Orthopaedics & Traumatology: Surgery & Research (2011) 97S, S37—S41
WORKSHOPS OF THE SOO (2010, LA ROCHELLE). SYMPOSIUM: THE ARTHRITIC WRIST
The arthritic wrist. II - The degenerative wrist:
Indications for different surgical treatments
J. Laulana,∗, G. Baclea, C. de Bodmana, N. Najihib, J. Richouc, E. Simonc,
Y. Saint-Castd, L. Oberte, A. Sarauxf, P. Bellemèreg, T. Dréanob,
M. Le Bourgh, D. Le Nenc
aService de chirurgie orthopédique 1 et 2, unité de chirurgie de la main, hôpital Trousseau, CHRU de Tours, 37044 Tours cedex,
bService de chirurgie orthopédique, CHU hôpital sud, 35203 Rennes cedex 2, France
cService de chirurgie orthopédique, hôpital de la Cavale-Blanche, CHU de Brest, 29200 Brest, France
dCentre de la main. 49100 Angers, France
eService de chirurgie orthopédique, hôpital Jean-Minjoz, CHU de Besanc ¸on, 25030 Besanc ¸on, France
fService de rhumatologie, hôpital de la Cavale-Blanche, CHU de Brest, 29200 Brest, France
gClinique Jeanne-d’Arc, 44100 Nantes, France
hCentre hospitalier privé, 35768 Saint-Grégoire, France
however very often the optimal surgical treatment is one that provides effective pain relief.
The patient must be informed of the potential complications and limitations of each procedure.
The patient’s psychological profile and functional requirements will determine how well he/she
adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence
the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson proce-
dure are two reference operations for osteoarthritis secondary to scapholunate instability and
scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to
each, they provide good results that are maintained over time. PRC, which can be performed
up to Stage II, is mainly indicated in patients with moderate functional demands, while the
Watson procedure is more often done on a patient who performs manual labour, as long as the
radiolunate joint space is maintained. Complete denervation is effective in three out of four
cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be
suggested in patients with a mobile wrist and low functional demands or in older patients, inde-
pendent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young
patient who performs heavy manual labour with extensive osteoarthritis and progressive forms
of Kienböck’s disease, this procedure provides the greatest chance of returning to work and not
being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in
the treatment arsenal need to be better defined.
© 2011 Elsevier Masson SAS. All rights reserved.
For the patient (and the surgeon) the ideal wrist is one that has good mobility,
∗Corresponding author. Tel.: +33 02 47 47 59 46.
E-mail address: firstname.lastname@example.org (J. Laulan).
1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
S38J. Laulan et al.
When faced with a painful, degenerative wrist, the dif-
ferent palliative surgical procedures can only be discussed
after conservative treatment has failed.
The choice between surgical options is difficult to make
because conclusions about the optimal procedure as a func-
tion of each radiological and clinical situation cannot be
drawn from the published literature. In practice, the indi-
cation is often based on the surgeon’s preferences and
experience with a certain technique. The various partic-
ipants in this work have reported good results with the
palliative technique they use most often . However, a
review of the literature is not as favourable as results
diverge widely, making it difficult to derive criteria on which
to base procedure choices.
In practice, although the decision is based on the aetiol-
ogy and extent of joint involvement, it is mostly influenced
by the patient’s functional demands and state of the wrist.
As a consequence, we were interested in finding out what
Survey of patients
To evaluate patients’ wishes, two surveys were carried out
by Charlotte de Bodman and Nabil Najihi. The first study,
done prospectively, sought to define how patients viewed an
ideal wrist. A questionnaire was given to patients who were
being seen for a non-wrist injury to prioritize three param-
eters: pain, mobility and strength. The second study, done
retrospectively, was given to patients after wrist surgery and
sought to define what the main cause of dissatisfaction was
after returning to work.
Among the 36 patients who responded to the question-
naire about the ‘‘ideal wrist’’, the priority was mobility for
48.5%, no pain for 34.8% and strength for 16.7%. Most of the
patients were ready to give up strength to improve the result
in terms of pain relief (73%) and mobility (83%); 59% were
ready to give up some mobility to have less pain.
Among the 66 operated patients (68 wrists) who were
satisfied (42%) or very satisfied (58%) with the result after
an average follow-up of 50 months, the primary regret was
the loss of mobility in 51% of cases. However the main cause
of dissatisfaction was ongoing pain in 61.5% of cases, insuf-
ficient mobility in 27% of cases and insufficient strength in
11.5% of cases.
The desire for a mobile wrist is certainly in the fore-
front, as one of two patients regrets the loss of mobility
after surgery. However, nearly 60% of patients are willing to
give up mobility to have less pain and the persistence of pain
is the main reason for dissatisfaction after a ‘‘successful’’
wrist operation. In a prospective study comparing full joint
fusion and the Watson procedure, Wieloch et al.  found
that the type of fusion did not affect satisfaction and that
the pain relief parameter was more important to the patient
than the mobility parameter. Thus, a procedure that main-
tains mobility should be favoured, but this mobility should
not be achieved at any price, and pain reduction should not
be compromised to preserve mobility.
