What Is the Best Surgical Treatment for Early Degenerative Osteoarthritis of the Wrist?

Published on 11/03/2015 by admin

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Chapter 12 What Is the Best Surgical Treatment for Early Degenerative Osteoarthritis of the Wrist?

GREG A. MERRELL, MD, ARNOLD-PETER C. WEISS, MD

SCAPHOTRAPEZIOTRAPEZOID JOINT ARTHRITIS

Although scaphotrapeziotrapezoid (STT) arthritis may be associated with chronic scapholunate injury and rotary subluxation of the scaphoid, it is also a relatively common site of focal arthritis, particularly in older women. The two most common surgical treatments for this problem are STT arthrodesis or distal scaphoid excision.

Evidence

No randomized trials have compared STT arthrodesis with distal scaphoid excision (Level I). No prospective comparative studies (Level II) or retrospective comparative studies (Level III) exist either. What is available to make a treatment decision is a collection of case series with few patients in each. Most of the reports on STT arthrodesis combine results from patients who had a fusion for scapholunate instability or other problems with patients who had the fusion for primary STT arthritis. This amalgamation of reported data also makes interpretation of outcome difficult.

In his monumental review of 800 triscaphe fusions, Dr. Watson ¹ does identify 98 patients whose arthrodesis was for primary STT arthritis. The case series review states that 62% of the patients were examined in the office and the others had data pulled from chart reviews. The mean follow-up was 3.4 years. Patients were immobilized for 3 weeks in a long arm cast, followed by 3 weeks in a short arm cast. Pain was graded by the patients as mild, moderate, or severe. The flexion extension arc was 85% and 80%, respectively, of the contralateral side. Grip strength was 77% of the other side. The results with regard to pain were not broken out independently for STT arthritis versus other indications for STT fusion. The rate of nonunion across all indications for STT arthrodesis was only 4%.

In a review of eight patients with STT arthritis, Srinivasan and Matthews ² found four were pain free, three had pain with certain activities, and one had constant pain. The flexion extension arc averaged 115 degrees compared with 124 degrees on the uninjured side. One of the eight had a nonunion. Follow-up averaged 4 years.

Only one case series describes results of distal scaphoid excision specifically for STT arthritis.³ Garcia-Elias and colleagues³ reported on 21 patients with a mean follow-up of 29 months. Patients were immobilized for 2 to 3 weeks in a short arm splint. The preoperative visual analog scale (VAS) pain score was 7.5, and the postoperative score was 0.6, with 13 having no pain. Grip improved from 57% of the contralateral side preoperatively to 83% of the contralateral side after surgery. Wrist flexion averaged 57 degrees and wrist extension averaged 61 degrees. The radiolunate angle increased from 9 degrees before surgery to 17 degrees after surgery.

RECOMMENDATIONS

In conclusion, a paucity of clinical data exists with which to make informed treatment decisions for primary STT arthritis. There is some intuitive attraction to the simplicity, low complication rate, and early return to function of a distal scaphoid excision. However, cause for concern also exists with this procedure because the longer term impact of an increased dorsal intercalated segment instability carpal position that appears to develop after distal scaphoid excision is unknown. Therefore, for primary STT arthritis, we believe it is not appropriate to make a recommendation for treatment. Surgeons must take into account their experience base, the age of the patient, and other variables to decide on the best course of action.

SCAPHOLUNATE ADVANCED COLLAPSE AND SCAPHOID NON-UNION ADVANCED COLLAPSE

Scapholunate advanced collapse (SLAC) wrist is the most common post-traumatic form of arthritis in the wrist and follows a predictable progression of arthrosis. Scaphoid nonunion advanced collapse (SNAC) wrist follows the same pattern of arthrosis, although it is less common. As evidenced by the numerous treatments proposed for these forms of arthritis, the best surgical option remains a source of considerable debate.

The two most common surgical options for chronic SLAC and SNAC wrist are either a proximal row carpectomy (PRC) or a four-corner (Capitate–Lunate–Hamate–Triquetrum) fusion. Proponents of PRC point to its technical simplicity, decreased time for immobilization, and lack of nonunion risk. Proponents of four-corner fusion highlight the maintenance of physiologic carpal height and a congruent radiolunate joint, which may theoretically allow a more durable articulation.

Evidence

No randomized trials have compared PRC with a four-corner fusion (Level I). No prospective comparative studies exist (Level II). Four retrospective comparative studies (Level III) have been reported, only one of which has a methodology that would minimize patient selection bias and the results of which might therefore be valid.⁴^–⁷

The highest quality study, by Cohen and Kozin ⁴ in 2001, retrospectively examined 2 cohorts of 19 patients at different institutions, which performed exclusively either PRC or four-corner fusions. Importantly, there were no preoperative differences with regard to age, sex, stage of arthritis, or preoperative pain or function. All patients were stage II, except one four-corner patient who was stage III. The most significant limitation is that the follow-up averaged 19 months for the PRC group and 28 months for the four-corner group. Typically, these procedures are performed on patients with the hope of decades of postoperative functionality, thus any conclusion based on 2 years of follow-up is limited. Nevertheless, it avoids the selection bias in other comparative studies where patients had one or the other procedure based on surgeon preference.

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