Proximal row carpectomy preferable to four-corner arthrodesis in wrist arthritis treatment

Curtis M. Henn, MD

The optimal surgical treatment of stage 2 SLAC and SNAC remains unclear. Given the wide variety of patients with stage 2 SLAC or SNAC, I think it will be difficult to definitively prove one procedure is better than the other for every patient. Therefore, I let the patient’s age, activity level, smoking status and even the shape of their capitate influence my surgical approach. I continue to rely on four-corner arthrodesis in younger, higher demand patients. I accept the risk of nonunion and the potential need for further surgery to maintain the native congruency of the radiolunate joint and the carpal height. I prefer to treat older patients and those who are smokers with proximal row carpectomy. However, given the mounting evidence that radiocapitate arthritis may not lead to symptomatic arthritis or the need for reoperation, I now have a lower threshold to perform a proximal row carpectomy in a younger patient. In patients in which either procedure is a good option, I will discuss both procedures with the patient and allow the patient to participate in the decision.

Sanjeev Kakar, MD

Stage 2 SLAC and SNAC wrist arthritis are common causes of wrist morbidity from untreated scapholunate injury or development of scaphoid nonunion, respectively. In terms of stage 2, this is where there is arthritis between the scaphoid facet and the scaphoid. There is controversy regarding the best management of this condition, be that proximal row carpectomy vs. a scaphoid excision and four-corner fusion. One of the concerns is the need for possibly proceeding with a total wrist arthrodesis in the future due to adjacent joint deterioration and also the complications with each procedure.

In this study, Garcia and colleagues performed a propensity score analysis of 251 matched patients who underwent proximal row carpectomy and 251 matched patients who underwent a scaphoid excision and four-corner fusion for these conditions. The authors noted a similar 10-year survival-free rate of conversion to total wrist arthrodesis in both groups but a higher complication rate requiring secondary surgery at the 1-, 5- and 10-year intervals for patients who have undergone scaphoid excision and four-corner fusion compared with those patients who underwent a proximal row carpectomy.

Overall, I think this study provides some important information. Despite the limitations that the authors state, including follow-up of no longer than 10 years, inability to review radiographs, patient activity levels and clinical outcomes, as well as surgeon preference or skill regarding the procedures, the study does draw one’s attention to the importance of patient counseling regarding the potential complication rates. Scaphoid excision and four-corner fusion is a technically demanding procedure and the results from this study would seem to support this. One of the concerns about performing a proximal row carpectomy, especially in a younger patient, is the development of symptomatic radiocapitate arthritis with the need for conversion to other surgical procedures, such as a wrist fusion. The authors do recognize this in that their follow-up of less than 10 years is limited to answer this question.

A study by Eric R. Wagner, MD, and colleagues looked at the outcomes and secondary surgeries in patients younger than 45 years old who underwent either proximal row carpectomy or scaphoid excision and four-corner fusion and noted slightly improved grip strength in those patients who underwent limited arthrodesis, a similar 10-year outcome free of moderate and severe arthritis between the two groups, but improved motion and fewer complications in those patients who underwent proximal row carpectomy.

Moving forward, I think it is important that we perform longer outcome studies in these patient groups and assess factors, such as the surgical skill in performing a limited arthrodesis and also the activity levels of the patients. A younger, manual laborer has different needs than say an equivalent person who has a more sedentary occupation.

Reference:

Wagner ER, et al. J Hand Surg Am. 2017;doi:10.1016/j.jhsa.2017.03.015.