86: Proximal Row Carpectomy

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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

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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

image The capsule is incised along the DIC and DRC ligaments raising a radially based flap (Fig. 86-7).

image If a soft tissue interposition using the capsule is planned, a proximally based, rectangular flap of capsule is harvested instead of using the capsular exposure previously described. The soft tissue interposition procedure is used if there is some articular wear on the capitate.

image

FIGURE 86-5

image

FIGURE 86-6

image

FIGURE 86-7

Pearls

The dorsal capsular ligaments are more prominent with the wrist in flexion. Placing a “bump” under the wrist facilitates visualization. Fatty perivascular tissue is sometimes prominent on the dorsal capsule. Bluntly dissecting it off the capsule with a sponge also facilitates visualization of the ligaments.

Leave a cuff of ligament along the radial rim for closure, but incise the ligament close enough to the radius to visualize the proximal carpal row.

Procedure

Step 1

image Inspection of the distal radius and midcarpal joint is performed. Ensure that the lunate fossa and proximal capitate are intact. Alternative procedures should be considered if there is damage to the midcarpal or radiolunate articulations (Fig. 86-8).

image

FIGURE 86-8

Step 1 Pearls

Mild degenerative change at the capitate head or radiolunate joint can be treated with proximal row carpectomy (PRC) and concomitant capsular interposition.

Osteochondral resurfacing has also been described as an adjunctive procedure with PRC for capitate chondrosis. An osteochondral graft is obtained from the excised carpus, usually the lunate, and inserted into the defect created after excising the area of cartilage loss (limited to a single area <10 mm in diameter).

Step 1 Pitfalls

Significant degenerative change at either the radiolunate or midcarpal joints precludes PRC, and alternative procedures should be performed.

Step 2

image The lunotriquetral ligament is divided, and the lunate is excised in its entirety by carefully dissecting it off the volar ligament. This technique minimizes the chance of bone attached to the capsule being left behind.

image Avoid injuring the cartilage surface of the radiolunate joint or capitate head.

Step 2 Pearls

A joystick can be placed in the lunate to facilitate manipulation.

Care is taken to avoid injury to the volar ligaments and cartilage of the distal radius and capitate.

It is easier to completely remove the bone using careful circumferential subperiosteal dissection rather than a piecemeal technique with a rongeur.

Step 2 Pitfalls

Injuring the volar extrinsic ligaments can lead to late instability and carpal translation.

Step 3

image The triquetrum can be excised in its entirety by careful circumferential subperiosteal dissection.

Step 3 Pearls

Similar to the lunate, it is easier to remove the triquetrum in one piece.

Step 3 Pitfalls

Avoid injury to the ulnar neurovascular bundle or the dorsal sensory branch of the ulnar nerve; both are in close proximity to the triquetrum.

Step 4

image After removal of the lunate and triquetrum, a joystick should be placed in the scaphoid (Fig. 86-9). Threaded Steinmann pins, Schanz screws, or threaded gimlets can be used. Avoid temptation for piecemeal excision using a rongeur because it is easier to remove the entire scaphoid using careful and deliberate subperiosteal dissection methods (Fig. 86-10).

image

FIGURE 86-9

image

FIGURE 86-10

Step 4 Pearls

A sharp curved elevator facilitates subperiosteal dissection and complete removal.

Step 4 Pitfalls

Avoid damage to the volar extrinsic ligaments, radial artery, and head of the capitates.

Step 5

image The capitate should seat in the lunate fossa and be stable. Styloid impingement is assessed, and, if present, a radial styloidectomy should be performed (Fig. 86-11).

image

FIGURE 86-11

Step 5 Pearls

Decompress the radiocarpal joint with radial styloidectomy.

Step 5 Pitfalls

Excessive bone resection during styloidectomy will compromise the integrity of the volar extrinsic ligaments.

Persistent stylocarpal impingement may persist if the radiocarpal joint is not decompressed.

