Goals. Overview. Proximal Row Carpectomy 6/24/2014

Transcription

1 6/24/2014 Proximal Row Carpectomy Description Biomechanics Indications Contraindications Surgical technique Post-operative care Outcomes PRC adjuncts Goals Overview Motion-preserving salvage procedure Resection of the proximal carpal row bones Allows the head of the capitate to articulate with the lunate facet of the distal radius Indicated in degenerative conditions of the wrist Reliably reduce pain & improve function Few complications 1

2 6/24/2014 Biomechanics Radius of curvature of capitate head not consistent with lunate fossa Increase pressure, decrease in contact area at the radiocapitate joint Translational motion of capitate in lunate fossa Indications Scapholunate advanced collapse (SLAC) Scaphoid nonunion advanced collapse (SNAC) Kienbock disease Failed lunate or scaphoid implant Chronic perilunate dislocation Severe flexion contractures Relative Contraindications Loss of cartilage on the head of capitate Loss of cartilage on the lunate fossa of the distal radius Inflammatory arthritis Aged < 35 yo 2

3 6/24/2014 Surgical Technique Regional or general anesthesia Tourniquet Wrist arthroscopy Dorsal longitudinal skin incision over Lister s tubercle Division of extensor retinaculum over the 3 rd compartment Identification & resection of the posterior interosseous nerve Surgical Technique Inverted-T capsular incision - Proximal carpal row exposed between 2 nd & fourth compartments Re-assessment of articular surfaces - Head of the capitate & lunate facet of the radius - Considered osteochondral grafting procedures (OATS), soft-tissue interposition, wrist arthrodesis Resection of the scaphoid, lunate & triquetrum bones Surgical Technique Intra-operative X-rays evaluation Complete proximal row carpal bones resection Stability of the neo radiocapitate joint Radial styloid impingement Closure of the capsular incision & approximation of the extensor retinaculum Sterile dressing & volar wrist splint Wrist 20 extension MCP joints free 3

4 6/24/2014 Post-operative care Therapy Wrist immobilization for 4 weeks Immediate active range of motion fingers Edema control & scar management Active wrist range of motion at 4 weeks Strengthening at 6-8 weeks Outcomes Retrospective cohort study n = 20 patients Mean follow-up 3 1/2 years Findings 15% motion 22% grip strength 82% believed their conditions were improved and said they would repeat the procedure Failure in all 3 patients with rheumatoid arthritis Outcomes 10 Year Follow Up 4

5 6/24/2014 Outcomes 15 Year Follow Up Retrospective cohort study n = 81 patients Mean follow-up 19.8 years Findings Pre- vs post-operative wrist AROM & grip strength not significantly different Radiographic evidence of radiocapitate joint narrowing & arthritic changes beyond 2 years 74% of patients not satisfied with the results of their surgery 64% of patients required daily pain medication 15% of patients underwent wrist arthrodesis Ali Hand 2011 Outcomes 20 Year Follow Up Retrospective cohort study n = 16 patients (17 wrists) 20 or more years of follow-up (mean of 24 y.) Findings In 65% no further surgery needed High satisfaction rate (91% of non re-operated patients) Minimal decrease in motion (flexion-extension arc of 68 ) & grip strength (72% contralateral side) No correlation between degenerative radiographic changes& level of satisfaction Patients younger than yo should not be excluded as PRC candidates Wall JHS 2013 OATS OATS lunate facet 1. Joint surfaces evaluation 2. Measurement of the osteochondral defect at the lunate facet 3. Osteocartilaginous graft harvesting (knee) 4. Recipient hole creation 5. Graft implantation Tang JWS

