Ovid: Chapman’s Orthopaedic Surgery

Editors: Chapman, Michael W.
Title: Chapman’s Orthopaedic Surgery, 3rd Edition
> Table of Contents > SECTION
III – THE HAND > Reconstructive Procedures > CHAPTER 72 –

Edward Akelman
Michael T. LeGeyt
Dina Hulsizer Galvin
E. Akelman, M. T. LeGeyt, and D. H. Galvin: Department of Orthopaedics, Brown University–Rhode Island Hospital, Providence, Rhode Island, 02905.
Pain-free use of the hand is critical to independent
functional and productive living. There are numerous medical conditions
that limit the use of the small joints of the hand because of pain,
deformity, dysfunction, and instability. Among these are trauma,
infection, connective tissue disease, arthritides, osteoarthrosis,
paralytic disorders, failed surgical procedures, and congenital
deformities. Many medical and surgical advances have been made to
improve the hand function of affected patients. One of the mainstays
has been to perform arthrodeses of selected joints of the hand and
wrist. Arthrodesis, or joint fusion, remains one of the most
time-tested, reliable, and useful hand surgery procedures (39,62). Reasons to perform small-joint arthrodesis are to correct deformity, to relieve


pain, to control instability, and to improve loss of function caused by neurovascular disease (9,48,55,74,89).
A properly performed small-joint arthrodesis can markedly improve hand
function and the overall quality of life for an afflicted patient.

Osteoarthritis commonly affects the distal
interphalangeal (DIP) joints of the fingers and, to a lesser extent,
the interphalangeal (IP) joint of the thumb. Other diseases that less
commonly affect the DIP joints are psoriatic arthritis, rheumatoid
arthritis, and infection. In all these diseases, hand function is
limited by painful motion of the joints. Arthrodesis of the DIP joint
is a successful way to eliminate the pain associated with these
The proximal interphalangeal (PIP) joints are more
commonly involved in rheumatoid arthritis as well as osteoarthritis.
Posttraumatic arthrosis of a single PIP joint is a common problem. The
disability for the rheumatoid patient is the associated swan-neck or
boutonnieére deformity, while for the posttraumatic arthritic patient
it is usually pain. Arthrodesis of the PIP joints is a reliable method
of returning function to these fingers, and it is especially
appropriate for the index and small fingers because of their unique
position as border digits.
Metacarpophalangeal (MCP) joints may be affected in
multiple fingers in rheumatoid arthritis, or singly in posttraumatic
arthritis. Arthroplasty is usually preferred for the MCP joints of the
fingers to preserve good motion and function. Arthrodesis is useful for
joints when arthroplasty is not indicated, or when a previous
arthroplasty has failed.
Carpometacarpal arthrodesis, although less commonly
performed, can also improve functional outcomes, particularly in the
fourth and fifth carpometacarpal joints, which may have osteoarthrosis
as a late sequela of fracture dislocations (15,17). Elimination of pain and increased stability improves hand function.
The thumb interphalangeal (IP) joint is not unlike the
IP joints of the digits. It is important for stable power pinch, which
may be compromised in osteoarthritis because of pain or connective
tissue disease caused by joint laxity.
The thumb MCP joint is different from the other MCP
joints in that significantly more stress is placed on the ligamentous
restraints than in the finger joints. This is because of the unique
position of the thumb and its role in pinch and grasp. Instability of
this joint is common because of chronic laxity after a missed acute
tear of the ulnar collateral ligament (gamekeeper’s thumb) and
rheumatoid arthritis (19,48).
While ligament reconstruction and soft-tissue procedures are usually
preferred, in the arthritic thumb MCP joint, arthrodesis (Fig. 72.1, Fig. 72.2) provides a more lasting option and is generally preferred to arthroplastic techniques for a number of different disorders (36).
Figure 72.1. Thumb metacarpophalangeal joint fusion, anteroposterior view.
Figure 72.2. Metacarpophalangeal joint fusion, lateral view.
In the thumb, the joint most commonly affected with osteoarthritis is the carpometacarpal (CMC) joint (6).
This is perhaps the most commonly involved joint in postmenopausal
women with early osteoarthritis. It has been postulated to be secondary
to laxity of the metacarpal volar beak ligament, allowing enough
subluxation and incongruity of the joint to become pathologic. A second
commonly affected group is young people with high demands on their
hands (e.g., manual laborers) who have posttraumatic arthritis after an
old intraarticular fracture of the base of the metacarpal (Bennett’s or
Rolando’s fracture). Eaton et al. (28a) have
classified this pattern of osteoarthrosis of the first CMC joint into
four stages. Stage I has normal intraarticular cartilage with
joint-space widening. In stage II, there is narrowing of the joint
space but the articular contours are normal. Stage III disease has


destruction of the thumb CMC joint, but the scaphotrapeziotrapezoidal
(STT) joint is normal. In stage IV disease, there is destruction of the
STT joint in addition to the first CMC joint. Arthrodesis of the thumb
CMC joint is indicated for stage III disease but is contraindicated in
the presence of any scaphotrapeziotrapezoidal disease (stage IV).

Patients who benefit most from an arthrodesis of the
thumb CMC joint are usually young, active people who require a strong,
stable, pain-free thumb to perform work activities (6,20). House et al. (43) found that arthrodesis of the first CMC improved hand function in patients with tetraplegia following spinal cord injury (see Chapter 68).
Arthrodesis is the best salvage procedure for failed arthroplasty or
previous infection of the first CMC joint. Older patients and patients
whose demands for strength of pinch and grip are not high are better
served with an arthroplasty (see Chapter 70). Moore et al. (72)
reported successful use of arthrodesis for a rare problem, laxity of
the thumb CMC joint in patients with Ehlers-Danlos syndrome. Thumb CMC
arthrodesis significantly limits thumb motion, although some
compensatory motion occurs at the STT and the MCP joints; therefore, in
patients who require motion of the thumb, arthrodesis is
Surgeons differ in the choice of skin incision; the
approach to the soft-tissue envelope about a joint; the manner in which
the joint surfaces are prepared; whether to use bone graft or bone
substitutes, or no graft; fixation methods; and postoperative
management, including rehabilitation (27). The
goals of arthrodesis in the small joints of the hands are uncomplicated
soft-tissue and skin healing, appropriate joint position, and bony
union in the shortest possible time (15). The
best techniques are simple, straightforward, and reliable, and they
allow early motion of the remainder of the hand. Successful fusion
requires a good soft-tissue envelope about the joint as well as
well-vascularized bone at the fusion site. Address any deficiencies
prior to undertaking a fusion.
  • Straight longitudinal incisions are the
    best incisions for fusions in the small joints of the hand. Use gentle
    curved incisions, and H, Y, V, and other types of incisions, only in
    good-quality, well-vascularized skin and soft tissue. Expose the thumb
    carpometacarpal joint through a Wagner type of anterior incision or
    through a dorsal incision directly over the joint (see Chapter 37).
  • Approach the DIP joints of the fingers
    and the IP joint of the thumb by transversely dividing the extensor
    mechanism and capsule. Debride the soft tissues as needed. We prefer
    excision of the radial and ulnar collateral ligament complexes prior to
  • Remove all marginal and dorsal osteophytes.
  • Approach the digital PIP joints by
    dividing the extensor tendon mechanism longitudinally. Careful
    dissection preserves the interval between the extensor mechanism and
    the dorsal joint capsule. Preserve the joint capsule if possible.
  • Approach the MCP joints of the fingers by
    dividing the ulnar sagittal fibers. Retract the entire extensor
    mechanism to one side and visualize the joint capsule. Then make a
    direct longitudinal approach through the capsule.
  • Approach the MCP joint of the thumb by
    dividing the radial sagittal fibers, detaching the extensor pollicis
    brevis insertion, and pulling the extensor pollicis longus (EPL)
    ulnarly. Incise the joint capsule longitudinally and debride as
  • For the carpometacarpal joint of the thumb, make a volar anterior approach.
  • Elevate the origin of the thenar musculature from the thumb metacarpal and trapezial area.
  • P.1972

