Salvage Procedures of the Wrist



Salvage Procedures of the Wrist


Edward W. Jernigan

Reid W. Draeger



INTRODUCTION



  • Primary arthrosis of the radiocarpal and midcarpal joints is uncommon.


  • Arthrosis of the wrist may be a result of the sequelae from trauma (bony or ligamentous), crystalline arthropathy, infectious etiology, blood dyscrasias, neoplasm, or infection.


  • Goals of treatment include a wrist that is pain-free, functional, and stable.


  • Salvage procedures of the wrist can be divided into motion-sparing versus wrist arthrodesis.



    • Functional range of motion of the wrist is approximately 40° of extension, 40° of flexion, and a radial/ulnar deviation arc of motion of 40°.1


    • Motion-sparing procedures can be performed with the goal of maintaining functional range of motion of the wrist, with the risks of continued degeneration across preserved articulations.


EVALUATION



  • History and physical examination



    • Important to consider patients’ age and occupation, which may have implications for preferred treatment methods.


    • Patients with history of inflammatory disease may have polyarticular involvement.


    • Any historic or physical examination findings concerning ongoing infection must be thoroughly evaluated. Any ongoing infection should be eradicated prior to instrumenting the wrist.


  • Radiographic evaluation



    • Plain radiographs—In addition to the standard posteroanterior (PA)/lateral/oblique views of the wrist, PA views of the wrist in
      maximum radial and ulnar deviation as well as an AP “clenched pencil” view (see Figure 25.1) can be helpful in determining carpal degenerative changes.2


  • Cross-sectional imaging



    • Computed tomography (CT)—When considering a motion-sparing procedure, CT can be helpful to evaluate for degenerative changes in joints adjacent to the anticipated site of arthrodesis.


    • Magnetic resonance imaging (MRI)—Can be helpful when assessing vascularity of bone fragments or adjacent soft tissue disease, such as synovitis and tenosynovitis in rheumatoid arthritis.






FIGURE 25.1 Clenched pencil (A) and lateral (B) radiographs demonstrating widening of the left scapholunate interval, radioscaphoid arthrosis, extension deformity of the lunate, and preservation of the articular surface of the lunate fossa.


MOTION-SPARING SURGICAL OPTIONS



  • Considerations



    • Must ensure adjacent articulations and resultant articulations are free of degenerative changes when performing motion-sparing surgical options


    • Can be assessed intraoperatively or with the assistance of preoperative imaging


    • Failure to appreciate preexisting arthrosis may result in continued pain or acceleration of degeneration between adjacent and/or resultant joints.


  • Scaphoid excision with capitate-lunate-hamate-triquetrum fusion (aka four-corner fusion with scaphoid excision)


  • Proximal row carpectomy (PRC)


  • Other partial wrist arthrodeses










TABLE 25.1 Other Motion-Sparing Arthrodesis Salvage Procedures of the Wrist





































Procedure


Common Indications and Etiologies


Contraindications


Radiolunate arthrodesis


Volar and ulnar translation of the carpus related to RA


Localized radiolunate arthritis secondary to die punch


Failed soft tissue scapholunate ligament reconstruction


Capitolunate arthrosis


Scaphocapitate arthrodesis


Rotatory subluxation of the scaphoid


Nonunion of scaphoid


Kienböck disease


Midcarpal instability


Radioscaphoid arthrosis


STT arthrosis


Radioscapholunate arthrodesis


Posttraumatic proximal row degenerative changes


Postinfection


Inflammatory arthritis


Midcarpal arthrosis


Scapholunate arthrodesis


Scapholunate dissociation


Limited indications due to high nonunion rates and unpredictable clinical results


Due to high nonunion rates and unpredictable clinical results, this procedure is not commonly performed


Lunotriquetral arthrodesis


Painful partial coalition of the lunotriquetral joint


Symptomatic lunotriquetral dissociative instability


Midcarpal arthritis, nondissociative ulnar midcarpal instability


Lunotriquetral dissociation with ulnocarpal impingement


Triquetrohamate arthrodesis


Treatment of painful midcarpal instability (limited indication)


Due to high nonunion rates and unpredictable clinical results, this procedure is not commonly performed


Scaphotrapeziotrapezoidal (STT) arthrodesis


Degenerative arthrosis of STT joint


Subluxation of scaphoid


Nonunion of scaphoid


Kienböck disease


Midcarpal instability


Congenital synchondrosis of the STT joint


Radioscaphoid degenerative changes; presence of thumb


CMC degenerative changes


Abbreviations: CMC, carpometacarpal; RA, rheumatoid arthritis.


Adapted from Rizzo M. Wrist arthrodesis and arthroplasty. In: Wolfe S, Hotchkiss R, Pederson W, Kozin S, Cohen M, eds. Green’s Operative Hand Surgery. Philadelphia, PA: Elsevier; 2017:373-417.




SCAPHOID EXCISION WITH CAPITATE-LUNATE-HAMATE-TRIQUETRUM FUSION (FOUR-CORNER FUSION)



  • Indications



    • Scapholunate advanced collapse (SLAC) wrist (see Figure 25.2)



      • Stage II—Pan-radioscaphoid arthrosis


      • Stage III—Arthrosis of the radioscaphoid and capitolunate joints


    • Scaphoid nonunion advanced collapse (SNAC) wrist



      • Stage II—Radioscaphoid and scaphocapitate arthrosis


      • Stage III—Periscaphoid arthrosis (with sparing of the radiolunate joint)


    • Goal is to stabilize wrist such that lunate transmits load across the preserved radiolunate joint with removal of the scaphoid to minimize persistent pain from the degenerated radioscaphoid articulation.3


  • Preoperative considerations



    • Radiolunate arthrosis is a contraindication.


    • Cross-sectional imaging can be a helpful modality to evaluate the status of the radiolunate joint; however, this articulation may also be evaluated intraoperatively.



  • Fixation techniques (see Figure 25.3)



    • Kirschner wire fixation4


    • Circular plate4,5



      • May have higher rates of impingement and nonunion6


    • Staples7


    • Headless compression screws8


  • Technique pearls9



    • The posterior interosseous nerve runs on the floor of the fourth dorsal compartment. Posterior interosseous neurectomy can help prevent postoperative pain.



    • A high-speed bur can be used to facilitate decortication and preparation of the bony surfaces for fusion. The bur can be used to create “craters” on sclerotic bone. Copious irrigation should be used during bur use to prevent thermal necrosis.


    • Autogenic cancellous graft can be harvested from the distal radius. The excised scaphoid may also be a source of bone graft.



      • In cases of SNAC wrist, the proximal pole of the scaphoid may be sclerotic and avascular and may be a less optimal graft choice.


    • The method of fixation is less important than appropriate preparation of the bone and use of bone grafting.


    • Prominent dorsal hardware may lead to impingement in extension.


    • Reduction of the radiolunate joint is facilitated by volar translation of the head of the capitate at the capitolunate articulation—best reduced prior to dechondrification of the midcarpal joint in preparation for fusion.



      • Reduction of the radiolunate joint out of extension can be provisionally held with a radiolunate K-wire while midcarpal joint is prepared for fusion.


    • Failure to reduce the lunate from its extension deformity may lead to impingement in extension.


  • Modifications

May 7, 2019 | Posted by in ORTHOPEDIC | Comments Off on Salvage Procedures of the Wrist
Premium Wordpress Themes by UFO Themes