- Email: [email protected]
Proximal Row Carpectomy
SURGICAL TECHNIQUE
Proximal Row Carpectomy David P. Green, MD,* Aimee C. Perreira, MD,* Lisa K. Longhofer, MD*
Proximal row carpectomy (PRC) has earned a respected place in the hand surgeon’s armamentarium. Prerequisites for the standard PRC are good cartilage on the proximal pole of capitate and in the lunate fossa of radius. If there is cartilage damage on the proximal pole of capitate, the modification of Salomon and Eaton is a reasonable alternative to the standard PRC. The most important surgical step is preservation of the radioscaphocapitate ligament. Good long-term results can be achieved, and with careful patient selection the operation can be done successfully in people who use their hands for heavy work. (J Hand Surg Am. 2015;40(8):1672e1676. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Wrist, carpals, surgical technique, scapholunate advanced collapse wrist, salvage. Surgical Technique
certainty who first proposed the idea of removing all 3 bones in the proximal carpal row, but that distinction should probably be given to T. T. Stamm of Guy’s Hospital in London.1 Stamm stated that he first performed a proximal row carpectomy (PRC) in 1939, but he credited Lambrinudi with suggesting the idea.2,3 Since then, many articles have been written about PRC4e7 and the procedure has earned a respected place in the hand surgeon’s armamentarium.
I
T IS DIFFICULT TO DETERMINE WITH
INDICATIONS AND CONTRAINDICATIONS The operation is indicated primarily in patients with scapholunate advanced collapse wrist or advanced Kienböck disease. Some patients with posttraumatic arthritis after fractures of the distal radius might be candidates, but articular incongruity in the lunate fossa of radius is a contraindication. From *The Hand Center of San Antonio, Department of Orthopaedics, University of Texas Health Science Center at San Antonio, San Antonio, TX. Received for publication February 19, 2015; accepted in revised form April 30, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David P. Green, MD, The Hand Center of San Antonio, Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 21 Spurs Lane #310, San Antonio, TX 78240; e-mail: [email protected]. 0363-5023/15/4008-0025$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.04.033
1672
r
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
SURGICAL TECHNIQUE Prerequisites for standard PRC are normal cartilage on the proximal pole of capitate and in the lunate fossa of radius. The operation is usually done through a longitudinal midline incision. If early postoperative motion is anticipated, a transverse incision will result in a more cosmetic scar, although this makes the procedure more difficult (and may require a second capsular incision on the ulnar side of the fourth compartment tendons). Skin flaps are dissected along the plane of the dorsal retinaculum and retracted, which protects the superficial branch of radial nerve and dorsal sensory branch of ulnar nerve. The tendon of extensor pollicis longus (EPL) is identified distal to the retinaculum and its sheath is opened retrograde to the Lister tubercle, where the dorsal retinaculum is divided between the third and fourth compartments. The EPL tendon is lifted out of the Lister canal and retracted to the radial side, and the retinaculum is divided in a straight proximal direction over the EPL tendon. The fourth dorsal compartment tendons (extensor digitorum communis) are retracted to the ulnar side. It is desirable but not necessary to keep the extensor digitorum communis tendon sheath intact. An adjunct procedure that is ordinarily done at this point (for presumed pain control) is to resect the terminal division of the posterior interosseous nerve, which is usually found adherent to the underneath surface of the fourth compartment tendon sheath. The
1673
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FIGURE 1: Salomon-Eaton modification of PRC. A If the surgeon is not certain about the quality of cartilage on the proximal pole of the capitate, it is advisable to open the capsule using 2 of the 3 sides of a flap based distally at the base of the metacarpals (dashed lines). B If the Salomon-Eaton modification is to be done, the remaining limb of the flap is cut and the flap is raised. C The proximal pole of capitate is cut off with an osteotome. D The flap is then sutured to the volar capsule and ligaments.
