Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

329. Proximal Row Carpectomy

Alex M. Meyers, Mark E. Baratz, and Thomas Hughes

DEFINITION

images Proximal row carpectomy (PRC) involves removal of the proximal carpal row (scaphoid, lunate, and triquetrum).

images PRC has been described as a treatment option for a number of pathologic conditions:

images Scaphoid nonunion advanced collapse (SNAC) wrist

images Scapholunate advanced collapse (SLAC) wrist

images Kienböck disease

images Chronic or missed perilunate dislocation

images Scaphoid osteonecrosis or Preiser disease

images Wrist deformity or contracture

ANATOMY

images The proximal row of the wrist consists of three bones: scaphoid, lunate, and triquetrum.

images The proximal row moves as a single unit through intercarpal ligamentous attachments and bony congruity.

images The proximal row flexes with radial deviation and extends with ulnar deviation.

images The capitate, in the distal row, articulates with the lunate.

images The proximal capitate articular surface is relatively, although not completely, congruous with the lunate facet of the radius.

PATHOGENESIS

images A number of pathologies may eventually result in wrist degeneration requiring PRC. Patients experience progressive pain and limitation in motion, often requiring PRC to improve symptoms.

images SNAC and SLAC

images Stage I: Degenerative changes along the radial half of the radioscaphoid articulation. In SNAC wrists, the degenerative changes are typically limited to the articulation between the distal scaphoid fragment and the radius.

images Stage II: Degenerative changes involving the entire radioscaphoid articulation (FIG 1). In SNAC wrists, the articulation between the proximal scaphoid fragment and the radius is preserved, and instead stage II degeneration occurs in the scaphocapitate joint.

images Stage III: Degenerative changes at the capitolunate joint. The radiolunate joint is spared.

images Kienböck disease

images Stage I: Normal plain radiographs with wrist pain and positive MRI finding

images Stage II: Sclerosis without collapse of the lunate

images Stage IIIa: Lunate collapse without instability

images Stage IIIb: Lunate collapse with carpal instability

images Stage IV: Fixed carpal instability with pan-carpal degenerative changes

images Missed perilunate dislocation

images Scaphoid osteonecrosis (Preiser disease)

images Congenital or spastic wrist and hand flexion contractures may be so severe that a PRC allows deformity correction that tendonlengthening procedures alone would be unable to correct.

PATIENT HISTORY AND PHYSICAL FINDINGS

images It is important to seek the cause of the wrist degeneration.

images Mechanical wrist pain is aggravated by use and relieved by rest. The history must support this for the proposed treatment to be successful.

images The history defines the patient's symptoms, level of severity, and progression over time, as well as any previous attempts at treatment.

images Limited and painful wrist motion with diminished grip strength tends to be a common denominator regardless of the initial source of pathology.

images Normal range of motion: wrist extension, 70 degrees; wrist flexion, 75 degrees; radial deviation, 20 degrees; ulnar deviation, 35 degrees

images Normal grip strength: Mean grip for males is 103 to 104 for the dominant extremity and 92 to 99 for the nondominant extremity. Mean grip for females is 62 to 63 for the dominant extremity and 53 to 55 for the nondominant extremity.

images Radioscaphoid joint line tenderness on palpation implies radioscaphoid arthritis.

images Swelling over the dorsal and dorsoradial aspects of the wrist can be associated with radiocarpal and intercarpal arthritis. Most often dorsoradial wrist swelling will be visible and palpable in cases of SLAC and SNAC.

images

FIG 1  Intraoperative photograph showing wear at the dorsal half of the scaphoid fossa seen with SLAC wrist, as indicated by the black arrow. Cartilage integrity is preserved in the lunate fossa, as indicated by the red arrow.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Plain radiographs assist with making the underlying diagnosis (eg, SNAC wrist, SLAC wrist, Kienböck disease).

images The surgeon should evaluate the articular facets and surfaces, specifically of the proximal capitate and lunate facet of the radius.

images The surgeon should evaluate for other sources of limited wrist motion, diminished grip strength, and pain (eg, thumb carpometacarpal arthritis, scapholunate instability without degenerative changes, fracture).

images Although MRI may assist in making the underlying diagnosis (eg, Kienböck disease, Preiser disease, scaphoid avascular necrosis) and evaluating the joint surfaces, it is rarely used.

