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begun at week 1with an emphasis on motion. Once sufficient
gains in motion are made then astrengthening program is begun.
Case Example-Arthroscopic Wafer
Aforty-five-year-old right-hand dominant male police officer
and avid golfer began having right-sided wrist pain about two
months prior to presentation to the office. There was no discrete
injury to the wrist but the pain was ulna sided and bothered him
with activities including golf. Radiographs revealed 2mmof
ulnar positive variance. Diagnosis of ulna impaction was made.
He failedconservative therapyand eventually underwent
arthroscopy.Atthe time of surgery adegenerative TFCC tear
was identified and an arthroscopic wafer procedure with TFCC
debridement was carried out. The patient returned to normal
law enforcement activity and golf with no pain.
&
COMPLICATIONS
Complications from these surgeries are uncommon. In one large
study of 211wrist arthroscopies, the major complication was
0.9% and the minor complication rate was 4.3%. However,58%
of these patients underwent subsequent open procedures, so it
is difficult to conclude if the arthroscopy or the open procedure
led to the complication. The most common complication was
dorsal sensory ulnar nerve neuropraxia (16). The routine use
of thermal ablation devices can be associated with burns or
chondrolysis.Incomplete ulnar head resectionleading to
continued ulnar-sided pain is atechnical error that can occur.
Because the ulna head in an open resection comes out as one
piece it can be judged to be completely removed.
&
OUTCOMES
Results from arthroscopic debridement of Palmer 1A TFCC are
favorable. At average follow-up of three years 84% of patients
have had relief of their symptoms (17). Astudy of patients
combining degenerative and traumatic tears treated with debridement noted the traumatic tears did better.Patients that were
ulna positive or had an associated LT ligament tear did worse
(18). Amorerecent study had similar results.Atfollow-up of
two to six years, 77% of patients had good to excellent results.
Interestingly 18 of the35patientshad associatedchondral
lesions (19).
Results from arthroscopic TFCC repair of Palmer 1B TFCC
tears are also favorable. Satisfactory results of greater than 90%
have been reported (20–22). Timing of the repair has also been
examined. They theorizedthat delays over sixmonths
increasedthe incidence of degeneration of the TFCC. This was
worse when there was an ulnar positive variant. Results when
the repair was performed without six months demonstrated
improvement in pain in all patients with 21 out of 24 achieving
complete relief(23).Morerecentstudies have confirmed
the previous data with 34 out of 37 patients having good to
excellent results. In this study,grip strength was noted to have
diminished to 72% of normal (24).
Arthroscopic treatment of Palmer 1D tears is controversial.
Becausethe radial side of theTFCCisavascular healing
potential has been questioned. Good results with repair have
been reportedinthe literature with 8out of 13 patients
returningtopreinjury activitylevel.Postoperative studies
includingarthrogram, MRI, andarthroscopy demonstrated
intact TFCC. This data clearly support the ability of the radial
aspect of the TFCC to heal to the radius (23).
Arthroscopic wafer procedure as treatment for ulnocarpal
impaction has had success. At three to five years results have
had good to excellent results in 75% of cases (24). Debridement
of 3mmofbone in acadaveric study lowered pressures on the
ulna side of the wrist by 10.8% (25). The arthroscopictechniques
give similarresults as theopenwafer procedurewithout
the need for postoperative immbolization (3). Excellent results
from combined arthroscopic TFCC debridement andwafer
procedurehave been recently reported with all patients being
satisfied with the results and an improvement in grip strength
by 36% (26). Patients with ulnocarpal impaction and associated
LT instability should be treated with ulna shortening osteotomy
andnot thewafer procedure. Theshorteningwill tighten
the ligaments on the ulnar side of the carpus. Without the LT
instability,the arthroscopic procedure has the benefit of no
hardware complications and no risk of nonunion.
&
SUMMARY
Wrist arthroscopy is aminimally-invasive technique that has
changed the way in which ulnar-sided wrist pain is treated.
Pioneering work done on the anatomy,function, and injuries
of the TFCC has been the stimulus to push the technology.
As was true in the knee and the shoulder,the original use of
the arthroscope was to assist in diagnosis. Treatments of the
pathologies found werelimited by the technology available.
Surgeons pushed the advance of the instrumentation in the
wrist which allowed for moretreatment possibilities. There has
been much advancement of the technology available for arthroscopy of thekneeand theshoulder. The amountofnew
instrumentation in the wrist has lagged behind the changes in
these other joints. One can envision atime in which repair
techniques such as knotless anchors will be perfected in the
wrist which would ease the repair of the radial-sided TFCC tear.
Thermal devices for ablation and shrinkage are in their infancy
and there future is unknown.
Indications for arthroscopic treatment of TFCC are tears in
the setting of:
&
Ulna-sided wrist pain failing conservative treatment
&
Ulna positive deformity leading to pain
&
LT ligament intact.
U
H
FIGURE 10 Arthroscopic wafer procedure demonstrating resected UH.
