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Proximal Row Carpectomy

PRC for SLAC/SNAC II and Kienbock: radiocapitate articulation, capitate/lunate-fossa gatekeeping, PRC vs four-corner fusion, capsular interposition, long-term survivorship.

Overview

Proximal row carpectomy (PRC) is a reliable, motion-preserving salvage procedure indicated for complete amputation at the wrist joint, scaphoid nonunion, and Lichtman stage IIIA or IIIB Kienböck's disease [1, 7, 9]. The procedure achieves good functional results in young individuals following complete amputation and provides pain-free function that compares favorably with total or limited carpal fusions for scaphoid nonunion [1, 7]. Long-term follow-up demonstrates that all patients older than thirty-five years of age maintain satisfactory range of motion, grip strength, and pain relief, with high patient satisfaction rates [5].

Outcomes vary by etiology and patient demographics. While PRC results in a stiffened, weakened wrist when performed for static scapholunate dissociation [3], findings for SNAC and SLAC wrists generally favor limited carpal fusion, though flexion-extension and grip strength favor PRC in women [11]. Biomechanically, the mean pivot point shifts proximally by 6.8 to 9.1 mm after PRC for all tested motions [2]. Arthroscopic PRC is a safe, effective, and reliable alternative to the open approach, allowing for rapid mobilization compared with open procedures [6].

Postoperative management is streamlined, as immobilization is not necessary following the procedure [8]. A palmar approach facilitates early rehabilitation with better recovery of wrist motility [4]. However, midcarpal tenodesis shows progressive carpal collapse over time even in the absence of symptoms [4]. For patients with contraindications for PRC, such as pre-existing arthritis in the capitate head or lunate facet of the radius, a clinical trial of a lateral meniscal interposition allograft is supported [14].

Anatomy & Pathophysiology

Kinematics and Load Transfer

Proximal row carpectomy (PRC) results in a stiffened and weakened wrist when performed for static scapholunate dissociation [3]. The procedure shifts the mean pivot point proximally by 6.8 to 9.1 mm after PRC for all tested motions [2]. Removal of the proximal carpal row decreases normal wrist flexion and extension [12], while radial deviation becomes limited by impingement of the trapezoid on the radial styloid [12]. Significant contact translation occurs after PRC [23]. The anatomical mismatch of the radiocapitate articulation leads to significant changes in load transfer and overloads the wrist [13]. Despite these changes, performing a PRC does not significantly alter the contact pressures or area of the lunate fossa of the radiocarpal joint [22].

Comparative Biomechanics and Outcomes

The four-bone arthrodesis wrist demonstrates significantly lower contact pressure compared with the PRC wrist [20]. Conversely, the four-bone arthrodesis wrist exhibits a greater contact area compared with the PRC wrist [20], yet both procedures result in equal contact translation [20]. Lunate excision alone preserves simulated active dart-throwing motion more effectively than PRC [26]. Regarding prognostic factors, the shape of the capitate is not a prognostic factor for functional outcome after PRC [25]. Primary radial styloidectomy reduces the risk of radial impingement without affecting clinical function or patient-related outcomes [21].

Classification

Indications by Pathology: Proximal row carpectomy is a useful procedure to preserve joint motion of the wrist in selected cases of complete amputation at the wrist joint [1] and achieves good functional results in young individuals following complete amputation at the wrist joint [1]. It serves as a reliable motion-preserving salvage procedure that can provide pain-free function that compares favorably with total or limited carpal fusions for scaphoid nonunion [7]. The procedure is a reliable and durable option for patients with Lichtman stage IIIA or IIIB Kienböck's disease at an average follow-up of 10 years [9]. Arthroscopic proximal row carpectomy appears to be a safe, effective, and reliable procedure for a variety of wrist conditions [6].

Acute Trauma: Acute proximal row carpectomy is an option for patients with complex carpal fracture dislocations, particularly those with fracture of the lunate [16]. This approach is also indicated for patients with concomitant scaphoid fracture and scapholunate ligament injury [16], as well as those with preexisting wrist arthritis [16].

