Introduction

Proximal row carpectomy is a motion-sparing salvage procedure that consists of excising the scaphoid, lunate, and capitate—thus converting a complex link joint into a simple hinge.¹ Although the procedure has historically been criticized for loss of motion and strength, progressive radio capitate arthritis, and unpredictability of outcome, much of this criticism has been anecdotal.² Recent studies, including three series with a minimum of nine years of follow-up, have demonstrated that proximal row carpectomy is as reliable a procedure as complex reconstructions and other salvage surgeries.^3–16 The advantages of proximal row carpectomy include preservation of a functional arc of motion, satisfactory strength, pain relief, and high patient satisfaction.

Wrist motion has been shown to be equal or slightly less than preoperative motion. Grip strength has been reported to range between 64 and 100% of the contralateral normal wrist.^{4,7,11,12,17–21} In addition, patients may be converted to a wrist arthrodesis or arthroplasty if painful osteoarthritis develops. The disadvantages of proximal row carpectomy include loss of carpal height, an incongruous joint, and possible progression of radiocapitate arthrosis. Imbriglia et al. have shown that the radius of curvature of the capitate is approximately two-thirds of the lunate fossa of the distal radius. Using cineradiography, they demonstrated that the motion of the capitate on the distal radius is translational with a moving center of rotation.²¹ Imbriglia reported that 12 of 27 patients in his long-term follow-up study developed radiographic evidence of cartilage space narrowing, although without clinical consequence.¹³

The role of wrist arthroscopy has vastly changed in the last decade. With advances in the development of smaller arthroscopes and instruments (as well as advances in arthroscopic surgery techniques), treatment of wrist pathology has significantly improved. The pathology the wrist arthroscopist can now treat includes but is not limited to triangular fibrocartilage complex (TFCC) tears, ganglion cysts, radiocarpal fractures, cartilage damage, loose bodies, and bony resections (including radial styloidectomy and proximal row carpectomy).

Literature regarding arthroscopic proximal row carpectomy is sparse. There are no long-term studies, although short-term results are promising. The majority of the literature mentions arthroscopy as an available technique for proximal row carpectomy without discussing clinical results.^5,22–25

Indications and Contraindications

The indications for arthroscopic proximal row carpectomy are the same as those for the standard open technique. These indications include symptomatic arthritic disease secondary to scapholunate dissociation, scaphoid nonunion, and Kienbock’s disease.

Proximal row carpectomy²⁶ has also been described in the treatment of failed carpal implants, cerebral palsy, spasticity, acute and chronic fractures and dislocations, and replantation. We do not currently recommend arthroscopic proximal row carpectomy in this latter subset of patients.

Other relative contraindications to proximal row carpectomy in general include degenerative changes of the capitate head or lunate fossa of the distal radius, multicystic carpal disease, and preexisting ulnar translocation of the carpus. Due to the high failure rate of open proximal row carpectomy in patients with inflammatory arthropathy (e.g., rheumatoid arthritis), both Culp et al. and Ferlic et al. do not recommend its use in these patients.^4,27

Technique

The patient is positioned supine on the operating table, with the affected arm positioned on a radiolucent hand table. A well-padded arm tourniquet is placed proximal to the arm. The procedure can be carried out under general or regional anesthesia because operative times are generally less than two hours. The wrist is then suspended in a traction tower and 10 to 15 pounds of traction is applied (Figure 26.1). After distraction is obtained, landmarks are outlined on the dorsum of the wrist and the portals are made. The tourniquet is routinely inflated without additional exsanguination. Routinely, the 3-4 portal is the initial viewing portal.

FIGURE 26.1 Standard traction tower with finger traps on the long and ring fingers. An 18-gauge needle in the 6-U portal to provide gravity drainage as outflow.

(Reproduced with permission from R.W. Culp et al, Tech in Hand and UE Surg 1997;(2):117).

After the 2.7-mm arthroscope is placed into the joint, outflow is established through the 6-R portal identified by triangulation and direct visualization upon entering the joint at the prestyloid recess. A mechanical pump is used to maintain a constant intra-articular pressure and flow rate. Initially, a routine evaluation of the joint is carried out. Particular attention is given to the lunate fossa of the distal radius. The radial volar extrinsic ligaments, particularly the radioscaphocapitate ligament, are identified and are preserved during the procedure. The arthroscope is then directed ulnarly, and the TFCC and extrinsic ulnar ligaments are identified.

Next, the midcarpal joint must be well visualized to ensure an adequate proximal capitate cartilaginous surface (Figure 26.2). If the status of the capitate joint is questionable, an alternative procedure is performed: four-corner fusion, capitolunate arthrodesis, proximal row carpectomy with interposition arthroplasty, or wrist arthrodesis. Assessment of the midcarpal articular surfaces is accomplished through the radial midcarpal portal, which is approximately 1 cm distal to the 3-4 portal. Arthroscopic instruments that will be needed to perform the proximal row carpectomy include a hook probe, a 2.9 shaver or radiofrequency device, a 4.0 bur, small sharp osteotomes, pituitary rongeurs, and an image intensifier.

FIGURE 26.2 View from radial midcarpal portal demonstrating a healthy-appearing proximal capitate.

(Reproduced with permission from Culp RW, Osterman AL, Talsania JS. Arthroscopic proximal row carpectomy. Tech Hand and Upp Ext 1997;2(1):116–19).

