special aspects of wrist arthritis management for slac and...

41 BulletinoftheHospitalforJointDiseases Volume63,Numbers1&2 2005

Abstract

Although midcarpal wrist arthrodesis is recognized as a standard procedure to treat scapholuate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) of the wrist, little has been reported about patients with bilat-eral involvement and the number, cause, and results of failed cases requiring conversion to total wrist arthrodesis. This study investigated the results of 20 patients with bilateral procedures and of 22 patients who underwent total wrist fusion after failed midcarpal arthrodesis out of an overall group of 907 patients treated by this method during a 12-year period. Of these, 16 bilateral and 20 converted cases were reexamined after an average of 48 months and 42 months, respectively. Patients after bilateral midcarpal arthrodesis expe-rienced a pain reduction by an average of 54% of the preoperative pain values at rest and by 56% at stress on the visual analog scale (scale range: 0 to 100) and from intolerable (3.7) to pain only during stress (1.9) on the verbal scale (scale range: 1 to 4). A mean arc of wrist extension and flexion of 53° on the right and 49° of the left wrist was preserved. The mean DASH score was 45 points and 70% of the patients felt impaired only during certain activities. Total arthrodesis reduced pain in 18 of 20 reexamined wrists by 67% of the previous values after the failed par-tial arthrodesis at rest and by 46% at stress on the visual

analog scale and from intolerable pain (3.7) to pain only during stress (2.1) on the verbal scale. Seven of the 20 reexamined patients noted complete pain relief at rest and two also under stress conditions. The DASH score averaged 39 points. A mean Krimmer score of 46 points and a mean Buck-Gramcko and Lohman evaluation of 6 points represented a satisfactory result. Grip strength of the operated hand averaged 53% of the opposite side. Subjectively, 30% felt impaired only during certain ac-tivities, 55% felt considerably and 15% strongly limited in daily life. However, all but two patients were satis-fied with the secondary total wrist fusion as pain was considerably reduced. Midcarpal arthrodesis reliably reduced pain and pre-served valuable wrist mobility thus improving daily activity and quality of life also in bilateral carpal collapse. In the rare cases when midcarpal arthrodesis failed, total wrist arthrodesis markedly improved the complaints in most patients, but in contrast to other studies complete pain was seldom.

Wrist arthritis precludes adequate hand functionduetostiffnessandpain.Watsonandcoworkersfoundthat95%ofalldegenerativechangesare

centeredaroundthescaphoid,mostlyduetolatesequelaeofscapholunatedissociationorchronicscaphoidnonunion,termedSLAC(scapholunateadvancedcollapse)andSNAC(scaphoidnonunionadvancedcollapse)wrist.1-4Bothpa-thologiesdisrupttheproximalcarpalrowaspartofaringundertensionwhichisessentialfortheequilibriumofthecarpal forces as described by Lichtman and Martin5 andpathologicalcarpalforcetransmissionandinstabilitywillcause destruction of the radioscaphoid followed by themidcarpalarticulationinastagedmanner. Inscaphoidnonunion, thedistal fragment is fixedinamalpositiontotheradiuswhichleadstoprogressive

Special Aspects of Wrist Arthritis Management for SLAC and SNAC Wrists Using Midcarpal ArthrodesisResults of Bilateral Operations and Conversion to Total Arthrodesis

Andreas Gohritz, M.D., Thomas Gohla, M.D., Nicolas Stutz, M.D., Veith Moser, M.D., Hilmar Koch, Hermann Krimmer, M.D., Ph.D., and Ulrich Lanz, M.D., Ph.D.

AndreasGohritz,M.D.,ThomasGohla,M.D.,NicolasStütz,M.D.,VeithMoser,M.D.,HilmarKoch,andUlrichLanz,M.D.,Ph.D.,areattheClinicforHandSurgery,BadNeustadt,Germany.HermannKrimmer,M.D.,Ph.D.,iswiththeClinicforHandSurgery,BadNeustadt,Germany;andtheCenterofHandSurgery,KrankenhausSt.Elisabeth,Ravensburg,Germany.Correspondence:PDDr.med.HermannKrimmer,ZentrumfürHandchirurgie, Krankenhaus St. Elisabeth, St.-Elisabethen-Str.15,D-88212Ravensburg,Germany.