Contraindications and Outcomes by Condition: Proximal row carpectomy performed for static scapholunate dissociation results in a stiffened, weakened wrist [3]. Findings among patients treated for SNAC and SLAC wrist conditions are in favour of Limited Carpal Fusion compared to Proximal Row Carpectomy [11], although in patients treated for SNAC and SLAC wrist conditions, flexion-extension and grip strength favor Proximal Row Carpectomy in women [11].

Age and Approach Considerations: Patients older than thirty-five years of age at the time of proximal row carpectomy maintained a satisfactory range of motion, grip strength, and pain relief at long-term follow-up [5] and were satisfied with the result at long-term follow-up [5]. Proximal row carpectomy by palmar approach allows early rehabilitation with better recovery of wrist motility [4], while arthroscopic proximal row carpectomy allows for rapid mobilization of the wrist compared with the open procedure [6]. Postoperative immobilisation is not necessary after proximal row carpectomy [8].

Biomechanical Consequences: The mean pivot point shifted proximally by 6.8-9.1 mm after proximal row carpectomy for all motions tested [2]. Removal of the proximal carpal row decreased normal wrist flexion and extension [12]. Radial deviation is limited by impingement of the trapezoid on the radial styloid after proximal row carpectomy [12]. The mismatch of the radiocapitate articulation led to significant changes in load transfer after proximal row carpectomy [13], and the wrist is overloaded after a proximal row carpectomy due to the anatomical mismatch of the radiocapitate articulation [13]. Midcarpal tenodesis shows progressive carpal collapse over time even in the absence of symptoms [4].

Clinical Presentation

Proximal row carpectomy (PRC) serves as a reliable motion-preserving salvage procedure, offering pain-free function that compares favorably with total or limited carpal fusions [7]. It is indicated for complete amputation at the wrist joint to preserve joint motion, yielding good functional results in young individuals [1]. For chronic conditions, PRC is a durable option for patients with Lichtman stage IIIA or IIIB Kienböck's disease at an average 10-year follow-up [9]. In acute settings, PRC is an option for complex carpal fracture dislocations, particularly involving lunate fractures, concomitant scaphoid fractures, scapholunate ligament injuries, or preexisting wrist arthritis [16].

Chronic Arthropathy and Functional Outcomes

Long-term outcomes for patients older than thirty-five years at the time of surgery demonstrate maintained satisfactory range of motion, grip strength, and pain relief with high patient satisfaction [5]. However, the procedure alters wrist kinematics; the mean pivot point shifts proximally by 6.8–9.1 mm for all tested motions [2]. Biomechanically, removal of the proximal carpal row decreases normal wrist flexion and extension [12]. Radial deviation is specifically limited by impingement of the trapezoid on the radial styloid [12]. Furthermore, the anatomical mismatch of the radiocapitate articulation leads to significant changes in load transfer, resulting in an overloaded wrist [13].

Comparative Efficacy and Complications

When comparing PRC to four-corner arthrodesis for SLAC or SNAC wrists, both procedures improve pain and subjective outcomes [18]. Four-corner arthrodesis provides significantly greater post-operative radial deviation and grip strength as a percentage of the opposite side compared to PRC [27]. Conversely, PRC results in better wrist flexion, extension, and flexion-extension arc [27]. PRC also demonstrates a lower overall complication rate than four-corner arthrodesis [27]. In patients with SNAC and SLAC conditions, findings generally favor limited carpal fusion over PRC, except regarding flexion-extension and grip strength in women [11].

Technical Considerations and Specific Pathologies

Arthroscopic approach allows for rapid mobilization of the wrist compared with the open procedure [6]. Postoperative immobilisation is not necessary after PRC [8]. However, PRC performed for static scapholunate dissociation results in a stiffened, weakened wrist [3]. A previously unreported cause of persistent ulnocarpal pain following PRC is pisiform bone impingement syndrome [10].

