Proximal Row Carpectomy 25215

synonyms: PRC

PRC CPT

• 25215 Carpectomy, all bones of proximal row
  

PRC Indications

• Disabling wrist pain, secondary to SLAC wrist,
• Kienbock's disease
• Scaphoid Nonunion / AVN
• Acute/Subacute severe carpal fracture/dislocations

PRC Contraindications

• Severe degenerative changes in the head of the capitate.
• Rheumatoid arthritis
• Patients >35y/o are more likely to require revision surgery (fusion).

PRC Alternatives

• Wrist Arthrodesis
• Wrist arthroplasty

PRC Planning / Special Considerations

• Radioscaphocapitate ligament is the prime stabilizer between the capitate and radius after PRC; must ensure it is preserved during surgery.
• PRC case card.

PRC Technique

• Sign operative site.
• Pre-operative antibiotics, +/- regional block.
• General endotracheal anesthesia
• Supine position. All bony prominences well padded.
• Examination under anesthesia.
• Well padded touniquet placed high on the arm.
• Prep and drape in standard sterile fashion.
• Exsanginate the arm with Eschmar bandage, inflate tourniquet to 250mmHg.
• Oblique longitudinal incision centered on radiocarpal joint from ulnar side of radius to the base of 2nd metacarpal.
• Dissection under 2.5x/3.5x loop magnification
• Identify extensor retinaculum. Incise longitudinally, opening the 4th extensor compartment. Preserve cuff of retinaculum for later repair.
• Isolate and retract extensor tendons with penrose drain.
• Identify PINin floor of the 4th dorsal compartment and transect proximally.
• Perform T-capsulotomy centered over scapholunate joint.
• Note dissociation of scapholunate ligament, degenerative changes in radioscaphoid joint etc, Preserved cartilage in capitate.
• Divide the scaphoid at its waist with in osteotome. Remove the proximal fragment.
• Excise distal fragment using a threaded Steinmann pin as a joy stick.
• Verify the integrity of the radioscaphcapitate ligament.
• Place Steinmann pin in lunate and excise lunate.
• Place Steinmann pin in triquetrum and excise.
• If needed radial styloidectomy may be performed with dissection between the 1st and 2nd dorsal compartments. Remove distal 5 to 7mm of radial styloid. Ensure radioscaphocapitate ligament is preserved.
• Irrigate.
• Repair capsule to maintain capitate in lunate fossa.
• Repair extensor retinaculum.
• Close in layers.

PRC Complications

• Degenerative changes in the radiocapitate articulation.
• Stiffness, motion loss.
• Weakness.
• CRPS
• Continued pain.
• Instability.
• Degenerative changes in the radiocapitate articulation, Stiffness, motion loss, Weakness, CRPS Continued pain, Instability.

PRC Follow-up care

• Post-op: Volar splint in neutral, elevation.
• 7-10 Days: Wound check, short arm cast.
• 4 Weeks: Cast removed, xray wrist. Start gentle ROM / strengthening exercises. Functional activities. Cock-up wrist splint prn / for light duty work. No heavy manual labor
• 3 Months:Full activities, may resume manual labor if adequate strength has been achieved.
• 6 Months:
• 1Yr: follow-up xrays, assess outcome

PRC Outcomes

• >10year follow-up: 18% failure requiring fusion at an average of seven years. All in patients < 35y/o at the time of the PRC. Average flexion-extension arc = 72°, average grip strength = 91% of contralateral side. (DiDonna ML, JBJS 2004;86A:2359).

PRC Review References

• Greens Hand Surgery
• Van Heest AE, in Masters Techniques: The Wrist, 2002
• Stern PJ, JBJS 2005;87:166
• Wyrick JD, JAAOS 2003;11:227