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

A Changing Landscape in the Surgical Management of Wrist Arthritis: An Analysis of National Trends From 2009 to 2019

PURPOSE

The purpose of this study was to analyze the trends in the annual volume and incidence of proximal row carpectomy (PRC), four-corner fusion (4CF), total wrist arthrodesis (TWF), and total wrist arthroplasty (TWA) from 2009 to 2019 in the United States.

METHODS

The IBM Watson Health MarketScan databases were queried to identify annual case volumes for PRC, 4CF, TWF, and TWA from 2009 to 2019. The annual incidence of these procedures was then calculated based on the population estimates from the US Census Bureau. Trends in annual volume and incidence over the study period were evaluated using regression line analysis. Further subgroup analysis was conducted based on age and region.

RESULTS

From 2009 to 2019, the total case volumes for the four procedures increased by 3.4%, but the incidence decreased by 2.8%. However, PRC case volume and incidence trends significantly increased (38.2% and 29.7%, respectively), whereas 4CF remained constant. Conversely, the case volume and incidence of TWA significantly decreased (-52.2% and -54.5%, respectively), whereas TWF remained constant. When stratified by age, all four procedures decreased in the <45-year-old cohort (combined -35.1%) significantly for 4CF, TWF, and TWA. TWA decreased significantly in the <45-year-old and 45- to 65-year-old cohorts (53.6% and 63.2%, respectively). For age >65 years, the total case incidence increased by 98.9%, including a significant positive trend in TWF (175%).

CONCLUSIONS

Surgical management of wrist arthritis remains a controversial issue. However, PRC has gained recent support in the literature, and our results reflect this shift, even for the <45-year-old cohort. Furthermore, TWA declined, despite reports of positive early outcomes for fourth-generation implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Proximal ROw carpectOmy versus four-corner Fusion (PROOF-trial) for osteoarthritis of the wrist: study protocol for multi-institutional double-blinded randomized controlled trial

BACKGROUND

Scapholunate advanced collapse (SLAC) and scaphoid non-union advanced collapse (SNAC) are common types of wrist osteoarthritis (OA). Non-operative treatment consists of pain medication, splinting, and avoiding activities that induce pain. However, in case a course of conservative treatment is unsuccessful, operative treatment is needed. The two most conventional operative approaches for SLAC/SNAC OA are four-corner arthrodesis (FCA) and proximal row carpectomy (PRC). Although FCA is the gold-standard operative technique and may lead to superior grip strength, the evident benefit of PRC is that it obviates any need for hardware removal and controlling for bony union. To date, no high-quality randomized controlled trial comparing FCA and PRC exists. As clinical outcomes seem comparable, a trial that assesses patient-reported outcomes, adverse events, and secondary operations may guide clinical decision making between these two procedures. Thus, the aim of this multi-institutional double-blind randomized controlled trial is to study whether PRC is non-inferior to FCA in treating SLAC/SNAC OA. We hypothesize that PRC is non-inferior to FCA with lower economic expanses.

METHODS

The trial is designed as a randomized, controlled, patient- and outcome-assessor blinded multicenter, two-armed 1:1 non-inferiority trial. Patients with SLAC/SNAC-induced wrist pain meeting trial inclusion criteria will undergo wrist arthroscopy to further assess eligibility. Each patient eligible for the trial will be randomly assigned to undergo either FCA or PRC. The primary endpoint of this study is the Patient Rated Wrist Evaluation (PRWE) at 1-year after FCA versus PRC. Secondary outcomes include Quick-Disabilities of the Arm, Shoulder and Hand, EQ-5D-5L, pain, grip strength, wrist active range of motion, radiographic evaluation, and adverse events. Trial design, methods, and statistical analysis plan will be presented here.

DISCUSSION

We present an RCT design comparing FCA vs PRC for SLAC/SNAC-induced OA. The results of this trial will assist in decision making when planning surgery for SLAC/SNAC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04260165 . Registered February 7, 2020.

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.

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.

A Failed 4-Corner Arthrodesis Using a Polyether-Ether-Ketone Implant: A Case Report

CASE

A 59-year-old man underwent scaphoidectomy and 4-corner arthrodesis with a polyether-ether-ketone (PEEK) circular plate for scapholunate advanced collapse of the wrist. Five years later, he presented with a symptomatic nonunion and radiocarpal arthritis. Total wrist arthrodesis with a dorsal plate was performed. During revision surgery, considerable synovitis was encountered. Histological evaluation revealed a foreign body response likely secondary to PEEK particles.

CONCLUSION

Use of PEEK implants can result in an adverse local tissue reaction if particles are generated. This is a rare biomaterial-related complication, and surgeons should be aware of this adverse tissue response when using this or other PEEK implants.