Proximal Row Carpectomy
DEFINITION
Proximal row carpectomy (PRC) involves removal of the proximal carpal row (scaphoid, lunate, and triquetrum).
PRC has been described as a treatment option for a number of pathologic conditions: Scaphoid nonunion advanced collapse (SNAC) wrist
Scapholunate advanced collapse (SLAC) wrist
Kienböck disease
Chronic or missed perilunate dislocation Scaphoid osteonecrosis or Preiser disease Wrist deformity or contracture
ANATOMY
The proximal row of the wrist consists of three bones: scaphoid, lunate, and triquetrum.
The proximal row moves as a single unit through intercarpal ligamentous attachments and bony congruity.
The proximal row flexes with radial deviation and extends with ulnar deviation.
The capitate, in the distal row, articulates with the lunate.
The proximal capitate articular surface is relatively, although not completely, congruous with the lunate facet of the radius.
PATHOGENESIS
A number of pathologic conditions lead to wrist degeneration requiring PRC. Patients with progressive pain and limited motion can gain relief following this procedure.
SNAC and SLAC
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.
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.
Stage III: degenerative changes at the capitolunate joint. The radiolunate joint is spared.
Kienböck disease
Stage I: normal plain radiographs with wrist pain and positive magnetic resonance imaging (MRI) finding Stage II: sclerosis without collapse of the lunate
Stage IIIa: lunate collapse without instability
Stage IIIb: where there is lunate collapse with carpal instability (dorsal intercalated segmental instability [DISI]: flexion of the scaphoid with extension of the lunate)
Stage IV: fixed carpal instability with pancarpal degenerative changes Missed perilunate dislocation
Scaphoid osteonecrosis (Preiser disease)
Congenital or spastic wrist and hand flexion contractures severe enough that a PRC allows deformity correction that tendon lengthening procedures alone would be unable to correct.
PATIENT HISTORY AND PHYSICAL FINDINGS
Determine the cause of the wrist degeneration.
Mechanical wrist pain is aggravated by use and relieved by rest. The history must support this for the proposed treatment to be successful.
The history defines the patient's symptoms, level of severity, and progression over time as well as any previous attempts at treatment.
Limited and painful wrist motion with diminished grip strength tends to be a common denominator regardless of the initial source of pathology.
Normal range of motion: wrist extension, 70 degrees; wrist flexion, 75 degrees; radial deviation, 20 degrees; ulnar deviation, 35 degrees. This varies considerably.
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.6
P.976
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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.
Radioscaphoid joint line tenderness on palpation implies radioscaphoid arthritis.
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.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain radiographs assist with making the underlying diagnosis (eg, SNAC wrist, SLAC wrist, Kienböck disease).
Evaluate the articular facets and surfaces, specifically the head of the capitate and lunate facet of the radius.
Look for other sources of limited wrist motion, diminished grip strength, and pain (eg, thumb carpometacarpal arthritis, scapholunate instability without degenerative changes, fracture).
MRI has limited use with the exception of suspected Kienböck disease or Preiser disease.
DIFFERENTIAL DIAGNOSIS
Triangular fibrocartilage complex or distal radioulnar joint pathology Extensor carpi ulnaris, flexor carpi ulnaris, flexor carpi radialis tendinitis De Quervain tenosynovitis
Thumb carpometacarpal arthritis
Scapholunate or lunotriquetral instability without degenerative changes
SURGICAL MANAGEMENT
The integrity of the articular cartilage on the head of the capitate and the lunate facet of the radius are critical. The ultimate assessment is made intraoperatively.
Indications
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)
Kienböck disease (stage IIIb)
Chronic or missed perilunate dislocations Scaphoid osteonecrosis (Preiser disease) Wrist deformity or contracture
Contraindications
Active inflammatory arthritis (rheumatoid arthritis). PRC may be used for inflammatory arthritis patients with “burnout” disease (those without active synovitis).
Advanced degenerative changes at the proximal articular surface of the capitate or lunate facet of the radius Ulnar carpal translation or subluxation of the radiocarpal joint
Relative contraindications
Heavy laborers
Young (younger than 35 years) active patients8
Preoperative Planning
Review the plain radiographs of the wrist. Scrutinize the location of degenerative changes.
