Proximal row carpectomy with interposition arthroplasty using both capsular flap and acellular human dermal matrix

BACKGROUND

In cases of wrist arthritis, proximal row carpectomy (PRC) has been widely utilized and shown favorable long-term outcomes. However, its applicability is limited in cases where arthritis extends to the lunate fossa or capitate. Recently, surgical approaches combining various methods of interposition arthroplasty have been introduced to overcome these drawbacks. The purpose of this study was to perform PRC and interposition arthroplasty with dorsal capsule and acellular dermal matrix(ADM),and analyze the clinical outcomes of these procedures.

METHODS

Fourteen cases who underwent PRC and interposition arthroplasty using both dorsal capsular flap and ADM were retrospectively recruited. The researchers assessed the patients' Visual Analog Scale (VAS) pain score, Disabilities of the Arm, Shoulder and Hand (DASH) scores, range of motion (ROM), retear, and radiocarpal distance (RCD).

RESULTS

One year post-surgery, both the VAS pain scores, DASH scores, and ROM showed statistically significant improvement compared to before the surgery. Upon reviewing the radiological results, the postoperative mean RCD was 4.8 ± 0.8 mm and one year follow up mean RCD was 3.6 ± 0.5 mm at one year post-surgery. Moreover, in the one year follow-up, there was no observed failure of the allodermis graft in any of the cases.

CONCLUSION

The PRC and interposition arthroplasty with ADM demonstrated significantly improved clinical outcomes after surgery, showing a maintain of RCD without graft failure effectively.

Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist, results after 3.5 years

The present study compares the postoperative clinical, radiological, and patient-reported functional results between the surgical procedures Proximal Row Carpectomy and Limited Carpal Fusion, in the treatment of SLAC and SNAC conditions of the wrist. 15 Proximal Row Carpectomy patients and 45 Limited Carpal Fusion patients were included in the study. Postoperative outcomes were assessed and compared for pain at load, range of motion, grip strength, Quick-DASH, and satisfaction. A radiological assessment was performed at the follow-up. The Proximal Row Carpectomy patients had a mean age of 60 years (range 31-77) and a mean follow-up of 42 months. The Limited Carpal Fusion patients had a mean age of 58 years (range 35-76) and a mean follow-up of 41 months. The patients treated with Limited Carpal Fusion performed significantly better regarding pain, radial-ulnar motion, and the Quick-DASH (p = 0.002, p = 0.003, and p = 0.002), respectively. The grip strength difference between the treatment groups was stratified for gender and was found significantly better for men in the LCF-treated patients, but not different for women (p = 0.03, p = 0.26), respectively. Differences in flexion-extension between the groups were insignificant (p = 0.525). A higher conversion rate to total wrist fusion was observed in the patients treated with the Proximal Row Carpectomy. All the Proximal Row Carpectomy patients had osteoarthritis at follow-up, whereas it was seen in 19% of the Limited Carpal Fusion patients. The patient-reported satisfaction was substantially better for the Limited Carpal Fusion patients. In conclusion, among patients treated for SNAC and SLAC wrist conditions, besides the findings of flexion-extension, and grip strength which were found without difference for women the findings are in favour of Limited Carpal Fusion compared to Proximal Row Carpectomy. Further, preferably prospective studies are needed to confirm or reject our findings.Level of evidence: Retrospective, comparative cohort study, level III.

The Effect of Proximal Row Carpectomy and Trapeziectomy on First Ray Stability: A Cadaveric Study

PURPOSE

Wrist and thumb pathology can coexist leading to potential indications for proximal row carpectomy (PRC) and trapeziectomy. In this setting, the axial stability of the first ray is not known. We sought to evaluate axial subsidence of the first metacarpal in cadavers following trapeziectomy and trapeziectomy with PRC to determine the mechanical effects of the procedures performed concurrently.

METHODS

Eleven fresh-frozen cadaveric distal forearm specimens were used in this study. The specimens were fixed in cement and mounted to a material test system frame. A predetermined force (20 N) was applied to the thumb metacarpal to simulate forces observed with lateral pinch. Axial displacement of the thumb metacarpal was measured. The application of force was repeated following trapeziectomy on each hand and then again following PRC. Analysis was performed to compare thumb metacarpal subsidence of the 3 groups: native, trapeziectomy, and trapeziectomy with PRC.

RESULTS

Before trapeziectomy, native cadaver specimens had an average of 5.1 ± 1.9 mm of thumb metacarpal subsidence under the material test system load (20 N), compared to 16.2 ± 3.4 mm following trapeziectomy, and 25.0 ± 5.5 mm for trapeziectomy with PRC.

CONCLUSION

We observed a significant increase in thumb metacarpal subsidence following concurrent trapeziectomy with PRC when compared to trapeziectomy alone. Our results suggest that performing both operations together would lead to a substantial risk of first ray subsidence.

CLINICAL RELEVANCE

When treating concurrent basilar thumb and wrist arthritis, it may be more effective to stage the procedures or use a form of thumb metacarpal suspension or arthrodesis.