nerve is transected distally and freed proximally, where it is transected so that its cut end will subsequently lie beneath the extensor muscles, taking care to preserve the tiny artery that accompanies it. The dorsal capsule of the wrist is exposed, and a decision must be made at this point. If the surgeon is absolutely certain that there is good cartilage on the proximal pole of capitate, a straight longitudinal incision may be made in the capsule, exposing the carpals. The problem is that it is not always possible to predict cartilage damage on the capitate preoperatively. Plain radiographs often show no apparent abnormality in the face of large cartilage defects, and even magnetic resonance imaging can be deceptive. For this reason, it is now our practice to anticipate the possible conversion of a standard PRC to an Eaton modification of the procedure as described below. This requires a distal-based flap of capsule that will be interposed between the proximal pole of capitate and radius, so the 2 limbs of that flap are made upon approach to the carpus (Fig. 1A). J Hand Surg Am.
The proximal pole of capitate and lunate fossa of radius are carefully inspected to ensure that these cartilage surfaces are not damaged (the 2 prerequisites for a successful PRC). If there is good cartilage on both, a standard PRC is done. The capsule is dissected off the carpals by sharp dissection so that a Homan retractor can be inserted on the ulnar side of the hamate and triquetrum. Removal of the proximal row of bones is most safely done with as much blunt dissection as possible. It is easiest to start by excising the triquetrum, the first step of which is to divide the dorsal triquetrolunate ligaments that are in direct view. With his or her nondominant hand, the surgeon grasps the triquetrum with a towel clip and uses this to manipulate the bone so that the flange at the tip of a Carroll elevator or similar instrument can be inserted on the volar side of the bone to separate it from its ligamentous attachments (Video 1, available on the Journal’s Web site at www.jhandsurg.org). A “scrunching” sound indicates that this is being done effectively. This is not an elegant procedure but it is
r
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Surgical Technique
FIGURE 2: Postoperatively, the capitate should be nestled in the lunate fossa of the radius in both A anteroposterior and B lateral views.
safer than trying to do this entirely by sharp dissection. Only when the triquetrum is lifted up do the ligaments come into view, so that a scalpel can then be used to divide them safely, keeping the knife blade directly on the bone. The lunate is then removed in similar fashion, taking care not to damage the articular cartilage on the proximal pole of capitate. The scaphoid is the final, most difficult, and most challenging bone to remove. The same technique of blunt dissection is used, and here it is even more important than on the ulnar side of the wrist. The single most important element of a PRC is to preserve the radioscaphocapitate (RSC) ligament. Unfortunately, the ligament cannot be seen until the scaphoid is removed because the bone straddles the ligament on its volar side. Great care and patience are required here, using blunt dissection as much as possible, particularly at the distal pole, where the scaphotrapezium-trapezoid ligaments are strong. Again, it must be emphasized that the knife is used only when a ligament can be seen clearly, and the scalpel must be kept close to the surface of the bone. If the scaphoid has been removed properly, the surgeon is rewarded by seeing the stout RSC ligament spanning the gap. Passive ulnar translocation of the carpus is attempted, and if the ligament is intact, the carpus cannot be pulled past the lunate fossa. The postoperative x-ray (Fig. 2) should show the capitate nestled in the lunate fossa of radius. If the RSC ligament is undamaged, no internal fixation is needed. If there is a small (< 10 mm) cartilage defect in the capitate, it can be repaired with osteochondral resurfacing, as described by Tang and Imbriglia.8 J Hand Surg Am.
