SCIENTIFIC ARTICLE
Distal Scaphoid Resection for Degenerative Arthritis Secondary to Scaphoid Nonunion: A 20-Year Experience Matthew M. Malerich, MD, Louis W. Catalano III, MD, Zachary D. Weidner, MD, Michael C. Vance, MD, Claire M. Eden, BA, Richard G. Eaton, MD
Purpose To evaluate the long-term results of distal scaphoid excision for degenerative arthritis secondary to scaphoid nonunion and compare them with our original results published in 1999. Methods Nineteen patients who were treated by distal scaphoid resection arthroplasty from 1987 through 2010 were included. The mean follow-up was 15 years (range, 10e25 y) vs 4 years in the previous study. Clinical evaluation included measurement of the visual analog pain scale, wrist range of motion, and grip strength. Radiographs were taken at follow-up to assess for signs of arthritis and wrist collapse. Results The outcomes of this procedure include increased grip strength and total arc of motion, a small decrease in revised carpal height ratio, and a small increase in radiolunate angle. Two patients failed distal scaphoid resection arthroplasty necessitating proximal row carpectomy (1) and wrist arthrodesis (1) for recalcitrant pain. More than half of the remaining patients developed midcarpal arthritis on radiographs that was asymptomatic. No patients developed radiolunate arthritis. Conclusions This study showed that distal scaphoid resection arthroplasty produced favorable, long-term clinical results and did not result in noteworthy wrist collapse. Midcarpal arthritis, which may develop after the procedure, did not cause appreciable deterioration in patient outcomes. This procedure also did not eliminate the option of using additional, more conventional reconstructive procedures if needed. (J Hand Surg Am. 2014;39(9):1669e1676. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Arthroplasty, degenerative arthritis, scaphoid nonunion, scaphoid resection.
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associated with scaphoid nonunion advanced collapse (SNAC) remains a clinical challenge. Patients report progressive activity-related pain with wrist motion and HRONIC SCAPHOID NONUNION
From the C.V. Starr Hand Surgery Center, St. Luke’s-Roosevelt Hospital, New York, NY. Received for publication July 15, 2013; accepted in revised form May 23, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Louis W. Catalano III, MD, C.V. Starr Hand Surgery Center, St. Luke’s-Roosevelt Hospital, 1000 Tenth Avenue, 3rd Floor, New York, NY 10019; e-mail: [email protected]. 0363-5023/14/3909-0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.05.031
loss of motion and weakness.1e4 Bone grafting of the scaphoid combined with radial styloid excision may be considered for stage I SNAC, but salvage procedures are often indicated for more advanced pathology.5 Proximal row carpectomy (PRC), scaphoid excision, and intercarpal 4-bone arthrodesis (4CA), and wrist arthrodesis are 3 well-studied techniques that reliably provide improvements in pain and activity tolerance for patients with SNAC.4,6e10 These salvage procedures, however, carry the risk of potential complications such as pin track infection, pseudarthrosis, hardware failure or prominence with soft-tissue irritation, and stiffness associated with prolonged immobilization.9,11 Additionally, both PRC and 4CA eliminate
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the midcarpal joint, and revision surgery would require a total wrist arthrodesis or arthroplasty. Distal scaphoid resection arthroplasty represents a relatively simple procedure for patients with recalcitrant symptoms secondary to chronic scaphoid nonunion and post-traumatic arthritis. Since the first description of this technique, subsequent studies have confirmed its success as a treatment option.12e15 However, the durability of the technique has not been established because previous studies have been limited by a relatively short-term follow-up of 5 years or less. The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of distal scaphoid resection arthroplasty over the course of a single surgeon’s 25-year experience. MATERIALS AND METHODS Institutional review board approval was obtained before we identified 19 consecutive patients treated with distal scaphoid resection by a single surgeon between 1987 and 1996. The average age at the time of surgery was 40 years (age range, 22e60 y). The group comprised 18 men and 1 woman. The dominant wrist was injured in 5 patients. Seven injuries were work-related, and 7 patients were manual laborers. Prior to undergoing distal scaphoid resection 5 patients had a volar approach to a scaphoid waist nonunion with unsuccessful Russe bone grafting, and 2 of these 5 underwent subsequent radial styloidectomy for persistent nonunion and radioscaphoid arthritis producing pain. All preoperative radiographs demonstrated scaphoid nonunion. In the 14 patients who could recall a specific injury, the mean interval from injury to their distal scaphoid pole excision was 13 years (range, 2e32 y). The indications for distal scaphoid resection were a painful chronic scaphoid waist nonunion with radial styloid-distal scaphoid arthritis with loss of wrist extension and radial deviation (Fig. 1). If the wrist had normal range of motion, an open reduction and internal fixation using distal radius bone graft was performed, and these patients were not included in the study. The loss of wrist motion occurs due to bony overgrowth of the distal pole of the scaphoid (Fig. 2). Seven of the initial cases had midcarpal arthritis, and because 3 of these had progressed radiographically in our 1999 series, we determined that pre-existing midcarpal arthritis should be a contraindication to distal scaphoid resection arthroplasty. Other contraindications included a torn scapholunate ligament and a dorsally subluxated midcarpal joint. J Hand Surg Am.
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FIGURE 1: Preoperative x-ray illustrating this patient’s (#9) scaphoid nonunion. The arrowheads denote the (1) capitolunate, proximal (2) and distal (3) scaphocapitate, and (4) styloscaphoid articulations. There is joint space narrowing at the distal scaphocapitate and styloscaphoid articulations. The flattening of the radial styloid was secondary to styloscaphoid impingement from overgrowth of the distal scaphoid pole, not a styloidectomy. This flattening was a consistent finding.