Immediate Proximal Row Carpectomy for Severe Perilunate Dislocation Injuries: A Minimum 5-Year Follow-Up

Background: In patients with perilunate injuries (PLI) with multiple ligamentous and bony injuries involving the proximal carpal row, open reduction and internal fixation (ORIF) can be difficult and lead to poor functional outcomes. Proximal row carpectomy (PRC) is an alternative procedure that has been used for severely comminuted fractures. The aim of our study is to evaluate the long-term functional outcome (minimum 5 years) of patients that underwent an emergency PRC for PLI. Methods: We conducted a retrospective study of patients who underwent PRC at our centre between 2001 and 2016. Only patients with follow-up data of more than 5 years were included in the study. We evaluated range of motion, grip strength, Mayo Modified Wrist Score (MMWS) and Quick Disabilities of Arm, Shoulder and Hand (Quick-DASH). Radiographic analyses were performed to assess the presence of radiocarpal osteoarthritis and the space between the radius and capitate. Results: Thirteen patients were included, with an average follow-up of 78.07 months (6.5 years). The MMWS was 65 points (four excellent and good, four fair and five poor results) and the Quick-DASH score was 30 points. X-ray analysis reported only 15.3% of patients with radiocarpal arthrosis and an average radio-capitate joint space of 1.92 mm. Conclusions: The outcomes of PRC in the management of PLI are comparable to the results reported in literature for conventional ORIF. PRC is a simpler procedure that minimises the need for re-intervention. Level of Evidence: Level IV (Therapeutic).

Pyrocarbon Lunate Replacements Perform Well at Two Years: A Retrospective Case Series and Technique from Two UK Tertiary Centres

Background: We report medium-term results in our case series of patients with Kienböck disease receiving a pyrocarbon lunate replacement (Integra, Smith and Nephew, Watford, UK). Methods: Patients with Kienböck receiving a pyrocarbon lunate between September 2012 and November 2020, with stage 3b and above were included. Patients were staged preoperatively with radiographs and MRIs. Pre- and postoperative visual analogue scores and movement were documented. Postoperative radiographs were obtained at 6 weeks, 6 months and 1 year. Results: Seven patients were identified, all female, with a median age of 28.0 years. All but one had 3b disease and the median follow-up was 2 years (range 13-112 months). A mean 9/10 preoperative VAS score improved to 1/10 by 3 months postoperatively (p < 0.001, paired t-test). No major complications were seen, and implants were stable radiologically. Conclusions: A semi-constrained pyrocarbon lunate can provide good results for patients with advanced Kienböck's disease, offering an alternative to proximal row carpectomy salvage surgery. Level of Evidence: Level IV (Therapeutic).

Wrist Salvage Procedures for the Treatment of Kienbock's Disease

Kienbock's disease is a progressive condition characterized by lunate collapse, carpal instability, and eventually perilunate arthritis. Etiology is likely multifactorial, including vascular and anatomic or osseus causes. In cases of advanced disease, disabling pain, limited motion, and decreased grip strength may be present. The preferred treatment options for the nonreconstructable wrist are proximal row carpectomy (PRC), total wrist arthrodesis, and total wrist arthroplasty (TWA). In the following chapter, we will discuss various surgical options for patients with advanced Kienbock's disease.

The role of routine radial styloidectomy in proximal row carpectomy: a retrospective review of 120 patients

Impingement between the radial styloid and the trapezium can occur after a proximal row carpectomy (PRC). We hypothesized that a PRC with primary radial styloidectomy reduces the risk of radial impingement, without affecting clinical or functional outcomes. In this retrospective cohort study, 120 patients were divided into two groups: PRC with or without primary radial styloidectomy. Patient-related outcome, strength and range of motion after proximal row carpectomy were measured in a subgroup. The occurrence of radial impingement was significantly lower in the group with primary radial styloidectomy versus those without (p = 0.002). Five patients in the latter group were subsequently treated by a secondary radial styloidectomy, as compared with one patient who underwent primary radial styloidectomy (p = 0.034). There were no significant differences in range of motion or patient-related outcome observed between the two groups. From our study, a radial styloidectomy is recommended as a routine part of the PRC procedure to prevent radial impingement without negatively impacting on function.Level of evidence: IV.

Secondary Wrist Arthritis in Active Workers: Does Capitate Pyrocarbon Resurfacing (RCPI) Improve Proximal Row Carpectomy? A Retrospective Cohort Study

Background: Proximal Row Carpectomy (PRC) is a widespread, safe and effective salvage surgical procedure for wrist arthritis. Some authors believe that PRC results in low grip strength (GS), due to the loss of carpal height, supporting the idea to discourage PRC in high-demanding patients. Resurfacing Capitate Prosthesis Implant (RCPI) allows extending the indication for PRC also in case of deformity and/or arthritis of the head of capitate, with possible implications of clinical outcomes, including GS. Methods: Retrospective multicentre study on a population of active workers, affected by secondary post traumatic wrist arthritis, who underwent PRC (27 patients) or PRC + RCPI (20 patients), Primary outcome was to assess GS between PRC and PRC + RCPI. Secondary outcome was to assess CHR and to search for any possible contributors to GS. Active range of motion (AROM), hand function (DASH, Work-DASH, VAS, PRWHE), pain, time to return to work, job maintenance, major complications and general satisfaction were also assessed. Results: PRC + RCPI results in more GS maintenance compared with PRC alone, with higher values of CHR. CHR values were associated with GS with a good correlation. According to linear regression model analysis within PRC + RCPI group (GS-CHR), it is esteemed that the increase in parameter CHR is associated with an increase in parameter GS. Looking at a multiple linear regression model analysis built on the whole sample (GS% increase - (group × CHR) + GS% pre-operative). It is estimated that the increase of one unit of the GS coefficient is associated with an increase in GS% increase. Furthermore, higher pre-operative GS values positively influence post-operative GS. No differences were revealed between the two treatments in terms of the remaining secondary outcomes. Conclusions: PRC alone and PRC + RCPI are both effective salvage procedures for wrist arthritis. RCPI provides a better GS preservation, in part due to the carpal height preservation.

