Garcia Brittany N, Lu Chao-Chin, Stephens Andrew R, Kazmers Nikolas H, Chen Wei, Leng Jianwei, Li Liang, Sauer Brian C, Tyser Andrew R
Department of Orthopaedic Surgery, University of Utah Hospital, Salt Lake City, Utah.
HSR&D IDEAS Center, Salt Lake City George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.
J Bone Joint Surg Am. 2020 Jun 17;102(12):1050-1058. doi: 10.2106/JBJS.19.00965.
For stage-II scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) patterns of wrist arthritis, the optimal method of surgical treatment remains unclear. Previous literature has demonstrated similar clinical outcomes between proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA), making the risk of reoperation a focus of particular interest. In the present study, the primary null hypothesis was that there would be no difference in the rate of conversion to total wrist arthrodesis between PRC and FCA. Additionally, we hypothesized that the rate of secondary surgical procedures would be similar between the 2 procedures.
The national Veterans Health Administration Corporate Data Warehouse was utilized to identify 2,449 patients who underwent either PRC or FCA between 1992 and 2016. With use of operative reports to identify the arthritis pattern, only cases of stage-II SLAC/SNAC were included. All complications and subsequent surgical procedures were confirmed by manual chart review. Propensity score analyses with matching weights were utilized to balance the PRC and FCA cohorts. The rates of conversion to wrist arthrodesis and secondary surgical procedures were calculated.
Of the 1,168 patients with stage-II SLAC/SNAC arthritis, 933 wrists underwent PRC and 257 wrists underwent FCA. Ten-year survival free of total wrist arthrodesis in the matching PRC (251 procedures) and FCA (251 procedures) cohorts was 94.3% (95% confidence interval [CI], 92.3% to 96.3%) and 94.1% (95% CI, 90.8% to 97.4%), respectively. Survival free of a secondary surgical procedure other than wrist arthrodesis was 99.7% (95% CI, 99.3% to 100.0%) for PRC and 83.5% (95% CI, 78.2% to 88.8%) for FCA.
PRC and FCA demonstrated similarly low rates of conversion to total wrist arthrodesis. In contrast, the rate of secondary surgical procedures following FCA was significantly higher compared with PRC. Given the historically similar clinical outcomes between PRC and FCA, the results of the present study show that PRC may be a preferable treatment for stage-II SLAC/SNAC wrist arthritis.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
对于腕关节关节炎的II期舟月骨高级塌陷（SLAC）和舟骨不愈合高级塌陷（SNAC）模式，最佳手术治疗方法仍不明确。既往文献表明，近端排腕骨切除术（PRC）和四角融合术（FCA）的临床结果相似，这使得再次手术的风险成为特别关注的焦点。在本研究中，主要无效假设是PRC和FCA转换为全腕关节融合术的发生率无差异。此外，我们假设这两种手术的二次手术率相似。
利用国家退伍军人健康管理局企业数据仓库，识别出1992年至2016年间接受PRC或FCA手术的2449例患者。通过手术报告确定关节炎模式，仅纳入II期SLAC/SNAC病例。所有并发症及后续手术均通过人工病历审查确认。采用倾向评分分析及匹配权重来平衡PRC和FCA队列。计算转换为腕关节融合术和二次手术的发生率。
在1168例II期SLAC/SNAC关节炎患者中，933例腕关节接受了PRC手术，257例腕关节接受了FCA手术。匹配的PRC队列（251例手术）和FCA队列（251例手术）中，10年无全腕关节融合术生存率分别为94.3%（95%置信区间[CI]，92.3%至96.3%）和94.1%（95%CI，90.8%至97.4%）。PRC组无腕关节融合术以外的二次手术生存率为99.7%（95%CI，99.3%至100.0%），FCA组为83.5%（95%CI，78.2%至88.8%）。
PRC和FCA转换为全腕关节融合术的发生率同样较低。相比之下，FCA后的二次手术率明显高于PRC。鉴于PRC和FCA在历史上临床结果相似，本研究结果表明，PRC可能是II期SLAC/SNAC腕关节关节炎的更优治疗方法。
治疗性III级。有关证据水平的完整描述，请参阅作者指南。
