Proximal row carpectomy with or without postoperative immobilisation

Comparison of Clinical Outcomes in Open and Arthroscopically-Assisted Mini Open Proximal Row Carpectomy for Lichtman Stage IIIB and IIIC Kienböck Disease

PURPOSE

Proximal row carpectomy (PRC) can be performed in the late stages of Kienböck disease using the traditional open technique or arthroscopically. In this study, we describe the arthroscopically-assisted mini-open PRC technique. The aim of the study was to compare the functional results with the open PRC technique in advanced-stage Kienböck disease.

METHODS

The medical records of patients with Kienböck disease who underwent open PRC between 2006-2010 (Cohort A) and arthroscopically-assisted PRC (AAPRC) between 2010-2018 (Cohort B) were analyzed. The Quick Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale, and Modified Mayo Wrist Scores were compared, which were obtained at the early postoperative (third month) and final follow-up.

RESULTS

Cohort A had 14 and Cohort B 21 patients. The preoperative, early, and final mean visual analog scale scores were 7, 3, and 0.3, respectively, for Cohort A, and 7, 0.3, and 0.1, respectively, for Cohort B. The preoperative mean Quick Disabilities of the Arm, Shoulder, and Hand scores decreased from 69 to 34 at the third-month and 6.1 on the final follow-up visit for Cohort A and from 77 to 18, and 5 for Cohort B. The final Mayo wrist scores were excellent in 4, good in 4, and moderate in 6 of the Cohort A patients, and excellent in 11, good in 8, and moderate in 2 of the Cohort B patients. Mean flexion increased to 52° from 43° for Cohort A and to 62° from 41° for Cohort B.

CONCLUSIONS

AAPRC, compared to the open PRC, resulted in increased wrist motion and increased Mayo wrist scores in the long-term. Also, the third-month patient-related outcomes revealed favorable results in the AAPRC group. We attribute these findings to the earlier initiation of postoperative wrist motion and the less invasive character of the AAPRC procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

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

Long-term 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.

Proximal row carpectomy on manual workers: 17 patients followed for an average of 6 years

Proximal row carpectomy (PRC) is indicated for the treatment of SNAC or SLAC wrist with preservation of the midcarpal joint. Our hypothesis was that PRC is not appropriate for treating advanced wrist osteoarthritis in patients who carry out heavy manual work. Twenty-three PRCs were performed on 21 patients, 5 women and 16 men with an average age of 54 years (33-77). All patients performed manual work; 11 of them performed heavy manual work. Etiologies were: SLAC wrist in 14 cases (2 stage III, 11 stage II, and 1 stage I) and SNAC wrist in 9 cases (6 stage IIIB and 3 stage IIB). At an average 75 months' follow-up (24-153), five patients were lost to follow-up. Radiocarpal arthrodesis was performed in one patient 10 years after the PRC. In the 17 remaining patients (18 wrists), pain (VAS) averaged 2.2, with residual pain of 5. Flexion-extension range was similar to preoperative levels (67% of contralateral wrist). Wrist strength was decreased by 34% compared to preoperative. The QuickDASH score averaged 26 points and the PRWE 20 points. Radiocapitate distance decreased by 0.3mm on average with joint line narrowing in 6 patients. The carpal translation index was 0.33mm, which was unchanged relative to preoperative values. Three patients had work-related limitations that required retraining and one patient had to be reassigned. PRC preserved the preoperative range of motion and reduced pain levels. However, significant loss of strength was observed, resulting in 23% of manual workers needing retraining or reassignment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Randomized clinical trial between proximal row carpectomy and the four-corner fusion for patients with stage II SNAC

Objective

To compare the outcomes of patients with stage II SNAC submitted to surgical treatment by proximal row carpectomy (PRC) or four-corner fusion (FCF).

Method

Twenty-seven patients aged 18–59 years (mean 37.52 years) were included. Thirteen patients underwent PRC in Group A, and 14 underwent FCF of the wrist in Group B. Evaluations were made before and after surgery with follow-up between 45 and 73 months. Range of motion (ROM); pain assessment with a visual analog scale (VAS); grip strength; disability of the arm, shoulder, and hand (DASH); and return to work were evaluated.

