Watson and colleagues described the evolution of arthritis in the wrist, but Vender and colleagues established the term scaphoid nonunion advanced collapse (SNAC) [1]. They described the stages as follows: stage I is characterized by arthrosis at the radial styloid–distal scaphoid articulation; stage II is characterized by involvement progressing to scaphocapitate arthrosis followed by stage III which is denoted by degenerative changes in the midcarpal joint—specifically, the capitolunate joint. Notably, the interface between the proximal pole of the fractured scaphoid and the radius is often spared. Based on the patient’s history, physical examination, and diagnostic studies, the patient was diagnosed with stage II SNAC .

Scaphoid excision and isolated capitolunate fusion with triquetral retention was chosen and is our procedure of choice for the majority of these patients. Critical factors in the decision include patient age/level of demand/comorbidities, preoperative ROM, and stage of disease. In lower demand patients, physiologically older patients, and those at higher risk of nonunion due to comorbidities, PRC is selected more often. Patients with pancarpal arthritis or very limited preoperative ROM are more often recommended total wrist fusion . Patients with very early degenerative changes (stage I), especially those who do not want to undergo a larger procedure, often undergo either Malerich arthroplasty +/− denervation (early SNAC) or arthroscopic radial styloidectomy with denervation (early SLAC). As mentioned above, we prefer isolated CL fusion with triquetral retention over four-corner fusion because of the lessened need for bone graft, lower risk of subsequent PT arthritis, shorter surgery time, and equivalent outcomes [2]. We now maintain the triquetrum as opposed to excising it, given the biomechanical data of increased load across the lunate associated with triquetral excision [3].

The patient underwent scaphoid excision and capitolunate arthrodesis approximately 1 month from the time of his initial evaluation. At his first postoperative visit, his surgical dressing was taken down and his sutures were removed. Active and passive range of motion of the wrist demonstrated smooth flexion, extension, ulnar, and radial deviation. He was placed into a short-arm cast and instructed to work on active range of motion exercises for the digits. He was counseled on smoking cessation. He returned to clinic at 6 weeks. At this visit, the patient admitted to performing repetitive heavy lifting and other vigorous activities with his operative extremity in spite of his ongoing restrictions. Radiographs were obtained and demonstrated intact hardware with a healing arthrodesis of the capitolunate joint (Fig. 24.2). The patient was placed into a removable splint, which he was instructed to use for all activities. A CT scan was ordered 3 months postoperatively to assess the arthrodesis site . The CT scan demonstrated intact hardware with bony bridging across the arthrodesis site between the capitate and lunate (Fig. 24.3). At the time of his final follow-up visit, the patient was no longer requiring narcotic pain medication, was able to perform all activities of daily living with minimal discomfort, and was anxious to return to work without restrictions. On examination, the patient’s incision was well healed without signs of infection, he had full and supple range of motion of his digits, and his wrist range of motion measured 15° of extension, 45° of flexion, 80° of pronation, and 80° of supination. The patient was released to full duty at 4 months postoperatively .