End-stage wrist arthritis does not have to mean the end of the activities you value. Dr. R. David Graham, MD is the #1 wrist arthroplasty volume surgeon in Northeast Florida, offering the full spectrum of wrist reconstruction — from partial fusions to total wrist replacement — matched precisely to each patient's needs and goals.
Understanding the Condition
The wrist is not a single joint — it is a complex of multiple articulations between the radius, the carpal bones, and the metacarpals, all working in concert to allow the hand to position itself in space. When the cartilage on those joint surfaces wears away — from arthritis, injury, inflammatory disease, or avascular necrosis — bone contacts bone, and the result is pain, swelling, limited motion, and progressive loss of hand function.
Early wrist arthritis can often be managed with activity modification, anti-inflammatory medications, corticosteroid injections, and splinting. When these measures are no longer sufficient — when pain is limiting daily function despite conservative care — surgical reconstruction becomes the appropriate next step.
The key question at that stage is not whether to intervene, but how. The right answer depends on which joints are involved, how much motion remains, the patient's activity level and physical demands, and whether prior procedures have changed the anatomy. Dr. Graham evaluates all of these factors to match each patient with the procedure most likely to achieve their specific goals.
The radiocarpal joint (radius meeting the proximal carpal row) and midcarpal joint (between proximal and distal carpal rows) are most commonly affected by arthritis. Total wrist replacement resurfaces the radiocarpal articulation. Partial fusions selectively stabilize the joints that are arthritic while preserving those that are not.
Who Needs Wrist Reconstruction
Dr. Graham treats wrist arthritis from all causes. The underlying diagnosis guides which reconstructive approach is most appropriate.
The most common cause in working-age adults. Prior wrist fractures — distal radius, scaphoid, or carpal fracture-dislocations — that healed in imperfect alignment or disrupted the joint surface eventually produce progressive arthritis. SLAC wrist (scapholunate advanced collapse) and SNAC wrist (scaphoid nonunion advanced collapse) are the most frequent patterns and are well-addressed by scaphoidectomy with capitolunate fusion or total wrist arthroplasty.
RA is a systemic inflammatory disease that preferentially attacks synovial joints — and the wrist is one of the most commonly affected. Chronic synovitis erodes cartilage and supporting ligaments, leading to progressive deformity and pain. Total wrist arthroplasty is particularly well-suited for RA patients, who typically have lower physical demands and benefit most from motion preservation.
AVN of the lunate (Kienböck's disease) or scaphoid results from disrupted blood supply to the bone, causing progressive collapse and secondary arthritis. Treatment depends on the stage — early disease may respond to unloading procedures, while advanced collapse with pan-carpal arthritis often requires reconstruction with proximal row carpectomy, partial fusion, or arthroplasty.
Psoriatic arthritis, gout, calcium pyrophosphate deposition disease (CPPD), and other inflammatory conditions can produce destructive wrist arthritis. Management requires coordination with rheumatology and surgical timing that accounts for systemic disease activity and immunosuppressive medications.
A painful proximal row carpectomy (PRC) — where the capitate-radial articulation has deteriorated — is one of the most common revision scenarios Dr. Graham addresses. He also treats painful outcomes after prior fusions, failed ligament reconstructions, and implant-related complications from wrist surgery performed elsewhere.
Primary osteoarthritis of the wrist — without a clear traumatic or inflammatory cause — is less common than in the hip or knee, but does occur, particularly in older patients. Localized degenerative changes limited to specific joints (such as scaphotrapezial arthritis) may respond well to targeted partial fusion or arthroplasty of the affected articulation.
The Right Procedure for the Right Patient
This is not a one-size decision. Dr. Graham's approach is driven by activity level, arthritis pattern, prior surgery, and the patient's own goals for recovery.
Procedures in Detail
Select a procedure to learn more about what it involves, who it is best suited for, and what recovery looks like.
Total wrist replacement resurfaces the radiocarpal joint with a prosthesis — a radial component anchored to the distal radius and a carpal component fixed to the distal carpal row. The damaged carpal bones between them are removed, and the implant recreates a smooth articulation that allows wrist motion without bone-on-bone pain.