The never-ending battle between proximal row carpectomy and four corner arthrodesis: A systematic review and meta-analysis for the final verdict

While scaphoid excision combined with Four Corner Arthrodesis (FCA) or Proximal Row Carpectomy (PRC) is a commonly-used salvage procedures to treat type two and type three Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC)-induced degenerative arthritis, controversy remains over which treatment intervention provides superior outcomes. We searched for articles comparing a range of motion, grip strength, complications requiring reoperation, conversion to wrist arthrodesis, pain, and disability of shoulder and arm scores between FCA and PRC-treated patients. The risk of bias was assessed using the National Institutes of Health (NIH) quality assessment tool. We performed a meta-analysis using Random-Effects Models. Fifteen articles (10 retrospective, 2 cross-sectional, 1 prospective, and 2 randomized trials) were included. There was no significant difference between PRC and FCA in any of the different outcome measures. The risk of bias was found consistently high across all studies. Despite the lack of high-quality evidence, based on existing literature, we recommend PRC as the preferred choice of treatment because of the simplicity of the surgical procedure, lack of hardware-related complications, and comparable long-term outcomes. Level of evidence: III - Therapeutic.

Kienbock's Disease: Treatment Options - A Search for the Apt!

Kienbock's disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from 'doing nothing' to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This 'black hole' in the literature presents difficulties to surgeons treating the condition and even patient's confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim to preserve the lunate while once the lunate is collapsed its removal is performed. The lunate preserving operations basically are either decreasing the load on the lunate to possibly permit its revascularization or are the procedures which are aimed at augmenting the vascularity of the lunate. Radius shortening osteotomy is the most popular treatment in the early stages especially in the patients' with negative ulnar variance and the proximal row carpectomy is most popular in the advanced stages of the disease. Authors present their algorithm of management of Kienbock's disease and discuss the various treatment options described in the literature in an attempt to find the apt in 2020.

The effect of four-corner fusion and proximal row carpectomy on uniplanar and multiplanar wrist motion: A biomechanical study

Purpose

To compare changes in wrist kinematics after scaphoidectomy and four-corner fusion (4CF), and proximal row carpectomy (PRC).

Methods

Six cadaveric specimens underwent flexion-extension, radial-ulnar deviation and circumduction in an active motion wrist simulator. Native state, "anatomic 4CF", "radial 4CF", and PRC were compared.

Results

Radial 4CF reduced wrist extension, while PRC reduced radial deviation. Fusion groups had similar motion profiles. 44%, 41%, and 32% of native circumduction was maintained in PRC, anatomic, and radial 4CF.

Conclusions

Both fusion positions resulted in comparable motion outcomes. Anatomic 4CF was restricted in wrist extension compared to PRC but provided favourable radial deviation.

Trapeziometacarpal osteoarthritis and arthritis of the wrist

Although the simultaneous occurrence of arthritis of the wrist and the base of the thumb is rare, it is nonetheless imperative to carry out a preoperative clinical and radiological assessment of the wrist when managing trapeziometacarpal osteoarthritis. The presence of pre-arthritic lesions or established wrist arthritis, even if treated, must be taken into consideration when treating osteoarthritis at the base of the thumb. The coexistence of these lesions determines the entire surgical strategy. Failure to take them into account during the surgical treatment often results in a compromised postoperative course and it often adversely impacts the outcome of secondary surgeries.

Proximal row carpectomy for complex perilunate fracture dislocations with migration of proximal scaphoid bone into the forearm

Complex perilunate dislocations include scaphoid, triquetrum, radial styloid fractures, and associated ligamentous injuries. The purpose of the study is to assess the role of proximal row carpectomy (PRC) in such complex injuries involving the proximal scaphoid migration and analyze the outcome. We operated on eighteen patients with complex perilunate dislocations and extreme proximal migration of proximal scaphoid by PRC between 2012 and 2018. We analyzed the postoperative radiographs, VAS pain score, range of motion, return to work, Quick DASH and Mayo wrist scores and assessed the overall functional outcome. The average follow-up was 46 months. The mean range of wrist flexion was 65%, extension 70 %, pronation 88%, supination 90%, and grip strength 70% of the opposite side. The median VAS pain score was 0.1 (range, 0-3). Median Quick DASH score was 4.4 (range, 3.3-6.7), and Mayo wrist score 70 (range, 65-75). The age, gender, side of injury, dominant hand, fracture displacement or type, osteochondral fracture of the capitate head, and treatment delay had no significant impact on the functional outcome. The presence of degenerative changes had no significant association with age, grip strength, range of movements, pain, and outcome scores. All patients had good subjective satisfaction with the surgery and functional outcome. PRC is a reliable option for complex perilunate fracture-dislocations with extended proximal migration of the scaphoid proximal pole. The degenerative changes after PRC may progress with time, mostly when done for young patients. Outcomes of salvage procedure in the long-term follow-up need to be taken into account when counselling patients on the treatment of these injuries.

Long-term radiological changes and functional outcomes after proximal row carpectomy: Retrospective study with 3 years' minimum follow-up

INTRODUCTION

The aim of this study was to analyze the radiological changes and determine the clinical and functional outcomes of proximal row carpectomy (PRC) over the long term.

HYPOTHESIS

Radiological changes after PRC occur in every patient while the clinical and functional outcomes remain stable over time.