The chief complaint was typically pain with wrist motion or activities that stressed the wrist, notable wrist stiffness, and an inability to perform activities that required a large range of wrist motion. All patients were unresponsive to nonsurgical treatment and not candidates for bone grafting because of posttraumatic arthritis and major loss of wrist motion.2,3 The scaphoid nonunion was at the waist in all patients except 1 (patient #15) who had a proximal pole fracture. For this patient we divided the scaphoid at its waist to preserve concavity of the scaphoidcapitate joint (Fig. 3). The surgical technique, which has been reported in detail elsewhere16, was similar for each patient and is reviewed briefly here. A 5-cm dorsal oblique incision was made starting at the Lister tubercle and extending distally over the extensor pollicis longus tendon. The third dorsal compartment was released at the Lister tubercle, and the joint was entered directly beneath the extensor pollicis longus tendon. An elevator was inserted into the scaphotrapeziotrapezoidal articulation to lift the distal fragment in order to incise its soft-tissue attachments. In 1 patient (patient #1, two failed Russe bone grafts), a volar incision was made to release the volar ligamentous attachments that could not be detached through Vol. 39, September 2014
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FIGURE 3: X-ray 4 years after distal pole scaphoid excision (patient #9). The arrowheads denote the radiographically normal capitolunate and proximal scaphocapitate articulations.
FIGURE 2: The sequence of events demonstrated roentgenographically (patient #9). A Sagittal computed tomography T scan image of an undisplaced scaphoid fracture. B Sagittal computed tomography scan image of a displaced scaphoid fracture. C Ten years after initial injury, there is bony overgrowth of the distal fragment along with site of abutment at the dorsal lip of radius with wrist extension. D The extracted specimen. df ¼ distal fragment.
the dorsal exposure. Postoperatively, patients were immobilized in an orthosis for 2 weeks, after which patients began occupational therapy for range of motion and grip-strengthening exercises for 4 weeks. We had all the patients use a spring-loaded gripping device from a sporting goods store and focus on passive wrist extension. At 6 weeks postoperatively, J Hand Surg Am.
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the patients were advanced gradually in their activities without limitations. One activity that was not permitted was loading the wrist in extension (ie, heavy barbells or push-ups). Grip strength was measured with the use of a Jamar dynamometer (Asimow Engineering, Santa Monica, CA) with the elbow at 90 of flexion and the forearm in neutral rotation. Wrist passive range of motion was measured with a goniometer. Both grip strength and wrist range of motion were assessed bilaterally before and after surgery. Overall patient satisfaction was determined by their ability to return to work, resumption of activities previously precluded by the condition, resumed participation in handle sports such as golf or tennis, necessity for narcotic pain medication, and results of their visual analog pain scale, which was completed by the patient during each visit. Radiographic assessment for carpal collapse and arthrosis was performed both preoperatively and postoperatively. Carpal collapse was discerned by measuring for an increase in dorsal intercalated segmental instability, an increase in the radiolunate angle,17 and a decrease in the revised carpal height ratio.18 Progressive arthrosis was defined as sclerotic or cystic changes or loss of joint space. The senior author (M.M.M.) was responsible for radiographic interpretation. The physical findings were evaluated by the senior surgeon, a second hand surgeon, residents involved in patient care, and a hand therapist. Statistical analysis comparing the cohort’s Vol. 39, September 2014
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TABLE 1.
DISTAL SCAPHOID RESECTION ARTHROPLASTY
Individual Patient Demographics
Patient No.
Present Age
Age at Surgery
1
73
2
50
3
42
Follow-Up Time (y)
Time From Injury (y)
No
17
32
Yes
14
5
10
17
Sex
Current Occupation
WC
56
M
Deceased
36
M
Store manager
32
M
SSD
Yes
4*
49
26
M
Realtor
No
23
?
5
40
28
M
Truck driver
Yes
12
2
6
32
22
M
Construction
Yes
10
?
7
57
46
M
SSD
No
11
?
8
49
35
M
Truck driver
Yes
14
10
9
64
39
M
Family and drug counselor
No
25
10
10
43
33
M
Unemployed
No
10
5
11
48
34
M
Carpenter
No
14
15
12
51
34
M
Oil field worker
No
17
20
13
NA
48
F
Housewife
No
Arthrodesis
15
14
55
34
M
Truck customizer
No
21
6
15
59
47
M
Tire shop manager
Yes
12
?
16
73
57
M
Retired
Yes
16
14
17
57
39
M
SSD
No
18
?
18
68
58
M
Realtor
No
10
15
19
NA
60
M
Prisoner
No
PRC
12
WC, worker compensated; PRC, proximal row carpectomy; SSD, Social Security Disability. *Bilateral Disease.
grip strength and range of motion from the preoperative time to final follow-up was conducted using the paired t-test with a P value of < .05 considered significant. RESULTS The patients’ demographic data are summarized in Table 1. Seventeen of the 19 original patients were included for follow-up between 10 and 25 years postoperatively (mean, 15 y). As documented in our 1999 study, 1 patient (#13) underwent early wrist arthrodesis for recalcitrant pain. Another patient (#19) underwent PRC between the time of our initial report and this study. Patient #4 had bilateral pathology and had surgery on 1 side, which precluded use of the untreated side for comparative grip and range of motion data. Long-term clinical and radiographic data are summarized in Table 2. Visual analog scale pain scores averaged 0.9 (range, 0e2) at latest follow-up. Grip strength averaged 16 kg preoperatively (range, 9e34 kg) compared to 33 kg (range, 23e50 kg) at latest follow-up. When compared to the contralateral J Hand Surg Am.
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extremity, grip strength increased from 36% preoperatively to 83% at latest follow-up (range, 45%e 160%; P < .001). To compensate for patient aging, we used percentages of grip strength compared with the opposite extremity (Table 2). Range of motion improved notably at the latest postoperative assessment (Table 2). The mean preoperative total arc of motion was 72 vs 139 at latest follow-up (P < .001). Postoperative flexion-extension arc averaged 79% of the contralateral wrist. Radialulnar deviation was 23 before, compared to 37 (range, 25 e50 ) after surgery; which was 80% of the radial-ulnar deviation of the opposite side. Radiographic analysis demonstrated postoperative progression or development of midcarpal arthrosis in 13 of 18 patients. All 4 patients followed 18 years or more developed midcarpal arthrosis, which was not present preoperatively (Fig. 4). There was no progressive arthritis identified in the proximal radioscaphoid or radiolunate articulations (Fig. 4). The first of 2 failures was patient #13, who had a subluxated midcarpal joint with noteworthy midcarpal arthrosis preoperatively and requested a wrist arthrodesis Vol. 39, September 2014
TABLE 2.
