Carpal height and postoperative strength after proximal row carpectomy or four-corner arthrodesis: Clinical, anatomical and biomechanical study

The Effect of Proximal Row Carpectomy and Trapeziectomy on First Ray Stability: A Cadaveric Study

PURPOSE

Wrist and thumb pathology can coexist leading to potential indications for proximal row carpectomy (PRC) and trapeziectomy. In this setting, the axial stability of the first ray is not known. We sought to evaluate axial subsidence of the first metacarpal in cadavers following trapeziectomy and trapeziectomy with PRC to determine the mechanical effects of the procedures performed concurrently.

METHODS

Eleven fresh-frozen cadaveric distal forearm specimens were used in this study. The specimens were fixed in cement and mounted to a material test system frame. A predetermined force (20 N) was applied to the thumb metacarpal to simulate forces observed with lateral pinch. Axial displacement of the thumb metacarpal was measured. The application of force was repeated following trapeziectomy on each hand and then again following PRC. Analysis was performed to compare thumb metacarpal subsidence of the 3 groups: native, trapeziectomy, and trapeziectomy with PRC.

RESULTS

Before trapeziectomy, native cadaver specimens had an average of 5.1 ± 1.9 mm of thumb metacarpal subsidence under the material test system load (20 N), compared to 16.2 ± 3.4 mm following trapeziectomy, and 25.0 ± 5.5 mm for trapeziectomy with PRC.

CONCLUSION

We observed a significant increase in thumb metacarpal subsidence following concurrent trapeziectomy with PRC when compared to trapeziectomy alone. Our results suggest that performing both operations together would lead to a substantial risk of first ray subsidence.

CLINICAL RELEVANCE

When treating concurrent basilar thumb and wrist arthritis, it may be more effective to stage the procedures or use a form of thumb metacarpal suspension or arthrodesis.

Managing Severe Postburn Wrist Flexion Contracture by Proximal Row Carpectomy and Abdominal Interpolation Flap

Introduction: Postburn upper extremity contractures can greatly diminish the quality of life. To successfully manage these contractures and achieve successful functional outcomes, an optimal surgical method should be planned to address all affected tissues on the extremities. Conventional soft tissue transfers after releasing the contracture, such as skin grafts or flaps, may be insufficient. In addition to capsulotomy, tendon release, and lengthening procedures, more aggressive modalities may be indicated. Methods: In this retrospective study, patients who developed wrist flexion deformities due to burn injuries and underwent proximal row carpectomy and abdominal interpolation flaps were included. Results: Between January 2019 and June 2020, 5 patients underwent surgery using this technique. All patients were male, 2 had thermal burns, 2 had electrical burns, and 1 had chemical burns. Preoperatively, all patients had severe flexion deformities ranging from 70° to 85°. There were no postoperative complications, and stable wrists with a good and functional alignment were achieved, although the preoperative and postoperative range of motion differences were limited, where a postoperative range of motions were ranging from 5 to 15 in terms of extension, 15 to 20 in terms of flexion. Preoperative QuickDash scores were between 79.5 and 95.5, postoperative scores ranged from 25 to 36.4. Conclusion Proximal row carpectomy shortens the length of the wrist, resurfaces the wrist joint, and provides a release in tendons and other soft tissues. Together with soft tissue transfer, this technique can be used for severe wrist flexion contractures.