6 6/24/2014 Proximal Carpectomy Soft Tissue Interposition If capitate is involved Kwon JBJS (Br) 2009 References Wall LB, Stern PJ. Proximal row carpectomy. Hand Clin Feb;29(1): Strauch RJ. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis- -update on evaluation and treatment. J Hand Surg Am Apr;36(4): Zinberg EM, Chi Y. Proximal row carpectomy versus scaphoid excision and intercarpal arthrodesis: intraoperative assessment and procedure selection. J Hand Surg Am Jun;39(6): Culp RW, McGuigan FX, Turner MA, Lichtman DM, Osterman AL, McCarroll HR. Proximal row carpectomy: a multicenter study. J Hand Surg Am Jan;18(1): Chim H., Moran SL. Long-term outcomes of proximal row carpectomy: a systematic review of the literature. J Wrist Surg Nov;1(2): Ali MH, Rizzo M, Shin AY, Moran SL. Long-term outcomes of proximal row carpectomy: a minimum of 15-year follow-up. Hand (N Y) Mar;7(1):72-8. Wall LB, Didonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: minimum 20-year follow-up.j Hand Surg Am Aug;38(8): Tang P, Imbriglia JE. Technique: Osteochondral Grafting of Capitate Chondrosis in PRC. J Wrist Surg Aug;2(3): Thank You 6

7 6/30/ and 4 Corner Fusions Greg Bain Flinders University South Australia No COI Indications for LWF Localised Disease Intact Complications of Intercarpal Arthrodesis McAuliffe JHS 1993 Complications Nonunion HOWEVER! STT, LT, SL fusion 1

8 6/30/2014 Joint principles Stand alone joint Stable - ligaments Containment Congruent Loading Move like a joint good long term Bain McGuire JWS 12 Open Fusion Volar ridge Maintain height Closing Fusion Bone apposition Stability Increased union rate Loose height Bain McGuire JWS 12 Grid Modification Remove Flexing Scaphoid Close the rows Bain McGuire JWS 12 2

9 6/30/2014 Grid Modification Closed Fusion Open Fusion Lunate Union? Carpal height Movement Radial Which Operation? 4CF RSL Fusion PRC 4CF RSL PRC FWF FWF Prerequisites Which Position? Bain McGuire JWS 12 3

10 6/30/2014 Self Selected Which Angle Position? 28 degrees Bain McGuire JWS 12 JHS Am 2010 Fusion 2 BG3 Ulnar wrist pain 2 Containment Bony restraints Decrease containment to increase motion Stability? Bain McGuire JWS 12 4

11 6/30/2014 Bain Sood JHS 09, JWS 14 4 OR 3 Bone Fusion? Scaphoid F 10% R-U 29% Triquetrium F 5% R-U 13% Bain Sood JHS 09 Load distribution Congruent joint Athlete Viegas JHS 91 5

12 Extension Extension 6/30/2014 JHS Am2012 Flexible Electrogoniometer Matlab Motion, Axis, Velocity, Smoothness Harvinder Singh, Norman Capener Travelling fellowship, Sponsor RCS (Eng) Circumduction 3 Vs 4 CF 3 18º 4 4º Ulnar Deviation Circumduction 3 Vs 4 CF Velocity and Smoothness of Motion 9º 19º 3 23º 4 Michigan Hand Questionnaire P <0.05 Ulnar Deviation (ADL, Satisfaction) 6

13 6/30/2014 Which Fixation? Spider Plates Varying Results 21 Stern, Wolfe, Weiss Staples Changes Triquetral Bone Graft Memory Staples 3 Corner Van Riet Bain THUES 07 PRC LONG TERM 4CF Better! 4/22 (18%) TWF at 10yrs Higher rate of OA Stern JBJS 04, Axelrod JHS 09 7

14 6/30/2014 4CF PRC Vs Patient Co-morbidities Smoker Cost Surgical Experienced 3 CFAuthor s Technique Triquetral Bain Excision G THUES Better ROM Best BG (cadaveric) Ulnar Pain Memory Staples KILL The Triquetrum RSL, FWF Patient Selection Summary urgical Technique Outcome greg@gregbain.com.a 8

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16 Optimizing Wrist Arthroplasty Brian D Adams, MD Professor Orthopedic Surgery and Biomedical Engineering University of Iowa Iowa City, Iowa 14 year post operative result of Universal total wrist 1

17 Factors influencing procedure selection Rehabilitation Technical ease Pain relief Strength Motion Risk Comparative Outcomes Patients prefer arthroplasty over arthrodesis Goodman & Millender 1980 Volz 1984 Vicar & Burton 1986 Kobus & Turner 1990 Figgie, et al 1990 Risk Management Risk to Benefit 2