DIFFERENTIAL DIAGNOSIS

images Triangular fibrocartilage complex or distal radioulnar joint pathology

images Extensor carpi ulnaris, flexor carpi ulnaris, flexor carpi radialis tendinitis

images De Quervain tenosynovitis

images First carpometacarpal arthritis

images Scapholunate or lunotriquetral instability without degenerative changes

images Midcarpal arthritis

SURGICAL MANAGEMENT

images Regardless of the initial source of pathology when considering treatment via PRC, the integrity of the articular cartilage and the congruity between the proximal capitate and the lunate facet of the radius are critical. This determination is often made intraoperatively.

images Indications

images SLAC and SNAC wrist degeneration: stage I, II, or III (only if the degenerative changes at proximal capitate are limited to thinning or minor fissuring)

images Kienböck disease (stage III and IV)

images Chronic or missed perilunate dislocations

images Scaphoid osteonecrosis (Preiser disease)

images Wrist deformity or contracture

images Contraindications

images Active inflammatory arthritis (rheumatoid arthritis). PRC may be used for inflammatory arthritis patients with “burnt-out” disease (those without active tenosynovitis).

images Advanced degenerative changes at the proximal articular surface of the capitate or lunate facet of the radius

images Ulnar carpal translation or subluxation of the radiocarpal joint

images Relative contraindications

images Heavy laborers

images Young (less than 35 years) active patients (controversial)7

Preoperative Planning

images Plain radiographs of the wrist should be reviewed. The surgeon should scrutinize the location of degenerative changes, should know the amount of radial styloid beaking (and potential need for radial styloidectomy), and should note any previous fractures or hardware (may need to be removed).

images The surgeon should discuss and obtain consent for alternative procedures from the patient (ie, if one should find excessive degenerative changes at the capitate, one might proceed with intercarpal arthrodesis).

images Regional anesthesia, general anesthesia, or a combination of the two (for postoperative analgesia) is suitable.

Positioning

images The patient is supine with the arm on a radiolucent armboard.

images A nonsterile tourniquet preset at 250 mm Hg is on the upper arm.

images The shoulder, elbow, and hand are positioned such that the hand rests in pronation at the center of the armboard (if a dorsal approach is planned).

TECHNIQUES

INCISION AND EXPOSURE

images  Make a dorsal longitudinal skin incision over the fourth dorsal compartment or a transverse incision across the dorsal wrist crease just distal to the tubercle of Lister.

images The longitudinal incision is more extensile and versatile.

images The transverse incision tends to be more cosmetic.

images  Expose the extensor retinaculum.

images Maintain full-thickness flaps when elevating soft tissues off the extensor retinaculum to minimize the risk of damage to the radial and ulnar sensory nerves (TECH FIG 1A).

images  Look for the distal extent of the posterior interosseous nerve (PIN) in the proximal portion of the incision on the radial floor of the fourth compartment. Perform a PIN neurectomy after coagulating the accompanying vessels.

images  Incise the extensor retinaculum in line with extensor pollicis longus (EPL) with scissors and transpose the EPL radially, dorsal to the retinaculum.

images  Incise the radial septum of the fourth dorsal compartment and expose the wrist capsule by retracting the fourth compartment extensor tendons ulnarly and the EPL and radial wrist extensor tendons radially.

images Create a distally based “inverted-U” capsular flap by first incising the wrist capsule transversely over the radiocarpal joint (from radial to ulnar) and then, at the margins, extending the incision distally (TECH FIG 1B).

images Making a U-shaped capsular hood provides flexibility should one elect to add a dorsal capsular interposition arthroplasty in the setting of mild midcarpal arthrosis.

images  The dorsal branch of the radial artery is radial to the second compartment, so take care at the radial aspect of the capsulotomy.

images Inspect the articular cartilage on the proximal capitate and lunate facet of the radius for any degenerative changes.

images  If the cartilage is in good condition, proceed with PRC; if not, consider alternative procedures (TECH FIG 1C).

images

TECH FIG 1  A. Superficial branches of the radial nerve and the dorsal cutaneous branch of the ulnar nerve. The dorsal branch of the radial artery is in danger deeper in the dissection as the wrist joint capsule is incised. B.Intraoperative photograph showing the distally based U-shaped dorsal capsular flap. This flap is centered over the capitate. The radial margin is just adjacent to the ulnar border of the extensor carpi radialis brevis tendon. The proximal margin is taken directly off the dorsal lip of the radius. (Red arrow points to distal articular surface of the hamate; the triquetrum has not yet been removed. Black arrow points to the dorsal lip of scaphoid fossa.) The ulnar margin is just radial to the extensor digiti minimi. C. Wear on the ulnar aspect of the head of the capitate is visualized in this case. (Arrowpoints to a cartilage defect on the capitate head.) Arthrosis affecting the non-weight-bearing portion of the capitate does not preclude the use of a proximal row carpectomy but one may want to include a capsular interposition. This is usually employed in older, lower-demand individuals.