The tourniquet is released and hemostasis is obtained. The dorsal capsule is repaired, the EPL tendon is replaced into its normal position, and the dorsal retinaculum is reapproximated. Salomon and Eaton modification of the PRC If the proximal pole of capitate is found to have major cartilage damage, the modified version of a PRC described by Salomon and Eaton9 is a reasonable alternative to consider rather than a partial or full wrist arthrodesis. If such a situation is encountered, the final limb of the distal-based flap is cut and freed (Fig. 1A, B). The flap can be tacked with a suture to the skin over the metacarpals to keep it out of the way until needed at the time of closure. After the 3 bones have been removed, the proximal pole of capitate is squared off with an osteotome in preparation for interposition of the flap (Fig. 1C). After achieving hemostasis, the flap is inserted into the space created by removal of the bones and sutured to the volar capsule (Fig. 1D). Salomon and Eaton recommended Steinmann pin fixation for 3 weeks with their modification of the PRC. POSTOPERATIVE MANAGEMENT Suction catheter drainage is used only if ideal hemostasis is not achieved. A bulky dressing incorporating a short arm orthosis (allowing full freedom of finger movement) is applied, which is changed to a short arm cast at 10 days. The cast is removed at approximately 3 weeks after surgery and referral is made to a hand therapist for a home program. Recovery from a PRC r
Vol. 40, August 2015
PROXIMAL ROW CARPECTOMY
takes 3 to 6 months before the patient reports that the wrist feels good and 12 months until maximum recovery is achieved. It is imperative to emphasize to the patient the importance of doing grip-strengthening exercises for these many months.
Long-term viability Failure rates of 0% to 35% have been reported in long-term studies, of which there have been only a few.16,17,19e22 In general, the causes of failure were either not addressed in these prior studies, or were related to radial impingement or progression of radiocapitate arthritis.11e13,15 Long-term outcomes for PRC in these few articles are mostly favorable,16,17,19e22 although one study showed poorer outcomes in patients aged less than 35 years and in manual laborers.19,20 In our series, a recent retrospective review selected patients with long-term follow-up. Nineteen patients underwent the procedure from 1980 to 1999, providing an average length of follow-up of 24 years (range, 15e34 y). Average age was 38 years (range, 16e63 y). Eleven of the 19 patients were identified as manual laborers (including mechanic, rancher, pipe fitter, throwing sport athlete, college football player, furniture maker, and rodeo cowboy). All of these patients returned to work or to their former level of activity. One patient was considered a failure and the PRC was revised to a wrist arthrodesis. One patient had a PRC in one wrist and an arthrodesis in the other; he said that he wished he had had a PRC in both. The average QuickeDisabilities of the Arm, Shoulder, and Hand questionnaire score in the group was 8.3 (range, 0e50) and no patients had major symptoms. Forty-two percent were asymptomatic and 58% had occasional mild discomfort. Average range of wrist motion was 95 (range, 70 to 135 ) and average grip strength was 89% of the contralateral side (range, 65% to 130%). Evidence from previous articles and the results of our study suggest that PRC is an effective operation and that good short-term relief of pain is a reliable indication that long-term benefit is likely to follow. With proper patient selection, the operation can be done successfully in people who use their hands for heavy manual activity.
COMPLICATIONS We recently reviewed the senior author’s personal series of 122 PRCs. Because several previous articles10e20 already established the efficacy of PRC, we sought to ask 2 additional questions: (1) When it failed, what was the reason? and 2) Does it provide good longterm benefit? Causes for failure Failure was defined as requiring conversion to an arthrodesis, which was the outcome in 12 of our 122 patients (10%). Although a primary goal of this study was to identify causes of failure, a reasonable cause was identified in only 4 of these 12 patients. Two patients had arthritis in the capitolunate joint not fully appreciated at the time of PRC and another patient had impingement of the radial styloid postoperatively. The most obvious cause of failure was a patient in whom the critical RSC ligament was inadvertently cut at the time of surgery. Although the complication was recognized and the ligament repaired, ulnar translocation developed, necessitating a subsequent wrist arthrodesis. This patient was one of the few in our series who had bilateral PRCs performed, and in the opposite wrist done before the failed operation, PRC was totally successful. Records were lost for 2 patients; in the remaining 6, no clear cause for failure could be identified. However, it is perhaps pertinent to note that 3 of these patients continued to have pain even after successful (ie, healed) wrist arthrodesis, and several required excessive and prolonged use of narcotics, which may speak to patient selection. Perhaps the most important observation among this group of 12 failures is that none had relief of pain postoperatively, not even transiently. After PRC most
ACKNOWLEDGMENT With appreciation to Stephen T. Gates, MD, and Christina I. Brady, MD, for their help in tracking down patients. r
Vol. 40, August 2015
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patients will not be totally asymptomatic at 3 or even 6 months, but they tend to show gradual and steady improvement and relief of symptoms. It would appear from these results that if a patient is still having major symptoms at 3 to 6 months after surgery, failure is likely to be the final outcome.