  • You may partially detach the thenar
    muscle and bone insertions of the abductor pollicis longus if necessary
    for exposure of the carpometacarpal joint. Pay careful attention to
    preserving the joint capsule for closure.
A patient who has disease throughout the small joints of
the hand will generally be better served with an arthroplasty of the
finger MCP joints and arthrodeses of the PIP and DIP joints. The
position for arthrodesis in the fingers is critical to hand function.
In general, there should be a gentle cascade from radial to ulnar with
more flexion of the ulnar digits, as can be appreciated in the normal
hand at rest.
  • Fuse the MCP joint of the index finger in
    25° to 30° of flexion, adding another 5° of flexion at each joint,
    moving ulnarly, to end at 40° to 45° of flexion in the small-finger MCP
  • There should be no radial or ulnar
    deviation at the MCP joints. Ensure that there is no rotational
    deformity, although some have suggested that gentle supination may help
    with thumb-pad pinch. There should be more flexion at the PIP joints
    than at the MCP joints in each digit.
  • Fuse the index-finger PIP joint at 40° to
    45° of flexion, with an additional 5° of flexion added at each PIP
    joint to end at 55° to 60° of flexion at the small-finger PIP joint.
  • The DIP joints are very important to hand
    function. Fusion in too much flexion is disabling and cosmetically
    undesirable. Our experience is that too much extension of these joints
    is tolerated better than too much flexion. Fuse the DIP joint at 0° to
    15° of flexion.
  • The thumb position is most critical to
    hand function because of its unique role. Fuse the thumb MCP joint in
    approximately 10° flexion with no radial or ulnar deviation.
  • Fuse the thumb IP joint in a position of 0° to 15° of flexion.
  • Fuse the thumb carpometacarpal joint in 15° to 20° of extension, 45° of palmar abduction, and 5° to 10° of pronation.
  • Check the positioning of all joint
    arthrodeses intraoperatively by temporarily fixing the joints with
    Kirschner wires (K-wires) prior to permanent fixation.
Successful arthrodesis of a small joint in the hand requires careful preparation of the bone surfaces of the joint (15,48). Excellent cancellous-to-cancellous bone contact gives the best chance for fusion.
Convex–Concave Technique
The convex–concave surgical technique is generally accepted as the most straightforward method (15).
  • Remove the articular cartilage and subchondral bone using a small curet or rongeur and expose the subchondral cancellous bone.
This allows maintenance of the normal contour of the
joint; therefore, minimal shortening is required and positioning is
easy in flexion/extension, radial/ulnar deviation, and rotation.
Cup and Cone Preparation
The cup and cone technique can be used with all fixation
systems. It is considered advantageous because it presents large,
opposing cancellous surfaces for fusion (19,66),
but it does increase digital shortening. Recently, cup and cone reamers
have been made available commercially that provide matching surfaces in
the joint. This method is generally used more commonly at the MCP
joints. The CMC joint of the thumb can be fused using this method, with
the cone being made from the first metacarpal base and the cup being
fashioned in the trapezium. Carroll (16) has shown excellent results.
Transverse cuts preserve digital length and are commonly used (19).
Although precise transverse or straight cuts are difficult to achieve,
this is our preferred method, and it provides excellent arthrodesis
rates (9).
The chevron arthrodesis popularized by Omer is believed to be more forgiving than transverse cuts (102,103).
Cancellous bone area for fusion is improved, but the technique causes
some digital shortening and is technically demanding. Cuts may be made
with the apex of the chevron pointing either distally or proximally.
Many techniques to stabilize small-joint arthrodeses
have been used, and multiple studies have described consistent success
using different techniques (5,9,12,15,16,17,19,20,27,31,36,45,48,49 and 50,54,55,58,66,67,74,82,83,85,86,88,89,93,96,102,103,107).
They differ with regard to the degree of difficulty of using the
instrumentation, whether bone grafts are harvested from other surgical
sites, and technical difficulty.
In a biomechanical study, Kovach et al. (54)
compared crossed K-wires, tension band wiring, and an interosseous loop
supplemented by a K-wire in a PIP arthrodesis model. Tension band
wiring was found to be the strongest. In a


study of four methods of fixation for CMC arthrodesis using crossed
K-wires, cerclage wiring, and cup and cone with single K-wire and
tension band wiring, Stokel et al. (86) found that tension band wire and cerclage techniques provided the most stable construct. Bamberger et al. (6) have used the cup and cone method originally described by Carroll and Hill (19)
with staple or K-wire fixation. They found a 42% delayed union/nonunion
rate for the staple method compared to an 11% rate of delayed union for
the K-wire group.

Crossed K-Wires and Tension Band
The crossed K-wire (15,19) (Fig. 72.3, Fig. 72.4) and tension band techniques (45,50,85,93) are the most frequently used of all fixation techniques in small-joint fusions (9,48).
They provide stable fixation, are relatively uncomplicated technically,
and may be used in conjunction with cup and cone, miter, or straight
cut techniques. They allow easier adjustment of the arthrodesis site
than many other techniques. Both techniques are excellent for the
patient with rheumatoid arthritis, in whom inadequate bone stock may
not allow screw techniques.
Figure 72.3. Metacarpophalangeal joint fusion with Kirschner wire fixation, lateral view.
Figure 72.4. Metacarpophalangeal joint fusion with Kirschner wire fixation, AP view.
  • Prepare both bone ends at the joint for
    arthrodesis and ensure good bone-to-bone contact. Then stabilize the
    arthrodesis by driving two crossed K-wires from distal to proximal
    across the joint. Pins driven from proximal to distal may distract the
  • Drive one pin first, and then check the
    arthrodesis position by intraoperative radiographs or imaging on a
    fluoroscope. If the position is acceptable, drive the second pin and
    check the position once more. Position the pins to avoid prominence
    that might cause soft-tissue damage.
  • We do not leave K-wires exposed but cut
    them off below the level of the skin. Remove the pins when fusion is
    healed, which is usually in 4–6 weeks.
  • For the tension band technique, prepare the joint surfaces and position the joint.
  • Drill two K-wires parallel to each other,
    leaving a dorsal wire protruding from the proximal portion of the
    distal bone, 6 mm distal to the cut surface.
  • Drill a transverse hole through the
    proximal fragment and pass a malleable monofilament stainless steel
    wire of appropriate size through the hole.
  • Tightly coapt the fusion site and pass
    the monofilament wire in a figure-eight fashion dorsally. Pass it
    beneath and tighten it around the ends of the K-wires. The arthrodesis
    site will be compressed as the figure-eight wire is tightened.
  • Cut the pins as low as possible and contour them to fit closely to the bone dorsally. (See Chapter 11 for more details.)
When the fusion is healed, most pins and wires need to
be removed as they are superficial and tender. Do not use tension band
wire techniques at the DIP joint because of the possibility of injury
to the germinal matrix of the nail.
Internal Fixation—Screw Techniques
Screw methods for fixing an arthrodesis provide stable rigid fixation, which is best used in young, active patients


with high activity demands. Screw fixation usually permits early motion
of the hand with a reduced risk of loss of fixation when compared to
K-wire fixation. Many varieties of screws are currently available and
all of them can be used to provide compression across the arthrodesis.
Screw techniques require careful attention to technical detail.