The first step in performing the proximal row carpectomy, after one is satisfied with the cartilage status of the proximal pole of the capitate and the lunate fossa, is to remove the scapholunate and lunatotriquetral ligaments with a shaver or radiofrequency device. This is performed through the 4-5 and/or 6-R portal. Next, the core of the lunate is removed with a bur. Care is taken to avoid damaging the lunate fossa and proximal capitate by leaving an “eggshell” rim of lunate, which is morcellized with a pituitary rongeur under direct vision and/or with image intensification (Figure 26.3).

FIGURE 26.3 Creation of a central cavity within the lunate is performed with a large round bur. Care is taken to protect the lunate fossa and proximal capitate articular surfaces throughout the procedure.

(Reproduced with permission from Culp RW, Osterman AL, Talsania JS. Arthroscopic proximal row carpectomy. Tech Hand and Upp Ext 1997;2(1):116–19).

Next, using the 3-4 or 4-5 portal as a working portal the scaphoid and triquetrum are fragmented with an osteotome and bur under image intensification (Figures 26.4 and 26.5) and removed piecemeal with a pituitary rongeur. Coring out and fragmenting the carpal bones allows for easy removal as well as protection of the articular cartilage. Great care is taken to avoid damaging the articular cartilage and to avoid damaging the volar extrinsic ligaments, especially the radioscaphocapitate—which will be responsible for maintaining the stability of the capitate in the lunate fossa.

FIGURE 26.4 Fluoroscopic guidance is utilized to aid fragmentation of the scaphoid and triquetrum.

(Reproduced with permission from Culp RW, Osterman AL, Talsania JS. Arthroscopic proximal row carpectomy. Tech Hand and Upp Ext 1997;2(1): 116–19).

FIGURE 26.5 Pituitary rongeur, under fluoroscopic guidance, to remove the fragmented scaphoid. This may be performed in the traction tower or with the hand prone on the radiolucent hand table.

(Reproduced with permission from Culp RW, Osterman AL, Talsania JS. Arthroscopic proximal row carpectomy. Tech Hand and Upp Ext 1997;2(1):116–19).

After the entire proximal row is removed, the wrist is examined under radiographic image intensification (Figures 26.6 and 26.7). Care is taken to ensure that there is not impingement of the trapezium against the radial styloid. Some authors advocate a modest styloidectomy. Although we rarely perform this procedure, if necessary it can be done arthroscopically with the aid of image intensification.

FIGURE 26.6 Preoperative radiograph demonstrating chronic scapholunate dissociation.

(Reproduced with permission from Culp RW, Osterman AL, Talsania JS. Arthroscopic proximal row carpectomy. Tech Hand and Upp Ext 1997;2(1):116–19).

FIGURE 26.7 Postoperative radiograph, following arthroscopic proximal row carpectomy.

(Reproduced with permission from Culp RW, Osterman AL, Talsania JS. Arthroscopic proximal row carpectomy. Tech Hand and Upp Ext 1997;2(1):116–19).

Posterior interosseous neurectomy may be performed through a separate 1.5-cm longitudinal incision just ulnar to Lister’s tubercle. The fourth compartment is partly opened on the radial side. One cm of the nerve is resected with bipolar electrocautery. The fourth compartment is then repaired with absorbable suture. All wounds are closed with 4-0 nylon monofilament suture.

Patients are initially placed in a short arm plaster splint. Sutures from the portals are removed at 7 to 10 days. The patients are then converted to a short arm thermoplastic splint for an additional three weeks. Gentle range-of-motion exercises are begun after splint removal at four weeks, and strengthening is begun approximately eight weeks postoperatively.

Complications

There are several potential complications associated with arthroscopic proximal row carpectomy that must be noted. Iatrogenic damage to articular cartilage must be avoided by careful instrument placement.

Care must be taken to avoid disrupting the volar extrinsic carpal ligaments, particularly the radioscaphocapitate ligament, during excision of the proximal carpal row (Figure 26.8). To avoid ligamentous injury, a thin shell of cortical bone may be left attached to the volar radiocarpal ligaments. In addition, there is also the potential to irritate nerves (particularly the dorsal ulnar sensory branch), and the possibility of damage to the median and ulnar nerves (particularly the ulnar nerve) while using the osteotomes.

FIGURE 26.8 Diagram of the important stabilizing volar extrinsic radiocarpal and ulnocarpal ligaments. Note ulnocapitate ligament, important due to its position and contribution to the ulnar limb of the arcuate ligament and their attachment to the capitate.

Because the dorsal capsuloligamentous structures have been minimally disrupted during the procedure, there is a theoretical complication that dorsal instability may occur secondary to less dorsal scar formation. Although this complication has not occurred in our patients, should dorsal capsular laxity become evident concurrent or subsequent electrothermal capsulorrhaphy may be considered.

Advantages

Arthroscopic proximal row carpectomy involves less dissection, less postoperative pain, less stiffness, and a shorter recovery time. There is less damage to the dorsal ligaments, which are left almost completely intact, in contrast to standard proximal row carpectomy. The excellent visualization provided by arthroscopy allows for an increased likelihood of volar extrinsic preservation. Finally, patients are pleased with the smaller scars associated with arthroscopy.

Summary

This procedure involves minimal dissection and potentially less morbidity. As with any arthroscopic procedure, this technique requires a hand surgeon highly skilled in wrist arthroscopy. Overall patient satisfaction with this procedure has been excellent. Immediate postoperative pain has been less compared to those who have had an open technique. In our experience, patients who underwent arthroscopic proximal row carpectomy report satisfactory pain relief, functional range of motion, and effective grip strength.