Obtain consent for alternative procedures from the patient (ie, if you find excessive degenerative changes on the capitate head, you might proceed with an intercarpal arthrodesis).
Regional anesthesia, general anesthesia, or a combination of the two (for postoperative analgesia) is suitable.
Positioning
The patient is supine with the arm on a radiolucent arm board.
A nonsterile tourniquet preset at 250 mm Hg is on the upper arm.
The shoulder, elbow, and hand are positioned such that the hand rests in pronation at the center of the arm board.
TECHNIQUES
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Incision and Exposure
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.
The longitudinal incision is more extensile and versatile. The transverse incision tends to be more cosmetic.
Expose the extensor retinaculum.
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).
Incise the extensor retinaculum in line with extensor pollicis longus (EPL) and transpose the EPL radially, dorsal to the retinaculum.
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.
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.
Create a distally based “inverted U-shaped” 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).
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.
The dorsal branch of the radial artery is radial to the second compartment, so take care at the radial aspect of the capsulotomy.
Inspect the articular cartilage on the proximal capitate and lunate facet of the radius for any degenerative changes.
If the cartilage is in good condition, proceed with PRC; if not, consider alternative procedures (TECH FIG 1C).
P.977
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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. (Arrow points 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 PRC, but one may want to include a capsular interposition. This is usually employed in older, lower demand individuals.
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Carpectomy
Divide the scapholunate ligament, if it is intact.
Split the scaphoid at its waist with a straight osteotome to facilitate scaphoid excision.
Note that the radioscaphocapitate ligament crosses obliquely at the waist of the scaphoid.
Orient the osteotome parallel with its fibers. If the osteotome should accidentally plunge beyond the scaphoid, the fibers will be split rather than divided (TECH FIG 2A,B).
The distal pole of the scaphoid is particularly difficult to remove (especially with SNAC wrist deformities).
Avoid iatrogenic injury to the cartilaginous surfaces of the capitate head and lunate facet of the radius.
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).
If possible, remove the carpal bones whole rather than piecemeal (TECH FIG 2E).
P.978
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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.
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Assessment of Reduction and Impingement
Once the proximal row is removed, ensure that the capitate sits in the lunate facet without translating ulnarly.
If the lunate translates easily, check to see if the radioscaphocapitate ligament is intact. Check for impingement between the trapezium and radial styloid with extreme radial deviation.
The trapezium is volar to the styloid, making impingement less common than once thought. If radial-sided impingement is a concern, proceed with a radial styloidectomy.
P.979
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Radial Styloidectomy
See Chapter 106.
Elevate the tendons of the second and then the first extensor compartments off the radial styloid through the same dorsal incision.
Take care to avoid injuring the dorsal branch of the radial artery just radial to the second dorsal compartment.
The styloidectomy can be performed from proximal radial to distal ulnar with a straight osteotome (remove no more than 5 to 7 mm) (TECH FIG 3).
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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.
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Wound Closure
Close the capsule with nonabsorbable 2-0 suture.
Plain radiographs or fluoroscopic images should be obtained in anteroposterior (AP) and lateral planes to ensure that the capitate is seated in the lunate fossae.
Although uncommon, radiocarpal subluxation is possible with a PRC.
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.
Close the retinaculum with nonabsorbable 3-0 suture, leaving the EPL superficial to the retinaculum.
Close the skin with a 3-0 running subcuticular monofilament, absorbable stitch reinforced with Steri-Strips.
Cover the incision with nonadherent gauze. Fashion a volar splint over a bulky dressing.
Keep the fingers and the thumb free proximal to the metacarpophalangeal joints. Hold the wrist at neutral or slight extension (10 degrees).
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Proximal Row Carpectomy with Interposition Arthroplasty
If mild to moderate chondral changes are noted on the capitate head, a PRC may still be possible with the addition of an interpositional arthroplasty between the capitate head and lunate fossae.
Use the previously created distally based inverted U-shaped capsular flap as the interpositional material.
Place three simple stitches (2-0 polydioxanone [PDS]) connecting the dorsal capsular flap to the palmar capsule.
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).
Loosely reapproximate the lateral margins of the dorsal flap to the residual dorsal capsule after interposing the dorsal capsule (TECH FIG 4B).
Postoperative management is not altered.
