Patient, a smoke, presented with right SLAC wrist, Watson Stage III — confirmed by MRI (10/1/2024) showing complete scapholunate ligament rupture, DISI deformity, mild radioscaphoid degenerative changes, and large joint effusions 56. Doctor staged the condition and identified a preserved radiolunate joint intraoperatively, confirming that a partial wrist fusion (capitolunate arthrodesis, or CLA) rather than total wrist fusion was appropriate. Doctor used two Arthrex DynaNite nitinol staples (15mm × 10mm), placed dorsally, as the exclusive fixation for the capitolunate arthrodesis. No compression screw was used. Both staples pulled through the lunate body within 14 days — before any meaningful biological healing. At the revision surgery, the surgeon found that "the entire dorsal rim of the capitate had fractured off and the staples had pulled through the body of the lunate. At revision, (11-14-2024) the surgeon attempted to place a second staple: "as I made the drill holes, we blew out the radial aspect of the lunate body". During the revision, a capitolunate fusion screw was used. Unfortunately, by 1/17/2025, the revision headless compression screw was broken with the lunate in persistent DIS. No salvage procedure was offered.
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Do you believe there might have been medical error?
There are features in this case suggesting error in judgment and technique. While partial wrist fusion is not strictly contraindicated in smokers, it carries an elevated risk of nonunion and fixation failure and smoking is therefore a relative contraindication to wrist fusion, whether partial or complete. The use of dorsal nitinol staples as the sole fixation method may have provided insufficient mechanical stability for capitolunate arthrodesis in this setting. The rapid postoperative failure characterized by staple pullout within two weeks and subsequent intraoperative bone compromise strongly suggests inadequate initial construct stability rather than biological failure. A motion-preserving alternative such as proximal row carpectomy may have been a reasonable option, depending on the condition of the capitate articular surface.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Causation is reasonably supported, though not in an absolute sense based on the limited data set available. The pattern and timing of failure, with construct collapse within two weeks, followed by intraoperative bone compromise and subsequent nonunion with hardware failure, point strongly toward mechanical insufficiency of the initial fixation and/or technique as a substantial contributing factor to the outcome. While the patient’s smoking status materially increased the baseline risk of nonunion, it would not typically account for such rapid structural failure before any meaningful biologic healing could occur. Taken together, it is more likely than not that the choice and/or execution of the initial fixation construct contributed in a causative way to the cascade of failure that followed, even if patient-related factors also played a secondary role. Access to the complete records including radiographs from intraoperative fluoro would be very helpful in this determination.
What makes you a good expert for this case?
I am a board-certified, fellowship-trained hand and upper extremity orthopedic surgeon with CAQ in Hand Surgery. I have served as the Clinical Director of Hand Surgery in my hospital for over two years. I trained in multiple level-one institutions with extensive experience evaluating and treating wrist arthritis and its sequelae. I have served as an expert witness in multiple cases with experience in review, deposition, and in-court testimony work, for both plaintiffs and defendants. I trained in one of the top hand surgery fellowships in the US with internationally-recognized experts in wrist arthritis. I am available to be retained for this case and have a flexible schedule to work on it, and I respond rapidly to queries and feedback.
How often do you encounter cases similar to this one in your practice?
Thankfully not very often in my primary practice, although I have seen a fair number of second opinions with nonunion or partial nonunion.
Do you believe there might have been medical error?
Without visually seeing the intraoperative x-rays, it is hard for me to definitively say there has not been medical error. However, loss of fixation in these small carpal bones is a known complication. Fixation methods which are standard of care include headless compression screws, staples, as well as small circular plates with screws. The use of staples alone is certainly a fixation method that is accepted within the Hand Surgery community. With the revision setting, it is certainly possible for the small lunate bone to be fractured as revision fixation is placed
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Hardware failure in scaphoid excision and capitolunate fusion is a known complication of surgery. These carpal bones are small and pull out of the hardware is a known issue. Without the radiographs to view the initial fixation placed intra-operatively, it is difficult to assess technical mistakes. However, use of two staples alone as fixation for a capitolunate fusion is certainly considered standard of care.
What makes you a good expert for this case?
I am a double board certified orthopedic surgeon who frequently performs this procedure
How often do you encounter cases similar to this one in your practice?
Cases with the initial presenting diagnosis are common occurrences in a busy Hand Surgery practice. Failure of fixation is rare but is known to occur and is certainly not out of the typical standard of care following a scaphoid excision and mid carpal fusion surgery. Salvage procedures at this point include proximal row carpectomy and total wrist fusion if the patient continues to have persistent pain.
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