Small arrows on the UH. Large arrows on the triangular fibrocartilage
complex rim. Abbreviations:UH, ul nar head. Source:Cour tesyof
Andrew K. Palmer M.D.
244
&
Ruggiero
Advantages of the arthroscopy over open procedures are:
&
Better visualization of theTFCCand associated
chondral lesions
&
Ease of repair of TFCC
&
Less invasive for debridement of TFCC
&
No risk of nonunion or hardware complication as in
ulnar shortening.
&
REFERENCES
1. Imbriglia JE, Bolan DS. Tears of the articular disc of the triangular
fibrocartilage complex:the results of excision of the articular disc.
JHand Surg [Am] 1983; 8:620.
2. Chun S, Palmer AK. The ulnar impaction syndrome: followup of
ulnar shortening osteotomy. JHand Surg [Am] 1993; 18:46–53.
3. Feldon P, Te rrono AL, Belsky MR. Wafer distal ulna resection for
triangular fibrocartilage tears and/or ulna impaction syndrome.
JHand Surg [Am] 1992; 17:731–7.
4. Friedman SL, Palmer AK. The ulnar impaction syndrome. Hand
Clin 1991; 7:295–310.
5. Hulsizer D, Weiss APC, Akelman E. Ulna-shortening osteotomy
after failed arthroscopic debridement of the triangularfibrocartilage complex. JHand Surg[Am] 1997; 22:694–8.
6. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains.
JHand Surg [Am] 1984; 9:502–14.
7. Tomaino MM. The importance of the pronated grip x-ray view in
evaluating ulnar variance. JHand Surg [Am] 2000; 25:352–7.
8. Potter HG, Asnis-ErnbergL,Weiland AJ, et al. The utility of highresolution magnetic resonance imaging in the evaluation of the
triangular fibrocartilage complex of the wrist. JBone Joint Surg
[Am] 1997; 79:1675–84.
9. Blazer P, Chan P, Kneeland J, et al. The effect of observer experience
on magneticresonance imaging interpretation and localization of
triangular fibrocartilagecomplex lesions. JHand Surg [Am] 2001;
26:742–74.
10. Palmer AK. Triangular fibrocartilage complex lesions: aclassification. JHand Surg [Am] 1989; 14:594–606.
11.Shih JT,Lee HM, Ta nCM. Early isolated triangular fibrocartilage
complex tears: management by arthroscopic repair.JTrauma 2002;
53:922–7.
12. Blackwell R, Jemison M, Fay B. The holmium:yttrium–aluminumgarnet laser in wrist arthroscopy: afive-year experience in the
treatment of central triangular fibrocartilage tears by partial
excision. JHand Surg[Am] 2001; 26:77–86.
13. Palmer AK, Werner FW, Glisson RR, et al. Partial excision of the
triangular fibrocartilage complex. JHand Surg [Am] 1988; 13:391–4.
14. Hermansdorfer JD, Kleinman WB .Management of chronic peripheral tears of the triangular fibrocartilage complex. JHand Surg
[Am] 1991; 16:340–6.
15. Sagerman SD, Short W. Arthroscopic repair of radial-sided
triangularfibrocartilage complex tears. Arthroscopy 1996;
12:339–42.
16. Beredjiklian PK ,BozentkaDJ, Leung L, et al. Complications of
wrist arthroscopy.JHand Surg [Am] 2004; 29:406–11.
17. OstermanAL. Arthroscopic de´bridement of triangular fibrocartilage complex tears. Arthroscopy 1990; 6:120–4.
18. MinamiA,Ishikawa J, Suenaga N, et al. Clinical results of
treatment of triangular fibrocartilage complex tears by arthroscopic debridement. JHand Surg[Am] 1996; 21:406–11.
19. Husby T, Haugstvedt TR.Long-term results after arthroscopic
resection of lesions of the triangularfibrocartilage complex.
Scand JPlast Reconstr Surg Hand Surg2001; 35:79–83.
20. Bednar JM. Arthroscopic treatment of triangularfibrocartilage
complex tears. Hand Clin 1999; 15:479–88.
21. Corso SJ, Savoie FH,Geissler WB,etal. Arthroscopic repair
of peripheralavulsions of the triangular fibrocartilage
complex of the wrist: amulticenter study.Arthroscopy 1997;
13:78–84.
22. De Araujo W, Poehling GG, Kuzma GR, et al. New Tu ohy needle
technique for triangularfibrocartilage complex repair: preliminary
studies.Arthroscopy 1996; 12:699–703.
23. Trumble TE ,Gilbert M, Ve dder N. Isolated tears of the triangular
fibrocartilage complex: management by early arthroscopic repair.
JHand Surg [Am] 1997; 22:57–65.
24. Nagle DJ. Arthroscopic treatment of degenerative tears of the
triangularfibrocartilage. Hand Clin 1994; 10:615–24.
25. Wnorowski DC, Palmer AK, Werner FW. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy
1992; 8:204–12.
26. Tomaino MM, Weiser RW.Combined arthroscopic TFCC debridement and wafer resection of the distal ulna in wrists with
triangularfibrocartilage complex tears and positive ulnar variance.