Graham and Detsky used decision analysis for the treat-
ment of early wrist arthritis and showed that the benefits
produced by proximal row carpectomy (PRC) and the Wat-
son procedure were slightly greater than a total joint fusion
techniques as a function of background.
(a and b) Indications ‘‘areas’’ for the main surgical
because mobility was preserved . But they brought up a
potential for residual pain in the remaining range of motion.
These results only include early stages of arthritis; the
potential for early failures after PRC and the appreciable
number of complications after partial joint fusion should not
be ignored. Finally, studies have shown that the results are
not as good when a total joint fusion is performed after the
early failure of a partial fusion [4—7].
Treatment choices and background
The choice of treatment mostly depends on the background:
patient age (young vs. older), functional demands (man-
ual labour vs. sedentary), and residual mobility of the wrist
(mobile vs. stiff). Based on data in the literature and results
provided by different surgeons, an attempt was made to
align the main palliative procedures with the background
(Figs. 1a and b). Significant overlap exists between the indi-
cations for the different techniques, resulting in multiple
options to meet each patient’s wishes and surgeon prefer-
PRC can only be performed if the cartilage in the lunate
fossa of the radius and head of the capitate are preserved.
The indications could be extended tostage III SLAC and SNAC
wrists by using an RCPI®resurfacing implant for the head of
the capitate , however this approach must be validated
over the medium and long term.
After PRC, we can expect that 80% of patients will be
satisfied, with 2/3 of the mobility and 2/3 of the strength (50
to 100%) maintained, along with a DASH of about 25 (range
The degenerative wrist: Indications for different surgical procedures S39
9 to 36). Although there is an early failure rate of 10 to
14% [9,10], mostly in younger patients , good results are
seen in the long term, despite progressive degradation of
the radio-capitate joint space being reported in 10 to 82%
PRC is simpler to execute and has fewer complications
than the Watson procedure [12—14]. It preserves more of
the mobility and gives similar results in terms of pain reduc-
tion and satisfaction for the patient. However, the risk of
degenerative osteoarthritis is greater, especially in young,
active patients, and strength is not as good [11,13]. Thus,
this procedure is indicated in patients who are mostly seden-
tary, perform light manual labour , or are older and still
have good mobility.
The results reported in the literature for the Watson
procedure vary [16,17]. Although there is a reduction in pre-
operative pain levels, complete pain relief only occurs in
one of two cases and there are an appreciable number of
complications. The rate of conversion to full wrist fusion is
high in some series [17,18] and varies from 2 to 36%. Overall,
the satisfaction rate was 80%, which is comparable to PRC.
The procedure maintains 50% of the mobility on average and
75% of the strength, with a DASH ranging from 15 to 30.
When compared to PRC, the Watson procedure results in
mobility that is not as good (50% vs. 66%) and more postop-
erative complications. Comparative studies show that PRC is
better for stages 1 and 2 [18,19]. However, it tends to bet-
ter restore strength (75% vs. 66%) with a lower risk of joint
space degeneration  and have good long-term results
[16,20]. This procedure is favoured in a person who per-
forms heavy manual labour  and has partially preserved
mobility, knowing that over time, younger subjects will have
greater joint space narrowing .
Complete denervation can be performed even if the radi-
olunate joint space is altered. The procedure is not perfect
but it gives useful long-term results, as it provides significant
pain relief in 75 to 80% of patient, does not affect mobility,
has few post-operative limitations (no immobilization) and
none or few complications . VAS is 2 to 3, strength is at
80% and the DASH between 25 and 30. The Brest and Tours
series  confirmed that the results are not age-related, but
that pain upon exertion is not uncommon and a patient who
performs heavy manual labour may need to change jobs. In
case of failure, the results of a potential surgical revision do
not seem to be compromised. There are two broad types of
indications: mostly sedentary patients of any age with good
wrist mobility, and older patients, independent of their wrist
Total joint fusion is used as a rescue procedure after
failure of another palliative intervention, but results are
uncertain in this context, especially with an early failure
[4,5,7]. Some patients indicated that they would have liked
the total wrist fusion to be performed sooner because of the
minimal benefit of the previous procedures . However,
we have previously shown [4,6] that if the total joint fusion
is performed as a first-line treatment, it provide effective
pain relief (VAS at 2), restores good strength (80 to 90%) and
under these conditions, the majority of patients do not feel
that the loss of mobility is a problem. It is indicated in a
patient who performs heavy manual labour , has a stiff
wrist and diffuse joint involvement. In a patient who has lit-
tle or no possibility of retraining, it often allows a return to
cal data (treatment of localized forms are not described in
detail). STT: scapho-trapezio-trapezoidal; SC: scaphocapitate;
RL: radiolunate, RSL: radio-scapho-lunate; MC: mid-carpal; CL:
capitolunate; PT: pisiform-triquetrum.
Decisional flow chart as a function of radiologi-
the same work or heavy manual labour. However, suggest-
ing a total joint fusion to a sedentary and/or older patient
does not seem justified if the patient still has good mobility,
except in special cases.