CARPECTOMY

images  Precisely ensure the anatomy and which bones are to be removed.

images Consider intraoperative fluoroscopy if there is any question.

images  Note the location of the radioscaphocapitate ligament at the waist of the scaphoid. Protect it and the other volar extrinsic ligaments while removing the proximal carpal row.

images  Avoid iatrogenic injury to the cartilaginous surfaces of the capitate head and lunate facet of the radius.

images  Osteotomize the scaphoid at its waist with a straight osteotome to facilitate scaphoid excision.

images Place the osteotome such that it parallels the flexor carpi radialis tendon to minimize the risk of transection (TECH FIG 2A,B).

images The distal pole of the scaphoid is particularly difficult to remove (especially with SNAC wrist deformities).

images  Consider using a threaded Kirschner wire (0.062 inch) or a large threaded Steinmann pin (5/32 inch) as a joystick to control the bone to be removed (TECH FIG 2C). Try to create tension between the proximal carpal bones during dissection (a combination of no. 15 blade; Beaver blade; periosteal, Freer, or Carroll elevator; and small straight or curved curettes is valuable; TECH FIG 2D).

images  If possible, remove the carpal bones whole rather than piecemeal. This facilitates removal when possible and ensures that no portions are left behind (TECH FIG 2E).

images

TECH FIG 2  A,B. The appropriate location for the scaphoid osteotomy. C. A large threaded pin inserted into the lunate is used to facilitate resection. D. An elevator placed in the lunotriquetral joint and then levered against the triquetrum helps strip the volar capsule off the lunate. E. Resected lunate.

ASSESSMENT OF REDUCTION AND IMPINGEMENT

images  Once the proximal row is removed, seat the capitate into the lunate facet on the radius to evaluate congruity.

images  Check for impingement between the trapezium and radial styloid with extreme radial deviation.

images  The trapezium has been shown to be volar to the styloid, making impingement less common than once thought.

images  If radial-sided impingement is a concern, proceed with a radial styloidectomy.

RADIAL STYLOIDECTOMY

images  See Chapter HA-86.

images  Elevate the tendons of the second and then the first extensor compartments off the radial styloid through the same dorsal incision.

images Take care to avoid injuring the dorsal branch of the radial artery just radial to the second dorsal compartment.

images  The styloidectomy can be performed from proximalradial to distal-ulnar with a straight osteotome (remove no more than 5 to 7 mm) (TECH FIG 3).

images

TECH FIG 3  The amount of radial styloid that is removed and the direction of the osteotomy. The origin of the radioscaphocapitate ligament is carefully preserved.

WOUND CLOSURE

images  Close the capsule with nonabsorbable 2-0 suture.

images  Plain radiographs or fluoroscopic images should be obtained in AP and lateral planes to ensure that the capitate is seated in the lunate fossae.

images While uncommon, radiocarpal subluxation is possible with a PRC.

images Maintenance of the volar ligaments (especially the radioscaphocapitate, which is most at risk during removal of the scaphoid) minimizes any risk of radiocarpal instability after PRC.

images  Close the retinaculum with nonabsorbable 3-0 suture, leaving the EPL superficial to the retinaculum.

images  Consider placing a drain in the subcutaneous tissues, to be removed in 24 to 48 hours.

images  Close the skin with a 3-0 nonabsorbable running subcuticular Prolene stitch with “rescue loops” to facilitate removal at 10 to 14 days.

images  Cover the incision with nonadherent gauze.

images  Fashion a sugar-tong splint over a bulky dressing.

images Keep the fingers and the thumb free proximal to the metacarpophalangeal joints.

images Hold the wrist at neutral or slight extension (10 degrees).

