Is a left proximal row carpectomy (removal of wrist bones) medically necessary for a patient with a displaced fracture of the proximal third of the navicular bone of the left wrist?

Proximal Row Carpectomy is Medically Necessary for This Patient

Given the failed vascularized ORIF with persistent nonunion of a far proximal pole scaphoid fracture, significant functional disability, and the patient's informed preference for a definitive salvage procedure over additional reconstructive attempts, proximal row carpectomy (PRC) is medically indicated. 1, 2

Clinical Rationale for Approval

Failed Primary Repair Establishes Salvage Indication

• The patient underwent vascularized sartorius flap repair for proximal pole scaphoid fracture nonunion, which has demonstrably failed on CT imaging at 10 weeks post-operatively 3
• Persistent fracture nonunion with dissociation of the scaphoid screw from the fragment and proximal contact with the distal radius represents a failed reconstruction requiring salvage intervention 1
• Proximal pole scaphoid fractures have the highest nonunion rates due to tenuous blood supply, and failed vascularized repairs indicate exhaustion of reconstructive options 1, 2

Functional Disability Meets Surgical Threshold

• The patient demonstrates severe functional impairment with only 10-15 degrees of wrist extension and flexion (normal is approximately 60-70 degrees each direction) 2
• She reports inability to load the wrist and significant pain with activity, preventing her from performing her occupation as a dietician 2
• This degree of functional limitation with failed prior surgery constitutes clear indication for salvage procedure 1, 2, 4

PRC is the Appropriate Salvage Option

• PRC is specifically indicated for failed scaphoid fracture repairs and chronic scaphoid nonunions when the capitolunate joint remains intact 1, 2, 4
• The imaging demonstrates no definite early arthrosis or joint space narrowing, confirming the lunate fossa and capitate head are suitable for PRC 2, 4
• Research demonstrates that PRC provides 70 degrees of combined flexion-extension arc, 51% grip strength of contralateral side, and significant pain relief (71% reduction at rest, 44% with activity) 2
• PRC allows return to work in 71% of patients and return to former occupation in 56% of cases 2

Alternative Options Are Less Appropriate

• Vascularized medial femoral condyle graft would require knee violation, which the patient explicitly wishes to avoid, and represents another reconstructive attempt with uncertain success after prior vascularized repair failure 1
• Autogenous proximal hamate graft similarly represents another reconstruction with additional donor site morbidity and no guarantee of union given the failed vascularized repair 1
• Wrist arthrodesis would eliminate all motion and is overly aggressive when PRC can preserve functional motion 2, 4
• The patient has made an informed decision favoring the more predictable salvage procedure over additional reconstructive attempts with uncertain outcomes 1, 2

Surgical Appropriateness

Technical Feasibility

• PRC is technically straightforward and can be completed in the proposed 2-hour timeframe under general anesthesia 2, 4
• The procedure involves excision of the scaphoid, lunate, and triquetrum, allowing the capitate to articulate with the lunate fossa 2, 5
• No hardware is required, eliminating complications of nonunion, hardware irritation, or impingement seen with other motion-preserving procedures 5

Expected Outcomes Support Approval

• Studies with follow-up ranging from 8 months to 20+ years demonstrate durable pain relief and functional improvement after PRC 2, 4
• Mayo and Krimmer wrist scores average 55 and 62 points respectively, indicating good results 2
• DASH scores average 26, representing acceptable upper extremity function 2
• Progressive degenerative arthritis of the radiocapitate articulation does not typically occur when the joint surfaces are intact at time of surgery 4

Critical Pitfalls to Avoid

• Do not deny this procedure based on patient age (35 years) - while PRC was historically reserved for older patients, modern evidence supports its use in younger patients when reconstructive options have failed 1, 2
• The absence of radiographic arthrosis is essential - the imaging confirms no joint space narrowing or early arthrosis, making this an ideal candidate 2, 4
• This is not a primary treatment but rather appropriate salvage after failed vascularized repair - the clinical context of failed reconstruction distinguishes this from inappropriate early salvage 1

Documentation Supports Medical Necessity

• Clear documentation of failed prior surgical intervention with objective CT evidence 3
• Quantified functional limitations (10-15 degrees motion vs. normal 60-70 degrees) 2
• Documented occupational disability preventing work as dietician 2
• Informed patient decision-making after discussion of all options including additional reconstructive attempts 1, 2
• Appropriate imaging confirming intact capitolunate articulation suitable for PRC 2, 4

The MCG criteria for musculoskeletal surgery requiring procedure for acquired dysfunction is clearly met, as this represents treatment of post-traumatic nonunion with failed prior repair causing significant functional impairment. 1, 2, 4