Four-Corner Arthrodesis Versus Proximal Row Carpectomy: A Retrospective Study With a Mean Follow-Up of 17 Years

Modified volar approach for proximal row carpectomy

Objectives

Proximal row carpectomy is a well-accepted surgical procedure for the management of traumatic and degenerative wrist pathologies. It is routinely performed through a dorsal approach; a volar surgical access was presented in order to enable concomitant carpal tunnel release and avoid flexion limitation or disabilities caused by adhesions of the dorsal capsule and extensor tendons. We propose a modification to the volar approach, with detailed description of skin incision (reproducing the standard palmar access to the scaphoid), capsular section (beginning with a longitudinal cut radial to flexor carpi radialis tendon and prolonged transversally along the radio-lunate joint) and sequence of carpal bone removal (starting with the scaphoid rather than the lunate).

Materials and methods

The patients who underwent surgical treatment with modified volar proximal row carpectomy between 1992 and 2015 were enrolled in a retrospective analysis.

Results

We report postoperative improvement in both the Mayo Wrist score and total active range of motion in 38 patients, in line with the outcomes of dorsal proximal row carpectomy.

Conclusions

The modified volar approach is highly recommended when better visualization and access to proximal carpal bones are needed (particularly useful for inveterate perilunate dislocations), moreover if concomitant carpal tunnel syndrome or extensor tendon pathologies are present.

Long-Term Patient-Reported Outcomes following Proximal Row Carpectomy

Background  Proximal row carpectomy (PRC) is a procedure used for pain relief from arthrosis that preserves some degree of range of motion (ROM). Dorsal capsular interposition (DCI) is an option for cases where some chondral loss of the capitate is present. Purposes  The aim of this study is to assess what factors influence long-term patient-reported outcomes following PRC and specifically to evaluate the role of DCI. Additionally, this study aims to report the long-term postoperative ROM in patients with DCI. Methods  Patients who underwent PRC in the period between 2002 and 2017 were retrospectively identified, resulting in a cohort of 162 patients. Patient-reported outcomes were obtained using validated questionnaires and were completed by 59 patients at a median follow-up time of 8.5 years (interquartile range [IQR]: 6.0-13). Multivariable linear regression was performed to identify factors independently associated with patient-reported outcomes. Results  The median PRWE (Patient-Rated Wrist Evaluation) score was 17 (IQR: 5.5-52), the median QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score was 16 (IQR: 4.5-39), and the median NRS (Numeric Rating Scale) Pain score was 1 (IQR: 0-3). The mean flexion-extension ROM was 70 ± 24 degrees. After correcting for gender, involvement of the capitate cartilage was independently associated with worse QuickDASH scores. Conclusions  PRC is associated with good functional outcomes and pain control at long-term follow-up. This generally also applied to patients who underwent DCI; however, the role of DCI in those with capitate cartilage injury remains unclear. Preexistent damage to the capitate cartilage was associated with worse QuickDASH scores. Level of Evidence  II, Prognostic study.

Lunate-capitate arthrodesis for scaphoid nonunion: a comparative study

BACKGROUND

Scaphoid nonunion advanced collapse (SNAC) injuries are frequently associated with irreversible degenerative wrist arthritic changes that necessitate surgical intervention. Midcarpal fusion remains the mainstay of the management of SNAC II and III injuries. A successful four-corner fusion (4CF) relies on a stable lunate-capitate fusion (LCF). There have been reports of management relying solely on LCF. The outcomes of LC- and 4 C-fusions in SNAC injuries were not widely documented. The objective of this research is to provide valuable insights into the effectiveness of both fusion procedures in the management of SNAC II and III wrist injuries, with a focus on reporting associated complications, functional and radiological outcomes.

PATIENTS AND METHODS

This retrospective study encompassed 65 patients diagnosed with SNAC II and III wrist injuries who underwent limited wrist fusion procedures between 2015 and 2024, with a minimum of 2 years of postoperative follow-up. Exclusion criteria encompassed patients with carpal instability, prior wrist surgical interventions, and scapholunate advanced collapse. Following the fusion procedure performed, patients were stratified into two groups: the LCF group consisting of 31 patients, and the 4CF group comprising 34 patients. Preoperative and intraoperative data were retrieved from the patient's medical records. At their final follow-up appointments, patients underwent comprehensive radiographic and clinical evaluations. Clinical outcomes including hand grip strength, range of motion, the Disabilities of the Arm, Shoulder, and Hand Score, and the Mayo Modified Wrist Score, were compared between groups. Any associated complications were reported.

RESULTS

The average healing time was 74.7 ± 15.6 and 72.2 ± 13.2 days for the LCF and 4CF groups, respectively. At the final visit, all patients showed functional improvement relative to their preoperative status, with comparable wrist range of motions observed in both groups. The functional wrist scores were slightly better in the LCF patients (P > 0.05). The average grip strength was significantly greater in the LCF group (P = 0.04), with mean strength values of 86.8% and 82.1% of the contralateral side, for the LCF and 4CF groups, respectively.

CONCLUSION

The LCF is not less efficient than the 4CF in the treatment of SNAC II and III wrist injuries. Through a less time-consuming procedure, LCF can efficiently provide comparable results to 4CF.

LEVEL OF EVIDENCE

level IV evidence.

A Comparison of Rib Osteochondral Graft to Medial Femoral Trochlear Osteocartilaginous Graft for the Salvage of the Fragmented Scaphoid Proximal Pole: A Single-Center Experience with Minimum 2-Year Follow-Up

Purpose  Fragmented fractures of the proximal pole of the scaphoid that cannot be internally fixed may be salvaged by four-corner arthrodesis or proximal row carpectomy. Replacement of the proximal scaphoid with costal-osteochondral graft (COG) or the medial femoral trochlea (MFT) graft are two alternative solutions for this clinical presentation. The purpose of this study was to compare the clinical and radiographic results of the COG and the MFT graft with a minimum 2-year follow-up from a single centre. Methods  A retrospective study was performed to investigate the outcome of COG and MFT with a minimum 2 year follow up. Demographic data and clinical assessment including wrist range of motion and grip strength measurements and Oxford Knee score were collected. Patients completed the outcome measures of Disabilities of Arm, Shoulder, and Hand (DASH), the Patient-Rated Wrist Evaluation (PRWE), and a ten-point visual analogue score for pain (VAS). Radiological examination was performed on all wrists at follow-up. Results  The visual analogue score, DASH and PRWE were similar between the two groups. There was radiographic evidence of arthritis between the radial styloid and distal scaphoid in all patients that underwent COG but no evidence in those that underwent MFT graft reconstruction. There were different complications in each group. Thirty percent of patients that underwent MFT reconstruction had persistent knee pain at follow up. Conclusion  Though there are notable differences in the follow-up period, patients undergoing MFT risk developing knee pain, while those undergoing COG risk radiographic progression of wrist arthritis. Level of Evidence  III - Comparative study.

Routinely-Collected Outcomes of Proximal Row Carpectomy

PURPOSE

To describe patient-reported pain and function 12 months after proximal row carpectomy (PRC). Secondary outcomes included return to work, grip strength, range of wrist motion, satisfaction with treatment results, and complications.