It is the motion-preserving alternative to total wrist fusion. Patients who choose arthroplasty are typically those for whom wrist motion matters — whether for daily activities, hobbies, bilateral wrist disease where fusing both wrists would be severely limiting, or occupations that require fine motor positioning of the hand.
Modern wrist arthroplasty implants have improved substantially in the past decade. Dr. Graham consults for orthopaedic industry companies and has early access to current-generation implants as evidence supports their use. He also performs revision wrist arthroplasty — including in the setting of painful proximal row carpectomy where conversion to arthroplasty is indicated.
Most patients return to the majority of activities they value. High-impact and very heavy repetitive loading are avoided to protect implant longevity, but daily activities, recreational pursuits, and light to moderate physical work are achievable goals.
Scaphoidectomy with capitolunate fusion (sometimes called four-corner fusion when hamate and triquetrum are also included) is Dr. Graham's most common partial wrist fusion procedure. It is ideally suited for patients with SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse) wrist — the two most common patterns of wrist arthritis.
The arthritic scaphoid is removed, relieving the primary source of pain. The remaining proximal row bones — lunate, triquetrum, and capitate — are fused together with a plate and screws, creating a stable carpal unit that articulates cleanly with the intact portion of the radius. The result is a wrist that is significantly less painful with approximately 50% of normal motion preserved — enough for most functional tasks.
Because the fusion is partial and the radiocarpal joint is preserved (the radius-lunate articulation is maintained), grip strength can approach near-normal levels. This makes capitolunate fusion particularly attractive for active patients who need strength for work or sport and can accept a moderate reduction in wrist arc.
Dr. Graham performs many of these each year — the volume and experience with the technical nuances of carpal fusion make a meaningful difference in achieving solid union and optimal positioning.
Proximal row carpectomy removes the three bones of the proximal carpal row — the scaphoid, lunate, and triquetrum — allowing the head of the capitate to articulate directly with the articular surface of the radius. This creates a new, simpler joint that can provide meaningful pain relief and preserves more motion than fusion procedures.
PRC is best suited for patients with preserved cartilage on both the capitate head and the lunate fossa of the radius — if either surface is significantly arthritic, the new articulation will be painful from the outset. It is a reliable procedure for carefully selected patients with Kienböck's disease (stages I–III), early SLAC wrist, or specific carpal pathology where the arthritic bones can simply be removed.
When a PRC becomes painful over time — most commonly from progressive capitate-radial arthritis — revision options exist. Dr. Graham offers conversion to total wrist arthroplasty for failed PRCs, and also performs dermal allograft augmentation of the capitate-radial articulation as an adjunct to PRC in select cases to improve the durability of the new joint surface.
Radioscapholunate (RSL) fusion selectively fuses the radius to the scaphoid and lunate — eliminating motion and arthritis at the radiocarpal joint — while leaving the midcarpal joint (between the proximal and distal carpal rows) intact and mobile. The result is a wrist with no radiocarpal motion but preserved midcarpal motion, which translates to approximately 30–50% of normal wrist arc.
RSL fusion is appropriate when arthritis is isolated to the radiocarpal joint but the midcarpal articulation is still healthy — a pattern that can occur in inflammatory arthritis, post-traumatic deformity, and specific ligamentous instabilities. It provides excellent pain relief with a durable, stable construct and is well-tolerated by patients who understand and accept the trade-off of some motion loss for reliable pain relief.
Because it preserves more motion than a total wrist fusion while providing a rigid radiocarpal construct, RSL fusion occupies an important niche in the reconstructive ladder for selected patients — particularly those with RA who cannot tolerate the demands of arthroplasty.
Total wrist fusion (pan-carpal arthrodesis) eliminates all wrist motion by fusing the radius, all carpal bones, and typically the index and middle finger metacarpals into a single rigid unit. The wrist is held in a functional position — slight extension and ulnar deviation — and the joint is permanently stable.
Total wrist fusion provides maximum pain relief and grip strength, and the construct is durable under any level of physical demand. It is the most reliable option when pan-carpal arthritis is present and no motion-preserving procedure is appropriate — typically in patients with very severe deformity, failed prior reconstructions, or those who require unrestricted physical loading.