METHODS

This was a retrospective single-center study of patients who underwent PRC between January 2004 and December 2014. A clinical assessment (range of motion, grip strength), functional assessment (Mayo Wrist score and QuickDASH) and radiographic assessment (radiocapitate osteoarthritis, radiocapitate congruency) was done in every patient at the longest follow-up.

RESULTS

Thirty-one patients were reviewed with a mean follow-up of 97.9 months. The indications for PRC were SLAC (n=10), SNAC (n=5), Kienböck disease (n=9) and other conditions (n=7). The radiocapitate index, which is the radius of curvature of the tip of the capitate divided by the mean radius of curvature of the lunate fossa, went from 0.68 immediately postoperative to 0.74 at the final assessment (p=0.035). The mean flexion/extension arc was 93°. The mean grip strength was 25 kg. The mean QuickDASH was 29 and the mean Mayo Wrist score was 69. Fifteen patients had radiocapitate osteoarthritis. Seven patients (22%) required revision surgery for wrist fusion after a mean of 18.6 months.

CONCLUSION

Radiological adaptation in the radiocapitate joint after PRC was found in this study. PRC is a reliable solution and yields stable outcomes over time for treating radiocarpal osteoarthritis, except in young adults and manual laborers who had a notable early revision rate.

LEVEL OF EVIDENCE

IV - retrospective study.

Proximal row carpectomy in patients older than 50 years: 3 to 16 years of follow-up

OBJECTIVE

To analyze the long-term results and the prognosis of patients who have undergone proximal row carpectomy (PRC) in our hospital.

MATERIAL AND METHOD

This is a retrospective study of 14 patients undergoing PRC with a follow-up of 3 to 16 years. The ability to perform daily activities, mobility and functional capacity after the surgery were assessed using the Patient-Rated Wrist Evaluation questionnaire (PRWE).

RESULTS

The range of movement was satisfactory. The mean score on the PRWE scale was 20.9±17.2 for the pain subscale and 39±35.5 for the functional capacity subscale. None of the patients required revision surgery or developed complications. Eighty percent of the patients were satisfied or very satisfied. Ninety percent of the patients would undergo surgery again.

DISCUSSION

The wrist's range of movement achieved with this technique is similar to that obtained with other mobility preservation techniques. Secondary arthritic changes in the radio-capitate joint do not necessarily produce pain. Some authors have described that the degree of satisfaction after PRC is equivalent to that of other procedures such as arthrodesis in 4 corners with circular plate arthrodesis or middle-carpal arthrodesis.

CONCLUSION

PRC achieved high satisfaction rates among the patients providing pain relief, good mobility and post-operative functionality of the wrist. In addition, it presented few complications.

Proximal Row Carpectomy Using Decellularized Dermal Allograft

Wrist arthritis is a common problem. When managed early, motion-sparing procedures can be performed with successful outcomes. Proximal row carpectomy (PRC) has demonstrated good functional results and high patient satisfaction with up to 20-year follow-up. The majority of patients with longer follow-up have, however, exhibited radiographic signs of progressive degeneration of the radiocapitate space. Although radiographic changes have not been shown to correlate with wrist pain and function, it remains a concern and questions the durability of the radiocapitate articulation with continued patient follow-up, especially those who underwent the original procedure at a younger age. Several modifications have been proposed and used to address this concern, including radiocapitate arthroplasty, with either distal radius hemiarthroplasty or tissue interposition grafts. Theoretical benefits to these adjuncts include minimizing wear and preserving the radiocapitate articulation as well as expanding the utility of a PRC even in the setting of a wrist with arthritis of the capitate head. We describe our surgical technique for managing radiocarpal arthritis with PRC and decellularized dermal allograft. Dermal matrix allografts have proved to be a safe adjunct in various orthopedic procedures, including those in the wrist and hand. This technique adds another surgical option for the treatment of radiocarpal arthritis and expands the indications for PRC to include select patients with degeneration of the capitate head.

Mid-term outcomes of routine proximal row carpectomy compared with proximal row carpectomy with dorsal capsular interposition arthroplasty for the treatment of late-stage arthropathy of the wrist

AIMS

The aims of this study were to compare the mid-term outcomes of patients with late-stage arthritis of the wrist treated with proximal row carpectomy (PRC) and dorsal capsular interposition (DCI) arthroplasty with a matched cohort treated with routine PRC alone.

PATIENTS AND METHODS

A total of 25 arthritic wrists (24 patients) with pre-existing degenerative changes of the proximal capitate and/or the lunate fossa of the radius were treated with PRC + DCI over a ten-year period. This group of patients were matched 1:2 with a group of 50 wrists (48 patients) without degenerative changes in the capitate or lunate fossa that were treated with a routine PRC alone during the same period. The mean age of the patients at the time of surgery was 56.8 years (25 to 81), and the demographics and baseline range of movement of the wrist, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were similar in both groups.

RESULTS

At a mean follow-up of 5.9 years (1.8 to 11.8), significant improvements in mean grip strength, the flexion-extension arc of movement of the wrist, QuickDASH, and PRWE scores were seen in both groups. There was no diifference between the groups for any of the outcomes. One patient in the PRC + DCI group required additional surgery for a deep infection, while two in the PRC group had complications (one wound dehiscence requiring revision closure, one transient radial sensory neuritis). One patient in each group required total arthrodesis of the wrist for progressive degenerative radiocarpal changes. A total of 70 patients (93%) were satisfied with the outcomes.