PEARLS AND PITFALLS The prerequisites for a successful PRC are undamaged cartilage on the proximal pole of capitate and in the lunate fossa of radius. The capsular flap described by Salomon and Eaton offers the surgeon an alternative if the proximal pole of capitate is seen to have major cartilage damage at surgery. By far the most serious intraoperative complication is disruption of the RSC ligament, which is best prevented by blunt dissection of the carpals.
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REFERENCES
Surgical Technique
13. Jebson PJ, Hayes EP, Engber WD. Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg Am. 2003;28(4): 561e569. 14. Dodona ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: study with a minimum of 10 years of follow-up. J Bone Joint Surg Am. 2004;86(11):2359e2365. 15. Croog AS, Stern PJ. Proximal row carpectomy for advanced Kienbock’s disease: average 10-year follow-up. J Hand Surg Am. 2008;33(7):1122e1130. 16. Lumsden BC, Stone A, Engber WD. Treatment of advanced-stage Kienbock’s disease with proximal row carpectomy: an average 15-year follow-up. J Hand Surg Am. 2008;33(4):493e502. 17. Liu M, Zhou H, Yang Z, Huang F, Pei F, Xiang Z. Clinical evaluation of proximal row carpectomy revealed by follow-up for 10-29 years. Int Orthop. 2009;33(5):1315e1321. 18. Richou J, Chuinard C, Moineau G, Hanouz N, Hu W, Le Nen D. Proximal row carpectomy: long-term results. Chir Main. 2010;29(1):10e15. 19. Chim H, Moran SL. Long-term outcomes of proximal row carpectomy: a systematic review of the literature. J Wrist Surg. 2012;1(2):141e148. 20. Wall LB, DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am. 2013;38(8): 1498e1504. 21. Ali MH, Rizzo M, Shin AY, Moran SL. Long-term outcomes of proximal row carpectomy: a minimum of 15-year follow-up. Hand. 2012;7(1):72e78. 22. Green DP. Proximal row carpectomy. Hand Clin. 1987;3(1): 163e168.
1. Stamm TT. Excision of the proximal row of the carpus. Proc R Soc Med. 1944;38(2):74e75. 2. Stack JK. End results of excision of the carpal bones. Arch Surg. 1948;57(2):245e252. 3. Stamm TT. Excision of the proximal row of the carpus. Guys’ Hosp Rep. 1963;112:6e8. 4. Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg Br. 1964;46:708e711. 5. Jorgensen EC. Proximal row carpectomy: an end result study of twenty-two cases. J Bone Joint Surg Am. 1969;51(6):1104e1111. 6. Inglis AF, Jones ED. Proximal row carpectomy for diseases of the proximal row. J Bone Joint Surg Am. 1977;59(4):460e463. 7. Nevaiser RJ. Proximal row carpectomy for posttraumatic disorders of the carpus. J Hand Surg. 1983;8(3):301e305. 8. Tang P, Imbriglia JE. Osteochondral resurfacing (OCRPRC) for capitate chondrosis in proximal row carpectomy. J Hand Surg Am. 2007;32(9):1334e1342. 9. Salomon GD, Eaton RG. Proximal row carpectomy with partial capitate resection. J Hand Surg Am. 1996;21(1):2e8. 10. Imbriglia J, Broudy A, Hagber W, McKernan D. Proximal row carpectomy: clinical evaluation. J Hand Surg Am. 1990;15(3):426e430. 11. Culp R, McGuigan F, Turner M, Lichtman D, Osterman L. Proximal row carpectomy: a multicenter study. J Hand Surg Am. 1993;18(1):19e25. 12. Tomaino M, Delsignore J, Burton R. Long-term results following proximal row carpectomy. J Hand Surg Am. 1994;19(4):694e703.
