Proximal row carpectomy is an accepted motion-sparing surgical procedure for the treatment of degenerative conditions of the wrist. However, there is little information regarding the long-term clinical and radiographic results following this procedure.
Twenty-two wrists in twenty-one patients underwent proximal row carpectomy for the treatment of degenerative arthritis between 1980 and 1992. Objective and subjective function was assessed after a minimum duration of follow-up of ten years (average, fourteen years).
There were four failures (18%) requiring fusion at an average of seven years. All four failures occurred in patients who were thirty-five years of age or less at the time of the proximal row carpectomy (p = 0.03). The wrists that did not fail had an average flexion-extension arc of 72°, associated with an average grip strength of 91% of that on the contralateral side. The patients were very satisfied with fourteen of the eighteen wrists that did not fail and were satisfied with the remaining four. The patients rated nine wrists as not painful, four as mildly painful, five as moderately painful, and none as severely painful. The average Disabilities of the Arm, Shoulder and Hand score was 9 points. Radiographs revealed no loss of the radiocapitate space in three of the seventeen wrists for which radiographs were made, reduced space in seven, and complete loss of the space in seven. With the numbers available, there was no significant association between loss of joint space seen on radiographs and subjective and objective function.
At the time of long-term followup, all patients older than thirtyfive years of age at the time of a proximal row carpectomy had maintained a satisfactory range of motion, grip strength, and pain relief and were satisfied with the result. Caution should be exercised in performing the procedure in patients younger than thirty-five years of age. Although degeneration of the radiocapitate joint was seen radiographically in fourteen of the seventeen wrists, it did not preclude a successful clinical result.
Proximal row carpectomy is an accepted motion-sparing procedure for a variety of degenerative conditions of the wrist. Salvage procedures for the wrist can be classified as motion-sparing or motion-sacrificing. Total wrist arthrodesis is a motion-sacrificing procedure. Proximal row carpectomy and scaphoid excision with four-corner fusion of the capitate, lunate, hamate, and triquetrum are two commonly performed motion-sparing procedures for disorders of the proximal carpal row. The former is preferred in the absence of degenerative changes in the capitolunate joint, whereas the latter is preferred in the presence of such changes1. Proximal row carpectomy involves excision of the scaphoid, lunate, and triquetrum, which allows the capitate to settle into and articulate with the lunate fossa of the distal part of the radius. The procedure is appealing because of its technical simplicity, its generally predictable outcomes, and the ease of rehabilitation following its performance. We describe the procedure in detail.
Either regional or general anesthesia is used, according to the discretion of the anesthesiologist and the patient's wishes. At our institution, regional nerve blocks are commonly administered as an adjunctive means of providing postoperative analgesia.
The patient is positioned supine on the operating table with the affected arm abducted 90° on a hand table. A tourniquet placed high on the brachium is used to achieve a bloodless field.
A dorsal longitudinal incision, 7 to 8 cm in length, is placed just radial to the Lister tubercle (Fig. 1). Dissection is carried down to the extensor retinaculum. Cutaneous flaps are elevated radially and ulnarly, with care taken to protect the sensory branches of the radial and ulnar nerves.
The extensor pollicis longus tendon is readily identified distal to the retinaculum as it crosses obliquely over the radial wrist extensors (Fig. 2). The retinaculum overlying the third dorsal compartment is divided in its entirety with use of scissors. The extensor pollicis longus is mobilized by placing a rubber tape around its tendon, and it is retracted radially. Just deep to the extensor pollicis longus, the extensor carpi radialis brevis is identified as it runs longitudinally to insert at the base of the third metacarpal. The extensor carpi radialis brevis tendon is also retracted radially. The posterior interosseous nerve is identified beneath the extensor tendons of the fourth dorsal compartment, and a 1-cm segment is resected. The dorsal capsule is longitudinally incised parallel to the extensor carpi radialis brevis, with care taken not to score the hyaline cartilage on the head of the capitate. Capsular flaps are then reflected radially and ulnarly from the distal part of the radius. Care should be taken to stay in the subperiosteal plane and to avoid entering the dorsal compartments. Distally, the capsule is elevated from the carpus in a similar fashion so that the scaphoid, lunate, and triquetrum are visualized (Fig. 3).
The integrity of the articular surfaces of the head of the capitate and the lunate facet of the distal part of the radius is then inspected. If there is loss of cartilage or eburnated bone on either of those surfaces, a proximal row carpectomy is contraindicated and the surgeon should consider an alternative procedure such as scaphoid excision with four-corner arthrodesis or a total wrist arthrodesis. If there is any question with respect to proper identification of the carpal bones, fluoroscopy with a metal probe should be used for confirmation.
Removal of Carpal Bones
There are many techniques for removing the scaphoid, lunate, and triquetrum. We remove the scaphoid first and start by sharply dividing the scapholunate interosseous ligament. Next, a threaded 1/8-in (3.2-mm) Steinmann pin is inserted into the scaphoid in a dorsal-proximal to volar-distal fashion to serve as a joystick. In addition, small Homan retractors are placed beneath the distal pole (tuberosity) of the scaphoid to facilitate removal of the entire bone (Fig. 4). With use of sharp dissection with a #15 blade, the volar capsular and ligamentous attachments are reflected from the scaphoid and the bone is removed in one piece. Attention is then turned to the removl of the lunate and triquetrum. These bones are usually easier to remove than is the scaphoid. Care must be exercised not to damage the head of the capitate or the lunate fossa of the distal part of the radius. Again, a threaded Steinmann pin can be used as a joystick to facilitate removal of these bones.
