Treatment of Complications of Midcarpal Joints Arthritis

15 Treatment of Complications of Midcarpal Joints Arthritis

Eva-Maria Baur and Riccardo Luchetti

Abstract

Carpal procedures are various and delicate; therefore, the number of different complications is high. Especially nonunion, malunion, malalignment, and stiffness are well-known problems after these operations. Less frequent, but equally important are infection, complex regional pain syndrome (CRPS), nerve lesions, and hardware-associated problems. Some of them are related to the technique other generic. Their knowledge allows them to be prevented and recognized for early treatment. The prevention and the treatment are described in this chapter.

Keywords: midcarpal procedures, partial wrist fusion, proximal row carpectomy, wrist stiffness, complication of SNAC treatment, complication of SLAC treatment

15.1 Introduction

The most common indications for midcarpal procedures are advanced carpal collapse due to different pathologies such as scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) and scaphoid chondrocalcinosis advanced collapse (SCAC). Salvage procedures are also common for Kienböck disease—depending on stages, if revascularization or levelling operations are no more an option. Other less common indications, for instance, isolated midcarpal osteoarthritis (OA), are sometimes seen in systemic inflammatory diseases like rheumatoid arthritis (RA) or others. Radiolunate OA or dislocation is also common in RA.

Severe nonreducible instability could also be an indication for partial wrist fusion, if ligament repair or reconstruction fails to provide the required strength and stability.

Malunion and sequelae after distal radius fracture (DRF) could also be an indication for midcarpal procedures like partial wrist fusion, e.g., radioscapholunate (RSL) fusion, arthroplasty, or prosthesis.

Different procedures can be performed for the above-mentioned indications and diseases: Proximal row carpectomy (PRC), partial wrist fusions, denervation, resection arthroplasties, and prosthesis.

The least invasive procedure is denervation. Denervation was introduced in the 1990s in a partial or total manner for all kind of painful wrist disorders. The most common performed procedures are proximal row carpectomy and partial wrist fusions. The choice for one of these two techniques depends on the extent of arthrosis, preference of surgeon, and wishes of the patient. A prerequisite for performing a proximal row carpectomy is that the capitate cartilage is not damaged like in SLAC and SNAC stage 2. Partial wrist fusions can be performed for different indications. Four-corner fusions (4CF) as well as two- or three-corner fusions can be used for SLAC/SNAC/SCAC stage 2 or 3.

Scaphocapitate or STT fusion is a salvage procedure in advanced Kienböck disease. STT fusion is an optional treatment for STT-OA or instability. RSL and RL fusion can be performed for arthrosis caused by DRF and RA, respectively. Resection arthroplasties without an interposition are rare in the wrist/midcarpal joint. Mostly, an interposition of a tendon or pyrocarbon or silicone implant is added.

Both total wrist prosthesis and partial prosthesis like a capitate head resection arthroplasty can be performed for midcarpal arthrosis. Naturally, no treatment is without complications and these will be discussed below.

15.2 Complications

Although not very invasive, denervation can lead to complications. A typical complication is a sensory nerve irritation. A lack of proprioception might occur after resection of the posterior interosseous nerve (PIN) but we only know this information for the healthy wrist.1 Recurrence of pain or no release of pain at all can occur after denervation.

15.2.1 Infection

Infection can occur after every operation. Even though it is rare in elective hand surgery—at least less common than in foot surgery—probably one explanation is the better blood supply in the upper extremity as well as easier hygienic situation postoperatively. The first treatment is to clean the joint (several times) open or arthroscopic and give an antibiotic treatment. Arthroscopic procedures seem to have an advantage regarding number of operations and functional results.² If there has been a delay already, sometimes damage of the cartilage (and bone) is so high that only a (partial) or total wrist fusion is the option. Prosthesis after a severe joint infection has always the risk of recurrence of the infection, especially in proven osteitis.

15.2.2 Hardware-Associated Problems

These problems are common in every region of the body and can therefore occur in the midcarpal joint as well. As the carpal tunnel and the palmar portion of the carpal tunnel are convex, and mostly the hardware is placed from the dorsal aspect, the screws or wires can protrude in the carpal tunnel. Here is a risk of flexor tendon damage. Unfortunately, the carpal tunnel X-ray view is no more an option due to limited wrist extension after midcarpal fusion. So, in any case of suspicion make a postop computed tomography (CT) scan to be sure there is no risk of tendon rupture (Fig. 15‑1). Also in midcarpal partial wrist fusion, the protrusion of a wire in the PT (pisotriquetral) joint can occur. For preventing or detecting during the operation make a PT view (20 degrees of supination in lateral view) to ensure there is no screw or wire in the PT joint (Fig. 15‑2).