42 Bulletinofthe HospitalforJointDiseases Volume63,Numbers1&2 2005

cartilageabrasionneartheradialstyloid(stageI)andthescaphoidfossauptothelevelofthenonunion(stageII).Untreatedscapholunatedissociationwithahyperflexedpositionofthescaphoidgivesrisetocartilagedegenera-tionbetweenthejointsurfacesofthedorsalradiusandthescaphoid,equivalenttoastageIISNACwrist.Additionalarthrosisof themidcarpalarticular surfacearound theheadofthecapitatecharacterizesstageIII.2,3,6

Historically, most posttraumatic wrist disorders weretreatedbytotalarthrodesiswhichentirelyabolishedwristmotionexcept for forearmrotationandoftencausedsig-nificant functional disability.7,8Theobservation that con-genitalcarpalfusionsorcoalitionsarefrequentlywithoutpain, weakness, or instability encouraged the concept ofintercarpal arthrodesis to eliminate not only the arthriticarticulationsbuttoalsomaintainmobilityintheintactjointsurfaces.Midcarpalarthrodesis,introducedbyWatsonandcoworkersmorethan20yearsago,reliesontheprinciplethatafterfusionofthemidcarpalarticulationsallthewristloadisbornebytheradiolunatejointthatusuallyescapesfromperiscaphoidalarthritisbecauseofthesphericalshapeofitsjointsurfaces.1-3,9

Inourdepartment,midcarpalarthrodesishasbecomeastandardizedtechniquewithexcisionoftheununitedormalrotatedscaphoid,neutralalignmentoftheremainingcarpusbyreducingthedorsalintercalarysegmentinsta-bility(DISI)positionofthelunate,andintentionalfusionof the articulating surfaces of the lunate, triquetrum,capitate,andhamate,termed“four-corner-fusion.”10

Theprocedurehasbeenusedbytheseniorauthor(U.L.)since1987andhasbecomethetreatmentofchoiceformostcasesofpainfulposttraumaticwristarthrosisduetocarpalcollapse(SNACandSLACwrist).6,11-13

The objective of this study was to investigate theresultsofthisprocedureinpatientswithadvancedcar-palcollapseofbothwristsandtoclarifythefrequency,cause,andresultofconversiontototalwristarthrodesis.Atpresent,thereisonlyscarceinformationconcerning

these rarebut importantpatientgroupsasassessedbyobjectiveandsubjectiveoutcomemeasures.

PatientsBetweenMay1992andMay2004atotalof907patientsunderwentmidcarpalwristarthrodesiswithbonegraftingandcompleteexcisionofthescaphoidatourinstitution.

Bilateral Midcarpal ArthrodesisAnevaluationofourcomputerdatabaserevealed20patients(19male,1female)withameanageof53(range:37to70years)whounderwentbilateralprocedures(Table1,Figs.1and2). Theratioofunilateralversusbilateralcaseswas44:1or2.3%.Theintervalbetweenthefirstandsecondpartialwristfusionaveraged25months(range:3to99months).Thefore-mostindicationformidcarpalarthrodesiswasascapholunateadvancedcollapsein34ofthe40wrists(Table2).

Conversion to Total ArthrodesisOfallpatients treatedbyamidcarpalarthrodesis,22(18male,4female)withanaverageageof53years(range:32to79years)requiredsecondarytotalarthrodesis.BetweenthefirstconversiontototalarthrodesisinJune1994andthelastinJune2003,597midcarpalarthrodeseswereperformed.Regardingthetotalnumberof907patientswhounderwentmidcarpalarthodesis,theconversionrateaccountedfor2.4%duringtheentire12-yearstudyperiod. Theprimarymidcarpalarthrodesishadbeen indicatedbyaSLACwristin17patientsandaSNACinthreecases,oneafteranintraarticularradiusfractureandoneresultingfromaperilunatefracturedislocation. Patients with previous midcarpal arthrodesis at otherinstitutionsorduetonon-traumaticorigin,suchaschon-drocalcinosis,wereexcludedfromthestudy.