Long-Term Clinical and Radiographic Data Early Follow-Up
Late Follow-Up
Yes/yes
Progressed
None (0)
No/no
Lunocapitate (3)
Yes/yes
67/350
None (0)
44/97
None (0)
27/52
40/64
33/107
30/83
8
20/90
9
RCHR Preop
RCHR Late
Radiolunate Angle Preop
Radiolunate Angle Late
Unchanged
1.4
1.35
30
35
0
None
Unchanged
1.42
1.32
20
30
1
Unchanged
Unchanged
1.35
1.38
37
30
1.5
No/yes
None
Unchanged
1.36
1.39
28
32
1
No/yes
None
Lunocapitate
1.5
1.3
30
40
0
None (0)
No/no
None
Lunocapitate
1.44
1.3
25
38
0
Proximal scaphoid-capitate (2)
Yes/yes
Unchanged
Unchanged
1.37
1.36
25
30
2
38/61
Proximal scaphoid-radius, proximal scaphoid-capitate (2)
Yes/yes
Progressed
Unchanged
1.4
1.38
30
40
0
53/84
39/89
None (0)
No/yes
None
Unchanged
1.38
1.42
30
30
1
10
31/93
34/65
None (0)
No/no
None
Unchanged
1.55
1.44
30
33
1
11
46/45
44/91
Lunocapitate (3)
Yes/yes
Unchanged
Unchanged
1.41
1.31
35
33
1
12
29/85
43/80
None (0)
No/no
None
Unchanged
1.45
1.44
24
30
1
13
20/NA
70/NA
Lunocapitate, proximal scaphoid-capitate (3)
Yes/yes
Progressed
Unchanged
NA
NA
NA
NA
NA
14
58/87
39/84
None (0)
No/yes
None
Lunocapitate
1.4
1.38
30
30
1
15
17/80
35/77
None (0)
No/no
None
Unchanged
1.45
1.4
25
25
1
16
33/94
35/97
Proximal scaphoid-radius (2)
No/yes
None
Unchanged
1.46
1.44
30
38
1.5
17
32/88
40/70
None (0)
No/yes
None
Unchanged
1.43
1.42
35
35
1
18
25/71
40/100
Proximal scaphoid-capitate (2)
Yes/yes
None
Unchanged
1.4
1.3
25
32
1
19
30/NA
70/NA
None
No/no
None
Lunocapitate
NA
NA
NA
NA
NA
J Hand Surg Am.
Grip Strength V
Range of Motion U
1
39/100
13/50
Lunocapitate (3)
2
25/73
56/89
3
40/111
74/60
4*
20/160
5
71/68
6 7
Preop (SNAC Stage)
VAS
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Midcarpal Arthritis preop/postop
Patient No.
Preoperative scaphoid nonunion advanced collapse stages included according to previously described classification system.5 RCHR, revised carpal height ratio. *Bilateral disease. VAs a percentage of the contralateral wrist before OR after surgery. UTotal wrist motion as a percentage of the contralateral wrist before or after surgery.
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FIGURE 4: X-rays for patient #9. A After 18 years, no midcarpal arthrosis is visible. B Degenerative changes are present in the midcarpal joint after 25 years. No proximal radioscaphoid or radiolunate arthrosis is present at either time interval.
prior to our first report. The second failure was patient #19, a 60-year-old man with diabetes, a heavy smoking history, avascular necrosis of the proximal pole, and scapholunate ligament diastasis. After surgery he complained of persistent wrist pain and had a PRC. His initial surgery, in retrospect, was ill advised due to the scapholunate ligament tear. The revised carpal height ratio decreased 4% from 1.42 preoperatively to 1.37 at latest follow-up (range, 1.30e1.44). The radiolunate angle increased from 29 to 33 (range, 25 to 40 ) (Table 2). There were no immediate postoperative complications. Seventeen of the 19 patients were satisfied at the latest follow-up with less pain, improved strength, improved mobility, and resumption of activities that were not possible prior to distal scaphoid excision. No patients required narcotic pain medication at latest follow-up. DISCUSSION Scaphoid nonunion resulting in advanced arthritic changes is a clinical problem that can be treated in several ways. This study suggests excision of the distal scaphoid may be a good option for these patients. We previously presented results in our series of 19 patients, and our current study demonstrated that the good results have continued for as long as 25 years. Soejima et al15 examined 9 patients at an average follow-up of 28 months and reported an increase in grip strength from 40% to 77% of the contralateral wrist with an increase in the flexionextension range of motion from 70 to 140 . There was no significant difference in carpal height or radiolunate angle. Ruch et al14 published results on 13 patients at an average follow-up of 5 years and found increased flexion-extension motion from 86 to 138 . Eleven of 13 patients were pain free. J Hand Surg Am.
