Proximal row carpectomy (PRC) alleviates arthritic joint pain caused by three fused bones. PRC restores 64% of movement and 65% of grip strength, and a cast is required for 4-6 weeks after surgery.
There are many activities that become frustratingly difficult due to chronic wrist pain, including opening jars and turning doorknobs. When pain is chronic and all other recommended treatments have been exhausted, it is not uncommon for an orthopedic surgeon to recommend a PRC.
PRC surgery eliminates the cause of pain while preserving range of motion. Knowing the details of the surgery, the recovery time, and the surgery’s effect long term, will all enhance a patient’s ability to make an informed decision to improve joint health.
This guide provides an overview of PRC, including what to expect in the early stages after the surgery through the last physical therapy session.
What is Proximal Row Carpectomy surgery and who needs it?
Articular carpectomy is performed on patients suffering from advanced wrist arthritis and certain other degenerative conditions, to excise the carpal bones of the wrist’s proximal row.
Surgeons normally recommend PRC surgery to patients that have one of the following conditions:
- SLAC (Scapholunate Advanced Collapse): Arthritis, which occurs following severe ligament injuries that result in scapholunate dislocation.
- SNAC (Scaphoid Nonunion Advanced Collapse): Arthritis following a scaphoid fracture with non-union.
- Kienböck’s disease: The lunate bone becomes avascular necrotic. Proximal row carpectomy is indicated for stages III and IV.
Research shows that this procedure is best for patients in the 35 to 40 age range and older. Younger patients may be more active, making demands on the wrist that will lead to degeneration of the newly configured wrist sooner.
How does the anatomy of the wrist lead to joint pain?
The bones of the wrist are small and are arranged into the carpal bones of the proximal row and distal row. The bones in the proximal row of the wrist closest to the forearm are the scaphoid, lunate and triquetral bones.
When the carpal bones are healthy, they are capped with a layer of smooth slippery cartilage which allows the bones to glide and facilitates motion of the wrist. When carpal bones are injured or become diseased, the cartilage is no longer present, and there is friction between the carpal bones. This bone-on-bone friction causes significant pain and stiffness.
How do orthopedic surgeons evaluate severe conditions of the wrist?
The goal of the evaluation of your wrist and the diagnosis of your condition is to relieve pain. The orthopedic surgeon will evaluate the injuries and the condition of your wrist using various imaging modalities.
The first part of your injury evaluation will be a physical examination. Your wrist is examined to determine your current strength, areas of pain, and your active range of motion. The next part of the evaluation will be a series of X-rays to evaluate your wrist joint for degeneration, formation of bone spurs, and the collapse of your wrist bones.
In some cases, physicians may order a Magnetic Resonance Imaging (MRI) scan or a Computed Tomography (CT) scan. These imaging technologies will help doctors determine the status of your ligaments and cartilage. For a successful proximal row carpectomy, a healthy capitate bone (in the distal row) is a must.
What are the non-invasive alternatives to wrist surgery?
Before deciding on a surgical remedy, doctors will consider more conservative treatment options. Choose non-invasive treatment options first if your wrist pain is not consistent and based on imaging studies, there is minimal cartilage deterioration.
In the conservative treatment of wrist arthritis, the most common options include taking nonsteroidal anti-inflammatory drugs (NSAIDs) to treat the arthritis symptoms. Corticosteroid injections may be given directly to the wrist joint and may help alleviate pain for several months. A rigid brace with a course of physical therapy may also reduce pain and improve function of the affected wrist.
When the conservative treatment options fail, and your quality of life is affected, surgery is the next logical option.
What occurs with proximal row carpectomy (PRC)?
Proximal row carpectomy is an outpatient procedure. In most instances, the patient is discharged to go home the same day. For this procedure, either a regional anesthesia (to block the entire arm) or a general anesthesia (to make the patient completely unconscious) is administered.
A surgical incision is made on the dorsal side of the wrist in order to open the joint capsule. The scaphoid, lunate, and triquetrum are removed. This ceases the bone-on-bone arthritic pain.
After removing the proximal row, the surgeon allows the distal row capitate bone to slide and rest in the natural socket of the radius bone in the wrist to form a simplified joint. The incision is closed, and the arm is fully immobilized in a bulky dressing or left in a plaster splint.
What does the recovery timeline for Proximal Row Carpectomy look like?
During the recovery period, you will have to be extremely disciplined and patient. The recovery is different for everyone, but it usually takes the same amount of time.
