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Proximal Row Carpectomy (for advanced arthritic wrist pain)

    Overview

    Learn the Proximal Row Carpectomy (for advanced arthritic wrist pain) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Proximal Row Carpectomy (for advanced arthritic wrist pain) surgical procedure.
    This is a detailed step by step instruction through a proximal Row Carpectomy (PRC), a procedure in which the proximal row of carpal bones (Scpahoid, Lunate and Triquetrum) are removed.
    The PRC is a salvage operation usually undertaken for wrist pain when the scaphoid fossa is damaged and arthritic. The most common cause for this is a Scapho-Lunate advanced collapse (SLAC) stage 2. The procedure can also be used for Keinbock’s disease, proximal carpal row instability resistant to initial surgery or if the wrist needs to be shortened due to trauma or Volkmann’s ischemic contracture.
    The critical point in planning this surgery is that the lunate fosse of the radius and the proximal capitate must be free from damage.
    During the surgery the wrist capsule is tightened and allowed to scar up to create a stable but mobile Neo-wrist joint.
    Following a period of 6-8 weeks in plaster cast and then rehabilitation, it is expected the patient will achieve around 50% of their normal range of movement.
    Once the wrist is fully healed and strengthened around 6 months post surgery then heavy work is possible although the range of motion and grip strength will be limited to around 50% and 65% respectively.
    One of the common alternative treatments to PRC is a four corner fusion. The advantage of a PRC over the technique is a slightly increased post operative range of movement, a lack of a need for metalwork, the PRC is less technically demanding and no bone healing required, an advantage in the unrepentant smoker.
    Readers will also find of interest the OrthOracle instructional technique Four Corner carpal Fusion using Medartis plate and scaphoid excision

    Indications

    Indications
    The PRC is a salvage procedure used to treat:
    Articular damage to the scaphoid fosse (radius fracture, SLAC 2) – The PRC sites the capitate on the radius and therefore the arthritic scaphoid fossa no longer has any bony contact to cause pain.
    Collapse of the lunate (Keinbock’s, fracture) – The PRC removes the Lunate which has reduced vascularity and has collapsed.
    Proximal carpal row instability (Peri-lunate non-dislocation injuries – PLIND) – Gross instability between the whole proximal row after Scapho-lunate and Luno-triquetreal injuries can be difficult to resolve and if initial ligament stability surgery fails then a PRC may be used to treat the persisting pain and instability.
    To allow shortening of the length of the wrist (e.g. trauma, Volkmann’s contracture of forearm muscles). In forearm crush or compartment syndrome the flexor and extensor tendons may contract and cause a contracture of the wrist . A PRC can be used to create laxity in the wrist capsule and tendons to improve movement and function.
    Symptoms
    The symptoms experienced will depend on the underlying pathology however, in the main the operation is undertaken for pain or dysfunction due to instability.
    Patients with degenerative change in the scaphoid fossa or lunate collapse will complain of pain on movement and loading and occasionally pain at rest in more severe cases. Patients with instability often complain of a painful clunk or a reluctance to use the hand for loading tasks due to its unreliability or pain when they experience the clunking.
    The patient’s job and hobbies often play a major role in their symptoms and therefore discussing these details and realistic expectations of the post-operative outcomes are essential in treatment selection.
    Examination
    For the arthritic patient (SLAC etc.) the patients often already have a reduced range of movement and complain of pain during active and passive movement especially at the end of range and into radial deviation. Palpation over the affected joint can be painful due to synovitis.
    The wrist is palpated systematically, usually starting away from the most painful site and progressing around the wrist generally over the radio-carpal, mid-carpal and distal radio-ulna joint lines but also more specifically over bony prominences such as the scaphoid tubercle, pisiform and hook of hamate. Palpation may also yield more information with different wrist positioning i.e. in flexion more of the scapho-lunate ligament is exposed to palpation and in ulnar deviation more of the waist of the scaphoid is palpable beyond the radial styloid. On the ulna side of the wrist tenderness over the Extensor carpi ulnaris (ECU) may actually be deeper pain within the TFCC and can be differentiated by palpation in supination where the tendon lies more dorsally and pronation where it lies more ulnarly.
    It is useful during the examination to try to elicit which joint (radiocarpal or midcarpal or both) the patient’s movement is coming from as often pre-operatively there has already been a loss of movement at the arthritic joint and therefore the post-operative range of movement is likely to be 50% of the normal movement not the pre-operative range.
    A Kirk-Waston test is often painful as this will shear the scaphoid in its fossa and irritate both the Radio-scaphoid joint and Scapho-trapezium-trapezoid (STT) joint.
    The Kirk-Watson test for SLIL instability
    The thumb is placed over the scaphoid tubercle and the index finger over the SLIL just distal to Lister’s tubercle. The wrist is take from ulnar to radial deviation with pressure applied to the tubercle. In a competent ligament the thumb is pushed away by the tubercle. In a incompetent ligament the volar tubercle pressure resists the scaphoid flexion and the proximal pole of the scaphoid dorsally subluxes off the scaphoid fosse of the distal radius with a clunk. When the wrist is take back into ulnar deviation another clunk is felt as the scaphoid proximal pole relocates.
    STT arthritis
    Focal volar STT joint pain. A painful Kirk Watson test with more pain in radial deviation and on the more palmar rather than dorsal as seen in SLIL tears.
    For instability cases, a Kirk-Watson test may be positive if SLAC is the pathology although it is often just painful with no clunking. There may be a positive mid-carpal clunk (Lichtman test) in the hyperlaxity patient or those with Luno-triquetral or volar extrinsic ligament injuries. A positive Reagan test or Kleinman Shuck test may also be present with underlying Luno-triquetral injuries.
    It may be difficult to elicit a positive result in some of these tests if pain is a major issue and the patient’s wrist is not relaxed during the examination.
    Lichtman test
    Stabilise the forearm in pronation and 15 degrees of ulnar deviation and apply direct pressure palmarly over capitate. Axial load wrist and further ulnar deviate to reproduce clunk and pain.
    Reagan test
    Stabilise the lunate between thumb and index finger of one hand and shear the triquetrum and pisiform volar to dorsal with the thumb and index finger of the other to reproduce pain and feel excess mobility
    Kleinman Shuck
    Place thumb over dorsum of lunate, index finger over pisiform. Squeeze thumb and index finger together. Displacing pisiform dorsal causes pain in lunotriquetral joint.