18 Design Challenges for a Wrist Implant Distal carpal row Proximal carpal row TFCC Radius Wrist axis of motion center of rotation is in capitate head Kinetics of Wrist Wrist and digital flexor forces must be resisted 3

19 Optimizing the Design Distal Component Fixation Within carpus (avoid metacarpals) Intercarpal fusion (solid foundation) Uncemented (screws) Articulation Unlinked (reduce stress of bone fixation) Broad (resists imbalance) Semi-constrained (resist dislocation) Proximal Component Replicate radius Minimize bone resection Uncemented (in-growth, press-fit) Integra ` UNI 2 SBI Remotion Biomet Maestro Integra Freedom Similar in some ways but different in other ways General Indications OA, SLAC, post-traumatic, & rheumatoid combined radiocarpal / midcarpal arthritis lower demand, preferably elderly patient patient recognizes lifetime limitations 4

20 General Contra-indications high physical demand patient regular dependence on walking aides absent motor control of wrist poor bone stock previous surgical fusion if wrist extensors have been sacrificed Specific Contraindications severe active bony erosion Example Cases 5

21 rheumatoid arthritis old scaphoid nonunion SNAC wrist post-traumatic arthritis old distal radius fx 6

22 Kienbock s disease Post-traumatic arthritis with radius deformity Failed Proximal Row Carpectomy (PRC) 7

23 Failed Four Bone Fusion 64 year old calligrapher with pseudogout and post-traumatic arthritis Minimal wrist motion Court 10/20/06 5 year post op 8

24 Massey Flossie In-growth fixation in osteopenia at 5 years Failure of intercarpal fusion Subsidence seen after two years SBI ReMotion 9

25 Poly exchange, debridement, and bone allografting 6 six years post op 1 year after poly exchange 17 of 21 pts had rheumatoid arthritis UNI 2 19 of 21 pts had rheumatoid arthritis 10

26 83 of 92 pts had rheumatoid arthritis Biomet Maestro 5 of 23 wrists had rheumatoid arthritis 13 of 20 pts had rheumatoid arthritis SBI ReMotion 11

27 SBI ReMotion 129 of 215 pts had rheumatoid arthritis ARTHRODESIS Intercalary allograft (cancellous femoral head) Dorsal plate BMP / bone substitute Consider Locking Plate 12

28 Risk Management Appropriate patient activity demands Stable disease Adequate bone stock Correctable deformity Good operative technique Match procedure & implant to the patient Thank You 13

29 Current Concepts in Wrist Arthritis VuMedi Webinar June 30, 2014 MIDCARPAL HEMIARTHROPLASTY FOR WRIST ARTHRITIS: 3 year results and update Scott Wolfe, MD, Greg Packer, MD; Joseph J. Crisco, Ph.D Hospital for Special Surgery, New York Weill Medical College of Cornell University Rhode Island Hospital, Brown University Medical Center Southend University Hospital, Southend-on-Sea, England DISCLAIMER Royalty and consulting fees received from Extremity Medical, Inc. Parsippany NJ Wrist hemiarthroplasty is not FDA approved for use in the United States INTRODUCTION Wrist Arthritis Debilitating condition Goal is a painless, stable joint Preserving ROM is ideal Etiology Varies SNAC / SLAC wrist Posttraumatic OA Kienböck's Disease Inflammatory arthritis 1

30 TRADITIONAL TREATMENTS Salvage Operations Ablative Styloidectomy Distal scaphoidectomy PRC Arthrodesis 4CF, RSL fusion Total wrist fusion? ARTHRODESIS Provides a stable, pain-free platform for hand function Supported by several excellent studies But not without issue Nonunion Hardware complications Loss of motion WRIST ARTHROPLASTY First described by Swanson, 1973 Motion preserving alternative to fusion Distal component failure Continues to plague modern designs 2