MethodsInadditiontoareviewofallpatientscharts,16ofthe20 patients with bilateral operations and 18 of the 22

Table 1 PatientswithBilateralMidcarpalFusionandConversionintoTotalWristArthrodesis

BilateralMidcarpalFusion ConvertedMidcarpalFusion

Numberofpatients 20 22 Femaletomaleratio 1:19 4:18 Meanageatfollow-up 53(range,37-70)years 53(32-79)years Follow-uptime 42(range,6-144)months 48(7-150)months

Table 2 IndicationsforBilateralMidcarpalArthrodesis

Indication NumberofPatients

Bilateralscapholunateadvancedcollapse(SLAC) 15 Bilateralscaphoidnonunionadvancedcollapse(SNAC) 1 SNACwristandoppositeSLACwrist 1 UnilateralSLACwristandoppositemidcarpalarthrosis 2 UnilateralSLACwristandoppositeradioscaphoidalarthrosis 1 Overall 20


patientswithconversiontototalarthrodesiswereevalu-atedpre-andpostoperatively.Handandwristfunctionwas assessed clinically and radiographs were takenunderstandardizedconditions.Painwasevaluatedpre-and postoperatively using visual (0 = no pain, 100 =maximal)andverbalanalog(1=nopain,4=intolerablepain)scales.Thefunctionalresultregardingdailyactiv-ityandqualityoflifewasestimatedbythedisabilitiesofarm,shoulder,andhand(DASH)scoreusingpartA(function)andB (symptoms)of thevalidatedGermanversion.14,15Inthisscore0pointsindicatenodisabilityatalland100pointsindicateamaximumofdisability.ThemodifiedMayowristscoreaccordingtoKrimmer16wasusedtoassesstheresultsafterconversiontototalwristarthrodesis.Inthisscoringsystem,0pointsrepresentsamaximumofdisabilityand100points representsanexcellent function with 80 points possible after wristarthrodesis.Furthermore,thetotalwristarthrodeseswereratedaccordingtoBuck-GramckoandLohmann17(9-10=excellent,7-8=good,5-6=satisfactory,>5points=poor).Both ratingsystemsarebasedonacomparisontothecontralateral,unoperatedsideandthereforewere

notusableforbilateralcases.

ResultsBilateral Midcarpal ArthrodesisOfatotalof40midcarpalarthrodeses,onehealedonlyafteradditionaliliacbonegrafting.Fourwristswereconvertedtototalwristarthrodesesafterameantimeof26months(range:8to44months):twoduetononunion,oneafterinfection,andanotherduetotechnicalerror. At a mean follow-up time of 42 months (range: 6 to144months)afterthesecondofthebilateralmidcarpalfu-sions,painwasreducedsignificantlyinbothwriststo46%(17/100)ofthepreoperativevalue(37/100)atrestandto44%(32/100)ofthepreviousintensity(73/100)atstressonthevisualanalogscale,respectively.Thepatientsnotedthatpainhaddiminishedfromintolerable(3.7)topainonlydur-ingstress(1.9)ontheverbalscale.Ausefulaverageactivewristextensionandflexionrangeofmotion(ROM)of53°(maximum:80°)ontherightand49°(maximum:75°)ontheleftwristremained,pro-andsupinationaveraged137°(range:85°to160°)ontherightand138°(range:110°to150°)ontheleftside(Table3).Gripstrengthmeasuredwith

Figure 1Rareoccurrenceofbilateralscaphoidnonunion advanced collapse (SNAC) wrist in a53-year-oldlorrydriverwhorememberedseveralfallsonhisoutstretchedhands.

Figure 2Bilateralscapholunateadvancedcollapse(SLAC)wrist.


astandardizedJamardynamometeraveraged32kg(range:8to54kg)ontherightand31kg(range:6to52kg)onthe left side.Themean totalDASHscorewas45points(range:10to81points),representinganacceptabledegreeofdisability.Fourteenof20(70%)patients felt impairedsubjectivelyonlyregardingcertainactivitiesintheirdailylifeandcouldresumetheiroriginaljobandactivitylevel(Fig.3).

