drugs (DMARDs) and biologic agents to balance infection risk against disease flare-ups.

SURGICAL TECHNIQUE: MILLENDER AND NALEBUFF

The following is a comprehensive, step-by-step expansion of the Millender and Nalebuff technique for total wrist arthrodesis.

1. Positioning and Exposure

The patient is positioned supine with the operative arm extended on a radiolucent hand table.
A well-padded proximal tourniquet is applied, and the limb is exsanguinated and elevated.
Incision: Make a dorsal, straight longitudinal incision centered over Lister's tubercle, extending from the distal third of the radius to the mid-shaft of the third metacarpal.
Soft Tissue Dissection: Deepen the incision through the subcutaneous tissues, taking care to identify and protect the dorsal sensory branches of the radial and ulnar nerves.
Extensor Retinaculum: Incise the extensor retinaculum over the third dorsal compartment. Transpose the extensor pollicis longus (EPL) tendon radially. Elevate the second and fourth compartment tendons subperiosteally to expose the radiocarpal and midcarpal joints. Protect the extensor tendons of the digits and wrist throughout the procedure.

2. Joint Preparation and Deformity Correction

Meticulous preparation of the fusion bed is the most critical step in preventing nonunion.

Decortication: Using a rongeur, osteotome, and high-speed burr, curet the remaining articular cartilage and sclerotic subchondral bone from the radiocarpal joint (radius, scaphoid, lunate) and the midcarpal joint (capitate, third metacarpal base) down to healthy, bleeding cancellous bone.
Deformity Reduction: In the rheumatoid wrist, the carpus is frequently dislocated volarly and translocated ulnarly. Varying amounts of bone may require resection to achieve reduction. It is often necessary to resect the dorsal lip of the distal radius and the proximal pole of the capitate to allow the carpus to hinge dorsally into a reduced, neutral alignment.
Bone Grafting: Preserve all resected local bone. It should be morselized and used as autograft to pack the interstices of the decorticated carpus.

🚨 Surgical Warning: Over-Resection

While bone resection is necessary for reduction, excessive shortening of the carpus can lead to profound extensor tendon laxity, resulting in an extensor lag of the digits. Resect only what is necessary to achieve a tension-free reduction.

3. Intramedullary Fixation Strategy

The hallmark of this technique is the use of a stout Steinmann pin (typically 1/8 inch or 3.2 mm, depending on canal diameter).

Standard Pin Insertion:
1. Manually reduce the wrist.
2. Drill the Steinmann pin distally into the carpus, directing it out between the second and third metacarpals.
3. Once the pin exits distally, reverse the drill.
4. Drive the pin proximally through the carpus and into the medullary canal of the distal radius.
5. Cut the distal end of the pin beneath the skin, ensuring it does not impinge on the extensor tendons.
Alternative Insertion (For Concurrent/Future MCP Arthroplasty):
Rheumatoid patients frequently require MCP joint arthroplasty. A standard pin exiting between the metacarpals or occupying the entire third metacarpal canal will block the insertion of an MCP prosthesis stem.
1. Resect the third metacarpal head (this prepares the joint for later or concurrent insertion of a silicone joint prosthesis).
2. Insert the Steinmann pin retrograde through the open medullary canal of the third metacarpal.
3. Drive it proximally through the prepared carpus and finally into the medullary canal of the radius.
4. Crucial Step: Advance the pin far enough proximally into the radius so that sufficient room is left distally in the third metacarpal canal to allow for the insertion of the proximal stem of the MCP prosthesis.
5. This intramedullary trajectory inherently places the wrist in a neutral position.

4. Rotational Control

A single intramedullary Steinmann pin provides excellent longitudinal alignment and bending stiffness but offers zero resistance to torsional forces. Rotational instability is a primary cause of nonunion in this technique.

To avoid rotational deformities and micromotion, supplemental fixation is mandatory.
Technique: Drive a heavy compression staple across the radiocarpal joint (typically from the distal radius to the capitate or third metacarpal base).
Alternative: Insert one or two oblique Kirschner wires (K-wires) crossing the radiocarpal and midcarpal joints.

5. Prevention of Pin Migration

Intramedullary pins in the upper extremity have a known propensity to migrate proximally or distally due to the pistoning forces of the hand.

To prevent the Steinmann pin from shifting and protruding through the skin or into the MCP joint space, a mechanical barricade must be created.
Technique: Pack a small plug of polymethyl methacrylate (PMMA) bone cement, or a dense plug of cancellous bone harvested from the resected metacarpal head, into the distal metacarpal shaft directly over the end of the Steinmann pin.

6. Closure and Drainage

Thoroughly irrigate the wound to remove bone debris.
Pack the remaining morselized local bone graft into any residual voids within the carpus.
Retinaculum: The extensor retinaculum is typically repaired deep to the extensor tendons to provide a smooth gliding surface and prevent bowstringing, leaving the EPL transposed subcutaneously.
Skin Closure: Close the skin wound loosely. Rheumatoid patients often have friable skin and are prone to significant postoperative edema and hematoma formation. Loose closure permits ample drainage and reduces the risk of skin necrosis.
Proceed with any other necessary operations on the digits (e.g., synovectomies, tendon transfers, or MCP arthroplasties).

