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SLAC & SNAC wrists Management & Results PowerPoint PPT Presentation


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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 l.jpg

SLAC & SNAC wristsManagement & Results

Satyam Patel

January 19th, 2007


Overview l.jpg

Overview

  • Definitions

  • Natural history

  • Treatment Options

  • Results


Definition l.jpg

SLAC = Scapho-Lunate Advanced Collapse

SNAC = Scaphoid Nonunion Advanced Collapse

PRC = proximal row carpectomy

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

Definition


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Natural History

  • Ligament disruption

    • Scapholunate

    • Radioscaphoid


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Natural History

  • Scaphoid flexes abnormally


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Natural History

  • Increased contact

    • Proximal pole + scaphoid fossa

    • Distal pole + radial styloid

    • Arthritic changes


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Natural History

  • DISI deformity develops

    • Lunate and triquetrum extend


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Natural History

  • Capitate migrates into scapholunate interval

  • Midcarpal arthritis at capitolunate articulation


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Natural History

  • SLAC wrist

    • Scapholunate advanced collapse

    • Constellation of findings

      • DISI

      • Radioscaphoid arthritis

      • Midcarpal arthritis

      • Sparing of radiolunate joint

      • Carpal collapse


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Natural History

  • SLAC wrist

    • Scapholunate advanced collapse

      • I radial styloid + distal pole scaphoid

      • II scaphoid fossa + proximal pole

      • III capitolunate

Radioscaphoid

Midcarpal


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Natural History

  • SLAC wrist

    • Scapholunate advanced collapse

      • I radial styloid + distal pole scaphoid

      • II scaphoid fossa + proximal pole

      • III capitolunate


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Natural History

  • SLAC wrist

    • Scapholunate advanced collapse

      • I radial styloid + distal pole scaphoid

      • II scaphoid fossa + proximal pole

      • III capitolunate


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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)


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Treatment Options

  • Relevant factors

    • Patient age

    • Activity Level

    • State of Degeneration


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Treatment Options

  • Conservative

    • Activity modification

    • Splinting

    • Steroid injection

    • NSAIDs


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Treatment Options

  • Surgical

    • PIN neurectomy

    • Total or partial wrist arthrodesis

    • Proximal row carpectomy

    • Distraction arthroplasty

    • Total wrist arthroplasty


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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


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Irreducible Carpus And Arthritis

  • RECALL:

  • SLAC wrist

    • Scapholunate advanced collapse

      • I radial styloid + distal pole scaphoid

      • II scaphoid fossa + proximal pole

      • III capitolunate


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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


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Irreducible Carpus And Arthritis

  • I

    • Radial styloidectomy

      • Removes arthritic joint

      • Does not prevent progression to stage II and III


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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


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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


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Irreducible Carpus And Arthritis

  • III

    • SLAC wrist procedure

      • Proximal row carpectomy not suitable due to midcarpal arthritis


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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)


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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


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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


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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


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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


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Salvage

  • Total wrist fusion

    • All arthritic joints fused

    • (radius - 3rd MC axis mandatory, others optional)

    • No motion / good strength


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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


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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 eachlargely 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.


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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)


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PRC - results

  • Jorgenson22 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%


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Results of 4CF & scaphoidectomy

  • Ashmead et. al

  • 44/12100 patients

  • E 32degF 42deg(53%)

  • Grip strength 80%

  • 78/85 satisfied (would undergo operation again)

  • 3% nonunion rate

  • Dorsal impingement 13%


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Results

  • Wrist fusion

    • 85% total pain relief

    • 65% return to former occupation

      Hastings and Silver


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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


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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


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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


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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


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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


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Results

Krakauer et al, 1994

Wyrick et al, 1995

Tomaino et al, 1994


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