A critical look at intercarpal arthrodesis: Review of the literature

A Critical Look at Intercarpal Arthrodesis: Review of the Literature Jane M. Siegel, MD, Nashville, IN, Leonard K. Ruby, MD, Boston, MA

Painful joints have long been treated by arthrodesis. Limited intercarpal arthrodesis as an alternative to total wrist arthrodesis began gaining popularity in the late 1960s. Peterson and Lipscomb described various combinations of intercarpal arthrodeses for painful conditions affecting selected carpal bones.~ The authors concluded that these limited wrist artha-odeses rclieved pain while providing stability and preserving motion. Since that time, many different limited intercarpal arthrodesis combinations have been described in the literature; these include the scaphotrapezium trapezoid, lunottiquetral, scapholuhate, scaphocapitolunate, scaphocapitate, capitolunate, and capitohamate-lunotriquetral arthrodeses. They are described for various indications such as intercarpal arthrosis and instability, but pain is the most conunon indication. Postoperative results have varied. We were interested in reviewing the reported data on intercarpal arflarodesis to obtain a clearer understanding of the outcomes of each type of arthrodesis and how the different t ~ e s compared in terms of nonunion, rate of other complications, postoperative grip strength, range of motion (ROM), and pain relief. We examined the limited intercarpal

From the Departmentof Orthopaedic Surgery,2he New England Medical CenterHospital and the Departmentof OrthopaedicSurgery, Tufts UniversitySchool of Medicine,Boston, MA, and the Southenl SportsMedicineand OrthopaedicCenter,Nash:41Ie,TN. Received for publication June 13, 1995; acceptedin revised form Oct.d, 1995. Nt~benefitsia any tonn havebeenreceivedor will be receivedfrom a commercialparry3:elateddirectlyor indirectlyto the subjectof this article. Reprintrequests:JaneM. Siegel,MD, SouthernSportsMedicineand Orthopaedic Center,BaptistMedicalPlaza II, 2rid floor,2021 Church Street,Nashville,TN 37203.

arthrodesis series reported in the English-language literature between 1924 and 1994. A truc meta-analysis of the literature could not be performed. Metaanalysis was originally designed to combine randomized, prospective studies, therefore exclttding less scientific papers from the review, Most of the reports in the literature on intercarpal arthrodeses are retrospective reviews and are not conducted or reported in a standardized fashion.

Scaphotrapezium-Trapezold Arthrodesis The scaphotrapezium-trapeziod (STT) arthrodesis is one of the more popular interearpal arthrodeses used today, and many authors have reported their experience with this technique z-14 (Table 1). Two hundred fifty-eight patients were reported who underwent STT arthrodesis. Indications for this technique were chronic static or dynamic scapholunate instability, scaphotrapezium-trapezoid arthrosis, Kienbrck's disease, and radiocarpal instability. The average follow up period for these studies was 38 months (range, 5-141 months). The nonunion rate averaged 13%. Complication rates were not reported by all authors. The complication rate of 43% is calculated only for those studies in which these values were given. Complications inchtded pin track infect-ion, osteomyelitis, avascular necrosis of the lunate, radioscaphoid arthrosis, any other progressive arthrosis, reflex sympathetic dystrophy, "nerve irritation;" and tendon rupture. Where reported, 49% of patients continued to have waist pain at follow-up examination. Pain was described in various ways in the different studies and was measured by a variety of pain scales. Kleinman, in his review of 47 patients who underwent STT arthrodesis, 6 tbund that 11 of the d-7 The lournaJ ol" Hand Surgery 717

