SURGICAL TECHNIQUE

Modified AO Arthrodesis of the Wrist (With Proximal

Row Carpectomy)
David P. Green, MD, Chance J. Henderson, MD

A technique that has proven highly predictable and successful for arthrodesis of the wrist
involves combining rigid internal fixation with concomitant removal of the proximal carpal
row bones, which are then morselized and used for bone graft. Advantages of this procedure
are (1) no distant bone graft site is required and (2) rigid internal fixation allows virtually
immediate rehabilitation. (J Hand Surg 2013;38A:388–391. Copyright © 2013 by the
American Society for Surgery of the Hand. All rights reserved.)
Key words Arthrodesis, wrist.
Surgical Technique

joint arthroplasty, ar- Another technique was described in the second edi-

E
VEN IN THIS ERA OF TOTAL
throdesis remains one of the most successful and tion of the AO Small Fragment Set Manual (1982)6
predictable operations in our armamentarium for using a 3.5-mm dynamic compression plate (DCP) for
the treatment of posttraumatic arthritis in the wrist, fixation combined with bone grafting. (This technique
especially in a patient who must use the hands for heavy did not appear in the first edition of this manual, pub-
work. lished in 1974.7)
For many years, the standard, accepted method of In the mid-1980s, an author of the current report
wrist arthrodesis was with a large corticocancellous iliac (D.P.G.) began to combine the AO and Louis et al
crest bone graft. The cortical component of the graft pro- techniques, using graft from the morselized carpals,
vided stability, and no internal fixation was used. The which eliminates the need for distant bone graft. The
operation could be done either from the radial side, using strong internal fixation provided by the 3.5-mm DCP
the technique of Haddad and Riordan,1 or through a dorsal obviated the need for any postoperative cast immobili-
incision, as described by Carroll and Dick.2 zation and healing proved to be much more rapid and
In 1984, Louis et al3 described a method of wrist predictable than with the older corticocancellous graft
arthrodesis specifically indicated for a child with spas- methods.
ticity. In an attempt to shorten the bony skeleton and A preliminary report of this technique was published
thereby lessen some of the tightness in the flexor ten- in 1993,8 and this follow-up article is based on a series
dons, a proximal row carpectomy was done and the of 110 wrists arthrodesed with this technique by a single
distal row of carpus was arthrodesed to the distal radius, surgeon (D.P.G.) in an 18-year period (1994 –2011).
using Steinmann pins for fixation. No bone graft was Several important lessons have been learned, and ap-
required. These authors noted that a similar type of propriate modifications have been made in the tech-
wrist arthrodesis had been described by Robinson and nique since the original article. The purpose of this
Kayfetz in 19524 and Hoffer and Zeitzew in 1988.5 report is to describe the revised operation in detail.
FromtheHandCenterofSanAntonio,DepartmentofOrthopaedics,UniversityofTexasHealthScience
Center at San Antonio. INDICATIONS AND CONTRAINDICATIONS
Received for publication October 9, 2012; accepted in revised form November 15, 2012. The most common indication for arthrodesis of the
No benefits in any form have been received or will be received related directly or indirectly to the wrist is degenerative or posttraumatic arthritis, and in
subject of this article. 46% of our patients, the diagnosis was scapholunate
Corresponding author: David P. Green, MD, The Hand Center of San Antonio, 21 Spurs Lane, advanced collapse (SLAC) or scaphoid nonunion ad-
#310, San Antonio, TX 78240; e-mail: [email protected]. vanced collapse (SNAC) wrist. Other indications in-
0363-5023/13/38A02-0029$36.00/0 cluded end-stage Kiënbock disease, spastic wrist con-
http://dx.doi.org/10.1016/j.jhsa.2012.11.010
tracture, nonunion or malunion of distal radius

388 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.

