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Proximal Row Carpectomy Technique

By Ron Carneiro, MD

I would like to comment on a very useful technique that I have been utilizing for about 15 years in situations where patients need a proximal row carpectomy but have a bad articular surface of the Capitate or Radius. My co-authors and I embraced the interposition of an allograft matrix and published a paper about that in 2011 (1). At that point we had 1 to 5 years data on 14 wrists. Now have 3 to 12 years follow-up on 38 patients, with remarkable results. No re operations, fusions or revisions were performed.

Recently a paper was published at the AJHS (2) with a similar title, but we have significant differences regarding technique:

1–The exposure is better when utilizing a proximally based U -shaped capsular flap approach to the dorsal wrist rather than a longitudinal capsular incision.

2- Resection of Anterior and Posterior Interosseous nerves, which is utilized by some authors are unnecessary steps, in my view. it can potentially harm recovery by decreasing proprioception of the wrist (3).  This is at least controversial (4) and I have not utilized them in my cases.

3- I do not fold the allograft into 2 layers. Instead, I have been utilizing the 1.5 to 2 mm thick Allograft Matrix (Graft Jacket, Wright Medical). The allograft is kept in place by 4-0 nylon sutures catching the volar wrist ligaments and the matrix after trimming it to fit the articular surface of the capitate-radius interface. No pinning of the joint is necessary or advisable.

Since I have not re-operated any of my patients, there was curiosity as to what the joint surfaces would look like. Recently, one of my patients developed a painful intra articular calcified 5mm floating body, 12 years post -surgery. The reconstructed joint was re-explored to remove it. The surface of the Capitate covered with the allograft was still preserved showing a thin layer of glistening, smooth gliding tissue similar to cartilage (figure 1).

In summary: Covering the articular surface of the capitate with a single layer of a thick allograft matrix and treating the patients postoperatively with immobilization for 4 weeks followed by vigorous hand therapy is yielding the same results as a simple proximal row carpectomy in patients with the classic indications. These results are incomparably better than any sort of fusion for arthritic or post traumatic wrist conditions.

Naples, Florida

  • (1) Carneiro RS, Dias CE, Baptista CM. Proximal Row Carpectomy With Allograft Scaffold Interposition Arthroplasty. Tech Hand Surg. 2011;15:253-256.
  • (2) Rabinivich RV, Lee SJ. Proximal Row Carpectomy Using Decellularized Dermal Allograft. J Hand Surg Am. 2018:43(4):392-399.
  • (3) Hagert E, Persson JKE. Desensitizing the Posterior Interosseous Nerve Alters Wrist Propriocepitive Reflexes. J Hand Surg Am. 2010; 35A:1059-1066.
  • (4) Patterson RW, Van Niel M, Simko P, Pace C, Seitz WH. Proprioception of the Wrist Following Posterior Interosseous Sensory Neurectomy. J Hand Surg Am. 2010; 35A:52-56.

 

Figure 1:  Articular surface of Capitate (C) 12 years after Proximal Row Carpectomy with Allograft matrix interposition on a 78 year old female patient. Initial surgery was performed for traumatic arthropathy of the wrist in January 2006.

Comments (3)
peter Bentivegna MD
September 20, 2018 11:35 pm

Great operation for those who do not want a wrist fusion , or intercarpal fusion which will still leave them with radial carpal pain. I have done this operation for many years but now do a wrist denervation procedure for my older patients and those without the time to be out of work or desire for a big procedure, longterm immobilization, and therapy

sometimes less is better..
Best Peter B

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Alfredo Neira
September 21, 2018 1:21 pm

Thanks
Yesterday I saw a 24 years old lady in my office that has an indication for PRC bit precisely I was concerned about articular Surface of the radius

I was thinking in using fascia lata, do you think it’s better the allograft matrix since since she has no sources and at least in Mexico is expensive

Thanks in advance!

Reply

Ronaldo Carneiro
September 21, 2018 10:56 pm

Alfredo: I think that the fascia lata should work fine. But think about capsular interposition too. Prior to the advent of allograft matrix I did a bunch of PRC with interposition of the capsule utilizing the U capsular flap based proximally and reconstruction of the dorsal capsule with the extensor retinaculum. That works really well too. The only detail that I would call your attention to is that you have to resect the posterior interosseous nerve when doing a capsular flap interposition otherwise the capitate will press against the nerve and cause pain.
Good luck
Ron

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