    Investigations
    Investigations include plain PA and lateral radiographs which can reveal which joints are arthritic. This may be enough to decide on treatment however if patients have marked pain with minimal X-ray changes then further investigations may be required to plan treatment.
    A CT scan can be useful and on occasion in SLAC wrists the scaphoid fossa appears falsely normal on plain radiograph and on a CT the scaphoid can be seen sitting on the dorsal lip of the radius confirming the diagnosis.
    An MRI can be useful to review the cartilage coverage of the essential lunate fosse of the radius and proximal capitate and if degeneration is found on these sites the a PRC is rule out as a treatment option .
    For the mid-carpal instability, hyperlaxity patients with no arthritis, a diagnostic arthroscopy may be the only way to determine if there are any ligament injuries (if MRI is normal). It can help decide if the wrist could be managed without a major fusion or excision operation like PRC if a single ligament reconstruction is an alternative.
    Non-operative Management
    Non-operative management for arthritis includes, analgesia, activity modification, wrist splinting, physiotherapy with wrist strengthening. Steroid injections may be used for diagnosis and temporary pain relief.
    For instability patients with no ligament injury, the key is to strengthen the wrist not only as a potential curative therapy but it is essential to optimise the wrist strength before any surgery for best outcomes.
    For these instability patients, a wrist splint which applies Pisiform pressure to support the ulnar carpus can also be useful.
    The PRC in Keinbock’s is used when the lunate itself is unsalvageable.
    Alternative operative Management
    The alternative operation to a PRC will depend upon the underlying pathology and surgeon’s skill and familiarity with these procedures.

    Scaphoid fossa arthritis – e.g. Trauma, SLAC stage 2 (where proximal capitate preserved) –
    Wrist Denervation to reduce pain with minimal surgical insult,
    4 Corner fusion – used as alternative to PRC or when the proximal capitate is damaged
    Limited wrist fusion (capito-lunate with scaphoid excision, radio-scapholunate with distal scaphoid exicision)
    Total wrist arthroplasty – to maintain movement although more complex procedure with likely future revision surgery
    Keinbock’s salvage surgery
    Wrist denervation to reduce pain with minimal surgical insult,
    Total wrist fusion,
    Lunate prosthetic replacement – pyrocarbcn replacement held with ligament FCR sling.
    Midcarpal instability with no arthritis
    Ligament stabilisations (e.g. ECRB transfer through capitate and triquetrum)
    Partial wrist fusions (capito-lunate).
    Contraindications
    Lunate fossa or proximal capitate arthritis.