JHand Surg [Am] 2001; 26:1047–52.
27. ConstantineKJ, To maino MM, Herndon JH, et al. Comparison of
ulnar shortening osteotomyand the wafer resection procedure as
treatment for ulnar impaction syndrome. JHand Surg [Am] 2000;
25:55–60.
28. Dailey S, Palmer A. The role of arthroscopy in the evaluation and
treatment of triangularfibrocartilage complex injuries in athletes.
Hand Clin 2000; 16:461–74.
29. Palmer AK. Tr iangular fibrocartilage disorders: injury patternsand
treatment. Arthroscopy 1990; 6:125–32.
30. Thiru-Pathi RG, Ferlic DC, Clayton ML, et al. Arterial anatomy of
the triangular fibrocartilage of the wrist and its surgical significance. JHand Surg [Am] 1986; 11 :258–63.
Triangular Fibrocartilage Tears and Ulnocarpal Impaction
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245
31
Minimally Invasive Treatment of Arthritis Associated with
Scapholunate and Scaphoid Nonunion Advanced Collapse
Charles M. Jobin, Steven H. Goldberg, and Robert J. Strauch
Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York, U.S.A.
&
INTRODUCTION
Scapholunateadvanced collapse (SLAC)isaprogressive
pattern of arthritis that develops in the setting of achronic
scapholunate ligament tear.This ligamentous injury leads to
abnormal carpal alignment, altered force transmission,and
increased focal joint contact (1–3). Scapholunate instability is
characterized radiographically by scapholunate joint widening,
extension of the lunate,palmarflexion of the scaphoid, and
capitate proximal and dorsal translation (4–6). In the normal
wrist, pressureorload across the carpus is unevenly distributed
and dependent on both the position of the wrist and on the
directionofmotion(7).One studydemonstratedthatwith
progressive scapholunate instability,contact area and pressure
is concentrated at the radioscaphoid rather than the radiolunate
joint(1,2).However,othersfoundthat with scapholunate
ligament sectioning, the radiocarpal pressureshifts from the
radioscaphoidtothe radiolunate fossa (8). Additionally,
scaphoid palmarflexion causes adecreased radioscaphoid
contactareaand changes contact to thedorsallip of the
radius(9).The greatest carpalshear forces lie between the
distal radius and scaphoid and between the proximal capitate
and the distal lunate. The above changes in carpal bone rotation
and translation, force concentration, and contact area explain
the radioscaphoid and lunocapitate arthritis (5,10,11).
SLAC wrist is classified into several stages that assists in
determining which surgical intervention can alleviate symptoms (10). Stage Iarthritis is limited to the radial styloid and
scaphoid waist articulation with pointing of the styloid (Figs. 1
and 2) and joint space narrowing. Stage II arthritis advances
proximally to involve the complete distal radius scaphoid fossa
andscaphoidarticular surfacesdue to continued,chronic
overload of this portion of the carpus (Fig. 3). In stage III
midcarpal arthritis develops at the capitolunate joint from axial
proximal collapseofthe capitatebetween thedissociated
scaphoid and lunate bones(Fig. 4).The proximallunate
articular surface and lunate facet of the distal radius have a
concentric spherical articulation. Thus, the extended lunate in
SLAC wrists does not result in abnormal shear forces at the
radiolunate articulation, causing this joint to be spared from
the arthritic process (10,12).
Scaphoid nonunion advanced collapse (SNAC) is asimilar,
but distinct, pattern of progressive arthritis with acomparable
natural history and treatment options. Similar to SLAC wrists,
pathologic carpal bone rotation occurs in SNAC wrists, particularlylunate extension. Thenonunionsiteundergoes bone
resorption and cystic changes in most patients after 18 months
allowing the distal scaphoid fragment to translate proximally
and contact the radial styloid (13). The distal scaphoid pole
rotates and develops abnormal motion through its intact ligaments to the distal carpal row.This leads to radioscaphoid
arthritis approximately five years after injury,which develops
in all patients by 10 to 20 years (14,15). However,the proximal
radioscaphoid joint is sparedsince the proximal pole has more
normal kinematics through its continuity to the proximal row
through the intact scapholunate ligament (13). Eventually,the
distal polerotationand radial styloid-scaphoidjoint space
narrowing allow proximal and radial migration of the capitate
whichcausesscaphocapitate and capitolunate arthritis(13).
This advanced arthritis typically develops after 20 years and
is present in most patients 30 years after injury.The magnitude
and amorediffuse pattern of arthritis correlate with increased
scaphoid displacement and carpal malalignment (14,15).
Many patients with SLAC or SNAC wrists mayhave
minimal symptoms for many years (16) and thereforeoperative
intervention should be reserved for those patients with significant pain.The choice of surgical procedureisprimarily
dictated by the location and extent of the arthritis. Operative
choices include arthroscopic debridement, radial styloidectomy
(17), excision of the distal scaphoid pole for nonunion (18),
proximal row carpectomy (19), limited intercarpal arthrodesis
with scaphoid excision (10,19), total wrist arthrodesis (12), and
total wrist arthroplasty.However,this chapter will focus on
minimally invasive treatments for patients with early SLAC or
SNAC wrist. Cases with stage III or diffuse arthritis require
moreextensive open procedures.
