86: Proximal Row Carpectomy

Published on 17/04/2015 by admin

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Last modified 17/04/2015

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Procedure 86 Proximal Row Carpectomy

Jeffrey A. Greenberg

imageSee Video 64: Proximal Row Carpectomy

Indications

image Scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) with preserved midcarpal joint (stages 1 and 2).

image Kienböck disease (Stage 3).

image Chronic carpal instability.

image Failed soft tissue reconstruction.

image In general, indications are similar to those for four-corner fusion; however, the midcarpal joint needs to be preserved.

Examination/Imaging

Clinical Examination

image Radioscaphoid and midcarpal joints may be tender to palpation.

image Visible fullness may be present secondary to hypertrophic synovitis.

image Decreased range of motion.

image Pain with loading of midcarpal joint, particularly with radial and ulnar deviation.

image Pain with extension loading.

image Decreased grip strength.

Imaging

image Plain radiographs are usually sufficient to stage the disease and ensure that the midcarpal joint is preserved (Figs. 86-1 and 86-2).

image Advanced imaging (computed tomography) can be performed to determine the status of the midcarpal joint; however, patients are made aware preoperatively that an intraoperative decision to convert to a limited wrist fusion can be made if there is excessive, unrecognized midcarpal joint degenerative change.

image

FIGURE 86-1

image

FIGURE 86-2

Surgical Anatomy

image In either SLAC or SNAC, there will be widening at the scapholunate interval.

image Significant scaphoid flexion, lunate extension, and dorsal lunate prominence develop.

image Radioscaphoid degenerative change with styloid prominence or osteophytes.

image Dorsal radial prominence.

image Synovitis.

image Proximal scaphoid pole necrosis and/or arthrosis.

image Scaphotrapeziotrapezoid arthrosis may be present.

image The volar extrinsic ligaments (radioscaphocapitate, short and long radiolunate) originate from the volar radius and extend obliquely to the carpus. These should be intact; insufficiency or iatrogenic damage could lead to ulnar translation and radiocapitate instability after surgery (Fig. 86-3). The dorsal ligaments of the wrist—dorsal radiocarpal (DRC) and dorsal intercarpal (DIC)—have a conjoined insertion on the triquetrum. They provide the capsulotomy landmarks for wrist exposure (Fig. 86-4).

image

FIGURE 86-3

image

FIGURE 86-4

Positioning

image The patient is positioned supine, the hand and forearm are supported on a hand surgery table, and a proximal tourniquet is used.

image Operating on the dorsal wrist is easier if the surgeon is positioned at the head of the patient as opposed to at the axilla.

Exposures

image A straight dorsal midline incision centered over the radiocarpal joint is used (Fig. 86-5).

image Flap elevation is performed sharply, protecting the cutaneous branches of the superficial radial and dorsal ulnar sensory nerves within the subcutaneous tissue.

image The retinaculum over the third dorsal compartment is incised and the extensor pollicis longus (EPL) retracted (Fig. 86-6).

image Retinacular flaps are raised exposing the second through fifth dorsal compartments.

image Retractors are placed between the second and fourth dorsal compartment tendons.

image A posterior interosseous neurectomy is performed. The PIN is located on the floor of the fourth dorsal compartment

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