Motion-preserving salvage surgery of the wrist after a scaphoid non

Volume 01 / Issue 02 / September 2013
Page 50
Peer-Reviewed Articles
Motion-preserving salvage
surgery of the wrist after
a scaphoid non-union or
scapholunate dissociation
Joseph J Dias
This article looks at salvage surgery of the
wrist after a scaphoid fracture non-union
or a scapholunate dissociation cause
arthritic change in the radioscaphoid joint.
All motion-preserving alternatives are
discussed. Of the common ones of scaphoid
excision and a four-corner fusion or a
proximal row carpectomy, in the medium
term a proximal row carpectomy retains
more physiological movement and therefore
better function but long-term results are
less certain. In such cases the orthopaedic
surgeon must discuss alternatives and tailor
a specific solution to the patient.
Joseph J Dias
Injury to the wrist is common
and usually affects young men.
The two injuries that can result
in early secondary osteoarthritis
are a scaphoid fracture1 that does
not heal and a scapholunate
dissociation2, which causes
Once degenerative change has
set in salvage procedures may be
needed if symptoms intrude on the
patients’ ability to perform activities
of daily living or activities at work.
Both injuries disrupt the continuity
of the proximal carpal row. This
row is then broken into two
unequal parts, the smaller radial
segment made up of a part or
whole of the scaphoid and the
longer ulnar segment of the lunate
and triquetrum with or without the
proximal part of the scaphoid. The
extent of degeneration reflects the
size of the radial segment of the
proximal carpal row, which flexes
after the non-union or dissociation.
There is point loading between
the radial segment of the proximal
carpal row and the dorsal rim of the
scaphoid facet of the distal radius.
This, in a very quick time, leads
to loss of joint cartilage. After a
scaphoid non-union (Figure 1) there
is a loss of wrist cartilage which is
noted on wrist radiographs within
five years in most patients3. The
arthritis initially occurs between
the radial segment of the proximal
carpal row and the styloid and
dorsal rim of the distal radius.
It rapidly extends to involve the
articulation between the radial
segment of the proximal carpal
row and the scaphoid fossa of
the distal radius. The next joint
to get involved is that between
the capitate and the proximal
scaphoid with the degeneration
slowly progressing (Figure 2). The
radiolunate joint and that between
the proximal scaphoid and the
radius is preserved until very late4.
The symptoms from the
degenerative arthritis do not
usually reflect the radiological
findings. Patients can present with
episodic sharp catching or painful
giving way, especially on gripping
forcefully. Persistent aching is
uncommon and, although patients
have restricted movement, what
is left permits most daily activities.
Patients cannot push up taking
weight on their palm. Once the
symptoms have become intrusive
and cannot be managed using
non-surgical methods (rest, splints,
analgesics NSAIDs or injections),
the surgeon needs to consider
possible intervention.
Surgical Options
The options the surgeon
may consider include advice,
debridement of osteophytes,
denervation, and partial excision
arthroplasty. Excision arthroplasty
commonly involves excision of the
scaphoid and midcarpal fusion or a
proximal row carpectomy. It is very
uncommon, in my experience, to
need total wrist arthroplasty5 or a
full wrist fusion6.
Volume 01 / Issue 02 / September 2013
Page 51
© 2013 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58
Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation
Authors: Joseph J Dias
Figure 1 - This radiograph demonstrates the features of a late result of a
scaphoid fracture non-union. The Scaphoid Non-union Advanced Collapse
(SNAC) wrist shows arthritis between the distal scaphoid and the scaphoid
facet of the distal radius. The radiolunate joint and that between the proximal
scaphoid and the radius is preserved. Note the hatching on the radial aspect
of the proximal capitate where there is point loading. There is also arthritis
between the capitate and the lunate. In this case a proximal row carpectomy
is contraindicated so a scaphoid excision and a four corner fusion would be a
reasonable alternative.
Denervation7 involves a careful
dissection of the branches from
the superficial division of the radial
and ulnar nerves from the extensor
retinaculum and the identification
and excision of a segment from the
posterior and interosseous nerves,
the latter distal to the pronator
quadratus8. Preoperative local
anaesthetic blocks of the nerves
to be divided may help identify
patients who may benefit but this
is not routinely done. The risks
of infection on complex regional
pain after surgery are very low and
recovery of function is rapid, as
patients do not need immobilisation
in a plaster cast or splint.
The advantage is that recovery time
is very short and risks are low but
the benefits from this procedure
are difficult to predict. At nine years
54% of patients retained benefit
after such surgery and 85% of
patients did not need to change
their occupation7.
