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SLAC & SNAC wrists Management & Results. Satyam Patel January 19th, 2007. Overview. Definitions Natural history Treatment Options Results. SLAC = Scapho-Lunate Advanced Collapse SNAC = Scaphoid Nonunion Advanced Collapse PRC = proximal row carpectomy

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slac snac wrists management results

SLAC & SNAC wristsManagement & Results

Satyam Patel

January 19th, 2007

overview
Overview
  • Definitions
  • Natural history
  • Treatment Options
  • Results
definition
SLAC = Scapho-Lunate Advanced Collapse

SNAC = Scaphoid Nonunion Advanced Collapse

PRC = proximal row carpectomy

4CF = 4 corner (Capito-Hamate-Lunate-Triquetrum) Fusion

Definition
natural history
Natural History
  • Ligament disruption
    • Scapholunate
    • Radioscaphoid
natural history5
Natural History
  • Scaphoid flexes abnormally
natural history6
Natural History
  • Increased contact
    • Proximal pole + scaphoid fossa
    • Distal pole + radial styloid
    • Arthritic changes
natural history7
Natural History
  • DISI deformity develops
    • Lunate and triquetrum extend
natural history8
Natural History
  • Capitate migrates into scapholunate interval
  • Midcarpal arthritis at capitolunate articulation
natural history9
Natural History
  • SLAC wrist
    • Scapholunate advanced collapse
    • Constellation of findings
      • DISI
      • Radioscaphoid arthritis
      • Midcarpal arthritis
      • Sparing of radiolunate joint
      • Carpal collapse
natural history10
Natural History
  • SLAC wrist
    • Scapholunate advanced collapse
      • I radial styloid + distal pole scaphoid
      • II scaphoid fossa + proximal pole
      • III capitolunate

Radioscaphoid

Midcarpal

natural history11
Natural History
  • SLAC wrist
    • Scapholunate advanced collapse
      • I radial styloid + distal pole scaphoid
      • II scaphoid fossa + proximal pole
      • III capitolunate
natural history12
Natural History
  • SLAC wrist
    • Scapholunate advanced collapse
      • I radial styloid + distal pole scaphoid
      • II scaphoid fossa + proximal pole
      • III capitolunate
snac natural history
SNAC - Natural History
  • Scaphoid nonunion leads to a series of degenerative changes that are similar to SLAC.
  • In general
    • 1 decade after fracture - scaphoid nonunion cystic changes
    • 2 decades - radioscaphoid degeneration
    • 3 decades - pancarpal arthritis
  • Stage I - radial styloid - scaphoid joint
  • Stage II - degeneration of radioscaphoid and scaphocapitate joints
  • Stage III - capitolunate degeneration
  • (proximal radioschaphoid and radiolunate joints are relatively well preserved)
treatment options
Treatment Options
  • Relevant factors
    • Patient age
    • Activity Level
    • State of Degeneration
treatment options15
Treatment Options
  • Conservative
    • Activity modification
    • Splinting
    • Steroid injection
    • NSAIDs
treatment options16
Treatment Options
  • Surgical
    • PIN neurectomy
    • Total or partial wrist arthrodesis
    • Proximal row carpectomy
    • Distraction arthroplasty
    • Total wrist arthroplasty
biomechanical basis for treatment
4-CF (+scaphoid excision)

Wrist motion occurs through preserved radiolunate and ulnocarpal joints

Including hamate and triquetrum increases fusion rate without sacrificing further motion

CI’s = radiolunate degeneration, ulnar carpal translation

PRC

Capitate articulates with lunate fossa

Difference in arc of rotation between C & L allows for radial and ulnar deviation

Preserving radio-scapho-capitate ligament is important for stability (N.B. if doing styloidectomy)