&
RADIAL STYLOIDECTOMY
&
Indications/Contraindications
Radial styloidectomyinvolves minimalsurgery, immobilization, and rehabilitation,and eliminatesthe painful
impingement betweenthe distal scaphoid and the radial
styloid in stage ISLAC or early SNAC wrist (17,20). It can be
performed alone or in combination with other procedures (18).
Additionally,styloidectomy may be performed at the time of
procedures designed to treat scapholunate dissociation (21,22).
Styloidectomy alone is contraindicated in stage II or III SLAC
wrist since the arthritis extends proximal to the styloid.
&
Considerations for Preoperative Planning
Similar preoperative planningwith respecttophysicaland
radiographic examination is applicable for all the techniques
in this chapter and will be described in detail in this section with
specific points highlightedinsubsequentsections. Patients
must be counseled that styloidectomy or the other procedures
may alleviate current symptoms, but they do not restore normal
carpal kinematics or alter the natural history of progressive
arthritis. Thus, patients may develop recurrent symptoms and
they may require additional surgery.Therefore, careful patient
selectioniscrucial. Sinceisolatedstyloidectomy treats the
painfulradialwrist pain butdoes notaddress thechronic
scapholunate instability,itisusually recommended in older
patients, patients with low-demands on wrist loading, patients
with radial wrist pain during activities of daily living, and
patients who do not wish to undergo moreextensive rehabilitation andimmobilization. It is notrecommendedasthe
definitiveinterventioninayoung, athleticperson whois
likelytodevelop recurrentorprogressive symptoms from
repetitive loading of an untreated scapholunate injury.
Priortoperformingstyloidectomy,careful questioning
and physical examinationare critical to determineifthe
patient has focal radial wrist pain over the radial styloid and
snuffbox area,orwhether diffusesymptomsare present.
Patients with focal symptoms may be candidates for an isolated
open or arthroscopic styloidectomy.Patients who have diffuse
wrist pain may have continued symptoms after styloidectomy
alone.
Usually X-rays are the only imaging study needed prior
to surgery.Routine radiographsinclude posteroanteriorin
neutral rotation, lateral, and oblique views. The presence of
joint space narrowing should be specifically noted at the radial
styloid-scaphoid waist, radial fossa-scaphoid proximal pole,
and capitolunate articulations. Because joint space width can
vary with wrist position, it is often useful to obtain bilateral
wristradiographsonthe same filmcassettetoassess for
asymmetry. Theradiographsshouldconfirmthatarthritis
appearstobelimited to theradial styloidand scaphoid
waist. Aposteroanterior radiograph in radial deviation may
help illustrate the point of maximal styloid-scaphoid contact.
Please refer to chapter 15 “RASL reconstruction for scapholunate instability” foradetailed descriptionofradiographic
abnormalities in scapholunate tears.
1
FIGURE 1 Posteroanterior radiographdemonstrating the beginning of
radial styloid pointing (1) without radioscaphoid joint space narrowing.
This indicates early stageIscapholun ateadvancedcollapsewrist
arthritis. Normal carpal alignment is present.
FIGURE 2 Chronic scapholunate instability is evident with astress
ulnar deviation,posteroanterior radiograph.
2
1
FIGURE 3 Posteroanterior clenched fist radiograph showing styloid
pointing (1) and joint space narrowing at the radial styloid-scaphoid (2)
and radial fossa-proximalscaphoid articulations. Note the widened
scapholunate interval and preservation of the capitolunate joint space,
making this stage II scapholunate advanced collapse wrist arthritis.
248
&
Jobin et al.
However,since radiographic findings often underestimate
the degree of articular cartilage injury and since SLAC wrist
arthritis is secondary to other ligamentous carpal injuries, we
recommend wrist arthroscopy be performed prior to styloidectomy,even if an open styloidectomy is planned in order to
thoroughly evaluate the radiocarpal and midcarpal joints. If the
arthriticchanges are isolated to theradialstyloid-scaphoid
articulation, then the surgeon can proceed with styloidectomy.
Additionally,debridement of inflamed synovium can eliminate
synovitis and relieve diffuse dorsal wrist pain. Synovial debridement also removes redundant tissue that can eliminate pain
emanating from mechanical impingement. Unstable flaps of a
torn scapholunate ligament should also be debrided (23,24).
&
Surgical Technique
The patient is placed supine on the operating room table with the
arm on an arm board and asterile tourniquet is applied. The
hand is suspended from atraction tower device with the index
and middle fingers placed in finger traps under 10 to 15 pounds
of traction. The radiocarpal joint is insufflatedwith normal saline
to distend the joint. This protects the articular surface during
portal establishmentbymovingthe capsuleawayfromthe
articular surface. During injection extravasation of fluid into
thedistalradioulnarjoint or extensor carpiulnaris sheath
suggests atriangular fibrocartilage complex tear.Alongitudinal
incision is made just through the skin at the 3–4 portal, asoft spot
distal and ulnar to Lister’s tubercle between the extensor pollicis
longusand extensor digitorum communiscompartments.