Fig. 15.1 Protruding screw in the carpal tunnel after 4CF (computed tomography [CT] scan).

Fig. 15.2 (a, b) Intraoperative, two samples of PT view.

Extensor tendons are at risk in cases where plates or wires are placed on the dorsum of the wrist. Either you can bend the wires and bury them in between the metacarpal bones or leave them sticking out of the skin. I personally prefer to bury them. A risk of the wires could be “moving wires” down to the surface of the radius or get in conflict with the extensor tendons.

15.2.3 Malalignment

Malalignment is common after insufficient or “wrong” reduction. The functional range of motion (ROM) of the wrist is 30–0-10 extension/flexion.3 So, after midcarpal partial wrist fusion, this is what we want to get at least and what we can expect. A bit more can be expected after arthroscopic procedures than in open procedures due to less scarring postoperatively. For this purpose, reduction of the flexed lunate to a neutral position is needed—or even better—is a slightly extended position to get more wrist extension than flexion after partial fusion (Linscheid maneuver). A ROM of 40–0-20 extension/flexion is functional better than 20–0-40, because the powerful grip needs extension of the wrist. In SLAC (or SNAC) in combination with a misaligned DRF, the midcarpal reduction can be good, even though the total wrist ROM is worse, due to the malalignment of the DRF (Fig. 15‑3). Sometimes the reduction from the lunate in a correct or slightly overcorrected position is not easy—but very important for the postoperative result.

Fig. 15.3 (a-c) Different range of motion (ROM) in extension/flexion due to malaligned distal radius fracture (DRF), even with good reduction of the 4CF; Flex/Ext 0–0-80.

Regarding the ulnar translation of the lunate and triquetrum in SLAC we need to reduce it underneath the capitate in an anatomic position, depending on the shape of the lunate type 1 or 2. Here we do not recommend an overcorrection; otherwise, the wrist gets stiffer.

15.2.4 Nonunion

In partial wrist fusions, nonunion is a common problem. Percentages range from 5 to 40% as described in the literature. It also depends on the hardware material used for the arthrodesis. It seems that plates in partial wrist fusions have a more common nonunion rate (e.g., Mulford et al⁴: 4.9–13.6% K-wires vs. plates in their systematic review).

For the last 9 years, the author has been performing partial wrist fusion only with an arthroscopic-assisted approach with screws or K-wires. No differences are seen in our own series using screws or wires in the arthroscopic procedures.⁵ We can see after a steep learning curve that the bony healing and postop ROM are better in arthroscopic than in open procedure. The ROM we get at the end of the operation in the OR, is what we can expect as final ROM—in contrast to open procedures, where a soft-tissue scarring decreases the ROM.

15.2.5 Secondary OA

Secondary OA is common in the long term after PRC, even though it’s not always painful or need to be treated. If it is symptomatic, it can only be resolved by a total wrist fusion, prosthesis, or capitate head replacement. About 25 to 35% needs conversion to a total wrist fusion 6 or revision surgery in long-term follow-up.⁷ An interposition arthroplasty with a tendon or artificial graft is an option, but there are no longstanding (good) results.

15.2.6 Prosthesis/Spacer

Well-known problems of prosthesis are either early or late loosening of prosthesis, as well as misplacement of the prosthesis. Early subclinical infection can lead to a loosening. The misplacement or misloading of the prosthesis leads more to a later loosening. Periprosthetic fractures of the bones can also be a problem. If the bony stock is very small to achieve bony healing, bone grafting can be used for resolution of the problem.

In case of spacers with no bony integration, the biggest problem is the dislocation besides the infection. This could be addressed with a stabilization procedure, like a ligamento-capsuloplasty. This does not always work. Sometimes the spacer has already molded a kind of a hole with stable walls, so just removal of the dislocated spacer can solve the problem.

15.2.7 Pain/CRPS

This can happen in every kind of operation. Anyway we need to check and exclude nerve, hardware, malreduction, etc., problems that we can solve and hence “heal” the CRPS. In a number of cases, we can figure out this and find an indication for revision surgery.⁸ Plexus anesthesia and catheter insertion can be helpful in these cases to achieve as much less pain as possible after the secondary operation.