Biomechanical basis for treatment
irreducible carpus and arthritis
Irreducible Carpus And Arthritis
  • RECALL:
  • SLAC wrist
    • Scapholunate advanced collapse
      • I radial styloid + distal pole scaphoid
      • II scaphoid fossa + proximal pole
      • III capitolunate
irreducible carpus and arthritis19
Irreducible Carpus And Arthritis
  • I
    • Radial styloidectomy +/- scaphoid fixation & bone graft
  • II
    • Proximal row carpectomy
    • 4 corner fusion +/- radial styloidectomy / scaphoid excision
  • III
    • 4 corner fusion with scaphoid excision or arthrodesis
      • Proximal row carpectomy unsuitable due to midcarpal OA
irreducible carpus and arthritis20
Irreducible Carpus And Arthritis
  • I
    • Radial styloidectomy
      • Removes arthritic joint
      • Does not prevent progression to stage II and III
irreducible carpus and arthritis21
Irreducible Carpus And Arthritis
  • II
    • Proximal row carpectomy
      • Converts wrist into ball and socket joint
      • Mismatching radiocapitate joint allows translation
      • Removal of arthritic joints while motion maintained
irreducible carpus and arthritis22
Irreducible Carpus And Arthritis
  • II - SLAC wrist procedure
    • Four corner fusion (capitate-lunate-hamate-triquetrum)
    • Scaphoid excision
    • Removes arthritic joints
    • Makes use of preserved radiolunate joint
    • Higher loss of motion, strength maintained
irreducible carpus and arthritis23
Irreducible Carpus And Arthritis
  • III
    • SLAC wrist procedure
      • Proximal row carpectomy not suitable due to midcarpal arthritis
indications for total wrist arthrodesis
Indications for total wrist arthrodesis
  • Diffuse arthritic change (capitate or lunate fossa involved)
  • Motion less than 30 / 30
  • Contraindication = if wrist dorsiflexion is required for tenodesis (e.g. tetraplegic patients)
prc technique
PRC - Technique
  • Longitudinal incision through EPL sheath
  • Capsulotomy
  • Excise lunate first
  • Then triquetrum and scaphoid via sharp dissection to preserve ligaments.
  • +/- radial styloidectomy
  • Dorsal capsular repair
  • 2-3/52 in cast
prc variations
PRC - variations
  • Pre-op arthroscopy to evaluate condition of cartilage
  • Temporary internal fixation with K-wires
  • dorsal capsule interposition
  • Radial styloidectomy
  • Proximal capitate excision (?)
  • N.B. caution in pts < 35 y.o., rheumatoid patients
slac wrist procedure four corner fusion with scaphoid excision

Technique

SLAC Wrist ProcedureFour-Corner-Fusion With Scaphoid Excision
  • Exposure as in PRC
  • Scaphoid excision
  • Radioscaphocapitate ligament preserved
  • Joints decorticated
  • ICBG or distal radius bone graft
  • Lunate reduced to capitate (slight flexion)
  • K-wires, staples, screws, “spider” plate
  • Avoid silastic scaphoid (synovitis)
  • 6/52 – 8/52 cast
variations of 4 corner fusion
Variations of 4 -corner fusion
  • Use of k-wires vs. use of spider plate
    • Trade-off between increased fusion rate and incidence of dorsal impingement
    • P. Stern
  • Excision of triquetrum (3 corner fusion / Capito-lunate fusion)
    • Better dorsiflexion in cadaveric study, no significant increase in ROM clinically thus far.
    • G. Bain, J. Calandruccio, R. Gelberman
salvage
Salvage
  • Total wrist fusion
    • All arthritic joints fused
    • (radius - 3rd MC axis mandatory, others optional)
    • No motion / good strength
results
Results
  • Limited fusions
    • STT
      • 14% nonunion (385 cases from multiple series)
      • Pain relief unpredictable
      • Add styloidectomy if impingement present
    • SL
      • 50% nonunion
    • SLC
      • 50% decrease in wrist motion
      • 4/11 required total wrist fusion
results32
Results

Degenerative Arthritis of the Wrist : Proximal Row Carpectomy versus Scaphoid excision and four-corner arthrodesis.