METHODS

This cohort study was part of the British Society for Surgery of the Hand Studyathon 2021, using ongoing routinely-collected data of 304 eligible patients who underwent PRC (73% scapholunate advanced collapse, 11% scaphoid nonunion advanced collapse wrist; 11% Kienböck, 5% other indications) from Xpert Clinics, the Netherlands between 2012-2020. The primary outcome was the Patient Rated Wrist/Hand Evaluation total score (range, 0-100, lower scores indicate better performance).

RESULTS

Of the 304 patients, the primary outcome was available in 217 patients. The total Patient Rated Wrist/Hand Evaluation score improved from 60 (95% confidence interval [CI], 57-63) to 38 (95% CI, 35-41) at 3 months, and 26 (95% CI, 23-29) at 12 months. The pain and function subscales improved by 18 (95% CI, 17-20) and 16 (95% CI, 14-18) points, respectively. At 12 months, 82% had returned to work at a median time of 12 (95% CI, 9-14) weeks following PRC. Grip strength did not improve. Wrist flexion and extension demonstrated a clinically irrelevant decrease. Satisfaction with treatment result was excellent in 27% of patients, good in 42%, fair in 20%, moderate in 6%, and poor in 5%. Complications occurred in 11% of patients, and conversion to wrist arthroplasty occurred in 2 patients.

CONCLUSION

A clinically relevant improvement in patient-reported pain and function was observed at 3 months after PRC, with continued improvement to 12 months. These data can be used for shared-decision making and expectation management.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Four-Corner Fusion Versus Proximal Row Carpectomy for Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Wrist: A Systematic Review and Meta-Analysis

PURPOSE

Although proximal row carpectomy (PRC) has increasingly been shown to have superior features to four-corner fusion (4CF), individual surgeons may remain convinced of the superiority of one procedure based on personal experience and individual biases. Hence, we sought to perform an updated meta-analysis with some of the largest studies to date to compare outcomes and complications between these procedures in the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists.

METHODS

A systematic review and meta-analysis was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane were queried for articles on PRC and 4CF performed for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist. Primary outcomes included wrist range of motion; grip strength; outcome measures, including Disabilities of Arm, Shoulder, and Hand and Quick Disabilities of Arm, Shoulder, and Hand scores, Patient-Rated Wrist and Hand Evaluation, and visual analog scale pain scores; and surgical complications.

RESULTS

Sixty-one studies reported on 3,174 wrists, of which 54% were treated with PRC and 46% were treated with 4CF. The weighted mean follow-up was 61 months (range, 12-216 months). Meta-analysis comparing PRC and 4CF demonstrated that PRC had significantly greater postoperative extension; ulnar deviation; postoperative improvement in extension, flexion, ulnar deviation; and visual analog scale score. No comparisons showed significant differences in grip strength. The percentage of wrists requiring arthrodesis was 5.2% for PRC and 11% for 4CF. There was an 8.9% (57/640 wrists) 4CF nonunion rate and 2.2% (17/789) hardware removal rate after 4CF.

CONCLUSIONS

In the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists, PRC results in better outcomes and a lower complication rate compared to 4CF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Isolated Osseous Excision in the Adult Carpus: A Narrative Review

Various pathologies of the adult carpus result in clinical scenarios where excision can be considered and even recommended. In the appropriate patient population, isolated carpal excision can alleviate pain and improve mobility. Excisions of the pisiform, trapezium, and trapezoid have abundant literature evidence to support positive long-term functional outcomes. In contrast, isolated excision of the capitate, hamate, and triquetrum has limited support in the literature secondary to compromise of carpal mechanics and lead to recurrent pain. Additionally, isolated scaphoid and lunate excision are best avoided secondary to carpal collapse and should be paired with concomitant stabilizing procedures in the carpus. This article provides a comprehensive literature review of isolated excision of each osseous carpal bone, their indications, and previously assessed outcomes.

Proximal row carpectomy versus four-corner arthrodesis: a retrospective comparative study

BACKGROUND

Four-corner arthrodesis with scaphoid excision (FCA) and proximal row carpal resection (PRC) are frequently performed in wrists with post-traumatic Scaphoid Non- Union Advanced Collapse (SNAC)/Scapho-Lunate Advanced Collapse (SLAC) osteoarthritis. The aim of this study was to compare the clinical outcomes of these two procedures.

METHODS

This single-center, retrospective cohort study included all patients who had PRC or FCA between January 1st, 2009 and January 1st, 2019 and who were followed up. Follow-up included: mobility (radial deviation, ulnar deviation, flexion, extension), strength (grip test, pinch test), function (QuickDash, patient-rated wrist evaluation [PRWE]), subjective mobility, and global satisfaction scores.

RESULTS

Among 25 patients included, 11 had PRC and 14 had FCA with a mean follow-up of 69.5 months [12-132]. Radial deviation was 18° versus 14° (p = 0.7), ulnar deviation was 21° versus 22° (p = 0.15), flexion was 39° versus 30° (p = 0.32), extension was 32.5° versus 29.5° (p = 0.09), grip test compared to the controlateral side was 72% versus 62% (p = 0.53), Quick Dash score was 12.5 versus 17.6 (p = 0.84), PRWE was 18.7 versus 17.6 (p = 0.38), subjective mobility was 7.8 versus 7.5 (p = 0.23), and satisfaction score was 8.7 versus 9 (p = 0.76), respectively, in the FCA group and the PRC group. Re-operation rates were 14% patients in the FCA group and 0% in the PRC group.

CONCLUSION

This study found no significant difference between FCA and PRC on strength, mobility, and function in patients with post-traumatic SLAC or SNAC stage II wrist arthritis. Both FCA and PRC seem to be reliable surgical techniques with good outcomes with more revision in the FCA group.

Proximal row carpectomy with interposition arthroplasty using both capsular flap and acellular human dermal matrix

BACKGROUND

In cases of wrist arthritis, proximal row carpectomy (PRC) has been widely utilized and shown favorable long-term outcomes. However, its applicability is limited in cases where arthritis extends to the lunate fossa or capitate. Recently, surgical approaches combining various methods of interposition arthroplasty have been introduced to overcome these drawbacks. The purpose of this study was to perform PRC and interposition arthroplasty with dorsal capsule and acellular dermal matrix(ADM),and analyze the clinical outcomes of these procedures.

METHODS

Fourteen cases who underwent PRC and interposition arthroplasty using both dorsal capsular flap and ADM were retrospectively recruited. The researchers assessed the patients' Visual Analog Scale (VAS) pain score, Disabilities of the Arm, Shoulder and Hand (DASH) scores, range of motion (ROM), retear, and radiocarpal distance (RCD).

RESULTS

One year post-surgery, both the VAS pain scores, DASH scores, and ROM showed statistically significant improvement compared to before the surgery. Upon reviewing the radiological results, the postoperative mean RCD was 4.8 ± 0.8 mm and one year follow up mean RCD was 3.6 ± 0.5 mm at one year post-surgery. Moreover, in the one year follow-up, there was no observed failure of the allodermis graft in any of the cases.

CONCLUSION

The PRC and interposition arthroplasty with ADM demonstrated significantly improved clinical outcomes after surgery, showing a maintain of RCD without graft failure effectively.