15.3 Stiffness

15.3.1 Causes of Stiffness

Stiffness can occur after a number of operations, although it seems to be more common in open than in arthroscopic procedures. Stiffness after carpal procedures (4CF or PRC) is determined by intra-articular, capsular, and/or extra-articular conditions. All of them can contribute to the stiffness, separately or in association. In the intercarpal fusion, all the procedures (2–3-4 bone fusion) that are used to fuse the midcarpal joint after scaphoid resection are to be considered as cause. Primary insult (chronic damage of the dorsal or palmar soft tissues) and prolonged immobilization had to be also considered. In 4CF and PRC, the intra-articular causes of rigidity are the fibrosis between the articular surface of the distal radius and the carpal bones (fibrotic tissue bands) and between the capsule and the carpal bones located mostly in the dorsal and less frequently in the volar part. In open surgery, the dorsal capsule contracture due to surgical approach is the main cause of wrist rigidity. It produces a loss of wrist flexion. This consequence is valid also for the PRC when the traditional surgical way is used. However, loss of extension should be expected as palmar surgery is used, for example, in the PRC by the palmar approach.⁹ The external causes of the wrist rigidity are the peritendinous and intertendinous adherence of extensor tendons as the dorsal approach is used (Table 15‑1). Postsurgery edema and complex regional pain syndrome (CRPS) are involved in the wrist stiffness with contemporary extension to the fingers.

Table 15.1 Possible causes of secondary wrist rigidity (extra-articular or intra-articular)

●After trauma

○Fracture

○Fracture-dislocation

○Dislocation

○Ligament lesion

●After surgery

○Dorsal wrist ganglia recurrence

○Treatment of scaphoid fracture/nonunion

○Intercarpal arthrodesis (four-bone fusion and so on)

○Ligament reconstruction (SL ligament and so on)

○Proximal row carpectomy

●Prolonged immobilization

●Erroneous wrist immobilization

Abbreviation: SL, scapholunate.

Wrist stiffness is less present after arthroscopic surgery due to less soft tissues damage and exposition. The PRC and 4CF can be done by arthroscopy. However, skilled arthroscopists are needed to perform such a difficult surgery. Sometimes the arthroscopic procedure needs bigger portals or an accessory short open approach to complete the procedure. As these are used, the technique risks being closer to the open surgery with the same consequences. In addition, in the intercarpal bone fusion K-wires are frequently used as method of fixation instead of the screws or plate, as used in the open surgery, with less stability of intercarpal fusion. Therefore, if a prolonged protection through wrist immobilization is adopted in order to obtain healing of the intercarpal fusion, the consequences (wrist stiffness) are even more in open than in arthroscopic surgery.

All these causes of wrist rigidity should be considered as the clinician approaches to solve problems secondary to 4CF or PRC.

15.3.2 Treatment of Stiffness

As the wrist rigidity does not show any improvement after adequate rehabilitation, patients should be considered candidates for surgical intervention.

Surgical management of wrist stiffness consists of arthrolysis of the wrist. Preoperatively, X-ray, CT scan, and magnetic resonance imaging (MRI) of the wrist should be performed to confirm the consolidation of the arthrodesis and to exclude any carpal malunion or osteochondritis which needs a different surgical solution.

Arthrolysis can be performed by open or arthroscopic surgery.

Arthrolysis: Open Procedure

The open arthrolysis is much more indicated for the intercarpal fusion in open approach due to contemporary extensor tendon adherence that needs tenolysis procedure as well (Fig. 15‑4). Dorsal skin incision on the scar of previous surgery allows reaching directly the extensor tendons which are released by the adherence using scalpel or scissor. The extensor retinaculum is protected and the tendons are released passing under it using a dissector or periosteal elevator. Once the tendons are free, the procedure continues through a transversal capsular incision along the dorsal margin of the distal radius. This incision gets into the radio carpal joint. The first step is to remove the scar at the radial side at the cavity created after scaphoid resection. Then the adherences between the radius and the lunate and dorsally to the lunate are released. At the end of these two steps the wrist flexion is tested. As the flexion is sufficient, the procedure is stopped. If the wrist flexion is not sufficient, the release of the anterior part of the radiocarpal joint is required and it should be done using a curved dissector passed radially to the lunate and under the lunate. The maneuver should be stopped as the ulnar margin of the radius is reached. Avoid, please, to release the ulnocarpal ligament to prevent an ulnar translation of the carpus.¹⁰^,¹¹ The wrist motion is tested again in flexion and extension. The dorsal intercarpal plate should be removed if needed (malposition) or simply released from the adherence. If screws are used for intercarpal fixation, one has to pay attention to verify if any osteochondritis or screws subsidence is present. In case of subsidence, the screw should be removed.

Fig. 15.4 Dorsal wrist arthrolysis using the same approach of the previous surgery (4CF). Dorsal capsule has been released exposing the radiocarpal joint (DR, distal radius; L, lunate; T, triquetrum).

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