Anesthesia
Either regional or general anesthesia is used, according to the discretion
of the anesthesiologist and the patient's wishes. At our institution, regional
nerve blocks are commonly administered as an adjunctive means of providing
postoperative analgesia.
Positioning
The patient is positioned supine on the operating table with the affected
arm abducted 90° on a hand table. A tourniquet placed high on the brachium
is used to achieve a bloodless field.
Skin Incision
A dorsal longitudinal incision, 7 to 8 cm in length, is placed just radial
to the Lister tubercle (Fig.
1). Dissection is carried down to the extensor retinaculum.
Cutaneous flaps are elevated radially and ulnarly, with care taken to protect
the sensory branches of the radial and ulnar nerves.
Carpal Exposure
The extensor pollicis longus tendon is readily identified distal to the
retinaculum as it crosses obliquely over the radial wrist extensors
(Fig. 2). The retinaculum
overlying the third dorsal compartment is divided in its entirety with use of
scissors. The extensor pollicis longus is mobilized by placing a rubber tape
around its tendon, and it is retracted radially. Just deep to the extensor
pollicis longus, the extensor carpi radialis brevis is identified as it runs
longitudinally to insert at the base of the third metacarpal. The extensor
carpi radialis brevis tendon is also retracted radially. The posterior
interosseous nerve is identified beneath the extensor tendons of the fourth
dorsal compartment, and a 1-cm segment is resected. The dorsal capsule is
longitudinally incised parallel to the extensor carpi radialis brevis, with
care taken not to score the hyaline cartilage on the head of the capitate.
Capsular flaps are then reflected radially and ulnarly from the distal part of
the radius. Care should be taken to stay in the subperiosteal plane and to
avoid entering the dorsal compartments. Distally, the capsule is elevated from
the carpus in a similar fashion so that the scaphoid, lunate, and triquetrum
are visualized (Fig. 3).
Inspection
The integrity of the articular surfaces of the head of the capitate and the
lunate facet of the distal part of the radius is then inspected. If there is
loss of cartilage or eburnated bone on either of those surfaces, a proximal
row carpectomy is contraindicated and the surgeon should consider an
alternative procedure such as scaphoid excision with four-corner arthrodesis
or a total wrist arthrodesis. If there is any question with respect to proper
identification of the carpal bones, fluoroscopy with a metal probe should be
used for confirmation.
Removal of Carpal Bones
There are many techniques for removing the scaphoid, lunate, and
triquetrum. We remove the scaphoid first and start by sharply dividing the
scapholunate interosseous ligament. Next, a threaded 1/8-in (3.2-mm) Steinmann
pin is inserted into the scaphoid in a dorsal-proximal to volar-distal fashion
to serve as a joystick. In addition, small Homan retractors are placed beneath
the distal pole (tuberosity) of the scaphoid to facilitate removal of the
entire bone (Fig. 4). With use
of sharp dissection with a #15 blade, the volar capsular and ligamentous
attachments are reflected from the scaphoid and the bone is removed in one
piece. Attention is then turned to the removl of the lunate and triquetrum.
These bones are usually easier to remove than is the scaphoid. Care must be
exercised not to damage the head of the capitate or the lunate fossa of the
distal part of the radius. Again, a threaded Steinmann pin can be used as a
joystick to facilitate removal of these bones.
CRITICAL CONCEPTSINDICATIONS:The articular surfaces of the capitate head and the lunate fossa of the
distal part of the radius must contain intact articular cartilage. The
indications for the procedure include:Scapholunate ligament disruption with radiocarpal arthritis (a scapholunate
advanced collapse [SLAC] wrist)Scaphoid nonunion with radiocarpal arthritis (a scaphoid nonunion advanced
collapse [SNAC] wrist)Kienböck disease with collapseUnreduced perilunate or transscaphoid perilunate dislocationChronic perilunate dislocationsFailed silicone lunate or scaphoid arthroplastyOsteonecrosis of the scaphoid (Preiser disease or posttraumatic
osteonecrosis)Severe flexion contractures associated with systemic diseases such as
cerebral palsy or arthrogryposisCONTRAINDICATIONS:Degenerative changes on the head of the capitate or on the lunate fossa of
the distal part of the radius (Fig.
