Proximal row carpectomy: Clinical evaluation Proximal row carpectomy
as a treatment of disorders of the radiocarpal joint remains contro-
versial despite numerous reports documenting clinically successful outcomes. Criticism includes postoperative loss of grip strength, unsatisfactory range of motion, prolonged rehabilitation time, and the potential for progressive painful arthritis. Twenty-seven
patients were studied to address
these concerns. The average length of follow-up was 4 years. Postoperative pain relief was achieved in 26 patients, allowing 24 of the 27 patients to return to their previous activity status within an average of 4.5 months after surgery. In all cases, range of motion matched or surpassed preoperative
values. Grip strength improved to an average of 80% of the contralateral
side. A
detailed radiographic analysis of the radii of curvature of the lunate fossa and the capitate showed that the radius of curvature
of the capitate is approximately
two thirds of the corresponding
value of the lunate. Motion between the capitate and the radius is translational
with a moving
center of motion, which may dissipate load on the radius and explain the relative success of the procedure. (J HAND SURG 1990;15A:426-30.)
Joseph E. Imbriglia, MD, Arnold S. Broudy, MD, William C. Hagberg, MD, and Daniel McKeman, MD, Pittsburgh, Pa.
A
ttempts to preserve useful wrist motion after traumatic and arthritic disorders of the radiocarpal and intercarpal joints led to the development of silicone and metal prostheses. Problems with material failure,’ prosthetic loosening,* and silicone synovitis3 have rekindled interest in solutions that avoid synthetic replacements and use residual biologic articular surfaces. Thus limited intercarpal fusions have been recommended4 to preserve functional arcs of motion and strength for those patients who prefer to avoid complete radiocarpal arthrodesis. During the past 2 decades, reports from a variety of centers advocated proximal row carpectomy as an alternative approach. 5-1oNevertheless, the procedure has remained somewhat controversial, being referred to as a “salvage procedure.“* Criticism of the results of prox-
From the Department of Orthopedic Surgery, University of Pittsburgh, Allegheny General Hospital, and Montetiore Hospital, Pittsburgh, Pa. Received for pubhcation June 13, 1989.
Nov. 16, 1988; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Arnold S. Broudy, MD, 3471 Fifth Ave., Suite 911, Pittsburgh, PA 15213. 3/l/15153
426
THE
JOURNAL
OF HAND
SURGERY
imal row carpectomy has included: inadequate strength, loss of motion, prolonged rehabilitation, and progressive painful arthritis. In this article, 27 patients were studied to address these specific concerns. Methods
Twenty-seven patients had a proximal row carpectomy between 1976 and 1985. Underlying conditions included: chronic scapholunate dissociation with arthritis (1 l), scaphoid nonunion with arthritis (7), Kienbock’s disease with collapse (5), failed scaphoid prostheses (3), and failed lunate prosthesis (1). The patients with arthritis did not have significant involvement of the lunate fossa or proximal pole of the capitate. Several patients had superficial cartilage abrasions. The series included 20 men and 7 women. Their ages ranged from 20 to 65 years, with a mean of 41 years and a median of 40 years. The dominant hand was involved in 17 patients. Average duration of symptoms before operation was 19 months. Approximately 70% of the patients were classified as heavy laborers engaging in such occupations as mining, steel work, carpentry, and construction. Other occupations represented included bus driver, hairdresser, nurses’ aide, and homemaker. Nine patients were receiving workers’ compensation. Clinical findings. Wrist pain affecting work capability was the presenting complaint in all patients. Pre-
Vol. 15A, No. 3 May 1990
Proximal row carpectomy: Clinical evaluation
427
Fig. 1. Three-dimensional computerized axial tomographic reconstruction of a patient’s wrist 8 years after proximal row carpectomy. Radial styloidectomy was not performed. There is adequate space between the trapezium (T) and radius (R). This patient has no problems with styloid impingement.