Proximal row carpectomy versus four-corner arthrodesis in the treatment of SLAC and SNAC wrist: meta-analysis and literature review

A systematic literature review was performed on 84 articles from 2000 to 2020 on proximal row carpectomy (PRC) or four-corner arthrodesis (FCA) in patients with posttraumatic wrist osteoarthritis. Qualitative assessment was conducted on 14 articles. Pain, range of motion (ROM), grip strength and complications were analyzed using weighted average means. Meta-analysis with a random effects model was performed for the flexion-extension arc and grip strength. A total of 1,066 PRCs and 2,771 FCAs were analyzed, with a mean follow-up of 9 and 7 years respectively. Mean flexion after PRC and FCA respectively was 36.2 ° and 31.1 °, mean extension 41.4 ° and 32.4 °, and mean grip strength 26.4 kg and 27.5 kg. PRC had a larger flexion-extension arc than FCA, with a standard mean difference (SMD) of 0.41 (range, 0.02-0.81). No significant difference was found for grip strength. Osteoarthritis occurred in 42.2% of PRC cases, independently of capitate shape. Conversion to wrist arthrodesis was performed in 10.1% of failed PRCs. Revision was chosen in 4.7% of FCAs and conversion to wrist arthrodesis in 4.6%. We conclude that the functional results of both techniques are similar, but prefer PRC to FCA because of the lower complications rate.

Long-term results of first row carpectomy with proximal capitate resurfacing using a pyrocarbon implant

The functional results of proximal row carpectomy with a proximal capitate resurfacing using a pyrocarbon implant were evaluated in a retrospective, multicentric, multi-operator study. The outcomes of patients operated on at five surgical centres between January 2005 and December 2018 were reviewed. The data were collected by an independent observer during standardized consultations. Based on 30 patients with a mean follow-up of 7 years, the median range of flexion and extension was 65° and the median radioulnar tilt was 45°. The median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 14 and the improvements in strength and pain were good. Compared with the preoperative values, significant improvements were seen in the flexion and extension range of motion, radioulnar tilt and pain score. No postoperative complications were recorded.Level of evidence: IV.

Surgical fixation techniques in four-corner fusion of the wrist: a systematic review of 1103 cases

BACKGROUND

Four-corner fusion (4CF) is a known treatment option for degenerative wrist conditions. Different techniques may be used and there is no general consensus on best implant. As such, it was the purpose of the current systematic review to compare fusion rates and outcomes depending on the fixation technique.

METHODS

The systematic review was registered in the international prospective register of systematic reviews (PROSPERO): CRD42020164301. It followed the PRISMA guidelines. Original articles were screened using the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and Web of Science Core Collection. Studies reporting on outcome for 4CF surgery were included. Studies with a minimum Level IV of evidence were considered eligible. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

A total of 29 studies met the inclusion criteria, for a total of 1103 wrists. The mean age was 41.8 years (range 19-83). Mean follow-up overall was 43.5 months (range 24-146 months). Reported fusion weighted rates were >90% and did not differ significantly between techniques. Reoperations due to different reasons occurred in 135 (12%) of all 1103. There was significant data heterogeneity regarding fusion rates (I² = 70%). Inconsistency and heterogeneity in data reporting did not allow meta-analysis with direct data pooling and comparison of subgroups.

CONCLUSIONS

Satisfactory fusion rates (over 90%) can be achieved independent of the fixation technique used in 4-corner arthrodesis. Due to the high data heterogeneity and reporting inconsistency across studies, no statements regarding PROMs, ROM or grip strength can be made.

LEVEL OF EVIDENCE

Systematic Review of Level IV Studies.

Proximal row carpectomy generates better mid- to long-term outcomes than four-corner arthrodesis for post-traumatic wrist arthritis: A meta-analysis

INTRODUCTION

In posttraumatic wrist arthritis of intermediate severity, two main palliative procedures are used to preserve some mobility in the wrist: proximal row carpectomy (PRC) and scaphoid excision followed by four corner arthrodesis (4CA). Despite satisfactory overall results, the debate continues about which one provides the best results and long-term outcomes, particularly prevention of arthritis progression. Recent comparative studies now provide us with information about mid- and long-term results. The aim of this study was to compare the clinical results, complications, conversion rate to total wrist arthrodesis and progression to osteoarthritis of PRC versus 4CA in the medium and long term.

HYPOTHESIS

The null hypothesis was that there is no significant difference between PRC and 4CA in the clinical results, complications, conversion to total wrist arthrodesis and arthritis progression.

