Retrospective Comparison of Capitolunate Arthrodesis Using Headless Compression Screws Versus Nitinol Memory Staples for SLAC and SNAC Wrist: Radiographic, Functional, and Patient-Reported Outcomes

Background Nitinol memory compression staples have been proposed as an effective alternative to compression screws for capitolunate arthrodesis (CLA) for scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrist. The purpose of this study was to compare the clinical outcomes of CLA for SNAC or SLAC wrist treatment using either compression screws or nitinol staples. Methods In all, 47 patients with CLA for SLAC or SNAC wrist with screws or nitinol staples were retrospectively identified. Primary outcome was fusion on radiographs and/or computed tomography. Secondary outcomes were hardware-related complications (HWCs) and other complications, range of motion, grip strength, and patient-reported outcome measures (PROMs), including Visual Analogue Pain scale; Disabilities of the Arm, Shoulder, and Hand score; and patient-rated wrist evaluation. Results Of the 47 eligible patients, 40 (85%) were included: 31 patients in the staple group and 9 patients in the screw group. The average age was 49 (17-80) years. There was an 89% union rate for the screw group and a 97% union rate for the staple group. Two patients had screw backout: one who went onto union after screw removal and the other who went onto nonunion after hardware removal. There were 2 (6.5%) HWCs in the staple group. One patient had staple loosening requiring revision and the other dorsal impingement requiring staple removal after radiographic union. In all subsequent cases, the staples were countersunk with no impingement. No significant differences existed between any additional outcomes. Conclusions We found no differences between nitinol staples and screws for CLA regarding HWCs or PROMs. Nitinol staples may offer additional benefits as a safe and effective alternative to compression screws for wrist fusions.

Outcomes after Scaphoid Excision and Midcarpal Arthrodesis for SNAC and SLAC Wrist Arthritis

Background. Persistent, long-lasting pseudoarthrosis of the scaphoid or scapholunate dissociation results in arthrosis of the radio-scaphoid joint termed scaphoid non-union advanced collapse (SNAC) or scapholunate advanced collapse (SLAC), which causes pain, reduction in wrist movements and weakness of the hand grip. Scaphoid resection followed by „four-corner” midcarpal arthrodesis is a recognized treatment for this condition. Material and methods. The study evaluated the results of treatment of 27 patients with arthrosis of the wrist type SNAC (n = 15) and SLAC (n = 12) after an average of 4 years after surgery (range from 2 to 8 years) Results. The mean numerical pain score for wrist movements was 3.6 (range: 1-5). The mean active range of wrist movement (affected vs healthy hand) was: flexion 27° vs 58° (46%), extension 27° vs 52° (53%), ulnar deviation 16° vs 26° (62%), radial deviation 9° vs 17° (53%), total grip strength 22 kG vs 29 kG (76%), The mean DASH score was 22 (range: 4-36) and the mean Mayo score was 72 (range: 65-80). None of the patients required revision surgery. Of the 16 patients employed prior to the surgery, 10 returned to work after a mean of 4 months of sick leave. Conclusions. 1. The results of the treatment presented in this stu­dy, after a relatively long follow-up period, show a beneficial effect of the surgery on pain intensity and improvement of hand dexterity, at the cost of a mild reduction in wrist movements. 2. It seems that this technique offers good, predicta­ble outcomes and may be recommended for Wa­t­son 2° and 3° SNAC or SLAC wrist arthrosis.

The Epidemiology of Scapholunate Advanced Collapse

Background: Scapholunate advanced collapse (SLAC) is the most common pattern of wrist arthritis. Sparse data exist regarding the SLAC wrist pattern of arthritis. This study aimed to document the epidemiology of advanced SLAC in terms of patients’ sociodemographics and possible association with trauma. Methods: Sixty-one patients with severe SLAC wrist were included. Baseline sociodemographic characteristics were reviewed. To evaluate the relationship to injury, this group of cases was compared with a control group of 61 patients with first carpometacarpal osteoarthritis (CMC OA). The following data were collected for both groups: age, gender, history of traumatic injury, history of manual labor, duration of symptoms, and dominant hand involvement. Pearson chi-square tests for categorical variables and independent samples t test for continuous variables were performed to determine differences between groups. Results: Patients with SLAC wrist were more likely to be male (80.3% vs 31.1%; p<0.001), have a history of a traumatic injury (69.5% vs 25.9%, P < .001), have longer symptom duration (10.3 ± 13.3 vs 3.5 ± 2.5 years, P = .001), be involved in a manual labor job (49.0% vs 20.0%, P = .002), and be younger (53.1 ± 10.4 vs 58.3 ± 9.8; P = .006) compared with patients with CMC OA. There was no difference in dominant hand involvement (49.2% vs 53.3%; P = .571) between the groups. Conclusions: This study identified the characteristics of patients with advanced SLAC wrist. Compared with a control cohort of CMC OA, patients with SLAC wrist were more likely to be male, have a history of a traumatic injury, and be younger.