operative wrist flexion averaged 30 degrees, extension 35 degrees, radial deviation 5 degrees, and ulnar deviation 10 degrees. Grip strength was decreased in all patients ranging from 20% to 75% of the uninvolved side. X-ray analysis. All patients had preoperative and postoperative films. The radii of curvature of the capitate and the lunate fossa of the radius were measured in anteroposterior and lateral views. In each instance, the radius of curvature was determined by applying a template of circles to the x-ray film. The radius whose arc best approximated the curvature was selected. The x-ray films were also placed on a computergraphics pad and the joint lines were traced. The radius of curvature was then calculated by computer analysis. The two techniques yielded comparable results (p = 0.01). One patient with 8-year follow-up had cineradiograms and a three-dimensional computerized axial tomographic reconstruction (Fig. 1).
The scaphoid, lunate, and triquetrum were then excised. Sharp division of the intercarpal ligaments facilitated mobilization of the bones, which were fragmented with a rongeur to expedite removal. The lunate was removed first, followed by the triquetrum and scaphoid. In several cases Kirschner wires were drilled into the bones to be used as handles or levers to improve exposure. The palmar capsule was preserved leaving small adherent fragments when necessary. After the proximal row was removed, the capitate was allowed to settle in the central portion of the lunate fossa. Passive flexion and extension of the hand were done in neutral and slight radial deviation to detect impingement of the trapezium against the radial styloid. Ten patients required radial styloidectomy. Capsular closure was done without significant imbrication. Postoperative immobilization with casts or splints in neutral position varied from 4 to 6 weeks. Motion of the digits was begun immediately.
Technique
Results
Dorsal longitudinal incisions incorporating existing scars were used. The extensor retinaculum in the fourth compartment was partially divided to facilitate tendon retraction. The wrist capsule was entered longitudinally to allow inspection of the lunate fossa and the articular surface of the proximal pole of the capitate. If no significant degenerative changes were present, the capsular incision was extended transversely to facilitate exposure .
Twenty-six patients had satisfactory relief of pain; none requires medication or splints. Of the 19 patients who performed vigorous manual labor, 16 returned to their previous occupations. Two patients required reoperation, both for excision of the radial styloid. A third patient had persistent pain that was treated with wrist fusion. There were no cases of carpal subluxation, infection, or reflex sympathetic dystrophy. Twenty-four patients
428
The Journal of HAND SURGERY
Imbriglia et al.
CHANGE
IN RATIO
OF RADII
OF CURVATURE
Post-Op
Pre-Op
RADIUS
A-P
.64
.67
LAT.
.60
.72
OF CURVATURE
LUNATE FOSSA 12.9
B
11.9
(mm)
A-P
8.3
LAT.
7.18
Fig. 2. A, Schematic representation of radii of curvature of lunate fossa of radius and capitate. B, Postoperative changes in radius of curvature for capitate and lunate fossa of radius. Curvatures
more closely approximate each other with time.
were able to resume their previous activities or new occupations within 4.5 months of surgery. Postoperative range of motion was correlated with preoperative motion. All patients maintained or increased tlexion and extension. The average total arc increased from 65 degrees before operation to 84 degrees. Average ulnar deviation was 23 degrees. There was a uniform loss of radial deviation, with only one patient exceeding 10 degrees. Twenty patients had 5 degrees of radial deviation or less. Grip strength in the 27 wrists, as measured by Jaymar dynamometer, improved to an average value of 80% of the nondominant side (range, 50% to 98%). Only three patients, all heavy laborers, were unable to return to their former occupations. Average follow-up was 4 years. The range was from 2 to 8 years. The radius of curvature of the cap&ate was found to
be 64% of the corresponding value for the lunate fossa in the preoperative AP view and 60% in the lateral (Fig. 2, A). After proximal row carpectomy these curvatures appeared to change with time to 67% AP view and 72% lateral view. Analysis of cineradiograms and flexion-extension films (Fig. 3) reveals that motion of the capitate on the radius consists of translation and rotation (hinge plus roll.)
