Treatment of Radiocarpal Degenerative Osteoarthritis by Radioscapholunate Arthrodesis and Distal Scaphoidectomy Marc Garcia-Elias, MD, PhD, Alberto Lluch, MD, PhD, Angel Ferreres, MD, PhD, Ilaria Papini-Zorli, MD, Zulfi O. Rahimtoola, MD, Barcelona, Spain Purpose: The purpose of this study was to assess wrist pain, range of motion, and the presence of radiographic midcarpal degenerative joint disease (DJD) in patients who had a distal scaphoidec- tomy in association to a radioscapholunate (RSL) arthrodesis and to compare these findings with prior studies of patients with only an RSL fusion. Methods: Sixteen patients with radiocarpal DJD treated by RSL arthrodesis and distal scaphoid- ectomy were evaluated retrospectively for pain relief and range of motion at an average follow-up period of 37 months (range, 12���84 mo). Radiographs were assessed for the presence of secondary radiographic midcarpal DJD. Results: Complete pain relief was obtained in 10 patients, 3 patients complained of slight pain during strenuous loading, and 3 patients had occasional pain with regular activities. The average postoperative ranges of motion were 32�� of flexion, 35�� of extension, 14�� of radial deviation, and 19�� of ulnar deviation. Two patients exhibited secondary midcarpal DJD. These results are significantly better compared with those previously published about RSL arthrodesis alone in terms of residual pain and decrease of wrist radial deviation and flexion. Conclusions: Patients who require an RSL arthrodesis for the treatment of severe localized radiocarpal DJD appear to have less pain and to retain more flexion and radial deviation if the distal scaphoid is excised concomitantly. This associated procedure also may help prevent secondary midcarpal DJD. (J Hand Surg 2005 30A:8���15. Copyright �� 2005 by the American Society for Surgery of the Hand.) Key words: Arthrodesis, radioscapholunate joint, scaphoidectomy, osteoarthritis. A number of posttraumatic, inflammatory, and non- inflammatory conditions may result in a degenerative joint disease (DJD) of the radioscapholunate (RSL) joint. When this problem remains symptomatic de- spite conservative treatment, different surgical op- tions may be considered: wrist denervation, radial styloidectomy, proximal row carpectomy, distraction resection arthroplasty, fascial implant arthroplasty, total wrist arthroplasty, and limited or total wrist arthrodesis.1���6 RSL arthrodesis is performed commonly when RSL DJD involves both the radiolunate and ra- dioscaphoid joints when the midcarpal joint is nor- mal.7���17 After this fusion, however, the proximally fixed scaphoid does not allow for much radial devi- From the Institut Kaplan, Hand and Upper Extremity Surgery, Barcelona, Spain. Received for publication April 2, 2004 accepted in revised form September 1, 2004. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Marc Garcia-Elias, MD, PhD, Institut Kaplan, Passeig de la Bonanova, 9, 2on 2a, 08022 Barcelona, Spain. Copyright �� 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A01-0002$30.00/0 doi:10.1016/j.jhsa.2004.09.001 8 The Journal of Hand Surgery

ation and flexion of the distal row relative to the fused proximal row.17 With time, the resultant in- creased stress at the scaphoid-trapezium-trapezoid (STT) joint may cause painful midcarpal DJD.9,17 We hypothesized that a distal scaphoidectomy could be beneficial in terms of less restriction of midcarpal motion, as recently shown in vitro by McCombe et al,18 and consequently less residual pain and im- proved function. The purpose of this study was to assess the range of wrist motion, residual pain, and incidence of late radiographic midcarpal DJD of patients who had a distal scaphoidectomy associated with an RSL arth- rodesis and to compare these findings with those reported in the literature from patients who had an RSL arthrodesis alone.9,12,17 Patients and Methods Sixteen patients with decreased and painful range of motion of the wrist secondary to isolated radiocarpal DJD were treated by RSL arthrodesis and distal scaphoidectomy. Most cases had been referred to us for surgical treatment once conservative measures had shown no success. There were 12 men and 4 women with an average age of 41 years, ranging from 18 to 64 years of age. In 7 patients the dominant side had surgery. Demographic data of the patients included in this study are provided in Table 1. Thirteen patients had suffered an intraarticular fracture of the distal radius, 2 patients had sustained a perilunate fracture���dislocation, and one had been diagnosed with Kienb��ck���s disease. Five of the 13 distal radius fractures had been treated by cast im- mobilization and the remaining 8 radius fractures had surgical intervention: 5 patients with external fixation and K-wire fixation and 3 patients with open reduc- tion and internal fixation with plates and screws. The 2 patients who had a perilunate fracture���dislocation were treated initially by closed reduction, percutane- ous fixation, and cast immobilization. One of these patients subsequently developed a pseudarthrosis of the scaphoid that was treated by open reduction, cancellous bone grafting, and internal fixation of the scaphoid. Solving the scaphoid nonunion, however, did not prevent the development of severe radiocar- pal DJD. The patient with Kienb��ck���s disease was not previously treated surgically. In the posttraumatic cases the surgery was performed at an average of 10 months after the initial injury, ranging from 2 weeks to 45 years. Surgical Technique The wrist joint was approached through a zigzag dorsal skin incision. The dorsal branches of the radial nerve were identified and protected. The extensor retinaculum was sectioned along the third dorsal compartment, and through this both the second and fourth compartments were opened. A distally based capsular flap was made to expose the radiocarpal and midcarpal joints. In the cases presenting with clinical and radiographic evidence of distal radioulnar joint pathology the incision was extended proximally for Table 1. Demographic Data of Patients Undergoing RSL Arthrodesis and Distal Scaphoidectomy Case Age (y) Gender Dominant/ Injured Diagnosis Follow-Up (mo) 1 35 Male R/R Distal radial fracture 70 2 27 Male R/R Distal radial fracture 57 3 54 Female L/R Distal radial fracture 19 4 58 Male R/R Distal radial fracture 20 5 44 Male R/L Distal radial fracture 22 6 60 Female R/R Distal radial fracture 14 7 43 Female R/L Kienb��ck���s disease 84 8 44 Male R/R Distal radial fracture 21 9 28 Male R/R Distal radial fracture 35 10 27 Male L/R Perilunate F-D 21 11 64 Female R/L Distal radial fracture 37 12 43 Male R/L Distal radial fracture 67 13 38 Male R/L Perilunate F-D 48 14 18 Male R/R Distal radial fracture 12 15 54 Male R/L Distal radial fracture 27 16 23 Male R/L Distal radial fracture 37 Average (SD) 41 (14) 37 (22) F-D, fracture-dislocation. Garcia-Elias et al / Radiocarpal Degenerative Osteoarthritis 9