AVARIETY OF POSTTRAUMATIC, inflammatory, and

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1 SURGICAL TECHNIQUE Radioscapholunate Arthrodesis With Compression Screws and Local Autograft Debdut Biswas, MD, MHS, Robert W. Wysocki, MD, Mark S. Cohen, MD, John J. Fernandez, MD Radioscapholunate arthrodesis is performed for patients who experience pain and disability from radiocarpal arthritis. Initial reports from the 1980s demonstrated high nonunion rates and marginal clinical outcomes. Improvements in surgical technique and clearly defined indications have reduced nonunion rates and improved patient satisfaction. We present a technique using headless compression screws inserted through a dorsal approach, which optimizes hardware placement and incorporates local bone graft harvested from the insertion site to supplement the arthrodesis. (J Hand Surg 2013;38A: Copyright 2013 by the American Society for Surgery of the Hand. All rights reserved.) Key words Arthrodesis, fusion, headless compression screw, radiocarpal, radioscapholunate. AVARIETY OF POSTTRAUMATIC, inflammatory, and noninflammatory disorders may result in destructive changes isolated to the radiocarpal joint. 1 3 If nonoperative management fails to alleviate pain and disability from a painful radiocarpal joint, several surgical treatments may be offered. These include proximal row carpectomy, total wrist arthrodesis, and partial wrist arthrodesis. 3 6 The ultimate objective of any surgical treatment for radiocarpal arthritis is to optimize range of motion (ROM), strength, function, and pain relief with special consideration given to the long-term durability of the procedure. Radioscapholunate (RSL) arthrodesis has been recognized and validated as an effective operative treatment for the management of isolated radiocarpal degenerative joint disease, optimizing wrist function by permitting painless ROM through the midcarpal joint after arthrodesis of the painful radiocarpal articulation. 1,4,6 Several authors have reported excellent clinical outcomes with respect to pain relief, ROM, and hand function after RSL arthrodesis, 1,4,5,7 although nonunion remains a notable complication of RSL arthrodeses, with reports ranging from 11% to 25%. Efforts continue toward improving implant design and innovations in surgical techniques to minimize complications and optimize outcomes. Improvements in the design of cannulated headless compression screws have expanded their use in hand surgery, particularly in cases where interfragmentary compression is necessary. Although favorable outcomes have been reported with these types of implants, their use has been mostly limited to fractures, intercarpal arthrodeses, and interphalangeal fusions of the digits. 8 There have been few reports on their use in radiocarpal arthrodesis. 9,10 The purpose of this report was to describe a technique of radioscapholunate arthrodesis using a headless compression screw placed through a dorsal approach. The technique allows for both the harvest and use of local autograft, and optimizes transarticular placement of the screws. From the Section of Hand and Elbow Surgery, Department of Orthopaedic Surgery, Rush University MedicalCenter, Chicago, IL. Received for publication June 12, 2012; accepted in revised form January 21, R.W.W. is a consultant for Acumed. Correspondingauthor: MarkS.Cohen,MD,SectionofHandandElbowSurgery,Departmentof Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison Street, Chicago, IL 60612; mcohen3@rush.edu /13/38A $36.00/0 SURGICAL TECHNIQUE The patient is positioned supine with the upper extremity placed on an arm board and a nonsterile tourniquet applied to the upper arm. A regional block is preferentially used for anesthesia. The wrist is exposed through a dorsal approach using an incision in line with the third metacarpal extending from the capitate to 2 cm proximal to Lister tubercle (Fig. 1). The exposure should ASSH Published by Elsevier, Inc. All rights reserved.