Discussion Proximal row carpectomy has carried the pejorative label of “salvage procedure” despite numerous reports of good clinical results. The six largest series5-’ in the literature demonstrated a failure rate of about 5%. In our series, the operation also appears to diminish pain, maintains a functional arc of motion, and improves grip
Vol. HA, No. 3 May 1990
Proximal row carpectomy: Clinical evaluation
429
strength. The rehabilitation time is comparable to that for limited or total wrist arthrodesis. Deterioration of the radiocapitate joint has not proved to be a problem. Relief of pain achieved by the operation is due to removal of arthritic, incongruous joints and replacement by a loose articulation between the capitate and lunate fossa of the radius. This has been characterized as a hinge joint,9 or ball and socket joint.” Motion between the capitate and the radius appears to be translational and rotational (hinge plus roll), which dissipates the load on the radius. This is corroborated by pressure distribution studies. I2Thus the discrepancy between the arcs of curvature of the lunate fossa and capitate may not be detrimental. The radial articular contour appears to undergo a gradual change with time, but there have not been any reports of long-term problems with the operation.5-9 The extensive capsular exposure and opening needed for proximal row carpectomy probably achieves a partial wrist denervation, which may also contribute to pain relief. In this series, postoperative range of motion was comparable to preoperative values. Since about one third of the extension and almost two thirds of flexion occur at the midcarpal level,13 elimination of this joint inevitably leads to a decreased arc. Nevertheless, our patients retained their preoperative range of motion, which was already decreased as a result of existing degenerative changes. All patients had at least 30 degrees of both flexion and extension. The patients with near normal motion before operation did not lose motion. Those with long-standing problems and restricted motion undoubtedly had some degree of capsular scarring and myostatic contracture, which also limited motion after ‘operation. Normally, ulnar deviation (37 degrees) is nearly twice radial deviation (20 degrees). I4 Radial deviation occurs primarily between the proximal and distal rows, while ulnar deviation occurs at both intercarpal and radiocarpal levels. Our patients had markedly restricted radial deviation (0 to 5 degrees), but ulnar deviation was reasonably preserved (23 degrees), consistent with previous reports.5-9 The motion reported here and published previously for proximal row carpectomy compare favorably to the values reported for motion in most series of prostheses’*-” without the same degree of attendant complications. Postoperative motion in proximal row carpectomy is comparable to reports for the SLAC wrist operation. ‘* Loss of grip strength has been related to pain associated with underlying musculoskeletal pathology. I9Improvement in grip strength is at least, in part, related
Fig. 3. Flexion and extension x-ray films after proximal row
carpectomy. Motion of the capitate on the radius consists of translation as well as rotation. to diminished pain. Our patients regained about 80% of strength of the contralateral side, which represents a loss of only 20% to 30% of normal values allowing for dominance. ‘O One patient, who had a proximal row carpectomy on his dominant side and fusion on the nondominant side, has superior grip strength on the arthrodesed side (95 pounds versus 8.5 pounds). Despite an 11% increase in grip strength, he far prefers the proximal row carpectomy in terms of function. Although proximal row carpectomy does not fully restore grip strength as measured by a dynamometer, for most patients the operation restores sufficient strength to allow them to return to work and perform the activities of daily living. Several authors have advised radial styloidectomy to prevent impingement after excision of the proximal carpal row.5’ ‘, 9 Others have found styloidectomy to be unnecessary.6, ’ One of us has not done radial styloidectomy in 11 cases and no problems with impingement have developed. A three-dimensional computed tomography (CT) reconstruction in a patient with 8year follow-up demonstrates that the trapezium lies palmar to the styloid process of the radius. Unless the radial styloid is enlarged or elongated, routine styloidectomy is not mandatory but should be performed in those cases where contact can be demonstrated at the time of surgery.6, ’ Excessive disruption of the radial ligamentous attachment can lead to migration or subluxation of the carpus. The principal contraindication to this procedure is the presence of significant degenerative change on the
430
The Journal of HAND SURGERY
Imbriglia et al.