J Hand Surg Am.
r
Vol. 40, August 2015
Proximal Row Carpectomy David P. Green, MD,* Aimee C. Perreira, MD,* Lisa K. Longhofer, MD*
Proximal row carpectomy (PRC) has earned a respected place in the hand surgeon’s armamentarium. Prerequisites for the standard PRC are good cartilage on the proximal pole of capitate and in the lunate fossa of radius. If there is cartilage damage on the proximal pole of capitate, the modification of Salomon and Eaton is a reasonable alternative to the standard PRC. The most important surgical step is preservation of the radioscaphocapitate ligament. Good long-term results can be achieved, and with careful patient selection the operation can be done successfully in people who use their hands for heavy work. (J Hand Surg Am. 2015;40(8):1672e1676. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Wrist, carpals, surgical technique, scapholunate advanced collapse wrist, salvage. Surgical Technique
certainty who first proposed the idea of removing all 3 bones in the proximal carpal row, but that distinction should probably be given to T. T. Stamm of Guy’s Hospital in London.1 Stamm stated that he first performed a proximal row carpectomy (PRC) in 1939, but he credited Lambrinudi with suggesting the idea.2,3 Since then, many articles have been written about PRC4e7 and the procedure has earned a respected place in the hand surgeon’s armamentarium.
I
T IS DIFFICULT TO DETERMINE WITH
INDICATIONS AND CONTRAINDICATIONS The operation is indicated primarily in patients with scapholunate advanced collapse wrist or advanced Kienböck disease. Some patients with posttraumatic arthritis after fractures of the distal radius might be candidates, but articular incongruity in the lunate fossa of radius is a contraindication. From *The Hand Center of San Antonio, Department of Orthopaedics, University of Texas Health Science Center at San Antonio, San Antonio, TX. Received for publication February 19, 2015; accepted in revised form April 30, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David P. Green, MD, The Hand Center of San Antonio, Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 21 Spurs Lane #310, San Antonio, TX 78240; e-mail: [email protected]. 0363-5023/15/4008-0025$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.04.033
1672
r
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
SURGICAL TECHNIQUE Prerequisites for standard PRC are normal cartilage on the proximal pole of capitate and in the lunate fossa of radius. The operation is usually done through a longitudinal midline incision. If early postoperative motion is anticipated, a transverse incision will result in a more cosmetic scar, although this makes the procedure more difficult (and may require a second capsular incision on the ulnar side of the fourth compartment tendons). Skin flaps are dissected along the plane of the dorsal retinaculum and retracted, which protects the superficial branch of radial nerve and dorsal sensory branch of ulnar nerve. The tendon of extensor pollicis longus (EPL) is identified distal to the retinaculum and its sheath is opened retrograde to the Lister tubercle, where the dorsal retinaculum is divided between the third and fourth compartments. The EPL tendon is lifted out of the Lister canal and retracted to the radial side, and the retinaculum is divided in a straight proximal direction over the EPL tendon. The fourth dorsal compartment tendons (extensor digitorum communis) are retracted to the ulnar side. It is desirable but not necessary to keep the extensor digitorum communis tendon sheath intact. An adjunct procedure that is ordinarily done at this point (for presumed pain control) is to resect the terminal division of the posterior interosseous nerve, which is usually found adherent to the underneath surface of the fourth compartment tendon sheath. The
1673
Surgical Technique
PROXIMAL ROW CARPECTOMY
FIGURE 1: Salomon-Eaton modification of PRC. A If the surgeon is not certain about the quality of cartilage on the proximal pole of the capitate, it is advisable to open the capsule using 2 of the 3 sides of a flap based distally at the base of the metacarpals (dashed lines). B If the Salomon-Eaton modification is to be done, the remaining limb of the flap is cut and the flap is raised. C The proximal pole of capitate is cut off with an osteotome. D The flap is then sutured to the volar capsule and ligaments.
nerve is transected distally and freed proximally, where it is transected so that its cut end will subsequently lie beneath the extensor muscles, taking care to preserve the tiny artery that accompanies it. The dorsal capsule of the wrist is exposed, and a decision must be made at this point. If the surgeon is absolutely certain that there is good cartilage on the proximal pole of capitate, a straight longitudinal incision may be made in the capsule, exposing the carpals. The problem is that it is not always possible to predict cartilage damage on the capitate preoperatively. Plain radiographs often show no apparent abnormality in the face of large cartilage defects, and even magnetic resonance imaging can be deceptive. For this reason, it is now our practice to anticipate the possible conversion of a standard PRC to an Eaton modification of the procedure as described below. This requires a distal-based flap of capsule that will be interposed between the proximal pole of capitate and radius, so the 2 limbs of that flap are made upon approach to the carpus (Fig. 1A). J Hand Surg Am.