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There is concern that distal scaphoid resection will further destabilize the wrist and lead to progressive arthritic change or possibly instability of the thumb.19 Though we did not observe any noteworthy thumb instability after distal scaphoid resection, there were 2 failures during our longitudinal study. No degenerative changes were identified radiographically at the proximal radioscaphoid or radiolunate joints.13e15 We believe that this helps account for the favorable outcomes reported in this series. It is unclear why painful carpal collapse occurs in some cases of distal scaphoid excision for treatment of scaphotrapeziotrapezoid joint arthritis but was not seen in our patients. In our series, the carpal collapse had already occurred and distal scaphoid pole excision resulted in only slight changes in the radiolunate angle and modified carpal height ratio at long-term follow-up. Preoperatively in patients with scaphotrapeziotrapezoid joint arthritis, often there is normal carpal alignment and no carpal collapse, and distal pole excision may lead to a painful dorsal intercalated segment instability.19,20 Long-term follow-up demonstrated that 12 of 18 patients had developed midcarpal arthrosis, with 1 (#5) having mild activity-related wrist pain with activities only. Four of the patients followed over 20 years developed midcarpal arthrosis that was not present preoperatively. One of these 4 (patient #9) had a normal midcarpal joint 18 years postoperatively. An important radiographic finding was that no patients had developed proximal radioscaphoid or radiolunate arthrosis at long-term follow-up. In our previous study, we proposed that capitolunate arthritis was a contraindication to distal scaphoid resection based on the rate of progressive arthritic changes in the joint in 3 of 7 patients. We no longer believe this. The capitolunate arthrosis Vol. 39, September 2014
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discovered in the current series at follow-up was asymptomatic. Furthermore, in the series of Soejima et al of 9 patients, 6 had preexisting capitolunate arthritis that remained stable and asymptomatic at an average 28 month follow-up.15 Distal pole excision improves motion by liberating the midcarpal and radiocarpal joints, and we postulate that pain relief occurs by transmission of force and motion to less diseased joints (ie, the radiolunate and proximal radioscaphoid joints). During a panel presentation at the annual meeting of the American Society for Surgery of the Hand in 1996, Malerich used a cadaver to demonstrate that full range of motion could be restored if half the scaphoid was excised after fusing the proximal radiocarpal joint. A formal study of this concept was subsequently published by McCombe et al in which the distal scaphoid was excised after radioscaphoid arthrodesis.21 The authors found a 203% increase in flexion-extension after distal pole excision. Distal scaphoid excision released the midcarpal restraint imposed by the scaphotrapeziotrapezoid joint linkages, thus converting the multiplanar midcarpal articulations to a simple joint. We believe it is important to compare the outcomes of distal scaphoid excision with those for PRC and 4CA because those are the 2 most accepted treatment methods for longstanding SNAC. Mulford et al reviewed 52 articles that examined outcomes of PRC and 4CA.22 The weighted average grip strength was 70% and 75% for PRC and 4CA, respectively, which is similar to our result of 83%. The systematic review demonstrated a 4% conversion rate to arthrodesis in the PRC patients, 6% nonunion rate with 4CA, and 3% dorsal impingement in 4CA patients. A 4CA requires prolonged immobilization, whereas distal scaphoid excision requires only 2 weeks of postoperative orthosis fabrication. Disadvantages of PRC include the potential for development of arthritis at the radiocapitate articulation, and PRC is contraindicated when arthrosis is present at the capitate head.23,24 A randomized controlled study comparing PRC, 4CA, and distal pole excision is needed to detect differences in outcomes. The present study does have limitations. The use of outcomes questionnaires, which were not available in the late 1980s when this study began, would have allowed objective qualification of pain and disability and also would have allowed for more direct comparison to published functional results. The lack of an independent reviewer of radiographic findings could have introduced a bias to our results. Also, our study lacked a control group. J Hand Surg Am.
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Distal scaphoid excision is technically easy to perform, does not rely on internal fixation or fusion, and requires minimal immobilization. Traditional options remain available if revision surgery is necessary. The finding that midcarpal arthrosis eventually develops at long-term follow-up yet remains asymptomatic has not detracted from the success of the operation. REFERENCES 1. Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br. 1981;63(2): 225e230. 2. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am. 1984;66(4):504e509. 3. Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am. 1987; 12(4):514e519. 4. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3): 358e365. 5. Krimmer H, Krapohl B, Sauerbier M, Hahn P. [Post-traumatic carpal collapse (SLAC- and SNAC-wrist)—stage classification and therapeutic possibilities]. Handchir Mikrochir Plast Chir. 1997;29(5): 228e233. 6. Clendenin MB, Green DP. Arthrodesis of the wrist-complications and their management. J Hand Surg Am. 1981;6(3):253e257. 7. Haddad RJ Jr, Riordan DC. Arthrodesis of the wrist. A surgical technique. J Bone Joint Surg Am. 1967;49(5):950e954. 8. Inglis AE, Jones EC. Proximal-row carpectomy for diseases of the proximal row. J Bone Joint Surg Am. 1977;59(4):460e463. 9. McAuliffe JA, Dell PC, Jaffe R. Complications of intercarpal arthrodesis. J Hand Surg Am. 1993;18(6):1121e1128. 10. Viegas SF. Limited arthrodesis for scaphoid nonunion. J Hand Surg Am. 1994;19(1):127e133. 11. Larsen CF, Jacoby RA, McCabe SJ. Nonunion rates of limited carpal arthrodesis: a meta-analysis of the literature. J Hand Surg Am. 1997; 22(1):66e73. 12. Malerich MM, Clifford J, Eaton B, Eaton R, Littler JW. Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion. J Hand Surg Am. 1999; 24(6):1196e1205. 13. Drac P, Manak P, Pieranova L. Distal scaphoid resection arthroplasty for scaphoid nonunion with radioscaphoid arthritis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2006;150(1): 143e145. 14. Ruch DS, Papadonikolakis A. Resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed previous surgical treatment. J Hand Surg Am. 2006;31(4):588e593. 15. Soejima O, Lida H, Hanamura T, Naito M. Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis. J Hand Surg Am. 2003;28(4):591e596. 16. Malerich MM, Littler JW, Eaton R. Distal scaphoid resection arthroplasty for the treatment of patients with degenerative arthritis secondary to scaphoid nonunion. Tech Hand Up Extrem Surg. 2002; 6(2):98e102. 17. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am. 1972;54(8):1612e1632. 18. Nattrass GR, King GJ, McMurtry RY, Brant RF. An alternative method for determination of the carpal height ratio. J Bone Joint Surg Am. 1994;76(1):88e94. 19. Garcia-Elias M, Lluch AL, Farreres A, Castillo F, Saffar P. Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis. J Hand Surg Br. 1999;24(4):448e452.
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20. Corbin C, Warwick D. Midcarpal instability after excision arthroplasty for scapho-trapezial-trapezoid (STT) arthritis. J Hand Surg Eur. 2009;34(4):537e538. 21. McCombe D, Ireland DC, McNab I. Distal scaphoid excision after radioscaphoid arthrodesis. J Hand Surg Am. 2001;26(5):877e882. 22. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid
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nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur. 2009;34(2):256e263. 23. Jebson PJ, Hayes EP, Engber WD. Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg Am. 2003;28(4):561e569. 24. Tomaino MM, Delsignore J, Burton RI. Long-term results following proximal row carpectomy. J Hand Surg Am. 1994;19(4): 694e703.