proximal pole of the capitate or the lunate fossa. Superficial abrasion or fibrillation of cartilage in peripheral areas does not preclude a successful outcome. For patients with centrally placed full-thickness cartilage lesions 3 mm or more in diameter, other options should be considered. We believe that proximal row carpectomy is a dependable, low-risk procedure for patients who wish to retain radiocarpal motion. On the basis of the clinical results in the laborers in this series, we agree with Crabbe’ that proximal row carpectomy is an acceptable alternative to arthrodesis even when the wrist is likely to be subjected to heavy use. The problems associated with prosthetic failure or loosening are obviated. Options are maintained in the event superior prostheses are developed in the future. To date, the literature does not reflect any long-term deterioration of results in proximal row carpectomy. Arthrodesis can still be done to treat an unfavorable outcome. REFERENCES 1. Brase DW, Millender LH. Failure of silicone rubber wrist arthroplasty in rheumatoid arthritis. J HAND SURG 1986;11:175-83. 2. Cooney WP, Beckenbaugh RD, Linshield RL. Total wrist
arthroplasty: problems with implant failures. Clin Orthop 1984;187:121-8. 3. Smith RJ, Atkinson RE, Jupiter JB. Silicone synovitis of the wrist. J HAND SURG 1985;1:47-60. 4. Watson HK, Goodman ML, Johnston TR. Limited wrist arthrodesis, II: intercarpal and radiocarpal combinations. J HAND SURG 1981;6:223-33. 5. Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg 1964;46B:708-11. 6. Jorgensen EC. Proximal row carpectomy: an end result of twenty-two cases. J Bone Joint Surg 1969;5 1A: 110411. 7. Inglis AE, Jones EC. Proximal row carpectomy for dis-
8. 9. 10.
11. 12.
13.
14.
eases of the proximal row. J Bone Joint Surg 1977; 59A:460-3. Neviaser RJ. On resection of the proximal row. Clin Orthop 1986;202:12-15. Green DP. Proximal row carpectomy. Hand Clinics 1987;3:163-8. White GM, Clark GL, Elias LS. Proximal row carpectomy for posttraumatic disorders of the wrist. J HAND SURG 1988;13A:310. Stamm TT. Excision of the proximal row of the carpus. Proc Royal Sot Med 1944;38:74-5. Hagberg WC, Imbriglia JE, McKeman DJ, Broudy AS, Mathews D. Biomechanical analysis of fit of the capitate in the lunate fossa after proximal row carpectomies. American Society for Surgery of the Hand, Baltimore, 1988. Sarjafian SK, Melamed JL, Goshgarian GM. Study of wrist motion in flexion and extension. Clin Orthop 1977;126:153-9. Youm Y, McMurty RY, Flatt AE, Gillespie TE. Kine-
matics of the wrist: an experimental study of radial-ulnar deviation and flexion-extension. J Bone Joint Surg 1978;60A:423-3 1. 15. Fatti JF, Palmer AK, Mosher JH. The long-term results of Swanson’s silicone rubber interpositional wrist arthroplasty. J HAND SURG 1986; 11: 166-75. 16. Swanson AB, Swanson GD, Maupin BK. Flexible implant arthroplasty of the radiocarpal joint: surgical technique and long-term study. Clin Orthop 1984;187:94106. 17. Volz RG. Total wrist arthroplasty: a clinical review. Clin Orthop 1984;187:112-20. 18. Watson HK, Bolles FL. Scapholunate advanced collapse pattern of degenerative arthritis. J HAND SURG 1984; 9A:358-65. 19. Czitrom AA, Lister GD. Measurement of grip strength in the diagnosis of wrist pain. J HAND SURG 1988; 13A:16-18. 20. Thongren KG, Werner CO. Normal grip strength. Acta Orthop Stand 1979;50:255-9.
