Scapholunate Advanced Collapse Treatment & Management
- Author: Dimitrios Danikas, MD, FACS; Chief Editor: Harris Gellman, MD more...
It is not uncommon to encounter a patient with an asymptomatic scapholunate advanced collapse (SLAC) wrist. The patient should be informed of the problem but may not require any treatment. If symptomatic, the patient should be given the various options for treatment.
Mild symptomatic SLAC can often be managed nonoperatively with periodic steroid injections, splinting, and NSAIDs. If the grip strength registers more than 80% that of the uninvolved wrist and the condition is not significantly impairing, then living with the condition is a valid option.
Limited wrist fusion (SLAC reconstruction)
A scapholunate advanced collapse (SLAC) reconstruction involves scaphoid excision and arthrodesis of the capitate, lunate, hamate, and triquetrum. Two parallel dorsal transverse incisions, a lazy S, or a central longitudinal incision over the distal radiocarpal joint and styloid process is made. The extensor retinaculum is incised through the third dorsal compartment. The terminal branch of the posterior interosseous nerve in the floor of the fourth extensor compartment can be sacrificed as an adjunctive pain relief measure. The wrist capsule is opened over the capitolunate joint. The scaphoid is resected in piecemeal fashion. Articular cartilage and subchondral bone are removed from the capitate, lunate, hamate, and triquetrum. Care should be taken to maintain the anatomic relationsp of the intercarpal intervals. Cancellous bone is harvested from the distal radius, the proximal ulna or, from the iliac crest.
Lunate dorsal intercalated segment instability (DISI) should be corrected, and 5 percutaneous Kirschner wires (K-wires) are used. Two wires are placed through the capitate into the lunate, one each through the hamate and triquetrum into the lunate, and a fifth wire through the triquetrum into capitate. Cancellous bone graft is packed between the interstices of the 4 bones.
A long arm splint is placed after the procedure. After a week, the splint is replaced with a long arm cast, which is maintained for 3 weeks. Then, a short arm cast is placed and maintained for an additional 2-4 weeks. The cast and wires are removed when fusion is evident on radiographs. See the images below.
Some newer fixation methods of this 4-quadrant fusion include the use of intercalary screws and a dorsal carpal plate marketed especially for this fusion. It remains to be seen whether the increased cost of such devices results in improved outcomes. More solid fixation does allow the use of a short arm cast and an earlier initiation of wrist ROM therapy.
Patients with radiolunate changes are not candidates for SLAC reconstruction. A wrist arthrodesis should be performed.
Proximal row carpectomy
Proximal row carpectomy (PRC) requires resection of the proximal row of wrist bones to allow articulation of the capitate within the lunate fossa.[14, 15, 16] For a successful procedure, both the proximal capitate articular surface and the lunate fossa should ideally be free of pathology. The procedure is usually effective only when the disease is restricted to the radioscaphoid joint. PRC provides the best motion (average arc 71°) but may be associated with painful narrowing of radiocapitate joint. It is not indicated for stage 2 SLAC wrist. It may serve as a salvage procedure for stages 1A and 1B when limited wrist fusion is not indicated. Failure of PRC requires conversion to wrist arthrodesis.
A dorsal longitudinal or transverse incision is used. The extensor tendons are retracted. A longitudinal capsulotomy is extended radially and ulnarly. The capitate is identified, and its articular surface is inspected. In the presence of capitate degenerative changes, the procedure should not be performed. If both proximal capitate articular surface and lunate fossa are free of pathology, the scaphoid, lunate, and triquetrum are excised. Both radioscaphocapitate and long radiolunate ligaments are preserved. Wrist collapse follows, with placement of the capitate head in the lunate fossa along with radial deviation of the wrist. If impingement between the radial styloid and the trapezium is present, a limited radial styloidectomy is performed. The capsulotomy incision is closed snugly.
Following the procedure, the wrist is splinted for 4 weeks. Early active digital flexion and extension are recommended. ROM exercises start 4 weeks after the procedure. Strengthening exercises and heavy lifting may begin 3 months after the procedure.