718 Siegel and Ruby/Intercarpal Arthrodesis patients ultimately had total wrist arthrodesis, and 2 others underwent total wrist arthroplasty secondary, to persistent wrist pain. tn addition, 8 patients had further surgery for painful nonunions, 2 patients had proximal row carpectomics, and 2 had radial styloidectomies performed secondary to continued or subsequent wrist pain, There was no final subjective pain evaluation for the entire group of paticnts, and theretbre, we did not include an eotry for persistent pain in Table 1. The patients of Watson et al., in one studyJ ~ were described as having mild pain during use of the wrist and an ache after heavy work. It is unclear how long these patients (4 of 30) were followed and if additional procedures Were necessary to alleviate their pain. In another study by Watson ct al.,~2 there were 6 patients of 16 with "residual pain during activity and postactiv'ity ache." It is mentioned in this report that four of these six patients ultimately required reoperation for postoperative pain. The final study by Watson et al. ;a includes individual descriptions of postoperative pain. In this study, 7 of 13 patients had some pain on follow-up examination. Thcsc patients were evaluated just 5 months after surgery. It is mentioned that one of these patients did ultimately have extension of his arthrodesis 4.5 years after his original STT arthrodesis. Frykman et al., in their study of 19 STT artkrodeses, 4 had 4 patients with painflfl nonunions that required reoperation and 2 patients who required extension of their arthrodeses to include the scaphocapitolunate (SCL) articulations secondary to continued postoperative wrist pain. At the final follow-up examination (average, 24 months), 4 patients had slight pain and 11 had pain with motion or strain. Two patients considered their pain to be worse after surgm'y. Four patients with continued pain remained out of work at the final follow-up examination, and 2 patients were awaiting total wrist arthmdesis. Fortin and Louis,-~in their follow-up evaluation of 14 patients with STT arthrodesis, tbund that all had some persistent wrist pain. These patients rated their pain on a scale of 1 to 10. Half the patienls rated their pain as less than 5 and half as 5 or greater. Interestingly, all rated their functional ability as 5 or less, with 9 paficnts of the 14 giving a rating of 3 or less. SL,~patients in this study went on to have subsequent surgery tbr progressive arthrosis. One of these patients underwent total wrist arthrodesis and one an extension of the intercarpal arthrodesis. This patient continued to have wrist pain. There were 3 painful nonunions, 2 of which remained painful alter reoper-

ation. The one patient who developed a postoperative infection ultimately had a total wrist arthrodesis. In the report by Eckenrode et al,, 2 6 of 9 patients had persistent wrist pain. Ttu-ee of these patients rated their pain as minimal and 3 believed the pain was unimproved by the surgery. One of these patients underwent extension of the intcrcarpal arthrodesis but continued to have pain. lshida and Tsai, -s in their follow-up study of 40 patients who underwent STT arthrodesis, had t2 patients who required reoperation for pain alter surgery, Four patients required surgery lor painflll nonunions and 2 for fractured bone mass, 2 patients underwent carpometacarpal arthroplasty for progressive arthrosis, 3 patients had a radial slyloidecmmy for radJoscaphoid impingement, and 1 patient underwent total wrist arthrodesis. At the final follow-up examinanon, 23 patients reported no pain or mittimal pain, 9 patients had mild pain, and 4 lind pain in all activities. X-ray film evaluation demonstrated 18 patients with evidence of progressive ar~d~rosis. These patients were asymptomatic at last follow-up examination. Minami et at.9 reported the results of STT arthrodesis with lunate excision performed in 15 patients for late stage KienbSck's disease. Half of these patients had pain after surgcry, the majority reporting their pain as minimal. Three patients had an unsatisfactory resnlt, 2 requiring wrist arthmdesis. Voche et al.~ also looked at STT arthrodesis performed for Kienb/3ek's disease. Nine patients developed arthrosis in the radiocarpal joint. Only 3 patients remained pain 1"*r at final follow-up examination. The authors attributed their low postoperative ROM (38%) m the fact flint all patients had advanced Kienb(Sck's disease. The ROM found in their study is sign ificantly lower than that found by Minami et ai.,~ who %1lowed a similar group of patients. Scaphotrapezium-trapezoid arthrodesis is frequently performed for isolated STT arthrosis. We tried to separate out the insults of STT arthrodesis performed for this indicatioll to see if pcrhaps the outcomes differed from the outcome in those cases in which the arthrodesis was performed tbr instability or Kienbdck's disease. There were three studies in which the data for patients with isolated STT arthrosis could be ascertained. 3.s,14 There were 12 patients in these ttn'ee studies. Three patients had nonnnions, 3 developed mild reflex sympathetic dystrophy, and 6 had postoperative pain. In 'addition, 2 patients developed radioscaphoid arthrosis and 3 developed carpometacarpal arthrosis in the follow-up period. There did not seem to be a significant difference in the outcome in this small group of patients.

