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Proximal row carpectomy vs. four-corner fusion: Patient selection is the key
Surgeons suggest PRC in patients older than 60 years and fusion in those younger than 45 years.
WASHINGTON –
For hand surgeons, choosing between proximal row carpectomy and four-corner
fusion for treatment of SLAC wrists may often be a “coin toss.”
While proximal row carpectomy (PRC) is a simpler operation, it carries a risk for developing arthritis within 10 to 20 years after surgery, according to Peter J. Stern, MD, of Cincinnati. Four-corner fusion, on the other hand, is a more difficult operation and patients often encounter hardware complications.
However, Arnold-Peter C. Weiss, MD, of Providence, R.I., who has performed the four-corner fusion for 15 years, said he has never seen a patient develop arthritis after the procedure.
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“I’ve never seen a four-corner that didn’t have some problem — minor or otherwise,” Weiss said. “But they usually work and fuse. And [the patients] don’t get arthritis.”
Noting that the procedures have comparable results, Weiss and Stern offered their own guidelines for choosing a procedure to treat SLAC (scaphoid lunate advanced collapse) wrist patients at the American Society for Surgery of the Hand annual meeting, held here.
Proximal row carpectomy
PRC offers long-term studies with more than 10-year follow-up – something that four-corner fusion lacks, Stern said.
“Proximal row carpectomy is a simple operation, the rehabilitation is fairly quick and the literature documents excellent long-term results, but the potential difficulty is development of symptomatic arthritis in the second or third decade,” Stern said.
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PRC patients may develop arthritis between the head of the capitate and the lunate facet of the distal radius. Stern blamed this risk on the translational motion, as opposed to ball-and-socket motion, between the capitate head and the lunate facet joint.
“In addition, the head of the capitate and the lunate facet have different radiuses of curvature,” Stern said. “So inevitably most of these patients will develop loss of cartilage at that articulation.”
Stern presented two studies with more than 10-years follow-up on patients treated with PRC. One study by DiDonna and colleagues had an 18% failure rate, all failures were in patients younger than 35 years. The other study by Jebson and colleagues found a 10% failure rate.
Lastly, young patients an get arthritis following a PRC. Although the PRC is an easy operation, Weiss said, surgeons should be careful in using it for younger patients, and in patients who have a “pointy” capitate head or large radial ridge. He also cautioned: “Make sure you don’t injure the radial scaphoid capitate ligament … when you’re taking out the scaphoid.”
Stern and Weiss agreed that the difficulty with four-corner fusion lies with the technique and hardware. “You have to use good quality bone graft,” Weiss said. “It doesn’t matter what fixation you use.”
“In a series we recently looked up, there was about a 25% nonunion rate,” Stern said. “It is a technically difficult operation. The lunate needs to be reduced … and I’m not sure it’s as easy to do as [some surgeons] think. I think sometimes it could be hard to maintain reduction.”
Weiss said the typical candidate for four-corner fusion is a young, active patient with reasonable bone stock and a slightly “ratty” capitate cartilage.
He warned colleagues not to use the excised scaphoid alone because it will not result in a fusion.
“Plates are for stability. They will not fuse the joint de novo,” Weiss said. “So staples, plates, preferred screws, whatever you want to use, they’re not going to make the fusion happen. You have to make the fusion happen.”
If surgeons place the hardware and bone graft correctly, they will have a 97% to 98% fusion rate, Weiss said, noting that he has had only three or four nonunions out of 120 four-corner fusions.
Finally, he said, “protect the long radiolunate ligament … and I think you’ll have a long-lasting [fusion].”
Comparable procedures
Stern said the literature reflects comparable results at short-term follow-up between four-corner fusion and PRC in pain relief, function, range of motion (60% to opposite side) and strength (80% to opposite side).
Weiss said he uses PRC in roughly half of his SLAC wrist patients. “[PRC] works reasonably well in patients 60 years or older – reasonably well, not great,” he said. “I use four-corner a lot in the other half and I think that works reasonably well in patients 45 years or younger.”
When treating patients between 45 years and 60 years of age, surgeons must make a decision based on the patient. Weiss suggested that surgeons evaluate the patient’s physiologic age; for example, some 65-year-old patients are healthier than some 35-year-old patients. Further, they need to evaluate the patient’s quality of bone stock. “This is never talked about, but it’s really important for both PRC and four-corner [fusion],” Weiss said.
Also important to evaluate: the shape of the capitate head, height of the ridge separating the scaphoid and lunate at the distal radius fossa, and the patient’s activity level.
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Images: Weiss APC |
For more information:
- Stern PJ, Weiss, APC. Controversy: Four-corner fusion. Precourse #6. Presented at the American Society for Surgery of the Hand 61st Annual Meeting. Sept. 7-9, 2006. Washington.
- DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: a study with a minimum of 10 years of follow-up. J Bone Joint Surg Am. 2004 Nov;86-A:2359-2365.
- Jebson PJ, Hayes EP, Engber WD. Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg [Am]. 2003 Jul;28(4)561-569.
- Peter J. Stern, MD, professor and chair, Department of Orthopedics, University of Cincinnati, P.O. box 670212, Cincinnati, OH 45267-0212; 513-558-4516; peter.stern@uc.edu.
- Arnold-Peter C. Weiss, MD, professor, Hand & Elbow Surgery and Microvascular Surgery, Brown Medical School, 2 Dudley Street, Suite 200, Providence, RI 02905; 401-457-1522; Arnold-Peter_Weiss@Brown.edu. He indicated that he has no financial relationship with any company or product mentioned in this article.