Treatment choices and radiographs
The treatment choice is then based on the aetiology and
extent of the arthritis. A decisional flow chart based specif-
ically on radiology assessments of the radiolunate and
capitolunate joint spaces, or even a CT scan of the joint,
has been defined (Fig. 2). Kienböck’s disease must be differ-
entiated from other causes of wrist arthritis as it brings up
Treatment indications in Kienböck’s disease
Although good results can be obtained in Stage IIIB by short-
ening the radius , palliative treatment is most often
needed when the disease has progressed. Even at this stage,
some have suggested doing a scapho-trapezio-trapezoidal
(STT) fusion  to unload the lunate, however this results
in more failures than a total joint fusion and a complication
rate of up to 40%, with 14% nonunion .
Data in the literature suggests that PRC provides infe-
rior results in Kienböck’s disease [9,12] and some authors
no longer perform a PRC in this indication . A synovitis
exists in certain cases, suggestive of a true local-regional
disease, which in our opinion could be responsible for the
failure of conservative procedures.
As a consequence, two main procedures are relevant
to the discussion: denervation and total joint fusion. Age,
residual mobility and the presence of synovitis should be
taken into account when choosing the treatment. In seden-
tary subjects with good mobility or in older patients,
denervation avoids a lengthy immobilization and the poten-
tial complications related to fusion. In a young patient who
performs heavy manual labour and has stage IIIB or IV dis-
ease, especially if synovitis is present, only fusion provides
S40J. Laulan et al.
reliable results. When the disease is in its later stages,
Tambe et al.  have shown that total joint fusion pro-
vides better results than partial fusion, and like them, we
believe that total joint fusion must be suggested early on in
these forms. And Laurent Obert  has shown that in cer-
tain cases, a resection of the lunate with a rib cartilage graft
may be appropriate.
Treatment indications for osteoarthritis due to
scapholunate instability (SLAC wrist) or scaphoid
non-union (SNAC wrist)
With stage II SLAC and SNAC wrists, three types of proce-
dures should be considered: PRC, Watson procedure and
complete denervation. The choice is mostly made as a
function of the patient’s age and functional demands. In
a patient who is still working in manual labour, a Watson
procedure seems the most logical, given that PRC or dener-
vation may not result in effective pain relief in this context.
PRC and denervation are possibilities in sedentary patients,
depending on age, mobility and wishes, and knowing that a
secondary PRC is still possible if the denervation fails early
on. Here also, the Besanc ¸on team reported that an osteo-
cartilage rib autograft can be used to replace the proximal
pole of the scaphoid .
With stage III SLAC and SNAC wrists, a PRC is no longer an
appropriate procedure . At this stage, three factors must
be taken into consideration: the radiolunate joint space,
residual mobility and activity. Lane et al.  have recently
reported that in cases of scapholunate dissociation, the radi-
olunate joint space is not always maintained and that a
CT scan should be performed before considering a Watson
If the radiolunate joint space is totally maintained and
there is good functional mobility in a patient who performs
manual labour, it would be logical to perform a Watson pro-
cedure. Denervation is mostly indicated in a sedentary or
older patient if preservation of mobility is a priority for the
In diffuse affections involving the radiolunate joint
space, choices include performing a primary total wrist
fusion in a young patient who performs manual labour and
denervation in a sedentary or older patient, especially if
the wrist is stiff and/or very painful. Similarly, when a pro-
cedure designed to maintain mobility in an active subject
fails, total joint fusion is indicated. In an older patient,
a partial implant or even a total wrist joint replacement
should be considered , either as primary intervention or
if denervation fails.
Indications for localized osteoarthritis
Cases of localized arthritis include stage I SNAC, radiolunate
or radio-scapho-lunate arthritis secondary to an articular
radius fracture, STT arthritis, isolated midcarpal arthritis
or pisiform-triquetrum arthritis.
For these types of arthritis, different procedures that
are more or less location-specific should be considered: par-
tial joint fusion, isolated resection arthroplasty or resection
arthroplasty with interposition (tendon, partial implant, rib
cartilage). An autologous osteochondral graft can also be
considered in the sequelae of die-punch fractures .
A simple resection of the pisiform can be carried out
to treat pisiform-triquetrum osteoarthritis after failure of
conservative treatment .
Although a mobility-preserving procedure is favoured, it
should not be done at any price, since the preservation of
a certain amount of wrist mobility is not essential to good
upper limb function .
The aetiology and stage of the arthritis allows certain
procedure choices to be eliminated, but the final choice
is based on residual wrist mobility, the patient’s wishes,
functional demands and potential for job retraining.
PRC is mainly indicated in a middle-aged patient, even
elderly who has good mobility and moderate functional
demands. The Watson procedure is mostly indicated in a per-
son who performs manual work, is not too old and still has
some mobility. Because of its low morbidity, complete den-
ervation can be suggested in patients with a mobile wrist and
low functional demands or in older patients, independent of
their wrist mobility. Total wrist fusion is mostly indicated in
young patients who perform heavy manual labour, especially
if the wrist is already stiff.
The role of osteochondral autografts, implants and wrist
prostheses in the treatment arsenal needs to be better
Disclosure of interest
The authors declare that they have no conflicts of interest
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