Afine,curvedhemostat is usedtobluntlyspread down to
the capsule to prevent cutaneous nerve or tendon injury and
the capsuleispenetrated in acontrolled manner.A2.7 mm
arthroscope is placed through the portal and the radiocarpal
compartment is visualized. An 18-gauge needle is placed in the
6U portal, which is located ulnar to the extensor carpi ulnaris, to
allow outflow.Additionally,midcarpal arthroscopy should be
performed using the radial midcarpal portal, 1cmdistal to the
3–4 portal to evaluate for capitolunate arthritis.
If no extensive midcarpal or radiocarpal arthritis is identified, the 1–2 portal is established between the extensor pollicis
brevis and extensor carpi radialis tendons and acovered bur
ranging in size from 2.9 to 4.0 mm is inserted. Alternatively the
arthroscope maybeplaced in the4–5 portalbetween the
extensor digitorum communis andextensor digiti minimi
with thebur placed throughthe 3–4portal.Radiocarpal
synovectomy should be performed to allow thorough observation of the radial styloid and volar ligaments. The amount of
styloid removed should not be more than 4mm from the tip of
the styloid and the width of the bur may be used as areference.
Post operatively patients should be placed in avolar short arm
splint for 10 to 14 days after which sutures are removed. Gentle
wristmotionisencouraged with restrictionfromvigorous
activity for six weeks.
&
Complications
Arthroscopic styloidectomy may have less morbidity than open
techniques as it avoids the need to identify and retract the
dorsal sensory branches of the radial nerve and involves less
capsular dissection. Failure to remove sufficient bone from the
styloidmay lead to persistentradiocarpalpainand loss of
motion. Careful analysisofpreoperative radiographs with
measurement of the location of radioscaphoid impingement
with respect to the styloid tip facilitates the determination of
the amount of bone resection necessary to adequately decompress thejoint.Additionally, arthroscopicvisualization and
intraoperative fluoroscopy provide adynamic assessment of
elimination of impingement. Alternatively,excessive resection
must be avoided. Ya oand Osterman (17) postulate that arthroscopicproceduresmay preventexcessive resectiondue to
visualization of the styloid and volar ligaments during resection. Removal of styloid beyond 4mmhas arisk of sacrificing
the radioscaphocapitate, dorsal radiocarpal, and long radiolunate ligaments which are integral in supporting the carpus and
preventingulnar andvolar translocation (25,26).The distal
radial and carpal articular surfaces should be protected from
iatrogenicdamage during the procedure. The comparison of
complications following open versus arthroscopic styloidectomy has not been specifically studied.
&
Outcomes
The superiority of arthroscopy over open styloidectomy has not
been shownwithregard to functionaloutcome or rate of
complications. There are very few reports on the outcome of
isolated radial styloidectomy in the treatment of SLAC wrist. A
report of isolated open styloidectomy for scaphoid nonunion
was made with satisfactory pain relief in 10 out of 13 patients
(20). Excellent or good results werereported in five out of eight
patients with scaphoid nonunion at 11 months follow-up after
open styloidectomy (27). Arthroscopic and open radial styloidectomy were discussed in relation to SLAC wrist in astudy by
Yaoand Osterman (17), but clinical results were not mentioned.
Acase series of three patients who underwent arthroscopic
styloidectomy and distal scaphoid excision was morerecently
described (18). At two year follow-up all patients were highly
3
2
1
FIGURE 4 Posteroanterior clenched fist radiographshowing styloid
pointing (1) and diffuse radioscaphoid arthritis (2) with involvement of the
capitolunate joint (3) indicating stage III scapholunate advanced collapse
wrist arthritis.
Minimal Invasive Treatment of SLAC/SNAC
&
249
satisfied, had pain relief,completereliefofmechanical
symptoms (catching, popping), improvement of the Modified
Mayo Wr ist Scores from 60 to 88, improved grip strength from
73% to 87% of the contralateral hand, improved range of motion
and no radiographic joint degeneration. No immobilization was
necessary and patients returned to work within two weeks on
light duty and four weeks for full duty.
&
DISTAL SCAPHOID EXCISION
&
Indications/Contraindications
Chronic scaphoid nonunion can be treated with excision of the
distal scaphoid pole when radiographic changes are consistent
with early SNAC wrist confined to the articulations between the
scaphoid distal pole and the radial styloid and radial surface of
the capitate (28,29). Distal pole scaphoidectomy is contraindicated in more advanced SNAC wrist in which the capitolunate
or proximal radioscaphoidjoint is involved.One author
described excision of the radial styloid in combination with
distal pole excision (18). In cases of SNAC wrist wherethe
nonunion site is proximal to the scaphoid waist on aposteroanterior radiograph in ulnar deviation creating small proximal
and largedistal pole fragments, we believe these injuries are
best treated by measures other than distal pole resection.