The Journal of Hand Surgery / Vol. 21A No. 4 July ~996

719

T a b l e 1. I n t e r c a r p a l A r t h r o d e s e s : R e s u l t s S u m m a r y

Scaphotral)ezium~Trapeziod Authors

No. of Patiems

Nonunion (%)

Eckcrttode el, al. 2 Fom'tin, I_,ouis~ Frykmml et al. 4 I shida, Tsai s Kleinman 6 M c A u l i f f e et al.;" M i n a m i et al. s MinalnJ ct at.9 Tom.ainu et al. m Voche ctal, ~E Watson et al)= Watson et al. 13 Watson, H e m p t o n 1r

9 14 19 40 47 25 7 15 7 16 16 30 13 q'otaf: 258

1 ( 11 ) 3 (21.4) 5 (26) 7 (22) 8 (17.) 6 (24) 0 (0) 0 (0) 3 (43) 0 (0) 0 (0) 0 (0) 1 (7.7) Average: :[3

I 15 5 20 21 18" 1 -(1 10 4 3 4 Average 43%

M c A u l i f f e et al.7 Nelson et aL 16 Keck, I-IastingsJK i r s c h e n b a u m et al. 17 Smith, R a y h a c k t Maitin el. al. TM Phi et a t ) 9

14 22 42 14 22 18 11 Total: 143

7 (50) 7 (3:1.8) 12 (28.6) 2 (14) 5 (22.7) 4 (22) 0 (0) Average: 26

9* -20 2 -. . 4 Average: 43%

Complicationx

Patients With Pain

Follo~vttp Period(too)

AverageRange AverageGrip of Motion (%) (%)

6 14 15 13 -. . 0 8 5 ]3 6 4 7 Average: 49%

19 62 24 4t 60 . 22 57 51. 27 20.5 47 30

62.5 74 59 68 61.5 72 68 70 . . . . . . . . . . 53 73 65 77 38 55 59 86.3 79 92 81 74 Average: 62 Average: 74

.

Lunotriquetral i 23 -27 5

22 11 1 I .

.

. l 2.7

7 Average 46%

__ 89 -86.5 --

__ 70 -93 --

78 Average: 84.5

59 Average: 74

.

Seapholunate McAuliffe et a t 3 Hastings, Silver z0 Honl, R u b y 2t

6 3 7 Total: 16

2 (33.3) 2 (66) 6 (85,7) Average: 62,5

.

.

0 2 Average: 20%

. -4 Average: 57%

.

. 42 48.7

-93.5

-88

--

--

Scaphocapitolunate Hastings, Silver ~o McAllliffe et a13 R o t m a n et al. 22 Viegas 23

3 3 21 6 Total: 33

[. (33) 0 (0) 3 (14) 0 (0) Average: 12

2

42

.

.

1 -Average: 12.5%

.

.

16 -Average: 76%

. 29 18

47 50.5 Average: 48.8

70 50 Average: 60

36 70 59

53 42 66 Average: 53.7

67 79.5 76.3 Average: 74.3

Capitolunate K i r s c h c n b a u m c t a l , 2* Krakauer e[ al,Z5 Watson, Ballet z6

18 8 3 Total: 29

6 (33) 4 (50) 0 (0) Average: 35

14 2 2 Average: 62%

8 5 2 Average: 51.7%

Scaphocapitute Pisano et al.27

17

2 (1 1,8)

2 (11.8)

7 (4t%)

23.4

47

74

48 41

53 45

81 79,5

Capitohamate-Lunotriquetral (Four-eorner)$ A s h m e a d et al. ~u Krakauer et al. 2s McAuliffe et al.7 Tolnaino ct al)0w Trumble et al. 29

100 23 2 9 4 Total: 138

3 (3) 2 (8,7) 1 (50) 0 (0) 0 (0) Average: 4.3

32 49 3 10 . . . 1 -0 4 Average: 26.5% Average: 49.6%

.