Your wrist will remain in a rigid splint or cast for the first 4 to 6 weeks, completely immobilized. This period is crucial for the soft tissue to heal in the surrounding area of the joint. During this period, you will lose stiffness in your fingers, but you will not be able to put any weight on your wrist.
The cast will be removed 4 to 6 weeks after the procedure. A removable, custom-designed splint will be substituted. You will be working with a physical therapist for the first time to begin a series of passive range-of-motion exercises. No strength exercises will be allowed for 6 weeks after the operation.
Between the 6 and 12-week period, the focus will begin on strengthening the wrist and improving scar tissue. Specialized massage techniques are to be used to get the scar less sensitive. The average recovery time is 8 weeks before patients have felt well enough to drive again.
What are the risks of carpectomy?
As with any other type of surgery, proximal row carpectomy has risks associated with it. General surgical complications which can affect any patient may include the following: infection, allergic or unexpected reactions and side effects of the anesthesia, and injury to peripheral nerves.
Among the complications which are more specific to proximal row carpectomy, the most significant is constant joint pain. Reports in the medical literature describe the procedure as having a failure rate of about 14%. In those instances when pain is not alleviated, complete wrist fusion is necessary as the subsequent salvage procedure.
Each patient should be aware of the risks which may require them to immediately contact the orthopedic surgeon. These include significant increases in pain, swelling, numbness of the fingers, and infection in the incision.
What can patients expect in the long-term regarding the functionality of their wrist?
Patients should understand carpectomy won’t restore complete functionality to the wrist. However, it is a highly successful surgery and the majority of patients experience significant pain relief.
Research has been done over the years to document the clinical outcomes of the procedure. Carpectomy patients have been shown to restore about 64% of their flexion-extension range of motion when compared to the unoperated wrist. Patients also maintain approximately 65% of their grip strength post carpectomy.
Finally, the survivorship of the procedure has also been documented. Patients have demonstrated that carpectomy has a 65% survivorship at 20 years post procedure, meaning that the majority of patients will not require a fusion of their wrist.
If more flexibility in your wrist matters more to you than being able to improve your grip strength to lift heavy objects, choose a proximal row carpectomy over a wrist fusion.
Managing severe wrist arthritis
Chronic wrist pain results in a serious loss of independence. The carpectomy of the proximal row is a proven pain relieving procedure that restores functional mobility. The carpectomy procedure of the proximal row is a bone removal procedure that relieves pain by simplifying the wrist joint. The procedure allows patients to return to their normal daily activities with a better pain-free wrist.
If your joint pain has progressed beyond the available conservative treatment options, the next step is a consultation with a board certified orthopedic hand surgeon. A hand surgeon of this caliber will analyze your medical history, evaluate your images, and discuss how a carpectomy of the proximal row will help improve the quality of your life.
Heath care carpectomy FAQs
What is the expected recovery time for a carpectomy of the proximal row?
Most patients report a maximum medical improvement within 12 months; however, the ability to engage in light daily activities and driving is usually permitted by the attending physician after 8 weeks. Strengthening the hand and improving the mobility of the joints requires several months of physical therapy.
Does insurance cover a carpectomy of the proximal row?
Most healthcare insurance carriers will cover the procedure if it has been deemed medically necessary by an orthopedic specialist. In this case, you will need evidence of a severe painful condition with advanced osteoarthritis, Kienböck’s disease, SLAC, or SNAC wrist along with documentation that other treatment options have been exhausted.
What is the difference between Proximal Row Carpectomy and complete wrist fusion?
Proximal row carpectomy maintains around 64% of your wrist’s natural range of motion and reorganizes the wrist bones to form a more functional joint. Complete wrist fusion means permanent fusion of the wrist bones with metal hardware. Wrist fusion means your wrist will no longer bend, but is completely functional for advanced lifting activities and eliminates pain.
Who is the best candidate to receive a Proximal Row Carpectomy?
An ideal candidate for a Proximal Row Carpectomy is a patient over the age of 35 with advanced arthritis of the proximal row of the carpal bones who has a healthy, smooth, cartilage covered capitate. Patients with demanding jobs with a high rate of physical activity are generally recommended to have a wrist Fusion.
How long is the Proximal Row Carpectomy effective?
Research examining the Proximal Row Carpectomy show it to be an effective, durable procedure. The long term results show a success rate of over 65% after 20 years, meaning that most people do not need a subsequent wrist Fusion surgery.