If there are large osteophytes on
the dorsum of the radius and the
contiguous part of the waist of the
scaphoid these can be excised via
an arthrotomy or arthroscopically
to prevent osteophyte
impingement. This usually
improves the range of movement
but relief of pain is unpredictable.
Figure 2 - This radiograph demonstrates a Scapho-Lunate Advanced
Collapse (SLAC) wrist with radioscaphoid and midcarpal osteoarthritis. Note
on the lateral radiograph that the lunate is tilted to face backward- the Dorsal
Intercalated Segment Instability (DISI) pattern
The two common options to
salvage a painful wrist with a high
chance of improving symptoms and
still retaining some wrist movement
are the excision of the scaphoid
and a four corner fusion of the
mid carpal joint or alternatively a
proximal row carpectomy excising
the scaphoid and along with it the
lunate and triquetrum.
Scaphoid excision and
Four Corner Fusion
When the arthritis between the
scaphoid and the radius is severe
and painful the surgeon can
consider excising the scaphoid
distal part. This therefore is an
excision arthroplasty similar to
a trapeziectomy. The main risk
of carpal collapse into a dorsal
intercalated segment instability
(DISI) pattern with the lunate tilting
to face dorsally is mitigated by
performing a midcarpal fusion.
The articulation preserved for wrist
motion is the radiolunate joint.
If this joint is involved then the
surgeon must consider whether
this procedure is appropriate.
This joint is usually preserved in
scapholunate dissociation (SLAC)
or scaphoid non-union (SNAC).
Clinicians have considered this for
a SLAC or SNAC wrist because
it maintains carpal height, This
maintains the best length of the
muscle tendon units across the
wrist so there is no weakening of
the muscles used to perform tasks.
So surgeons have traditionally
considered this option when they
have wanted to retain maximum
strength in the hand9.
Volume 01 / Issue 02 / September 2013
Page 52
Peer-Reviewed Articles
Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58
Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation
Authors: Joseph J Dias
Patients are told that the scaphoid
will be excised and the mid-carpal
joint will be fused. They will be
immobilised in a plaster cast for a
while between six and 12 weeks.
Patients are informed that their
wrist movement will be reduced
and that the procedure does not
restore normality. They are warned
of the other risks of non-union, malalignment of the wrist joint, ulnar
sided pain in addition to the usual
surgical risks of infection, stiffness,
algodystrophy and nerve injury. All
other alternatives are discussed and
a shared decision is made.
My preference is to do this
procedure through a dorsal
longitudinal incision centred over
the middle finger ray. The extensor
retinaculum is divided transversely
and the stout septum between
the third and fourth extensor
retinaculum is divided. This allows
the distal part of the retinaculum
to be retracted, exposing the
Extensor Pollicis Longus tendon
and the tendons of the fourth
compartment. These are retracted
radially and ulnar-wards to expose
the dorsum of the wrist capsule.
The posterior interosseous nerve
is identified as it courses to the
dorsum of the wrist. A onecentimetre section is excised
from as proximal as the incision
permits. Once the nerve is divided
the radiocarpal joint is entered
distal to the Lister’s tubercle and
the capsulotomy extended radially
to the styloid. On the ulnar side
the incision is oblique through the
middle of the dorsal radiotriquetral
ligament towards the triquetrum
and then distally for one centimetre.
The incision into the capsule then
goes radially to the scaphoid and
the dorsal radially based flap is
elevated from the carpal bones
fully exposing the mid carpal joint.
Figure 3 - This intra-operative photograph shows the scaphoid excised and the midcarpal joint stabilised with a circular plate.
The scaphoid is then mobilised and
removed using sharp dissection
and a periosteal elevator. The
palmar ulnar corner of the scaphoid
tuberosity can at times cause
a problem as it is very strongly
attached. Sometimes the scaphoid
is large and may need to be divided
using Lambotte osteotomes. Bone
nibblers are used to complete
the excision. When dealing with a
SNAC wrist we usually retain the
proximal scaphoid. The area is
washed and any debris removed.
Attention is turned to the dorsal
osteophytes, which are trimmed
back, and the radial styloid is
trimmed with osteotomes to
present a rounded surface and
avoid impacting on the trapezium
on radial deviation.
Attention is then turned to the
mid carpal joint, which is usually
unaffected. The surfaces of the
capitate, hamate, triquetrum
and lunate are cut back to good
bleeding bone using a combination
of rongeurs, osteotomes and a 4
mm burr. The area is washed to
remove debris, and packed with
cancellous bone. We prefer to
obtain good quality cancellous
bone from the patient’s opposite
iliac crest. This is morcellised using
a bone cutter and packed into
the mid carpal joint. The joints are
stabilised using 1.1 mm Kirschner
wires, with attention being paid
to correct any dorsal tilting of the
lunate. The position is checked on
image intensifier.