The proximal pole of capitate and lunate fossa of radius are carefully inspected to ensure that these cartilage surfaces are not damaged (the 2 prerequisites for a successful PRC). If there is good cartilage on both, a standard PRC is done. The capsule is dissected off the carpals by sharp dissection so that a Homan retractor can be inserted on the ulnar side of the hamate and triquetrum. Removal of the proximal row of bones is most safely done with as much blunt dissection as possible. It is easiest to start by excising the triquetrum, the first step of which is to divide the dorsal triquetrolunate ligaments that are in direct view. With his or her nondominant hand, the surgeon grasps the triquetrum with a towel clip and uses this to manipulate the bone so that the flange at the tip of a Carroll elevator or similar instrument can be inserted on the volar side of the bone to separate it from its ligamentous attachments (Video 1, available on the Journal’s Web site at www.jhandsurg.org). A “scrunching” sound indicates that this is being done effectively. This is not an elegant procedure but it is
r
Vol. 40, August 2015
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PROXIMAL ROW CARPECTOMY
Surgical Technique
FIGURE 2: Postoperatively, the capitate should be nestled in the lunate fossa of the radius in both A anteroposterior and B lateral views.
safer than trying to do this entirely by sharp dissection. Only when the triquetrum is lifted up do the ligaments come into view, so that a scalpel can then be used to divide them safely, keeping the knife blade directly on the bone. The lunate is then removed in similar fashion, taking care not to damage the articular cartilage on the proximal pole of capitate. The scaphoid is the final, most difficult, and most challenging bone to remove. The same technique of blunt dissection is used, and here it is even more important than on the ulnar side of the wrist. The single most important element of a PRC is to preserve the radioscaphocapitate (RSC) ligament. Unfortunately, the ligament cannot be seen until the scaphoid is removed because the bone straddles the ligament on its volar side. Great care and patience are required here, using blunt dissection as much as possible, particularly at the distal pole, where the scaphotrapezium-trapezoid ligaments are strong. Again, it must be emphasized that the knife is used only when a ligament can be seen clearly, and the scalpel must be kept close to the surface of the bone. If the scaphoid has been removed properly, the surgeon is rewarded by seeing the stout RSC ligament spanning the gap. Passive ulnar translocation of the carpus is attempted, and if the ligament is intact, the carpus cannot be pulled past the lunate fossa. The postoperative x-ray (Fig. 2) should show the capitate nestled in the lunate fossa of radius. If the RSC ligament is undamaged, no internal fixation is needed. If there is a small (< 10 mm) cartilage defect in the capitate, it can be repaired with osteochondral resurfacing, as described by Tang and Imbriglia.8 J Hand Surg Am.
