Hand and Upper Extremity Surgery Unit, Lapeyronie Hospital, Montpellier University Medical Center, Av. du Doyen Gaston Giraud 371, 34295 Montpellier, France; Collège des Jeunes Orthopédistes, Rue Boissonade 56, 75014 Paris, France.
Department of Physical Medicine and Rehabilitation, Dijon-Bourgogne University Hospital, Boulevard du Maréchal de Lattre de Tassigny 2, 21000 Dijon, France; InterSyndicale Nationale des Internes, Rue du Fer À Moulin 17, 75005 Paris, France.
Orthop Traumatol Surg Res. 2022 Nov;108(7):103373. doi: 10.1016/j.otsr.2022.103373. Epub 2022 Aug 5.
In posttraumatic wrist arthritis of intermediate severity, two main palliative procedures are used to preserve some mobility in the wrist: proximal row carpectomy (PRC) and scaphoid excision followed by four corner arthrodesis (4CA). Despite satisfactory overall results, the debate continues about which one provides the best results and long-term outcomes, particularly prevention of arthritis progression. Recent comparative studies now provide us with information about mid- and long-term results. The aim of this study was to compare the clinical results, complications, conversion rate to total wrist arthrodesis and progression to osteoarthritis of PRC versus 4CA in the medium and long term.
The null hypothesis was that there is no significant difference between PRC and 4CA in the clinical results, complications, conversion to total wrist arthrodesis and arthritis progression.
A systematic literature review was carried out by following the PRISMA guidelines. Included were studies comparing 4CA and PRC for the treatment of post-traumatic wrist arthritis secondary to scapholunate dissociation (SLAC) and scaphoid nonunion (SNAC) with a mean follow-up of 5 years. A search was performed of the MEDLINE, EMBASE and Cochrane databases that identified 831 articles. After removing 230 duplicates and excluding 595 articles based on their title and/or abstract, and then adding 1 article manually, 7 articles were included in our analysis. Parameters analyzed were range of motion (ROM), pain, grip strength, functional scores, complications, conversion to total wrist arthrodesis, and arthritis progression.
In the 7 articles, 1059 wrists - 582 PRC and 477 4CA - were analyzed with follow-up ranging from 5.2 to 18 years. PRC produced significantly better ROM in flexion (weighted mean difference [WMD]=10.0°; p<0.01) and in ulnar deviation (WMD=8.7°; p<0.01) along with significantly lower complication rates (OR=0.3; p<0.01) and reoperation rates (OR=0.1; p<0.01). There was no significant difference in the conversion rate, grip strength, extension, radial deviation, pain, DASH and PRWE scores. The progression of osteoarthritis could not be analyzed due to lack of data.
This meta-analysis was the first to include recently published mid- and long-term studies comparing PRC and 4CA. The main finding is that PRC is superior overall with better ROM and a lower complication rate. Another important finding was the absence of differences in grip strength and the conversion rate to total wrist arthrodesis. Unfortunately, the lack of systematic studies on arthritis progression leaves this question unanswered. Our findings must be interpreted cautiously because it was impossible to stratify the cases by etiology and osteoarthritis stage.
III; systematic review and meta-analysis.
在中度创伤性腕关节炎中，有两种主要的姑息性手术可用于保留腕关节的一些活动度：近排腕骨切除术（PRC）和舟状骨切除后四角融合术（4CA）。尽管整体结果令人满意，但关于哪种手术提供最佳结果和长期结局，特别是预防关节炎进展，仍存在争议。最近的一些比较性研究为我们提供了有关中期和长期结果的信息。本研究旨在比较 PRC 和 4CA 在中期和长期的临床结果、并发症、向全腕关节融合术的转化率以及关节炎进展方面的差异。
零假设是 PRC 和 4CA 在临床结果、并发症、向全腕关节融合术的转化率以及关节炎进展方面没有显著差异。
按照 PRISMA 指南进行了系统的文献回顾。纳入的研究比较了 4CA 和 PRC 治疗因舟状骨月骨分离（SLAC）和舟状骨非愈合（SNAC）引起的创伤性腕关节炎，平均随访时间为 5 年。在 MEDLINE、EMBASE 和 Cochrane 数据库中进行了检索，共确定了 831 篇文章。在去除 230 篇重复文章并根据标题和/或摘要排除 595 篇文章后，又手动添加了 1 篇文章，最终有 7 篇文章纳入我们的分析。分析的参数包括活动范围（ROM）、疼痛、握力、功能评分、并发症、向全腕关节融合术的转化率以及关节炎进展。
在这 7 篇文章中，共分析了 1059 只腕关节，其中 582 只接受了 PRC 治疗，477 只接受了 4CA 治疗，随访时间从 5.2 年到 18 年不等。PRC 在屈曲（加权均数差值[WMD]=10.0°；p<0.01）和尺侧偏斜（WMD=8.7°；p<0.01）方面的 ROM 显著更好，并发症发生率（比值比[OR]=0.3；p<0.01）和再手术率（OR=0.1；p<0.01）显著更低。但在向全腕关节融合术的转化率、握力、伸展、桡侧偏斜、疼痛、DASH 和 PRWE 评分方面无显著差异。由于缺乏数据，无法分析骨关节炎的进展情况。
这是首次纳入最近发表的比较 PRC 和 4CA 的中期和长期研究的荟萃分析。主要发现是 PRC 总体上更优，ROM 更好，并发症发生率更低。另一个重要发现是握力和向全腕关节融合术的转化率无差异。不幸的是，由于缺乏系统的关节炎进展研究，这个问题仍未得到解答。我们的发现必须谨慎解释，因为无法按病因和骨关节炎阶段对病例进行分层。
III；系统评价和荟萃分析。