CONCLUSION

PRC with DCI is an effective form of treatment for late-stage arthritis of the wrist involving the capitolunate joint, with mid-term outcomes that are similar to those in patients without degenerative changes affecting the capitate or lunate fossa who are treated with a routine PRC alone. Cite this article: Bone Joint J 2018;100-B:197-204.

Update on the operative treatment of scapholunate instability for radiologists. II. Salvage procedures, total wrist arthrodesis, and total wrist arthroplasty

Scapholunate (SL) instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management, and postoperative follow-up of SL instability. In the final stage of SL instability, known as scapholunate advanced collapse, progressive degenerative changes occur at the carpal level. The goals of this article are to review the surgical options available for addressing the different stages of scapholunate advanced collapse, along with an emphasis on normal postoperative imaging and complications associated with each surgical option.

Case Report: SPECT/CT as the New Diagnostic Tool for Specific Wrist Pathology

Introduction

Single photon emission computed tomography has been introduced as a promising new diagnostic tool in orthopaedic pathology since the early 90'. Computed tomography, the combined with SPECT, gives insight in the specific sight of wrist pathology. Literature already supports introduction of SPECT/CT in wrist pathology, but clinical application is lagging.

Case Report

A 40yr old patient reported first in 2004 with persisting pain after a right distal radius fracture. Several diagnostics and operative interventions were performed, all unsuccessful. Because of the persisting pain a SPECT-CT was performed which showed a cyst in the hamate bone, which was successfully enucleated. The patient was finally pain free at recent follow-up. With a QDash-score of 43 and a PRW (H) E-DLV-score of 58/150.

Discussion

In this case report, SPECT/CT proved a very sensitive diagnostic tool for specific pathology of the wrist. It offered precise localisation and thereby the clinically suspected diagnosis was confirmed and the patient successfully treated.

Connecting the wrist to the hand: A simulation study exploring changes in thumb-tip endpoint force following wrist surgery

The wrist is essential for hand function. Yet, due to the complexity of the wrist and hand, studies often examine their biomechanical features in isolation. This approach is insufficient for understanding links between orthopaedic surgery at the wrist and concomitant functional impairments at the hand. We hypothesize that clinical reports of reduced force production by the hand following wrist surgeries can be explained by the surgically-induced, biomechanical changes to the system, even when those changes are isolated to the wrist. This study develops dynamic simulations of lateral pinch force following two common surgeries for wrist osteoarthritis: scaphoid-excision four-corner fusion (SE4CF) and proximal row carpectomy (PRC). Simulations of lateral pinch force production in the nonimpaired, SE4CF, and PRC conditions were developed by adapting published models of the nonimpaired wrist and thumb. Our simulations and biomechanical analyses demonstrate how the increased torque-generating requirements at the wrist imposed by the orthopaedic surgeries influence force production to such an extent that changes in motor control strategy are required to generate well-directed thumb-tip end-point forces. The novel implications of our work include identifying the need for surgeries that optimize the configuration of wrist axes of rotation, rehabilitation strategies that improve post-operative wrist strength, and scientific evaluation of motor control strategies following surgery. Our simulations of SE4CF and PRC replicate surgically-imposed decreases in pinch strength, and also identify the wrist's torque-generating capacity and the adaptability of muscle coordination patterns as key research areas to improve post-operative hand function.

Clinical outcomes of proximal row carpectomy by preoperative midcarpal joint morphological classification: Viegas type I versus type II

The midcarpal joint can be classified into two anatomical types - Viegas type I and Viegas type II - based on the absence or presence of a medial facet for the hamate on the lunate (lunohamate facet). Type I is associated with a round capitate shape, which theoretically allows better congruence with the lunate fossa of the distal radius following proximal row carpectomy (PRC). This morphological feature has never been considered as a predictive factor of clinical outcome for this surgical procedure. This study aimed to compare the clinical and radiological outcomes of the two Viegas types following PRC. A retrospective single-center study was carried out on patients who underwent PRC for wrist osteoarthritis. Minimum follow-up was 2 years. Lunate type was determined based on preoperative CT arthrography. The clinical evaluation included range of motion (ROM) and strength as well as the functional DASH, Mayo Wrist scores and a VAS for pain. The outcome of radiocapitate osteoarthritis was assessed on plain radiographs. Forty patients were reviewed with a mean follow-up of 57 months. Twenty-one Viegas type I and 19 Viegas type II were identified on preoperative CT arthrography. The etiologies included 23 SLAC wrists (12 Viegas type I, 11 type II), 8 SNAC wrists (4 Viegas type I, 4 type II), 6 cases of Kienböck's disease (3 type IIIa, 3 type IIIb with 3 Viegas type I and 3 type II), 1 Preiser's disease and 2 cases of transscaphoid perilunate dislocation of the carpus. Patients with a Viegas type I lunate had significantly greater flexion-extension ROM: 83.5° vs. 71° (P=0.04) and radial deviation: 12° vs. 7° (P=0.013) than those with Viegas type II. However, three cases of complex regional pain syndrome (CRPS) were reported in the Viegas type II group vs. zero in the Viegas type I group. There were no differences between the two groups in terms of strength, functional scores or VAS pain. The outcome of radiocapitate osteoarthritis was similar in both groups. Considering the number of CRPS cases in the Viegas type II group and similar functional results in both groups, the worse outcomes of the Viegas type II patients in terms of ROM cannot be considered as clinically relevant. This comparative study does not provide a reasonable basis for concluding that Viegas type I patients are better candidates for PRC than Viegas type II patients.

Treatment of acute perilunate dislocations: ORIF versus proximal row carpectomy

PURPOSE

Some authors have proposed performing proximal row carpectomy (PRC) as the initial treatment for perilunate dislocations.

