Proximal Row Carpectomy

Partial wrist fusion and proximal row carpectomy for wrist arthritis

What is wrist arthritis?

Arthritis can be divided into osteoarthritis and inflammatory arthritis. Osteoarthritis is commonly referred to as degenerative or “wear and tear” arthritis. Inflammatory arthritis is considered an autoimmune disease where the body attacks itself. Common examples of inflammatory arthrits are rheumatoid arthritis, lupus, gout, scleroderma, and psoriatic arthritis.

How does arthritis occur?

In osteoarthritis, articular cartilage degenerates and results in weakening of the cartilage and eventual death of cartilage. Cartilage is the smooth gliding surface between bones.  Dr. Kavi Sachar likes to think of it as two sheets of ice with fluid in between acting as a lubricant. In osteoarthritis, this “ice” melts and patients are eventually left with the bones rubbing against each other like two pieces of concrete. This can result in pieces of bone breaking off and the bone softening and collapsing. Osteoarthritis is divided into 4 stages based on x rays.

• Grade 0: Normal appearing joint with no cartilage loss
• Grade 1: minor Joint space narrowing with small bone spurs
• Grade 2: definite joint space narrowing with bone spurs
• Grade 3: moderate joint space narrowing with large bone spurs and possible deformity
• Grade 4: severe joint space narrowing with bone-on-bone contact, large bone spurs and deformity

Inflammatory arthritis occurs when the body attacks itself. This is considered a systemic disease that can affect not just joints, but organs, ligaments, and other tissue as well. Each form of inflammatory arthritis is unique and often requires a medical doctor or rheumatologist to be involved in management and treatment.

Diagnosing arthritis

Both osteoarthritis and rheumatoid arthritis may present with pain and swelling. Patients will have difficulty with activities such as lifting and twisting. They may notice weakness and may frequently drop things. Typically, rheumatoid arthritis may be more painful in the morning whereas osteoarthritis may get worse as the day goes on.

In the wrist, patients may notice swelling. The wrist may have decrease motion. There may be a history of a fracture in the past, such as a scaphoid fracture, that may not have healed resulting in altered biomechanics that leads to osteoarthritis.

Non-surgical treatment of arthritis

When treating arthritis, Dr. Kavi Sachar likes to describe a spectrum of treatment that ranges from conservative treatment to surgery. Many conservative treatments may be offered because patient response can be variable. Sometimes, the simplest treatment may work, helping to avoid surgery.  Conservative treatment consists of rest, splint immobilization, anti-inflammatory, therapy, cortisone injections and biological injections. There are some holistic remedies such as diet modification that can help some patients (link to arthritis sheet).  Therapy can help build the muscles and help strengthen the joint. Cortisone injections can temporarily help with the pain. Platelet Rich Plasma (PRP) is a treatment where a patient’s own blood is drawn, and the platelets are concentrated via centrifuge to isolate Platelet Derived Growth Factor which can help in tissue healing. Favorable results have been reported in some patients.

In the wrist, conservative treatment of arthritis often involves bracing and activity modification. Therapy can help build strength around the wrist. Selective corticosteroid injections can both help with treatment and to help establish the diagnosis.

Surgically treating arthritis

When conservative treatment fails, some consideration is given to surgical treatment. The surgery offered will vary on the specific body point and joint involved. Typically, surgery involves either a joint replacement, a joint reconstruction or a joint fusion.

In the wrist, surgery may involve arthroscopy, partial wrist fusion or wrist replacement. Dr. Kavi Sachar will evaluate your condition and determine which treatment is best for you.

Partial Wrist Fusion (four corner fusion)

The wrist is composed on 8 bones divided into two rows. In fractures and ligament tears, the biomechanics of the wrist may be altered resulting in arthritis between certain bones of the wrist. As opposed to the hip, which has only two bones that articulate, this 8 bone joint has advantages. When there is arthritis between only some of the bones, Dr. Kavi Sachar can take advantage of the remaining healthy bones and allow for surgery that maintains motion but eliminates pain.  A four bone or four corner fusion removes the arthritic bones in the wrist while maintaining the healthy bones. In a four corner fusion, the arthritic scaphoid is removed the remaining 4 bones are fused together. The advantage of this is it removes the arthritis while preserving the healthy bones. Dr. Kavi Sachar has had great success with this procedure in patients for whom it is indicated. Not all patients are candidates for this procedure so an evaluation with Dr. Kavi Sachar is necessary to see if this procedure is indicated in you.

Proximal Row Carpectomy

The wrist joint is composed of 8 bones and 2 rows. In a proximal row carpectomy, the proximal row consisting of the scaphoid, lunate and triquetrum is removed. This allows for the capitate to drop down into the arthritic lunate’s slot and perform its function. The lunate and the capitate are shaped similarly allowing the capitate to be the new bone the wrist rotates around. Patients often ask if their wrist will look different and the answer is no. Wrist range of motion is restored and the wrist often functions seamlessly.

Proximal row carpectomy and four corner fusion are similar procedures used to treat wrist arthritis that improve pain and maintain motion. The decision on which one to perform is based on many factors. Dr. Kavi Sachar will evaluate you and determine which procedure is best for you.

Recovering from arthritis surgery

Depending on the surgery performed, Dr. Kavi Sachar’s goal is to make you as functional as possible after surgery. Many surgeries require short term immobilization to allow for tissue healing. As soon as motion and strength are possible, Dr. Kavi Sachar will advance you to allow for activity, function and getting you back to what you like to do.

Schedule a consultation

Board-certified and fellowship-trained hand surge Dr. Kavi Sachar is widely regarded as one the nation’s leading experts on arthritis. Dr. Sachar has three office locations in Vail, Aspen and Frisco, Colorado. If you or a family member has suffered arthritis, contact Sachar today. Dr. Sachar is part of the world-renowned Steadman Clinic. Dr. Sachar and his team are here to help.