Herbert Screw
The Herbert screw (Zimmer, Warsaw, IN) is a headless screw (see Chapter 11) originally used to fix fractures of the scaphoid (5,31,49,58).
  • To perform an arthrodesis on a PIP joint utilizing the Herbert screw, prepare the joint surfaces as previously described.
  • Drill a pilot hole with an 0.045 K-wire.
    Drill from the dorsal surface of the proximal phalanx into the
    medullary canal of the middle phalanx. We have found that starting the
    hole relatively proximal makes the dorsal cortical bridge larger,
    preventing fracture.
  • Use a small-diameter Herbert screw drill
    bit to enlarge the drill hole through its entire length, from proximal
    to distal. Avoid breaking the dorsal cortical bridge between the entry
    hole and the fusion site.
  • Enlarge the cortical opening with a small rongeur.
  • Using a large-diameter Herbert screw
    drill, overdrill the hole in the proximal phalanx. Then insert a
    Herbert screw tap through the arthrodesis site.
  • Use intraoperative radiography or
    fluoroscopy to help determine the size of the screw to be chosen. The
    screw should be at least 2 mm shorter than the measured length to allow
    the screw head to sink into the proximal phalanx and not cause
    soft-tissue irritation.
  • Place the Herbert screw of appropriate
    size. It is important to hold the arthrodesis site compressed in
    appropriate position as the screw is tightened.
Arthrodesis can also be performed on the DIP joint using Herbert screw fixation (Fig. 72.5, Fig. 72.6).
Figure 72.5. Intraoperative confirmation of distal interphalangeal joint arthrodesis with Herbert screw fixation.
Figure 72.6. Intraoperative confirmation of position, Herbert screw fixation, lateral view.
  • After preparing the joint surfaces, make
    a K-wire pilot hole drilling from proximal to distal through the center
    of the distal phalanx. The wire exits just under the hard nail, through
    the distal skin.
  • Make a transverse skin incision at this
    level and enlarge the pilot hole, using the small-diameter drill bit,
    from distal to proximal.
  • Position the arthrodesis site, and pass the small-diameter drill across the joint from distal to proximal.
  • Tap the drill hole from distal to proximal with the Herbert screw tap.
  • Use intraoperative fluoroscopic imaging to determine the length of the screw.
  • Place an appropriate-length Herbert screw
    from distal to proximal, countersinking the proximal threads of the
    Herbert screw deep enough to keep it from irritating the tip of the
    finger (84). Take care, as germinal matrix
    injuries can occur. Note that this technique at the DIP joint requires
    more extension than other techniques (Fig. 72.7, Fig. 72.8).
    Figure 72.7. Distal interphalangeal joint arthrodesis with Herbert screw fixation, AP view.
    Figure 72.8. Distal interphalangeal joint arthrodesis with Herbert screw fixation, lateral view.
Acutrak Screw
The Acutrak variable pitch conical screw (Acutrak, Acumed, Beaverton, OR) has been designed specifically


for small-joint fusions. Techniques are as previously described for the Herbert screw.

AO Screw Fixation
Joint arthrodesis using the AO screw technique generally
proceeds as described for the Herbert screw, with the following
differences (88). The AO 2.7 mm screw is a
standard screw with threads on one end and a head on the other;
therefore, compression requires lag technique. Overdrill the proximal
phalanx with a 2.7 mm drill bit to gain compression. Countersink the
drill hole before you place the screw, which allows the screw to sit
flush with the bone.
This screw can be inserted in a retrograde fashion for
fusion of the DIP joint. In our experience, the AO screw head is too
prominent, causing too much pain in the fingertip; therefore, we
currently do not use it for DIP joint fusion.
Internal Fixation—Plate Fixation
Plate-and-screw fixation is the most stable construct
available for performing an arthrodesis in the hand. Plating is an
excellent technique when bone grafting is required. It requires
significant soft-tissue stripping and is more complex, so it is used
less commonly for a simple primary arthrodesis. Plate fixation is used
more commonly for salvage of failed previous procedures.
  • After the joint ends have been exposed
    and prepared for arthrodesis, expose the dorsal aspects of the proximal
    and distal bone surfaces as necessary for plate application.
  • Once the bone ends are prepared and any
    bone graft has been selected, tailored, and placed, select a
    mini-semitubular plate that allows for at least two screws in the
    middle phalangeal shaft and two screws in the proximal phalangeal
    shaft. Generally, a four-hole plate will not bridge a significant
    defect, so a five- or six-hole plate may be required.
  • Contour the plate to fit over any bone graft dorsally.
  • Fix the plate with screws to the dorsal
    aspect of the distal bone first. Check the screw lengths using
    intraoperative fluoroscopy or radiographs.
  • Use the dynamic compression principle (Chapter 11) to apply compression between the bone ends and across any graft that is needed.
Because of the extensive surgery as well as the
prominence of the plate and screws, removal and/or extensor tenolysis
may be required as a second-stage procedure.
External Fixation
Compression arthrodesis is possible with mini-external fixators (12,83).
Fusion rates are excellent but we feel that most external fixation
devices are too bulky and limit the motion of other digits. The
transverse wires and compression devices may cause scarring of the
extensor mechanism. External fixators are most appropriate for fusions
after severe articular surface bone and soft-tissue injuries
complicated by joint infection and osteomyelitis (102). We do not recommend external fixation for uncomplicated phalangeal and MCP joint arthrodeses.
  • We prefer absorbable sutures for closure
    of the joint capsule and extensor tendon mechanism because the lack of
    joint motion after fusion takes tension off the tendon repair.
    Nonabsorbable sutures may cause patient discomfort after surgery by
    irritating the skin edges.
  • After closure of the deep soft tissues, injection of 0.5% bupivacaine may diminish postoperative discomfort.
  • Close the skin with interrupted nonabsorbable sutures.
  • Apply a well-padded bulky dressing, and
    splint the fused joints for comfort and to protect the arthrodesis. At
    10–14 days, change the dressings and encourage motion at joints other
    than the fusion. Fashion an orthoplast splint to the fused joint and
    keep it in place until the fusion is radiographically solid. Protect
    thumb MCP and carpometacarpal fusions in thumb spica casts for 4–6
Alt hough uncommon, complications in fusions of the small joints of the hand can be minimized by meticulous surgical technique (55,84,93).
Management of complications begins with understanding the potential for
them prior to surgery, and making the patient aware of them. Detect
vascular compromise by carefully observing capillary refill in the
operated digit after tourniquet deflation. Any impairment requires
immediate intervention to prevent loss of the digit. Pin track
infection can be minimized by keeping pins under the patient’s skin.
Diminish wound


by using straight longitudinal dorsal incisions, especially in patients
with immunocompromised status, such as those with diabetes mellitus or
connective tissue diseases. Prevent nonunion by establishing broad bone
contact at the arthrodesis site and stable fixation.

