Proximal Row Carpectomy

Why this approach — at MOS

Patient selection is the most important determinant of PRC success. The capitolunate cartilage must be intact — we confirm this by both MRI and pre-operative radiographic assessment of the capitolunate joint space. When there is any question about capitolunate cartilage quality at the time of surgery, the joint can be assessed with wrist arthroscopy prior to or concurrently with the procedure. A capitate head with even focal cartilage damage will produce pain in the new capitoradial joint, compromising the result.

Age and activity demands matter. PRC provides a reliable, durable result in patients with moderate activity demands. For younger patients under 35–40 who perform heavy manual labor and need maximum grip strength, four-corner fusion may provide more durable long-term stability, at the cost of more restricted wrist arc. This tradeoff — motion versus strength/durability — is discussed in detail with each patient before surgery.

Patients presenting to our Bethesda and Germantown offices with longstanding wrist pain after old wrist injuries, or with a history of untreated or failed scaphoid fracture treatment, should be evaluated for SNAC or SLAC wrist. These are predictable consequences of specific untreated wrist injuries, and when identified at the right stage, PRC provides excellent functional outcomes that are far superior to total wrist fusion for patients who want preserved motion.

Who is a candidate?

Indications

• SLAC or SNAC wrist with Stage II–III arthritis (radioscaphoid arthritis present but capitolunate cartilage intact)
• Failed conservative management: chronic wrist pain and weakness significantly limiting daily function
• Patient who requires some preserved wrist motion for occupational or personal needs
• Age typically 40–65 with low to moderate activity demands (though appropriate in older patients)
• Failed prior wrist surgery (e.g., scaphoid nonunion treatment) that has progressed to advanced arthritis

Contraindications

• Capitolunate arthritis — destroyed capitolunate cartilage is the primary absolute contraindication; the capitate must be cartilage-intact to create a functional new joint
• High-demand heavy labor patients who require maximum wrist strength — PRC provides 50–70% of grip strength, not 100%
• Young patients (under 35–40) with very high physical demands — total wrist fusion or four-corner fusion may be considered for better long-term durability
• Inflammatory arthritis involving the capitolunate joint
• Active infection

Conservative Treatment First

Wrist arthritis — including SLAC and SNAC patterns — is managed conservatively before surgical intervention. Custom wrist splinting or a thermoplastic wrist orthosis reduces pain by limiting motion across the arthritic joint surfaces. Anti-inflammatory medications reduce synovial inflammation and secondary pain. Corticosteroid injection into the wrist joint provides significant, though generally temporary, relief and is repeated selectively (no more than 3 injections per year).

Activity modification — avoiding heavy lifting, vibrating tools, and repetitive extremes of wrist motion — reduces load on the compromised cartilage. For patients with SLAC or SNAC wrist who have limited activity demands, conservative management can maintain acceptable function for years. When pain significantly impacts daily life despite these measures, surgical options are discussed. PRC and four-corner fusion (scaphoidectomy with fusion of the remaining capitate-lunate-hamate-triquetrum) are the two main motion-preserving alternatives; total wrist fusion is considered when capitolunate cartilage is also compromised.

The procedure

What Is Proximal Row Carpectomy?

Proximal row carpectomy (PRC) is surgery to treat advanced wrist arthritis by removing the scaphoid, lunate, and triquetrum — the three carpal bones that form the proximal row. This allows the capitellum bone (of the distal row) to articulate directly with the radius, creating a new, functional joint that preserves partial wrist motion. It is an alternative to total wrist fusion for patients with preserved capitolunate cartilage.

The wrist contains eight carpal bones arranged in two rows. The proximal row — the scaphoid, lunate, and triquetrum — sits between the radius and ulna and the distal row of bones. These three bones are connected to each other and to the radius primarily by ligaments rather than bony geometry, making them inherently more mobile and also more vulnerable to arthritis from ligament disruption and abnormal loading.

The most common patterns of advanced wrist arthritis that lead to PRC are SLAC (scapholunate advanced collapse) and SNAC (scaphoid nonunion advanced collapse) wrist. In SLAC wrist, rupture of the scapholunate ligament causes the scaphoid to rotate abnormally, creating destructive forces on the radioscaphoid and then the capitelolunate joint cartilage. In SNAC wrist, a nonunited scaphoid fracture disrupts the mechanics of the proximal row, leading to the same progressive arthritis pattern. Both conditions spare the capitolunate joint initially — and this is the critical prerequisite for PRC.

When the scaphoid, lunate, and triquetrum are removed, the rounded head of the capitate bone (the largest carpal bone of the distal row) settles into the lunate fossa of the distal radius — a reasonably congruent contact surface that functions as a new, lower-demand joint. The result is a functional wrist with preserved motion — typically 50–70% of normal flexion-extension — and significantly reduced pain. This compares favorably to total wrist fusion, which eliminates pain completely but abolishes wrist motion entirely.

What Happens During Proximal Row Carpectomy?

Setting and anesthesia: Performed at an ambulatory surgery center under regional anesthesia (brachial plexus block) or general anesthesia. The procedure takes 60–90 minutes.

Positioning: The arm is positioned palm-down on a hand table. A tourniquet is applied to the upper arm.

Dorsal approach: A longitudinal incision is made on the back of the wrist, centered over the carpus. The extensor tendons are carefully retracted on either side, and the dorsal wrist capsule is incised and elevated, exposing the carpal bones. The wrist capsule is opened with capsulotomy flaps that will later be repaired.

Bone removal: The scaphoid, lunate, and triquetrum are removed sequentially. Each bone must be dissected carefully from its surrounding soft tissue attachments — including the radial artery, which passes through the scaphoid fossae, and the ligamentous attachments to the distal row bones. All three bones must be completely removed to allow the capitate head to seat properly in the radius without impingement.

Capitate seating: Once all three proximal row bones are removed, the capitate head is assessed for congruence with the lunate fossa of the radius through wrist range of motion. The fit is typically reasonably congruent — the curved capitate head articulates against the concave lunate fossa. If the capitate head is not fully cartilaginous or appears damaged, the indication for PRC is reconsidered.

Capsular repair: The dorsal wrist capsule is repaired over the capitate head. A secure capsular repair is important to maintain the capitate in position and to provide soft-tissue stability to the new articulation. The wound is closed and a sugar-tong splint applied.

Recovery timeline

Frequently Asked Questions