P.980
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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. (Arrow points 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.
Intraoperative pearls
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Threaded Kirschner wires (0.062 inch) or large threaded Steinmann
pins (5/32 inch) in the scaphoid, lunate, or triquetrum can serve as a joystick or fulcrum to assist in removing the carpal bones.
Excessive
styloidectomy
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Removing more than 5-7 mm of the radial styloid has been associated
with compromise of the radioscaphocapitate ligament, with resultant ulnar carpal translation and radiocarpal instability.
Reflex sympathetic
dystrophy
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Thought to be minimized by accelerated rehabilitation (immediate finger
motion) and by avoiding tight postoperative dressings.
Damage to the radial
sensory and dorsal ulnar sensory branches
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Dissect directly down to the extensor retinaculum and elevate
subcutaneous fat in full-thickness flaps off the extensor retinaculum to minimize the risk of nerve injury.
PEARLS AND PITFALLS
POSTOPERATIVE CARE
PRC tends to be an outpatient procedure; an overnight stay may be necessary for postoperative pain or nausea.
A short splint is applied in the operating room with the wrist in neutral and the fingers and thumb free at the metacarpophalangeal joints.
Passive thumb and finger motion is encouraged immediately postoperatively, along with elevation and ice for the first 48 hours.
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.
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.
Scar massage can begin once the incision is healed.
Edema control may be necessary with compressive dressings.
The removable splint can be discontinued as the patient feels comfortable (typically in 3 to 4 weeks).
Therapy is initiated if the patient struggles to regain finger motion by 10 to 14 days. Therapy for wrist motion is initiated, if necessary, at 6 to 8 weeks.
At 3 months, full activities are permitted.
OUTCOMES
A broad range in grip strength outcome has been reported postoperatively.
A 60% to 100% grip strength of the contralateral wrist (and a 20% to 30% increase in postoperative grip vs. preoperative grip) can be expected.1,4,8
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%,4 and a 72- to 76-degree arc of motion in flexion and extension.3,7,8
Satisfactory pain relief can be expected in 80% to 100% of patients.4,5
P.981
A Brazilian prospective randomized control trial comparing four-corner fusion to PRC showed similar functional results, decreased pain in both groups, and no statistically significant differences in range of
motion or grip strength.2
Return to work for manual laborers after PRC has been unpredictable, varying from 20% in one series4 to 85% in another.5
A study with a minimum of 20-year follow-up showed 65% survival of the PRC, with failure (conversion to arthrodesis) at an average of 11 years postoperatively.9
Age younger than 35 years has been shown to be predictive of early failure with PRC.
COMPLICATIONS
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).
Reflex sympathetic dystrophy
Excessive styloidectomy and compromise of the radioscaphocapitate ligament Compromise of the radioscaphocapitate ligament can lead to ulnar carpal subluxation.
Conversely, failure to check intraoperatively for radialsided impingement may lead to radial-sided wrist
pain postoperatively.
Damage to sensory nerves (radial sensory and dorsal ulnar branches) Progressive arthritis
REFERENCES
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Begley BW, Engber WD. Proximal row carpectomy in advanced Kienböck's disease. J Hand Surg Am 1994;19(6):1016-1018.
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Bisneto EN, Freitas MC, Paula EJ, et al. Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study. Clinics 2011;66:51-55.
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Calandruccio JH. Proximal row carpectomy. J Am Soc Surg Hand 2001;1:112-122.
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Culp RW, McGuigan FX, Turner MA, et al. Proximal row carpectomy: a multicenter study. J Hand Surg Am 1993;18:19-25.
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Imbriglia JE, Broudy AS, Hagberg WC, et al. Proximal row carpectomy: clinical evaluation. J Hand Surg Am 1990;15:426-430.
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Mathiowetz V, Kashman N, Volland G, et al. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 1985;66:69-74.
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Richou J, Chuinard C, Moineau G, et al. Proximal row carpectomy: long-term results. Chir Main 2010;29:10-15.
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Stern PJ, Agabegi SS, Kiefhaber TR, et al. Proximal row carpectomy. J Bone Joint Surg Am 2005;87(suppl 1, pt 2):166-174.
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Wall LB, Didonna ML, Kiefhaber TR, et al. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am 2013;38:1498-1504.