The never-ending battle between proximal row carpectomy and four corner arthrodesis: A systematic review and meta-analysis for the final verdict

Patient reported and functional outcome measures after surgical salvage procedures for posttraumatic radiocarpal osteoarthritis - a systematic review

BACKGROUND

Posttraumatic wrist osteoarthritis is an irreversible and often progressive condition. Many surgical treatments, used in (daily) practice, aim to relieve symptoms like pain and restore function. The aim of this systematic review is to assess the patient reported and functional outcomes of the most common surgical interventions in patients with posttraumatic wrist osteoarthritis. This overview can help clinicians select the best treatment and manage patient's expectations.

METHODS

A literature search was performed in Pubmed, Embase and Cochrane for articles published between 1990 and November 2022 according to the PRISMA guidelines. The study protocol has been registered in the PROSPERO database (CRD42017080427). Studies that describe patient reported outcomes (pain and Disability of Arm, Shoulder and Hand (DASH) -score) and functional outcomes (range of motion (ROM) and grip strength) after surgical intervention with a minimal follow-up of 1 year were included. The identified surgical procedures included denervation, proximal row carpectomy, interpositional- and total arthroplasty, and midcarpal-, radiocarpal- and total arthrodesis. The pre-and postoperative outcomes were pooled and presented per salvage procedure.

RESULTS

Data from 50 studies was included. Pain score improved after all surgeries except denervation. Flexion/extension decreased after radiocarpal arthrodesis, did not show significant changes after proximal row carpectomy, and improved for all other surgeries. DASH score improved after arthroplasty, proximal row carpectomy and midcarpal arthrodesis. Grip strength improved after interposition arthroplasty and partial arthrodesis.

CONCLUSION

Evidence from this review did not support the indication for denervation in this particular patient population. In patients with SLAC/SNAC II, proximal row carpectomy might be favourable to a midcarpal arthrodesis solely based on better FE ROM of the radiocarpal joint after proximal row carpectomy. In terms of radiocarpal mobility, total wrist arthroplasty might be preferred to radiocarpal arthrodesis in patients with osteoarthritis after a distal radius fracture. More uniform measurements of outcomes would improve the understanding of the effect of surgical treatments of the posttraumatic osteoarthritic wrist.

[Osteoarthritis of the wrist]

The term osteoarthritis (OA) of the wrist can be used as an umbrella term for various, often independent areas of OA, as the wrist is made up of several joints. Radiocarpal OA often occurs after untreated ligament injuries, incorrectly healed bone fractures in the carpus or after radius fractures involving the joint. A typical sequence of propagation is known for radiocarpal OA following scapholunate (SL) insufficiency or scaphoid pseudarthrosis. Other causes include inflammation, crystal deposits or bone necrosis. Ulnocarpal arthrosis occurs posttraumatically or primarily when there are differences in levels between the ulna and radius. When treating wrist arthrosis, after conservative measures have been exhausted a surgical procedure should be chosen that enables the best possible load-bearing and residual mobility, considering the surgical risks and individual requirements. During salvage operations, the defective cartilage areas are either fused directly or eliminated using appropriate diverting partial fusions and resection arthroplasty. An accurate analysis of the affected zones is crucial for selecting an appropriate intervention.

Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC): A Review of Treatment Options for Stage II

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) represent clinical entities identified by a pattern of predictable degenerative changes. They are the most common causes of wrist arthritis. Both entities can remain asymptomatic for many years and may go undiagnosed. Diagnosis is usually confirmed through clinical examination, which reveals progressive wrist pain and instability. Radiographically, degenerative changes in the radiocarpal and midcarpal joints are present, as well as nonunion of the scaphoid fracture in SNAC. The management differs according to the stage. Particularly in this review article, we reviewed the treatment options for stage II SLAC and SNAC wrist. In addition to the well-described surgical techniques such as proximal row carpectomy and four-corner fusion, alternatives such as capitolunate arthrodesis, three-corner fusion, and soft tissue procedures like capsulodesis and tenodesis are available. Proximal row carpectomy and partial arthrodeses yield comparable results. Soft tissue procedures are viable alternatives and are preferred in younger patients to avoid early salvage operations.

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.

