Die mediokarpale Teilarthrodese des Handgelenks

Summary

Goal of Surgery

Elimination or reduction of pain of the wrist while maintaining the residual motion.

Indications

Nonunion of scaphoid.

Scapholunate dissociation with advanced collapse (SLAC).

Osteoarthritis of radioscaphoid and midcarpal joints accompanied by pain and swelling of wrist.

Contraindications

Concomitant osteoarthritis of radioulnar joint, i. e. in instances of chronic rheumatoid arthritis or chondromalacia of lunate.

Positioning and Anaesthesia

Supine, tourniquet.

General anaesthesia (bone graft harvesting from iliac crest).

Surgical Technique

Dorsal approach. Mobilisation of retinaculum and opening of 2nd and 4th tendon compartment. Resection of dorsal interosseous nerve. Removal of scaphoid and resection of articular cartilage between capitate, lunate, hamate and triquetrum.

Correction of intercarpal malposition (DISI) and interposition of cancellous bone grafts. Internal fixation with Kirschner wires.

Postoperative Management

Elevation of arm. After removal of drain and regression of swelling: forearm cast. Radiographic control after 6 weeks, and active and passive exercises as soon as fusion is solid. Removal of wires 2 to 3 months postoperatively.

Possible Complications

Injury of nerves or vessels. Irritation of tendons due to Kirschner wires exceeding bony surface. Nonunion, infection, SRD, osteoarthritis of radioulnar joint.

Results

45 patients, 41 men and 4 women, mean age 42 years (21 to 70 years). Mean follow-up time 41 months (8 to 54 months). Loss of combined flexion—extension 21% in comparison to preoperative state. Loss of ad- and abduction of 12% but increase of strength by 38% (Table 2). Decrease of pain from 75 points preoperatively to 19 points postoperatively (Table 3). 36 patients were satisfied, 34 returned to previous occupation which consisted of heavy manual labor in 28. No improvement in 7 patients. Wrist fusion became necessary twice, a revision on account of nonunion in 4 patients and an ulnar styloidectomy for impingement in 3 patients.

Up to now no rapidly progressing radiolunar osteoarthritis or ulnar drift of carpus.