In stage IV Kienbock's Disease, good results have been reported with Proximal Row Carpectomy (PRC) and wrist arthrodesis (total fusion).

Choice between the two procedures is determined by the needs and desires of the patient and the integrity of the articular surfaces of the lunate fossa and the capitate.

Proximal row carpectomy should be reserved for those people who desire motion over strength, whereas the wrist fusion is preferable in those people who need strength. Total wrist arthroplasty is generally contraindicated in young active people. Treatment choice must be based on a number of variables, including the experience of the surgeon, the desires and activity level of yourself.

In the early stages, efforts should be made to salvage the lunate and prevent loss of normal architecture. In the later stages, efforts should be made to restore that architecture. In the end stage, normal architecture must be sacrificed to restore function.

PROXIMAL ROW CARPECTOMY:

Excising the proximal carpal row so that the capitate articulates with the lunate fossa on the radius is rarely indicated, as the capitate and radial articulations are almost invariable damaged by the disease process to the lunate. However, the procedure can produce good results in carefully selected cases of wrist arthritis where the two key articular surfaces are considered to be satisfactory on radiographic assessment. The proximal carpul bones are excised through a dorsal approach with dorsal capular repair. The wrist is rested in a cast in neutral flexion/extension for 4-6 weeks and the mobilized. Power and movement are only slowly regained but the patient usually obtains 40-60' of flexion/extension range around the neutral point with moderate grip strength one year after surgery. If the key articular surfaces were in satisfactory condition pre-operatively, reasonable pain relief is obtained.

ARTHRODESIS of the wrist.

Fusion of an osteoarthritic wrist is most commonly obtained by the use of a plate and screws to radius, carpus and third metacarpal, augmented with cancellous bone graft. Slight dorsal angulation potentiates grasp. The dorsal incision extends to the radius, retracting the extensor indicis proprius compartment radially and the extensor compartment ulnarly. The dorsal two thirds of the articular surfaces of the wrist joint are rawed and the cavitates packed with cancellous bone. Modern low profile plates and screws are not unduly prominent, and there is normally no need to remove the metal work unless discomfort is experienced. The stability of the fixation is such that the fingers and the thumb can be mobilized immediately. The dissection can largely avoid direct exposure of the extensor tendons, reducing the risk of tendon adhesions.

DENERVATION of the wrist.

No attempt is made to treat the arthritis, simply the pain that it causes. The nerves that supply the carpus are classified into radial, median and ulnar groups, and a serial nerve blocks will reveal to an extent the likely result of ablation of these various nerves. An extensive long term study has shown it to be useful in reducing pain but retaining movement, apparently without the risk of a Charcot joint. ninety per cent of these series were considered to have gained reasonable pain relief (60% pain free and 30% improved).

OPERATION DETAILS

(44 year old patient0

(P2) Bilateral Wrist Denervation / 3 Incisions on each wrist / 2 Dorsal Incisions / 4th & 5th Compartments / Posterior Interosseous Nerve divided / Branches of Ulnar Nerve divided / Volar Curved Incisions / Radial Nerve and Vessel Branches divided / Anterior Interosseous Nerve and Branches Identified and divided / 20mls Ropivacaine to each wrist / Vicryl Fat / Nylon Skin / Jelenet/Melolin/Wool/Crepe

POST OP COMMENTS - Elevate / Home / Reduce dressing 72 hrs / Out Patients Review 2 weeks

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