MATERIALS AND METHODS

A systematic literature review was carried out by following the PRISMA guidelines. Included were studies comparing 4CA and PRC for the treatment of post-traumatic wrist arthritis secondary to scapholunate dissociation (SLAC) and scaphoid nonunion (SNAC) with a mean follow-up of 5 years. A search was performed of the MEDLINE, EMBASE and Cochrane databases that identified 831 articles. After removing 230 duplicates and excluding 595 articles based on their title and/or abstract, and then adding 1 article manually, 7 articles were included in our analysis. Parameters analyzed were range of motion (ROM), pain, grip strength, functional scores, complications, conversion to total wrist arthrodesis, and arthritis progression.

RESULTS

In the 7 articles, 1059 wrists - 582 PRC and 477 4CA - were analyzed with follow-up ranging from 5.2 to 18 years. PRC produced significantly better ROM in flexion (weighted mean difference [WMD]=10.0°; p<0.01) and in ulnar deviation (WMD=8.7°; p<0.01) along with significantly lower complication rates (OR=0.3; p<0.01) and reoperation rates (OR=0.1; p<0.01). There was no significant difference in the conversion rate, grip strength, extension, radial deviation, pain, DASH and PRWE scores. The progression of osteoarthritis could not be analyzed due to lack of data.

DISCUSSION

This meta-analysis was the first to include recently published mid- and long-term studies comparing PRC and 4CA. The main finding is that PRC is superior overall with better ROM and a lower complication rate. Another important finding was the absence of differences in grip strength and the conversion rate to total wrist arthrodesis. Unfortunately, the lack of systematic studies on arthritis progression leaves this question unanswered. Our findings must be interpreted cautiously because it was impossible to stratify the cases by etiology and osteoarthritis stage.

LEVEL OF EVIDENCE

III; systematic review and meta-analysis.

Arthroscopic Radiocarpal Tendinous Inter-Position for Grade 2 Scapholunate Advanced Collapse – Surgical Technique

Grade 2 scapholunate advanced collapse (SLAC 2) can be treated by proximal row carpectomy with satisfactory results. However, this method is invasive and can limit function. The senior author had proposed an arthroscopic alternative with tendon interposition between the radius and proximal carpal row (arthroscopic interposition tendon arthroplasty [AITA]). However, this arthroscopic technique is technically difficult and requires a risky palmar arthroscopic portal. We report a modification of AITA, the one-loop arthroscopic radiocarpal tendon inter-position (1L-ARTI) that is simpler and needs only dorsal arthroscopic portals.

Level of Evidence: Level V (Therapeutic)

Does Proximal Row Carpectomy Improve Union in Wrist Arthrodesis? A Retrospective Cohort Study

Background  Some surgeons advocate for concomitant proximal row carpectomy (PRC) with total wrist arthrodesis (TWA), though there are limited data to support or oppose this view. Questions/Purposes  Does concomitant PRC improve rates of union, revision, hardware loosening, hardware failure, and hardware removal in TWA? Patients and Methods  A retrospective cohort study of patients who underwent TWA with and without concomitant PRC between January 2008 and December 2018 was undertaken. Patients were included if they underwent TWA using a dorsal spanning plate. Patients were excluded if they underwent partial wrist arthrodesis, revision TWA, or TWA with nondorsal spanning plate fixation. Results  A total of 183 wrists in 180 patients were included in the study, 96 (52.5%) in the TWA only and 87 (47.5%) in the TWA + PRC groups. Median clinical and radiographic follow-up was 18.0 months (3.0-133.0 months) in the TWA + PRC group and 18.5 months (2.0-126.0 months) in the TWA only group ( p  = 0.907). No difference in nonunion (TWA + PRC: 13/87 [14.9%], TWA only: 18/96 [18.8%], odds ratio: 0.76, p  = 0.494), revision (TWA + PRC: 5/87 [5.75%], TWA only: 8/96 [8.33%], hazard ratio [HR]: 0.73, p  = 0.586), loosening (TWA + PRC: 4/87 [4.60%], TWA only: 6/96 [6.25%], HR: 0.74, p  = 0.646), failure (TWA + PRC: 5/87 [5.75%], TWA only: 4/96 [4.17%], HR: 1.55, p  = 0.530), and removal (TWA + PRC: 12/87 [13.8%], TWA only: 16/96 [16.7%], HR: 0.84, p  = 0.634) were identified. Conclusion  Concomitant PRC might not improve rates of union or diminish complications in patient undergoing TWA. The role of PRC and the rationale for its use in TWA need to be individualized and discussed with patients prior to surgery. Level of Evidence  This is a Level IV, therapeutic study.

