Commentary & Perspective

Commentary & Perspective on
"Proximal Row Carpectomy: Study with a Minimum of Ten Years of Follow-up"
by Michael E. DiDonna, MD, et al.

Commentary & Perspective by
James R. Urbaniak, MD*,
Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina

Proximal row carpectomy was first described by Stamm in 1944¹. Historically, its value has been controversial, and generally it has been given a "bad rap." These negative opinions have been based on the false beliefs that proximal row carpectomy results in weakness in the hand and that, over the long term, the procedure results in painful degenerative arthritis of the wrist. In contrast, the relatively long-term results presented by DiDonna, Kiefhaber, and Stern, along with the results in two recent publications by other authors^2,3, provide rather convincing evidence that supports the use of this technique in selected patients. These patients mainly include those with advanced avascular changes of the scaphoid or lunate and degenerative changes of the wrist joint when the lunate fossa is spared.

The authors state that capitolunate arthritis is a contraindication to proximal row carpectomy. One might argue that, since the long-term results show that radiocapitate arthritis eventually develops in most patients who have undergone proximal row carpectomy, minimal or moderate capitolunate arthritis may not be a contraindication. Some surgeons even recommend partial proximal excision of the capitate with soft-tissue interposition when performing proximal row carpectomy⁴.

Concerning their technique, I agree with not using pins and have not inserted pins for proximal row carpectomy in the last twenty years. I have also performed a radial styloidectomy in most patients in the past several years.

In my opinion, the results of DiDonna et al. that indicate an 18% failure rate over a ten-year period are certainly acceptable for management of these difficult wrist problems; the procedure is just as reliable as limited wrist arthrodesis for similar indications. In younger patients, i.e., thirty-five years of age or less, I would choose a four-corner fusion and scaphoid excision for a scaphoid nonunion and advanced collapse or scapholunate advanced collapse. For patients older than thirty-five years of age, I agree that a proximal row carpectomy is at least as reliable as a limited wrist arthrodesis and is usually associated with a quicker recovery and fewer complications. Proximal row carpectomy should no longer be considered a "salvage procedure" but a first-line method of obtaining a long-term outcome of relief of pain, good grip, and functional range of motion in more than 80% of patients.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Stamm TT. Excision of the proximal row of the carpus. Proc R Soc Med. 1944;38:74-5.
2. Imbriglia JE. Proximal row carpectomy. Technique and long-term results. Atlas Hand Clinics. 2000;5:101-9.
3. Jebson PJ, Hayes EP, Engber WD. Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg (Am). 2003;28:561-9.
4. Eaton R. Personal communication, 2004.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.