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Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: Retrospective single-center 24-case series
Journal Pre-proof Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: retrospective single-center 24-case series G. Lafaye M. Rongi`eres P. Mansat J.L. Grolleau S. Riot
PII:
S2468-1229(19)30367-6
DOI:
https://doi.org/doi:10.1016/j.hansur.2019.11.005
Reference:
HANSUR 1081
To appear in:
Hand Surgery and Rehabilitation
Received Date:
30 April 2019
Accepted Date:
4 November 2019
Please cite this article as: G. LafayeM. Rongi`eresP. MansatJ.L. GrolleauS. Riot Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: retrospective single-center 24-case series (2019), doi: https://doi.org/10.1016/j.hansur.2019.11.005
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Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: retrospective single-center 24-case series Évaluation fonctionnelle de la prise en charge chirurgicale de l’arthrose scapho-trapézotrapézoïdienne isolée : série rétrospective monocentrique de 24 patients Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: retrospective single-center 24-case series Évaluation fonctionnelle de la prise en charge chirurgicale de l’arthrose scapho-trapézotrapézoïdienne isolée : série rétrospective monocentrique de 24 patients G. Lafaye1, M. Rongières2, P. Mansat2, J.-L. Grolleau1, S. Riot1
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1 : Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1, avenue du Professeur Jean Poulhès, 31400 Toulouse, France 2 : Chirurgie orthopédique-chirurgie de la main, Institut locomoteur Pierre-Paul Riquet, Hôpital Purpan, CHU de Toulouse, Place du Dr Baylac, 31059 Toulouse cedex, France
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Corresponding author : Dr Samuel RIOT, Interne des hôpitaux Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1 Avenue du Professeur Jean Poulhès, 31400 Toulouse , France Phone number : 0561322472 E-mail : [email protected]
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Other authors: Michel RONGIERES : Maître de Conférence des Universités, Chirurgie orthopédiquechirurgie de la main, Institut locomoteur Pierre-Paul Riquet, Hôpital Purpan, CHU de Toulouse, Place Baylac, 31059 Toulouse cedex, France Pierre MANSAT : Professeur des Universités, Chirurgie orthopédique-chirurgie de la main, Institut locomoteur Pierre-Paul Riquet, Hôpital Purpan, CHU de Toulouse, Place Baylac, 31059 Toulouse cedex, France Jean-Louis GROLLEAU : Professeur des Universités, Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1 Avenue du Professeur Jean Poulhès 31400 Toulouse, France Samuel RIOT : Chef de clinique des universités, Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1 Avenue du Professeur Jean Poulhès 31400 Toulouse, France Conflict of interest: The authors declare that they have no competing interest.
Abstract Isolated scaphotrapeziotrapezoid (STT) osteoarthritis has functional consequences on the wrist. The main objective of our study was to evaluate the functional outcomes of patients managed surgically during the last 12 years at the Toulouse University Hospital, regardless of the surgical technique used, for isolated STT osteoarthritis. We performed a single-center
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retrospective observational study using the CCAM database. The inclusion criteria were patients treated surgically for isolated STT osteoarthritis who did not respond to conservative treatment, with at least 6 months of clinical and radiological follow-up. Twenty-four patients were treated between 2006 and 2018. Partial arthroplasty of the distal pole of the scaphoid with or without interposition and total trapeziectomy had been performed on these patients. The mean follow-up was 79 ± 46.8 months. The wrist range of motion (ROM) and the Kapandji score were not significantly reduced postoperatively. The mean postoperative QuickDASH score was 29.15 ± 8.46. The mean pain assessed using a visual analog scale was 6.6 ± 1.17 preoperatively versus 1.25 ± 1.51 postoperatively (p=0.003). Statistical subgroup analysis found no predictive factor for a better postoperative QuickDASH score, and no surgical technique was superior at halting the progression of intracarpal misalignment and postoperative ROM. Surgical treatment of isolated STT osteoarthritis resistant to conservative treatment leads to significant functional improvement, particularly in terms of pain, without altering the wrist’s overall mobility.