Additional Steps

image Anatomic capsular closure using nonabsorbable suture is performed.

image The extensor retinaculum is closed, leaving the EPL transposed (Fig. 86-12).

image Skin is closed with interrupted nonabsorbable suture.

image A well-padded dressing is applied to control edema yet allow digital range of motion.

image A radiograph is taken to ensure that the capitate is reduced on the radius (Figs. 86-13 and 86-14).

image

FIGURE 86-12

image

FIGURE 86-13

image

FIGURE 86-14

Postoperative Care and Expected Outcomes

image Dressing and suture are removed 2 weeks after surgery.

image A short-arm cast is worn until 6 weeks after surgery.

image A removable splint is applied and range of motion initiated 6 weeks after surgery.

image Strengthening exercises can begin at 10 to 12 weeks.

image Expect 70 degrees of arc of motion and recovery of 70% of grip strength.

image Postoperative swelling can persist.

image Recovery can be prolonged—up to 12 to 18 months.

Evidence

Cohen MS, Kozin SH. Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. J Hand Surg [Am]. 2001;26:94-104.

This comparative study looked at 19 patients in two groups from two different institutions. No significant differences in motion, grip strength, or function were noted between the groups. (Level III evidence)

Croog AS, Stern PJ. Proximal row carpectomy for advanced Kienböck’s disease: average 10-year follow-up. J Hand Surg [Am]. 2008;33:1122-1130.

This study evaluated 21 patients with Lichtman stage IIIA, IIIB, or IV Kienböck disease who underwent PRC. Eighteen of the 21 patients with an average follow-up of 10 years achieved an average wrist flexion-extension arc of 105 degrees and maximal grip strength of 35 kg, which averaged 87% of that of the contralateral wrist. The average DASH score was 12 points, and the average PRWE score was 17, each representing minimal functional limitation. Two of 3 patients who required a radiocapitate arthrodesis had stage IV disease, and the authors express caution with use of PRC in this population of patients. There was no significant association between postoperative radiographic findings and clinical outcomes. (Level IV evidence)

DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: study with a minimum of ten years of follow-up. J Bone Joint Surg [Am]. 2004;86:2359-2365.

Twenty-two PRCs in 21 patients were reviewed with an average follow-up time of 14 years. Eighteen of the 22 patients demonstrated satisfactory pain relief, 72 degrees of flexion-extension arc, and recovery of 91% of grip strength of the opposite side. Pain relief was graded as complete in 9, mild in 4, and moderate residual in 5. There were 4 failures, all in patients younger than 35 years old. (Level IV evidence)

Lumsden BC, Stone A, Engber WD. Treatment of advanced-stage Kienböck’s disease with proximal row carpectomy: an average 15-year follow-up. J Hand Surg [Am]. 2008;33:493-502.

Proximal row carpectomy was used to treat 17 patients with advanced-stage (Lichtman IIIA and IIIB) Kienböck disease. Thirteen of the 17 patients with an average follow-up of 15 years were evaluated. Twelve of 13 patients demonstrated excellent or good results. They achieved a total arc of motion of 73% of the uninvolved side and grip strength that averaged 92% of the uninvolved side. All patients demonstrated some degree of degenerative changes. Despite radiographic evidence of radiocapitate degenerative change in nearly all patients, clinical results did not correlate with radiographic degeneration. (Level IV evidence)

Tang P, Imbriglia JE. Osteochondral resurfacing (OCRPRC) for capitate chondrosis in proximal row carpectomy. J Hand Surg [Am]. 2007;32:1334-1342.

This paper presents a novel approach to the use of PRC in patients with Outerbridge grade II to IV capitate chondrosis. The authors performed osteochondral resurfacing of the capitate in addition to PRC. Eight patients with an average follow-up of 18 months demonstrated improved pain and maintenance of wrist range of motion and grip strength. Mayo wrist scores improved from 51 to 68. DASH score averaged 19.5 postoperatively. Seventy-five percent of patients had mild to no degenerative change on postoperative radiographs, and magnetic resonance imaging 21 months after surgery showed graft incorporation. (Level IV evidence)

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