Investigations

Plain radiography: Preoperative radiographs often underestimate degenerative changes at the radiolunate joint, showing poor correlation with intraoperative findings [29]. Proximal row carpectomy is indicated for Lichtman stage IIIA or IIIB Kienböck's disease, where it remains a reliable and durable procedure at 10-year follow-up [9]. The procedure is also a viable option for acute complex carpal fracture dislocations, specifically involving lunate fractures, concomitant scaphoid fractures, scapholunate ligament injuries, or preexisting wrist arthritis [16]. In patients with SNAC or SLAC wrists, limited carpal fusion is generally favored over proximal row carpectomy, except regarding flexion-extension and grip strength in women [11].

Other Considerations: Proximal row carpectomy is a useful motion-preserving salvage procedure for complete wrist amputation in young individuals, yielding good functional results [1]. It provides satisfactory range of motion and grip strength with few complications when capitolunate arthrosis is absent [17]. Long-term follow-up indicates that all patients older than 35 years maintain satisfactory range of motion, grip strength, and pain relief [5]. However, the procedure results in a stiffened, weakened wrist when performed for static scapholunate dissociation [3]. Biomechanically, the removal of the proximal carpal row decreases normal wrist flexion and extension [12], while radial deviation is limited by trapezoid impingement on the radial styloid [12]. The anatomical mismatch of the radiocapitate articulation leads to significant changes in load transfer and wrist overload [13]. The mean pivot point shifts proximally by 6.8–9.1 mm after the procedure [2]. Persistent ulnocarpal pain may result from pisiform bone impingement syndrome [10]. For patients with contraindications such as pre-existing arthritis in the capitate head or lunate facet of the radius, a lateral meniscal interposition allograft is supported for clinical trial [14].

Surgical Approach and Rehabilitation: The palmar approach allows for early rehabilitation with better recovery of wrist motility [4]. Arthroscopic proximal row carpectomy is a safe, effective, and reliable procedure that permits rapid mobilization compared with the open technique [6]. Postoperative immobilization is not necessary following the procedure [8]. Midcarpal tenodesis, however, shows progressive carpal collapse over time even in the absence of symptoms [4].

Treatment

Operative

Indications: Proximal row carpectomy is indicated as a motion-preserving salvage procedure for scaphoid nonunion, providing pain-free function that compares favorably with total or limited carpal fusions [7]. The procedure is reliable and durable for patients with Lichtman stage IIIA or IIIB Kienböck's disease at an average follow-up of 10 years [9]. It is also a useful procedure to preserve joint motion in selected cases of complete amputation at the wrist joint, achieving good functional results in young individuals [1]. Patients older than thirty-five years of age at the time of surgery maintained satisfactory range of motion, grip strength, and pain relief at long-term follow-up, with high satisfaction rates [5]. Conversely, the procedure is contraindicated for static scapholunate dissociation, as it results in a stiffened, weakened wrist [3]. For patients with contraindications such as pre-existing arthritis in the capitate head or lunate facet of the radius, a lateral meniscal interposition allograft is supported for clinical trial [14].

Surgical Approach / Technique: The palmar approach to proximal row carpectomy allows for early rehabilitation with better recovery of wrist motility [4]. Arthroscopic proximal row carpectomy appears to be a safe, effective, and reliable procedure for a variety of wrist conditions and allows for rapid mobilization of the wrist compared with the open procedure [6]. Postoperative immobilisation is not necessary after proximal row carpectomy [8]. Biomechanically, the mean pivot point shifts proximally by 6.8-9.1 mm after proximal row carpectomy for all motions tested [2]. While midcarpal tenodesis is sometimes considered, it shows progressive carpal collapse over time even in the absence of symptoms [4].

Other Considerations: Persistent ulnocarpal pain after proximal row carpectomy may be caused by pisiform bone impingement syndrome, a previously unreported etiology [10]. Total wrist arthrodesis combined with proximal row carpectomy provides reliable and reproducible benefits [28].

