07 Jul 2011
By: JOAN CHEW
Several were offered, but it seems that only two have said okay to replacing their wrists with implants.
One of the two is retiree Tang Geok Lee, 59, who is the first in Singapore to get a wrist implant or prosthesis. The other patient, a chef in his 30s, is scheduled to get his next week.
Others preferred to have their damaged wrist joints fused, whether partially or totally, even if this might mean permanently disabling their wrists.
Doctors say money is a reason as wrist replacement can cost between $10,000 and $20,000, almost twice as much as wrist fusion.
Then there is the prospect of having to go through a second surgery, once the wrist implant wears out in about 10 to 15 years.
Dr Winston Chew, head of the hand and microsurgery section at Tan Tock Seng Hospital (TTSH), said he had offered wrist replacement to five to 10 patients in the last few years before Madam Tang. All declined.
Dr Andrew Chin, head of the department of hand surgery at Singapore General Hospital (SGH), did three such wrist replacements in Britain where he was trained.
But none of the five patients who were given this option at SGH took it up.
Dr Chin thinks the main reason for the low demand is the lack of awareness of the procedure but believes it will become the preferred choice as the technology improves. An important improvement would be the durability of the implant.
Not everyone with a damaged wrist should have it replaced.
The procedure is best for older arthritic patients who do not require heavy use of their wrists, said Dr Chew.
But if their bones have been eroded to the point where the wrist joints are unstable, or where the ligaments are no longer intact, they would not be suitable candidates for wrist replacement, he added.
Dr Lim Yi Jia, a consultant from the department of orthopaedic surgery at Changi General Hospital, thinks that wrist replacement would not be suitable for young patients who require heavy use of their wrists.
He said placing a lot of stress on the wrist will increase the chance of the implant loosening and also wear off its surfaces faster.
He performs up to 10 wrist fusion operations each year for patients whose wrists were damaged in accidents.
Similarly, Dr David Tan, consultant at the Hand and Reconstructive Microsurgery Centre at National University Hospital, carries out two to three wrist fusions each year.
These patients are usually younger ones who ended up with arthritic wrists as a result of accidents and are not ideal candidates for wrist replacement, he said.
People who opt for total wrist fusion should be mindful of its drawbacks. Some patients are unable to do simple activities like unhooking a bra and cleaning their own backs.
They will need to depend on the adjacent healthy joints to compensate for the lack of wrist motion. This is all well and good if the patient’s other joints are healthy but this is not usually the case for those with rheumatoid arthritis, who tend to have many inflamed joints.
For instance, if a rheumatoid arthritis patient can no longer rotate his shoulder and has his wrist fused as well, he will not be able to scratch his back, said Dr Tan.
Tough to replicate hand motions
Wrist replacements are newer and less established than hip and knee replacements, which have been done since the 1950s and 1960s.
It was not until the 1970s that wrist replacement surgery became popular in the West, said DrAndrew Chin, the head of the department of hand surgery at Singapore General Hospital.
It is now being performed in countries like the United States, Britain, Japan and Malaysia.
A reason for wrist replacement lagging behind hip and knee is the complexity of the surgery, said DrDavid Tan, consultant at the Hand and Reconstructive Microsurgery Centre at National University Hospital.
It is surgically more difficult to execute than hip or knee replacement, as there are more ligaments in the wrist compared to those in the lower limbs, he said.
These ligaments make it a challenge to keep the implant stable in the wrist.
Another reason is the quality of the implants, said Dr Winston Chew, head of the hand and microsurgery section at Tan Tock Seng Hospital.
Previously, implants were made of silicone, which reacted with soft tissues in the wrist, resulting in a high rate of implant failure, he said.
Dr Chin said the wrist’s motion is highly complex: Wrist movements require the wrist to bend towards the thumb, towards the little finger and move the palm towards the forearm.
The mechanism still cannot be fully recreated in an implant, even though the quality of implants has been improving.
Doctors said a wrist replacement, or wrist arthroplasty, can help a patient regain about 50 to 80 per cent of the motion he or she had, before the joint was diseased.
Artificial hips and knees also have a limited lifespan, with knee implants lasting about 10 to 15 years and hip ones, 20 years.
Patients have also been less ready to embrace wrist replacements because it is easier for patients to live with a fused wrist than a fused hip or knee.
The impact of a fused wrist is not as great as that of a fused hip or knee, which would compromise a patient’s ability to sit, squat or walk, said Dr Chew.
Data from the Health Ministry showed that from last June to May this year, public hospitals here carried out 2,134 knee replacements and 372 hip replacements.
In contrast, Madam Tang Geok Lee’s surgery last year was the first wrist replacement in Singapore.
Dr Lim Beng Hai, a surgeon with his own practice at Paragon, said the high standards of health care in Singapore may explain why wrist replacement is less sought after here than elsewhere.
He noted that the bulk of the suitable candidates for wrist replacement here is made up of accident victims.
These patients whose wrists are damaged often have their fractures fixed so well that they do not go on to develop arthritic wrists that require further surgery and implants, he said.
Email: joanchew@sph.com.sg
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