PROXIMAL ROW CARPECTOMY WITH INTERPOSITION ARTHROPLASTY

images  If mild to moderate chondral changes are noted on the capitate head, a PRC may still be indicated with the addition of an interpositional arthroplasty between the capitate head and lunate fossae.

images  Use the previously created distally based inverted Ushaped capsular flap as the interpositional material.

images  Place three simple stitches (2-0 PDS) connecting the dorsal capsular flap to the palmar capsule.

images  Place and tag all stitches into the dorsal capsule (passing from deep to superficial) and into the palmar capsule (passing from proximal to distal) before tying them down to the palmar capsule (TECH FIG 4A).

images  Loosely reapproximate the lateral margins of the dorsal flap to the residual dorsal capsule after interposing the dorsal capsule (TECH FIG 4B).

images  Postoperative management is not altered.

images

TECH FIG 4  A. Sutures are passed in a mattress fashion through dorsal capsule, volar capsule, and then dorsal capsule to interpose the dorsal capsular flap between the capitate and lunate fossa. (Arrowpoints to the head of the capitate.) B. The dorsal capsule interposed between the capitate (shown above) and the radius (shown below) after the PDS sutures have been tied down.

images

POSTOPERATIVE CARE

images PRC tends to be an outpatient procedure; an overnight stay may be necessary for postoperative pain or nausea.

images A short splint is applied in the operating room with the wrist in neutral and the fingers and thumb free at the metacarpophalangeal joints.

images Passive thumb and finger motion is encouraged immediately postoperatively, along with elevation and ice for the first 48 hours.

images At the first postoperative follow-up visit (in 10 to 14 days) the splint is removed, plain wrist AP and lateral radiographs are obtained to ensure the capitate is located in the radial lunate facet, and sutures are removed.

images At 2 weeks postoperatively, gentle active wrist extension and flexion and radioulnar deviation are added and a removable cock-up wrist splint or custom Orthoplast wrist splint is worn between exercises.

images Scar massage can begin once the incision is healed.

images Edema control may be necessary with compressive dressings.

images The removable splint can be removed as the patient feels comfortable (typically in 3 to 4 weeks).

images At 6 weeks, objective measurements of wrist extension, flexion, radioulnar deviation arcs, grip and pinch strength should be obtained.

images Therapy is initiated if the patient seems to be struggling to regain wrist or finger motion.

images At 3 months, full activities are encouraged.

OUTCOMES

images A broad range in grip strength outcome has been reported postoperatively.

images 60% to 100% grip strength of the contralateral wrist (and a 20% to 30% increase in postoperative grip versus preoperative grip) can be expected.3,7

images A decrease in postoperative wrist motion can be expected, as well as a decrease in flexion–extension by 20%, a decrease in radioulnar deviation by 10%,3 and a 72to 75degree arc of motion in flexion and extension.2,7

images Satisfactory pain relief can be expected in 80% to 100% of patients.3,5

images Return to work for manual laborers after PRC has been unpredictable, varying from 20% in one series3 to 85% in another.5

images Age less than 35 years has been shown to be predictive of early failure with PRC.

COMPLICATIONS

images Incomplete removal of the carpal bones (typically distal scaphoid)

images Use of pins has been associated with pin site infections and rapid degenerative changes when placed through the radiocapitate articulation (because of this, pins are not routinely recommended as they once were).

images Reflex sympathetic dystrophy

images Excessive styloidectomy and compromise of the radioscaphocapitate ligament

images Compromise of the radioscaphocapitate ligament can lead to ulnar carpal subluxation.

images Conversely, failure to check intraoperatively for radialsided impingement may lead to radial-sided wrist pain postoperatively.

images Damage to sensory nerves (radial sensory and dorsal ulnar branches)

images Progressive arthritis

REFERENCES

1.     Begley BW, Engber WD. Proximal row carpectomy in advanced Kienböck's disease. J Hand Surg Am 1994;19A:1016–1018.

2.     Calandruccio JH. Proximal row carpectomy. J Am Soc Surg Hand 2001;1:112–122.

3.     Culp RW. Proximal row carpectomy: a multicenter study. J Hand Surg Am 1993;18:19–25.

4.     Nakamura R, Horii E, Watanabe K, et al. PRC vs. limited wrist arthrodesis for advanced Kienböck's disease. J Hand Surg Br 1998; 23:741–745.

5.     Imbriglia JE, Broudy AS, Hagberg WC, et al. Proximal row carpectomy: clinical evaluation. J Hand Surg Am 1990;15:426–430.

6.     Mathiowetz V, Kashman N, Volland G, et al. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 1985;66: 69–74.

7.     Stern PJ, Agabegi SA, Kiefhaber TR, et al. Proximal row carpectomy. J Bone Joint Surg Am 2004;86A:2359–2365.



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