A review of scaphoid fracture, treatment outcomes, and consequences

PURPOSE

Scaphoid fractures are the most common carpal fracture and can lead to severe complications like carpal collapse and osteoarthritis. This study reviewed scaphoid fracture patterns, outcomes, and consequences in conservative and surgical management.

METHODS

Sixty-four patients with scaphoid fracture who attended the hand clinic at King Hussein Medical City from January 2022 to December 2022 were included and reviewed regarding the anatomical fracture site, the associated injury, the treatment modality (conservative versus surgical), the healing time, and fracture sequelae such as nonunion and scaphoid nonunion advanced collapse.

RESULTS

Most patients were males (62 patients, 96.9%), and most (47, 73.4%) fell within 25 to 40 years. Scaphoid waist fracture was the most common location (40, 52.5%). Most patients (47, 73.4%) received conservative treatment and 17 (26.6%) were fixed acutely. However, nonunion complicated 53 fractures (82.8%). Notably, there were no differences in the union rate or time between cases of scaphoid nonunion treated with vascularized or nonvascularized grafts. Furthermore, there were no variations in union rates among genders, extremities, age, fracture locations, or among smokers. However, a higher union rate was noted in office workers and those who received conservative treatment.

CONCLUSION

Nonunions were higher in our study than in the literature, as our department is a referral center for established nonunion cases. For conservative treatment, we recommend aggressive management and follow-up with a clinical and CT scan at three months and early referral of non-united fractures to the hand clinic to avoid the advanced collapse of the scaphoid.

Proximal Row Carpectomy Does Not Alter Contact Pressures of the Lunate Fossa: A Cadaveric Study

BACKGROUND

Previous studies have suggested that proximal row carpectomy (PRC) results in increased contact pressures and decreased contact areas in the radiocarpal joint. Such experiments, however, used older technologies that may be associated with considerable measurement errors. The purpose of this study was to determine whether there was a significant difference in contact pressure and contact area before and after PRC using Tekscan, a newer pressure sensing technology.

METHODS

Ten nonpaired cadaveric specimens were dissected proximal to the carpal row and potted. An ultra-thin Tekscan sensor was secured in the lunate fossa of the radius. The wrists were loaded with 200 N of force for 60 seconds to simulate clenched-fist grip; contact pressure and area was assessed before and after PRC.

RESULTS

Performing a PRC did not significantly increase mean contact pressure at the lunate fossa compared to the native state (mean increase of 17.4 ± 43.2 N/cm2, P = .184). Similarly, the PRC did not significantly alter peak contact pressures at the lunate fossa (intact: 617.2 ± 233.46 N/cm2, median = 637.5 N/cm2; PRC: 707.8 ± 156.6 N/cm2, median = 728.5 N/cm2; P = .169). In addition, the PRC (0.46 ± 0.15 cm2, median = 0.48 cm2) and intact states (0.49 ± 0.25 cm2, median = 0.44 cm2) demonstrated similar contact areas (P = .681).

CONCLUSIONS

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.

Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients

PURPOSE

Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC.

METHODS

The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation.

RESULTS

There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA.

CONCLUSIONS

Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

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.

Relationship Between Preoperative and Postoperative Motion After Four-Corner Wrist Fusion for Osteoarthritis: Clustering and Regression Analyses

PURPOSE

Four-corner fusion (4CF) is a surgical option for refractory scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist arthritis. Preoperative range of motion (ROM) predicts outcomes in many orthopedic procedures. This study investigates ROM in a cohort of 4CF patients to examine the relationship between preoperative and postoperative motion and identifies different clinical patterns.

METHODS

We performed a retrospective review of 4CF patients. Patients with a history of inflammatory arthritis and radiographic characteristics of inflammation were excluded. Demographics, prior wrist surgery history, and ROM data were collected at preoperative and postoperative intervals after cast removal at 8 weeks, 3 months, and 8 months. Regression analysis compared the motion before and after 4CF. Subsequent cluster analysis to reduce confounding compared postoperative motion differences in the top 20% to the bottom 20% of patients by preoperative motion.

RESULTS

We included 148 patients; 27 had prior surgery on the ipsilateral wrist. Preoperative arc averaged 86° ± 28° (flexion 46° ± 17°, extension 40° ± 15°); 8-week arc 43° ± 19° (flexion 19° ± 12°, extension 24° ± 12°); 3-month arc 62° ± 17° (flexion 30° ± 12°, extension 32° ± 11°); and 8-month arc 74° ± 17° (flexion 36° ± 11°, extension 37° ± 12°). Preoperative and final arcs were (r = 0.39). Clustering by the preoperative arc, the top 20% (mean 124° ± 15°) achieved a mean final arc of 81° ± 16°, while the bottom 20% (mean 47° ± 16°) achieved a mean final arc of 65° ± 19°. Intercluster differences were statistically significant. The bottom 20% gained motion postoperatively. Most patients in the middle 60% did not differ significantly in postoperative motion.

CONCLUSIONS

Although wrist motion following 4CF correlates positively with preoperative motion, most patients do not differ significantly in postoperative motion. Patients with substantial preoperative motion deficits gain motion after 4CF. This information is important when counseling patients, determining the timing of surgical intervention, and managing expectations related to motion outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Four-Corner Arthrodesis versus Proximal Row Carpectomy: Risk Factors and Complications Associated with Prolonged Postoperative Opioid Use

Introduction  This article compares opioid use patterns following four-corner arthrodesis (FCA) and proximal row carpectomy (PRC) and identifies risk factors and complications associated with prolonged opioid consumption. Materials and Methods  The PearlDiver Research Program was used to identify patients undergoing primary FCA (Current Procedural Terminology [CPT] codes 25820, 25825) or PRC (CPT 25215) from 2007 to 2017. Patient demographics, comorbidities, perioperative opioid use, and postoperative complications were assessed. Opioids were identified through generic drug codes while complications were defined by International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification codes. Multivariable logistic regressions were performed with p < 0.05 considered statistically significant. Results  A total of 888 patients underwent FCA and 835 underwent PRC. Three months postoperatively, more FCA patients (18.0%) continued to use opioids than PRC patients (14.7%) ( p = 0.033). Preoperative opioid use was the strongest risk factor for prolonged opioid use for both FCA (odds ratio [OR]: 4.91; p < 0.001) and PRC (OR: 6.33; p < 0.001). Prolonged opioid use was associated with an increased risk of implant complications (OR: 4.96; p < 0.001) and conversion to total wrist arthrodesis (OR: 3.55; p < 0.001) following FCA. Conclusion  Prolonged postoperative opioid use is more frequent in patients undergoing FCA than PRC. Understanding the prevalence, risk factors, and complications associated with prolonged postoperative opioid use after these procedures may help physicians counsel patients and implement opioid minimization strategies preoperatively.

Combined Treatment of Trapeziometacarpal Joint Arthritis and Scapholunate Advanced Collapse Wrist

PURPOSE

The combined treatment of trapeziometacarpal joint arthritis and scapholunate advanced collapse (SLAC) wrist presents unique challenges. The consequences of the loss of radial column support caused by scaphoidectomy and trapeziectomy are not well known. The purpose of this study was to evaluate the outcomes of the simultaneous and staged treatment of trapeziometacarpal joint arthritis and SLAC wrist.