Progression of arthritis in adjacent joints is a concern
in any arthrodesis because stress is added across these joints. Carroll
(16) found no evidence of STT arthritis after
CMC joint fusion in patients less than 50 years old who were followed
for 3–25 years. More recently, Bamberger et al. (6)
had radiographs of their series of patients reviewed independently for
progression of STT arthrosis after CMC arthrodesis. They found
progression of STT arthritis in 2 of 12 patients but attributed this to
error in technique. Guiral et al. (38) reported
a rare complication of arteriovenous fistula with venous aneurysm after
thumb carpometacarpal joint arthrodesis. This was treated by ligation
and resection of the aneurysm. A painful scar from injury to the
branches of the radial sensory nerve is avoided by careful technique.
Problems with painful implants can be resolved by removal.
Limited wrist arthrodesis and intercarpal arthrodesis are useful for treating degenerative arthritis, carpal instability (57), fracture nonunion, ligament tears, Kienböck’s disease (60,70), osteonecrosis of the carpus, and congenital synchondrosis or partial fusion of various carpal intercarpal joints (4,7,13,24,34,37,51,53,75,91,95,97,98,99,100 and 101,106). A less desirable alternative in some cases is proximal row carpetomy (8,25,46,52).
Successful treatment using these surgical procedures is
based on the biomechanical principle of load transfer from one side of
the carpus to another. The intercarpal mobility that is preserved
compensates for the motion lost to arthrodesis.
Currently, the most commonly performed limited wrist
fusion procedures include STT fusion; scaphocapitate (SC) fusion;
lunotriquetral (LT) fusion; and fusion of the capitate, hamate, lunate,
and triquetrum, which is known as a four-bone fusion.
Recent studies have evaluated the range of motion needed for normal activities of daily living (ADL). Palmer et al. (73)
showed that the range of motion of the wrist required for ADL is 5° of
flexion, 30° of extension, 10° of radial deviation, and 15° of ulnar
deviation. Brumfield and Champoux (14) showed that 10° of flexion and 35° of extension are required. Ryu et al. (80) showed that 40° of extension, 40° of flexion, and 40° of combined radial and ulnar deviation are needed to perform ADL.
The scaphoid is unique in that it spans both the
proximal and the distal carpal rows. Because of its unusual anatomy,
deformity of the wrist follows well-delineated patterns when the
scaphoid or its ligamentous restraints are injured (see Chapter 41 and Chapter 42).
One of these patterns, the scapholunate advanced collapse (SLAC)
pattern of wrist arthritis, accounted for 57% of degenerative wrist
arthritis when Watson and Ballet (98) reviewed
4,000 radiographs. These authors also reported primary triscaphe joint
arthritis in 27% of these patients and a combination of both in 15% of
patients. The primary disorder in the SLAC wrist is that of
scapholunate dissociation secondary to scapholunate interosseous
ligament rupture (3). This allows for unopposed volar flexion of the scaphoid and the dorsal intercalated segmental instability (DISI) pattern (26).
Lateral radiographs may show the scapholunate angle to be increased
beyond 60°, which is felt to be the upper limit of normal. On an
anteroposterior (AP) radiograph, the scaphoid appears foreshortened,
has a “cortical ring” sign and there is a scapholunate gap of greater
than 3 mm.
The SLAC pattern of arthritis begins in its earliest
stage, stage 1 arthritis, with destruction of the distal aspect of the
radioscaphoid joint (2). This is caused by the
incongruity between the scaphoid and the scaphoid facet of the radius
when the scaphoid is extremely volar flexed. In stage 2, the entire
radioscaphoid joint is arthritic. Stage 3 is characterized by further
separation between the scaphoid and the lunate, allowing the capitate
to migrate proximally. When this occurs, the SC and capitolunate joints
become arthritic. Stage 4, in which the radiolunate joint becomes
arthritic, is rarely seen because the spherical shape of the proximal
lunate and the lunate fossa of the radius make incongruity unlikely
except in the most severe cases.
A nonunion of a fracture of the scaphoid also leads to a
predictable pattern of wrist arthritis when not treated. Because of its
similarity to the SLAC pattern in both progression and treatment, it
has been called the scaphoid nonunion advanced collapse (SNAC) pattern.
In it, volar flexion of the distal pole of the scaphoid leads to
radioscaphoid arthritis (101). The proximal
pole, restrained by the scapholunate interosseous ligament, remains in
normal alignment with the lunate. Given the dissociation between the
proximal and distal rows as a result of the nonunion, a DISI pattern of
deformity results. If left untreated, the


wrist will undergo the same degenerative pattern seen in a SLAC wrist.

Treatment of these two similar disorders has been mainly proximal row carpectomy (46) or scaphoid excision (52) and lunate-capitate-hamate-triquetral (four-corner) arthrodesis (Fig. 72.9 and Fig. 72.10). Although it is not yet clear whether proximal row carpectomy or four-corner fusion provides better results (106)
for stage 2 or 3 SLAC/SNAC disease, it is clear is that scaphoid
excision and four-corner fusion are preferred to proximal row
carpectomy when the capitate head is arthritic.
Figure 72.9. Capitohamate triquetrolunate intracarpal arthrodesis with spider plate fixation.
Figure 72.10. Capitohamate triquetrolunate intracarpal arthrodesis with spider plate fixation, lateral view.
With this procedure, pain relief and resolution of
symptoms are predictable. In patients with stage 2 or 3 SLAC/SNAC
disease, when strength is important and the patient’s activities do not
require a full range of wrist motion, we perform scaphoid excision and
four-corner fusion, as described later.
Another common problem in the wrist is isolated STT
arthritis. The pain associated with this disorder can be surprisingly
debilitating. The disability associated with STT arthritis can be best
appreciated in activities that axially load the thumb (e.g., strong
pinch, key turning). Watson et al. (99)
attributed rotatory subluxation of the scaphoid as a possible cause of
isolated STT arthritis. They noted early degenerative changes in these
joints when performing rotary subluxation of the scaphoid (RSS
surgery). For isolated STT arthritis, STT arthrodesis has been found to
give good function and excellent pain relief and is preferred by other
authors (53,97).
A less common but equally disabling degenerative pattern
of arthritis in the wrist occurs between the lunate and the triquetrum (24,42,51).
This pattern of arthritis is most probably a result of a chronic
lunotriquetal ligament tear that has not healed. Patients typically
have the radiographic findings associated with volar intercalated
segmental instability (VISI). The scapholunate angle on a lateral
radiograph is less than 30°, the lower limit of normal. This indicates
that the ligamentous complex between the lunate and the triquetrum is
disrupted, allowing the lunate to volar-flex and align with the
scaphoid. Another cause of isolated LT arthritis is incomplete carpal
coalition of the lunate and triquetrum (1).
Degenerative wrist disease evolves when scaphoid
nonunion is left untreated, and in the SLAC wrist deformity. Watson and
Weinzweig (101) described the use of STT
arthrodeses to manage scaphoid nonunion for three specific indications:
scaphoid fractures with a very small proximal fragment, a distal
scaphoid nonunion causing malalignment of the triscaphe joint, and
scaphoid fracture in association with scapholunate dissociation. With
small scaphoid proximal fragments, Watson prefers a dorsal approach
with bone grafting of the nonunion, with a simultaneous triscaphe
arthrodesis. STT arthrodesis is used in distal scaphoid nonunions to
improve alignment in the STT joint. Scapholunate dissociation may be
treated by intercarpal arthrodesis when it is associated with scaphoid
A detailed description of carpal instability can be found in Chapter 41. Instabilities result from a wide range of injuries that are either static or dynamic (24,65).
Static instabilities have malalignments seen on standard radiographs.
Dynamic instabilities may appear normally aligned on standard
radiographs but are often exhibited on stress views or other special
projections. Acute injuries (up to 1 week old) have the maximum
potential to go on to primary healing of the ligaments. Subacute
injuries (1–6 weeks old) still can heal and do not display fixed
deformity or arthrosis. Chronic injuries older than 6 weeks have the
least potential for healing, may have fixed deformities or


