In this retrospective study we report on two comparable groups of patients with advanced carpal arthritis treated with either proximal row carpectomy combined with a pyrocarbon resurfacing of the capitate (31 patients) or a four-corner arthrodesis and dorsal plating (26 patients). Follow-up time was 46 months (24-118). Except for a modestly higher radial wrist deviation in the patients treated with four-corner arthrodesis, there were no significant differences in outcomes between the groups. Asymptomatic progression of osteoarthritis in the lunate fossa was observed in four cases in both groups. Two cases were converted to a total wrist arthrodesis in the pyrocarbon group compared with one case in the four-corner arthrodesis group. Although four-corner arthrodesis remains the reference standard in the treatment of wrist osteoarthritis with involvement of the midcarpal joint, proximal row carpectomy combined with pyrocarbon resurfacing of the capitate is an alternative option. It can even be used in selected cases with erosion of the lunate fossa.