Vol. 39, September 2014
Distal Scaphoid Resection for Degenerative Arthritis Secondary to Scaphoid Nonunion: A 20-Year Experience Matthew M. Malerich, MD, Louis W. Catalano III, MD, Zachary D. Weidner, MD, Michael C. Vance, MD, Claire M. Eden, BA, Richard G. Eaton, MD
Purpose To evaluate the long-term results of distal scaphoid excision for degenerative arthritis secondary to scaphoid nonunion and compare them with our original results published in 1999. Methods Nineteen patients who were treated by distal scaphoid resection arthroplasty from 1987 through 2010 were included. The mean follow-up was 15 years (range, 10e25 y) vs 4 years in the previous study. Clinical evaluation included measurement of the visual analog pain scale, wrist range of motion, and grip strength. Radiographs were taken at follow-up to assess for signs of arthritis and wrist collapse. Results The outcomes of this procedure include increased grip strength and total arc of motion, a small decrease in revised carpal height ratio, and a small increase in radiolunate angle. Two patients failed distal scaphoid resection arthroplasty necessitating proximal row carpectomy (1) and wrist arthrodesis (1) for recalcitrant pain. More than half of the remaining patients developed midcarpal arthritis on radiographs that was asymptomatic. No patients developed radiolunate arthritis. Conclusions This study showed that distal scaphoid resection arthroplasty produced favorable, long-term clinical results and did not result in noteworthy wrist collapse. Midcarpal arthritis, which may develop after the procedure, did not cause appreciable deterioration in patient outcomes. This procedure also did not eliminate the option of using additional, more conventional reconstructive procedures if needed. (J Hand Surg Am. 2014;39(9):1669e1676. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Arthroplasty, degenerative arthritis, scaphoid nonunion, scaphoid resection.
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associated with scaphoid nonunion advanced collapse (SNAC) remains a clinical challenge. Patients report progressive activity-related pain with wrist motion and HRONIC SCAPHOID NONUNION
From the C.V. Starr Hand Surgery Center, St. Luke’s-Roosevelt Hospital, New York, NY. Received for publication July 15, 2013; accepted in revised form May 23, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Louis W. Catalano III, MD, C.V. Starr Hand Surgery Center, St. Luke’s-Roosevelt Hospital, 1000 Tenth Avenue, 3rd Floor, New York, NY 10019; e-mail: [email protected]. 0363-5023/14/3909-0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.05.031
loss of motion and weakness.1e4 Bone grafting of the scaphoid combined with radial styloid excision may be considered for stage I SNAC, but salvage procedures are often indicated for more advanced pathology.5 Proximal row carpectomy (PRC), scaphoid excision, and intercarpal 4-bone arthrodesis (4CA), and wrist arthrodesis are 3 well-studied techniques that reliably provide improvements in pain and activity tolerance for patients with SNAC.4,6e10 These salvage procedures, however, carry the risk of potential complications such as pin track infection, pseudarthrosis, hardware failure or prominence with soft-tissue irritation, and stiffness associated with prolonged immobilization.9,11 Additionally, both PRC and 4CA eliminate
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the midcarpal joint, and revision surgery would require a total wrist arthrodesis or arthroplasty. Distal scaphoid resection arthroplasty represents a relatively simple procedure for patients with recalcitrant symptoms secondary to chronic scaphoid nonunion and post-traumatic arthritis. Since the first description of this technique, subsequent studies have confirmed its success as a treatment option.12e15 However, the durability of the technique has not been established because previous studies have been limited by a relatively short-term follow-up of 5 years or less. The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of distal scaphoid resection arthroplasty over the course of a single surgeon’s 25-year experience. MATERIALS AND METHODS Institutional review board approval was obtained before we identified 19 consecutive patients treated with distal scaphoid resection by a single surgeon between 1987 and 1996. The average age at the time of surgery was 40 years (age range, 22e60 y). The group comprised 18 men and 1 woman. The dominant wrist was injured in 5 patients. Seven injuries were work-related, and 7 patients were manual laborers. Prior to undergoing distal scaphoid resection 5 patients had a volar approach to a scaphoid waist nonunion with unsuccessful Russe bone grafting, and 2 of these 5 underwent subsequent radial styloidectomy for persistent nonunion and radioscaphoid arthritis producing pain. All preoperative radiographs demonstrated scaphoid nonunion. In the 14 patients who could recall a specific injury, the mean interval from injury to their distal scaphoid pole excision was 13 years (range, 2e32 y). The indications for distal scaphoid resection were a painful chronic scaphoid waist nonunion with radial styloid-distal scaphoid arthritis with loss of wrist extension and radial deviation (Fig. 1). If the wrist had normal range of motion, an open reduction and internal fixation using distal radius bone graft was performed, and these patients were not included in the study. The loss of wrist motion occurs due to bony overgrowth of the distal pole of the scaphoid (Fig. 2). Seven of the initial cases had midcarpal arthritis, and because 3 of these had progressed radiographically in our 1999 series, we determined that pre-existing midcarpal arthritis should be a contraindication to distal scaphoid resection arthroplasty. Other contraindications included a torn scapholunate ligament and a dorsally subluxated midcarpal joint. J Hand Surg Am.
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FIGURE 1: Preoperative x-ray illustrating this patient’s (#9) scaphoid nonunion. The arrowheads denote the (1) capitolunate, proximal (2) and distal (3) scaphocapitate, and (4) styloscaphoid articulations. There is joint space narrowing at the distal scaphocapitate and styloscaphoid articulations. The flattening of the radial styloid was secondary to styloscaphoid impingement from overgrowth of the distal scaphoid pole, not a styloidectomy. This flattening was a consistent finding.