&
Considerations for Preoperative Planning
Despite treatment of scaphoid nonunions with vascularized or
nonvascularizedbonegraftingstabilizationand internal
fixation (30–32), success is not guaranteed and postoperative
immobilization is often necessary for aprolonged time. Patients
may not wish to undergo multiple attempts to achieve scaphoid
union and once arthritis has developed, union alone may not
alleviate all symptoms. Thus, in patients with SNAC wrist and
whohaveprimarilyradial wristpain worseninginradial
deviation, distal scaphoid pole excision canbeperformed.
This is minimally invasive with arapid rehabilitation making
it auseful option for low demand individuals or individuals
whocannot tolerate prolongedimmobilizationand lifting
restrictions due to work or personal obligations. Preoperatively
alternativetreatment optionsshould be discussedwiththe
patient in the event that diffuse arthritis is found at the time
of arthroscopy.
&
Surgical Technique
Standard wrist arthroscopy positioning and equipment is used
as described in the previous section. The arthroscope is placed
in the moreulnar 4–5 or 6R portal (radial to the extensor carpi
ulnaristendon) to gain widerperspective of theproximal
scaphoid and distal radius scaphoid fossa articular surfaces
(18). The midcarpal joint should also be examined. During the
diagnostic arthroscopy it is often helpful to perform athorough
radial-sided synovectomy with debridement of any unstable
chondral or ligamentous flaps of tissue using a2.9 mm fullradius resector to establish alarger unobstructed field of view
and working space in the region of the radioscaphoid joint and
scaphoid nonunion site. Synovectomy allows enhanced visualizationofthe palmar radiocarpalligamentsthatmustbe
preserved to prevent postoperative ulnar carpal translocation.
Dependingonthe patient’sunique anatomy suchasradial
height and inclination, the arthroscope and bur can be alternatelyswitchedbetween multiple portalstoimprove
visualization and working angles that permit styloidectomy
and scaphoid excision withoutinducing newiatrogenic
chondral injury.With the arthroscope in the 3–4 portal, insertion
of the 2.9 mm bur through the moreradial 1–2 portal facilitates
removal of the radial styloid.
Sequential synovectomy and styloidectomy further opens
the radiocarpal joint improving access to the distal pole of the
scaphoid. This may also permit upsizing the bur to a3.5 mm
diameter which increases the efficiency of bone removal and
decreases the frequency of instrument and line clogging by bone
fragments. In an effort to improve working angles, attention
should be paid to not removing more than 4mmofthe arthritic
styloidtopreservethe dorsal and palmarligaments. The
amount of resection can be judged based on the known bur
diameter and marking thestyloid articular surface 4mm
proximal to the tip at the initiation of styloidectomy.Finally,
the distal scaphoid can be removed through the previously
establishedportals, switchinginstrument, andarthroscope
location as necessary. Adequate resectionofthe styloid
and distal pole should be confirmed with intraoperative
fluoroscopy.
&
Complications
Carpal instability could occur if extrinsic or intrinsic carpal
ligaments are injuredduring bone resection. Articular cartilage
or radial artery injury could also occur during the removal of
the distal scaphoid pole.
&
Outcomes
In thelargest series of opendistalscaphoidresection,19
patients werefollowed an average of 49 months (28). Flexion
and extension arc improved from 498 to 928 .The radial and
ulnar deviation arc improved from 238 to 418 .Postoperative grip
strength improved to 75% of the opposite side. No radiographic
carpal collapse was noted. Thirteen patients had complete pain
relief and all but one returned to their prior job. In another series
of open distal scaphoid excision four of the nine patients had no
wrist pain and the remaining five patients had only mild pain
with strenuous activity after surgery (29). The wrist range of
motion improved from 708 to 1408 (94% of the opposite wrist)
and grip strength improved to 77% of the opposite wrist. There
was no observed radiographic progression of arthritis in eight
patients. The series of three patients who underwent arthroscopic styloidectomyand distal pole excision had good
outcomes (see previous section for details) (18).
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PROXIMAL ROW CARPECTOMY
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Indications/Contraindications
Proximal rowcarpectomy (PRC) is amotion-sparing surgical
procedureconverting an unstable, painful SLAC or SNAC wrist
into asimple hinge joint by removing the scaphoid, lunate
and triquetrum and allowing the capitate to articulate with
the lunate fossa of the distal radius. PRC is primarily indicated
in chronic scapholunate ligament disruption with stage IorII
arthritis and SNAC wrist confined to the radioscaphoid joint.
