Review Question - QID 219942

This 62-year-old male demonstrates a stage IV scapholunate advanced collapse wrist. Because of the patient's radiolunate osteoarthritis, scaphoidectomy with four-corner fusion is contraindicated (Answer 4) and the patient would be best treated with total wrist fusion.

Radiocarpal osteoarthritis is a fairly common entity encountered in hand practices, and results mainly from two entities: scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC). While the resulting arthritis stems from different etiologies, the progression of the disease occurs similarly, and as such, the treatment paradigms significantly overlap. While some debate exists over the number of stages, stage I involves arthritis localized to the scaphoid and radial styloid, stage II involves the entire radioscaphoid facet (SLAC) or involvement of the scaphocapitate joint (SNAC), and stage III involves degeneration of the capitolunate articulation with proximal capitate head migration. Some include a fourth stage, which involves arthritis of both the radiocarpal (radiolunate, radioscaphoid) and intercarpal joints (scaphocapitate, scapholunate). Importantly, stage IV is uncommon in SNAC and SLAC wrists and represents severe, prolonged disease, and often may be an indication of additional processes (e.g., rheumatoid, avascular necrosis) that may be contributing to the wrist osteoarthritis.

After failing non-operative treatment, early arthritis (stage I) involves radial styloidectomy, distal scaphoid pole excision (SNAC wrists) or denervation procedures. In contrast, late arthritis (stages II-III) commonly requires more intensive procedures attempting to maintain motion, namely scaphoidectomy with four-corner fusion or proximal row carpectomy. The former requires an intact radiolunate facet, as radiocarpal motion solely relies upon this articulation following scaphoidectomy. In contrast, proximal row carpectomies require an intact radiolunate facet and capitolunate articulation, as the head of the capitate serves as the sole articulation with the radius following the removal of the proximal carpal row. In instances of radiolunate arthritis (stage IV), total wrist fusion is the preferred procedure.

Weiss and Rodner write a review examining wrist osteoarthritis. They discuss the progression of arthritis associated with SLAC and SNAC wrists, detailing stages I-IV. The authors stress the importance of a thorough physical exam to identify which joints are most symptomatic. They then detail the surgical options for each joint that may become symptomatic. Ultimately, the authors recommend performing the most appropriate surgery to relieve pain and maintain motion.

Shah and Stern similarly examine the pathophysiology, diagnosis, treatment options, and outcomes of wrist osteoarthritis secondary to the SNAC and SLAC processes. The authors report on the subtle differences between SNAC and SLAC wrists, highlighting the preservation of the proximal pole of the scaphoid in SNAC wrists secondary to decreased load, as it essentially functions as an extension of the lunate due to the intact scapholunate ligament. The authors conclude the treatment of SNAC and SLAC wrists is dependent on a number of factors, including how symptomatic the patient is, the patient's age, level of physical activity, and radiographic stage.

Figures A-C represent an AP, oblique, and lateral views of the right hand demonstrating stage IV SLAC wrist, as evidenced by pancarpal arthritis with degeneration of the scaphocapitate and scapholunate articulations, as well as the radioscaphoid and radiolunate facets. Illustration A is a depiction demonstrating the progression of wrist osteoarthritis extracted from the Weiss and Rodney study.

Incorrect Answers:
Answer 1: Radioscaphoid arthritis is a common process seen early on in SNAC and SLAC wrists and acts as an indication for scaphoidectomy and four-corner fusion or proximal row carpectomy
Answer 2: Capitolunate arthritis is an indication for scaphoidectomy and four-corner fusion and serves as a contraindication for proximal row carpectomy.
Answers 3 and 5: Scapholunate ligament disruption and scaphoid avascular necrosis are not contraindications for surgical intervention and serve as the basis for the onset and progression of arthritis