HYPOTHESIS

The goal of this retrospective study was to compare the results of a cohort of perilunate dislocation cases that were operated by open reduction and internal fixation (ORIF) or by PRC between 2006 and 2011.

METHODS

The cohort consisted of 21 men with a mean age of 33years, who either had an isolated perilunate dislocation (7 cases) or a fracture-dislocation (14 cases). All dislocations were dorsal, with 10 stage I and 12 stage II. Thirteen patients had been treated by ORIF (group 1) a mean of 1.2days after the injury. Eight patients had been treated by PRC (group 2) a mean of 18.7days after the injury. Immobilization time was 6-12weeks in group 1 and 2weeks in group 2.

RESULTS

The mean operative time was 95minutes in group 1 and 65minutes in group 2. After a mean follow-up of 35months, the following outcomes were found for groups 1 and 2, respectively: pain 3/10 and 1/10, strength 77% and 73%, strength in supination 79% and 93%, strength in pronation 67% and 95%, QuickDASH 27/100 and 16/100, PRWE 43/150 and 15.5/150, flexion 69% and 57%, extension 84% and 58%, pronation 97% and 103%, supination 98% and 97%. There were four cases of osteoarthritis in both groups.

CONCLUSION

Treatment of acute perilunate dislocations by PRC leads to medium-term results that are at least as good as those with ORIF treatment. The surgery duration is shorter with PRC, as is the immobilization period.

TYPE OF STUDY

Retrospective comparative.

LEVEL OF EVIDENCE

III.

Scapholunate Advanced Collapse: Motion-Sparing Reconstructive Options

Scapholunate advanced collapse (SLAC) is a predictable pattern of degenerative wrist arthritis that develops as a result of scapholunate dissociation. The purpose of this article is to review outcomes for the various motion-sparing surgical treatments for SLAC wrist.

Proximal row carpectomy in total arthrodesis of the rheumatoid wrist

BACKGROUND

Advanced proximal carpal row damage is common in rheumatoid arthritis (RA). Proximal row carpectomy (PRC) simplifies total wrist arthrodesis, obviating the need for an iliac bone graft. In theory, PRC also improves the chances of healing, as fusion of a single joint space is needed for the procedure to be successful. Potential effects of the loss of carpal height related to PRC are unknown.

HYPOTHESIS

We hypothesised that PRC performed concomitantly with total wrist arthrodesis in patients with RA produces good clinical and radiological outcomes, without inducing loss of strength or digital deformities.

MATERIAL AND METHODS

In 38 total arthrodeses of rheumatoid wrists, a clinical evaluation was performed, including a visual analogue scale (VAS) pain score, the Patient-Rated Wrist Evaluation (PRWE), grip strength, digital deformities, and patient satisfaction. A standard radiographic workup was obtained to assess healing and carpal height indices.

RESULTS

After a mean follow-up of 50 months, the mean VAS pain score was 0.4 (range: 0-7), the mean PRWE score was 21 (range: 0-80.5), and grip strength as a percentage of the contralateral limb was 76%. The healing rate was 92% (35/38 wrists), and 34 (90%) patients reported being satisfied or very satisfied. No effects of carpal height loss on clinical or radiographic parameters was detected.

DISCUSSION

Total wrist arthrodesis combined with PRC provides reliable and reproducible benefits. This study found no evidence of adverse effects related to the loss of carpal height.

LEVEL OF EVIDENCE

IV, retrospective study.

Limited intercarpal fusion as a salvage procedure for advanced Kienbock disease

BACKGROUND

With progressive lunate collapse, salvage procedures in advanced Kienbock disease attempt to provide pain relief and maintain motion. Scaphocapitate arthrodesis may provide a durable option with comparable outcomes to proximal row carpectomy in the well-selected patient.

METHODS

We performed a retrospective chart review of all consecutive patients with Lichtman stage IIIA or IIIB Kienbock's disease who underwent either scaphocapitate or scaphotrapeziotrapezoid-capitate arthrodesis from January 2004 to December 2013.

RESULTS

Twelve patients were included with a mean age of 41.6 years. Ten patients underwent scaphocapitate arthrodesis, while two patients underwent scaphotrapezio-trapezoid-capitate arthrodesis with an average clinical follow-up of 13.1 months. All patients achieved fusion. The average postoperative flexion-extension arc was 53° (range 20-110°). The average ulnar deviation was 9° (range 5-15°), and the average radial deviation was 13° (range 5-25°). Postoperative pain scores were significantly improved, having changed from an average of 6.6 preoperatively to 2.8 on a 10-point scale (W = 18, P < 0.05).

CONCLUSIONS

Despite a mean flexion-extension arc that is reduced from that of a normal individual, the postoperative range of motion following a midcarpal arthrodesis was not significantly different than that reported in a recent systematic review of proximal row carpectomy (73.5° compared with 53°, respectively) (P = 0.05). Additionally, given the significant postoperative reduction in associated pain symptoms at the time of follow-up, scaphocapitate arthrodesis should be considered as a treatment option for wrist salvage in the patient with advanced Kienbock's disease.

Salvage Operations for Wrist Ligament Injuries with Secondary Arthrosis

Wrist ligamentous injuries can be challenging to treat successfully. In some cases the ligament repair or reconstruction fails, resulting in instability and progressive degenerative changes. In other cases the original injury is missed, and the patient presents for the first time with established wrist arthritis. Multiple operations have been devised to treat patients with arthrosis secondary to wrist ligament injuries. This article discusses definitive salvage operations such as intercarpal arthrodeses and proximal row carpectomy, as well as other alternatives such as wrist denervation and radial styloidectomy.