and often require surgical repair and reconstruction. It is apparent
that early detection is most important. The position of the lunate as
seen on lateral radiographs is one of the key elements used to
determine loss of normal carpal alignment. The terms dorsal intercalated segmental instability and volar intercalated segmental instability describe the malaligned dorsal or volar tilted lunate of unstable wrists (61).
Although many instability classifications have been proposed, none have
gained universal acceptance, which underscores the complexities of
these injuries and the lack of our present comprehension of this

The effects of intercarpal arthrodesis on wrist
kinematics is not well understood. When choosing the surgical
procedure, consider the amount of wrist motion that will remain and to
what extent compensatory increases in wrist motion will occur over
time. Although the proximal and distal rows function separately, an
intercarpal arthrodesis that links these rows will have long-term
effects on wrist motion and on radiocarpal and ulnocarpal loading that
could lead to degenerative arthritis in the long term. Gellman et al. (35)
showed that fusion within a carpal row has minimal effect on wrist
motion in all planes. Their study demonstrated that two thirds of
flexion occurs at the radiocarpal joint and one third occurs at the
mid-carpal joint. It also showed that capitolunate fusion caused the
greatest loss of motion in a flexion/extension arc, with STT fusion
causing the greatest loss of motion in the radioulnar plane.
Garcia-Elias et al. (34) studied
the effects of intercarpal arthrodeses on wrist range of motion. They
showed that STT fusions had a greater loss of flexion than SC fusion,
which resulted in a greater loss of extension and radial deviation.
Shear stress was noted to be increased at the radiolunate joint. Viegas
et al. (95) reported that STT and SC fusions
decrease axial load through the radioscaphoid fossa, while
scapholunocapitate and capitolunate fusions distribute load through
both the radioscaphoid and radiolunate fossae.
Watson and Weinzweig (101) have outlined three major principles that apply to limited wrist arthrodesis:
  • Unaffected joints must be left unfused.
  • Normal external dimensions of carpal bones included in the arthrodesis must be preserved.
  • Bone fixation must include only those bones that are involved in the arthrodesis.
Adherence to these principles is important. STT
(triscaphe) fusion results in a single bony unit that preserves the
external dimensions of these three carpal bones. Current indications
for STT fusion are STT arthrosis, Kienböck’s disease, and carpal
instability, including static or dynamic rotary subluxation of the
  • Make a dorsal transverse incision on the wrist just distal to the radial styloid (10).
  • Expose the radial styloid through an incision in the capsule overlying the radial styloid and scaphoid junction.
  • Remove the distal 5 mm of the styloid with a rongeur, sloping in a palmar direction from distal to proximal.
  • Make a transverse dorsal capsular incision and evaluate the radioscaphoid interval.
  • Watson and Ashmead (97)
    recommend performing a SLAC wrist reconstruction rather than a
    triscaphe arthrodesis if there is any articular cartilage damage. It is
    critical in an STT fusion to have normal articular cartilage between
    the distal radius and the proximal scaphoid.
  • Remove the articular surfaces between the
    scaphoid, trapezium, and trapezoid with a small rongeur, taking only
    the proximal half of the trapezium and trapezoid articulations. Remove
    the hard subchondral bone down to softer cancellous surfaces.
  • Remove the dorsal cortex of the trapezium and trapezoid to provide a broader surface area for bone graft.
  • Use the distal radius as a source of cancellous bone for grafting (71).
    To harvest the graft, make a second, transverse incision 3 cm proximal
    to the radial styloid, extending from Lister’s tubercle to just palmar
    to the first dorsal compartment. A flat surface on the radius can
    always be identified between the first and second extensor
    compartments, and a constant periosteal artery is seen in this area.
  • Incise the periosteum and make a cortical
    window. Remove cancellous bone from the distal radius and replace the
    cortical window after harvesting the graft.
  • The most important part of this procedure is the reduction of the scaphoid. Watson and Ashmead (97)
    do this by placing a 5 mm spacer, which is usually the handle of a
    small bone hook, into the scaphotrapezoid space to maintain the
    original external dimensions of the triscaphe joint and manipulate the
    scaphoid into proper position. Then drive one or two K-wires from the
    trapezium and trapezoid into the scaphoid, avoiding impingement of the
    radioscaphoid joint.
  • Remove the spacer and pass a second K-wire on the ulnar side of fusion construct (Fig. 72.11).
    Figure 72.11. Capitohamate triquetrolunate arthrodesis with Kirschner wire fixation, AP view.
  • Pin the scaphoid to lie at approximately
    55° of palmar flexion relative to the long axis of the radius when seen
    on a lateral radiograph. When the wrist is placed in full


    radial deviation and 45° of dorsiflexion, the scaphoid tuberosity should be reduced.