METHODS

A retrospective review of patients who underwent surgery for both trapeziometacarpal joint arthritis and SLAC wrist was performed. The wrist and thumb range of motion; grip and pinch strength; pain; quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; and radiographs were analyzed.

RESULTS

Twenty-four patients who underwent both trapeziectomy and 1 of 3 procedures for SLAC wrist (4-corner fusion [n = 10]), proximal row carpectomy [n = 9], and total wrist arthroplasty [n = 5]) in a single stage (n = 10) or in 2 stages (n = 14) were included. The median age was 63 years. The median follow-up period was 35 months. Twelve (50%) patients underwent complete scaphoidectomy, and 12 (50%) patients underwent partial scaphoidectomy. All 3 procedures resulted in an improvement in pain at rest, pain during activity, and quick Disabilities of the Arm, Shoulder and Hand scores. The final range of motion, grip and pinch strength, and complication rates were consistent with those reported in the literature for isolated procedures.

CONCLUSIONS

Trapeziometacarpal joint arthritis and SLAC wrist may be treated either simultaneously or in stages.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

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.

The Biomechanical Effects of Simulated Radioscapholunate Fusion With Distal Scaphoidectomy, 4-Corner Fusion With Complete Scaphoidectomy, and Proximal Row Carpectomy Compared to the Native Wrist

PURPOSE

To determine the effect of simulated radioscapholunate fusion with distal scaphoid excision (RSLF+DSE), 4-corner fusion with scaphoidectomy (4-CF), and proximal row carpectomy (PRC) on the wrist's range of motion (ROM), contact pressure, and contact force in a cadaveric model.

METHODS

Ten freshly frozen cadaveric wrists were tested under 4 sequential conditions: native wrist, RSLF+DSE, 4-CF, and PRC. The simulated fusions were performed using two 1.6-mm Kirschner wires. The ROM in the flexion-extension and radioulnar deviation planes was evaluated. Contact area, contact pressure, and contact force were measured at the scaphocapitolunate joint for the RSLF+DSE simulation and radiocarpal joint for the 4-CF and PRC simulations. Mechanical testing was performed using a 35-N uniaxial load and pressure-sensitive film.

RESULTS

The RSLF+DSE and 4-CF groups had a decreased wrist arc ROM compared with the native wrist. The PRC group had a greater wrist arc ROM compared with the RSLF+DSE and 4-CF groups, but compared to the native wrist, it demonstrated a mildly decreased wrist arc ROM. The carpal pressure and contact force were significantly increased in the RSLF+DSE, 4-CF, and PRC groups compared with those in the native wrist. The RSLF+DSE group had the smallest increase in the carpal pressure and contact force, whereas the PRC group had the greatest increase.

CONCLUSIONS

Our study validates previous findings that PRC is motion-conserving but has the greatest contact force, whereas RSLF-DSE and 4-CF may cause a decrease in the ROM but have lower contact forces.

CLINICAL RELEVANCE

Understanding the underlying native wrist biomechanics and alterations following different surgical treatments may assist hand surgeons in their clinical decision making for the treatment of stage II scapholunate advanced collapse.

Arthroscopic three-corner or lunocapitate arthrodesis: technical tips and early outcomes

The purpose of the study is to present a technical approach for arthroscopic three-corner or lunocapitate arthrodesis with mini-open scaphoid excision and to report about the early clinical and functional results. The median surgery time was 112 min with shorter times achieved once mastering the technique. Radiological and clinical union was observed in 11 out of 12 patients in a median time of five months. For final assessments nine patients were included with a median follow-up of 15 months. Wrist extension and flexion after surgery decreased to 58 and 62% of preoperative measurements and represented 37 and 42% of the unaffected side. Grip strength also decreased to 80% of the preoperative value and 57% of the unaffected side. All patients reported significant pain relief and functional improvement. Arthroscopic three-corner or lunocapitate arthrodesis was a safe, reliable and minimally invasive technique for treating wrist osteoarthritis, while it was technically demanding and time-consuming during learning curve.

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.

Proximal Row Carpectomy Using Decellularized Dermal Allograft: Preliminary Results

Objective  The purpose of this study was to evaluate the short-term outcomes of patients undergoing proximal row carpectomy (PRC) with interposition arthroplasty using a decellularized dermal allograft. Methods  Patients with a minimum of 1-year follow-up after undergoing a PRC using decellularized dermal allograft were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as well as the modified Likert scale for patient satisfaction. Nine of ten (90%) consecutive patients who were treated using this surgical technique were available for follow-up. Results  At a mean follow-up of 18 months, a total of nine patients achieved a mean flexion-extension arc of 113 degrees, pronosupination of 170.5 degrees, grip strength of 68 Ibs and pinch strength of 17 Ibs. Relative to the contralateral side, these values were 95, 100, 84 and 82%, respectively. There was significant improvement in the mean DASH score from 63.5 preoperatively to 23.8 postoperatively. Patient satisfaction postoperatively achieved a mean modified Likert score of 1.5. There was no evidence of radiocarpal joint space degeneration or dislocation in any of the patients. No patient suffered wound-related issues, foreign-body reaction to the graft, or other complications. Conclusion  PRC with interposition arthroplasty using a decellularized dermal allograft in patients with degenerative changes at the lunate fossa or capitate demonstrates short-term outcomes comparable to what has been reported for routine PRC in patients without degenerative changes affecting the radiocapitate joint. This method of interposition arthroplasty expands the indications for PRC and may help avoid salvage, motion-sacrificing procedures in select patients with late-stage wrist arthritis. Level of Evidence  This is a level IV, therapeutic study.

Surgical Treatment of Wrist Arthritis in Young Patients

Surgical treatment of wrist arthritis in the younger patient population remains a challenging issue, and various surgical options need to be carefully considered for each patient. Proximal row carpectomy and 4-corner arthrodesis have proven to be reliable options for reducing pain and restoring adequate function in most young high-demand patients if the lunate facet is spared. Selective neurectomy has proven to be a promising stand-alone or complementary procedure for the treatment of pain that is associated with wrist arthritis in patients of all ages, with spared motion and the opportunity to perform additional procedures if pain continues. Alternative procedures, including capitolunate arthrodesis, total wrist arthrodesis, radial styloidectomy, total wrist arthroplasty, and wrist hemiarthroplasty, have considerable strengths and weaknesses and need to be studied further in younger patients.

Long-term radiological changes and functional outcomes after proximal row carpectomy: Retrospective study with 3 years' minimum follow-up

INTRODUCTION

The aim of this study was to analyze the radiological changes and determine the clinical and functional outcomes of proximal row carpectomy (PRC) over the long term.

HYPOTHESIS

Radiological changes after PRC occur in every patient while the clinical and functional outcomes remain stable over time.

METHODS

This was a retrospective single-center study of patients who underwent PRC between January 2004 and December 2014. A clinical assessment (range of motion, grip strength), functional assessment (Mayo Wrist score and QuickDASH) and radiographic assessment (radiocapitate osteoarthritis, radiocapitate congruency) was done in every patient at the longest follow-up.