Radiocapitate congruency as a predictive factor for the results of proximal row carpectomy

PURPOSE

To evaluate whether the congruency between the joint surfaces of the lunate fossa of the distal radius and the proximal capitate might be a prognostic factor for functional, clinical, or radiographic results after proximal row carpectomy (PRC).

METHODS

After reconstructing the computed tomographic arthrogram of patients with PRC, we evaluated the shape of the proximal capitate by measuring the radius of curvature of the tip of the capitate. The congruency of the future radiocapitate joint was then evaluated by the radiocapitate index in the frontal and sagittal planes. This was calculated by dividing the radius of curvature of the tip of the capitate by the mean radius of curvature of the lunate fossa. We determined the relationship between these morphological results and the functional (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Wrist score, and pain relief), clinical (mobility and strength) and x-ray results (radiocapitate arthrosis).

RESULTS

A total of 27 patients were reviewed at a mean follow-up of 59 months. The shape of the proximal capitate did not affect outcomes. In the frontal plane, a better radiocapitate congruency was significantly associated with an increase in wrist flexion and better functional results for the DASH. There was a non-significant relationship between congruency and improvement of Mayo Wrist score and pain relief. In the sagittal plane, the DASH score tended to improve when congruency was better.

CONCLUSIONS

The shape of the capitate was not a prognostic factor for functional outcome after PRC. The radiocapitate index seems more relevant in predicting results at last follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Wrist salvage procedures alter moment arms of the primary wrist muscles

BACKGROUND

Proximal row carpectomy and scaphoid-excision four-corner fusion are salvage procedures that relieve pain by removing arthritic joint surfaces. While numerous studies have examined how these procedures affect joint motion, few have examined how they influence muscle mechanical actions. This study examines whether muscle moment arms change after these procedures.

METHODS

Moment arms of primary wrist muscles were measured in 8 cadaveric specimens using the tendon excursion method. In each specimen, moment arms were measured for two degrees of freedom (flexion-extension and radial-ulnar deviation) and three conditions (nonimpaired, scaphoid-excision four-corner fusion, and proximal row carpectomy). For each muscle and degree of freedom, moment arm versus joint angle curves for the three conditions were statistically compared.

FINDINGS

Wrist salvage procedures significantly alter moment arms of the primary wrist muscles. Proximal row carpectomy primarily alters flexion-extension moment arms, while scaphoid-excision four-corner fusion primarily alters radial-ulnar deviation moment arms. Both procedures also alter the balance between agonist and antagonist wrist muscles. Following proximal row carpectomy, wrist extensors have smaller moment arms in extended postures. Following scaphoid-excision four-corner fusion, radial deviators have larger moment arms throughout radial-ulnar deviation.

INTERPRETATION

Different moment arms indicate that different forces are required to complete the same tasks in nonimpaired and surgically altered wrists. The altered muscle moment arms likely contribute to post-operative impairments. Understanding how salvage procedures alter muscle mechanical actions is a critical first step toward identifying the cause of post-operative impairments and is necessary to develop effective interventions to augment deficient muscles and improve overall function.

Wrist osteoarthritis

Painful wrist osteoarthritis can result in major functional impairment. Most cases are related to posttraumatic sequel, metabolic arthropathies, or inflammatory joint disease, although wrist osteoarthritis occurs as an idiopathic condition in a small minority of cases. Surgery is indicated only when conservative treatment fails. The main objective is to ensure pain relief while restoring strength. Motion-preserving procedures are usually preferred, although residual wrist mobility is not crucial to good function. The vast array of available surgical techniques includes excisional arthroplasty, limited and total fusion, total wrist denervation, partial and total arthroplasty, and rib-cartilage graft implantation. Surgical decisions rest on the cause and extent of the degenerative wrist lesions, degree of residual mobility, and patient's wishes and functional demand. Proximal row carpectomy and four-corner fusion with scaphoid bone excision are the most widely used surgical procedures for stage II wrist osteoarthritis secondary to scapho-lunate advanced collapse (SLAC) or scaphoid non-union advanced collapse (SNAC) wrist. Proximal row carpectomy is not indicated in patients with stage III disease. Total wrist denervation is a satisfactory treatment option in patients of any age who have good range of motion and low functional demands; furthermore, the low morbidity associated with this procedure makes it a good option for elderly patients regardless of their range of motion. Total wrist fusion can be used not only as a revision procedure, but also as the primary surgical treatment in heavy manual labourers with wrist stiffness or generalised wrist-joint involvement. The role for pyrocarbon implants, rib-cartilage graft implantation, and total wrist arthroplasty remains to be determined, given the short follow-ups in available studies.

Distal radius fracture after proximal row carpectomy

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We encountered a patient with distal radius fracture (DRF) after proximal row carpectomy (PRC). The mechanism of the DRF after PRC is discussed in this report.

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The DRF is needed wrist range of motion. Since the wrist range of motion decreased and the lunate fitted into the joint surface after PRC, making the forearm join with the hand like a single structure, pressure may have been loaded on the weak distal end of the radius from the dorsal side, causing volar displacement and fracture.

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The pressure distribution and range of motion of the radiocarpal joint after PRC are different from those of a normal joint, and the mechanism of fracture also changes with it.

Introduction

We encountered a patient with distal radius fracture (DRF) after proximal row carpectomy (PRC). The mechanism of the DRF after PRC is discussed in this report.