  • Densely pack cancellous bone into the spaces between the trapezium, the trapezoid, and the scaphoid.
  • Cut the K-wires short and leave them under the skin.
  • Close only the skin and subcutaneous tissues.
Postoperative Care
Apply a bulky noncompressive dressing, incorporating a
long-arm plaster splint to place the hand in a functional position,
with the wrist in slight extension and radial deviation, the forearm in
neutral position, and the elbow at 90° of flexion. Three to 5 days
later, change this and apply a long-arm thumb spica cast. At 4 weeks,
exchange the cast for a short-arm thumb spica cast. At 6 weeks after
surgery, if there is radiographic evidence of healing, remove the
K-wires. Begin range-of-motion exercises once fusion is ensured.
Indications for scaphocapitate (SC) fusion include
rotary subluxation of the scaphoid and scaphoid instability, resistant
scaphoid nonunion, and Kienböck’s disease.
  • Make a longitudinal skin incision of sufficient length over the third dorsal compartment, and open the retinaculum.
  • Free the EPL tendon proximally and
    distally, and transpose it radially. This allows retraction of the
    radial wrist extensors, the EPL, and the digital extensors.
  • Make a longitudinal incision in the capsule and develop radial and ulnar flaps.
  • Inspect the proximal scaphoid and distal
    radial articular cartilage as for the STT arthrodesis. If there is any
    indication of degenerative arthritis in the radiocarpal joint, do a
    SLAC wrist reconstruction instead.
  • Remove the articular surface between the scaphoid and the capitate, using rongeurs and curets.
  • Harvest a bone graft from the radius, as described previously for the STT fusion.
  • After aligning the scaphoid, drive two 0.045 K-wires from the scaphoid into the capitate.
  • Pack bone graft into the
    scaphoid–capitate gap. Cut off the K-wires under the skin, and close
    the capsule with absorbable suture. Close the third dorsal compartment
    with absorbable suture.
  • Close the skin and subcutaneous fat with nonabsorbable suture and inject 0.5% bupivacaine for postoperative pain control.
  • Postoperative immobilization is identical to that of the STT fusion, as is the postoperative management.
A SLAC wrist reconstruction along with excision of the
scaphoid is an excellent method to treat radioscaphoid degenerative
arthritis and chronic nonunion of the scaphoid, as well as advanced
destruction from scapholunate dissociation or idiopathic avascular
necrosis of the scaphoid.
  • Make a longitudinal incision dorsally, over the third and fourth dorsal compartments.
  • Open the third dorsal compartment, and
    transpose the EPL tendon radially. Then retract the radial wrist
    extensors radially and the digital extensors ulnarly.
  • Then open the capsule with a longitudinal incision and elevate the capsule to create radial and ulnar flaps.
  • Excise the scaphoid.
  • Prepare the articular surfaces between
    the capitate, lunate, triquetrum, and hamate by removing the articular
    cartilage and subchondral bone between them.
  • Harvest cancellous bone proximally from the distal radius, as previously described.
  • Anatomic alignment of the four carpal
    bones is important to provide an excellent outcome. The position of the
    lunate is critical.
  • Flex the lunate from its extended
    position into a neutral position, generally by using a “joystick,” such
    as a 0.045 K-wire inserted into the lunate.
  • Fix the remaining four carpal bones. Confirm proper position with a radiograph. K-wires (Fig. 72.11),
    Herbert and other types of screws, and, recently, new plate–screw
    systems have been used to provide fixation and allow early mobilization
    (Fig. 72.9, Fig. 72.10). After


    fixation, pack the intercarpal spaces with cancellous bone.

  • Cut off any K-wires beneath the patient’s
    skin and close the capsule with absorbable suture. Close the skin with
    nonabsorbable suture, and inject the operative site with 0.5%
Postoperative Care
Apply a short-arm thumb spica splint, and exchange it
5–7 days later for a short-arm thumb spica cast. Generally, leave wires
in for 6 weeks. At that time, remove the K-wires if early union is seen.
Lunotriquetral (LT) arthrodesis is indicated in patients with LT instability, LT arthrosis, or LT ligament disruption.
  • Make a longitudinal incision between the fifth and sixth dorsal compartments.
  • Protect the dorsal sensory branch of the ulnar nerve throughout the procedure.
  • Open the joint capsule between the lunate and the triquetrum.
  • Remove the articular cartilage between these two bones down to subchondral bone.
  • Place three 0.045 K-wires or compression screws across this joint.
  • Pack the gap between the two bones with bone graft harvested from the radius as described previously.
  • Close the capsule with absorbable sutures and the skin with nonabsorbable sutures.
Postoperative Care
Apply a padded long-arm splint and keep it in place for
5–7 days, then exchange it for a long-arm cast. Keep this in place for
6 weeks to allow for adequate healing, as evidenced clinically and
radiographically. Then remove pins and use a short-arm splint for 4–6
Complications of limited wrist arthrodeses may be split
into two categories: intraoperative complications and problems with
long-term outcomes (13,53,106).
Major complications from STT arthrodesis include radiocarpal arthrosis,
trapeziometacarpal arthrosis, nonunion, osteomyelitis, and radial
styloid scaphoid impingement (79). This last
complication has been diminished by radial styloidectomy at the time of
surgery. Inadequate reduction of the scaphoid in this procedure leads
to a predictable progression of radiocarpal arthritis. The proximal
pole of the scaphoid must be reduced anatomically into the scaphoid
fossa of the radius, and the radioscaphoid angle must be approximately
45° to 55°.
Similar complications have been reported for SC
arthrodesis. Long-term follow-up has shown a greater loss of wrist
flexion with the latter procedure. Relatively few complications have
been reported with the SLAC wrist reconstruction or four-bone
arthrodesis. Nonunion has been rare, and the development of radiolunate
arthritis and impingement between the fusion mass and the distal radius
have been reported. The most common complication of LT joint
arthrodesis is nonunion, with a reported incidence of 10% to 50% (13,52,53,91,100,106).
Radiocarpal or wrist arthrodesis involves fusion of the
radiocarpal and mid-carpal joints, including the radiolunate,
radioscaphoid, and radiocapitate joints. It is one of the oldest, most
common, longest-used, and most successful reconstruction procedures for
the wrist (39,40 and 41,44,59). It predictably relieves pain, but it does eliminate all radiocarpal motion.
Currently, the most common indication for total wrist
arthrodesis is posttraumatic degenerative arthritis of the radiocarpal
and midcarpal joints (41). This includes
chronic carpal dissociations as well as complex intracarpal and distal
radius intraarticular fractures. Other indications for arthrodesis
include the following:
  • Chronic infection unresponsive to limited surgical debridement (29,30)
  • Paralysis about the wrist and hand
    (arthrodesis provides the stability required for tendon transfers about
    the thumb and digits) (87)
  • Rheumatoid arthritis and other inflammatory disorders involving the radiocarpal joint (18,28,63,64)
  • Limited arthrodeses that have not provided stability or pain relief
  • Loss of soft tissue and bone as a result of severe trauma or tumor resection
Spastic paralysis of the wrist from cerebral palsy, strokes, or polio can lead to severe disfigurement of the


extremity and loss of hand function. Stabilization of the wrist makes
the flexor and extensors of the wrist available as transfers to restore
power and function to the fingers. Pomerance and Keenan (76)
demonstrated that by performing total wrist fusion, tendon transfers,
and muscle releases in a single staged procedure, they were able to
correct the severe contractures of the hand and wrist with resolution
of the preoperative hygiene problems. (See Chapter 66, Chapter 67 and Chapter 68 for more details.)