The chief complaint was typically pain with wrist motion or activities that stressed the wrist, notable wrist stiffness, and an inability to perform activities that required a large range of wrist motion. All patients were unresponsive to nonsurgical treatment and not candidates for bone grafting because of posttraumatic arthritis and major loss of wrist motion.2,3 The scaphoid nonunion was at the waist in all patients except 1 (patient #15) who had a proximal pole fracture. For this patient we divided the scaphoid at its waist to preserve concavity of the scaphoidcapitate joint (Fig. 3). The surgical technique, which has been reported in detail elsewhere16, was similar for each patient and is reviewed briefly here. A 5-cm dorsal oblique incision was made starting at the Lister tubercle and extending distally over the extensor pollicis longus tendon. The third dorsal compartment was released at the Lister tubercle, and the joint was entered directly beneath the extensor pollicis longus tendon. An elevator was inserted into the scaphotrapeziotrapezoidal articulation to lift the distal fragment in order to incise its soft-tissue attachments. In 1 patient (patient #1, two failed Russe bone grafts), a volar incision was made to release the volar ligamentous attachments that could not be detached through Vol. 39, September 2014
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FIGURE 3: X-ray 4 years after distal pole scaphoid excision (patient #9). The arrowheads denote the radiographically normal capitolunate and proximal scaphocapitate articulations.
FIGURE 2: The sequence of events demonstrated roentgenographically (patient #9). A Sagittal computed tomography T scan image of an undisplaced scaphoid fracture. B Sagittal computed tomography scan image of a displaced scaphoid fracture. C Ten years after initial injury, there is bony overgrowth of the distal fragment along with site of abutment at the dorsal lip of radius with wrist extension. D The extracted specimen. df ¼ distal fragment.
the dorsal exposure. Postoperatively, patients were immobilized in an orthosis for 2 weeks, after which patients began occupational therapy for range of motion and grip-strengthening exercises for 4 weeks. We had all the patients use a spring-loaded gripping device from a sporting goods store and focus on passive wrist extension. At 6 weeks postoperatively, J Hand Surg Am.
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the patients were advanced gradually in their activities without limitations. One activity that was not permitted was loading the wrist in extension (ie, heavy barbells or push-ups). Grip strength was measured with the use of a Jamar dynamometer (Asimow Engineering, Santa Monica, CA) with the elbow at 90 of flexion and the forearm in neutral rotation. Wrist passive range of motion was measured with a goniometer. Both grip strength and wrist range of motion were assessed bilaterally before and after surgery. Overall patient satisfaction was determined by their ability to return to work, resumption of activities previously precluded by the condition, resumed participation in handle sports such as golf or tennis, necessity for narcotic pain medication, and results of their visual analog pain scale, which was completed by the patient during each visit. Radiographic assessment for carpal collapse and arthrosis was performed both preoperatively and postoperatively. Carpal collapse was discerned by measuring for an increase in dorsal intercalated segmental instability, an increase in the radiolunate angle,17 and a decrease in the revised carpal height ratio.18 Progressive arthrosis was defined as sclerotic or cystic changes or loss of joint space. The senior author (M.M.M.) was responsible for radiographic interpretation. The physical findings were evaluated by the senior surgeon, a second hand surgeon, residents involved in patient care, and a hand therapist. Statistical analysis comparing the cohort’s Vol. 39, September 2014
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TABLE 1.
DISTAL SCAPHOID RESECTION ARTHROPLASTY
Individual Patient Demographics
Patient No.
Present Age
Age at Surgery
1
73
2
50
3
42
Follow-Up Time (y)
Time From Injury (y)
No
17
32
Yes
14
5
10
17
Sex
Current Occupation
WC
56
M
Deceased
36
M
Store manager
32
M
SSD
Yes
4*
49
26
M
Realtor
No
23
?
5
40
28
M
Truck driver
Yes
12
2
6
32
22
M
Construction
Yes
10
?
7
57
46
M
SSD
No
11
?
8
49
35
M
Truck driver
Yes
14
10
9
64
39
M
Family and drug counselor
No
25
10
10
43
33
M
Unemployed
No
10
5
11
48
34
M
Carpenter
No
14
15
12
51
34
M
Oil field worker
No
17
20
13
NA
48
F
Housewife
No
Arthrodesis
15
14
55
34
M
Truck customizer
No
21
6
15
59
47
M
Tire shop manager
Yes
12
?
16
73
57
M
Retired
Yes
16
14
17
57
39
M
SSD
No
18
?
18
68
58
M
Realtor
No
10
15
19
NA
60
M
Prisoner
No
PRC
12
WC, worker compensated; PRC, proximal row carpectomy; SSD, Social Security Disability. *Bilateral Disease.
grip strength and range of motion from the preoperative time to final follow-up was conducted using the paired t-test with a P value of < .05 considered significant. RESULTS The patients’ demographic data are summarized in Table 1. Seventeen of the 19 original patients were included for follow-up between 10 and 25 years postoperatively (mean, 15 y). As documented in our 1999 study, 1 patient (#13) underwent early wrist arthrodesis for recalcitrant pain. Another patient (#19) underwent PRC between the time of our initial report and this study. Patient #4 had bilateral pathology and had surgery on 1 side, which precluded use of the untreated side for comparative grip and range of motion data. Long-term clinical and radiographic data are summarized in Table 2. Visual analog scale pain scores averaged 0.9 (range, 0e2) at latest follow-up. Grip strength averaged 16 kg preoperatively (range, 9e34 kg) compared to 33 kg (range, 23e50 kg) at latest follow-up. When compared to the contralateral J Hand Surg Am.
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extremity, grip strength increased from 36% preoperatively to 83% at latest follow-up (range, 45%e 160%; P < .001). To compensate for patient aging, we used percentages of grip strength compared with the opposite extremity (Table 2). Range of motion improved notably at the latest postoperative assessment (Table 2). The mean preoperative total arc of motion was 72 vs 139 at latest follow-up (P < .001). Postoperative flexion-extension arc averaged 79% of the contralateral wrist. Radialulnar deviation was 23 before, compared to 37 (range, 25 e50 ) after surgery; which was 80% of the radial-ulnar deviation of the opposite side. Radiographic analysis demonstrated postoperative progression or development of midcarpal arthrosis in 13 of 18 patients. All 4 patients followed 18 years or more developed midcarpal arthrosis, which was not present preoperatively (Fig. 4). There was no progressive arthritis identified in the proximal radioscaphoid or radiolunate articulations (Fig. 4). The first of 2 failures was patient #13, who had a subluxated midcarpal joint with noteworthy midcarpal arthrosis preoperatively and requested a wrist arthrodesis Vol. 39, September 2014
TABLE 2.