Presentation of case

The patient was a 73-year-old female who had undergone PRC due to Kienböck disease before. The wrist range of motion was: 45° on dorsiflexion and 20° on flexion. DRF has occurred at 3 years after PRC. The fracture type was extra-articular fracture. Osteosynthesis was performed using a volar locking plate. No postoperative complication developed, the Mayo score was excellent at 6 months after surgery, and the daily living activity level recovered to that before injury.

Discussion

Since the wrist range of motion decreased and the lunate fitted into the joint surface after PRC, making the forearm join with the hand like a single structure, pressure may have been loaded on the weak distal end of the radius from the dorsal side, causing volar displacement and fracture.

Conclusion

The pressure distribution and range of motion of the radiocarpal joint after PRC are different from those of a normal joint, and the mechanism of fracture also changes due to PRC.

Dynamic assessment of wrist after proximal row carpectomy and 4-corner fusion

PURPOSE

To investigate the effect of 4-corner fusion (4CF) or proximal row carpectomy (PRC) on wrist motion, strength, and outcome for 2 different cohorts from 2 separate institutions performing either 4CF or PRC for stage 2/3 scaphoid nonunion advanced collapse and scapholunate advanced collapse.

METHODS

The researchers assessed 46 subjects (24 4CF and 22 PRC), mean age 54 years, with a flexible electrogoniometer to measure maximum wrist motion and circumduction and compare it with the nonsurgical wrist. We analyzed the shape, size, rate, and smoothness of the circumduction curves. We assessed the maximum grip and sustainability of grip for 60 seconds using a digital grip analyzer. Patient evaluation measure and Michigan Hand Questionnaires measured patient-reported outcomes.

RESULTS

Flexion-extension in the surgically treated wrist was 50% of the nonsurgical side after a 4CF and 65% after a PRC. The radioulnar deviation component in circumduction of the surgically treated wrist was similar but markedly decreased after either procedure. The mean area of circumduction of the surgically treated wrist was similar after a PRC and a 4CF but was 30% of the nonsurgical wrist. The center of the circumduction ellipse after a PRC was closer than after a 4CF to the opposite wrist. The orientation of the plane of circumduction was 22° to the vertical flexion-extension plane after a PRC. After a 4CF, the plane was more vertical (9°). The peak grip strength and the area under the force time curve was 80% of the nonsurgical side after a PRC and 60% after a 4CF. The Michigan Hand Questionnaire result was 90% of the score for the nonsurgical hand after a PRC and 75% of score for the nonsurgical hand after a 4CF.

CONCLUSIONS

The PRC provided improved flexion-extension with a circumduction curve concentric with the nonsurgical wrist. The 4CF limited extension and ulnar deviation more than did a PRC.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Acute Proximal Row Carpectomy after Complex Carpal Fracture Dislocation

Acute proximal row carpectomy is an uncommon definitive treatment for perilunate fracture dislocations. In this report, we present five patients who had acute proximal row carpectomy (PRC) to treat perilunate fracture-dislocations. All patients were men between ages 31 and 87. The indication for PRC was lunate fracture in two patients, concomitant displaced scaphoid fracture and scapholunate ligament injury in two patients, and perilunate fracture-dislocation with preexisting articular damage from long-standing gout in one patient. At the final follow-up ranged from 4.5 month to 7.5 years, four patients had no pain and one patient was lost to follow-up. One patient had a concomitant PRC and a bridging plate that was never removed. The remaining three patients gained satisfactory range of motion. Our observation reveals that acute proximal row carpectomy is an option for some patients with complex carpal fracture dislocations, particularly those with fracture of the lunate, concomitant scaphoid fracture and scapholunate ligament injury, or preexisting wrist arthritis.

Long-term outcomes of proximal row carpectomy: a minimum of 15-year follow-up

INTRODUCTION

Proximal row carpectomy (PRC) is a popular procedure for the treatment of wrist arthritis; however, the long-term clinical outcomes of this procedure are not well-characterized. The purpose of this study was to evaluate long-term results with PRC and to identify factors that may improve clinical outcomes.

METHODS

A retrospective study was performed on all patients who underwent proximal row carpectomy between January 1967 and January 1992. Medical records and available radiographs were reviewed. The Disabilities of the Arm, Shoulder and Hand, and Patient Rated Wrist Exam, as well as hand motion diagrams were sent to all surviving patients. The contralateral extremity was used as a control. Data was analyzed using multivariant analysis and a Student's t test.

RESULTS

Eighty-one patients underwent PRC. Average age at the time of surgery was 41 years. Average follow-up was 19.8 years. Sixty-one patients responded to the questionnaires. On final follow-up, wrist motion and grip strength were not significantly different from preoperative values. Radiographic follow-up beyond 2 years revealed joint narrowing and arthritic changes within the radiocapitate joint. Forty-six patients (74%) were not satisfied with the results of their surgery due to persistent pain or inability to return to previous occupational activities. Fifty-two patients required daily pain medication for wrist pain. Twelve patients had undergone a wrist arthrodesis.

CONCLUSIONS

Post-operative motion and grip strength values following PRC appear to remain stable over time. Surgical failure rates with conversion to wrist fusion occurred early within the post-operative follow-up. Many patients continued to complain of pain requiring daily medication and were unable to return to manual labor type jobs. The results of this study suggest that long-term patient satisfaction following PRC can be poor and the surgeon may wish to consider alternative treatment options for younger patients and those with high-demand jobs.