 MODIFIED AO ARTHRODESIS OF THE WRIST 389

fractures, pseudarthrosis of previous arthrodesis proce- With the distal radius and carpus thus fully exposed,
dure, failed proximal row carpectomy, failed scapholu- the 3 proximal carpals are removed. It is usually easier
nate ligament reconstruction, Preiser avascular necrosis to start with the triquetrum, then the lunate, and finally
of the scaphoid, silicone synovitis, and previous infec- the scaphoid. The scaphoid is cut transversely with an
tion. osteotome, leaving the distal one third of the bone still
The most significant contraindication would be active attached to the trapezium and trapezoid. A parallel cut
infection, but this operation has been successfully done in is then made through the tip of the radial styloid.
patients with previous infection in which the inflammatory With the proximal row removed, the hand is flexed
process had been rendered totally quiescent. to expose the distal articular surface of the radius. Using
A theoretical contraindication would be osteoporotic the cautery mark on the dorsal cortex of radius, the
bone, which would preclude rigid fixation, but that was proximal pole of the capitate is aligned with the radius;
not seen in any of these patients, in part probably owing this line becomes the center of the concavity that is to
to the relative younger age of most of our patients be created in the distal radius. It is imperative when
(range, 19 –76, average, 49.8 y). excavating the cavity to avoid the distal radioulnar joint
A relative contraindication is rheumatoid arthritis, (DRUJ), and a line drawn along the sigmoid notch with
not because this procedure would not work, but because a blue marking pen is the best way to prevent inadver-

Surgical Technique
a simpler type of wrist arthrodesis described by Mil- tent violation of that joint. A circle approximately the
lender and Nalebuff9 is the authors’ preferred method in diameter of the capitate is then drawn on the articular
rheumatoid patients. surface of distal radius (usually this will span the scaph-
oid and lunate fossae), and a narrow osteotome is used
SURGICAL TECHNIQUE to outline the circle. With a combination of osteotomes
A longitudinal midline incision is made from the distal and gouges, a concavity is then created in the distal
aspect of the third metacarpal to the outcropper muscle radius well into cancellous bone.
group in the distal forearm. Subcutaneous vessels are Cartilage and subchondral bone are then removed
cauterized or ligated, and the skin flaps are raised to with a rongeur from the proximal articular surfaces of
expose the dorsal retinaculum. The extensor pollicis the capitate and hamate, and the capitate is matched up
longus (EPL) tendon is exposed distal to the retinacu- with the new concavity in the distal radius until there is
lum as it runs obliquely over the radial wrist extensors. a snug fit. Some adjustment may need to be made in the
The EPL sheath is entered and followed proximally to 2 parallel cuts in the scaphoid and radial styloid to
the Lister tubercle, and from this point, the retinaculum ensure a good fit. Usually, there will be some space
is opened longitudinally between the third (EPL) and between the scaphoid and the styloid. The proximal two
fourth (extensor digitorum communis [EDC]) dorsal thirds of the third metacarpal is then exposed subperi-
compartments. Although not critical, it is preferable if osteally.
the fourth compartment is reflected ulnarly with the The ideal fixation for this type of arthrodesis is the
tendon sheath intact. One or both of the radial wrist 9-hole tapered plate in the AO wrist arthrodesis set
extensors (extensor carpi radialis brevis [ECRB] and (3.5-mm screws proximally, 2.7-mm screws distally)
extensor carpi radialis longus [ECRL]) may be tran- (Fig. 1). A slight (10°–15°) bend is made in the plate
sected to facilitate exposure because they will no longer between the 2 most distal large holes to position the
have functional significance. The distal stump of the wrist in slight extension. Greater degrees of bend will
ECRB can be left attached distally with 2 to 3 cm of result in excessive extension.
tendon, which can be used for soft tissue coverage of With the capitate nestled snugly into the cavity of the
the distal aspect of the plate if needed during closure. distal radius, preliminary fixation of the plate is accom-
The dorsal capsule of the wrist is then opened with a plished by first inserting the most distal 2.7-mm screw
longitudinal incision, exposing the entire carpus, and into the third metacarpal and then the most proximal
the distal radius is exposed subperiosteally at least as far 3.5-mm screw into the radius. Exposure for the latter
proximal as the outcropper muscle bellies. may require slightly more dissection to retract the out-
A critical step at this point is to mark the dorsal cropper muscle bellies.
cortex of the distal radius in line with the midline of A very critical step in this operation is to take a
the capitate, which will facilitate proper alignment radiograph at this point, with only these 2 screws in
of the carpus after the proximal row has been re- place. Even though care was taken to position the
moved. The electrocautery turned up to high power is carpus correctly with the aid of the cautery marker lines,
an easy way to make this indelible line. it is very easy to misalign the arthrodesis. If the carpus