2 RSL ARTHRODESIS WITH HEADLESS COMPRESSION SCREWS 789 FIGURE 1: Lister tubercle and the proposed longitudinal incision are marked. FIGURE 3: After subperiosteal dissection, the capsulotomy is performed, exposing the radiocarpal joint. The scapholunate ligament is intact. FIGURE 2: The extensor retinaculum is divided over the third compartment, and the EPL is transposed radially. FIGURE 4: A burr is used to denude the surfaces of the scaphoid, lunate, and articular surface of the distal radius. allow for sufficient access to the metaphysis of the distal radius to create a cavity for optimal screw placement. The dorsal sensory nerves are protected in full-thickness flaps off the retinaculum and the wrist is entered through the third compartment. The extensor pollicis is released and transposed into the subcutaneous tissues above the retinaculum (Fig. 2). If desired, the posterior interosseous nerve may be resected for additional pain relief. Subperiosteal dissection is performed beneath the second and fourth compartments, extending to the diaphyseal-metaphyseal junction of the radius. An inverted T-shaped capsulotomy (Fig. 3) is performed in the dorsal capsule. The carpus is exposed and the radiocarpal and midcarpal joints are inspected to ensure that degenerative changes are limited only to the radiocarpal articulation. The distal one-third of the scaphoid is then resected. This unlocks the midcarpal joint, reduces the development of degenerative changes in the adjacent joints, and decreases the rate of nonunion. 6,11 13 This can be completed with an osteotome, oscillating saw, or rongeur. Care is taken to preserve the support of the scaphoid under the capitate and avoid injury to the cartilage surface of the capitate. The entire triquetrum can also be resected, because evidence has suggested improvements in wrist motion with the addition of triquetrectomy. 11 A provisional pin is placed across the scapholunate joint to maintain their relationship, and the cartilage and subchondral bone are removed from the surfaces of the scaphoid, lunate, and distal radius. This can be done with a rongeur and high-speed burr; irrigation helps prevent thermal necrosis (Fig. 4). The scaphoid and

3 790 RSL ARTHRODESIS WITH HEADLESS COMPRESSION SCREWS FIGURE 5: A At least 2 cm from the subchondral surface of the distal radius B the crescent shaped corticotomy is marked. C Variable-angle curettes are then used to harvest cancellous bone graft. lunate are reduced to the distal radius with fluoroscopic guidance, ensuring proper congruity. A dorsal corticotomy of the distal radius is performed to harvest bone graft and allow optimal placement of the fixation screws. A crescent-shaped corticotomy is made using a burr along the dorsal 30% of the distal radius. This should begin 2 cm proximal to the radiocarpal joint and extend approximately 1 cm proximally (Fig. 5A, B). Curettes are used to harvest cancellous bone graft from this metaphyseal trough (Fig. 5C). Great care is taken to preserve at least 1.5 cm of bone proximal to the fusion site, to maximize screw purchase within the subchondral bone of the distal radius. The bone graft is then applied to the fusion site (Fig. 6). The scaphoid and lunate are reduced relative to the distal radius and the capitate, maintaining neutral rotation relative to the capitate. Manual compression is applied across the carpus while guide pins for the cannulated screws are inserted. The guide pins are placed with fluoroscopic guidance, antegrade through the dorsal corticotomy within the bone graft defect (Fig. 7). Their trajectory begins just beneath the dorsal cortex and enters the scaphoid and lunate in their midpoints, as seen on posteroanterior and lateral fluoroscopic views. The dorsal corticotomy FIGURE 6: Cancellous bone graft is applied to the radiocarpal joint. and bone graft defect allow for central placement of the screws in the midcoronal plane that otherwise would not be possible. Passive motion in both flexion and extension across the wrist is evaluated to see whether adjustments in the position of the scaphoid and lunate are necessary. There should be a bias toward extension of the scaphoid and lunate to allow for greater wrist extension than flexion. A cannulated depth gauge is placed over the guide pin to measure its length across the arthrodesis. The

