With contemporary teaching and advanced-imaging diagnostic protocols, the incidence of advanced wrist arthritis related to scaphoid nonunion and carpal instability seems to be decreasing. When this condition does present, the longstanding debate about treatment pits preserving the carpal bone mass with a 4-corner arthrodesis (FCA) against resecting the proximal row of carpal bones (proximal row carpectomy, or PRC) to provide better motion. At issue have been concerns about the durability and reoperation rates for these two treatment approaches.
In the June 17, 2020 issue of The Journal, Garcia et al. tap into the Veterans Health Administration data warehouse to help clarify this treatment dilemma. The authors identified 1,168 patients with stage-II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse) patterns of wrist arthritis. The outcomes of interest were subsequent conversion to total wrist arthrodesis and secondary surgical procedures after FCA and PRC.
Using propensity score analysis, the authors established matched cohorts of 251 cases of each procedure. The rate of conversion to total wrist arthrodesis was virtually identical in both matched groups, but far fewer patients who underwent FCA avoided a subsequent nonarthrodesis operation compared with those who underwent PRC (83.5% vs 99.7%, respectively).
Based on these findings and the evidence in previously published literature, the authors say, “We believe that PRC may be preferable to FCA in patients with symptomatic stage-II SLAC/SNAC wrist arthritis.” I think this choice should always be the result of shared decision making that itemizes the pros and cons of both procedures—especially taking into account patient preferences related to expected functional outcomes.
Marc Swiontkowski, MD