Neurectomy During Wrist Salvage Surgery is Associated with Lower Rates of Revision to Wrist Fusion

Proximal row carpectomy (PRC) and four-corner arthrodesis (FCA) are options for salvage treatment of osteoarthritis of the wrist after scapholunate dissociation or scaphoid nonunion. Historically, PRC and FCA have comparable outcomes, but short-term conversion to wrist arthrodesis (fusion) is more common after FCA. Most studies of these procedures have involved relatively small cohorts, so there are limited insights into what factors are associated with conversion.

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Neal C. Chen, MD, chief of the Hand and Arm Center in the Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues conducted a retrospective chart review on 266 adults who underwent PRC or FCA. In the February 2020 lead article of The Journal of Hand Surgery, they report that intraoperative anterior and/or posterior interosseous nerve (AIN/PIN) neurectomy was associated with less risk of conversion to wrist arthrodesis, while smoking was associated with higher risk.

Study Subjects

The cohort included 186 patients who underwent PRC and 80 who underwent FCA between January 1, 2002, and December 31, 2016, at one of five urban hospitals in the northeastern U.S. The median age was 54 and 55, and the median follow-up times were 8.1 and 7 years for the PRC and the FCA groups respectively.

Complications

Postoperative complications were significantly more common in the FCA group than the PRC group (16% vs. 5%; P < .05):

• Nonunion (FCA, n=2)
• Hardware complications (FCA, n=8)
• Infection (PRC, n = 7; FCA, n=1)
• Pisotriquetral arthritis (PRC, n=1; FCA, n=2)
• Ulnocarpal impingement (PRC, n=1)

Reoperation

For reoperation, the researchers found:

• The risk of reoperation was three times higher in the FCA group than in the PRC group (34% vs. 11%; OR, 3.4; 95% CI, 1.7–6.8)
• Most late reoperations were for wrist arthrodesis (PRC, n = 17; FCA, n = 2) or hardware removal (FCA, n = 19)
• One patient in the FCA group had a hardware removal operation followed by conversion to wrist arthrodesis

In multivariable analysis, manual labor was associated with a fivefold higher risk of reoperation in patients undergoing FCA (OR, 5.4; 95% CI, 1.5–19.1). In multivariable subanalysis restricted to the PRC group, AIN/PIN neurectomy was associated with an 82% lower rate of reoperation (OR, 0.18; 95% CI, 0.06–0.57).

Conversion to Wrist Arthrodesis

The analysis found:

• The median time for conversion to wrist arthrodesis was 16 months in the PRC group, versus 32 months in the FCA group
• 55% of all arthrodeses were performed at least 18 months after the index procedure
• The primary indications for arthrodesis were persistent pain (PRC, n=16; FCA, n=3) and infection (PRC, n=1)

In multivariable analysis, AIN/PIN neurectomy was associated with 82% lower odds of conversion (OR, 0.18; 95% CI, 0.06–0.57). Smoking was associated with fivefold higher odds (OR, 4.9; 95% CI, 1.8–13.5).

Applying the Findings to Practice

Denervation procedures of the wrist performed at the time of PRC and FCA was associated with lower rates of conversion to wrist arthrodesis.

The effect of smoking is less clear-cut. Significantly more smokers underwent PRC than FCA (22% vs. 6%; P < .05), which may have increased the reoperation rate in the PRC group and decreased it in the FCA group. Counseling about smoking cessation is recommended before these procedures. In addition, smoking is related to less effective coping strategies, which may affect whether patients decide to pursue reoperation.

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