RESULTS

Thirty-one patients were reviewed with a mean follow-up of 97.9 months. The indications for PRC were SLAC (n=10), SNAC (n=5), Kienböck disease (n=9) and other conditions (n=7). The radiocapitate index, which is the radius of curvature of the tip of the capitate divided by the mean radius of curvature of the lunate fossa, went from 0.68 immediately postoperative to 0.74 at the final assessment (p=0.035). The mean flexion/extension arc was 93°. The mean grip strength was 25 kg. The mean QuickDASH was 29 and the mean Mayo Wrist score was 69. Fifteen patients had radiocapitate osteoarthritis. Seven patients (22%) required revision surgery for wrist fusion after a mean of 18.6 months.

CONCLUSION

Radiological adaptation in the radiocapitate joint after PRC was found in this study. PRC is a reliable solution and yields stable outcomes over time for treating radiocarpal osteoarthritis, except in young adults and manual laborers who had a notable early revision rate.

LEVEL OF EVIDENCE

IV - retrospective study.

Cost-Effectiveness Analysis of Motion-Preserving Operations for Wrist Arthritis

BACKGROUND

The authors conducted a cost-effectiveness analysis to answer the question: Which motion-preserving surgical strategy, (1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty, used for the treatment of wrist osteoarthritis, is the most cost-effective?

METHODS

A simulation model was created to model a hypothetical cohort of wrist osteoarthritis patients (mean age, 45 years) presenting with painful wrist and having failed conservative management. Three initial surgical treatment strategies-(1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty-were compared from a hospital perspective. Outcomes included clinical outcomes and cost-effectiveness outcomes (quality-adjusted life-years and cost) over a lifetime.

RESULTS

The highest complication rates were seen in the four-corner fusion cohort: 27.1 percent compared to 20.9 percent for total wrist arthroplasty and 17.4 percent for proximal row carpectomy. Secondary surgery was common for all procedures: 87 percent for four-corner fusion, 57 percent for proximal row carpectomy, and 46 percent for total wrist arthroplasty. Proximal row carpectomy generated the highest quality-adjusted life-years (30.5) over the lifetime time horizon, compared to 30.3 quality-adjusted life-years for total wrist arthroplasty and 30.2 quality-adjusted life-years for four-corner fusion. Proximal row carpectomy was the least costly; the mean expected lifetime cost for patients starting with proximal row carpectomy was $6003, compared to $11,033 for total wrist arthroplasty and $13,632 for four-corner fusion.

CONCLUSIONS

The authors' analysis suggests that proximal row carpectomy was the most cost-effective strategy, regardless of patient and parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.

Comparison of clinical outcomes of three-corner arthrodesis and bicolumnar arthrodesis for advanced wrist osteoarthritis

We retrospectively compared results of 27 wrists with bicolumnar arthrodesis with mean follow-up of 67 months to 28 wrists with three-corner arthrodesis adding triquetral excision with mean follow-up of 74 months in 54 patients (55 wrists). Minimal follow-up was 2 years for all patients. Capitolunate nonunion occurred in three wrists with bicolumnar arthrodesis and six wrists with three-corner arthrodesis, and radiolunate arthritis developed in four wrists with three-corner arthrodesis. Among patients with bicolumnar arthrodesis, hamatolunate arthritis occurred in seven wrists, all with a Viegas type II lunate; and pisotriquetral arthritis occurred in three wrists. At mean 5 years after surgery, 45 wrists had not needed revision surgery, and both groups had similar revision rates. The wrists with three-corner arthrodesis and bicolumnar arthrodesis had similar functional outcomes, and range of wrist motion was not significantly different between the two groups. We concluded that bicolumnar arthrodesis results in greater longevity than three-corner arthrodesis for a type I lunate. We do not recommend bicolumnar arthrodesis for type II lunate. We also concluded that three-corner arthrodesis has a greater incidence of radiolunate arthritis and capitolunate nonunion.Level of evidence: III.

Risk of Total Wrist Arthrodesis or Reoperation Following 4-Corner Arthrodesis or Proximal Row Carpectomy for Stage-II SLAC/SNAC Arthritis: A Propensity Score Analysis of 502 Wrists

BACKGROUND

For stage-II scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) patterns of wrist arthritis, the optimal method of surgical treatment remains unclear. Previous literature has demonstrated similar clinical outcomes between proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA), making the risk of reoperation a focus of particular interest. In the present study, the primary null hypothesis was that there would be no difference in the rate of conversion to total wrist arthrodesis between PRC and FCA. Additionally, we hypothesized that the rate of secondary surgical procedures would be similar between the 2 procedures.

METHODS

The national Veterans Health Administration Corporate Data Warehouse was utilized to identify 2,449 patients who underwent either PRC or FCA between 1992 and 2016. With use of operative reports to identify the arthritis pattern, only cases of stage-II SLAC/SNAC were included. All complications and subsequent surgical procedures were confirmed by manual chart review. Propensity score analyses with matching weights were utilized to balance the PRC and FCA cohorts. The rates of conversion to wrist arthrodesis and secondary surgical procedures were calculated.

RESULTS

Of the 1,168 patients with stage-II SLAC/SNAC arthritis, 933 wrists underwent PRC and 257 wrists underwent FCA. Ten-year survival free of total wrist arthrodesis in the matching PRC (251 procedures) and FCA (251 procedures) cohorts was 94.3% (95% confidence interval [CI], 92.3% to 96.3%) and 94.1% (95% CI, 90.8% to 97.4%), respectively. Survival free of a secondary surgical procedure other than wrist arthrodesis was 99.7% (95% CI, 99.3% to 100.0%) for PRC and 83.5% (95% CI, 78.2% to 88.8%) for FCA.

CONCLUSIONS

PRC and FCA demonstrated similarly low rates of conversion to total wrist arthrodesis. In contrast, the rate of secondary surgical procedures following FCA was significantly higher compared with PRC. Given the historically similar clinical outcomes between PRC and FCA, the results of the present study show that PRC may be a preferable treatment for stage-II SLAC/SNAC wrist arthritis.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-Effectiveness Analysis Comparing Proximal Row Carpectomy and Four-Corner Arthrodesis

Background:

The optimal surgical treatment for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) remains unclear. To inform clinical decision-makers, we conducted a cost-effectiveness analysis comparing proximal row carpectomy (PRC) and four-corner arthrodesis (FCA).

Methods:

A Markov microsimulation model was used to compare clinical outcomes, costs, and health utilities between PRC and FCA. The model used a 10-year time horizon and a 1-month cycle length, and it was evaluated from the societal perspective. Utilities and clinical parameters including transition probabilities for debridement for infection, removal of implants, conversion to total wrist arthrodesis, revision FCA, and revision total wrist arthrodesis were obtained from published literature. Timing of complications was estimated from the literature. Direct medical costs were derived from Medicare ambulatory surgical cost data, and indirect costs for missed work due to surgical procedures and complications were included. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analysis and 1-way threshold analysis for utilities were performed.