PRCiscontraindicated in patientswithdegenerative
changes on the lunate fossa of the distal radius, and inflammatory arthropathy which has ahigh failurerate because of
progressivepancarpal arthritis (33).Lossofcartilage of the
proximal capitate head canbeacontraindicationaswell
(SLAC stage III). However,PRC with proximal capitate resection
and/or soft tissue interposition resulted in agood outcome in
several patients with lunocapitate or radiolunate disease, which
may slightly expand the indications for PRC(34,35). Others
report that capitatefocal chondral defectsupto3mm are
250&Jobin et al.
amenable to PRC(33,36).Ifthere is anyquestionabout
the severity of capitate cartilage wear,analternative procedure
such as scaphoid excision and four corner fusion (lunate-triquetrum-capitate-hamate)shouldbeconsidered. Arelative
contraindication is an active patient less than 35 years of age (37).
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Considerations for Preoperative Planning
Since PRC is performed in patients with more advanced disease,
physical examination should confirm diffuse, rather than focal
wrist pain and radiographs should reveal diffuse radioscaphoid
arthritis without significant capitolunate arthritis.
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Arthroscopic Proximal Row Carpectomy
Technique
Through standard radiocarpal and midcarpal portals, aPRC
can be achieved (38,39). Use of atourniquet and amechanical
infusion system establishes aclear visual field. The arthroscope
is initially placed in the 3–4 portal to systematically examine the
radiocarpal joint. If there is no significant radial-lunate fossa
arthritis, theradialmidcarpal portal is established and the
arthroscope is introduced to confirm the absence of significant
capitate arthritis. The arthroscope is then replaced in the 3–4
portal and ashaver is placed through the 4–5, 6U, and/or 6R
portals depending on patient anatomy and surgeon preference
andthe scapholunate and lunotriquetral ligamentsare
removed. Then the center of the lunate is removed with a2.9
or 3.5 mm bur.Inorder to protect the proximal capitate, the
distal lunate is not resected with the bur,but rather apituitary
rongeur is used to carefully remove the remaining lunate shell.
An assistant stabilizes the traction tower with one hand and
places the other hand on the palmar wrist to apply palmar to
dorsal counterpressure. The arthroscope and asmall osteotome
can be alternately switched between the previously established
radiocarpal portals to fragment the scaphoid and triquetrum.
The scaphoid and triquetral fragments can then be removed
with abur andpituitary rongeur. Occasionally, an anterior
radiocarpal portal is usefultovisualize thedorsalcarpal
bones. It is established by placing aswitching stick through
the 3–4 portal and between the radioscaphocapitate and long
radiolunate ligaments (40). Then avolar incision is made over
the switching stick and the flexor carpi radialis is retracted. The
arthroscopic cannula is placed over the switching stick, the stick
is removed, and the arthroscope is introduced into the cannula.
Care must be takentoavoid injuring thevolar capsuleor
radiocarpal ligaments.
Digital motion is encouraged immediately after surgery.
The first dressing change is performed at 10 or 14 days to
remove the sutures. The wrist remains immobilized in asplint
for three to fourweeks to allow ligamentous and capsular
healing. Then occupational therapy for wrist range of motion
is initiated. Aremovable neutral wrist splint is continued when
not in therapy.After six weeks no immobilization is needed
and at eight weeks astrengthening program is initiated. By
three months postoperatively,the patient may return to full
unrestricted activities.
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Complications
Complications of proximal row carpectomy are relatively infrequent. During either open or arthroscopic approaches injury to
the dorsal sensory branches of the radial or ulnar nerve can
occur.Iatrogenic damage to the articular surface of the proximal
capitate or the lunate fossa of the distal radius could occur
during carpectomy.Damagetovolar radiocarpalligaments
during carpectomy can result in unrestrained ulnar translation
of the carpus. Recognized ligament injury should be primarily
repaired with sutureorbone anchors depending on the location
of injury.Finger weakness theoretically could occur from loss
of carpal height leading to laxity of extrinsic tendons. Relative
incongruity between the capitate head and lunate fossa could
result in capitate changes, which has been reported in two
studies in 6out of 20 and 14 out of 17 patients an average of
13 years after open surgery (36,37). Both groups found radiocapitate joint space narrowing to be often asymptomatic in these
patients. Complications from the arthroscopictechnique have
not been well-studied and the risk-benefit profile of arthroscopic versus open PRC is unknown.
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Outcomes
Only two studies describing arthroscopic PRC could be found.
Culp et al.(39)reported aqualitative descriptionofseven
patients who all experienced pain relief, good grip strength,
and afunctional range of motion. However,the authors did not
state length of follow-up, preoperative symptoms and physical
exam findings, or quantify postoperative parameters such as
pain relief, grip strength, or range of motion. No validated
outcome measureswere used. Roth and Poehling also described
asingle patient in which arthroscopic PRC was performed, but
did notstate thepostoperative outcome(38). Thus, further
studies documenting the safety and efficacy of arthroscopic
PRC are needed beforeroutine use can be recommended.
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Open Proximal Row Carpectomy Technique
SinceopenPRC is amuchmorecommonlyperformed
procedure than therecentlydescribed arthroscopicmethod
and has been proven effective over the past four decades (41),
we will briefly discuss the open approach. We believe the open
approachisaminimally invasive technique since long-term
immobilization is not necessary and careful preservation of the
nerves, tendon, capsule, and ligaments is performed. Either
regional or general anesthesia is used with the patient placed
supine and the affected arm abducted 908 on ahand table.