*May include nonunions. +Author citations taken from Nelson et. al.16 :i:Some patients h a d silicone scaphoid implants, while others did not. w 2 patients with capitolunate arthrodesis. Reported results could lint be separated.

. 48 24

4t 63 Average: 50.5

76 74 Average: 77.6

720 Siegel and Ruby/Inlercarpal Arthrodesis

There was a .group of patients, reported o n b y Sennwald and Segmuller, 1.~ who underwent STY arthrodesis with implant arthroplasty of the carpometacarp~d joint of thc thumb. These 13 patients had a final ROM of 77% and grip strength of 64% of the opposite side. These are in [i~m with our average measurements. The rest of the follow-up evaluation, and even the grip strength measurements, were too intimately involved with the fate of the thumb prosthesis to be included with the collected data.

were a neuropraxia of the sensory branch of the radial nerYe and a neuroma at the distal end of the posterior interosseous nerve. The rate of postoperative pain was calculated as 4 of 7. One patient experienced mild pain after surgery, and three patients had severe pain requiring extension of the i ntercarpal arthrodesis. All patients with postoperative pain had a nonunion or psendarthrosis. As with the lunotriquetral arthrodesis, excellent postoperative wrist motion was obtained.

Lunotriquetral Arthrodesis

Scaphocapitolunate Arthrodesis

Ltmotriquetral arthrodeses are reported as a treatment option for lunotriquetral ligament tears and post-traumatic instabilityvary-t9 (Table 1). We identified 143 patients in the literature who underwent this type of litnited intercarpal arthrodesis. The average follow-up period was short--only 17 months--but length of the follow-up period was not consistently reported by all authors and may actually have been higher or lower. The nonunion rate was 26% and the complication rate 43%. These rates were reported for only 81 of the 143 patients, and included mostly neuropraxia and hardware problems. Where reported, 46% of patients had persistent postoperative pain. Three of the studies discussed postoperative pain. Pin et at.,9 had a patients with pain on extremes of motion and 3 with persistent pain. Any additional proeedmes were not discussed. In the study by Nelson et al.,m all 22 of the patients who underwent lunotriquetral arthrodesis had some pain on followup examinatkm. In this series, 4 patie1~ts required reoperation for painful nonunion. Kirschenbaum et all7 initially had 2 patients with postoperative pain. One of these patients had a pseudarthrosis that required reoperation, He was pain free at last follow9up examination.

Scapholunate Arthrodesis Three reports of scapholunatc (NL) arthrodeses were found, for a total of 16 patientsT,2~ (Table 1). Indications fur SL m-throdesis were post-traumatic instabilit>5 including SL instability and dorsal intercalated segment instability defbrmity. Average follow-up time was 45 months. The average nonunion rate tbr these patients was high, at 10 of 16, with a nonunion rate of 6 of 7 reported by l-lore and Ruby. 2t Theh two complications, combined with the zero rate of complication h~ the Hastings study,2~ gives an overall rate of 2 of 10. Complications reported

A total of 33 patients were identified who under went SCL arthrodesisT.Zo,22,~- (Table 1). The followup period averaged 30 months (range, 7-102 months). Indications t o , this type of intercarpal arthrodesis were Kienbrck's disease, rotatory subluxation of the scaphoid, scaphoid fracture and nonunion, and chronic volar intercalated segment instability deformity. The nonunion rate was only t 2%. The complication rate was 3 of 24; it included cases of infection arid tendon injury. The low ROM, 48.8%, is not u~expected, as the arthrodesis crosses the midcarpal row. In the study by Rotman et al.,2a 16 of 2t patients reported postoperative pain. Five patients had occasional pain with heavy or repetitive activity, 4 had consistent pain with heavy or repetitive activity, 6 patients had pain with light activitics, and 1 patient had pain with wrist motion. The authors believed there was a strong correlation between persistent pain and unsettled workers' compensation claims. There was 1 patient in this study who went on to total wrist artbrodesis s e c o n d l y to infection who was not included in further follow-up evaluation.