Results:

In the base-case model, PRC dominated FCA (i.e., PRC had lower cost and greater effectiveness). The mean (and standard deviation) for the total cost and QALYs per patient were $30,970 ± $5,931 and 8.24 ± 1.28, respectively, for PRC and $44,526 ± $11,205 and 8.23 ± 1.26, respectively, for FCA. In the probabilistic sensitivity analysis, PRC dominated FCA in 57% of the 1 million iterations. The cost-effectiveness acceptability curve indicated that PRC is the most cost-effective strategy regardless of the willingness-to-pay threshold up to $100,000/QALY.

Conclusions:

PRC dominated FCA in the base-case analysis and in the probabilistic sensitivity analysis. These results suggest that PRC is the optimal strategy for Stage-I or II SLAC and for SNAC in patients ≥55 years of age.

Level of Evidence:

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Proximal Row Carpectomy Versus 4-Corner Fusion: Incidence, Conversion to Fusion, and Cost

PURPOSE

The primary objective of this study was to compare incidence, demographic trends, and rates of subsequent fusion between proximal row carpectomy (PRC) and 4-corner fusion (4CF) among patients in the United States.

METHODS

A total of 3,636 patients who underwent PRC and 5,047 who underwent 4CF were identified from the years 2005 through 2014 among enrollees in the PearlDiver database. Regional distribution, demographic characteristics, annual incidence, comorbidities, and subsequent wrist fusion were compared between the 2 groups. Of the patients identified, 3,512 from each group were age- and sex-matched and subsequently compared for rates of converted fusion, 30- and 90-day readmission rates, and average direct cost.

RESULTS

Patients undergoing 4CF and PRC did not have statistically significant differences in comorbidities. The incidence of the procedures among all subscribers increased for both PRC (1.8 per 10,000 to 2.6 per 10,000) and 4CF (1.2 per 10,000 to 2.0 per 10,000) from 2005 to 2014. Comparing the matched cohorts, patients who underwent 4CF had a higher rate of subsequent fusion than those who underwent PRC (2.67% vs 1.79%). Readmission rates were not significantly different at 30 or 90 days. Average direct cost was significantly greater for 4CF than for PRC.

CONCLUSIONS

Both PRC and 4CF have been utilized at increasing rates in the past decade. Wrist fusion rates and average costs are higher in the 4CF group without a significant difference in readmission rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Factors Associated With Reoperation and Conversion to Wrist Fusion After Proximal Row Carpectomy or 4-Corner Arthrodesis

PURPOSE

Proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA) are common salvage procedures for the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse. This study aimed to assess rates of reoperation and conversion to wrist fusion and to assess the factors associated with reoperation and conversion to wrist fusion for patients treated with PRC and FCA.

METHODS

A retrospective chart review was performed evaluating 266 adult patients undergoing PRC or FCA at a single institutional system from 2002 to 2016. Demographic data, patient- and injury-specific data, reoperation and conversion rates, and complications were collected. Potential factors associated with reoperation or wrist fusion were evaluated using a bivariate, followed by a multivariable, analysis.

RESULTS

Reoperation was more commonly performed in FCA (34%) than in PRC (11%) (odds ratio [OR], 3.4; 95% confidence interval [95% CI], 1.7-6.8) and occurred at a shorter postoperative interval. In a multivariable analysis for reoperation, manual labor was associated with reoperation in patients undergoing FCA (OR, 5.4; 95% CI, 1.5-19.1). In those undergoing PRC, anterior interosseous nerve (AIN) and/or posterior interosseous nerve (PIN) neurectomy was associated with a lower rate of reoperation (OR, 0.18; 95% CI, 0.06-0.57). In a multivariable analysis for conversion to wrist arthrodesis, intraoperative AIN and/or PIN neurectomy (OR, 0.18; 95% CI, 0.06-0.57) was associated with a lower rate of conversion to wrist fusion, and smoking (OR, 4.9; 95% CI, 1.8-13.5) was associated with a higher rate of conversion to wrist fusion. In the subanalysis of patients who underwent PRC, only AIN and/or PIN neurectomy was associated with lower rates of conversion to wrist arthrodesis (OR, 0.15; 95% CI, 0.04-0.56).

CONCLUSIONS

In our cohort, we observed that AIN and/or PIN neurectomy reduced the risk of reoperation and conversion to wrist arthrodesis after PRC. Smoking increased the odds of conversion to wrist arthrodesis in the combined PRC/FCA cohort; however, it is unclear whether this was due to smoking itself or whether the indications for PRC or FCA were affected, leading to this result.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

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.

Proximal row carpectomy in patients older than 50 years: 3 to 16 years of follow-up

OBJECTIVE

To analyze the long-term results and the prognosis of patients who have undergone proximal row carpectomy (PRC) in our hospital.

MATERIAL AND METHOD

This is a retrospective study of 14 patients undergoing PRC with a follow-up of 3 to 16 years. The ability to perform daily activities, mobility and functional capacity after the surgery were assessed using the Patient-Rated Wrist Evaluation questionnaire (PRWE).

RESULTS

The range of movement was satisfactory. The mean score on the PRWE scale was 20.9±17.2 for the pain subscale and 39±35.5 for the functional capacity subscale. None of the patients required revision surgery or developed complications. Eighty percent of the patients were satisfied or very satisfied. Ninety percent of the patients would undergo surgery again.

DISCUSSION

The wrist's range of movement achieved with this technique is similar to that obtained with other mobility preservation techniques. Secondary arthritic changes in the radio-capitate joint do not necessarily produce pain. Some authors have described that the degree of satisfaction after PRC is equivalent to that of other procedures such as arthrodesis in 4 corners with circular plate arthrodesis or middle-carpal arthrodesis.

CONCLUSION

PRC achieved high satisfaction rates among the patients providing pain relief, good mobility and post-operative functionality of the wrist. In addition, it presented few complications.

Distal Pole Resection of the Scaphoid for the Treatment of Scaphotrapeziotrapezoid Osteoarthritis

BACKGROUND

Distal pole resection of the scaphoid is one of the surgical techniques applied for the treatment of painful scaphotrapeziotrapezoid osteoarthritis (STT-OA).

METHODS

In this retrospective study, we evaluated midterm outcomes in a consecutive series of patients who underwent distal pole resection of the scaphoid: 13 patients (15 wrists) with a mean follow-up of 4.1 years. We examined objective functional and patient-reported outcome measures. In addition, we assessed the degree of dorsal intercalated segment instability (DISI) and postoperative complications.

RESULTS

All patients scored within a normal range on objective functional and patient-reported outcome measures. We observed a mild postoperative DISI deformity with an average lunocapitate angle of 22° (range, 0°-44°), which did not correlate with pain scores. In the opposite wrists, with and without STT-OA, the average lunocapitate angle was 6° (range, 0°-20°).

CONCLUSIONS

According to this study, midterm results for distal pole resection of the scaphoid are satisfactory.

No Benefits of Combining Proximal Row Carpectomy With PIN Neurectomy for Wrist Disorders-A Comparative Study With Systematic Review of the Literature

Background

Posterior interosseous nerve (PIN) resection in combination with proximal row carpectomy (PRC), is a preferred method in order to obtain rapid recovery. However, the contribution of such combination to results isn't known well.