The tourniquet is released and hemostasis is obtained. The dorsal capsule is repaired, the EPL tendon is replaced into its normal position, and the dorsal retinaculum is reapproximated. Salomon and Eaton modification of the PRC If the proximal pole of capitate is found to have major cartilage damage, the modified version of a PRC described by Salomon and Eaton9 is a reasonable alternative to consider rather than a partial or full wrist arthrodesis. If such a situation is encountered, the final limb of the distal-based flap is cut and freed (Fig. 1A, B). The flap can be tacked with a suture to the skin over the metacarpals to keep it out of the way until needed at the time of closure. After the 3 bones have been removed, the proximal pole of capitate is squared off with an osteotome in preparation for interposition of the flap (Fig. 1C). After achieving hemostasis, the flap is inserted into the space created by removal of the bones and sutured to the volar capsule (Fig. 1D). Salomon and Eaton recommended Steinmann pin fixation for 3 weeks with their modification of the PRC. POSTOPERATIVE MANAGEMENT Suction catheter drainage is used only if ideal hemostasis is not achieved. A bulky dressing incorporating a short arm orthosis (allowing full freedom of finger movement) is applied, which is changed to a short arm cast at 10 days. The cast is removed at approximately 3 weeks after surgery and referral is made to a hand therapist for a home program. Recovery from a PRC r
Vol. 40, August 2015
PROXIMAL ROW CARPECTOMY
takes 3 to 6 months before the patient reports that the wrist feels good and 12 months until maximum recovery is achieved. It is imperative to emphasize to the patient the importance of doing grip-strengthening exercises for these many months.
Long-term viability Failure rates of 0% to 35% have been reported in long-term studies, of which there have been only a few.16,17,19e22 In general, the causes of failure were either not addressed in these prior studies, or were related to radial impingement or progression of radiocapitate arthritis.11e13,15 Long-term outcomes for PRC in these few articles are mostly favorable,16,17,19e22 although one study showed poorer outcomes in patients aged less than 35 years and in manual laborers.19,20 In our series, a recent retrospective review selected patients with long-term follow-up. Nineteen patients underwent the procedure from 1980 to 1999, providing an average length of follow-up of 24 years (range, 15e34 y). Average age was 38 years (range, 16e63 y). Eleven of the 19 patients were identified as manual laborers (including mechanic, rancher, pipe fitter, throwing sport athlete, college football player, furniture maker, and rodeo cowboy). All of these patients returned to work or to their former level of activity. One patient was considered a failure and the PRC was revised to a wrist arthrodesis. One patient had a PRC in one wrist and an arthrodesis in the other; he said that he wished he had had a PRC in both. The average QuickeDisabilities of the Arm, Shoulder, and Hand questionnaire score in the group was 8.3 (range, 0e50) and no patients had major symptoms. Forty-two percent were asymptomatic and 58% had occasional mild discomfort. Average range of wrist motion was 95 (range, 70 to 135 ) and average grip strength was 89% of the contralateral side (range, 65% to 130%). Evidence from previous articles and the results of our study suggest that PRC is an effective operation and that good short-term relief of pain is a reliable indication that long-term benefit is likely to follow. With proper patient selection, the operation can be done successfully in people who use their hands for heavy manual activity.
COMPLICATIONS We recently reviewed the senior author’s personal series of 122 PRCs. Because several previous articles10e20 already established the efficacy of PRC, we sought to ask 2 additional questions: (1) When it failed, what was the reason? and 2) Does it provide good longterm benefit? Causes for failure Failure was defined as requiring conversion to an arthrodesis, which was the outcome in 12 of our 122 patients (10%). Although a primary goal of this study was to identify causes of failure, a reasonable cause was identified in only 4 of these 12 patients. Two patients had arthritis in the capitolunate joint not fully appreciated at the time of PRC and another patient had impingement of the radial styloid postoperatively. The most obvious cause of failure was a patient in whom the critical RSC ligament was inadvertently cut at the time of surgery. Although the complication was recognized and the ligament repaired, ulnar translocation developed, necessitating a subsequent wrist arthrodesis. This patient was one of the few in our series who had bilateral PRCs performed, and in the opposite wrist done before the failed operation, PRC was totally successful. Records were lost for 2 patients; in the remaining 6, no clear cause for failure could be identified. However, it is perhaps pertinent to note that 3 of these patients continued to have pain even after successful (ie, healed) wrist arthrodesis, and several required excessive and prolonged use of narcotics, which may speak to patient selection. Perhaps the most important observation among this group of 12 failures is that none had relief of pain postoperatively, not even transiently. After PRC most
ACKNOWLEDGMENT With appreciation to Stephen T. Gates, MD, and Christina I. Brady, MD, for their help in tracking down patients. r
Vol. 40, August 2015
Surgical Technique
patients will not be totally asymptomatic at 3 or even 6 months, but they tend to show gradual and steady improvement and relief of symptoms. It would appear from these results that if a patient is still having major symptoms at 3 to 6 months after surgery, failure is likely to be the final outcome.