4 RSL ARTHRODESIS WITH HEADLESS COMPRESSION SCREWS 791 FIGURE 7: A Clinical photograph and B corresponding fluoroscopic image of the proximal row reduced to the distal radius with compression and Kirschner-wires advanced as provisional fixation, to maintain reduction. FIGURE 8: After placement of each guidewire and measurement, a cannulated screw is advanced over each guidewire. actual screw length should be approximately 4 mm shorter than this measurement to allow for compression and countersinking. The selected screw is advanced over the guidewire (Fig. 8) using fluoroscopy. This is to confirm its path and ensure that the distal tip does not penetrate into the midcarpal joint (Fig. 9). Whereas the metaphyseal bone of the distal radius features predominantly cancellous bone, our anecdotal experience demonstrates excellent transarticular compression with the use of headless compression screws between both the radioscaphoid and radiolunate joints. We routinely confirmed this with tactile feedback as well as intraoperative fluoroscopy. The guidewires are removed and the corticotomy is filled with crushed cancellous allograft to expedite the healing process. The dorsal wrist capsule and retinaculum are repaired followed by a layered closure of the subcutaneous tissues and skin. A soft, gently compressive dressing and splint are applied with the wrist in neutral position. FIGURE 9: Anteroposterior radiograph demonstrating screw placement; the distal tip of each screw is situated short of the subchondral bone of the midcarpal joint. POSTOPERATIVE CARE The patient is placed in a short-arm cast or splint at the first postoperative visit. Range of motion is encouraged in the digits and occupational therapy is prescribed as needed. Subsequent evaluations are usually performed at 4-week intervals until there is radiographic evidence of fusion (Fig. 10). This typically occurs between 6 and 12 weeks. The fusion can be further evaluated and confirmed with a computed tomography scan. After confirmation of successful fusion, immobilization is discontinued and a progressive range of motion and strengthening program of the wrist is initiated. RESULTS Between August 2010 and October 2011, we identified 9 patients who underwent RSL arthrodesis performed by the senior authors (M.S.C. and J.J.F.) for degenerative joint disease isolated to the radiocarpal articula-

5 792 RSL ARTHRODESIS WITH HEADLESS COMPRESSION SCREWS FIGURE 10: A, B Preoperative radiographs of a 51-year-old man who previously underwent open reduction and internal fixation of a comminuted, intra-articular distal radius fracture at an outside institution; he later developed arthrosis of the radiocarpal joint and required hardware removal. Note the preserved midcarpal joint. C, D Postoperative radiographs after RSL arthrodesis demonstrate complete consolidation across the radioscaphoid and radiolunate articulations. tion using the surgical technique described here. The primary diagnoses were posttraumatic arthritis (7 patients), primary osteoarthritis (1 patient), and rheumatoid arthritis (1 patient). The average age at the time of arthrodesis was 43 years (range, y). There were no intraoperative or postoperative complications. All 9 wrists exhibited radiographic evidence of solid arthrodesis at the time of follow-up, with no evidence of midcarpal arthrosis at a mean follow-up of 12 months. DISCUSSION Isolated degeneration of the radiocarpal joint may occur posttraumatically and can be associated with both noninflammatory and inflammatory arthropathies. Over the past several decades, RSL arthrodesis has been validated as a motion-preserving surgical treatment for this condition. Innovations in surgical technique and implant design have improved the efficacy and outcomes of RSL arthrodesis. 1,4,5,7 Several studies have demonstrated superior biomechanical performance of cannulated compression screws compared with isolated Kirschner wire fixation in the treatment of scaphoid injuries and partial fusions of the wrist. 8,14 17 Kirschner wire fixation also runs the risk of additional soft tissue complications such as infection and tendon or nerve irritation, and may necessitate a subsequent operative procedure to remove hardware. Early reports of RSL arthrodesis demonstrated relatively high rates of nonunion as well as secondary degenerative changes of the midcarpal joint. Using isolated Kirschner wire fixation, Watson et al 18 encountered 1 nonunion in four patients undergoing RSL fusion. Sturznegger and Buchler 19 reported nonunions in 2 of 15 RSL fusions (13%) using a variety of techniques, including 3.5-mm T-plates, S-fragment condylar plates, and memory staples. This study also documented secondary degeneration of the midcarpal joint in 36% of patients. These findings led the authors to question the efficacy of RSL arthrodesis. As surgical techniques and principles for RSL fusion evolved, nonunion rates decreased and clinical outcomes improved (Table 1). The use of an appositional technique for arthrodesis to maximize surface area, as opposed to maintaining carpal height with an interca-