Conversion to Total Wrist ArthrodesisPlatearthrodesisusingadorsalapproachwasused inallcases.Nonunionsrequiredrevisionosteosynthesisandbonegrafting in three patients, one hardware failure and oneinfection occurred and one patient developed ulnocarpal

instabilityaftersubsequenthemiresectionoftheulnaheadbecauseofdistalradioulnarjointarthrosis. Themeantimeintervalbetweenmidcarpalarthrodesiswith complete scaphoid excision and conversion to totalwrist arthrodesis averaged 25 months (range: 3 to 99months). Aradiologicalexplanationforpersistingpainwasfoundin17ofthe22patients.Intenofthesepatients,failurewasretrospectively attributed to technical errors – in all sixcasesofpersistentnonunionandinfourcasesofradiolunatedegeneration thiswasdue to incompletereductionof thelunateorintraarticularpositioningoftheK-wiretip.Intheremainingfivecasestotalarthrodesiswasperformedduetopainpersistencedespiteinconspicuousradiographs(Table4). After conversion to total wrist arthrodesis, pain di-minishedin18of20re-examinedwristsfromanaverageintensityof55/100to18/100(33%)underrestandfromanaveragepainlevelof72/100to46%(35/100)understressconditionsasjudgedbythevisualanalogscaleanddimin-ishedfromanaverageofintolerablepain(3.7)topainonlyduringstrain(2.1)ontheverbalscale. Onepatientwithprimarynonunionnotedthathissymp-tomsremainedunchangeddespitesolidbonyunionofthetotalarthrodesis.Anotherpatientwhohadasimultaneous

Figure 3Radiographof44-year-oldcarpenterafterbilateralmidcarpalarthrodesiswhonotedonlymildpainatstress,feltimpairedonlyduringspecialactivities,andhadaDASHscoreof14points(secondbestoverallresult).

Table 3 PreservedRangeofMotion(ROM)afterBilateralMidcarpalArthrodesis

AverageROM Extension/Flexion Ulnar-/Radialduction Pro-/Supination

Rightwrist 53°(0°-80°)* 35°(0°-50°)* 137°(85°-160°) Leftwrist 49°(0°-75°)* 37°(0°-55°)* 138°(110°-150°) *Fourpatientswithbilateralmidcarpalarthrodesishadunilateralconversionintototalwristarthrodesis

Table 4 IndicationforConversionofMidcarpalintoTotalWristFusion

Radiologicalpicture Number

Radiolunatearthritis 6 Ulnartranslocationofthecarpus 4 Infection 1 Persistentnonunion 6 Unremittingpainwithoutradiologicalcorrelate 5 Overall 22


ulnaheadhemiresectionarthroplastyexperiencedadete-rioratedofhisoverallpainsituationduetoachronicandpainfululnocarpalinstability. However,despiteamarkedoverallpainreduction,only7 of 20 patients (35%) felt entirely pain free at rest andonlytwo(10%)werepainfreealsounderstressconditions.ThemeanDASHscoreaveraged39points(range:11to82points).Gripstrengthoftheoperatedhandaveraged54%(range:16%to100%)andforearmrotation84%(range:56%to100%)comparedtotheoppositeside.ThemeanwristscoreaccordingtoKrimmerreached46points(range:20to70points)ofamaximumof80pointspossibleafterwristarthrodesis.TheevaluationoftheresultafterwristfusionaccordingtoBuck-GramckoandLohmannaveraged6points(range:4to8points)representingasatisfactoryresult. Subjectively,nopatientnotedunimpairedwristfunction,30%feltimpairedonlyduringcertainactivities,55%feltconsiderableand15%stronglimitationsintheiractivitiesofdailyliving,but13of22patientssaidtheycouldreturn

totheirpreviousoccupationoractivitylevel. Retrospectively,allbuttwoofthepatients(90%)weresatisfiedwiththeoutcomeofthetotalwristfusioncomparedtotheprevioussituationafterfailedpartialfusion(Fig.4).

DiscussionDuringthelastdecade,numerousstudieshaveconfirmedthat midcarpal arthrodesis reliably reduces pain, pre-serves useful motion and wrist function, and results inhighpatientsatisfactionwithanacceptablecomplicationrate.6,10-13,16,18-20

Despite that this procedure is today recognized as aclassic operation, certain aspects remained unclear. Isthe procedure applicable also in patients with bilateralinvolvement?Howfrequentisfailureandifitoccurs,doesconversiontototalarthrodesisreallyimprovethesituationofthesepatients?Toinvestigatetheseissuesweundertookthepresentreviewofourownresultswithaspecialregardtothesepatientgroups.