    Setup

    Pre-operative preparations and Equipment
    The operation can be performed under general or regional anaesthetic. As the duration of surgery is around 2 hours, a sterile Esmarch is used once the skin markings are completed to reduce tourniquet time and access to a sterile forearm tourniquet may useful if the patient under regional anaesthetic starts to struggle with tourniquet pain. Tourniquet is set to 250mmHg.
    Equipment – Fine bone nibblers, plaster cast.
    A single dose of antibiotics are given pre-operatively.

    Operation – 1

    The surface anatomy is marked.
    After the arm is prepped and draped, the dorsal surface anatomy is marked.
    The Carpo-metacarpal joints – CMCJ
    Lister’s tubercle – LT
    The outline of the distal radio-ulna joint – DRUJ
    The planned dorsal incision is then drawn in the midline, a 5cm incision from a point level with the LT then travelling distally.
    NB – The arthroscopy portals created prior to the PRC can also be seen in this picture. This is not routine. However if there are concerns regarding cartilage cover of the lunate fosse and proximal capitate due to the underlying pathology/injury it may be necessary it proceed choose the best operative intervention.

    The skin is incised.

    Subcutaneous fat is dissected and superficial veins coagulated.As this is a midline incision there are not major nerve in the wound however branches of the superficial radial nerve may be present on the radial aspect of the incision.

    The subcutaneous fat is swept off the extensor retinaculum (ER) to reveal its transverse fibres.The scissors are pointing to the ER.

    The ER is divided with sharp dissection over the 4th extensor compartment (EC).The incision through the ER is not extended proximally to the LT as this means that the ER will not need to be formally repaired later on.
    The 4th EC contains the Extensor digitorum communis and Extensor Indicis tendons.

    This slide shows the Extensor indices (held in the forceps) which can been seen as the most distally based muscle belly at the wrist, justifying is ‘meat to the wrist’ description.

    Blunt dissection is performed distally and radially to reveal the tendons of the second EC.During the dissection, the Extensor pollicis longus is not seen as it deviates radially over the 2nd EC (Extensor Carpi Radialis Brevis (ECRB) and Longus (ECRL) more proximally).
    The dissection need to extend to the 2nd EC as this lie over the radial styloid which need to be accessed to remove the scaphoid.

    The extensors are retracted and the Posterior interosseous nerve is identified.A West retractor is used to retract the extensor tendons. The smaller side is placed under the ECRL/B and the larger side under the finger extensors.
    At the base of the 4th EC the posterior interosseous nerve and artery (PIN, PIA) can be seen. This is a branch of the radial nerve and travels along the interosseous membrane and is predictably on the radial aspect of the bed of the 4th EC. Distally it inserts into the joint capsule to supply the wrist capsule and ligaments with proprioception and pain sensation.
    PIN pointed out by the forceps.

    The capsular incision is extended radially to the tip of the styloid.The West retractor is removed and a Ragnell is used to elevate the ECRL/B tendons to incise more radially and access the tip of the styloid.

    With the capsule further retracted, the Scaphoid, lunate and scapho-lunate ligament (SLIL) is seen.
    The scissors can be seen pointing at the SLIL.

    Lunate located deep the forceps below the extensor tendons.

    The capsule is retracted and its attachments to the distal lunate and scaphoid are released, opening the mid-carpal joint.The capsule is lifted under tension and its deep attachments to the distal lunate and dorsal ridge of the scaphoid are cut with scissors to open the mid-carpal joint.

    The capsule is incised on its ulnar aspect.For ease of access the finger extensors are retracted radially now and the incision is continued deep onto the back of the triquetrum.
    Be careful not to extend the incision proximally to the TFCC or too superficial in the ulnar direction into the ER where the Extensor Digiti Minimi is located.
    EDC/I – Tendons of the 4th EC
    ER – The roof of the 4th compartment is reflected here with EDM deep to the forceps and vulnerable to iatrogenic injury.

    The radio-carpal joint capsule is incised along the line of the radial styloid.The dorsal distal edge of the radius is palpated and progressing radially the radial styloid can be felt easily. The capsule is incised along this joint line leaving a small lip of capsule is left on the radius to allow repair on closure.

    The ulnar incision is joined with the radial incision beneath the extensors.Take care not to injure the extensor tendons at this point.
    A skin hook creating traction on the capsule can assisted the final joining of the two capsular incisions.

