Wrist Instability (Scapholunate Ligament Injuries): Salvage Procedure (Bone Removal)

Wrist Instability (Scapholunate Ligament Injuries): Salvage Procedure (Bone Removal)

This video will demonstrate a proximal-row carpectomy and addition of a biologic skin graft for an advanced scapholunate ligament injury known as scapholunate advanced collapse or SLAC wrist. SLAC wrist can occur from an untreated scapholunate ligament injury. It results in arthritis and instability of the wrist that may lead to pain, decreased range of motion, and weakness.

The surgeon will be demonstrating a procedure called a proximal-row carpectomy. Proximal means the row closest to the body, and carpectomy means removal of the carpal or wrist bones. The 3 bones removed in the proximal row are the scaphoid, lunate, and triquetrum. By removing these bones, a new joint is made between the remaining wrist bones and the forearm. To achieve the desired outcome, a biologic skin graft will be used in this demonstration as a cushion for the newly formed joint.

The overall goal of the procedure is to improve pain by removing the arthritic and unstable bones, while maintaining motion and strength in the wrist joint. Here is an x-ray demonstration of the desired result. The removed row of wrist bones is shown here, and although not visible on x-rays, the biologic skin graft will reside in this space. The procedure will be demonstrated on a cadaveric specimen.

Here is the right hand. The surgeon has marked the hand where the incision will be made on top of the wrist. The soft tissues around the wrist joint will then be carefully opened. The surgeon will then identify the proximal row of bones that will be removed. The soft tissues around these bones will be cut to free them up for removal. Here, the desired bones have now been removed.

Once the bones are removed, the surgeon will begin preparing the biologic skin graft. The graft will be folded in half and placed in the joint space. The surgeon will measure the graft and determine if a portion needs to be trimmed, as shown here. To keep the graft from sliding, it will be sewn together with surgical sutures into a pillow-like cushion.

Now that the graft is prepared, it will be secured to the nearby bones and soft tissue in a box configuration. First, the suture for the bone will be placed with bone anchors. A small drill will be used to make a hole for the first incoming bone anchor in the capitate bone. The anchor and sutures will be placed into the bone together. This process will then be repeated for another bone suture anchor in the nearby hamate bone.

Two more sutures without anchors will be placed in the bottom and top of the wrist to secure the graft further. Finally, the sutures will each be sewn to the graft, starting with the suture at the base of the wrist. The remaining 3 sutures will be passed through the graft to secure it in place. Once the graft is in place, the wrist is shown freely moving with the newly created joint. The sutures will be trimmed, and the incision will be closed. The surgery is now complete.