Once a satisfactory position is
obtained we prefer to hold position
using a circular plate (Figure 3).
There are many alternative ways of
holding the bones in position10 and
the surgeon needs to be familiar
with a few of these techniques.
The capsule is then closed with
a few interrupted sutures. The
transverse split in the extensor
retinaculum is quickly closed
with a running absorbable suture.
The wound is infiltrated with a
long acting local anaesthetic.
The longitudinal skin incision is
closed and the wrist bandaged.
We routinely apply a plaster of
Paris cast on the palmar surface to
immobilise the wrist.
Volume 01 / Issue 02 / September 2013
Page 56
Peer-Reviewed Articles
Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58
Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation
Authors: Joseph J Dias
This procedure needs the
midcarpal bones to fuse. This
takes up to 12 weeks and the wrist
requires immobilisation in a plaster
slab or wrist support. It requires
the fusion of normal joints; around
5% of cases have failure of union
and may need re-arthrodesis11. It is
usual to retain 60% of movement
but this is not predictable and
some patients can lose much more
than this. Most patients retain 80%
of grip strength but around 25%
continue to experience some pain
even after solid midcarpal fusion.
Salvage for a failed four-corner
fusion is a total wrist replacement
or a total wrist fusion.
Figure 4 - This patient had midcarpal fusions on both sides using stout
Kirschner wires. Note the solid fusion and the preservation of radiolunate
joint height. Note that on the right the radial styloid has been excised to avoid
impingement between the trapezium and the radial styloid on radial deviation.
The immediate aftercare is to
elevate the wrist and hand for a
few hours and start early exercises
to recover hand and finger
movement. The plaster of Paris
slab is retained for a few weeks
and then the wrist is supported
in a removable splint. Union is
assessed on radiographs at six
and 12 weeks (Figure 4). Any
uncertainty about union is resolved
using a wrist CT scan to establish
whether there is bridging bone.
Tricks and tips
There are three problems that
can be avoided by attention to
technical detail:
1. Range of wrist movement
is retained if the DISI is
corrected. So careful attention
to this and checks before
stabilisation using intraoperative fluoroscopy helps
avoid a fusion in persistent
DISI position.
2. Radial tilting of the hand can
be avoided by allowing the
capitate to find its neutral
position and by not trying to
locate the capitate into the
cup of the lunate. This causes
a fusion where the carpus will
assume a position of radial
deviation as the radiolunate
ligament is rendered slack
in this manoeuvre. So, as it
regains its taut position, the
lunate tilts radially.
3. The third problem is the pain
on the ulnar side. This needs
attention to ensure that the
triquetrum is not fused so it
protrudes towards the ulna
leading to secondary impaction
after the four-corner fusion.
Proximal row
This is an arthroplasty that excises
not just the scaphoid but also the
remainder of the proximal carpal
row and includes excision of the
lunate and the triquetrum.
This needs the articular cartilage
on the proximal capitate and the
lunate facet of the distal radius
to be preserved. Low-demand
patients are considered suitable for
this. The concern about a proximal
row carpectomy is that the
carpal height is reduced thereby
weakening the muscle tendon units
of the long flexors and extensors
of the fingers and wrist. In addition
there is concern about rotational
stability of the new joint. This
procedure has been considered for
those not needing forced grip in
their daily and work activities9.
Patients are advised that they will
need to protect the hand from
forceful use for a few weeks. They
are told that the weakness in
their hands will persist and that a
proportion of them will continue to
have some pain in the wrist. They
are also warned of weakness in
tasks needing forearm rotation,
such as opening doors.
The approach to the wrist is exactly
the same as for four-corner fusion.
After the scaphoid and radius
osteophytes are excised the lunate
and the triquetrum are removed.
Care is taken to retain the radioscapho-capitate ligament when
dealing with the radial styloid. The
capsule closure is as before.
Tricks and tips
The surgeon needs to be aware
of the shapes of the capitate12.
Those with a distinct ridge are
more likely to have point loading
and early degenerative change in
the new joint between the capitate
and radius.
The hand is elevated initially and
the wrist may be immobilised in
a plaster of Paris slab for the first
week or so and then the wrist
supported by a wrist splint. Full
activities, which are not forceful,
are permitted from the outset.
Radiographs are obtained and
follow-up is arranged for six and
12 weeks.
The wrist movement surprisingly
does not improve significantly after
a proximal row carpectomy. Once
again patients usually retain twothirds their range of movement and
80% of their maximal grip strength.
However 5% need salvage surgery
and around 25% continue to
experience some pain, even after a
proximal row carpectomy.