The articular surfaces of the capitate head and the lunate fossa of the distal part of the radius must contain intact articular cartilage. The indications for the procedure include:
Scapholunate ligament disruption with radiocarpal arthritis (a scapholunate advanced collapse [SLAC] wrist)
Scaphoid nonunion with radiocarpal arthritis (a scaphoid nonunion advanced collapse [SNAC] wrist)
Kienböck disease with collapse
Unreduced perilunate or transscaphoid perilunate dislocation
Chronic perilunate dislocations
Failed silicone lunate or scaphoid arthroplasty
Osteonecrosis of the scaphoid (Preiser disease or posttraumatic osteonecrosis)
Severe flexion contractures associated with systemic diseases such as cerebral palsy or arthrogryposis
Degenerative changes on the head of the capitate or on the lunate fossa of the distal part of the radius (Fig. 7).
Inflammatory arthropathy (e.g., rheumatoid arthritis). Typically, the articular surfaces of the capitate and the distal part of the radius are involved by inflammatory arthropathies so there is a high rate of failure of proximal row carpectomy in patients with this type of disease2,3.
An active patient, especially one who is less than thirty-five years old. (This is a relative contraindication.)
Injury to the dorsal sensory branch of the radial or ulnar nerve during subcutaneous dissection.
Failure to look for and recognize loss of articular cartilage from the capitate head and from the lunate fossa of the distal part of the radius. If there is evidence of chondromalacia on those surfaces, either scaphoid excision with four-corner arthrodesis or total wrist fusion should be considered.
Iatrogenic damage to the articular surface of the capitate or the lunate fossa of the distal part of the radius during removal of the bones in the proximal row.
Damage to volar radiocarpal ligaments (especially the radioscaphocapitate ligament) during removal of the proximal row, as this could produce ulnar translation of the carpus.
AUTHOR UPDATE: There have been no changes in the surgical technique since publication of the original article.
Some surgeons prefer to remove the bones piecemeal; however, we have found that this takes longer and may risk injury to the volar capsule or ligaments. During the removal of the carpal bones, care must be taken to not injure the radiocarpal ligaments, which extend obliquely from the distal-volar lip of the radius to the carpus. The radioscaphocapitate ligament, in particular, can be visualized in the depths of the wound and must not be violated. It courses from the radius and inserts onto the capitate, thereby preventing postoperative ulnar translation of the carpus.
After the bones in the proximal row are removed, the capitate settles into the lunate fossa of the distal part of the radius (Fig. 5).
Radial Styloidectomy and Temporary Pinning of the Radius to the Distal Carpal Row
Both of these techniques were frequently recommended in the past, but neither is necessary. We do not routinely perform a radial styloidectomy. Surgeons once argued that there could be impingement of the trapezium on the styloid in radial deviation. However, anatomically, the trapezium is anterior to the styloid. Furthermore, with an overly generous styloidectomy, there is a risk of detaching the volar radiocarpal ligaments (specifically the radioscaphocapitate ligament), which could lead to ulnar translation of the carpus.
We do not pin the radius to the capitate because pinning does not offer any benefit if a good capsular closure is performed and also because pinning is associated with the risk of pin-track infection.
The capsule is closed with interrupted 2-0 nonabsorbable sutures. Biplanar radiographs are then made to ensure that the head of the capitate is seated in the lunate fossa of the distal part of the radius. No attempt is made to replace the extensor pollicis longus in the third dorsal compartment, and the retinaculum is approximated with a 3-0 nonabsorbable suture. A drain is inserted deep to the subcutaneous tissue and is removed forty-eight hours postoperatively. The subcutaneous tissue is approximated with a 3-0 absorbable suture, after which the skin is closed. A bulky dressing, extending from the fingertips to the midpart of the forearm, is applied. A volar plaster splint is molded to maintain the wrist in 10° of extension. The tourniquet is then deflated (Figs. 6-A, 6-B, 6-C, 6-D, 6-E, 6-F, 6-G, 6-H, 6-I, 6-J, 6-K).
The procedure can be done in either an inpatient or an outpatient setting. The patient returns one week after the surgery for the wound to be checked and the dressing to be changed. Digital motion is encouraged after the first dressing change. The wrist is immobilized for three weeks, after which a range of motion of the wrist is initiated, preferably with the supervision of a qualified hand therapist. The patient wears a neutral thermoplastic wrist splint, when he or she is not exercising the wrist, for an additional three weeks. If there is wrist swelling, an elastic garment can be applied for edema control. By six weeks, no immobilization is necessary and an aggressive strengthening program can be initiated. Three months postoperatively, the patient can return to full unrestricted activities.
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
The line drawings in this article are the work of Joanne Haderer Müller of Haderer & Müller ().
Investigation performed at the University of Cincinnati College of Medicine, Cincinnati, Ohio
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 2359-2365, November 2004
- Copyright © 2005 by The Journal of Bone and Joint Surgery, Incorporated