Most patients who are considered for arthrodesis have
undergone failed attempts at both conservative and surgical treatments.
Hastings et al. (41) reported that 71% of the
112 wrists that underwent arthrodeses for posttraumatic arthritis had
undergone 137 prior surgical procedures, for an average of 2.3
procedures each. Field et al. (32) found a mean
of three operations (mostly limited carpal fusions) performed on the
wrist in their 20 patients undergoing arthrodesis for posttraumatic
conditions. By the time many of these patients present for arthrodesis,
they have so much pain in the wrist that they have little or no motion
remaining. For these patients, a total wrist fusion improves stability
and function, decreases deformity, and relieves pain.
The usual recommendation is to fuse the wrist in dorsiflexion from 0° to 30° to preserve grip and pinch strength. Colonna (23) described power grip as maximal with the wrist in slight extension and slight ulnar deviation. Kraft and Detels (56)
simulated wrist arthrodesis in varying degrees of flexion and extension
in 20 normal volunteers by immobilizing them in leather gauntlets. This
study showed that from 15° of flexion to 30° of extension, the grip
strength was equal in all positions except for 15° flexion, where it
was decreased. Their overall recommendation was to avoid fusing the
wrist in flexion. They recommended placement of the wrist in palmar
flexion only when there is bilateral involvement and one wrist is
placed in extension, the other in flexion to improve independent
feeding and perineal care.
Hastings et al. (41) found that function after radiocarpal fusion was comparable to that for limited wrist fusion. Whereas Jebsen et al. (47) and Purdue (90) found hand function to be poor based on testing, Field et al. (32) found that all patients were satisfied and would have had the procedure sooner. Weiss et al. (105)
found that most patients functioned well after wrist arthrodesis for
posttraumatic conditions and that the most difficult tasks were
perineal care and manipulating the hand in tight spaces. Rayan et al. (78)
reviewed the function of nine rheumatoid arthritis patients and found
that even among those who underwent bilateral radiocarpal arthrodesis,
seven of nine had improvement of subjective function, two of nine
remained the same, and no patient was made worse.
Vicar and Burton (94) compared
the results of arthroplasty versus radiocarpal arthrodesis in
rheumatoid arthritis patients. They found that the arthrodesis group
had overall 97% good results compared to 75% good results in the
arthroplasty group. The arthrodesis group had an 18% complication rate,
while the arthroplasty group had a 25% complication rate, 4 of 37
requiring revision, at an average follow-up of 51 months.
Radiocarpal arthrodesis seems to be the treatment of
choice for the most severe wrist deformities, but efforts to perfect
wrist arthroplasty and motion-preserving operations continue. While it
is likely true that most patients would prefer a motion-sparing
procedure to radiocarpal arthrodesis, function after complete wrist
fusion is surprisingly good and therefore this remains the gold
standard to which all other procedures should be compared. With the
right indications, radiocarpal arthrodesis can salvage function for an
otherwise debilitated patient.
Position for radiocarpal arthrodesis is directly related
to the final function desired, and although a wrist fused in a poor
position may be pain free, function suffers. The ideal position for
radiocarpal arthrodesis is controversial. Several studies recommended
fusion in 20° to 30° of extension (11,18,21,22,32,41,44,59,62,64,68,70,81,104) and Clayton and Ferlic (21)
recommended neutral position. Although the ideal position for
radiocarpal fusion likely will continue to be debated, functional
outcome studies show that a position in 0° to 10° of extension and 0°
to 10° of ulnar deviation seems to give the best results.
The methods advocated for radiocarpal arthrodesis are quite numerous. Techniques utilizing a distal radius sliding graft (22), an AO plate (101), and intramedullary pins or rods (64,68) have been described.
Evaluate patients medically and understand the medical
diagnosis underlying the wrist deformity in patients with systemic
disease before performing surgery. This is most important in evaluating
patients with rheumatoid arthritis.
Rheumatoid arthritis is a systemic disease affecting many joints in the body. These patients often have a “Z-collapsed” deformity, where deformity in a proximal joint provokes a reciprocal deformity at a distal joint (70).
Surgical procedures performed on any of these joints affect the more
distal or proximal joints. In patients with rheumatoid arthritis, keep
procedures minimal and simple. Wrist fusion using a Steinmann pin for
intramedullary fixation is better than using a dorsal plate, as it is
less likely to cause problems with the skin and extensor tendons.
Stability is adequate, immobilization is shortened, an iliac


crest graft is usually not required, and splinting and partial weight bearing early is possible. Millender and Nalebuff (68)
reported that patients were able to walk with platform crutches 1 week
after surgery using this technique. Another advantage of this procedure
is that it can be performed rapidly enough to allow other surgical
procedures to be performed concomitantly, as is necessary in many
patients with severe rheumatoid arthritis (69). (See Chapter 70 for more details on treatment of the rheumatoid hand.)

Patients with posttraumatic arthritis place heavier
loads and higher demands on their hands and wrists than do patients
with rheumatoid arthritis. Rigid internal fixation is crucial. Recent
studies have shown that plate fixation with the application of local
bone graft provides reliable fusion and early rehabilitation (11,104).
Perform surgery with preoperative intravenous
antibiotics and axillary block or general anesthesia. All patients with
connective tissue diseases or in whom there is concern of cervical
spine instability are prescreened with cervical spine radiographs.
Perform all surgery under tourniquet control, through a dorsal
longitudinal skin approach to the extensor retinaculum.
We prefer a modification of techniques originally proposed by Clayton and Ferlic (21), Mannerfelt and Malmsten (64), and Millender and Nalebuff (68), as follows.
  • Use a longitudinal skin incision just ulnar to Lister’s tubercle.
  • Make a longitudinal incision through the fascia of the third dorsal compartment, and transpose the EPL tendon.
  • Incise the floor of the third compartment
    and extend it distally to the base of the third metacarpal, staying
    ulnar to the extensor carpi radialis brevis (ECRB) tendons.
  • Using subperiosteal dissection, raise medial and lateral flaps to expose the entire distal radius, ulna, and carpus.
  • We resect the posterior interosseous
    nerve in the floor of the fourth compartment to provide lasting pain
    relief. Because of the commonly associated disease of the distal
    radioulnar joint (DRUJ) in patients with rheumatoid arthritis, we
    prefer to perform a Darrach resection of the distal ulna by transecting
    the distal ulnar shaft just proximal to the ulnar head, using an
    oscillating saw (see Chapter 43).
  • Use a subperiosteal approach to excise the entire distal ulna. Preserve the ulnar head for use as autogenous bone graft.
  • Using a small rongeur, resect the
    remaining radiocarpal and intercarpal articular surfaces, including the
    third CMC and intercarpal joints, until you expose cancellous bone. Use
    the harvested distal ulna to fill the defects between the intercarpal
    joints. If more bone graft is needed, use a curet to harvest any needed
    bone from the distal radius through the base of Lister’s tubercle.
  • Insert a 3.2 or 3.6 mm Steinmann pin
    either down the medullary canal of the third metacarpal shaft or
    between the second and third metacarpal bases for more ulnar deviation,
    and bring it out distally through the skin.
  • Reduce the wrist into final position, and
    slip a drill guide over the distal end of the pin. Slide a similar-size
    pin into the guide and tap the pin across the wrist into the radius in
    a retrograde fashion. Bury the pin distally under the skin.
  • Confirm adequate pin position with intraoperative radiographs or insert the pin under fluoroscopic control.
  • Transpose approximately one third to one
    half of the extensor retinaculum palmar to the extensor tendons, and
    suture it into place with absorbable sutures. Place a suction drain
    deep into the wound and bring it out distally for ease of removal the
    following day. Place subcutaneous sutures and then close the skin with
    nonabsorbable sutures in an interrupted fashion.
Postoperative Care
Apply a palmar plaster splint and dressing to control
rotation. Remove the drain in 24 hours. After 1 week, remove the
dressing and inspect the wound. Generally leave sutures in for 2 weeks
and keep the patient in a splint or cast until their removal. At 2
weeks postoperatively, remove the sutures and place the patient into a
short-arm cast for an additional 2–4 weeks, or until clinical and
radiographic union is achieved. Encourage the patient to mobilize his
or her fingers as much as possible until the cast is removed. At that
time, evaluate the patient and treat any remaining stiffness with
aggressive hand therapy.
When performing radiocarpal arthrodesis for indications
other than rheumatoid arthritis, we prefer to use the AO method of
plate fixation popularized by Hastings (39) and others (81) (Fig. 72.12 and Fig. 72.13).
Most commonly, the indication for this type of arthrodesis is
posttraumatic arthritis of the wrist or failed wrist arthroplasty.
Figure 72.12. Radiocarpal arthrodesis using wrist fusion plate, AP view.
Figure 72.13. Radiocarpal arthrodesis using wrist fusion plate, lateral view.
  • Make a midline dorsal longitudinal skin incision.
  • Open the third dorsal compartment and
    transpose the EPL tendon. Expose the entire carpus and distal radius,
    as well as the base of the third metacarpal subperiosteally. Do not
    enter the DRUJ unless there is concomitant disease that is being
    treated surgically. The best


