The intercarpal articular surfaces
of the triquetrum, hamate, capitate, scaphoid and
trapezoid are removed using a curette or burr (Avoiding
the carpal component fixation screws). Cancellous
chips from prevously resected bone are packed into
the spaces. The dorsal capsule is reattached
to the distal margin of the radius using the previously
placed sutures. The capsule is reapproximated at
the distal radioulnar joint or attached to the ulnar
neck using the previously placed sutures if the
head was resected. The medial and lateral aspects
of the capsule are also closed. If the capsule is
insufficient for closure with the wrist flexed 30°,
the extensor retinaculum is divided in line with
its fibers and one half is placed under the tendons
to augment the capsule. The entire prosthesis must
be covered to achieve its proper stability and function
and to avoid extensor tendon irritation. The remaining
extensor retinaculum is repaired over the tendons
to prevent bowstringing, however, the EPL, ECRB
and ECRL are typically left superficial to the retinaculum.
If necessary to maintain the ECU dorsally over the
ulna, a separate sling is made from the retinaculum.
A suction drain is placed and the skin is closed
in layers. A bulky gauze dressing and a short arm
plaster splint are applied.
Post-Operative Management
Strict elevation and early passive and active digital
motion are encouraged to reduce swelling. At approximately
10 days, the sutures are removed and an x-ray is
obtained to confirm prosthetic reduction. A removable
wrist splint is fabricated and used when not performing
exercises. Gentle wrist exercises are begun, including
active flexion and extension, radial and ulnar deviation,
and pronation and supination. A therapist may be
engaged to ensure progress. The splint is discontinued
at the 4th postoperative week and hand use advanced.
The exercise program is continued and strengthening
is added. Power grip and lifting is discouraged
for the first 8 weeks. A dynamic splint is occasionally
used if recovery of motion is difficult or incomplete.
The patient is advised against impact loading of
the wrist and repetitive forceful use of the hand.
