Salvage Procedures for Advanced Carpal Collapse

Abstract

Objective: Salvage procedures for advanced carpal collapse (scapholunate advanced collapse [SLAC], scaphoid nonunion advanced collapse [SNAC]) include mainly four-corner fusion (4-CF) and the proximal row carpectomy (PRC). To facilitate the decision-making procedure between the two operations, we initiated a follow-up study of our salvage procedures. Methods: Between 2008 and 2015, we performed 248 salvage procedures in our Hand Surgical Department. In all, 172 4-CFs and 76 PRCs were carried out, of which we were—so far (study is still going on)—able to follow up retrospectively n = 67 of the 4-CF group (mean follow-up 33 months) and n = 27 of the PRC group (mean follow-up 34 months). We evaluated the pain score (visual analogue scale [VAS] 1-10) in rest and on exertion. Disabilities of the Arm, Shoulder and Hand (DASH) scores were routinely recorded preoperatively, at 6 months and on follow-up exam. Grip strength (Jamar) and range of motion (ROM) were examined on the operated and on the opposite hand. Results: The 4-CF group showed a mean DASH score of 18.9 (preoperative 44.3), and the PRC group 26.5 (preoperative 46.9). Pain was reduced for the 4-CF group to 0.90 VAS (during rest: R) and 3.29 VAS (on exertion: E)—2.87 (R) and 7.5 (E), preoperatively. The PRC group claimed a pain score of 1.36 VAS (R) and 3.96 VAS (E)—1 (R) and 7.0 (E), preoperatively. Jamar Grip was 82.7% compared with the nontreated hand in the 4-CF group and 84.4% in the PRC group. The active ROM for wrist extension and flexion showed in the 4-CF group 87.2° and in the PRC group 97.9° preoperatively, worsened 6 months after the operation in both groups (54.9°, respectively, 58°) and was measured in the follow-up 68.7° in patients with 4-CF and 77.2° in patients with PRC. In addition, 75% would choose the same treatment again and were satisfied in both groups. Conclusions: In our patients, 4-CF and PRC proved to be reliable procedures for advanced carpal collapse. Although there is no significant difference in the outcome, we tend to suggest 4-CF to younger patients due to the anatomic reconstruction and the tendency of a (not significant) better DASH and a lower pain score on exertion. Because of the possibility of osteoarthritis of the lunate fossa, we tend to promote the PRC procedure to patients with less demand or higher age, if not yet progressed to a third stage carpal collapse.