Comparisons between PRC and other techniques can be found in Vanhove et al and Dacho et al. Van Riet and Bain present findings using memory staples in the three-corner wrist fusion technique.
Total wrist arthrodesis
Total wrist fusion (see the images below) diminishes pain, but wrist function is sacrificed. Patients may have functional limitations interfering with lifestyle, and total fusion does not always result in complete pain relief.
Using a central, dorsal, longitudinal incision, the extensor retinaculum is incised. The incision is carried down to bone surface from middle finger metacarpal to distal radius, raising capsular and periosteal flaps. Articular cartilage and subchondral bone are resected from the radioscaphoid, radiolunate, lunocapitate, scaphocapitate, and middle finger carpometacarpal joints. The radioulnar joint should not be entered. The index finger carpometacarpal joint may also be opened for fusion. The radial metaphysis is generally used for the necessary cancellous bone graft and more distal harvest is not required.
Bone grafts are placed in the radiocarpal, midcarpal, and carpometacarpal fusion sites, and a wrist fusion plate is applied. The fusion plate is secured with screws at the middle finger metacarpal, the capitate, and the radius. Periosteal and capsular flaps are reapproximated. A short arm splint is applied until fusion can be seen on radiographs. Fusion is usually evident in 6-8 weeks.[21, 22]
Total wrist arthroplasty
Total wrist arthroplasty is an alternative to diffuse arthrosis of the wrist, especially in rheumatoid arthritis and if bilateral disease is present. With bilateral disease, a combination of a total wrist arthroplasty and a contralateral total wrist fusion is an option. Numerous implants have been used; however, major complications of implant loosening and wear of the components are common.
See Outcome and Prognosis.
Outcome and Prognosis
In a series of 250 procedures, Watson and Weinzweig reported nonunion in 1%, wound infection in 1%, reflex sympathetic dystrophy in 1.5%, and capitate-radial impingement requiring revision arthroplasty in 13%. The high incidence of dorsal impingement was the result of noncorrection of the lunate dorsal intercalated segment instability (DISI) deformity. A flexion/extension arc of 60-65° can be expected with a 4-bone fusion. Brown and Erdmann present complications after 50 consecutive limited wrist fusions.
Proximal row carpectomy
Krakauer et al compared scapholunate advanced collapse (SLAC) reconstruction with proximal row carpectomy (PRC). Patients with PRC had 71° of motion, and patients with SLAC reconstruction had 54° of motion. Krakauer et al recommend PRC for patients without lunate pathology and SLAC reconstruction for patients with capitolunate arthritis. Wyrick et al presented similar results and recommendations. Total wrist motion was 85° and grip strength 94% in the PRC group. Total wrist motion was 67° and grip strength 74% in the SLAC group. Imbriglia et al presented results of long-term follow-up after proximal-row carpectomy. Four years after the procedure, 26 of 27 patients had pain relief, ROM did not deteriorate, and 80% of patients improved their grip strength. PRC appears to offers better ROM and almost normal grip strength. In some patients, conversion to wrist arthrodesis may be required because severe pain persists.[29, 30, 31, 32]
Kiefhaber et al report a higher number of complications in the 4-corner fusion group, including nonunion and hardware-related problems. The failure rate and need to convert to a fusion is higher in patients who have a PRC and are younger than 35 years. This author prefers 4-corner fusion for patients younger than 35 years and for middle-aged patients with high demand. A PRC is favored for all others.
Total wrist arthrodesis
Hastings et al reported a 2% nonunion rate with total wrist fusion. The most common nonunion site was the middle finger carpometaphalangeal joint. To prevent this complication, complete decortication of the dorsal 80% of the carpometaphalangeal joint is recommended. Other complications were tendon adhesions (in 3.5% of patients), carpal tunnel syndrome, and iliac crest harvest site problems (in 1.7% of patients). Weiss et al discuss upper extremity function after arthrodesis. Dacho et al discuss long-term results.
Total wrist arthroplasty
Major complications of implant loosening and wear of the components are common.
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