The use of resurfacing capitate pyrocarbon implants (RCPI) in chronic diseases of the wrist: outcomes of more than 100 cases

INTRODUCTION

In advanced chronic post-traumatic wrist pathology, the goal of surgery has always been to reduce pain while trying to preserve the function of the wrist itself as much as possible; numerous interventions have been developed to achieve these goals (partial arthrodesis, 4-angle arthrodesis, the use of prosthetic implants…).

PURPOSES

The purpose of the study is to evaluate outcomes and complications rate of proximal row carpectomy associated with the resurfacing capitate pyrocarbon implant (RCPI) for chronic diseases of the wrist.

MATERIALS AND METHODS

A retrospective analysis of the patients operated on between June 2004 and March 2021 was performed. Pain, wrist range of motion in flexion, extension, radial and ulnar deviation and grip strength were compared preoperatively and at 1, 6, 12 and 24 months. Complications and additional procedures were recorded.

RESULTS

A total of 112 patients underwent surgery for proximal row carpectomy and placement of RCPI with a mean follow-up of 6.6 years. Between the preoperative and the 2-year follow-up, a reduction in pain (VAS from 7.3 to 0.5), an increase in grip strength (from 8 to 17 kg) and an increase in ROM in all planes (flexion from 19° to 44°, extension from 20° to 46°, radial deviation from 7° to 14° and ulnar deviation from 13° to 28°) were recorded. Ten (8.9%) patients required additional surgery, with only 2 (1.8%) patients requiring revision of the implant.

CONCLUSIONS

Proximal row carpectomy associated with RCPI is an excellent surgical strategy to relieve pain and to improve wrist range of motion and grip strength in patients with chronic diseases of the wrist.

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.

Wrist Arthritis and Arthrodesis: Preserving Function, Minimizing Problems

Wrist arthritis is a common condition with numerous causes and presentations. Several management options exist, and treatment should be individualized based on patient age, comorbidities, occupation, duration of symptoms, and failed treatment modalities. Arthroscopy and denervation are appealing because of shorter recovery time and preservation of motion, but duration of effectiveness varies between patients. Patients who fail these smaller procedures or those with pancarpal arthrosis are treated effectively with total wrist arthrodesis or total wrist arthroplasty in lower-demand patients. This article reviews causes and patterns of wrist arthritis and discusses treatment strategies aimed at preserving function and minimizing complications.

Total Wrist Arthroplasty for Posttraumatic Wrist Osteoarthritis: A Cohort Study Comparing Three Indications

Scapholunate ligament ruptures and scaphoid nonunion with consecutive advanced collapse (SLAC and SNAC wrists) as well as intra-articular distal radius fractures (DRF) are prone to cause posttraumatic wrist osteoarthritis. The aim of this study was to compare the outcomes of these indications for total wrist arthroplasty. We included 13, 11, and 8 patients with an overall mean age of 60 ± 9 years in the SLAC, SNAC, and DRF cohort, respectively. After an average follow-up period of 6 ± 3 years, we found no difference between our groups regarding pain levels and functional scores, although these parameters significantly improved compared to preoperative parameters. Complication and revision rates revealed no significant difference. However, significantly higher extension, arc of range of motion values in the flexion-extension, as well as in radial-ulnar deviation plain were detected in the SLAC compared to the DRF group. Finally, TWA proved to show a beneficial performance in all three investigated indications.

Wrist Hemiarthroplasty for Complex Intraarticular Distal Radius Fracture in a Patient with Manifest Osteoporosis

Distal radius fracture (DRF) is one of the most common fractures of the elderly. The higher the degree of joint surface destruction, and the more adverse factors are involved, the more challenging proper treatment becomes. In this regard, osteoporosis as underlying systemic disease, chondropathy or degeneration of adjacent wrist bones as well as incompliance significantly impair the success of the chosen primary therapy. Wrist hemiarthroplasty has already been reported as primary or secondary procedure for DRFs. In this case report, we present a patient with a severely comminuted DRF including posttraumatic degeneration of the lunate as well as manifest osteoporosis. Wrist hemiarthroplasty using the ReMotion radius component in combination with proximal row carpectomy was performed as secondary surgery. This procedure proved to be a viable treatment option in terms of achieving low pain levels, high range of motion values and stable osteointegration over a course of 6.5 follow-up years.