Proximal Row Carpectomy

About
Treatment
Recovery
Risks & Complications

Proximal row carpectomy (PRC) is a surgical procedure that removes one of the two rows of small bones in the wrist. It essentially converts a complex wrist joint into a simple, yet workable hinge. Operation involves excision of the scaphoid, lunate, and triquetrum which sit in the first row of bones (Picture 1). This allows the second row of bones to move up and articulate with the radius one of the forearm bones directly (Picture 2). It is a destructive, salvage, but motion-preserving treatment for advanced arthritic changes in the wrist. Operation effectively reduces pain, but results in reduced range of motion (by approximately 50%)  i.e. pain relief is exchanged for some stiffness.

The procedure is appealing because of its technical simplicity, generally predictable outcomes, and the ease of rehabilitation following surgery.

Indications

The indications for the procedure include:

  • Scapho-lunate ligament disruption with radiocarpal arthritis (so called scapho-lunate advanced collapse [SLAC] wrist)
  • Scaphoid nonunion with radiocarpal arthritis (so called a scaphoid nonunion advanced collapse [SNAC] wrist
  • Kienböck disease with collapse
  • Perilunate dislocation (acute and/or chronic)
  • Failed wrist arthroplasties
  • Severe flexion contractures of the wrist

The most important pre-requisite for successful outcome is that the good (healthy) cartilage exists over the wrist surfaces which will bear most of the loading forces postoperatively.  Good articular condition is most reliably assessed with wrist arthroscopy (‘key hole’ like examination of the wrist) ahead of the proximal row carpectomy itself. This can be done in the same sitting, or more commonly, by two separate operations.

Before Operation

  • Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.
  • Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery.
  • Plan your time off school / work / sports.
  • Allow at least few weeks after surgery before considering a holiday.

Surgery and Recovery

Operation is carried out on a day care basis under the regional or general anesthesia and takes between 60-90 min. Incision (and the future scar) is placed at the back of the wrist and can be either longitudinal or transverse and is between 8-15 cm long. Relevant bones are removed preserving important anatomical structures, nerves, tendons, capsule of the joint and so on.

Either absorbable or non-absorbable sutures can be used to close the wound at the end. The wrist is bandaged and immobilised with the splint for approximately 4-5 weeks postoperatively.

You should be fit to go home soon after the operation, but must be escorted by a family member or a friend. The anaesthetic wears off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 7-10 days to prevent the hand swelling and aggravated pain. Your wounds may show some blood staining for the first 24 hours. This is quite normal and nothing to worry about. There may be some bruising which usually clears within two weeks.

You need to take it easy and get plenty of rest when you get home for the first 7-10 days. Few days after surgery, the cast applied at the time of surgery is replaced by custom made (light weight) splint specially designed for you by the hand therapist. This splint is usually secured by Velcro straps and is easy to put on and remove at home. Immobilisation of the wrist is required for 4-5 weeks, but gentle wrist movements are advised from 10-14 days, usually supervised by the physiotherapist.

For two days following a general anaesthetic you should not:
Drive a car or ride a motorbike i.e. do not attempt to drive until you are in complete control of your hand. It is also advisable to check with your car insurance company, as some policies state that you must not drive for a specified period of time after an operation.

Rehabilitation

The rehabilitation will be geared towards your needs at home, work, and hobbies. Finger movements are encouraged straight after surgery whereas wrist motion exercises are started 5-7 days after the operation. If there is a wrist swelling, an elastic garment can be applied for edema control.

By six weeks, no immobilization is necessary and an aggressive strengthening program can be initiated. Three months postoperatively, the patient can return to full unrestricted activities.

Pain relief, improved motion, and increased function are the main long-term goals, but this requires a lot of time and patience, for patients, surgeons and therapist alike. Adequate rehabilitation aims to restore wrist stability and the load bearing function of the joint, but biomechanical properties remain compromised in comparison to healthy, strong wrist joints. Many patients are able to return to work with no restrictions, but those involved with demanding, strenuous tasks should consider work restrictions or changes in work duties.

Potential risks and complications

Complications are rare, but as with any surgical procedure, there are general and procedure specific risks which patients should be aware of:

General complications:

  • Adverse reaction to the general anaesthetic
  • Skin/wound infection
  • Numbness
  • Hypertrophic (lumpy and itchy) scarring
  • Reflex Sympathetic Dystrophy – RSD (bad reaction to surgery with painful and stiff hands – this can occur with any hand surgery, from a minor procedure to a complex reconstruction)

Specific complications:

  • Tendon injury (< 1%)
  • Damage to surrounding wrist ligaments
  • Nerve injury resulting in either: Numbness or Neuroma (painful nerve lump extremely sensitive to touch)
  • Joint infection
  • Damage to the articular surface of the neighbouring bones during removal of the bones in the proximal row of the wrist
  • Stifness
  • Residual wrist pain
  • Further, more radical operations (total wrist fusion or wrist replacement)

All proximal row carpectomies are associated with reduced range of wrist motion in comparison to preoperative measurements. Over the time, wear and tear arthritis can develop over the new articulation, but these changes can remain symptom free for several years. If symptoms deteriorate significantly, further surgery might be required (usually joint fusions or replacements).

Things to look out for after surgery:

  • Disproportionate swelling and pain in your hand
  • Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
  • Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
  • Increased temperature in the area
  • Strange smells coming from the wounds.

If you notice any of above symptoms in the first few days, feel free to contact the team on numbers below. If you have any concerns following your surgery please contact:

  • Hospital where you were operated: Ashtead 01372 221 442; St Anthony’s 020 8337 6691; Parkside 020 8971 8000
  • Your GP practice
  • My secretary on 0845 026 7776 (Monday – Friday, 9:30 – 18:00)
  • This leaflet provides only basic and generic information, but full details and explanations are provided at the consultation as no two patients are the same and each person’s circumstances are highly individual.

      PRC

    Picture 1: First (proximal) row of bones (Scaphoid - ; Lunate - L; triquetrum - T) is removed by the Proximal Row Carpectomy

    post PRC

    Picture 2: Wrist bones arrangements after the Proximal Row Carpectomy - - the second row of bones articulates with the forearm bones directly

    Synopsis:

    Hospital stay Day care
    Anaesthetic General or Regional (the whole arm is numbed)
    Surgery time 60-90 minutes
    Wound healing 2 weeks
    Splintage 4-5 weeks
    Hand therapy 5-6 weeks
    Washing from week 2
    Time off work 2 weeks for office based work; 6-8 weeks for manual work
    Sports and exercise 3 months
    Driving from week 2 (automatic car week 1) please check details with your insurance company
    Full recovery 8 weeks
     

    Contact

    All appointments, correspondence and enquiries are handled through the Practice Manager: Arabella Burwood

    Ashtead Hospital, The Warren, Ashtead, Surrey KT21 2SB

    Tel: +44 (0)845 026 7776 | Fax: +44 (0)845 026 7772

    Email: contact@sonjacerovac.com