Figure 4A,Midcarpalarthrodesisforscapholunateadvancedcollapse.B,Treatmentfailureduetopersistentpainasaresultofnon-union.C,Situationafterconversionintocompletewristarthrodesiswhichresultedinalmostcompletepainreliefatrest(10/100)andonlymildsymptomsduringstress(25/100).

Table 5 ComparisonofWristFunctionafterMidcarpalArthrodesisandTotalWristArthrodesisRegardingtheDASHScore

Procedure Numberofownpatients Average (Authorsandyearofstudy) (follow-uptime) DASHscore

Unilateralmidcarpalwristarthrodesis 37(8.1years) 24 (Kitzingeretal.,2003)26 Conversionofmidcarpaltototalwristarthrodesis 22(4.2years) 39 (Presentstudy,2004) Bilateralmidcarpalarthrodesis 20(3.5years) 45 (Presentstudy,2004) Bilateraltotalarthrodesis 10(5.5years) 55 (Gohritzetal.,2004)28


Bilateralcasesareonlyveryscarcelydocumented incontrasttounilateralmidcarpalfusion,mostprobablyduetoitsrareoccurrence(onlyaround2%ofthepatientsinthislargepatientcohortfromasingleinstitution). However,bilateralscapholunateadvancedcollapsebe-ingtheforemostetiologyinourpatientgroup,isnotanewpathology,asfindingsofbilateralSLACwristonaprehis-toricskeletonfromHassi-el-Abiodsite inMalianSaharaprovidepaleopathologicalevidenceoftheexistenceofthisdisease7,000yearsago.21Characteristicfeatureslikebilat-eralstyloidandposteriorosteophytesof thedistal radiusrimandivorysclerosisoftheradioscaphoidalsurfacesinaprehistoric skeletonaredescribedand the investigatorsalsomentionfivepatientsseenintheirunitduringaperiodoftenyearswhoallhadahistoryofrepeatedmicrotraumaduetointensivesportormanualworkactivity.Regrettably,the treatment and clinical course of these patients is notspecifiedand,asidefromthisreview,littlehasappearedintheliteratureconcerningbilateralcarpalcollapse.20,22-24OnlyAshmeadandcolleagues25mentionfourbilateralcasesoutoftheir100patientsthatcouldreturntotheiroriginaloc-cupationafterSLACwristsalvage. ThemeanDASHscoreof45pointsinourpatientsafterbilateralmidcarpalfusionrepresentsanacceptabledegreeofimpairment,thoughitwashigherthanthefiguresweknowfrom unilateral cases.10,16,26On the other hand, accordingtothisstudy,bilateralpartialarthrodesisdidnotinterferewithdailylifeactivitiesinthemajorityofpatients,butledtoasignificantrehabilitationofupperextremityfunctioncomparedtotheprevioussituationascanbeseenfromthesubjectiveevaluation. Themostimportantreasonforthismaybetheconsider-ablepainreductioninallbilateralpatients;thereductionofpainrestoredpatients’gripstrengthandthusmostactivi-tiesofdailylivingbecamefeasibleagain.Additionallythepreserved wrist motion in these patients is an advantageover total arthrodesis. Furthermore, a great capacity tocompensatelostwristmobilitythroughelbowandshouldermovementscanbeobservedinthesepatients.Thiswasevenmoreastonishinginourrecentstudy28thatalsoinvolvedtenbilateraltotalwristarthrodesis,thusconfirmingtheresultsofRayanandcoworkers29whoprovedthat,inabsenceofpain,evenbilateraltotalwristfusionislessdisablingthanformerlybelieved. Total wrist fusion is commonly recommended when

Table 6 ConversionRatesofMidcarpalintoTotalWristArthrodesisasReportedintheLiterature

Authors Meanfollow-up Midcarpal Conversions Conversion Meantime (yearofpublication) time(years) fusions rate interval