7).Inflammatory arthropathy (e.g., rheumatoid arthritis). Typically, the
articular surfaces of the capitate and the distal part of the radius are
involved by inflammatory arthropathies so there is a high rate of failure of
proximal row carpectomy in patients with this type of
disease2,3.An active patient, especially one who is less than thirty-five years old.
(This is a relative contraindication.)PITFALLS:Injury to the dorsal sensory branch of the radial or ulnar nerve during
subcutaneous dissection.Failure to look for and recognize loss of articular cartilage from the
capitate head and from the lunate fossa of the distal part of the radius. If
there is evidence of chondromalacia on those surfaces, either scaphoid
excision with four-corner arthrodesis or total wrist fusion should be
considered.Iatrogenic damage to the articular surface of the capitate or the lunate
fossa of the distal part of the radius during removal of the bones in the
proximal row.Damage to volar radiocarpal ligaments (especially the radioscaphocapitate
ligament) during removal of the proximal row, as this could produce ulnar
translation of the carpus.AUTHOR UPDATE: There have been no changes in the surgical technique
since publication of the original article.
CRITICAL CONCEPTS
INDICATIONS:
The articular surfaces of the capitate head and the lunate fossa of the
distal part of the radius must contain intact articular cartilage. The
indications for the procedure include:
Scapholunate ligament disruption with radiocarpal arthritis (a scapholunate
advanced collapse [SLAC] wrist)Scaphoid nonunion with radiocarpal arthritis (a scaphoid nonunion advanced
collapse [SNAC] wrist)Kienböck disease with collapseUnreduced perilunate or transscaphoid perilunate dislocationChronic perilunate dislocationsFailed silicone lunate or scaphoid arthroplastyOsteonecrosis of the scaphoid (Preiser disease or posttraumatic
osteonecrosis)Severe flexion contractures associated with systemic diseases such as
cerebral palsy or arthrogryposis
Scapholunate ligament disruption with radiocarpal arthritis (a scapholunate
advanced collapse [SLAC] wrist)
Scaphoid nonunion with radiocarpal arthritis (a scaphoid nonunion advanced
collapse [SNAC] wrist)
Kienböck disease with collapse
Unreduced perilunate or transscaphoid perilunate dislocation
Chronic perilunate dislocations
Failed silicone lunate or scaphoid arthroplasty
Osteonecrosis of the scaphoid (Preiser disease or posttraumatic
osteonecrosis)
Severe flexion contractures associated with systemic diseases such as
cerebral palsy or arthrogryposis
CONTRAINDICATIONS:
Degenerative changes on the head of the capitate or on the lunate fossa of
the distal part of the radius (Fig.
7).Inflammatory arthropathy (e.g., rheumatoid arthritis). Typically, the
articular surfaces of the capitate and the distal part of the radius are
involved by inflammatory arthropathies so there is a high rate of failure of
proximal row carpectomy in patients with this type of
disease2,3.An active patient, especially one who is less than thirty-five years old.
(This is a relative contraindication.)
Degenerative changes on the head of the capitate or on the lunate fossa of
the distal part of the radius (Fig.
7).
Inflammatory arthropathy (e.g., rheumatoid arthritis). Typically, the
articular surfaces of the capitate and the distal part of the radius are
involved by inflammatory arthropathies so there is a high rate of failure of
proximal row carpectomy in patients with this type of
disease2,3.
An active patient, especially one who is less than thirty-five years old.
(This is a relative contraindication.)
