Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Boston, MA.
Department of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
J Hand Surg Am. 2020 Feb;45(2):85-94.e2. doi: 10.1016/j.jhsa.2019.10.023. Epub 2019 Dec 13.
Proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA) are common salvage procedures for the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse. This study aimed to assess rates of reoperation and conversion to wrist fusion and to assess the factors associated with reoperation and conversion to wrist fusion for patients treated with PRC and FCA.
A retrospective chart review was performed evaluating 266 adult patients undergoing PRC or FCA at a single institutional system from 2002 to 2016. Demographic data, patient- and injury-specific data, reoperation and conversion rates, and complications were collected. Potential factors associated with reoperation or wrist fusion were evaluated using a bivariate, followed by a multivariable, analysis.
Reoperation was more commonly performed in FCA (34%) than in PRC (11%) (odds ratio [OR], 3.4; 95% confidence interval [95% CI], 1.7-6.8) and occurred at a shorter postoperative interval. In a multivariable analysis for reoperation, manual labor was associated with reoperation in patients undergoing FCA (OR, 5.4; 95% CI, 1.5-19.1). In those undergoing PRC, anterior interosseous nerve (AIN) and/or posterior interosseous nerve (PIN) neurectomy was associated with a lower rate of reoperation (OR, 0.18; 95% CI, 0.06-0.57). In a multivariable analysis for conversion to wrist arthrodesis, intraoperative AIN and/or PIN neurectomy (OR, 0.18; 95% CI, 0.06-0.57) was associated with a lower rate of conversion to wrist fusion, and smoking (OR, 4.9; 95% CI, 1.8-13.5) was associated with a higher rate of conversion to wrist fusion. In the subanalysis of patients who underwent PRC, only AIN and/or PIN neurectomy was associated with lower rates of conversion to wrist arthrodesis (OR, 0.15; 95% CI, 0.04-0.56).
In our cohort, we observed that AIN and/or PIN neurectomy reduced the risk of reoperation and conversion to wrist arthrodesis after PRC. Smoking increased the odds of conversion to wrist arthrodesis in the combined PRC/FCA cohort; however, it is unclear whether this was due to smoking itself or whether the indications for PRC or FCA were affected, leading to this result.
TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.
近排腕骨切除术（PRC）和四角融合术（FCA）是治疗舟月骨骨不连和月骨周围腕骨塌陷的常用挽救性手术。本研究旨在评估接受 PRC 和 FCA 治疗的患者再次手术和转为腕关节融合的比率，并评估与再次手术和转为腕关节融合相关的因素。
对 2002 年至 2016 年在单一机构系统中接受 PRC 或 FCA 的 266 例成年患者进行回顾性图表审查。收集人口统计学数据、患者和损伤特异性数据、再次手术和转换率以及并发症。使用双变量分析评估与再次手术或腕关节融合相关的潜在因素，然后进行多变量分析。
FCA（34%）再次手术的发生率高于 PRC（11%）（比值比[OR]，3.4；95%置信区间[95%CI]，1.7-6.8），且发生在更短的术后间隔。在 FCA 再次手术的多变量分析中，体力劳动与 FCA 术后再次手术相关（OR，5.4；95%CI，1.5-19.1）。在接受 PRC 的患者中，正中神经（AIN）和/或尺神经（PIN）神经切断术与较低的再次手术率相关（OR，0.18；95%CI，0.06-0.57）。在腕关节融合术的多变量分析中，术中 AIN 和/或 PIN 神经切断术（OR，0.18；95%CI，0.06-0.57）与较低的腕关节融合率相关，而吸烟（OR，4.9；95%CI，1.8-13.5）与较高的腕关节融合率相关。在接受 PRC 的患者的亚分析中，仅 AIN 和/或 PIN 神经切断术与较低的腕关节融合率相关（OR，0.15；95%CI，0.04-0.56）。
在我们的队列中，我们观察到 AIN 和/或 PIN 神经切断术降低了 PRC 后再次手术和转为腕关节融合的风险。吸烟增加了 PRC/FCA 联合队列中转为腕关节融合的几率；然而，尚不清楚这是由于吸烟本身还是由于 PRC 或 FCA 的适应证受到影响，导致了这一结果。
类型的研究/证据水平：预后 IV 级。