Die dorsale Bandplastik bei posttraumatischer skapholunärer Dissoziation

ZusammenfassungDie veraltete skapholunäre Dissoziation (SLD) Stadium 2 und 3 kann bei fehlender Therapie zu posttraumatischen Folgeschäden führen. Verschiedene Therapieansätze wie Kapsulodesen, Tenodesen oder andere Verfahren wurden beschrieben. Ziel aller Verfahren ist die Palmarkippung des Kahnbeines mit nachfolgender Arthrose (SLAC-wrist) zu vermeiden. Ziel dieser Studie war die Evaluation der Ergebnisse einer in unserem Haus durchgeführten modifizierten dorsalen Bandplastik bei Patienten mit SLD 2° und 3° im Rahmen eines prospektiven Studiendesigns. Weiterhin sollte ermittelt werden, ob eine Korrelation zwischen klinischen und radiologischen Parametern besteht und ob durch die Operation die Entstehung eines SLAC-wrist verhindert werden kann. In unserer Klinik wurden zwischen 2007 und 2011 29 Patienten mit einer modifizierten dorsalen Bandplastik bei veralteter SLD 2° und 3° operativ versorgt. Im Rahmen der prospektiven Studie konnten 25 Patienten nach durchschnittlich 18 Monaten nachuntersucht werden. Präoperativ wurden die klinischen Parameter ROM, DASH und VAS-Schmerzskala sowie die radiologischen Parameter SL-Distanz in Ruhe und Kraftgriff sowie SL-Winkel erhoben; postoperativ zusätzlich die Greifkraft der operierten und der gesunden Gegenseite, der Mayo Wrist Score (MWS) und die subjektive Gesamtbeurteilung. Die subjektive Gesamtbeurteilung postoperativ lag bei durchschnittlich gut. Die postoperative Beweglichkeit ROM lag bei 83,8 % der ROM der gesunden Gegenseite und verminderte sich im Vergleich zu präoperativ um 11 % (nicht signifikant). Die postoperative Kraft lag bei 85,7 % der Kraft der gesunden Gegenseite. Die VAS-Schmerz-Skala lag postoperativ bei durchschnittlich 2,7, präoperativ bei durchschnittlich 6,7, die Schmerzabnahme war signifikant. Der postoperative DASH-Score lag präoperativ bei 60 und verbesserte sich postoperativ signifikant auf 22,5. Der postoperative MWS lag bei 73. Alle postoperativen radiologischen Parameter waren signifikant verbessert (p < 0,001), lagen aber durchschnittlich noch im pathologischen Bereich. In der Pearson Korrelationsanalyse zeigte sich keine relevanten Korrelationen zwischen den radiologischen Parametern und den klinischen Scores. In 3 Fällen (12 %) waren Folgeoperationen nötig. Die beschriebene modifizierte dorsale Bandplastik bietet eine Therapieoption bei veralteter SLD Grad 2 und 3. Sie lieferte gute klinische Ergebnisse bei geringer Komplikationsrate und kleiner Zugangsmorbidität. Kritisch zu sehen ist die geringe Nachuntersuchungszeit von durchschnittlich 18 Monaten, eine erhöhte SLAC-Rate bei längerer Nachuntersuchungszeit kann nicht ausgeschlossen werden.

Limited Wrist Arthrodesis for Scapholunate Advanced Collapse Wrist: Triangle Fixation for Four-Corner Fusion

Background: Limited wrist arthrodesis with scaphoid excision is a useful treatment for scapholunate advanced collapse (SLAC) of the wrist. Multiple Kirschner wires were originally used for internal fixation of the four carpal bones, however long-term cast immobilization, pin tract infection, and hardware removal are still problematic. We introduce and evaluate the clinical outcomes of an internal fixation technique; triangle fixation for four-corner fusion, using three headless screws, as an alternative to conventional multiple Kirschner wires for the treatment of SLAC wrist. Methods: Five male patients with SLAC wrist secondary to three scaphoid nonunions and two scapholunate dissociations were treated with four-corner fusion using triangle fixation with three Double-threaded Japan screws. The mean age was 59.5 years (35–79 years) and the mean follow-up period was 40 months. After surgery, short arm splints were applied for 3–4 weeks, and then range of motion exercises were initiated. Results: Wrist range of motion and grip strength both improved postoperatively. At the final follow-up evaluation, bone union was completely achieved and satisfactory pain relief was observed in all patients. Conclusions: Compared with the conventional Kirschner wire technique, the present technique shortens the period of splint immobilization due to a strong compression force in a skewed position, does not require pin removal or cause pin tract infections, and provides satisfactory results.

Reproducibility of radiographic classification of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist

The aim of this study was to measure inter- and intra-observer agreement on the radiographic classification of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist. Radiographs of 41 patients with SLAC wrist and 47 patients with SNAC wrist were graded on two separate occasions by four orthopaedic consultants specializing in hand and wrist surgery. Inter-observer agreement was evaluated using the multi-rater kappa value. Landis and Koch criteria were used to assess the level of agreement. Intra-observer agreement was tested by re-grading the radiographs after an interval of 2 to 4 weeks and calculating the weighted kappa value. For SLAC wrist, the inter-observer agreement was moderate (kappa value = 0.59) and intra-observer agreement substantial (kappa value = 0.65). For SNAC wrist, the inter-observer agreement was slight (kappa value = 0.20) and intra-observer agreement was fair (kappa value = 0.29). Radiographic classification of SLAC wrist has moderate reliability and reproducibility, whereas classification of SNAC wrist has limited reliability.