as a treatment of disorders of the radiocarpal joint remains contro-
versial despite numerous reports documenting clinically successful outcomes. Criticism includes postoperative loss of grip strength, unsatisfactory range of motion, prolonged rehabilitation time, and the potential for progressive painful arthritis. Twenty-seven
patients were studied to address
these concerns. The average length of follow-up was 4 years. Postoperative pain relief was achieved in 26 patients, allowing 24 of the 27 patients to return to their previous activity status within an average of 4.5 months after surgery. In all cases, range of motion matched or surpassed preoperative
values. Grip strength improved to an average of 80% of the contralateral
side. A
detailed radiographic analysis of the radii of curvature of the lunate fossa and the capitate showed that the radius of curvature
of the capitate is approximately
two thirds of the corresponding
value of the lunate. Motion between the capitate and the radius is translational
with a moving
center of motion, which may dissipate load on the radius and explain the relative success of the procedure. (J HAND SURG 1990;15A:426-30.)
Joseph E. Imbriglia, MD, Arnold S. Broudy, MD, William C. Hagberg, MD, and Daniel McKeman, MD, Pittsburgh, Pa.
A
ttempts to preserve useful wrist motion after traumatic and arthritic disorders of the radiocarpal and intercarpal joints led to the development of silicone and metal prostheses. Problems with material failure,’ prosthetic loosening,* and silicone synovitis3 have rekindled interest in solutions that avoid synthetic replacements and use residual biologic articular surfaces. Thus limited intercarpal fusions have been recommended4 to preserve functional arcs of motion and strength for those patients who prefer to avoid complete radiocarpal arthrodesis. During the past 2 decades, reports from a variety of centers advocated proximal row carpectomy as an alternative approach. 5-1oNevertheless, the procedure has remained somewhat controversial, being referred to as a “salvage procedure.“* Criticism of the results of prox-
From the Department of Orthopedic Surgery, University of Pittsburgh, Allegheny General Hospital, and Montetiore Hospital, Pittsburgh, Pa. Received for pubhcation June 13, 1989.
Nov. 16, 1988; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Arnold S. Broudy, MD, 3471 Fifth Ave., Suite 911, Pittsburgh, PA 15213. 3/l/15153
426
THE
JOURNAL
OF HAND
SURGERY
imal row carpectomy has included: inadequate strength, loss of motion, prolonged rehabilitation, and progressive painful arthritis. In this article, 27 patients were studied to address these specific concerns. Methods
Twenty-seven patients had a proximal row carpectomy between 1976 and 1985. Underlying conditions included: chronic scapholunate dissociation with arthritis (1 l), scaphoid nonunion with arthritis (7), Kienbock’s disease with collapse (5), failed scaphoid prostheses (3), and failed lunate prosthesis (1). The patients with arthritis did not have significant involvement of the lunate fossa or proximal pole of the capitate. Several patients had superficial cartilage abrasions. The series included 20 men and 7 women. Their ages ranged from 20 to 65 years, with a mean of 41 years and a median of 40 years. The dominant hand was involved in 17 patients. Average duration of symptoms before operation was 19 months. Approximately 70% of the patients were classified as heavy laborers engaging in such occupations as mining, steel work, carpentry, and construction. Other occupations represented included bus driver, hairdresser, nurses’ aide, and homemaker. Nine patients were receiving workers’ compensation. Clinical findings. Wrist pain affecting work capability was the presenting complaint in all patients. Pre-
Vol. 15A, No. 3 May 1990
Proximal row carpectomy: Clinical evaluation
427
Fig. 1. Three-dimensional computerized axial tomographic reconstruction of a patient’s wrist 8 years after proximal row carpectomy. Radial styloidectomy was not performed. There is adequate space between the trapezium (T) and radius (R). This patient has no problems with styloid impingement.