Dr. Graham rarely performs total wrist fusion as a primary procedure, given the breadth of motion-preserving options now available. However, it remains an important tool for specific situations — including salvage after failed arthroplasty, severe inflammatory destruction where arthroplasty carries unacceptable revision risk, or patients who explicitly prioritize maximum strength and durability over any residual motion.
Revision & Complex Reconstruction
Complex wrist reconstruction is a subspecialty within a subspecialty. Many orthopaedic surgeons — even hand surgeons — do not perform wrist arthroplasty or manage revision wrist cases routinely. When they encounter patients with failed prior wrist surgery, painful proximal row carpectomies, or complex deformity, they refer to Dr. Graham.
Dr. Graham performs revision wrist arthroplasty and accepts referrals for all forms of complex wrist reconstruction, regardless of where the primary surgery was performed. Second opinions are welcome and encouraged for patients facing major wrist reconstruction decisions.
One specific scenario worth highlighting: the painful proximal row carpectomy. Over time, some PRCs develop progressive arthritis at the capitate-radial articulation, resulting in return of pain. Revision options include conversion to total wrist arthroplasty and, in select cases, dermal allograft augmentation of the joint surface to extend the life of the PRC.
Failed implants, loosening, instability, or painful conversion from PRC. Dr. Graham performs both revision of existing arthroplasty and conversion of prior procedures to arthroplasty.
Progressive capitate-radial arthritis after proximal row carpectomy. Options include dermal allograft augmentation and conversion to total wrist arthroplasty depending on timing, severity, and patient factors.
A biologic tissue graft used to enhance the articular surface at the time of PRC — extending the durability of the articulation by providing a cushioning layer at the capitate-radial interface. Dr. Graham offers this as an adjunct in selected PRC cases.
Wrist deformity from prior fractures, failed ligament surgery, or progressive post-traumatic collapse. Reconstruction strategy is individualized based on remaining motion, arthritis pattern, and patient goals.
Patients facing major wrist reconstruction decisions — or those unsatisfied with their current trajectory after prior surgery — are welcome to schedule a consultation with Dr. Graham for an independent assessment.
Recovery
Recovery timelines vary by procedure. Total wrist arthroplasty and capitolunate fusion follow different paths — this represents a general guide. Your specific plan is discussed at consultation.
Wrist protected in a splint or cast. Fingers are free to move immediately — active finger exercises begin day one to prevent stiffness and reduce swelling. Wound check at 10–14 days.
For arthroplasty: gentle wrist motion begins with therapy. For fusions: cast maintained until X-ray shows consolidation. Swelling and sensitivity at the incision are normal and improve steadily.
Formal hand therapy with progressive resistive exercises. Wrist motion improving week by week. Most patients are performing light daily activities. Driving typically resumes by 8–10 weeks.
Majority of daily activities without restriction. Most patients describe meaningful pain improvement by this point. Grip strength progressively returning. Return to recreational activities individualized.
Final strength, motion, and function achieved. Most patients have returned to activities they value. Ongoing activity guidelines are discussed to optimize implant longevity for arthroplasty patients.
Most return to the majority of activities they value — daily activities, recreational pursuits, light to moderate physical demands. High-impact activities and very heavy repetitive loading are avoided to protect implant longevity. For many patients, particularly those with RA or bilateral disease, arthroplasty dramatically improves quality of life and independence.
Capitolunate fusion and other partial fusions allow return to most activities including manual work and sport — grip strength is near-normal and the stable wrist inspires confidence. Total wrist fusion patients face no activity restrictions after healing and can return to heavy labor. The trade-off is permanent loss of wrist motion, which most patients find manageable once pain is resolved.
Why This Practice
Total wrist arthroplasty and partial wrist fusion are not common procedures. Most general orthopaedic surgeons perform them rarely — if at all. The learning curve is steep, the implant selection is nuanced, and the consequences of technical errors are significant. Volume is not the only thing that matters, but it is a meaningful proxy for experience in a low-frequency, high-complexity procedure.
Dr. Graham is the #1 wrist arthroplasty volume surgeon in Northeast Florida. He performs wrist reconstructions of all types — arthroplasty, partial fusions, PRC, revision surgery — as a core part of his practice, not as occasional cases. He consults for orthopaedic industry companies, giving patients access to current-generation implants as evidence supports their use. And when other surgeons face complex wrist cases, they refer here.
Common Questions