Capitolunate Arthrodesis Three slndies reported o,1 the results of capitolunatc (CL) arthrodesis 24 z6 (Table 1). There were 29 patients identified. The average follow-up period was 55 months. Indications for CL arthrodesis were degenerative disease in the CL articulation, scaphoid fracture, rotatory subLuxation of the scaphoid, scaphotunate adv~mced collapse wrist, SL dissociation, and radioscaphoid arthrosis. In some cases, a silicone scaphoid implant was used. The nonunion rate was 35%. The complication rate was quite t'figh at 62%. Complications included reflex sympathetic dystrophy, radial sensory neuroma, broken Kirschner wires and pin track infections, discomfort around staples, and progressive radiolunate arthrosis. There

The Journal of Hand Surgery/Voh 21A No. 4 July I996

were no reported complications with the silicone implants. Of patients studied, 51.7% had persistent postoperative pain. Kirschenbamn et al.,24 in their report of 18 patients who underwent CL arthrodesis, had 8 patients with persistent pain. Five patients had mild pain. Three of thcsc patients had a pseudarthrosis but required no additional surgery. Three patients had moderate pain after surgery. Two of these patients had reopecation for pseudarthrosis and 1 patient went on to have a total wrist arthrodesis. In Watson and Ballet's study, 2 of 3 patients had postoperative pain, but they reported only that it was "less" than preoperative pain. 26 In the study by Krakauer et al., 25 5 of 8 patients bad some pain at linal follow-up examimttion. Only 1 patient, found to have nonunion, had severe pain and underwent repeat bone grafting. kn the study by Kirschenbamn et al., 24 8 patients had silicone scaphoid imptmlts and 10 patients did not. Of the 8 patients who had the implants, 5 implants were noted to be subluxed or dislocated on follow-up examination. There were no cases of silicone synovitis, and removal of the implants was not required in any case. There was no apparent correlation between the implant and postoperative pain. This arthrodesis crosses the midcarpal row, and therefore postoperative ROM is reduced significantly to 53.7% of normal.

Scaphocapitate Arthrodesis Pisano et al. reported on the results of 17 patients treated with scaphocapitate (SC) arthrodeses 27 (Table 1). In their study, the indications for this intercarpal arthrodesis included scaphoid nonunion, chronic dorsal intercalated segment instability defortrdty with rotatory scaphoid instability, Kienb~ick's disease, ~ d lunate nonunion. Their follow-up period ranged from 16 to 57 months. They had a nonunion rate of only 2 of 17 and a complication rate of 11.8%. Their complications were both minor dystro phies. Of the patients in this study, 7 had persistent postoperative pain. All 7 were reported to have mild to moderale pain with work or recreational activity. None of these patients had additional surgery, although 1 patient remains disabled secondary to continued pain.

Capitohamate-Lunotriquetral Arthrodesis The capitohamate-lunotriquetral--or four-comer-arthrodesis is a popular arthrodesis for the treatment of scapholunate advanced collapse wrist and chronic

721

volar intercalated segment instability deformity. We identified 138 patients in the literature who underwent this type of intercarpal arthrodesis, with and without silicone scaphoid implantation7,m,25,2~,29 (Table 1). The nonunion rate for this at~.rodcsis was low, at 4.3%. The complication rate was 26.5% and included cases of infection, reflex sympathetic dystrophy, and dislocations of silicone scaphoid implants, The fol low-up period averaged 40 months (range, 4-132 months). Three of the studies reported persistent pain at postoperative follow-up examination. In those studies, the incidence of postoperative pain was 63 of 127. Trumble et al. 29 reported persistent pain in all 4 of their patients. These patient:s were described as having occasional pain with changes in the weather and with heavy lifting. In the report by Ashmead et al.,28 49 of 100 patients had some degree of postoperative pain. However, 91 patients questioned said they would have the surgery again. Eighty patients ha this group had silicone scaphoids implanted at the time of fourcorner arthrodesis. Nine of these patients developed complications related to the implant, including 7 with silicone synovitis. The authors also state that some degree of implant malrotation and subluxafion was extxernely common. They no longer use the implant when performing this type of artltrodesis and do not recommend its use. The other major late complication found in their patient review was dorsal impingement of the capitate on the radius. They believed, in retrospect, that this represented a technical error at the time of surgery. Impingement occurred in those patients who had inadequate reduction of an existing dorsal intercalated segment instahi lity deformity. This technical point was also brought out by Tomaino et al. in their review, t~