Complications

Stiffness / Arthrofibrosis: Proximal row carpectomy performed for static scapholunate dissociation results in a stiffened wrist [3]. While midcarpal tenodesis demonstrates progressive carpal collapse over time even in the absence of symptoms, proximal row carpectomy via a palmar approach facilitates early rehabilitation with superior recovery of wrist motility [4].

Instability: Proximal row carpectomy performed for static scapholunate dissociation results in a weakened wrist [3].

Other Considerations: Among patients treated for SNAC and SLAC wrist conditions, findings favor Limited Carpal Fusion compared to Proximal Row Carpectomy regarding outcomes, except for flexion-extension and grip strength in women [11]. Pisiform bone impingement syndrome is a recognized cause of persistent ulnocarpal pain following the procedure [10].

Recovery

Light activity (weeks): Early rehabilitation is facilitated by the palmar approach, which allows for earlier mobilization compared to midcarpal tenodesis [4]. Furthermore, arthroscopic proximal row carpectomy enables rapid mobilization of the wrist relative to the open procedure [6]. Postoperative immobilization is not necessary following the procedure [8].

Full activity (months): Patients older than thirty-five years of age at the time of proximal row carpectomy maintain satisfactory range of motion, grip strength, and pain relief at long-term follow-up [5]. The procedure preserves joint motion of the wrist in selected cases of complete amputation and achieves good functional results in young individuals following such amputation [1]. Additionally, patients experience good pain relief and preservation of wrist motion following the surgery [15].

Complete recovery / outcome plateau (months): The mean pivot point shifts proximally by 6.8 to 9.1 mm after proximal row carpectomy for all motions tested [2]. Patients older than thirty-five years of age at the time of proximal row carpectomy remain satisfied with the result at long-term follow-up [5]. The procedure is a reliable and durable option for patients with Lichtman stage IIIA or IIIB Kienböck's disease at an average follow-up of 10 years [9].

Rehabilitation protocol: The palmar approach for proximal row carpectomy allows better recovery of wrist motility compared to midcarpal tenodesis [4]. Arthroscopic proximal row carpectomy allows for rapid mobilization of the wrist compared with the open procedure [6]. Postoperative immobilization is not necessary after proximal row carpectomy [8].

Functional milestones: Proximal row carpectomy provides pain-free function that compares favorably with total or limited carpal fusions for scaphoid nonunion [7]. The procedure is a reliable motion-preserving salvage procedure for scaphoid nonunion [7]. Patients older than thirty-five years of age at the time of proximal row carpectomy maintain satisfactory grip strength and range of motion at long-term follow-up [5].

Other Considerations: Proximal row carpectomy performed for static scapholunate dissociation results in a stiffened and weakened wrist [3]. Midcarpal tenodesis shows progressive carpal collapse over time even in the absence of symptoms [4]. Pisiform bone impingement syndrome is a cause of persistent ulnocarpal pain after proximal row carpectomy [10].

