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Procedure

Proximal Row Carpectomy


Proximal row carpectomy (PRC) is a reliable alternative to arthrodesis in the treatment of wrist osteoarthritis. PRC is a motion-preserving salvage procedure that involves excision of the scaphoid, lunate, and triquetrum and converts the complex link joint of the wrist into a simple hinge.

The procedure has faced considerable criticism in regard to alteration of the normal anatomy of the wrist joint, impairment of strength and motion, improper redistribution of joint loading, subsequent radiocapitate arthritis, and an unpredictable outcome.

Conversely, many investigators have documented satisfactory motion preservation, maintained grip strength, pain relief, and patient satisfaction. Several medium- and long-term follow-up studies have demonstrated that Proximal Row Carpectomy is a reliable procedure with outcomes comparable to those of other reconstructive and salvage procedures of the wrist.

Related Anatomy

The wrist joint allows complicated interactions among an array of anatomic structures, each playing a role in radiocarpal stability and mobility. A host of factors contribute to the precise mechanism of wrist function, and traumatic disruption of any link in the anatomic chain alters the carpal mechanics, leading to a predictable and progressive degeneration of the joint.

Scaphoid pathology is often primarily responsible for the development of wrist arthritis. As articular contact area decreases, load distribution becomes irregular, and shearing occurs.

The proximal row of carpal bones operates as an intercalated segment between the distal radius and the distal carpal row. Proximal row intercarpal ligament disruption leads to wrist instability. Injuries to the scapholunate interosseous ligament and the extrinsic ligamentous complex allow the lunate to extend, creating dorsal intercalated segment instability.

The resultant palmar flexion of the scaphoid alters load distribution across the radioscaphoid articulation, increasing contact pressures and eventually leading to degenerative changes. The sequential progression of arthritis that ensues is referred to as scapholunate advanced collapse (SLAC) wrist.

Stage I SLAC wrist involves degeneration between the distal pole of the scaphoid and the radial styloid. In stage II, joint degeneration includes the scaphoid’s proximal pole and the entire scaphoid fossa. In the third stage, the capitate drifts proximally between the scaphoid and lunate, and the capitolunate articulation degenerates. Another form of scaphoid pathology associated with wrist arthritis is that which results from nonunion or malunion after a scaphoid fracture. This arthritic condition also follows a predictable pattern of progression, known as scaphoid nonunion advanced collapse (SNAC).

Proximal Row Carpectomy Indications

The indications for the Proximal Row Carpectomy include:

  1. degenerative conditions of the proximal carpal row, such as SLAC, SNAC, chronic perilunate dislocation,
  2. Preiser’s disease,
  3. Kienböck’s disease.
  4. Complex fracture dislocation of the wrist.
  5. Failed carpal implants
  6. cerebral palsy and spasticity.

Contraindications

The relative contraindications to Proximal Row Carpectomy are:

  1. multicystic carpal disease,
  2. preexisting ulnar translocation of the carpus,
  3. degenerative changes of the lunate fossa or capitate head.
  4. Inflammatory arthropathy (high failure rate).
proximal row carpectomy surgery xray

Proximal Row Carpectomy Surgery

Proximal Row Carpectomy can be performed with open technique or arthroscopic technique:

Arthroscopic Technique

The patient is placed in the supine position, with the affected upper extremity on a radiolucent hand table. Operative time is usually less than 2 hours, and regional or general anesthesia is adequate for this procedure. A well-padded tourniquet is wrapped around the upper arm, and the wrist is suspended in a traction tower with 10 to 15 pounds applied. The tourniquet is inflated, but additional exsanguination is unnecessary. After distraction is introduced, the dorsal aspect of the wrist is palpated for landmarks, and the portals are made. The 3-4 portal is routinely used as the primary viewing portal.

Arthroscopic Proximal Row Carpectomy

To perform an arthroscopic Proximal Row Carpectomy, the required instruments include:

  1. a traction tower,
  2. a 2.7-mm arthroscope,
  3. a hook probe,
  4. a 2.9-mm shaver or radiofrequency tool,
  5. a 4.0-mm burr,
  6. small osteotomes,
  7. pituitary rongeurs,
  8. image intensification equipment.

The 2.7-mm arthroscope is introduced after the radiocarpal joint is insufflated with saline solution. A 6-R outflow portal is created under direct visualization at the pre-styloid recess. Constant intra-articular pressure and flow are maintained with a mechanical pump. The joint is inspected in a routine fashion, with particular attention directed to the lunate fossa of the distal radius. The volar extrinsic ligaments are identified and preserved throughout the procedure—particularly the radioscaphocapitate, because it plays an essential role in stabilizing the new joint and preventing volar dislocation and ulnar translocation of the distal carpal row. The ulnar extrinsic ligaments and triangular fibrocartilage complex are identified as the arthroscope is directed ulnarly.

To assess the integrity of the proximal capitate surface, the midcarpal joint is visualized. If the quality of this cartilaginous surface is questionable, we proceed to an alternative procedure (i.e., four-corner fusion, capitolunate arthrodesis, Proximal Row Carpectomy with interpositional arthroplasty, or wrist arthrodesis). Visualization of the midcarpal joint is performed by establishing a radial midcarpal portal. This location is determined by measuring approximately 1 cm distal to the 3-4 portal.