Watsonetal,19999 4.3 252 1 0.4% notspecified Sauerbieretal,200027 2.1 43 2 5% notspecified Kitzingeretal,200326 8.1 108 7 7% 29months Wyricketal,199432 2.3 17 3 17% notspecified SiegelandRuby,199633 5.5 14 4 28% 29months Presentstudy,2004 3.5 597 22 4% 25months

painpersistsafteracorrectlyperformedmidcarpalarthrod-esis.16,17,30Thistrade-offtrustsintheassumptionthatatotalsacrificeofmotionwillreliablyleadtocompletepainrelief.Thishasbeenamatterofcontroversy.7,8Besides,therewasalackofobjectiveinformationontheexactindicationandtimingoftotalwristfusioninthisspecificindication. Shin31compiledtheresultsof8differentseriescompris-ing431four-cornerfusionsandfoundonly7failuresthatledtototalarthrodesis,givinganoverallincidenceof2%.Thiscontraststoothersmallerseriesthatindicateconver-sionratesofupto17%reportedbyWyrickandassociates32oreven28%intheseriesreportedbySiegelandRuby,33whereasWatsonandcolleagues9performed252SLACre-constructionsandwithin4.3yearsonlyhadoneconversionintototalwristarthrodesisaccountingforapercentageof0.4%.Wereportafailurerateof2.4%after4yearsinaverylargepatient group froma singlehospital.Similarly lowratesoffailurewerereportedbySauerbierandassociates,27Kitzingerandcoworkers,26andKrakauerandcolleagues4withanincidenceof5%after2.1years,7%after8.1years,and12%after4.1years,respectively.Ofcourse,wecannotruleoutthepossibilitythatsomeofourpatientscontinuedtreatmentelsewherewhenpainpersistedornewlyoccurredaftermidcarpalarthrodesisandthereforeourpercentageoffailuremightbeslightlyhigherthanweareabletoreport.ThedramaticincreaseofmidcarpalarthrodesisduringtherecentyearsperformedatourunitasastandardprocedureforSLACandSNACwristarthritisprecludedourcontactingallpatients,butmanyofthepatientshavebeenreevaluatedinthemid-andlong-termasreportedinseveralstudiesfromourgroup.6,10-13,26

Regarding the cause for conversion, most previouslymentioned investigators described unremitting pain, butdidnotclarify theunderlyingpathology.In thisstudy, in17of22 cases, apossible explanation couldbedetectedthroughtheradiologicalreevaluation.Twelvepatientshadeither progressive radiolunate degeneration or persistingnonunion,fourpatientshadanincompleterepositionofthelunatewithapersistingDISIpositionofthelunateoranulnartranslocationofthecarpus.Inretrospect, it isnotalwayseasytodecidewhetherthesechangesresultedfromnaturalprogressionofthecarpalcollapse,awrongindication,oratechnicalerroronthepartofthesurgeon.Acriticalanalysisofourfailedproceduresindicatedthattechnicalerrorswerethe cause inoverhalf of these cases–not a progressive


long-termdegenerationoftheintercarpalarthrodesis. Topreventfailureduetofalseindicationsandtechnicalerrors,advanceddegenerationoftheradiolunatejointandanunreducibleulnartranslocationofthecarpusshouldbeseenasanabsolutecontraindicationthatindicatessevereinstabil-ityoftheextrinsicligaments.Thisimpedesaphysiologicalmovementofthelunateinthefossalunataandthisincongru-encepromotedbyincreasedloadbearingwillfinallyleadtoacompletedestructionofthejoint.23Topreventradioluntaedegeneration,thepositionofthetransfixingK-wiresshouldalsobecheckedthoroughlytoensurethatthewiretipsdonotpenetrate into the joint.Nonunion, themost frequentcauseoffailure,maybepreventablebyexposingenoughcancellousboneduringtheresectionofthejointsurfaces. Radiographically, progressive changes of the fossalunataoranulnarshiftoftheremainingcarpusmayoccuroverthelong-termasobservedrecentlybyKitzingerandcolleagues,26 but these changes did not correlate with aclinicaldeteriorationofthepostoperativeresult. The most important benefit of total arthrodesis wasamarkedreductionofpain.This, togetherwithanonlyslightlyimpairedpronation-supinationandasatisfactorygripstrengthof54%ofthecontralateralside, improvedtheprevious situation inallbut twoofourpatientsandreestablishedusefulhandfunction.Thisshouldnotbeliethat subjectively, 55% of our patients felt considerablyand15%stronglylimitedintheirdailylifeactivitiesaftersalvagingafailedmidcarpalarthrodesis.Wesharetheex-perienceofSauerbierandassociates8whohadcomparableobjectiveresultsintheirserieswithameanKrimmerwristscoreof50.5pointsandanoverallDASHscoreof51.4points.Even80%oftheirpatientscomplainedoffunctionaldeficits,but70%couldadapttotherequirementsoftheirprofessionallifeandresumepreviousoccupation.Theseinvestigatorsreportedthatcompletereliefofsymptomswasonlyachievedin5%.Thiscontrastswithotherstudies;forexample,WeissandHastingsreportedthatnoneoftheir28posttraumaticpatientsfeltpainorinstabilityaftertotalwristarthrodesis.ThisstudyrevealedsimilarresultsasintheseriesofKalbandcoworkers7whoreportedthatonly3 of 35 patients were entirely pain free postoperativelyand corresponds to the findings of Bolano and Green34whoreportedthat,althoughwristarthrodesissignificantlyreducedpreoperativepain,twothirdsoftheirpatientsstillhavemildtomoderatepainwithheavyworkdespiteafu-sion.