Key Evidence

  • [L4] Proximal row carpectomy is a useful procedure to preserve joint motion of the wrist in selected cases of complete amputation at the wrist joint, achieving good functional results in young individuals. (10.1007/s11552-008-9141-z)
  • [Paper] The mean pivot point shifted proximally (6.8-9.1 mm) after proximal row carpectomy for all motions tested. (10.1016/j.clinbiomech.2011.03.002)
  • [L4] Proximal row carpectomy, when performed for static scapholunate dissociation, results in a stiffened, weakened wrist. (10.1177/1753193410382719)
  • [L4] The proximal row carpectomy by palmar approach allows early rehabilitation with better recovery of wrist motility, while the midcarpal tenodesis shows progressive carpal collapse over time even in the absence of symptoms. (10.1177/1753193418775067)
  • [L4] At the time of long-term follow-up, all patients older than thirty-five years of age at the time of a proximal row carpectomy had maintained a satisfactory range of motion, grip strength, and pain relief and were satisfied with the result. (10.2106/00004623-200411000-00001)
  • [L4] Arthroscopic proximal row carpectomy appears to be a safe, effective, and reliable procedure for a variety of wrist conditions, and it allows for rapid mobilization of the wrist compared with the open procedure. (10.1016/j.jhsa.2011.01.009)
  • [L4] Proximal row carpectomy has proven to be a reliable motion-preserving salvage procedure that can provide pain-free function that compares favorably with total or limited carpal fusions. (10.1016/s0749-0712(21)01450-5)
  • [L3] The authors conclude that postoperative immobilisation is not necessary after proximal row carpectomy. (10.1177/1753193408092490)
  • [L4] At an average follow-up of 10 years, proximal row carpectomy is a reliable and durable procedure for patients with Lichtman stage IIIA or IIIB Kienböck's disease. (10.1016/j.jhsa.2008.02.031)
  • [L4] Pisiform bone impingement syndrome is a previously unreported cause of persistent ulnocarpal pain after proximal row carpectomy. (10.1007/s00402-014-2002-z)
  • [L3] Among patients treated for SNAC and SLAC wrist conditions, findings are in favour of Limited Carpal Fusion compared to Proximal Row Carpectomy, except for flexion-extension and grip strength in women. (10.1186/s13018-023-04177-7)
  • [L5] Removal of the proximal carpal row decreased normal wrist flexion and extension, with radial deviation limited by impingement of the trapezoid on the radial styloid. (10.1016/j.jhsa.2006.10.014)
  • [L5] The study confirmed that the mismatch of the radiocapitate articulation led to significant changes in load transfer, with the wrist being overloaded after a proximal row carpectomy due to the anatomical mismatch of the radiocapitate articulation. (10.1177/1753193409344527)
  • [L5] These results support the clinical trial of a lateral meniscal interposition allograft in patients with contraindications for proximal row carpectomy, such as pre-existing arthritis in the capitate head or lunate facet of the radius. (10.1016/j.jhsa.2008.10.030)
  • [L3] Patients experienced good pain relief with preservation of wrist motion. (10.1177/1753193415597096)
  • [L5] Acute proximal row carpectomy is an option for some patients with complex carpal fracture dislocations, particularly those with fracture of the lunate, concomitant scaphoid fracture and scapholunate ligament injury, or preexisting wrist arthritis. (10.1007/s12593-014-0162-2)
  • [L5] PRC provides satisfactory postoperative wrist range of motion and grip strength with few complications, especially when there is no capitolunate arthrosis. (10.1016/j.hcl.2012.08.022)
  • [L4] Both procedures provide improvements in pain and subjective outcome measures for patients with symptomatic and appropriately staged SLAC or SNAC wrists. (10.1177/1753193408100954)
  • [L5] The FBA wrist has significantly lower contact pressure, greater contact area, and equal contact translation compared with the PRC wrist. (10.1016/j.jhsa.2012.05.040)
  • [L4] Primary radial styloidectomy reduced the risk of radial impingement without affecting clinical function or patient-related outcomes. (10.1177/17531934221087588)
  • [L5] In contrast to prior studies that demonstrated significant increases in contact pressure and decreases in contact area after PRC, our findings propose that performing a PRC does not significantly alter the contact pressures or area of the lunate fossa of the radiocarpal joint. (10.1177/15589447221105542)
  • [L5] There is significant contact translation after PRC, which provides quantitative support of the theory that translational motion of the PRC may explain its good clinical outcomes. (10.1016/j.jhsa.2008.12.004)
  • [L3] The shape of the capitate was not a prognostic factor for functional outcome after PRC. (10.1016/j.jhsa.2015.02.019)
  • [L5] Lunate excision alone preserved simulated active dart-throwing motion more effectively than PRC. (10.1016/j.jhsg.2026.101029)
  • [L1] Four-corner arthrodesis provided significantly greater post-operative radial deviation and grip strength as a percentage of the opposite side, while proximal row carpectomy resulted in better wrist flexion, extension, and flexion-extension arc, along with a lower overall complication rate. (10.1177/1753193414554359)
  • [Paper] Total wrist arthrodesis combined with PRC provides reliable and reproducible benefits. (10.1016/j.otsr.2015.09.032)
  • [L4] Preoperative radiographs did not correlate well with intraoperative findings, often underestimating degenerative changes at the radiolunate joint. (10.1016/j.jhsa.2014.03.032)

