Mir H Ali, MD; Marco Rizzo, MD; Alexander Y Shin, MD and Steven L Moran, MD

Hand, 7(1), 72-78

Abstract: Introduction: Proximal row carpectomy (PRC) is a popular procedure for the treatmet of wrist arthritis; however, the long-term clinical outcomes of this procedure are not well characterized. The purpose of this study was to evaluate long-term results with PRC and to identify factors that may improve clinical outcomes.

Methods: A retrospective study was performed on all patients who underwent proximal rowcarpectomy between January 1967 and January 1992. Medical records and available radiographs were reviewed. The Disabilities of the Arm, Shoulder, and Hand and Patient Rated Wrist Exam, as well as hand motion diagrams were sent to all surviving patients. The contralateral extremity was used as a control. Data was analyzed using multivariant analysis and a Student’s t test.

Results: Eight-one patients underwent PRC. Average age at the time of surgery was 41 years. Average follow-up was 19.8 years. Sixty-one patients responded to the questionnaires. On final follow-up, wrist motion and grip strength were no significantly different from preoperative values. Radiographic follow-up beyond 2 years revealed joint narrowing and arthritic changes within the radiocapitate joint. Forty-six patients (74%) were not satisfied with the results of their surgery due to persistent pain or inability to return previous occupational activities. Fifty-two patients required daily pain medication for wrist pain. Twelve patients hand undergone a wrist arthrodesis.

Conclusions: Post-operative motion and grip strenght valued following PRC appear to remain stable over time. Surgical failure rates with conversion to wrist fusion occured early within the post-operative follow-up. Many patients continued to complain of pain requiring dialy medication and were unable to return to manual labor type jobs. The results of this study suggest that long-term patient satisfaction following PRC can be poor and the surgeon may wish to consider alternative treatment options for younger patients and those with high-demand jobs.

Rudnick B, Goljan P, Pruzansky J, Bachoura A, Jacoby S, Rekant M

The Journal of Hand Surgery, 34(8), 1407-1412, October 2009

Purpose: To compare the clinical outcomes of scaphoid and triquetral excision combined with capitolunate arthrodesis versus 4-corner (capitate, hamate, lunate, triquetrum) intercarpal arthrodesis.

Methods: We retrospectively identified 50 patients with scapholunate advanced collapse wrist changes who had 4-corner arthrodesis. Thirty-four patients were able to return and complete all follow-up evaluations. Patient demographics were similar between the 2 groups. Follow-up evaluation included radiographs, wrist range of motion (flexion-extension, radial-ulnar deviation, and pronation-supination); grip strength; visual analog scale (VAS); and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Complications of nonunion, hardware migration, conversion to wrist arthrodesis or arthroplasty, and pisotriquetral arthritis were recorded.

Results: Sixteen patients had capitolunate arthrodesis, and 18 patients had a 4-corner arthrodesis. There was no statistical difference in radial-ulnar deviation, pronation-supination, grip strength, VAS, or DASH scores between groups. There was a slight increase in flexion-extension in the 4-corner group. There were 2 nonunions in the 4-corner group and none in the capitolunate group. Five patients in the capitolunate group required screw removal secondary to migration. Three patients in the 4-corner group required a subsequent pisiform excision.

Conclusions: Capitolunate arthrodesis compared favorably to 4-corner arthrodesis at an average 3-year follow-up in this series with respect to the range of motion, grip strength, DASH scores, and VAS. Advantages of capitolunate arthrodesis include a lessened need for bone graft harvesting while maintaining a similarly low nonunion rate, easier reduction of the lunate following triquetral excision, and avoiding subsequent symptomatic pisotriquetral arthritis. Screw migration, however, remains a concern with this technique.

Type of study / level of evidence: Therapeutic III.

Isaacs, J., M.D., Yen Shipley, N., M.D., Owen, J., M.D., Patterson Owings, F., B.A., Wayne, J., PhD.

The Journal of Hand Surgery, 33(10), 1765-1769, December 2008

Purpose: Radioscapholuate arthrodesis is an accepted treatment for posttraumatic radiocarpal arthritis that preserves some wrist motion. Good results are dependent on secure fixation while avoiding hardware-related side effects. A small radiolucent countersunk circular plate placed over the radiocarpal joint may offer a low-profile technique for achieving secure fixation of the radioscapholunate joint. The purpose of this study was to compare the biomechanical performance of this circular plate, when applied in this manner, to that of a more conventional fixation technique such as 3.5-mm T-plate.