M. Cohen S. Kozin J. Hand Surg. 2001 26A:94-104

2 cohorts of 19 patients each largely stage 2 arthritis, most SLAC, 3 SNAC in one arm 6 in the other.

- Early follow-up results (DASH, SF-36)

No significant differences in pain, grip strength, ROM

4CF group scored higher on mental-health component of SF-36 and retained a slightly greater radial-ulnar deviation arc.

results33
Results
  • Acta Orthop Belg 2006
    • Salvage procedures for degenerative osteoarthritis of the wrist due to advanced carpal collapse
    • 63 patients - 19 fused, PRC 26, scaphoidectomy +4CF 18
    • PRC significantly better (DASH =16)
    • No significant differences between 4CF and arthrodesis (DASH = 39, 45)
prc results
PRC - results
  • Jorgenson 22 PRC cases over 20 years
  • Increased ROM, subjective feeling of weakness
  • Scand J Plast Reconstr Surg & Hand Surg 2006
      • 51 patients PRC between 1992 & 200211% required arthrodesis (9 patients)
      • 34 returned to work (avg. 6/12)
      • F 66% E 73% RD 74% UD 76%
      • Grip 70%
results of 4cf scaphoidectomy
Results of 4CF & scaphoidectomy
  • Ashmead et. al
  • 44/12 100 patients
  • E 32deg F 42deg (53%)
  • Grip strength 80%
  • 78/85 satisfied (would undergo operation again)
  • 3% nonunion rate
  • Dorsal impingement 13%
results36
Results
  • Wrist fusion
    • 85% total pain relief
    • 65% return to former occupation

Hastings and Silver

summary no arthritis
Summary: No Arthritis
  • Reducible + adequate ligament
    • Reduction, repair, pinning
  • Reducible + inadequate ligament
    • Soft tissue vs. bony procedure
  • Irreducible
    • Treat as SLAC wrist vs. Limited fusion (STT)

Next page

summary arthritic wrist
Summary: Arthritic Wrist
  • Stage I
    • Radial styloidectomy
  • Stage II
    • Proximal row carpectomy: maintain motion, fast recovery
    • Four corner fusion + scaphoidectomy : strength ?
  • SLAC III
    • Four corner fusion + scaphoidectomy
  • Salvage
    • Wrist fusion
irreducible carpus without arthritis
Irreducible Carpus Without Arthritis
  • Why is it not reducible?
    • Fibrous tissue in joints
    • Deformed articular surfaces
    • Ligament shortening and laxity
  • Solution
    • Remove fibrous tissue from joints
    • Remove deformed articular surfaces
    • Remove lax / stiff ligaments
  • Limited carpal fusion
    • Removes intraarticular block to reduction
    • Fixes reduced scaphoid position to carpus
    • Prevents further carpal collapse
    • Spares uninvolved joints
irreducible carpus without arthritis42
Irreducible Carpus Without Arthritis
  • STT fusion + dorsolateral styloidectomy
  • SL / SC / SLC fusion
  • Without reduction of deformity, progression to SLAC wrist
  • Results of limited wrist carpal fusions may not be good enough or predictable enough to justify using them -- safer option is to treat as SLAC wrist
stt fusion

Technique

STT Fusion
  • Transverse dorsal incision
  • Retract superficial radial n. and v.
  • Open retinaculum along EPL
  • B/w ECRL and ECRB
  • Open STT
  • Open radioscaphoid joint
    • If arthritic go to SLAC wrist reconstruction
  • Reduce scaphoid and fix to carpus
  • Remove STT joint preserving height
  • Distal radius graft
  • 3 x 0.045 K-wires across STT
results44
Results

Krakauer et al, 1994

Wyrick et al, 1995

Tomaino et al, 1994

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