Scapholunate Advanced Collapse Wrist: Proximal Row Carpectomy versus Four-Corner Arthrodesis Belgian Hand Group 17 november 2007 W. Vanhove MD J. De Vil

Scapholunate Advanced Collapse Wrist:

Proximal Row Carpectomyversus

Four-Corner Arthrodesis

Belgian Hand Group 17 november 2007

W. Vanhove MDJ. De Vil MD – P. Vanseymortier MD – M. Mombert MD

Department of Orthopaedic Surgery UGent

Scapholunate Advanced Collapse

Traumatic scapholunate dissociation



Terry Thomas Sign



Rotatory subluxation of scaphoid – Dorsal Intercalated Segment Instability (DISI)


SLAC stage 1


SLAC stage 2


SLAC stage 3

Surgical options

Four-Corner Arthrodesis (SLAC 2-3):

Surgical options

Four–Corner Arthrodesis:

Surgical options

Proximal Row Carpectomy (SLAC 2):

Surgical options

Proximal Row Carpectomy :

Literature (Cohen et al.)

Mobility 4CA 15° more rad dev (P<0,05)

Pain score end F/E worse for PRC

Function VAS = Jebsen: picking up small objects better following PRC

Literature

Surgical options Four-Corner Arthrodesis Proximal Row Carpectomy

Mobility Force

Socio economic impact.

}

Unknown in literature}

No difference

Our Study

Mobility Force Complications Functionality

Economic and insurance issues

General Data

30 patients Surgeon Dr W Vanhove Time of Surgery 1998 → 2004

Four-Corner Arthrodesis 15 Proximal Row Carpectomy 15

General Data

Age: Four-Corner Arthrodesis: 38 y (21-49) Proximal Row Carpectomy: 45 y (29-62)

Follow up

40m

Sex ratio Four-Corner Arthrodesis: 10 ♂ 5 ♀ Proximal Row Carpectomy: 8 ♂ 7 ♀

Preoperative data

Demographics No Significant difference

Mobility No Significant difference

Job related data

Ergos Job Description program

Preoperative physical workload

Ergos Job Description programma

4 CA PRC Total

workload Very light 1 1 2

light 2 4 6

average 8 7 15

Heavy labour

2 2 4

Total 13 14 27

Preoperative data

Demographics No Significant difference

Mobility No Significant difference

Job related data

Workload No Significant difference

Postoperative evaluation:

Mobility Force Complications Functionality Economic and insurance issues

0

5

10

15

20

25

30

35

40

45

50

U/R arc preop U/R arc postop

4CA PRC

Mobility

64

66

68

70

72

74

76

78

80

F/E arc preop F/E arc postop

4CA PRC

U/R deviation arc

F/E arc

Force

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Force 1 Force 2 Force 3 Force 4 Force 5

Four-cornerarthrodesisProximal rowcarpectomy

0

5

10

15

20

25

30

Force 1 Force 2 Force 3 Force 4 Force 5

Four-cornerarthrodesisProximal rowcarpectomy

% of contralateral side Absolute value (KgF)

Position 1 => 5 Position 1 => 5

Literature

Studies comparing 4CA & PRC

4 CA Krakauer J et al (Force)

PRC Wyrick J et al

Tomaino M et al ( mobility)Krakauer J et al (mobility)

4CA=PRC

Cohen M et alTomaino M et al ( Force)

Lucas B et al

Non conclusive

0

2

4

6

8

10

12

14

16

4CA PRC

normal

CTS

Complications

Carpal Tunnel Syndrome

Complications

Carpal Tunnel Syndrome

Theories

4CA bonegraft in carpal tunnel

immobilisation (subclinical CRPS, less nervegliding)

PRC shorter carpal tunnel is less length to compress?

EAROM = nerve gliding

Any suggestions ?

General functional scores

Cooney Score (less is worse) Four-Corner Arthrodesis: 61 Proximal Row Carpectomy: 67

=> No Significant difference

DASH Score (more is worse) Four-Corner Arthrodesis: 22 Proximal Row Carpectomy: 10

=> No Significant Difference

Economic & Insurance issues

Hospital stay physiotherapy Back to Work Postoperative working capacity

Hospitalisation

Days in

hospital

4 CA PRC

0

2

4

6

8

Physiotherapy

Number of

sessions

4 CA PRC

0

20

40

60

80

Time Off Work

weeks

4 CA PRC

0

20

40

60

80

100

Return to work following 4CA

200

13

21

4

8

preop postop

same work

adaptations at work

other work

non active

Return to work following PRC

100

14

101

13

preop postop

same work

adaptations at work

other work

non active

Conclusion

Four-Corner Arthrodesis Proximal Row Carpectomy

ProPhysiological

Short hospital stay

Technically easierEarly mobility

Few complicationsVery short hospital stayFaster to resume work

Few adaptations at work

Contra

Technically demandingImmobilisation

Complications (nonunion, CTS,…)

Slower to resume workMore adaptations at work

Non-physiologicalStage III

No difference Mobility, Force, Function

Conclusion


ProPhysiological

Short hospital stay




Contra






Conclusion


ProPhysiological

Short hospital stay




Contra






Conclusion

Stage 3 PRC

What have we learned ?

We no longer perform 4CA

What do we do with SLAC 3

wrists in young patients doing heavy labour?

variation of 3CA using shortening capitolunate fusion

(Herbert screw, no bonegraft, 3 weeks casting, preserves original radiolunate joint, avoids ulnocarpal impingement)

W. Vanhove MD

J. Devil MD

P. Vanseymortier MD

M. Mombert MD

Dept. of orthopaedic surgery

University Hospital Gent

Invaliditeit (fys AO) A:

Art. 150 : beperkingen van de bewegingen der radiocarpale en mediocarpale gewrichten

Flexie/Extensie: Radio/ulnaire deviatie

Niet apart Als gelijklopend beschouwd

Tabel III PRC: F/E : 39°/0°/40° = 4 + 2/2 = 5% 4CA: F/E : 45°/0°/31° = 7 + 1/2 = 7.5%

Invaliditeit (fys AO) B:

Art. 150 : Bewegingsbeperking F/E Tabel III

PRC: F/E : 39°/0°/40° = 4 + 2/2 = 5% 4CA: F/E : 45°/0°/31° = 7 + 1/2 = 7.5%

Art. 153 : “Uitgesproken krachtsvermindering” Op basis van amytrofie of EMG

+ 1 à 5%

Art. 154 : Restpijn + 1 à 10%

Art 153 & 154 : niet combineren

Documents

Scapholunate Advanced Collapse Wrist: Proximal Row Carpectomy versus Four-Corner Arthrodesis Belgian Hand Group 17 november 2007 W. Vanhove MD J. De Vil