Discussion The data gathered by this literature review have several inherent flaws. Objective data were reported fairly consistently; however, the manner in which they reported varied widely. We used 120 ~ as normal when making calculations :for wrist ROM. Where dynamometer readings were given as grip strength measurements, we used the age-adjusted values given in the American Medical Association guidelines ~0 to convert these to a percentage of normal strength. Another problem encountered was in the reporting of postoperative complications. Some authors included nonunions as complications and some did

722 Siegel and Ruby/[ntercarpal Arthrodesis not. Nonunions were separated out whenever possible. Some authors were very specific in their reporting o f postoperative complications; the complication rate may appear higher in studies in which this was the case. The subjective cJJterion examined was postoperative pain. We were very strict in our evaluation of postoperative pain. In this study, any complaint related to pain was designaled as positive. One &'awback o f this strict system of evaluation is that not all cases involving mild postoperative pain had poor results. Because there was tm way to standardize all the various descriptions of postoperative pain reported in the literature, this all-inclusive method was deemed the most uniform. Looking at the objective criteria, certain conclusions can be drawn. The arthmdeses that involve the greatest surface area have the lowest rates of nonunion. The four-comer arthrodesis has the lowest rate of nonunion in the series compared. Complication rates were highly variable and probably reflect the specificity of each author in the reporting of postoperative complications. Postoperative grip strength was relatively uniform for all arthrodesis types. Not surprisingly, however, postoperative R O M was significantly decreased for the arthrodeses that cross the midcarpal joint the SCL, SC, CL, and fbur-corner arthmdeses. Douglas et al. ~] did an in vitro study of selected interearpal arthrodeses in which they compared the postopera live ROM for each ~throdesis type. Comparing their results to those in the literature, we find that, as predicted, arthrodeses that do not cross the midcarpal row have t h e greatest postoperative ROM. The in vitro study also predicts the dramatic decrease in R O M that occurs when the i n t e r e ~ a l arthrodesis crosses thc midcarp~d articulation. We found in our review that arthrodeses thai cross the midcarpal row limit postoperative R O M by about 50%. it is important to preserve motion to maximize functional ability, Several authors have attempted to define the minimum ROM o f the wrist necessary to perform most activities of daily living)2->4 This value ranges from a 35 ~ arc of flexion and extension to an 80 ~ arc, or from 29% to 67% o f normal wrist motion, All the measured ROMs following the different intercarpal arthrodeses fall within or above this functional range. Viegas et al)5 reported the results of an in vitro study of load transmission across the radiocarpal joint after various types of interearpal atIhrodesis. They

lound that STT and SC arthrodeses tr~msmit al most all load through the scaphoid lbssa of the wrist, whereas SL, SCL, and CL arthrodeses distribute load more proportionately, These results seem to correlate with the results of several studies in the literature. Ishida and Tsai, s Kleinman, c' Minami et al., 9 and Vochc ct al. 11 all found nmncrous cases of radioscaphoid arthrosis developing after STT arthrodesis. None o f the reported results on SL, SCL, or C L artl-n-odeses report the development of radioscaphoid arthrosis. From our review of the literature, we fo~,nd that only 47% of patients who underwent any type o f intercarpal arthrodesis had complete relief of their preoperative wrist pain. Although we found a strong correlation between pain and functional ability, this was impossible to quanlitatc. We do agree with the conclusions o f Tomaino et al.36 that satisfactory postoperative function appears to be more dependent on pare relief than on objective measurements.