After the surgeon is satisfied with the status of the cartilaginous surfaces of the proximal capitate and lunate fossa, the first step in performing the Proximal Row Carpectomy is to remove the scapholunate and lunatotriquetral ligaments with a shaver or radiofrequency probe. This step is carried out through the 4-5 portal or the 6-R portal, or both. This is followed by removal of the core of the lunate with a burr. Care is taken not to damage the proximal capitate or lunate fossa, which is accomplished by leaving behind an eggshell rim of the lunate. This remainder of the lunate is then morcellized with a pituitary rongeur under direct vision or image intensification.

The next step is fragmentation of the scaphoid and triquetrum with an osteotome and burr under image intensifi cation and removal of the fragments in a piecemeal fashion with a pituitary rongeur while working through the 3-4 or 4-5 portal. The surgeon can ensure easy removal and greater protection of the articular cartilage by first coring out and fragmenting these carpal bones.

After the entirety of the proximal carpal row has been removed, the wrist is examined under image intensification. Special attention is paid to the radial styloid area to be sure there is no impingement against the trapezium. Some surgeons recommend a moderate styloidectomy. Although we rarely carry out this aspect of the procedure, it can be done quite easily with the aid of the image intensifier.

If the surgeon chooses, a posterior interosseous neurectomy can be performed through a separate 1.5-cm incision just on the ulnar side of Lister’s tubercle. The fourth extensor compartment is opened on its radial side, and with a bipolar electrocautery, 1 cm of the nerve is resected. The fourth compartment is repaired with absorbable suture, and all wounds are closed with a 4-0 nylon monofilament suture.

Proximal Row Carpectomy arthroscopic surgery
Removal of distal ulnar pole of scaphoid

Postoperative Rehabilitation

Initially, patients are placed in a short arm volar plaster splint. Between 7 and 10 days postoperatively, the portal sutures are removed, and immobilization is continued with a short arm thermoplastic splint for an additional 3 weeks. At 4 weeks, the splint is removed and gentle range-of-motion exercises are begun. Strengthening is started approximately 8 weeks after surgery.

Complications

Arthroscopic Proximal Row Carpectomy has several potential complications, they include:

  1. Infection and neurovascular embarrassment, which results from use of the osteotomes and may involve the dorsal ulnar sensory, median, and especially the ulnar nerves.
  2. Iatrogenic articular cartilage damage must be avoided, especially at the lunate fossa and proximal capitate.
  3. The surgeon must not violate the extrinsic ligaments, particularly the radioscaphocapitate ligament, while excising the proximal carpal row. This is accomplished by coring out these carpals in such a way that a thin shell of cortical bone is left attached to the volar radiocarpal ligaments.

Open Technique

Proximal Row Carpectomy surgery is performed as following:

Make a transverse incision on the dorsum of the wrist 5 to 10 mm distal to the radiocarpal joint and extending from the dorsal aspect of the ulnar styloid to the radial styloid. Deepen the incision to the extensor retinaculum, preserving the sensory branches of the radial and ulnar nerves. Ligate and divide the superficial veins.

Divide the retinaculum longitudinally on the radial and on the ulnar sides of the extensor digitorum communis tendons; avoid damaging the extensor pollicis longus tendon as it crosses the wound diagonally.

Expose the dorsum of the proximal row of carpal bones through two longitudinal incisions in the capsule—one in the interval between the extensor digitorum communis tendons and the extensor carpi ulnaris and one between the extensor carpi radialis brevis tendon and the extensor digitorum communis.

If the capitate articular surface shows erosion, fashion a capsular flap, based distally, by connecting the parallel capsular incisions with a transverse incision, proximally, near the dorsum of the distal radial articular surface. (Because the extensor pollicis longus tendon crosses this area diagonally, it can be retracted medially or laterally as necessary.)

Expose the lunate by elevating the capsule of the wrist beneath the extensor digitorum communis tendons; insert a threaded pin into the lunate, apply traction to the bone through the pin, and excise the bone by dividing its capsular attachments with sharp pointed scissors. A small, angled cleft palate blade also is helpful. Carefully fragment the lunate with a small bone cutter, osteotome, or saw to facilitate removal.

Proximal Row Carpectomy surgery
Exposure and morcellization of scaphoid and lunate between second and fourth dorsal compartments.

Insert the pin into the triquetrum, and excise it in a similar manner. (The lunate and triquetrum are excised first to provide more space for the more difficult excision of the scaphoid.)

Through the more radial of the two incisions in the capsule, excise the ulnar fragment of the scaphoid first in the manner just described and then the radial fragment, but dissect close to this fragment to avoid injuring the radial artery.

Align the capitate with the lunate fossa. Use a Steinmann pin to stabilize the capitate if needed. If the palmar radiocapitate ligament is preserved, this may be unnecessary. Obtain hemostasis or drain the wound as needed, and close the wound in layers. Apply a sugar-tong splint with the hand and wrist in a functional position.

The wrist is immobilized in slight extension and with the hand in the functional position in a plaster sugar-tong splint for 2 or 3 weeks. If a Steinmann pin has been used, it is removed at about 4 weeks. Active motion of the digits is encouraged soon after surgery and is continued throughout the convalescence. When the soft tissues have healed, active motion of the wrist is increased gradually. Active exercises to strengthen grip are of utmost importance.

Proximal Row Carpectomy surgery
Exposure of triquetrum between fourth and fifth extensor compartments for triquetrum excision. ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; EIC, extensor indicis communis; EDQP, extensor digiti quinti proprius; EDL, extensor pollicis longus.

References

  1. Campbel’s Operative Orthopaedics 12th edition Book.
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Last Reviewed
August 16, 2022
Contributed by
OrthoFixar

Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice.

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