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 390 MODIFIED AO ARTHRODESIS OF THE WRIST

imal row carpectomy has been done in a previous

procedure, the proximal tibia should be prepared and
the patient advised before surgery of a distant (cancel-
lous) bone graft, but this was not necessary in any of
our patients.
The arthrodesis can be combined with any of the
various salvage procedures for the DRUJ, as indicated
in each individual patient. Most of our patients did not
have a concomitant DRUJ operation.
Final radiographs are taken after all the screws have
been inserted, primarily to be sure that all screws are of
the correct length.
The tourniquet is released and hemostasis secured. The
dorsal retinaculum is reapproximated, and the EPL tendon
is transposed superficially to a new position overlying the
retinaculum. Because the wrist is now fused and there will
Surgical Technique

be no movement to cause hypertrophy of the scar, it is not

necessary to do a layered closure with separate sutures in
the subcutaneous layers, but a subcuticular closure of the
skin is preferred to obviate cross hatches in the scar.
Suction drainage is used routinely and is generally re-
moved 24 hours after surgery.
Because of the rigid internal fixation, no splinting is
required, although the soft dressing may have to be split
FIGURE 1: Following removal of the proximal carpal row because there is usually moderately severe swelling
bones, the capitate (C) is seated into a cavity in the distal following this very extensive operation. It is recom-
radial articular surface. The distal pole of scaphoid (S) is left mended that a carpal tunnel release be done in all
intact and a parallel cut is made through the radial styloid; patients who have not had a previous release because an
bone graft is packed into the gap between them. Precise acute carpal tunnel after surgery can have serious im-
alignment of the carpus with the distal radius is one of the plications.
most critical details of this operation. H, hamate.
POSTOPERATIVE MANAGEMENT AND
is fixed too far radially, the end result is a very prom- REHABILITATION
inent ulnar styloid, which is unattractive and may result When the sutures are removed around 10 days after
in an unhappy patient. surgery, the patient is given a home program of exercise
If the alignment is satisfactory, the remaining screws and strengthening by a hand therapist. An important
are inserted. To gain better purchase, it is advisable to part of the program must be intrinsic stretching exer-
direct the most distal screw in the radius at an oblique cises because periosteal stripping of the third metacar-
angle to engage the thicker cortical bone of diaphysis pal will almost inevitably result in intrinsic contracture
rather than into the thinner bone in the metaphysis (Fig. in the middle finger if stretching is not done.
2A). The longest screws are usually this screw and the Follow-up radiographs are taken at 2-month inter-
next most distal one, which passes into the capitate and vals until clear radiographic union is present, which
rarely has good purchase because that bone has been occurred in virtually all of our patients by 4 months.
decorticated. The most proximal small (2.7-mm) screw In our series of 110 patients, grip strength when the
goes into the base of the third metacarpal, taking care to dominant hand was operated on was 98% of the oppo-
avoid the carpometacarpal (CMC) joint. A formal arth- site side. If the nondominant hand was done, grip
rodesis (ie, decortication) of the CMC joint is not done, strength was 53% of the opposite side.
but the plate spans that joint (see note later).
The removed carpals are then morselized to create PEARLS AND PITFALLS
small (2 ⫻ 2-mm) cancellous chips that can be packed This technique is relatively easy to perform and has a
in around the capitoradius site and also in between the high degree of predictability for success. The two major
distal pole of scaphoid and the radial styloid. If a prox- advantages of this method are (1) no distant bone graft