Methods: Ten pairs of fresh-frozen cadaveric wrists were amputated 7 cm proximal to the radiocarpal joint. One wrist from each pair was fixed with a T-plate (DePuy, Inc., Warsaw, IN), and the contralateral wrist was fixed with a circular plate (Xpode Plate; TriMed, Inc., Valencia, CA). The radius and scaphoid-lunate complex were each rigidly held and mounted into a materials testing machine. Translational forces to mimic extension and flexion movements were applied cyclically for 40 cycles, followed by failure testing in extension.

Results: Cyclic tests revealed no statistically significant differences between the 2 fixation plates although resistance to flexion motion was higher than resistance to extension motion. The average load at failure was no different between the T-plate and circular plate. However, a ratio of the failure loads (T-plate to circular plate) demonstrated a 58% higher load for the circular plate.

Conclusions: A countersunk circular plate provides similar biomechanical performance to the T-Plate for radioscapholuate arthrodesis.

J. Kraisarin, MD; D.G. Dennison, MD; L.J. Berglund, BS; K.N. An, PhD and Alex Y. Shin, MD

 Journal of Hand Surgery (European Volume), 36(7), 560-567. Sept 7, 2011

Abstract: Clinical results following four-corner arthrodesis vary and suggest that nonunion may be related to certain fixation techniques. The purpose of our study was to examine the displacement between the lunate and capitate following a simulated four-corner arthrodesis with the hypothesis that three types of fixation (Kirschner wires, dorsal circular plate, and a locked dorsal circular plate) would allow different amounts of displacement during simulated wrist flexion and extension. Cadaver wrists with simulated four-corner arthrodeses were loaded cyclically either to implant failure or until the lunocapitate displacement exceeded 1mm. The locked dorsal circular plate group was significantly more stable than the dorsal circular plate and K-wires groups (p=0.018 and p=0.006). While these locked dorsal circular plates appear to be very stable our results are limited only to the biomechanical behavior of these fixation techniques within a cadaver model.

Rhee PC, Shin AY

Journal of Hand Surgery (European Volume), 38(7), 767-773. Feb 6, 2013

Abstract: The purpose of this study is to evaluate the rate of union after four-corner arthrodesis with a locking, dorsal circular plate comprised of polyether-ether-ketone. A retrospective review was conducted of all patients who underwent four-corner arthrodesis with a locking, dorsal circular plate at our institution from January 2005 to May 2009. The primary outcome measure was radiographic and clinical union. During the study period, 26 consecutive wrists underwent four-corner arthrodesis with a locking, dorsal circular plate. Twenty-three wrists were included. The mean clinical follow-up was 16 months (range 3-37). Union was achieved in 22 of 23 wrists at a mean time of 3 months (range 1-12). There was no partial union that underwent successful revision arthrodesis. In summary, four-corner fusion with a polyether-ether-ketone locking, dorsal circular plate results in high union rates. The use of a radiolucent plate allows for a more accurate assessment of union with the biomechanical advantages of a fixed angle construct.

Rudnick B, Goljan P, Pruzansky J, Bachoura A, Jacoby S, Rekant M

Technique and Outcomes. Hand, 9(3), 315-321, September 2014

Abstract: Background: Scaphoid excision and four-corner arthrodesis (FCA) is an acceptable motion sparing procedure used to treat wrist arthritis. Recently, a locking dorsal circular plate composed of polyether-ether-ketone has been introduced (Xpode, TriMed, Inc.). The purpose of this study is to assess the efficiancy of this specific plate design with regard to FCA.

Methods: A retrospective chart review of all patients who underwent FCA with an Xpode between January 1, 2008 and December 31, 2012 was conducted. Patients were contacted and asked to return to clinic for clinical and radiographic follow-up. Patient demographics, range of motion, grip strenght, and complications were collected from medical records. Patients completed a patient-rated wrist evaluation (PRWE). A paired t test was used to compare means, and p valued < 0.05 were considered statistically significant.

Results: Twenty-six procedures (24 patients) were identified. One patient required full wrist fusion following the initial procedure. Of the 25 remaining wrists, arthrodesis was sucessfully achieved in 20 (80%). Eleven patient (13 wrists, 52%) returned to clinic for an average follow-up of 28 months. Mean wrist extension improved from 30 to 47*, and flexion decreased from 33 to 23*. Average grip strength was 77% of the uninjured side. The mean PRWE scores for pain and function were 19.7 and 17.1, respectively. Five patients underwent additional operations (two hardware removals, two contracture releases, and one distal radial ulnar join arthroplasty).

Conclusions: FCA with the Xpode yielded reasonable results for pain and function and demonstrated a fusion rate of 80%