Volume 01 / Issue 02 / September 2013
Page 57
© 2013 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58
Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation
Authors: Joseph J Dias
Salvage for a failed proximal row
carpectomy is a capitate hemireplacement or a total wrist fusion.
So on the current evidence
whether the patient is offered one
or the other procedure very often
comes down to the preference of
the surgeon.
Outcomes in
We investigated the function of
the wrist and hand after a fourcorner fusion and proximal row
carpectomy and found that pain
relief was comparable but the axis
of wrist movement13 14 was parallel
to that of the normal wrist after a
proximal row carpectomy and was
more vertical after a four-corner
fusion. Function as assessed by
the timed Sollerman hand function
test15 was better and quicker after a
proximal row carpectomy but tasks
needing forearm rotation were more
compromised after a proximal row
carpectomy. We used two patient
reported outcome questionnaires,
the Patient Evaluation Measure16
and Michigan Hand Questionnaire17
. Both have been validated for
wrist disorders. Patient were more
satisfied, and had better pain relief
and function after a proximal row
carpectomy. A systematic review
of the literature comparing the
two techniques demonstrated
no difference between the two
techniques although the risk
of delayed arthritis in the joint
between the capitate and radius
was much greater after a proximal
row carpectomy19. Another study
comparing the two procedures in 20
patients also found no difference20.
At six years after a proximal row
carpectomy in 23 patients, patients
had 61% of range and 79% of
strength21. Another study in 24
patients at 10 years found similar
range and strength but noted
radiographic arthritis in 52%22. But
at 15 years 46 of 61 patients had
persistent pain and were dissatisfied
and arthritis between the capitate
and radius was observed on
radiographs and 12 of 61 (19.6%)
needed full wrist fusion23.
After midcarpal fusion 37 patients
were reviewed at 8 years and had
range and strength that was similar
to that seen after a proximal row
carpectomy but 10/37 (27%) had
developed radiolunate arthritis24.
However, after either of these two
procedures my clinical experience is
that the need for further surgery after
a successful operation is very low.
Other options:
Total Wrist Fusion,
Total Wrist Arthroplasty
In those patients with persisting
disabling pain after these motionpreserving procedures or in
those where the extent of arthritis
precludes these operations, the
surgeon may consider a total wrist
arthroplasty or total wrist fusion.
Both these procedures improve pain.
Fusion of the wrist gives more
certain control of wrist pain but has
a profound impact on the function
of the arm6 25 26. The risks of fusion
surgery are well established27. Nonunion is unlikely but complications
were noted: 50 of 71 (70%) wrists
fused, with reoperation to remove
the fusion plate needed in 20%.
Eighteen wrists were left with
permanent problems. 55 of 71 (77%)
wrists fused had a stable pain-free
wrist after a total wrist fusion27. Total
wrist fusion is a reliable procedure
but has a high problem rate and 1:4
will continue to have problems.
The other alternative is to perform
a total wrist arthroplasty. Total
wrist arthroplasty has evolved
over recent decades and we now
have experience and information
on indications, techniques,
complications and their
salvage28-30. As our knowledge and
experience of wrist arthroplasty
in patients with post-traumatic
arthritis increase31 32 this may
become the intervention of choice
especially when motion-preserving
procedures fail.
We found that patients with a
proximal row carpectomy had
restricted movement, but retained
the dart-throwing axis. Patients
having a scaphoid excision and
four-corner midcarpal fusion
lost the dart-throwing axis of
movement. There was nearly 65%
loss of area of circumduction
compared to the opposite wrist.
Peak strength was similar after
each of these operations. Patients
reported better outcomes (PEM,
MHQ) after a proximal row
carpectomy but took longer to
perform activities requiring forearm
rotation. Based on our findings, a
proximal row carpectomy is better,
at least in the medium term.
If pain relief is inadequate the
surgeon can consider either a wrist
arthroplasty or a full wrist fusion
using a custom fusion plate.
In summary, wrist salvage surgery
for post-traumatic pain due to
degenerative change needs to be
specifically tailored to each patient.
There are many surgical options
and good shared-decision-making
and technical execution are the key
to obtaining a satisfactory outcome.
Of the two procedures that
preserve motion, the proximal
row carpectomy is superior in
the medium term as it retains the
natural axis of wrist movement. But
late reviews suggest that 1:4 cases
will continue to have or develop
wrist pain after either of these
two common motion-preserving
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Volume 01 / Issue 02 / September 2013
Page 58
Peer-Reviewed Articles
Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58
Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation
Authors: Joseph J Dias
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The Journal of hand surgery
Prof. J J Dias
Clinical Sciences Unit, Off Ward 11
Leicester General Hospital
Gwendolen Road
Leicester LE5 4PW
Email: [email protected]