operative wrist flexion averaged 30 degrees, extension 35 degrees, radial deviation 5 degrees, and ulnar deviation 10 degrees. Grip strength was decreased in all patients ranging from 20% to 75% of the uninvolved side. X-ray analysis. All patients had preoperative and postoperative films. The radii of curvature of the capitate and the lunate fossa of the radius were measured in anteroposterior and lateral views. In each instance, the radius of curvature was determined by applying a template of circles to the x-ray film. The radius whose arc best approximated the curvature was selected. The x-ray films were also placed on a computergraphics pad and the joint lines were traced. The radius of curvature was then calculated by computer analysis. The two techniques yielded comparable results (p = 0.01). One patient with 8-year follow-up had cineradiograms and a three-dimensional computerized axial tomographic reconstruction (Fig. 1).
The scaphoid, lunate, and triquetrum were then excised. Sharp division of the intercarpal ligaments facilitated mobilization of the bones, which were fragmented with a rongeur to expedite removal. The lunate was removed first, followed by the triquetrum and scaphoid. In several cases Kirschner wires were drilled into the bones to be used as handles or levers to improve exposure. The palmar capsule was preserved leaving small adherent fragments when necessary. After the proximal row was removed, the capitate was allowed to settle in the central portion of the lunate fossa. Passive flexion and extension of the hand were done in neutral and slight radial deviation to detect impingement of the trapezium against the radial styloid. Ten patients required radial styloidectomy. Capsular closure was done without significant imbrication. Postoperative immobilization with casts or splints in neutral position varied from 4 to 6 weeks. Motion of the digits was begun immediately.
Technique
Results
Dorsal longitudinal incisions incorporating existing scars were used. The extensor retinaculum in the fourth compartment was partially divided to facilitate tendon retraction. The wrist capsule was entered longitudinally to allow inspection of the lunate fossa and the articular surface of the proximal pole of the capitate. If no significant degenerative changes were present, the capsular incision was extended transversely to facilitate exposure .
Twenty-six patients had satisfactory relief of pain; none requires medication or splints. Of the 19 patients who performed vigorous manual labor, 16 returned to their previous occupations. Two patients required reoperation, both for excision of the radial styloid. A third patient had persistent pain that was treated with wrist fusion. There were no cases of carpal subluxation, infection, or reflex sympathetic dystrophy. Twenty-four patients
428
The Journal of HAND SURGERY
Imbriglia et al.
CHANGE
IN RATIO
OF RADII
OF CURVATURE
Post-Op
Pre-Op
RADIUS
A-P
.64
.67
LAT.
.60
.72
OF CURVATURE
LUNATE FOSSA 12.9
B
11.9
(mm)
A-P
8.3
LAT.
7.18
Fig. 2. A, Schematic representation of radii of curvature of lunate fossa of radius and capitate. B, Postoperative changes in radius of curvature for capitate and lunate fossa of radius. Curvatures
more closely approximate each other with time.
were able to resume their previous activities or new occupations within 4.5 months of surgery. Postoperative range of motion was correlated with preoperative motion. All patients maintained or increased tlexion and extension. The average total arc increased from 65 degrees before operation to 84 degrees. Average ulnar deviation was 23 degrees. There was a uniform loss of radial deviation, with only one patient exceeding 10 degrees. Twenty patients had 5 degrees of radial deviation or less. Grip strength in the 27 wrists, as measured by Jaymar dynamometer, improved to an average value of 80% of the nondominant side (range, 50% to 98%). Only three patients, all heavy laborers, were unable to return to their former occupations. Average follow-up was 4 years. The range was from 2 to 8 years. The radius of curvature of the cap&ate was found to
be 64% of the corresponding value for the lunate fossa in the preoperative AP view and 60% in the lateral (Fig. 2, A). After proximal row carpectomy these curvatures appeared to change with time to 67% AP view and 72% lateral view. Analysis of cineradiograms and flexion-extension films (Fig. 3) reveals that motion of the capitate on the radius consists of translation and rotation (hinge plus roll.)