    The whole capsular flap is retracted distally after being peeled off the dorsal triquetrum.The capitate is pointed out by the forceps now the mid-carpal joint is open.
    With both mid-carpal and radio-carpal joints open, the articular surfaces can be examined to check they are not damaged and therefore amenable to continue the PRC: (Normal proximal Capitate and the Lunate fosse of Radius cartilage).
    The dorsal Scapho-lunate ligament is also cut at this point.
    ECRL/B
    Lunate
    SLIL – Scapho-lunate interosseous ligament

    The Luno-triqutral ligament is divided.The knife is place in the Luno-triqutral joint which can be seen as transverse fibres.
    The knife can be used to find the gap between the lunate and Triquetrum by firm probing until it drops between the bones.
    Sc – Scaphoid
    L – Lunate
    Tq – Triqutrum

    The scaphoid is split with an osteotome.Care is taken to protect the Capitate with a McDonald retractor during this step.
    Sc – Scaphoid
    C – Capitate

    The proximal scaphoid is excised.Just the proximal part of the scaphoid is removed at this point with a combination of bone nibblers and sharp dissection. The distal half of the scaphoid will be easier to removed once the Lunate and Triquetrum are excised.
    Sc – Cancellous bone of waist of scaphoid at level of the osteotomy

    The Lunate can be seen to have a proximal ulnar defect in its cartilage.
    L – Lunate
    4 – Grade 4 damage of cartilage (Outerbridge)

    The Lunate is split with an osteotome into volar and dorsal sections. Once again take care to protect adjacent articular surfaces from damage. In this case the Lunate fosse of the Radius.
    This can be achieved by placing a McDonalds retractor on the opposite side of the bone to protect the distal radius cartilage.
    Care also should be take when using the bone nibblers to not snatch at the bone and cause iatrogenic injury to the adjacent cartilage.
    L – Lunate
    Sc – Scaphoid

    The rest of the Lunate is excised with bone nibbler and sharp dissection.One can attempt to remove the Lunate in one piece although this is more difficult and increases risk of damage to the volar arcuate ligament of the wrist which should be preserved to add stability in the post-op recovery.
    If injured the arcuate ligament should undergoing direct repair with suture.
    L – Lunate
    C – Capitate

    The Capitate now can be clearly seen and the Triquetrum is being indicated with the blade at the bottom of the picture.
    C – Capitate

    The dorsal ligaments are sharply dissected off the TriquetrumThe ligaments are that of the Dorsal radio-carpal and Dorsal inter-carpal which are attached to the dorsum of the Triquetrum. Using sharp dissection on the dorsal surface of the Triquetrum all the soft tissue are elevate of to allow the bone to be mobilised.
    Tq – Triquetrum
    C – Capitate
    H – Hamate

    The sharp dissection is continued around the ulnar and volar aspects of the Triquetrum until it is free.Tq – Triquetrum
    C – Capitate
    H – Hamate

    The Triquetrum can be seen excised whole with the helicoid hamate articulation at the upper aspect of the bone.

    Operation – 2

    With most of the proximal row removed, the wrist capsule is now more lax and now allows easier access to the rest of the Scaphoid.
    Sc – Scaphoid
    C – Capitate
    H – Hamate

    A retractor is placed in the Scapho-trapezio-trapezoidal joint (STT) joint.This exposes the rest of the Scaphoid for excision.
    Sc – Scaphoid
    C – Capitate

    The Scaphoid is split again with an osteotome.The Capitate once again is protected during this stage and the Scaphoid removed with bone nibblers.
    Sc – Scaphoid
    C – Capitate

    The baggy volar wrist capsule can be seen pointed at by the Watson-Cheyne elevator.
    C – Capitate

    With most of the tubercle removed the Radio-scapho-capitate (RSC) ligament can be seen in the base of the wound.
    C – Capitate
    RSC – Radio-scapho-capitate

    The space where the Scaphoid tubercle was is seen distal to the RSC ligament and with a few fragments of bone still remaining which will be removed with the bone nibblers.
    C – Capitate
    T – Space left by removing scaphoid tubercle.

    The Capitate is formally inspected for damage.Now all the bony work is done the proximal Capitate cartilage is inspected for wear and iatrogenic damage as this will now be the main load bearing joint and sit in the lunate fosse of the radius.
    In this case there is some mild Grade 2 wear on the dorsal third and a small area of Grade 4 wear ulnarly where the Capitate will not articulate with the Radius.
    C – Capitate
    H – Hamate
    The Outerbridge classification for cartilage wear is as follows:
    1 – Softening and swelling of cartilage
    2- Superficial fissuring of cartilage
    3- Fissuring to sub-chondral bone
    4- Exposed sub-chondral bone

    The Radius’ cartilage is inspected in particular the Lunate fosseNormal cartilage is seen on the Radius in this case
    ScF – Scaphoid Fosse
    LF – Lunate Fosse

    The capsule is closed with a 3/0 vicryl.With the lip of the capsule that was left on the Radius, the capsule is closed with some slight overlap and reefing to tighten the now loose joint capsule.
    One variation to this procedure is the possible interposition of the dorsal capsular into the joint in an attempt to pad the joint to reduce future wear. The is no clear evidence to suggest this is beneficial and therefore is not the preference chosen here.