PITFALLS:
Injury to the dorsal sensory branch of the radial or ulnar nerve during
subcutaneous dissection.Failure to look for and recognize loss of articular cartilage from the
capitate head and from the lunate fossa of the distal part of the radius. If
there is evidence of chondromalacia on those surfaces, either scaphoid
excision with four-corner arthrodesis or total wrist fusion should be
considered.Iatrogenic damage to the articular surface of the capitate or the lunate
fossa of the distal part of the radius during removal of the bones in the
proximal row.Damage to volar radiocarpal ligaments (especially the radioscaphocapitate
ligament) during removal of the proximal row, as this could produce ulnar
translation of the carpus.
Injury to the dorsal sensory branch of the radial or ulnar nerve during
subcutaneous dissection.
Failure to look for and recognize loss of articular cartilage from the
capitate head and from the lunate fossa of the distal part of the radius. If
there is evidence of chondromalacia on those surfaces, either scaphoid
excision with four-corner arthrodesis or total wrist fusion should be
considered.
Iatrogenic damage to the articular surface of the capitate or the lunate
fossa of the distal part of the radius during removal of the bones in the
proximal row.
Damage to volar radiocarpal ligaments (especially the radioscaphocapitate
ligament) during removal of the proximal row, as this could produce ulnar
translation of the carpus.
AUTHOR UPDATE: There have been no changes in the surgical technique
since publication of the original article.
Some surgeons prefer to remove the bones piecemeal; however, we have found
that this takes longer and may risk injury to the volar capsule or ligaments.
During the removal of the carpal bones, care must be taken to not injure the
radiocarpal ligaments, which extend obliquely from the distal-volar lip of the
radius to the carpus. The radioscaphocapitate ligament, in particular, can be
visualized in the depths of the wound and must not be violated. It courses
from the radius and inserts onto the capitate, thereby preventing
postoperative ulnar translation of the carpus.
After the bones in the proximal row are removed, the capitate settles into
the lunate fossa of the distal part of the radius
(Fig. 5).
Radial Styloidectomy and Temporary Pinning of the Radius to the
Distal Carpal Row
Both of these techniques were frequently recommended in the past, but
neither is necessary. We do not routinely perform a radial styloidectomy.
Surgeons once argued that there could be impingement of the trapezium on the
styloid in radial deviation. However, anatomically, the trapezium is anterior
to the styloid. Furthermore, with an overly generous styloidectomy, there is a
risk of detaching the volar radiocarpal ligaments (specifically the
radioscaphocapitate ligament), which could lead to ulnar translation of the
carpus.
We do not pin the radius to the capitate because pinning does not offer any
benefit if a good capsular closure is performed and also because pinning is
associated with the risk of pin-track infection.
Closure
The capsule is closed with interrupted 2-0 nonabsorbable sutures. Biplanar
radiographs are then made to ensure that the head of the capitate is seated in
the lunate fossa of the distal part of the radius. No attempt is made to
replace the extensor pollicis longus in the third dorsal compartment, and the
retinaculum is approximated with a 3-0 nonabsorbable suture. A drain is
inserted deep to the subcutaneous tissue and is removed forty-eight hours
postoperatively. The subcutaneous tissue is approximated with a 3-0 absorbable
suture, after which the skin is closed. A bulky dressing, extending from the
fingertips to the midpart of the forearm, is applied. A volar plaster splint
is molded to maintain the wrist in 10° of extension. The tourniquet is
then deflated (Figs. 6-A, 6-B,
6-C, 6-D,
6-E,
6-F, 6-G,
6-H, 6-I,
6-J, 6-K).
Postoperative Management
The procedure can be done in either an inpatient or an outpatient setting.
The patient returns one week after the surgery for the wound to be checked and
the dressing to be changed. Digital motion is encouraged after the first
dressing change. The wrist is immobilized for three weeks, after which a range
of motion of the wrist is initiated, preferably with the supervision of a
qualified hand therapist. The patient wears a neutral thermoplastic wrist
splint, when he or she is not exercising the wrist, for an additional three
weeks. If there is wrist swelling, an elastic garment can be applied for edema
control. By six weeks, no immobilization is necessary and an aggressive
strengthening program can be initiated. Three months postoperatively, the
patient can return to full unrestricted activities.