Objectives

We performed a comparative study to evaluate the effects of PIN neurectomy for PRC and a systematic review of the literature was performed to identify whether such combination has an advantage.

Methods

Patients with wrist diseases who underwent PRC were evaluated retrospectively. Patients without PIN neurectomy (group 1, n = 7) and with PIN neurectomy (group 2, n = 8) were compared in respect of mean age, follow-up, gender, Q-DASH, VAS, MAYO wrist scores, flexion-extension/radial-ulnar deviation range of motion at final follow-up. The MEDLINE database was searched for studies published between 2005 and 2015, as the second part of the study. The following keywords were used: "proximal," "row," "carpectomy." Studies, which met the inclusion criteria, were evaluated in terms of such combination.

Results

There were no significant difference between the groups in regard with age (P = .463), follow-up period (P = .728), the ranges of flexion-extension (P = .431) and radio-ulnar deviation (P = .689), Q-DASH (P = .452), and MAYO scores (P = .728). In the second part of the study, 12 studies met the inclusion criteria and none of them was specifically evaluating such combination. Only one study had specific comments on PRC with PIN neurectomy.

Conclusion

According to our study (which, to our knowledge, was the first comparative study in the literature), we advocate not to combine PRC with PIN neurectomy for such an approach has no advantage.

Comparison of Direct Surgical Costs for Proximal Row Carpectomy and Four-Corner Arthrodesis

Background  Proximal row carpectomy (PRC) and four-corner arthrodesis (FCA) are common treatments for stage II scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists, with similar functional and patient-reported outcomes reported in the peer-reviewed literature. Questions  Study questions included (1) whether surgical encounter total direct costs (SETDCs) differ between PRC and FCA, and (2) whether SETDC differs by method of fixation for FCA. Patients and Methods  Consecutive adult patients (≥ 18 years) undergoing PRC and FCA between July 2011 and May 2017 at a single tertiary care academic institution were identified. Patients undergoing additional simultaneous procedures were excluded. Using our institution's information technology value tools, we extracted prospectively collected cost data for each surgical encounter. SETDCs were compared between PRC and FCA, and between FCA subgroups (screws, plating, or staples). Results  Of 42 included patients, mean age was similar between the 23 PRC and 19 FCA patients (51.2 vs. 54.5 years, respectively). SETDCs were significantly greater for FCA than PRC by 425%. FCA involved significantly greater facility costs (2.3-fold), supply costs (10-fold), and operative time (121 vs. 57 minutes). Implant costs were absent for PRC, which were responsible for 55% of the SETDC for FCA. Compared with compression screws, plating and staple fixation were significantly more costly (70% and 240% greater, respectively). Conclusion  SETDCs were 425% greater for FCA than PRC. Implant costs for FCA alone were 130% greater than the entire surgical encounter for PRC. For FCA, SETDC varied depending on the method of fixation. Level of Evidence  This is a level III, cost analysis study.

Arthroscopic Wrist Debridement and Radial Styloidectomy for Advanced Scapholunate Advanced Collapse Wrist: Long-term Follow-up

BACKGROUND

Symptomatic stage 2 or 3 scapholunate advanced collapse (SLAC) wrist is aggressively treated with salvage procedures, such as proximal row carpectomy or partial wrist fusion with resultant pain relief but limited motion. We hypothesize that arthroscopic synovectomy, radial styloidectomy, and neurectomy will preserve wrist motion, relieve pain, and delay or avoid salvage procedures.

METHODS

We evaluated outcomes in 13 wrists through questionnaires and 11 of these through additional physical examination at a mean follow-up of 5.0 years. Eight wrists were stage 2 and 5 were stage 3. Data at final follow-up included mobility/strength measurements, subjective outcome scores (Disabilities of the Arm, Shoulder, and Hand [DASH] and visual analog scale [VAS] pain), patient satisfaction, and return to work statistics.

RESULTS

Patients had an average flexion-extension arc of 88.0° in the treated wrist and an average grip strength that was 95.0% of the contralateral side. No patients required revision surgery at follow-up. The 13 wrists reported an average DASH score of 16.4 and mean VAS pain score at rest and with activity of 17.9 and 31.6, respectively. All patients working prior to the procedure (n = 8) were able to immediately return to work. In all, 84.6% of patients were satisfied.

CONCLUSIONS

The procedure studied may have advantages in relieving pain, while preserving wrist motion for SLAC stage 2 or 3 disease. This procedure does not preclude future salvage procedures in those patients with severe disease who prefer to maintain wrist motion for the short term. Patients experience good functional outcomes with the majority experiencing a reduction in pain with the ability to return to work.

Mid-term outcomes of routine proximal row carpectomy compared with proximal row carpectomy with dorsal capsular interposition arthroplasty for the treatment of late-stage arthropathy of the wrist

AIMS

The aims of this study were to compare the mid-term outcomes of patients with late-stage arthritis of the wrist treated with proximal row carpectomy (PRC) and dorsal capsular interposition (DCI) arthroplasty with a matched cohort treated with routine PRC alone.

PATIENTS AND METHODS

A total of 25 arthritic wrists (24 patients) with pre-existing degenerative changes of the proximal capitate and/or the lunate fossa of the radius were treated with PRC + DCI over a ten-year period. This group of patients were matched 1:2 with a group of 50 wrists (48 patients) without degenerative changes in the capitate or lunate fossa that were treated with a routine PRC alone during the same period. The mean age of the patients at the time of surgery was 56.8 years (25 to 81), and the demographics and baseline range of movement of the wrist, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were similar in both groups.

RESULTS

At a mean follow-up of 5.9 years (1.8 to 11.8), significant improvements in mean grip strength, the flexion-extension arc of movement of the wrist, QuickDASH, and PRWE scores were seen in both groups. There was no diifference between the groups for any of the outcomes. One patient in the PRC + DCI group required additional surgery for a deep infection, while two in the PRC group had complications (one wound dehiscence requiring revision closure, one transient radial sensory neuritis). One patient in each group required total arthrodesis of the wrist for progressive degenerative radiocarpal changes. A total of 70 patients (93%) were satisfied with the outcomes.

CONCLUSION

PRC with DCI is an effective form of treatment for late-stage arthritis of the wrist involving the capitolunate joint, with mid-term outcomes that are similar to those in patients without degenerative changes affecting the capitate or lunate fossa who are treated with a routine PRC alone. Cite this article: Bone Joint J 2018;100-B:197-204.