Long-Term Clinical and Radiographic Data Early Follow-Up
Late Follow-Up
Yes/yes
Progressed
None (0)
No/no
Lunocapitate (3)
Yes/yes
67/350
None (0)
44/97
None (0)
27/52
40/64
33/107
30/83
8
20/90
9
RCHR Preop
RCHR Late
Radiolunate Angle Preop
Radiolunate Angle Late
Unchanged
1.4
1.35
30
35
0
None
Unchanged
1.42
1.32
20
30
1
Unchanged
Unchanged
1.35
1.38
37
30
1.5
No/yes
None
Unchanged
1.36
1.39
28
32
1
No/yes
None
Lunocapitate
1.5
1.3
30
40
0
None (0)
No/no
None
Lunocapitate
1.44
1.3
25
38
0
Proximal scaphoid-capitate (2)
Yes/yes
Unchanged
Unchanged
1.37
1.36
25
30
2
38/61
Proximal scaphoid-radius, proximal scaphoid-capitate (2)
Yes/yes
Progressed
Unchanged
1.4
1.38
30
40
0
53/84
39/89
None (0)
No/yes
None
Unchanged
1.38
1.42
30
30
1
10
31/93
34/65
None (0)
No/no
None
Unchanged
1.55
1.44
30
33
1
11
46/45
44/91
Lunocapitate (3)
Yes/yes
Unchanged
Unchanged
1.41
1.31
35
33
1
12
29/85
43/80
None (0)
No/no
None
Unchanged
1.45
1.44
24
30
1
13
20/NA
70/NA
Lunocapitate, proximal scaphoid-capitate (3)
Yes/yes
Progressed
Unchanged
NA
NA
NA
NA
NA
14
58/87
39/84
None (0)
No/yes
None
Lunocapitate
1.4
1.38
30
30
1
15
17/80
35/77
None (0)
No/no
None
Unchanged
1.45
1.4
25
25
1
16
33/94
35/97
Proximal scaphoid-radius (2)
No/yes
None
Unchanged
1.46
1.44
30
38
1.5
17
32/88
40/70
None (0)
No/yes
None
Unchanged
1.43
1.42
35
35
1
18
25/71
40/100
Proximal scaphoid-capitate (2)
Yes/yes
None
Unchanged
1.4
1.3
25
32
1
19
30/NA
70/NA
None
No/no
None
Lunocapitate
NA
NA
NA
NA
NA
J Hand Surg Am.
Grip Strength V
Range of Motion U
1
39/100
13/50
Lunocapitate (3)
2
25/73
56/89
3
40/111
74/60
4*
20/160
5
71/68
6 7
Preop (SNAC Stage)
VAS
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Midcarpal Arthritis preop/postop
Patient No.
Preoperative scaphoid nonunion advanced collapse stages included according to previously described classification system.5 RCHR, revised carpal height ratio. *Bilateral disease. VAs a percentage of the contralateral wrist before OR after surgery. UTotal wrist motion as a percentage of the contralateral wrist before or after surgery.
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FIGURE 4: X-rays for patient #9. A After 18 years, no midcarpal arthrosis is visible. B Degenerative changes are present in the midcarpal joint after 25 years. No proximal radioscaphoid or radiolunate arthrosis is present at either time interval.
prior to our first report. The second failure was patient #19, a 60-year-old man with diabetes, a heavy smoking history, avascular necrosis of the proximal pole, and scapholunate ligament diastasis. After surgery he complained of persistent wrist pain and had a PRC. His initial surgery, in retrospect, was ill advised due to the scapholunate ligament tear. The revised carpal height ratio decreased 4% from 1.42 preoperatively to 1.37 at latest follow-up (range, 1.30e1.44). The radiolunate angle increased from 29 to 33 (range, 25 to 40 ) (Table 2). There were no immediate postoperative complications. Seventeen of the 19 patients were satisfied at the latest follow-up with less pain, improved strength, improved mobility, and resumption of activities that were not possible prior to distal scaphoid excision. No patients required narcotic pain medication at latest follow-up. DISCUSSION Scaphoid nonunion resulting in advanced arthritic changes is a clinical problem that can be treated in several ways. This study suggests excision of the distal scaphoid may be a good option for these patients. We previously presented results in our series of 19 patients, and our current study demonstrated that the good results have continued for as long as 25 years. Soejima et al15 examined 9 patients at an average follow-up of 28 months and reported an increase in grip strength from 40% to 77% of the contralateral wrist with an increase in the flexionextension range of motion from 70 to 140 . There was no significant difference in carpal height or radiolunate angle. Ruch et al14 published results on 13 patients at an average follow-up of 5 years and found increased flexion-extension motion from 86 to 138 . Eleven of 13 patients were pain free. J Hand Surg Am.