Opioid Prescribing for Proximal Row Carpectomy versus Four-Corner Arthrodesis

Background  Proximal row carpectomy (PRC) and four-corner arthrodesis (4-CA) represent motion-sparing procedures for addressing degenerative wrist pathologies. While both procedures demonstrate comparable functional outcomes, postoperative pain presents a surgical challenge that often necessitates the use of opioids. Objectives The aim of this study was to (1) compare opioid prescribing patterns surrounding PRC and 4-CA, (2) identify risk factors predisposing patients to increased perioperative and prolonged postoperative opioids, and (3) examine the association between opioids and perioperative health care utilization. Patients and Methods  PearlDiver Patients Records Database was used to retrospectively identify patients undergoing primary PRC and 4-CA between 2010 and 2018. Patient demographics, comorbidities, prescription drug usage, and perioperative health care utilization were evaluated. Perioperative opioid prescriptions and post-operative opioid prescriptions were recorded. Logistic regression analysis evaluated the association of patient risk factors. Results  There was no significant difference in perioperative (PRC [odds ratio {OR}: 0.84, p  = 0.788]; 4-CA [OR: 0.75, p  = 0.658]) or prolonged postoperative opioid prescriptions (PRC [OR: 0.95, p  = 0.927]; 4-CA [OR: 0.99, p  = 0.990]) between PRC and 4-CA. Chronic back pain and use of benzodiazepines or anticonvulsants were associated with increased risks of prolonged postoperative opioids. Prolonged postoperative opioids presented increased risks of emergency department visits (OR: 2.09, p  = 0.019) and hospital readmissions (OR: 10.2, p  = 0.003). Conclusion  No significant differences exist in the prescription of opioids for PRC versus 4-CA. Both procedures have high amounts of prolonged postoperative opioid use, which is associated with increased risks of emergency department visits and hospital readmissions. Level of Evidence  This is a level III, retrospective comparative study.

Long-term outcomes of the four-corner fusion of the wrist: A systematic review

BACKGROUND

Four-corner fusion (4CF) is a motion sparing salvage procedure that is used to treat osteoarthritis secondary to advanced scapholunate collapse or longstanding scaphoid nonunion advanced collapse. Little is known about the long-term survivorship and outcomes of 4CF.

AIM

To report on clinical and functional long-term outcomes as well as conversion rates to total wrist fusion or arthroplasty.

METHODS

The systematic review protocol was registered in the international prospective register of systematic reviews (PROSPERO) and followed the PRISMA guidelines. Original articles were screened using four different databases. Studies with a minimum Level IV of evidence that reported on long-term outcome after 4CF with a minimum follow-up of 5 years were included. Quality assessment was performed using the Methodological Index for Non-Randomized Studies criteria.