Long-Term Outcome and Secondary Operations after Proximal Row Carpectomy or Four-Corner Arthrodesis

Background  Proximal row carpectomy (PRC) and four-corner arthrodesis (FCA) are common surgical procedures used to treat degenerative wrist conditions; however, complications and failures can occur. Purpose  This study aimed to investigate and compare the long-term rate of secondary surgeries including conversion to total wrist arthrodesis in patients who underwent PRC or FCA. Materials and Methods  A retrospective chart review of all patients who underwent PRC or FCA in the past 20 years at a tertiary referral institution and associated Veterans Affairs (VA) hospital was performed. Patient demographics, comorbidities, surgical indications, and associated complications were tabulated. Patients were contacted via phone to obtain additional follow-up information regarding any additional surgeries, 10-point visual analog scale (VAS) for pain, quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) scores, hand dominance, and occupational data. Results  A total of 123 wrists made up the final dataset. Sixty-two wrists treated with PRC and 61 wrists treated with FCA were reviewed at a mean follow-up of 8.2 years. We did not find a significant difference in the rate of conversion to total wrist arthrodesis between the PRC (14.5%) and FCA (19.5%, p  = 0.51) cohorts. Secondary operations were significantly greater in the FCA group (34.4%) compared with the PRC group (16.1%, p  = 0.02). Females were 2.6 times more likely than males to undergo secondary operations when controlling for surgical procedure and smoking status ( p  = 0.04). We did not detect a significant difference in VAS pain or in quickDASH scores between the two groups ( p  = 0.35, 0.48, respectively). Conclusion  PRC and FCA have comparable patient reported outcomes and wrist arthrodesis conversion rates at a mean follow-up of 8.2 years. In contrast, the FCA patient group had a significantly higher rate of secondary operations, including those for nonunion, symptomatic hardware, and other implant-related issues, when combined with wrist arthrodesis conversion. Level of Evidence  Level IV, therapeutic study.

Ten-Year Minimum Follow-Up of 4-Corner Fusion for SLAC and SNAC Wrist

BACKGROUND

Scapholunate advanced collapse (SLAC) of the wrist is the most common degenerative condition of the wrist. Four-corner fusion (4CF) is performed as salvage surgery, though there is limited information on its long-term results. We hypothesized that 4CF is a durable surgery with good clinical long-term function.

METHODS

A retrospective chart review of patients undergoing 4CF as well as an interview and recent radiographs were obtained. Patients with a follow-up period of less than 10 years were excluded. Long-term evaluation included standard wrist radiographs, wrist range of motion, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Radiographs were evaluated and described by the Kellgren-Lawrence classification.

RESULTS

Four hundred eighty-nine wrists underwent a 4CF for SLAC wrist from 1982 to 2003. Twelve patients (15 wrists) were available for follow-up. Average age at surgery was 49.1 years (range, 25-67 years). Average follow-up postsurgery was 18 years (11-27). Scapholunate advanced collapse was the etiology in 13 wrists and scaphoid nonunion advanced collapse in 2 wrists. Average extension/flexion arc was 68.6° (0°-96°), and radial/ulnar deviation arc was 32.9° (0°-5°). QuickDASH scores averaged 7.8 (range, 0-32.5), with only 1 score above 16. Seventy-three percent of radiographs showed minimal to moderate joint destruction, and 27% showed severe joint destruction.

CONCLUSIONS

Scaphoid excision and 4CF remains a reliable procedure for patients with advanced wrist arthritis. Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. Patient satisfaction was high, and functional impairment was low.

A Comparative Analysis of Resource Utilization Between Proximal Row Carpectomy and Partial Wrist Fusion: A Population Study

PURPOSE

We conducted a population-level analysis comparing proximal row carpectomy (PRC) and partial wrist arthrodesis (PWA) for treatment of chronic wrist arthritis to (1) characterize national practice patterns, (2) determine the rate of conversion to total wrist arthrodesis (TWA), and (3) calculate the associated direct cost of care.

METHODS

Using the Truven MarketScan databases from 2009 to 2015, we identified patients 18 years or older with a diagnosis of wrist osteoarthritis who had a PRC or PWA and were followed for 18 months. We used Chi-square analysis and multivariable logistic regression to examine patient characteristics associated with conversion to a TWA. Rates of repeat PWA were also obtained, including the total number of procedures until completion and direct treatment cost.

RESULTS

Of a total of 3,388 eligible patients, 1,305 had a PRC (39%) and 2,083 had a PWA (61%). In patients 54 years of age or younger, PWA was more commonly performed than PRC (49% vs 38%). The TWA rates were significantly higher for patients of all ages who underwent PWA (19.2%) versus PRC (4.9%). Those undergoing PWA required more total procedures than patients who received a PRC (average, 1.7 vs 1.1) resulting in a greater average direct cost per patient ($10,842 vs $7,171).

CONCLUSIONS

Conversion rates to a TWA are significantly higher with a PWA (19.2%) than with a PRC (4.9%) and have a greater associated direct cost. This includes younger patients, who in the past were considered better candidates for PWA. Our findings suggest that surgeons may need to reevaluate their indications for PWA and that there may need to be a paradigm shift in the current practice patterns for salvage treatment of wrist arthrosis, more often considering PRC for all age groups.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Four-dimensional rotational radiographic scanning of the wrist in patients after proximal row carpectomy

We measured cartilage thickness, contact surface area, volume of the capitate and shape of the capitate during motion in the operated and unaffected wrists of 11 patients with a mean follow-up of 7.3 years after proximal row carpectomy. Radiocapitate cartilage thickness in the operated wrists did not differ significantly from radiolunate cartilage thickness in the unaffected wrists. The radiolunate surface area was significantly less than the radiocapitate surface area. The volume of the capitate was significantly increased in the operated wrists. The shape of the capitate changed significantly in two of three orthogonal directions. The combination of remodelling of the capitate, increase in its surface area and intact cartilage thickness could help to explain the clinical success of proximal row carpectomy.

[Proximal carpal row carpectomy]

OBJECTIVE

Resection of the proximal carpal row, termed proximal row carpectomy (PRC), is performed in order to treat pathologies of the proximal carpal row or radiocarpal joint between the scaphoid and scaphoid facet. It entails the articulation of the capitate and the lunate facet.

INDICATIONS

Lunate necrosis, carpal collapse, joint infection with concomitant intercarpal ligament lesions.

CONTRAINDICATIONS

Severe cartilage lesions of the lunate facet and the capitate, wrist capsule laxity, rheumatoid arthritis, neuromuscular dysbalance of the wrist-covering soft tissue structures.

SURGICAL TECHNIQUE

Dorsal approach to the wrist, incision of the third and fourth extensor compartments, resection and coagulation of the dorsal interosseous nerve, usage of a ligament-sparing capsule incision, identification of the proximal carpal row and inspection of cartilage of the lunate facet and capitate, mobilization and excision of the lunate, scaphoid and triquetrum, articulation of lunate facet and capitate is controlled clinically and fluoroscopically, wound closure, application of plaster slabs.

POSTOPERATIVE MANAGEMENT

Immobilization of the wrist on plaster slabs for 2 weeks, removal of sutures after 14 days.

RESULTS

PRC is a surgical procedure with few complications. Satisfactory range of motion and grip strength could be preserved without limiting function of the upper extremity. Postoperative osteoarthritis of capitate and lunate facet did not correlate with the good clinical outcome.

Salvage Operations for Wrist Ligament Injuries with Secondary Arthrosis

Wrist ligamentous injuries can be challenging to treat successfully. In some cases the ligament repair or reconstruction fails, resulting in instability and progressive degenerative changes. In other cases the original injury is missed, and the patient presents for the first time with established wrist arthritis. Multiple operations have been devised to treat patients with arthrosis secondary to wrist ligament injuries. This article discusses definitive salvage operations such as intercarpal arthrodeses and proximal row carpectomy, as well as other alternatives such as wrist denervation and radial styloidectomy.