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There is concern that distal scaphoid resection will further destabilize the wrist and lead to progressive arthritic change or possibly instability of the thumb.19 Though we did not observe any noteworthy thumb instability after distal scaphoid resection, there were 2 failures during our longitudinal study. No degenerative changes were identified radiographically at the proximal radioscaphoid or radiolunate joints.13e15 We believe that this helps account for the favorable outcomes reported in this series. It is unclear why painful carpal collapse occurs in some cases of distal scaphoid excision for treatment of scaphotrapeziotrapezoid joint arthritis but was not seen in our patients. In our series, the carpal collapse had already occurred and distal scaphoid pole excision resulted in only slight changes in the radiolunate angle and modified carpal height ratio at long-term follow-up. Preoperatively in patients with scaphotrapeziotrapezoid joint arthritis, often there is normal carpal alignment and no carpal collapse, and distal pole excision may lead to a painful dorsal intercalated segment instability.19,20 Long-term follow-up demonstrated that 12 of 18 patients had developed midcarpal arthrosis, with 1 (#5) having mild activity-related wrist pain with activities only. Four of the patients followed over 20 years developed midcarpal arthrosis that was not present preoperatively. One of these 4 (patient #9) had a normal midcarpal joint 18 years postoperatively. An important radiographic finding was that no patients had developed proximal radioscaphoid or radiolunate arthrosis at long-term follow-up. In our previous study, we proposed that capitolunate arthritis was a contraindication to distal scaphoid resection based on the rate of progressive arthritic changes in the joint in 3 of 7 patients. We no longer believe this. The capitolunate arthrosis Vol. 39, September 2014
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discovered in the current series at follow-up was asymptomatic. Furthermore, in the series of Soejima et al of 9 patients, 6 had preexisting capitolunate arthritis that remained stable and asymptomatic at an average 28 month follow-up.15 Distal pole excision improves motion by liberating the midcarpal and radiocarpal joints, and we postulate that pain relief occurs by transmission of force and motion to less diseased joints (ie, the radiolunate and proximal radioscaphoid joints). During a panel presentation at the annual meeting of the American Society for Surgery of the Hand in 1996, Malerich used a cadaver to demonstrate that full range of motion could be restored if half the scaphoid was excised after fusing the proximal radiocarpal joint. A formal study of this concept was subsequently published by McCombe et al in which the distal scaphoid was excised after radioscaphoid arthrodesis.21 The authors found a 203% increase in flexion-extension after distal pole excision. Distal scaphoid excision released the midcarpal restraint imposed by the scaphotrapeziotrapezoid joint linkages, thus converting the multiplanar midcarpal articulations to a simple joint. We believe it is important to compare the outcomes of distal scaphoid excision with those for PRC and 4CA because those are the 2 most accepted treatment methods for longstanding SNAC. Mulford et al reviewed 52 articles that examined outcomes of PRC and 4CA.22 The weighted average grip strength was 70% and 75% for PRC and 4CA, respectively, which is similar to our result of 83%. The systematic review demonstrated a 4% conversion rate to arthrodesis in the PRC patients, 6% nonunion rate with 4CA, and 3% dorsal impingement in 4CA patients. A 4CA requires prolonged immobilization, whereas distal scaphoid excision requires only 2 weeks of postoperative orthosis fabrication. Disadvantages of PRC include the potential for development of arthritis at the radiocapitate articulation, and PRC is contraindicated when arthrosis is present at the capitate head.23,24 A randomized controlled study comparing PRC, 4CA, and distal pole excision is needed to detect differences in outcomes. The present study does have limitations. The use of outcomes questionnaires, which were not available in the late 1980s when this study began, would have allowed objective qualification of pain and disability and also would have allowed for more direct comparison to published functional results. The lack of an independent reviewer of radiographic findings could have introduced a bias to our results. Also, our study lacked a control group. J Hand Surg Am.
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Distal scaphoid excision is technically easy to perform, does not rely on internal fixation or fusion, and requires minimal immobilization. Traditional options remain available if revision surgery is necessary. The finding that midcarpal arthrosis eventually develops at long-term follow-up yet remains asymptomatic has not detracted from the success of the operation. REFERENCES 1. Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br. 1981;63(2): 225e230. 2. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am. 1984;66(4):504e509. 3. Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am. 1987; 12(4):514e519. 4. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3): 358e365. 5. Krimmer H, Krapohl B, Sauerbier M, Hahn P. [Post-traumatic carpal collapse (SLAC- and SNAC-wrist)—stage classification and therapeutic possibilities]. Handchir Mikrochir Plast Chir. 1997;29(5): 228e233. 6. Clendenin MB, Green DP. Arthrodesis of the wrist-complications and their management. J Hand Surg Am. 1981;6(3):253e257. 7. Haddad RJ Jr, Riordan DC. Arthrodesis of the wrist. A surgical technique. J Bone Joint Surg Am. 1967;49(5):950e954. 8. Inglis AE, Jones EC. Proximal-row carpectomy for diseases of the proximal row. J Bone Joint Surg Am. 1977;59(4):460e463. 9. McAuliffe JA, Dell PC, Jaffe R. Complications of intercarpal arthrodesis. J Hand Surg Am. 1993;18(6):1121e1128. 10. Viegas SF. Limited arthrodesis for scaphoid nonunion. J Hand Surg Am. 1994;19(1):127e133. 11. Larsen CF, Jacoby RA, McCabe SJ. Nonunion rates of limited carpal arthrodesis: a meta-analysis of the literature. J Hand Surg Am. 1997; 22(1):66e73. 12. Malerich MM, Clifford J, Eaton B, Eaton R, Littler JW. Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion. J Hand Surg Am. 1999; 24(6):1196e1205. 13. Drac P, Manak P, Pieranova L. Distal scaphoid resection arthroplasty for scaphoid nonunion with radioscaphoid arthritis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2006;150(1): 143e145. 14. Ruch DS, Papadonikolakis A. Resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed previous surgical treatment. J Hand Surg Am. 2006;31(4):588e593. 15. Soejima O, Lida H, Hanamura T, Naito M. Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis. J Hand Surg Am. 2003;28(4):591e596. 16. Malerich MM, Littler JW, Eaton R. Distal scaphoid resection arthroplasty for the treatment of patients with degenerative arthritis secondary to scaphoid nonunion. Tech Hand Up Extrem Surg. 2002; 6(2):98e102. 17. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am. 1972;54(8):1612e1632. 18. Nattrass GR, King GJ, McMurtry RY, Brant RF. An alternative method for determination of the carpal height ratio. J Bone Joint Surg Am. 1994;76(1):88e94. 19. Garcia-Elias M, Lluch AL, Farreres A, Castillo F, Saffar P. Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis. J Hand Surg Br. 1999;24(4):448e452.
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20. Corbin C, Warwick D. Midcarpal instability after excision arthroplasty for scapho-trapezial-trapezoid (STT) arthritis. J Hand Surg Eur. 2009;34(4):537e538. 21. McCombe D, Ireland DC, McNab I. Distal scaphoid excision after radioscaphoid arthrodesis. J Hand Surg Am. 2001;26(5):877e882. 22. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid
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nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur. 2009;34(2):256e263. 23. Jebson PJ, Hayes EP, Engber WD. Proximal row carpectomy: a minimum 10-year follow-up study. J Hand Surg Am. 2003;28(4):561e569. 24. Tomaino MM, Delsignore J, Burton RI. Long-term results following proximal row carpectomy. J Hand Surg Am. 1994;19(4): 694e703.
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