31 WRIST HEMIARTHROPLASTY Rationale - Avoids issue of distal component loosening - Minimal activity restrictions - Appropriate for younger pts (SLAC/SNAC, posttaumatic OA) - Satisfactory early outcomes Boyer, J.S., Adams, B.D.: Iowa Orthop. J: 2010 WRIST HEMIARTHROPLASTY Mid term outcomes worrisome - N = 10, avg f/u 19 months - High rate of complications - Polyethylene erosion - Aseptic osteolysis 30% - Capitate bone spur - Contracture 30% Culp,R.W., et al. J.Wrist Surg. 1(1): 2012 MIDCARPAL HEMIARTHROPLASTY KinematX prosthesis Anatomic design Preserves midcarpal joint Coupled Motion Maintains wrist anatomic center of rotation Ligament sparing (dorsal and palmar) Preserves radial subchondral plate, DRUJ PRC/Hemi Midcarpal Hemi 3

32 DART-THROWER S MOTION Coupled motion Radial extension to ulnar flexion Utilized in many recreational & occupational activities Does not coincide with anatomic axes of F/E, RD/UD Moritomo et al. Crisco, JJ et al., JBJS 2005 & YR Update PURPOSE Update early results and complications of wrist midcarpal hemiarthroplasty for wrist arthritis METHODS KinematX implanted in 20 patients beginning Feb SLAC (10), posttraumatic OA (6), Inflammatory arthritis (3), Kienböck s (1) Avg age 50.6 yrs (range, 23-74) Prospective data collection Mayo, DASH, ROM, grip, xrays Mean follow-up 48 wks (range, ) KinematX Midcarpal Hemi-arthroplasty 10 cm midline incision Surgical technique 4

33 KinematX Midcarpal Hemi-arthroplasty Anatomic ligament-preserving approach Proximal based ligament-sparing rectangular capsular flap is raised. PIN is spared. A wafer of the dorsal triquetrum is raised with the flap to protect the DRT and DIC ligament insertions Surgical technique KinematX Midcarpal Hemi-arthroplasty Proximal row carpectomy Surgical technique KinematX Midcarpal Hemi-arthroplasty Exposure Surgical technique 5

34 KinematX Midcarpal Hemi-arthroplasty Elliptical power rasp removes cartilage and SL ridge, preserves subchondral bone Surgical technique KinematX Midcarpal Hemi-arthroplasty Midline canal finder Surgical technique KinematX Midcarpal Hemi-arthroplasty Box cutter prepares canal for broaching Surgical technique 6

35 KinematX Midcarpal Hemi-arthroplasty Broach to size Surgical technique KinematX Midcarpal Hemi-arthroplasty Trial component Surgical technique KinematX Midcarpal Hemi-arthroplasty Reduction Surgical technique 7

36 KinematX Midcarpal Hemi-arthroplasty Trial range of motion Surgical technique KinematX Midcarpal Hemi-arthroplasty Final prosthesis press-fit Surgical technique KinematX Midcarpal Hemi-arthroplasty Fluoro films Surgical technique 8

37 RESULTS RESULTS Mean total surgery time = 53 min (range: 41-65) PRE-OP POST-OP SIGNIFICANCE MAYO SCORE DASH F-E ARC (DEGREES) R-U ARC (DEGREES) GRIP (KG) GRIP (% OPPOSITE SIDE) RESULTS Mean total surgery time = 53 min (range, 41-65) PRE-OP POST-OP SIGNIFICANCE MAYO SCORE DASH F-E ARC (DEGREES) R-U ARC (DEGREES) GRIP (KG) n.s. GRIP (% OPPOSITE SIDE) 64% 96% n.s. 9

38 RESULTS Worse results in the three inflammatory patients Perhaps due to unrecognized synovitis or distal carpal erosion When 3 pts with inflammatory arthritis excluded, ROM increased further Flexion-Extension (p < 0.04) Radio-ulnar Deviation (p < 0.04) COMPLICATIONS Stiffness Manipulation under anesthesia: 4 patients 2 SLAC, 1 OA, 1 inflammatory > 50 degree gain of FE No component loosening, revision, infection Patient #1 108 weeks DASH 0.0 Grip 85% FE 82% 10

39 MIDCARPAL HEMIARTHROPLASTY Novel technique, 3 years experience Maintains coupled wrist ROM Avoids complications associated with distal component Preliminary results demonstrate: Technique is safe and promising Improves motion, function Low complication profile Procedure may be better suited for posttraumatic patients Current Concepts in Wrist Arthritis VuMedi Webinar June 30, 2014 Thank you 11