WRIST ARTHROPLASTY: CONSIDERATIONS AND CAVEATS

While arthrodesis is the definitive solution, Total Wrist Arthroplasty (TWA) remains an option for low-demand patients who prioritize motion over absolute stability. However, the surgeon must approach TWA with extreme caution.

Soft Tissue Balancing

The success of a wrist arthroplasty relies heavily on the integrity of the surrounding envelope. The soft tissues must be released adequately to correct preoperative contractures, the bones must be aligned correctly to restore the center of rotation, and the musculotendinous units must be meticulously balanced. Failure to achieve this balance will inevitably lead to recurrence of the deformity, eccentric loading of the implant, and early failure.

Complication Rates

Historically, and even with contemporary implants, complication rates for TWA remain high (often cited at 50% or more over long-term follow-up). Complications include:
* Aseptic loosening (particularly of the distal carpal component).
* Implant subsidence.
* Dislocation and instability.
* Periprosthetic fracture.
* Deep infection.

Due to these high failure rates, surface replacement arthroplasties must be used with strict patient selection criteria. For the high-demand patient, the manual laborer, or the patient with profound bone loss and uncorrectable soft-tissue imbalance, arthrodesis remains the vastly superior and more reliable choice.

POSTOPERATIVE CARE AND REHABILITATION

The postoperative protocol is designed to protect the soft tissues, manage edema, and provide absolute stability until osseous integration is complete.

Immediate Postoperative Phase (Weeks 0-2):
- A bulky, well-padded volar splint is applied in the operating room.
- For the first 2 weeks, a splint is preferred over a circumferential cast to avoid complications from postoperative swelling and to allow for wound inspection.
- Strict elevation of the limb is enforced.
- Immediate active range of motion (ROM) of the fingers, thumb, elbow, and shoulder is encouraged to prevent stiffness and promote venous return.
Intermediate Phase (Weeks 2-8):
- At 2 weeks, sutures are removed.
- The wrist is protected with a short-arm cast or a rigid custom thermoplastic splint.
- The extent and type of splinting depend heavily on the activities, compliance, and specific needs of the patient.
Late Phase (8+ Weeks):
- Immobilization is continued until definitive radiographic evidence of bony union is observed (typically bridging trabeculae across the radiocarpal and midcarpal joints, usually occurring between 8 to 12 weeks).
- Once union is confirmed, the splint is weaned, and progressive strengthening of the hand and forearm is initiated.

💡 Clinical Pearl: Assessing Union

Do not rely solely on the absence of pain to confirm union, as the rigid Steinmann pin can mask the symptoms of a nonunion. Serial radiographs are essential. If doubt exists at 12 weeks, a CT scan is the modality of choice to definitively assess trabecular bridging.

COMPLICATIONS AND MANAGEMENT

Despite meticulous technique, complications can occur, particularly in the immunocompromised rheumatoid population.

Nonunion (Pseudarthrosis): Occurs in 2% to 5% of cases. Risk factors include inadequate decortication, failure to utilize rotational control (staple/K-wires), and smoking. Treatment requires revision arthrodesis with structural bone grafting and potentially transitioning to dorsal plate fixation.
Pin Migration: If the PMMA or bone plug fails, the Steinmann pin may back out proximally into the forearm or distally into the MCP joint. Symptomatic hardware requires removal once solid bony union is achieved.
Wound Healing Issues: Superficial necrosis or delayed healing is common in RA patients on chronic corticosteroids. Management includes local wound care, delayed suture removal, and occasionally, local rotational flaps.
Extensor Tendon Irritation: Less common with the intramedullary technique compared to dorsal plating, but can occur if the distal pin is not cut sufficiently short or if the staple backs out.

CONCLUSION

Arthrodesis of the wrist utilizing the Millender and Nalebuff intramedullary technique is a highly effective, durable procedure for the management of end-stage wrist pathology. By providing a stable, neutral axis and accommodating future digital reconstructions, it remains an indispensable tool in the armamentarium of the reconstructive hand surgeon. Strict adherence to joint preparation, rotational control, and postoperative protection ensures high union rates and excellent patient satisfaction.

Authoritative Medical Review

This academic synthesis is based on established protocols from Hutaifortho's Operative Orthopaedics and has been medically reviewed by Prof. Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon. It is designed to assist orthopedic residents, fellows, and practicing surgeons in surgical preparation and board reviews (AAOS, FRCS, Arab Board).

Clinical Disclaimer: The surgical techniques, indications, and medical guidance detailed herein are for advanced educational purposes only. They do not supersede institutional guidelines or independent surgical judgment.

Operative Principles of Lower Extremity Arthrodesis: Ankle and Knee

Wrist Arthrodesis: The Millender and Nalebuff Technique

Key Takeaway