    The self retainer is removed to allow the tendons to resite.
    As noted previously the ER needs no repair as it has not be released proximally over the radius.
    ER – Extensor retinaculum
    EDC/EIP – Tendons of 4th EC

    The skin is closed with 4/0 vicryl rapide.

    An adherent dressing is applied.

    Gauze and wool is applied and split to allow for swelling.The wool is split (see image) then covered with a layer of non circumferential wool to allow for swelling and reduce painful constriction of the dressings.

    A dorsal slab of plaster cast is applied.

    The PA pre-operative radiograph reveals well preserved joint spaces and normal bony alignment but a cyst in both the Lunate and Triquetrum is present.
    The patient had previously injured their wrist and been treated in cast elsewhere with no clear diagnosis. With continued pain they developed a Chronic regional pain type picture and it was felt a single definitive operative was required to end their 18 months of pain.

    Lateral pre-operative radiograph appearing normal.
    No carpal mal-alignment was seen.

    Pre-operative MRI revealing marked cysts and oedema in the Lunate and Triquetrum with the cysts exiting proximally.
    No clear ligamentous injury was identified.

    Post-operative PA radiograph with Capitate in situ resting in Lunate fosse.

    Post-operative lateral radiograph with Capitate in situ resting in Lunate fosse.

    Post Operative

    As this is a painful operation, it is paramount to advise the patient that it is very painful, advise strict elevation in a sling provided and provide opiate analgesia.
    We provide Ibuprofen, paracetamol, codeine and oral morphine with an antiemetic (cyclizine) and laxative (Senna).
    Patients are sent home the same day and return to clinic for a wound review and cast change within the week.
    At this point the wrist is still swollen and will need reviewing again in another week for conversion to a full cast.
    If the fingers are stiff at this point a hand therapy review with the new cast in place is advised.
    The cast is then continued for another 4 weeks to make a total of 6 weeks in cast.
    Once the cast is discontinued and PA and lateral X-ray of the wrist is performed. If all is as expected then start hand therapy for wrist movement active and passive.
    It is expected that patients will regain 30 degrees wrist extension and 30 degrees wrist flexion.
    It will usually take patients 8-10 weeks to return to light work and 4-6 months to return to heavy work.


    Recommended Reading

    Complications
    Following PRC, there is around a 15% complication rate with the most common issues being wrist pain, stiffness, oedema and synovitis. Tendon injury, infection, nerve injury and CRPS are uncommon but possible complications.
    Grip strength is expect to be around 65% of normal and with patients achieve a movement arc of around 75 degrees.
    Over the longer term (10 years), due to the incongruent proximal Capitate and Lunate fosse, 50% will develop moderate to severe wrist arthritis. The radiographic picture correlates poorly with the clinical picture in these patients and only 14% require wrist arthrodesis within 10 years.

    Below are two papers which can be read to provide further information on the outcomes of PRC.

    B M Saltzman, J M Frank, W Slikker, J J Fernandez, M S Cohen, R W Wysocki. Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: a systematic review. J Hand Surg Eur Vol. 2015 Jun;40(5):450-7.
    Saltzman et al reviewed 7 studies including 242 wrists. They concluded that for 4 corner fusion and PRC respectively the average wrist extension was 39 vs 43 degrees, flexion 32 vs 36 degrees, wrist arc 62 vs 75 degrees and grip strength 74% vs 67% of normal.
    A complication rate of 29% vs 14% was seen with the most common complication in PRC being synovitis and oedema (3%).
    In summary, the PRC provides a better range of movement with a lower complication rate but a lower grip strength than a 4 corner fusion.

    Chim, S. Moran. Long-term outcomes of proximal row carpectomy: a systematic review of the literature. J Wrist Surg. 2012 Nov;1(2):141-8.
    Chim et al reviewed 6 studies with 10 or more years follow up which included a total of 147 patients. The majority of patients were male labourers. Grip strength was around 68% of normal post-op and there were 14% failures needing further surgery at a mean 54 months
    On assessing the radiographic deterioration of the wrist, the authors did not find that the clinical picture, or need for revision surgery, correlated closely with radiographic degeneration.

    Reference

    • orthoracle.com

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