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 MODIFIED AO ARTHRODESIS OF THE WRIST 391

FIGURE 2: Postoperative radiographs. A In the lateral view, note that the most distal screw in the radius is angled proximally to
gain purchase on more solid cortical bone. B In this patient, a solid fusion was achieved between the radial styloid and the distal
pole of the scaphoid, but in many patients, only fibrous union was achieved here.

site is required and (2) rehabilitation can be started Only 2 patients (of 110) failed to fuse between the
almost immediately after surgery because no immobi- capitate and the radius. One of these was a patient with
lization is required. an old, infected nonunion of a distal radius fracture who
It is absolutely imperative to position the carpus in had apparent pseudarthrosis when he was last seen 3
correct alignment with the radius, and failure to achieve months after surgery. The other was a patient with stage
this is not uncommon unless the steps described in the III SLAC wrist, who had a questionable nonunion when

Surgical Technique
Technique section are carried out. she was lost to follow up 2.5 months after surgery.
Conversely, failure to achieve radiographic union
COMPLICATIONS
between the radial styloid and the distal pole of scaph-
The most common complications in the early years of this oid was common (72 patients), but this did not appear
series were tenderness over the 3.5-mm DCP and intrinsic to make any appreciable difference in the final result.
contracture of the middle finger, and it was not uncommon In conclusion, this technique of wrist arthrodesis
that hardware removal and Littler instrinsic release were combining previously described methods of proximal
required in 12 patients. With the introduction by AO of the
row carpectomy and rigid internal fixation has proved
tapered wrist arthrodesis plate and with our own recogni-
to be a highly predictable operation with much less
tion of the intrinsic contracture problem, the need for a
morbidity and fewer complications than with the older
second operation was virtually eliminated.
techniques using distant bone graft.11
For the first 7 years of this series, it was our routine
practice to do a formal arthrodesis of the third CMC joint.
However, in 2002, Nagy and Büchler10 published a paper REFERENCES
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desis. Because of this report, we did a retrospective review arthritis. J Bone Joint Surg Am. 1971;53(7):1365–1369.
of patients who had hardware removal and discovered 3. Louis DS, Hankin FM, Bowers WH. Capitate-radius arthrodesis: An
virtually identical results. Subsequent to this, we have not alternative method of radiocarpal arthrodesis. J Hand Surg Am.
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4. Robinson RF, Kayfetz DO. Arthrodesis of the wrist. Preliminary
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Problems can be created in forearm rotation owing to 5. Hoffer MM, Zeitzew S. Wrist fusion in cerebral palsy. J Hand Surg
penetration of the sigmoid notch during excavation of Am. 1988;13(5):667– 670.
the distal radius. Careful avoidance of the sigmoid notch 6. Heim U, Pfeiffer KM. Small Fragment Set Manual. Technique
Recommended by the ASIF Group. 2nd ed. Berlin, Heidelberg, New
and triangular fibrocartilage (TFC) during this part of the
York: Springer-Verlag; 1982.
operation obviates subsequent DRUJ problems. 7. Heim U, Pfeiffer KM. Small Fragment Set Manual. Technique
Two patients developed an acute carpal tunnel syn- Recommended by the ASIF Group. 1st ed. Berlin, Heidelberg, New
drome immediately after surgery, requiring a return to York: Springer-Verlag; 1974.
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comparison of two methods. J Hand Surg Am. 1993;18(5):786–791.
manent diminution of sensibility in the median nerve 9. Millender LH, Nalebuff EA. Arthrodesis of the rheumatoid wrist. An
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release having been done within 24 hours of the wrist technique. J Bone Joint Surg Am. 1973;55(5):1026 –1034.
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