Discussion Proximal row carpectomy has carried the pejorative label of “salvage procedure” despite numerous reports of good clinical results. The six largest series5-’ in the literature demonstrated a failure rate of about 5%. In our series, the operation also appears to diminish pain, maintains a functional arc of motion, and improves grip
Vol. HA, No. 3 May 1990
Proximal row carpectomy: Clinical evaluation
429
strength. The rehabilitation time is comparable to that for limited or total wrist arthrodesis. Deterioration of the radiocapitate joint has not proved to be a problem. Relief of pain achieved by the operation is due to removal of arthritic, incongruous joints and replacement by a loose articulation between the capitate and lunate fossa of the radius. This has been characterized as a hinge joint,9 or ball and socket joint.” Motion between the capitate and the radius appears to be translational and rotational (hinge plus roll), which dissipates the load on the radius. This is corroborated by pressure distribution studies. I2Thus the discrepancy between the arcs of curvature of the lunate fossa and capitate may not be detrimental. The radial articular contour appears to undergo a gradual change with time, but there have not been any reports of long-term problems with the operation.5-9 The extensive capsular exposure and opening needed for proximal row carpectomy probably achieves a partial wrist denervation, which may also contribute to pain relief. In this series, postoperative range of motion was comparable to preoperative values. Since about one third of the extension and almost two thirds of flexion occur at the midcarpal level,13 elimination of this joint inevitably leads to a decreased arc. Nevertheless, our patients retained their preoperative range of motion, which was already decreased as a result of existing degenerative changes. All patients had at least 30 degrees of both flexion and extension. The patients with near normal motion before operation did not lose motion. Those with long-standing problems and restricted motion undoubtedly had some degree of capsular scarring and myostatic contracture, which also limited motion after ‘operation. Normally, ulnar deviation (37 degrees) is nearly twice radial deviation (20 degrees). I4 Radial deviation occurs primarily between the proximal and distal rows, while ulnar deviation occurs at both intercarpal and radiocarpal levels. Our patients had markedly restricted radial deviation (0 to 5 degrees), but ulnar deviation was reasonably preserved (23 degrees), consistent with previous reports.5-9 The motion reported here and published previously for proximal row carpectomy compare favorably to the values reported for motion in most series of prostheses’*-” without the same degree of attendant complications. Postoperative motion in proximal row carpectomy is comparable to reports for the SLAC wrist operation. ‘* Loss of grip strength has been related to pain associated with underlying musculoskeletal pathology. I9Improvement in grip strength is at least, in part, related
Fig. 3. Flexion and extension x-ray films after proximal row
carpectomy. Motion of the capitate on the radius consists of translation as well as rotation. to diminished pain. Our patients regained about 80% of strength of the contralateral side, which represents a loss of only 20% to 30% of normal values allowing for dominance. ‘O One patient, who had a proximal row carpectomy on his dominant side and fusion on the nondominant side, has superior grip strength on the arthrodesed side (95 pounds versus 8.5 pounds). Despite an 11% increase in grip strength, he far prefers the proximal row carpectomy in terms of function. Although proximal row carpectomy does not fully restore grip strength as measured by a dynamometer, for most patients the operation restores sufficient strength to allow them to return to work and perform the activities of daily living. Several authors have advised radial styloidectomy to prevent impingement after excision of the proximal carpal row.5’ ‘, 9 Others have found styloidectomy to be unnecessary.6, ’ One of us has not done radial styloidectomy in 11 cases and no problems with impingement have developed. A three-dimensional computed tomography (CT) reconstruction in a patient with 8year follow-up demonstrates that the trapezium lies palmar to the styloid process of the radius. Unless the radial styloid is enlarged or elongated, routine styloidectomy is not mandatory but should be performed in those cases where contact can be demonstrated at the time of surgery.6, ’ Excessive disruption of the radial ligamentous attachment can lead to migration or subluxation of the carpus. The principal contraindication to this procedure is the presence of significant degenerative change on the
430
The Journal of HAND SURGERY
Imbriglia et al.