ConclusionBasedonourexperiencewithmorethan900cases,mid-carpalarthrodesiswithcompleteexcisionofthescaphoidappearstobeareliablemethodformanagingwristarthritisduetoscapholunatedissociation(SLACwrist)andscaph-oidnonunion(SNAC).Itmarkedlyreducespainandsparesvaluable wrist motion enabling a satisfactory outcomeconcerning the activities of daily living.The procedure

workswellalsoincasesofbilateralcarpalcollapse. Thetreatmentfailurerateisverylow.Iftechnicalerrors,hardwareproblems,progressivedegenerationpatterns,orunremittingpainoccur, totalarthrodesisasamethodoflastresortmayimprovethecomplaintsinmostpatients.However, in contrast to the widely accepted hypothesis“nomotion,nopain,”anentirelyasymptomaticwristmayresultonlyinfewcases.

References1. WatsonHK,GoodmanML,JohnsonTR:Limitedwristar-

throdesis.PartII:Intercarpalandradiocarpalcombinations.JHandSurgAm1981;6(3):223-33.

2. WatsonHK,BalletFL:TheSLACwrist:Scapholunatead-vancedcollapsepatternofdegenerativearthritis.JHandSurgAm1984;9:358-65.

3. WatsonHK,RyuJ:Evolutionofarthritisofthewrist.ClinOrthopRelRes1986;202:57-67.

4. Krakauer JD, BishopAT, Cooney WP: Surgical treat-mentofscapholunateadvancedcollapse.JHandSurgAm1994;19:751-9.

5. LichtmanRL,MartinRA:Introductiontothecarpalinsta-bilities.In:LichtmanRL(ed):The Wrist and its Disorders.Philadelphia:WBSaunders,1998,pp.244-250.

6. KrimmerH,LanzU:DerposttraumatischekarpaleKollaps–VerlaufundTherapiekonzept.Unfallchirurg2000;103:260-6.

7. KalbK,LudwigA,TauscherA,etal.:BehandlungsergebnissenachoperativerHandgelenkversteifung.HandchirMikrochirPlastChir1999;31:253-9.

8. Sauerbier M, Kluge S, Bickert B, et al: Subjective andobjective outcomes after total wrist arthrodesis in patientswithradiocarpalarthrosisorKienböck’sdisease.ChirMain2000;19:223-31.

9. WatsonHK,WeinzweigJ,GuideraPM,etal:Onethousandintercarpalarthrodeses.JHandSurgBr1999;24:307-15.

10. KrimmerH,LanzU:MediokarpaleTeilarthrodesedesHand-gelenks.OperatOrthopTraumatol1996;8A:175-84.

11. KrimmerH,SauerbierM,Vispo-SearaJL,etal:Fortgeschrit-tener karpaler Kollaps (SLAC-Wrist) bei Skaphoidpseu-darthrose.Therapiekonzept: mediokarpaleTeilarthrodese.HandchirMikrochirPlastChir1992;24(4):191-8.

12. Krimmer H, Krapohl B, Sauerbier M, et al: Der posttrau-matischekarpaleKollaps(SLAC-undSNAC-wrist)–Sta-dieneinteilungundtherapeutischeMöglichkeiten.HandchirMikrochirPlastChir1997;29:228-33.

13. LanzU,KrimmerH,SauerbierM:Advancedcarpalcollapse:Treatmentbylimitedwristfusion.In:BüchlerU(ed):Wrist Instability.London:MartinDunitz,1996,pp.139-145.