Results

Group A patients had 68.5% and Group B patients, 58.01% of the ROM of the contralateral side. The VAS score was 2.3 in Group A and 2.9 in Group B. Grip strength was 78.67% and 65.42%, respectively, relative to the side not affected. The DASH score was 11 for PRC and 13 for FCF. In Group A, 9/13 (69.23%) and in Group B, 8/14 (57.14%) patients are currently working. Complications were symptomatic osteoarthritis in the mid-carpal joint in Group A and loosening of a screw in Group B.

Conclusion

The clinical and functional results do not present statistically significant differences for both analyzed methods.

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

PURPOSE

To compare the long-term outcomes of proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA) in a consecutive series of patients surgically treated between 1989 and 1998 in a single teaching hospital.

METHODS

We included 12 patients (14 wrists) in the PRC group and 8 patients (8 wrists) in the FCA group. Mean follow-up time was 17 years. We compared functional outcome measures (range of motion and grip strength) and patient-reported outcome measures (visual analog score for pain, Mayo Wrist Score, and Michigan Hand Questionnaire). Radiographic evaluation of joint degeneration using the Culp and Jebson scoring system and postoperative complications were assessed for both groups.

RESULTS

Active range of motion was slightly better after PRC. There were no differences in grip strength and patient-reported outcomes between groups. Severity of degenerative changes did not differ between groups and was not correlated with pain scores. The FCA group showed more postoperative complications.

CONCLUSIONS

Considering the objective and patient-reported outcomes of this study, both types of surgery perform well in the long run. Proximal row carpectomy seems to result in slightly better movement of the wrist with fewer surgical complications and no need for hardware removal. Moreover, postoperative immobilization time was much shorter.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are the two most common patterns of posttraumatic wrist arthritis. This review discusses the etiology and clinical evaluation, as well as up-to-date treatment options, for both of these conditions. Classic as well as newer innovative techniques are discussed with clinical outcomes in order to provide an evidence-based review of the world's literature on SLAC/SNAC wrist.

Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis--update on evaluation and treatment

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse are common patterns of wrist arthritis. Scaphoid nonunion advanced collapse is caused by trauma, whereas SLAC wrist may also result from chronic pseudogout and can appear bilaterally without a clear history of injury. Surgical treatment for SLAC wrist includes 4-corner arthrodesis, capitolunate arthrodesis, complete wrist arthrodesis, proximal row carpectomy (PRC), denervation, and radial styloidectomy. Scaphoid nonunion advanced collapse wrist has the additional surgical option of excision of the distal ununited scaphoid fragment. Controversy persists over the relative merits of PRC versus 4-corner arthrodesis and whether PRC may be performed in the setting of capitate arthritis.

Proximal row carpectomy: Is early postoperative mobilisation the right rehabilitation protocol?

PURPOSE OF THE STUDY

To determine the feasibility and interest of an early rehabilitation protocol with no initial immobilisation after proximal row carpectomy.

MATERIAL AND METHODS

Thirteen patients were included in this retrospective study. Range of motion (ROM) and wrist strength (grip strength and grasp strength) were evaluated 3 and 6 weeks after surgery on the both wrists (operated and non-operated). Postoperatively, patients had no immobilisation of the wrist, and began a rehabilitation program immediately after surgery in the department of Physical Therapy and Rehabilitation under multidisciplinary team supervision. The same surgical technique was used for all patients by the same surgeon.

RESULTS

Six weeks after PRC, there was a 25-51% deficit in passive ROM and 54-64% deficit in active ROM compared to the corresponding non-operated wrist. Six weeks after PRC, mean overall grip strength was nearly 55% and Jamar dynamometer grip strength was 51% of the contralateral side.

DISCUSSION

This study shows that immediate immobilisation following PRC is unnecessary, and that early rehabilitation is of the essence. Early rehabilitation could reduce the delay necessary to recover range of motion and strength, and probably the time to return to work.

LEVEL OF EVIDENCE

Level 4, prospective cohort study.