References l. Peterso~q VIA,.Lipscomb PR, Interearpal arthrodesis. Arch Surg 1967;95:127-134, 2, Eckenrode JE Louis Ds Greene TL. Scapho-trapeziumtrapezoid fusion ]n the treatment of ct~'onic scapho~una~e instability. I Hand Surg 1986;11A:497 502. 3. Fortitl PT, Louis DS. gong-term fbllow-up of scapho trapezium-trapezoid arthmdesis. 1 Hand Surg 1993;18A:675~81. 4. Frykman EB, Ekenstam FA, Wadin K. TJscaphoid ~xrt~,dcsis and its complications. J H~mdSurg 198g;13A:844-849~ 5. Islti&i O, Tsai ~KM.Complications and resu[~s of scaphotrapczio-t~apezoid arthrodcsls. Clin Orthop 1993;287: 125-130. 6. Kleinman WB. Scapho-trapezio-t~pezoid a**hrodesis for treatment of chronic static and dynastic scapho-lunate inslability: a 10-year perspective on pit.~itlls *rod complications. J Hand Surg 1990; [ 5A:408414. 7. McAutiffe JA, Dell PC, J~'e R. Complications of in,rcarpal artl~odesis. J Hand Surg 1993; 18A:1121-1128. 8. Minaret A, Ogino T, Minami M. Limited wrist fusions. ,I Hand Surg 1988; 13A:660-667. 9. Minaret A, Kimnra T, Suzuki K. Long-term results of Kicnb(Sck's disease u'eated by triscaphe arthrodesis and excJslonal ~throplasty with a coiled pak~_cris longus ten(ton. ,I Hand Surg 1994; 19A:219-228. 10. Tomaino MM, Millr R.I, Cole I, Burton R1. Scapholunate advm~ced collapse wrist: proximal row carpectomy or limited wrist artttrodesis with scaphoid excision? J Hand Surg 1994; 19A:134-142. ]1. Voche R Bour C, Merle M. Scapho-tral:ezio-U'apezoid arthrodcsis in the treatment of Kienb~ck's disease. J I land Surg 1992;t7B:5 It. 12. Watson HK, Ryu J, DiBclla A. An app~oach to K[enb6ck's disease: triscaphe arthrodesis. I Hand Surg 1985;10/%.: 179.-187.

The Journal of Hand Surgery/Vol. 2lA No. 4 luly 1996 13. Watson HK, Ryu J, Akelrnan E. Limited trisc'-~phokt intercarpal arthrodesis for rotatory subluxation ~f the scaphoid. J Bone Joint Surg 1986;68A:345-.-349. 14. Watson HK, Hcmpmn RR l~imited wrist arthrodesis. I. The triscaphoid joint. J Hand Surg 1980;5:320-327. 15. Sennwald GR, Segmuller G. The value of scaphot.rapezh)-trapezoid arthrodesis combined with "de la c',fffiniere'" arthmPtasty for the t~'eatments of paa-trapez~al osteoarthritis. J Hand Surg 1993;18B:527-532. t6. Nelson DL, Manske I'R, Pruitt DL, Gilula LA, Morton RA. Lanotfiquetral arthrodesis. J Hand St~rg 1993;18A: 1113-1 t20. 17. Kirschenbaum D, Coyle MR Lcddy JP. Chro~ic lunc~triquetral instability: diagnosis and treatment. J H:md Surg 1993:18A:1107-i 1t2. 18. Maiten EC, Born FW, Osturrnan AL. Lunato-triquetl:al instability: a cause of chronic wrist pain. J l-land Surg 1988; 13A:309. 19. Pin PG, Young L, Gilula LA, Weeks PM. Management of chronic lunou'iClUctraI ligament tears. I Hand Surg 1989;14A:77 83. 20. Hastings DE, Silver RI,. lnLercarpal arthrodesis in the rnaalagement of chronic carpal instability after trauma. J Hand Surg :1984;9A:834---840. 21. Horn S, Ruby LK. Attempted scapholunate arthrodesis for chrouic scaplmlunate dissociation. J Hand Surg 1.99] ;l 6A:334-339. 22. Rotruan MB, Manske PR, Pruitt DL, Szerzinskl J. ScaphocapitoltLnate arthrodesis. J Hand Surg 1993;18A: 26-33. 23. Viegas SF. Limited ~throdesis for scaphoid nonuni~.m..I Hand S urg 1994; 19A: 127-133. 24. Kirschenbaum D, Schneider LH, Kirkpatrick WH, Adams DC, Cody RR Scaphoid excisiota and c,'.Lpitolunate arthrodesis for radioscaphoid arthritis. J I land Surg 1993; 1gA:780-785.

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