RESULTS

A total of 11 studies including 436 wrists with a mean follow-up of 11 ± 4 years (range: 6-18 years) was included. Quality assessment according to Methodological Index for Non-Randomized Studies criteria tool averaged 69% ± 11% (range: 50%-87%). Fusion rate could be extracted from 9/11 studies and averaged 91%. Patient-reported outcomes were extracted at last follow-up from 8 studies with an average visual analog scale of 1 ± 1 (range: 0-2) and across 9 studies with an average Disabilities of the Arm, Shoulder and Hand score of 21 ± 8 (range: 8-37). At last follow-up, the cumulative conversion rate to total wrist fusion averaged 6%. There were no conversions to total wrist arthroplasty.

CONCLUSION

The 4CF of the wrist is a reliable surgical technique, capable of achieving a good long-term patient satisfaction and survivorship with low rates of conversion to total wrist fusion.

Long-Term Outcome of Surgical Treatment for Kienböck Disease Using an Articular-Based Classification

PURPOSE

The aim of this study was to report the outcomes of surgery using the Bain and Begg articular-based classification for the treatment of Kienböck disease.

METHODS

We identified and followed patients who had surgery for Kienböck disease between 1995 and 2014. Assessment included functional scoring using a modification of the Gartland and Werley score, pain levels, and grip strength.

RESULTS

Thirty-one patients were operated on for Kienböck disease between 1995 and 2014. Twenty-seven patients were assessed (12 men and 15 women). Mean age at the index procedure was 45.1 years (range, 20-82 years). Median follow-up after the index procedure was 10 years (range, 2-18 years). On the Bain and Begg classification, 5 patients had grade 0, 4 had grade 1, 5 had grade 2a, 10 had grade 2b, 1 had grade 3, and 1 had grade 4. The median pain visual analog scale improved from a preoperative score of 5 (interquartile range [IQR], 5-6) to a postoperative score of 2 (IQR, 0-3). The median functional scores from the modified Gartland and Werley score improved from 67 (IQR, 57.0-78.5) to 97 (IQR, 90.0-97.0). Eighteen out of 20 working patients returned to the same level of work. There was a significant improvement in power grip and tip pinch following surgery. One patient required a secondary salvage procedure. No patient required a full wrist fusion or arthroplasty.

CONCLUSIONS

This study confirms that the Bain and Begg arthroscopic classification and an articular-based approach to Kienböck disease provide a high probability of good long-term relief of pain and a minimal chance of requiring a salvage procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Functional Outcomes After Salvage Procedures for Wrist Trauma and Arthritis (Four-Corner Fusion, Proximal Row Carpectomy, Total Wrist Arthroplasty, Total Wrist Fusion, Wrist Denervation): A Review of Literature

Background:

Several salvage procedures for the arthritically destroyed wrist exist. Each of these has advantages as well as disadvantages.

Aims:

The aim of this article is to give practical insights for the clinician on: (1) biomechanical and clinical fundamentals of normal and impaired wrist motion; (2) difficulties in assessment of postoperative outcome between measured motion by the surgeon and self-reported outcome by the patient; (3) indications for each procedure; and (4) differences in functional outcome between partial and complete motion-preserving as well as complete motion-restricting salvage procedures.

Methods:

In trend, Proximal Row Carpectomy (PRC) is slightly superior over four-corner fusion (4CF) in terms of functional outcome, but the methodology-related postoperative motion is decreased for both procedures. Furthermore, PRC is easier to perform, needs lower costs, and has fewer complications than 4CF. Total Wrist Arthroplasty (TWA) has the advantage compared to PRC and 4CF that the preoperative motion values are preserved, but it is limited by decreased load-bearing capacity for the wrist. Total Wrist Fusion (TWF) is associated with a higher load-bearing capacity for the wrist than TWA, but it is limited for carrying out essential activities of daily living. Both PRC and 4CF can be combined primarily by wrist denervation. Wrist denervation alone does not impair the movement of the wrist.

Results and Conclusion:

Salvage procedures for the arthritically destroyed wrist should be detected regarding patients age- and gender-related claims in work and leisure. Not all of them can be successfully re-employed in their original occupations associated with high load-bearing conditions.

Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis

BACKGROUND

Two mainstay surgical options for salvage in scapholunate advanced collapse and scaphoid nonunion advanced collapse are proximal row carpectomy and four-corner arthrodesis. This study evaluates the cost-utility of proximal row carpectomy versus three methods of four-corner arthrodesis for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist.

METHODS

A cost-utility analysis was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A comprehensive literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analogue scale survey of expert hand surgeons estimated utilities. Overall cost, probabilities, and quality-adjusted life-years were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Forty studies yielding 1730 scapholunate advanced collapse/scaphoid nonunion advanced collapse wrists were identified. Decision tree analysis determined that both four-corner arthrodesis with screw fixation and proximal row carpectomy were cost-effective options, but four-corner arthrodesis with screw was the optimal treatment strategy. Four-corner arthrodesis with Kirschner-wire fixation and four-corner arthrodesis with plate fixation were dominated (inferior) strategies and therefore not cost-effective. One-way sensitivity analysis demonstrated that when the quality-adjusted life-years for a successful four-corner arthrodesis with screw fixation are lower than 26.36, proximal row carpectomy becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model.

CONCLUSIONS

Four-corner arthrodesis with screw fixation and proximal row carpectomy are both cost-effective treatment options for scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist because of their lower complication profile and high efficacy, with four-corner arthrodesis with screw as the most cost-effective treatment. Four-corner arthrodesis with plate and Kirschner-wire fixation should be avoided from a cost-effectiveness standpoint.

Arthroscopic Interposition Tendon Arthroplasty for Stage 2 Scapholunate Advanced Collapse

PURPOSE

To report and analyze the functional outcomes of arthroscopic interposition tendon arthroplasty (AITA) in stage 2 scapholunate advanced collapse (SLAC).

METHODS

Sixteen patients with stage 2 SLAC who underwent AITA between 2009 and 2014 with a minimum of 24-month follow-up were retrospectively evaluated. Medical records were assessed for preoperative and postoperative range of motions, grip strength, visual analog scale, disabilities of the arm, shoulder, and hand (DASH) score, scapholunate angle, and scaphoid fossa-to-scaphoid space.

RESULTS

After exclusion of 2 patients, 14 patients were available for this study. At final follow-up, improvements were found for the following variables: extension (preoperative mean, 49.29°; VS postoperative mean, 61.07°; P = .025, 95% confidence interval [CI], 1.74-21.85), radial deviation (preoperative mean, 6.43°; postoperative mean, 17.14°; P < .001, 95% CI, 6.06-15.36), grip strength (preoperative mean, 18.93 kg; postoperative mean, 29.64 kg; P < .001; 95% CI, 6.81-14.61), visual analog scale (preoperative mean, 8.07; postoperative mean, 2.50; P < .001; 95% CI, -6.52 to -4.61), and DASH (preoperative mean, 60.39; postoperative mean, 10.28; P < .001, 95% CI, -43.04 to -57.28), scapholunate angle (preoperative median, 67.50°; postoperative median, 55.00°, P = .002, Z = -2.831), and scaphoid fossa-to-scaphoid space (preoperative median, 0.00 mm; postoperative median, 1.00 mm; P < .001, Z = -3.145). There was no improvement in flexion (preoperative mean, 40.00°; postoperative mean, 50.00°^;P = .025; 95% CI, -4.45 to -24.45), ulnar deviation (preoperative median, 25.00°; postoperative median, 30.00°^;P = .063, Z = -2.060), or flexion-extension arc (preoperative mean, 89.28°; postoperative mean, 111.07°; P = .067; 95% CI, -1.79 to -45.36) following AITA. Nine of 13 patients were satisfied with the procedure, 3 were moderately satisfied, and 1 was not satisfied.

CONCLUSIONS

Arthroscopic interposition tendon arthroplasty is an acceptable procedure for stage 2 SLAC. This procedure preserves motion, yields acceptable functional outcome, and reduces pain.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.