    to avoid the problem of DRUJ instability after arthrodesis is to keep
    the volar and dorsal radioulnar ligament complex intact.

  • Decorticate the dorsal 50% of the joint
    surfaces of the radioscapholunate, the radioscaphocapitate, the
    scapholunate, the lunocapitate, and the capitate, and the third
    metacarpal base until you expose cancellous bone.
  • Arthrodesis of the remaining joints of
    the carpus and the second carpometacarpal joint can be performed, but
    we add these joints only if concomitant arthrosis exists. Keeping the
    volar 50% of the articular surface intact maintains alignment of the
    carpus better than if the entire joint is taken.
  • Harvest cancellous bone graft from the
    distal radius by removing Lister’s tubercle and widening the cortical
    defect with a curet.
  • Contour the dorsal surfaces of the distal
    radius, lunate, capitate, and third metacarpal base with an osteotome
    so that the plate fits against the bone without gaps or defects.
  • Before fixing the plate to the wrist,
    pack cancellous bone graft between the joint surfaces to be fused.
    Apply the plate (we prefer the precontoured AO wrist fusion plate,
    which provides 10° to 15° of wrist extension) first to the third
    metacarpal with at least three 2.7 mm cortical screws. Stabilize the
    distal radius with at least three (usually four) 3.5 mm cortical
    screws. Then use a cancellous screw to affix the plate to the carpus
    (usually the capitate).
  • Ensure that the position of the hardware
    is adequate with intraoperative radiographs or fluoroscopy, and make
    changes as necessary.
  • Close the wound by transposing one third to one half of the extensor retinaculum volar to the extensor tendons over the plate.
  • Place a suction drain deep into the wound and bring it out distally for removal the next day.
  • Close the skin with interrupted horizontal mattress sutures of 4-0 nylon.
Postoperative Care
Apply a sterile bandage and a short-arm volar splint.
After 1 week, remove the bandage and splint; inspect the wound and
remove the sutures if it is adequately healed. Apply a custom-molded
plastizote splint and begin a controlled-motion hand therapy protocol.
Do not permit active exercises


against resistance until clinical and radiographic union is achieved, usually in 6–10 weeks.

Numerous authors using different surgical techniques
have reported complications of radiocarpal arthrodesis. Clendenin and
Green (22) divided these into major
complications (requiring revision surgery or prolonged hospitalization)
and minor (when morbidity is prolonged but resolves without further
hospitalization). Major complications include nonunion, wound
infection, painful neuromas, fracture of a previously healed fusion,
iliac crest bone graft site complications, acute carpal tunnel
syndrome, plate failure, DRUJ and ulnocarpal impingement (33,77,92),
and chronic pain syndromes. Minor complications include postoperative
pain caused by tight dressings, sensory neurapraxias, minor skin
irritations, and necrosis. Hastings (39) noted
that major complications are less common in internal fixation with a
wrist fusion plate than in other surgical methods. Bone graft donor
site morbidity can be diminished by using local bone graft for
radiocarpal arthrodesis.
Overall rates of nonunion range from 5% to 20% (22,39), whereas rates of nonunion with the AO wrist fusion plate technique have been reported to be from 0% to 2% (32,41,104).
Each reference is categorized according to the following
scheme: *, classic article; #, review article; !, basic research
article; and +, clinical results/outcome study.
+ 1. Alberts KA, Engkvist O. Arthrodesis of the First Metacarpal Joint: 33 Cases of Arthrosis. Acta Orthop Scand 1989;60:258
# 2. Ashmead D, Watson HK. SLAC Wrist Reconstruction. In: Gelberman R, ed. The Wrist. New York: Raven Press, 1994.
+ 3. Ashmead D, Watson HK, Damon C, et al. Scapholunate Advanced Collapse Wrist Salvage. J Hand Surg [Am] 1994;19:741.
+ 4. Ashmead D, Watson HK, Weinzweigh J, Zeppieri J. One Thousand Intercarpal Arthrodeses. J Hand Surg [Br] 1996;21:10.
+ 5. Ayres JR, Goldstrohm GL, Miller GJ, Dell PC. Proximal Interphalangeal Joint Arthrodesis with the Herbert Screw. J Hand Surg [Am] 1988;13A:600.
+ 6. Bamberger HB, Stern PJ, Kiefhabert TR, et al. Trapeziometacarpal Joint Arthrodesis: A Functional Evaluation. J Hand Surg [Am] 1992;17:605.
+ 7. Bednar JM, Osterman AL. Carpal Instability: Evaluation and Treatment. J Am Acad Orthop Surg 1994;19A:1016.
+ 8. Begley BW, Engber WD. Proximal Row Carpectomy in Advanced Kienböck’s Disease. J Hand Surg [Am] 1994;19:1016.
+ 9. Bishop AT. Small Joint Arthrodesis. Hand Clin 1993;9:683.
+ 10. Biyani
A, Ebraheim NA, Lu J, Yeasting RA. A Modified Dorsal Approach to the
Wrist for Arthrodesis of the Non-Rheumatoid Wrist. An Anatomical Study.
J Hand Surg [Br] 1996;21:434.
+ 11. Bolano LE, Green DP. Wrist Arthrodesis in Post-Traumatic Arthritis: A Comparison of Two Methods. J Hand Surg [Am] 1993;18:786.
+ 12. Braun RM, Rhoades CE. Dynamic Compression for Small Joint Arthrodesis. J Hand Surg [Am] 1985;10:340.
+ 13. Brown RE, Erdmann D. Complications of 50 Consecutive Limited Wrist Fusions by a Single Surgeon. Ann Plastic Surg 1995;35:46.
! 14. Brumfield RH, Champoux JA. A Biomechanical Study of Normal Functional Wrist Motion. Clin Orthop 1984;187:23.
+ 15. Burton RI, Margles SW, Lunseth PA. Small Joint Arthrodesis in the Hand. J Hand Surg [Am] 1986;11:678.
+ 16. Carroll RE. Arthrodesis of the Carpometacarpal Joint of the Thumb. A Review of Patients with a Long Postoperative Period. Clin Orthop 1987;220:106.
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