14. GermannG,WindG,HarthA:DerDASH-Fragebogen-einneues Instrumentzur“outcome”EvaluationanderoberenExtremität.HandchirMikrochirPlastChir1999;31:149-52.

15. JesterA,HarthA,WindJ,etal:DisabilitiesofArm,Shoulderand Hand (DASH) questionnaire: Determining functionalactivityprofilesinpatientswithupperextremitydisorders.JHandSurgBr2005;30:23-8.

16. Krimmer H, Wiemer P, Kalb K: VergleichendeErgebnisbewertung des Handgelenks – mediokarpaleTeilarthrodeseundTotalarthrodese.HandchirMikrochirPlast


Chir2000;32:369-74.17. Buck-GramckoD,LohmannH:Compressionarthrodesisof

thewrist.In:TubianaR(ed):The Hand Vol.2.Philadelphia:WBSaunders,pp.723-729.

18. MinamiA,KatoH,IwasakiN,etal:Limitedwristfusion:Comparisonofresults22and89monthsaftersurgery.JHandSurgAm1999;24(1):133-7.

19. Tomaino MM, Miller RJ, Cole I, et al: Scapholunate ad-vancedcollapsewrist:Proximalrowcarpectomyorlimitedwristarthrodesiswithscaphoidexcision?JHandSurgAm1994;19:134-42.

20. Tünnerhoff HG, Haussmann P: Komplikationen nach me-diokarpaler Teilarthrodese-Versuch einer Fehleranalyse.HandchirMikrochirPlastChir2003;35:288-98.

21. MasmejeanE,DufourO,TouamC,etal:SLACwristbilatéral:uneentitéàpart.Àproposd’uncaspréhistoriquede7000ans.AnnChirMain1997;16(3):207-14.

22. CrittendenJJ,JonesDM,SantarelliAG:Bilateralrotationaldislocationofthecarpalnavicular.Radiology1970;94:629-30.

23. Vance RH, Gelberman RH, Braun RM: Chronic bilateralscapholunatedissociationwithout symptoms. JHandSurgAm1979;4:178-80.

24. WittJD,McCulloughCJ:Bilateralspontaneousscapho-lunatesubluxationtreatedbylimitedcarpalfusion.JHandSurgBr1990;15(4):460-2.

25. AshmeadD,WatsonHK,DamonC,etal:Scapholunatead-vancedcollapsewristsalvage.JHandSurgAm1995;19:741-50.

26. KitzingerHB,LöwS,KarleB,etal:DerposttraumatischekarpaleKollaps-längerfristigerVerlaufnachmediokarpalerTeilarthrodese.HandchirMikrochirPlastChir2003;35:282-7.

27. SauerbierM,TränkleM,LinsnerG,etal:Midcarpalarthrod-esiswithcompletescaphoidexcisionandinterpositionbonegraft in the treatmentofadvancedcarpalcollapse (SNAC/SLACwrist):Operativetechniqueandoutcomeassessment.JHandSurgBr2000;25:341-5.

28. GohritzA, et al:Functional resultsof total fusionofbothwrists:Analysisof10cases.JHandSurgBr2005;30(Suppl1):38.

29. RayanGM,BrentlingerA,PurnellD,etal:Functionalas-sessment of bilateral wrist arthrodeses. J Hand SurgAm1987;12:1020-4.

30. WeissAP,HastingsH2nd:Wristarthrodesisfor traumaticconditions:Astudyofplateandlocalbonegraftapplication.JHandSurgAm1995;20(1):50-6.

31. ShinAY:Four-cornerarthrodesis.Journalof theAmericanSocietyofSurgeryoftheHand2001;1:93-111.

32. WyrickJD,SternPJ,KiefhaberTR:Motion-preservingpro-ceduresinthetreatmentofscapholunateadvancedcollapsewrist:Proximalrowcarpectomyversusfour-cornerarthrod-esis.JHandSurgAm1995;20(6):965-70.

33. SiegelJM,RubyLK:Midcarpalarthrodesis.JHandSurgAm1996;21(2):179-82.

34. BolanoLE,GreenDP:Wristarthrodesis inpost-traumaticarthritis:A comparison of two methods. J Hand SurgAm1993;18(5):786-91.

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