PEARLS AND PITFALLS The prerequisites for a successful PRC are undamaged cartilage on the proximal pole of capitate and in the lunate fossa of radius. The capsular flap described by Salomon and Eaton offers the surgeon an alternative if the proximal pole of capitate is seen to have major cartilage damage at surgery. By far the most serious intraoperative complication is disruption of the RSC ligament, which is best prevented by blunt dissection of the carpals.
J Hand Surg Am.
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PROXIMAL ROW CARPECTOMY
REFERENCES
Surgical Technique
13. Jebson PJ, Hayes EP, Engber WD. Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg Am. 2003;28(4): 561e569. 14. Dodona ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: study with a minimum of 10 years of follow-up. J Bone Joint Surg Am. 2004;86(11):2359e2365. 15. Croog AS, Stern PJ. Proximal row carpectomy for advanced Kienbock’s disease: average 10-year follow-up. J Hand Surg Am. 2008;33(7):1122e1130. 16. Lumsden BC, Stone A, Engber WD. Treatment of advanced-stage Kienbock’s disease with proximal row carpectomy: an average 15-year follow-up. J Hand Surg Am. 2008;33(4):493e502. 17. Liu M, Zhou H, Yang Z, Huang F, Pei F, Xiang Z. Clinical evaluation of proximal row carpectomy revealed by follow-up for 10-29 years. Int Orthop. 2009;33(5):1315e1321. 18. Richou J, Chuinard C, Moineau G, Hanouz N, Hu W, Le Nen D. Proximal row carpectomy: long-term results. Chir Main. 2010;29(1):10e15. 19. Chim H, Moran SL. Long-term outcomes of proximal row carpectomy: a systematic review of the literature. J Wrist Surg. 2012;1(2):141e148. 20. Wall LB, DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am. 2013;38(8): 1498e1504. 21. Ali MH, Rizzo M, Shin AY, Moran SL. Long-term outcomes of proximal row carpectomy: a minimum of 15-year follow-up. Hand. 2012;7(1):72e78. 22. Green DP. Proximal row carpectomy. Hand Clin. 1987;3(1): 163e168.
1. Stamm TT. Excision of the proximal row of the carpus. Proc R Soc Med. 1944;38(2):74e75. 2. Stack JK. End results of excision of the carpal bones. Arch Surg. 1948;57(2):245e252. 3. Stamm TT. Excision of the proximal row of the carpus. Guys’ Hosp Rep. 1963;112:6e8. 4. Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg Br. 1964;46:708e711. 5. Jorgensen EC. Proximal row carpectomy: an end result study of twenty-two cases. J Bone Joint Surg Am. 1969;51(6):1104e1111. 6. Inglis AF, Jones ED. Proximal row carpectomy for diseases of the proximal row. J Bone Joint Surg Am. 1977;59(4):460e463. 7. Nevaiser RJ. Proximal row carpectomy for posttraumatic disorders of the carpus. J Hand Surg. 1983;8(3):301e305. 8. Tang P, Imbriglia JE. Osteochondral resurfacing (OCRPRC) for capitate chondrosis in proximal row carpectomy. J Hand Surg Am. 2007;32(9):1334e1342. 9. Salomon GD, Eaton RG. Proximal row carpectomy with partial capitate resection. J Hand Surg Am. 1996;21(1):2e8. 10. Imbriglia J, Broudy A, Hagber W, McKernan D. Proximal row carpectomy: clinical evaluation. J Hand Surg Am. 1990;15(3):426e430. 11. Culp R, McGuigan F, Turner M, Lichtman D, Osterman L. Proximal row carpectomy: a multicenter study. J Hand Surg Am. 1993;18(1):19e25. 12. Tomaino M, Delsignore J, Burton R. Long-term results following proximal row carpectomy. J Hand Surg Am. 1994;19(4):694e703.
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Vol. 40, August 2015