6 RSL ARTHRODESIS WITH HEADLESS COMPRESSION SCREWS 793 TABLE 1. Previous Reports of RSL Arthrodesis, Including Method of Fixation and Nonunion Rate Author Technique/Fixation Nonunion Rate Comments Watson et al 18 Kirschner wire 1 of 4 patients (25%) Sturznegger and Buchler mm T-plate (12), S-condylar plate (2), Shapiro staple (1) 2 of 15 patients (13%) Midcarpal arthrosis noted in 35.7% of patients Bach et al 9 Kirschner wire (21), Herbert screw (15) 2 of 18 patients (11%) Garcia-Elias et al 13 Kirschner wire (13), Herbert screw (2), T-plate (1) 0 of 16 patients Distal scaphoidectomy performed in conjunction with RSL arthrodesis Shin and Jupiter mm distal radius plate 0 of 4 patients Iliac crest bone used for bone graft Bain et al 4 Memory staples 0 of 23 patients Distal scaphoid and triquetrum excised in all cases lated graft, greatly improved fusion rates. Excision of the distal pole of the scaphoid improved postoperative range of motion but also reduced stress at the proximal radioscaphoid articulation, thereby promoting the development of a successful arthrodesis. 13 As more authors recognized the importance of a normal midcarpal joint as well as improved surgical technique, a variety of fixation techniques, including Kirschner wires, Herbert screws, memory staples, and distal radius plates, all resulted in excellent outcomes and minimal nonunion rates. 4,5,13,20 Although the series of Bain et al 4 achieved 100% union rates with the use of memory staples, the use of this fixation is technically demanding and is contingent on accurate drill hole placement as well as temperaturedependent changes in the architecture of the memory staple to achieve compression. Similarly, Shin and Jupiter 5 achieved 100% union rates in their series using plate fixation, but also harvested and applied autogenous iliac crest bone graft. Garcia-Elias et al 13 reported 100% union rates with Kirschner-wire fixation, but the patients in their cohort required a second procedure for pin removal. Although we did not conduct a comparison with these other techniques in our study, we describe a technique that we believe offers several advantages over traditional methods of RSL arthrodesis. The principal benefits are the added compression and stability provided by screw fixation compared with isolated Kirschner wires, as well as the technical ease of placing headless, cannulated compression screws compared with more complex fixation (ie, memory staples). The limited use of Kirschner wires decreases the risk of tendon or dorsal radial sensory nerve injury and further minimizes the risk of infection. This also eliminates the need for later procedures to remove the hardware. In addition, the use of buried screws has an advantage over dorsal plate fixation, which may result in extensor tendon related complications. The harvest of autogenous bone graft from the distal radius metaphysis affords a better-quality and more abundant cancellous bone graft than when harvested from excised portions of the carpus (ie, distal scaphoid). This also obviates the need to harvest from other sites (eg, olecranon or iliac crest). There are limitations to this technique. The corticotomy typically includes approximately 75% of the width of the dorsal distal radius, which could serve as a stress riser and increase the risk of postoperative fracture. No patients in this cohort experienced a postoperative fracture through the corticotomy site, and we routinely apply cancellous allograft to reconstitute the harvest site to expedite healing and decrease this risk. We believe that this is an effective method to perform a radioscapholunate arthrodesis in the appropriately selected patient with a preserved midcarpal joint. Clinical follow-up in a patient cohort is under way at our institution to determine whether this technique achieves favorable clinical and functional outcomes while maintaining a 100% union rate. REFERENCES 1. Raven EE, Ottink KD, Doets KC. Radiolunate and radioscapholunate arthrodeses as treatments for rheumatoid and psoriatic arthritis: long-term follow-up. J Hand Surg Am. 2012;37(1): Sraj SA, Seitz WH Jr. Scaphoid hemiresection and arthrodesis of the radiocarpal joint. Tech Hand Up Extrem Surg. 2010;14(3): Meek MF, Heras-Palou C. Radioscapholunate arthrodesis for advanced degenerative radiocarpal osteoarthritis. Tech Hand Up Extrem Surg. 2008;12(1): Bain GI, Ondimu P, Hallam P, Ashwood N. Radioscapholunate arthrodesis a prospective study. Hand Surg. 2009;14(2-3): Shin EK, Jupiter JB. Radioscapholunate arthrodesis for advanced degenerative radiocarpal osteoarthritis. Tech Hand Up Extrem Surg. 2007;11(3): Nagy L, Buchler U. Long-term results of radioscapholunate fusion following fractures of the distal radius. J Hand Surg Br. 1997;22(6): Pervaiz K, Bowers WH, Isaacs JE, Owen JR, Wayne JS. Range of motion effects of distal pole scaphoid excision and triquetral exci-

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