Scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) with preserved midcarpal joint (stages 1 and 2).

Kienböck disease (Stage 3).

Chronic carpal instability.

Failed soft tissue reconstruction.

In general, indications are similar to those for four-corner fusion; however, the midcarpal joint needs to be preserved.

In either SLAC or SNAC, there will be widening at the scapholunate interval.

Significant scaphoid flexion, lunate extension, and dorsal lunate prominence develop.

Radioscaphoid degenerative change with styloid prominence or osteophytes.

Dorsal radial prominence.

Synovitis.

Proximal scaphoid pole necrosis and/or arthrosis.

Scaphotrapeziotrapezoid arthrosis may be present.

The volar extrinsic ligaments (radioscaphocapitate, short and long radiolunate) originate from the volar radius and extend obliquely to the carpus. These should be intact; insufficiency or iatrogenic damage could lead to ulnar translation and radiocapitate instability after surgery (Fig. 86-3). The dorsal ligaments of the wrist—dorsal radiocarpal (DRC) and dorsal intercarpal (DIC)—have a conjoined insertion on the triquetrum. They provide the capsulotomy landmarks for wrist exposure (Fig. 86-4).

The patient is positioned supine, the hand and forearm are supported on a hand surgery table, and a proximal tourniquet is used.

Operating on the dorsal wrist is easier if the surgeon is positioned at the head of the patient as opposed to at the axilla.

A straight dorsal midline incision centered over the radiocarpal joint is used (Fig. 86-5).

Flap elevation is performed sharply, protecting the cutaneous branches of the superficial radial and dorsal ulnar sensory nerves within the subcutaneous tissue.

The retinaculum over the third dorsal compartment is incised and the extensor pollicis longus (EPL) retracted (Fig. 86-6).

Retinacular flaps are raised exposing the second through fifth dorsal compartments.

Retractors are placed between the second and fourth dorsal compartment tendons.

A posterior interosseous neurectomy is performed. The PIN is located on the floor of the fourth dorsal compartment

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28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 26: Reconstruction of Key Pinch in Tetraplegia Patients 33: Correction of Swan-Neck Deformity in the Rheumatoid Hand 89: Total Wrist Fusion

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