proximal pole of the capitate or the lunate fossa. Superficial abrasion or fibrillation of cartilage in peripheral areas does not preclude a successful outcome. For patients with centrally placed full-thickness cartilage lesions 3 mm or more in diameter, other options should be considered. We believe that proximal row carpectomy is a dependable, low-risk procedure for patients who wish to retain radiocarpal motion. On the basis of the clinical results in the laborers in this series, we agree with Crabbe’ that proximal row carpectomy is an acceptable alternative to arthrodesis even when the wrist is likely to be subjected to heavy use. The problems associated with prosthetic failure or loosening are obviated. Options are maintained in the event superior prostheses are developed in the future. To date, the literature does not reflect any long-term deterioration of results in proximal row carpectomy. Arthrodesis can still be done to treat an unfavorable outcome. REFERENCES 1. Brase DW, Millender LH. Failure of silicone rubber wrist arthroplasty in rheumatoid arthritis. J HAND SURG 1986;11:175-83. 2. Cooney WP, Beckenbaugh RD, Linshield RL. Total wrist
arthroplasty: problems with implant failures. Clin Orthop 1984;187:121-8. 3. Smith RJ, Atkinson RE, Jupiter JB. Silicone synovitis of the wrist. J HAND SURG 1985;1:47-60. 4. Watson HK, Goodman ML, Johnston TR. Limited wrist arthrodesis, II: intercarpal and radiocarpal combinations. J HAND SURG 1981;6:223-33. 5. Crabbe WA. Excision of the proximal row of the carpus. J Bone Joint Surg 1964;46B:708-11. 6. Jorgensen EC. Proximal row carpectomy: an end result of twenty-two cases. J Bone Joint Surg 1969;5 1A: 110411. 7. Inglis AE, Jones EC. Proximal row carpectomy for dis-
8. 9. 10.
11. 12.
13.
14.
eases of the proximal row. J Bone Joint Surg 1977; 59A:460-3. Neviaser RJ. On resection of the proximal row. Clin Orthop 1986;202:12-15. Green DP. Proximal row carpectomy. Hand Clinics 1987;3:163-8. White GM, Clark GL, Elias LS. Proximal row carpectomy for posttraumatic disorders of the wrist. J HAND SURG 1988;13A:310. Stamm TT. Excision of the proximal row of the carpus. Proc Royal Sot Med 1944;38:74-5. Hagberg WC, Imbriglia JE, McKeman DJ, Broudy AS, Mathews D. Biomechanical analysis of fit of the capitate in the lunate fossa after proximal row carpectomies. American Society for Surgery of the Hand, Baltimore, 1988. Sarjafian SK, Melamed JL, Goshgarian GM. Study of wrist motion in flexion and extension. Clin Orthop 1977;126:153-9. Youm Y, McMurty RY, Flatt AE, Gillespie TE. Kine-
matics of the wrist: an experimental study of radial-ulnar deviation and flexion-extension. J Bone Joint Surg 1978;60A:423-3 1. 15. Fatti JF, Palmer AK, Mosher JH. The long-term results of Swanson’s silicone rubber interpositional wrist arthroplasty. J HAND SURG 1986; 11: 166-75. 16. Swanson AB, Swanson GD, Maupin BK. Flexible implant arthroplasty of the radiocarpal joint: surgical technique and long-term study. Clin Orthop 1984;187:94106. 17. Volz RG. Total wrist arthroplasty: a clinical review. Clin Orthop 1984;187:112-20. 18. Watson HK, Bolles FL. Scapholunate advanced collapse pattern of degenerative arthritis. J HAND SURG 1984; 9A:358-65. 19. Czitrom AA, Lister GD. Measurement of grip strength in the diagnosis of wrist pain. J HAND SURG 1988; 13A:16-18. 20. Thongren KG, Werner CO. Normal grip strength. Acta Orthop Stand 1979;50:255-9.