See Also

References

[1] Hand Replantation with Proximal Row Carpectomy. HAND. 2008. DOI: 10.1007/s11552-008-9141-z

[2] Effects of proximal row carpectomy on wrist biomechanics: A cadaveric study. Clinical Biomechanics. 2011. DOI: 10.1016/j.clinbiomech.2011.03.002

[3] Proximal row carpectomy for scapholunate dissociation. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410382719

[4] Proximal row carpectomy, scaphoidectomy with midcarpal arthrodesis or midcarpal tenodesis: when and how to use. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418775067

[5] Proximal Row Carpectomy: Study with a Minimum of Ten Years of Follow-up. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200411000-00001

[6] Arthroscopic Proximal Row Carpectomy. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.01.009

[7] PROXIMAL ROW CARPECTOMY FOR THE TREATMENT OF SCAPHOID NONUNION. Hand Clinics. 2001. DOI: 10.1016/s0749-0712(21)01450-5

[8] Proximal Row Carpectomy With or Without Postoperative Immobilisation. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408092490

[9] Proximal Row Carpectomy for Advanced Kienböck's Disease: Average 10-Year Follow-Up. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.031

[10] Two cases of pisiform bone impingement syndrome after proximal row carpectomy. Archives of Orthopaedic and Trauma Surgery. 2014. DOI: 10.1007/s00402-014-2002-z

[11] Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist, results after 3.5 years. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04177-7

[12] Carpal Kinematics After Proximal Row Carpectomy. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.10.014

[13] Biomechanics of the wrist after proximal row carpectomy in cadavers. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409344527

[14] Proximal Row Carpectomy: Role of a Radiocarpal Interposition Lateral Meniscal Allograft. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.10.030

[15] Factors associated with improved outcomes following proximal row carpectomy: a long-term outcome study of 144 patients. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415597096

[16] Acute Proximal Row Carpectomy after Complex Carpal Fracture Dislocation. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-014-0162-2

[17] Proximal Row Carpectomy. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2012.08.022

[18] Proximal Row Carpectomy vs Four Corner Fusion for Scapholunate (Slac) or Scaphoid Nonunion Advanced Collapse (Snac) Wrists: A Systematic Review of Outcomes. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408100954

[20] Scaphoid Excision and 4-Bone Arthrodesis Versus Proximal Row Carpectomy: A Comparison of Contact Biomechanics. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.05.040

[21] The role of routine radial styloidectomy in proximal row carpectomy: a retrospective review of 120 patients. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221087588

[22] Proximal Row Carpectomy Does Not Alter Contact Pressures of the Lunate Fossa: A Cadaveric Study. HAND. 2022. DOI: 10.1177/15589447221105542

[23] Comparison of the “Contact Biomechanics” of the Intact and Proximal Row Carpectomy Wrist. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.12.004

[25] Radiocapitate Congruency as a Predictive Factor for the Results of Proximal Row Carpectomy. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.02.019

[26] Biomechanical Effects of Lunate Excision Alone and Proximal Row Carpectomy on Dart-Throwing Motion, Circumduction, and Carpal Stability: A Cadaveric Study. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.101029

[27] Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: a systematic review. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414554359

[28] Proximal row carpectomy in total arthrodesis of the rheumatoid wrist. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.09.032

[29] Proximal Row Carpectomy Versus Scaphoid Excision and Intercarpal Arthrodesis: Intraoperative Assessment and Procedure Selection. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.032

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.