Undertourniquetcontrol atransverseincisionismade
centered over theproximal carpal row,providing excellent
exposurewith acosmetic scar (Fig. 5). Dissection is carried
down to the extensor retinaculum (Fig. 6) with care taken to
protect the sensory branches of the radial and ulnar nerves. The
extensor pollicis longus (EPL) tendon is retracted radially out of
theopenedthird dorsal compartment.The extensor carpi
radialis brevis(ECRB)isalsothenidentified andretracted
radially andthe fourth compartment tendonsare retracted
ulnarly.The posterior interosseous nerve is identified and a
1-cm segment is resected. The dorsal capsule is longitudinally
incised parallel to the ECRB. Staying within the subperiosteal
plane, to avoid entering the dorsal compartments, the dorsal
capsule is elevated (Fig. 7). The integrity of the articular surfaces
of the head of the capitate and the lunate facet of the distal
radius are inspected for chondromalacia. If significant eburnation is found on the capitate head, PRC should be abandoned
and either atotal wrist fusion or scaphoidectomy with four
corner fusion performed.
There are various techniques for excision of the scaphoid,
lunate, and triquetrum. The scaphoid can be removed first by
sharplydividing anyremaining fibersofthe scapholunate
interosseous ligament and then inserting aSteinmann pin into
thescaphoidtouse as ajoystick(Fig. 8).The scaphoidis
removed intact by sharply reflecting the volar capsular and
ligamentous attachments to the scaphoid, although the distal
Minimal Invasive Treatment of SLAC/SNAC&251
scaphoid tubercle need not be completely removed in order to
preserve distal ligaments (Fig. 9). The lunate and triquetrum
may be removed en-bloc or piecemeal, often with ajoystick to
rotate the bones to facilitate removal of the investing ligaments.
Afterthe proximalrow carpal bones are removed,the
capitate settles into the lunate fossa of the distal radius. The
capsule is closed with interrupted sutures after which orthogonal radiographs are taken to ensure that all of the proximal
carpal-rowbones are removed, and that the head of the capitate
is seated in the lunate fossa of the distal radius (Figs. 10–12).
The EPL is left out of the thirddorsal compartment and the
retinaculum is approximated with a3–0 absorbablesuture.
The skin is closed in standard fashion. Avolar plaster splint is
applied. Postoperative immobilization and rehabilitation are
similar to the arthroscopic technique described above.
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Open Proximal Row Carpectomy Outcomes
Twowelldesignedstudies analyzed thelong-term clinical
and radiographic results in atotal of 42 patients an average of
13 years afteropen PRC(36,37). Thewristshad an average
flexion-extension arc of 728 and 778 and an average grip strength
of 83%to91% of thecontralateral side.Fourteenout of 18
and 17 out of 20 patients were satisfied. Radiographs revealed
radiocapitate joint space narrowing, but there was no significant
association between loss of joint space and subjective or objective
function. There were four failures (18%) in patients under 35
years of age, in one of the studies that required fusion at an
average of seven years after PRC (37). Asummary of long-term
outcomes after proximal rowcarpectomy is reported (Table 1).
FIGURE 5 Adorsal horizontal incision, 4to5cm in length, is made
centered over the proximal carpal row. Lister’s tubercle (L) is marked.
FIGURE7 Thetendons of theextensordigitorumcommu nisare
retracted ulnarlyand the extensor pollicis longus andradial wrist
extensors are retracted radially to expose the dorsal capsule that has
been incised vertically.Radial and ulnar capsular flaps havebeen
elevated and retracted, exposing the carpal bones. If the proximal pole
of the capitatehas no or minimal chondromalacia,proximalrow
carpectomy is initi ated by sectioning the lunotriquetral (scalpel)and
scapholunate ligaments to facilitate mobilization of the proximal carpal
bones.
FIGURE 6 Dissection is carrieddowntothe extensorretinaculum
(horizontal fibers) with care taken to protect the sensory branches of
the radial and ulnar nerves.
252
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Jobin et al.
FIGURE 8 Kirschner wires are inserted into the scaphoid and lunate to
be used as joysticks to facilitate carpal bone rotation, permitting direct
visualizationduring carefulrefl ectionofthe capsuloligamentous
attachments.
FIGURE 9 The Kirschner wire is placed percutaneously just distal to the
level of the radial styloid to illustrate the location of the RSC ligament.
After proximal row carpectomy has been completed, the intact RSC
ligament(suture) is important to preserve carpal stability. Abbreviation:
RSC, radioscaphocapitate.
FIGURE 10 Intraoperative fluoroscopic posteroanterior image of the
completedproximal row carpectomy.
FIGURE11 Followupposteroanterior radiograph six months after
proximal row carpectomy in a34-year-old man who developed Kienbock’s disease with afractured, collapsed lunate with avascularnecrosis.
Minimal Invasive Treatment of SLAC/SNAC
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