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Résumé L’arthrose scapho-trapézo-trapézoïdienne (STT) isolée engendre un retentissement fonctionnel sur le poignet. L’objectif principal de notre étude était d’évaluer les résultats fonctionnels des patients pris en charge chirurgicalement au CHU de Toulouse durant les douze dernières années, quelle que soit la technique chirurgicale utilisée, pour une arthrose STT isolée. Nous avons réalisé une étude observationnelle rétrospective monocentrique en utilisant la base de données CCAM. Les critères d’inclusion étaient : patient pris en charge chirurgicalement pour une arthrose STT isolée résistant au traitement médical, avec un suivi clinique et radiologique supérieur à 6 mois. Vingt-quatre patients ont été pris en charge chirurgicalement entre 2006 et 2018. La résection arthroplastique partielle du pôle distal du scaphoïde avec ou sans interposition et la trapézectomie totale avaient été utilisées. Le recul moyen était de 79±46,8 mois. Les mobilités articulaires du poignet et le score de Kapandji n’étaient pas diminués de manière significative en postopératoire. Le score QuickDASH moyen postopératoire était de 29,15±8,46. La douleur moyenne appréciée sur une échelle visuelle analogique était de 6,6±1,17 en préopératoire contre 1,25±1,51 en postopératoire (p=0,003). Une analyse statistique en sous-groupes n’a pas permis de mettre en évidence de facteur prédictif d’un meilleur score QuickDASH postopératoire, ni la supériorité d’une technique chirurgicale sur l’évolution de la désaxation intracarpienne et les mobilités postopératoires. Le traitement chirurgical de l’arthrose STT isolée résistant au traitement médical apporte une amélioration fonctionnelle non négligeable, notamment sur la douleur sans altérer les mobilités globales du poignet. Keywords: Osteoarthritis; Scaphoid; Trapezium; Trapezoid; Carpal bones Mots-clés : Arthrose ; Scaphoïde ; Trapèze ; Trapézoïde ; Carpe
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1. Introduction Osteoarthritis of the scaphotrapeziotrapezoid (STT) joint was initially described by Carstam et al. in 1968 [1]. Unlike trapeziometacarpal osteoarthritis, STT osteoarthritis affects the biomechanics of the carpal bones with the development of intracarpal misalignment of the lunate (dorsal intercalated segment instability DISI, non-dissociative). This causes significant functional repercussions over time in the carpus. Its isolated form is rare. In fact, in general, it is part of peritrapezial osteoarthritis, which is associated with trapeziometacarpal osteoarthritis [2]. At the epidemiological level, it mainly affects women over 50 years in a bilateral form. As for prevalence, Viegas et al. [3] who found degeneration of the STT joint on 15% of wrist X-rays and in 21% of cadaver wrists. In addition, it is frequently associated with chondrocalcinosis. In his study, Saffar [4] found STT osteoarthritis in 61% of patients with chondrocalcinosis. We will focus on its isolated form here. After failure of well-conducted conservative treatment, several surgical options can be proposed: arthrodesis [5-11], partial arthroplasty resection of the distal pole of the scaphoid with or without tendon interposition [12-14], partial arthroplasty resection of the distal pole of the scaphoid with prosthetic interposition [15-19] or trapeziectomy with tendon interposition [20-22]. Few studies have documented the long-term functional outcomes of surgical management of isolated STT osteoarthritis. The main objective of our study was to evaluate the functional outcomes of patients with isolated STT osteoarthritis managed surgically at the Toulouse University Hospital, regardless of the surgical technique used, during the last 12 years. The secondary objectives were to find predictive factors for a better postoperative QuickDASH functional score, as well as to evaluate the impact of the chosen surgical technique on radiological intracarpal misalignment and postoperative mobility of the wrist.
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2. Patients and methods We performed a single-center retrospective observational study at the University Hospital of Toulouse (France). The inclusion criteria were patients treated surgically for isolated STT osteoarthritis resistant to conservative treatment with at least 6 months of clinical and radiological follow-up. The outcomes related to our principal objective were pain level, range of motion (ROM) in flexion and extension of the wrist, Kapandji score [23], radiological lunocapitate angle, as well as the QuickDASH functional score [24]. These outcomes were determined pre- and postoperatively. We identified eligible patients through the CCAM coding database (Common Classification of Medical Procedures). This French nomenclature gathers all the specific codes associated with each surgical technique. At the follow-up, all patients were reviewed in consultation by an independent surgeon. At each consultation, administrative, clinical and paraclinical data were collected pre- and postoperatively. In the medical history, the investigators inquired specifically about the history of wrist trauma, dominant hand, affected side, occupation (manual or not) as well as pre- and postoperative pain assessed using a visual analog scale (VAS) from 1 to 10. The QuickDASH functional score [24] assessed the patient’s pain and functional limitations over the prior 7 days pre- and postoperative. During the clinical examination, wrist flexion and extension were evaluated. The Kapandji score was also calculated to evaluate the overall mobility of the thumb [23]. Paraclinically, anteroposterior and lateral X-rays of the wrist were made. Staging of STT osteoarthritis was done using the Crosby classification as modified by Goubier et al. [7] (Table 1). Carpal bone misalignment was evaluated by measuring the lunocapitate angle on a lateral X-ray view. A lunocapitate angle greater than 15° was
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considered "pathological" and the wrist was classified in category B (misaligned wrist). Finally, postoperative complications were recorded. We used the “Numbers 4.3.1” software to calculate the mean, median, standard deviation, minimum and maximum values. The statistical analysis was carried out using R software. Student’s t test was used to compare the measurements of a quantitative variable between two groups when the studied population followed a normal distribution; if it did not follow a normal distribution, a Mann-Whitney test was used. The threshold value of significance was 5% (p < 0.05).
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3. Results Between 2006 and 2018, 623 patients met the search criteria in the CCAM database. Of these, only 26 patients were surgically treated for isolated STT osteoarthritis after failure of conservative treatment. Two patients were lost to follow-up before 6 months. In the end, 24 patients were included in our study. The patients had been operated by seven senior surgeons. Our case series included 15 women (62.5%) and 9 men (37.5%) with an average age of 62 ± 9.3 years at the time of surgery. None of these patients responded to well-conducted conservative treatment including brace immobilization, NSAIDs for analgesic purposes, intraarticular injections of corticosteroids as well as physical therapy. Our series was composed of 21 right-handed (87.5%) and 3 left-handed (12.5%) individuals; the dominant hand was operated in 16 patients (66.6%). Seventeen patients performed manual work (70.8%). Two patients had a history of wrist trauma (scaphoid fracture of the distal pole treated surgically, and fracture of the distal radius treated by intramedullary fixation) and three patients with a history of chondrocalcinosis. One patient had been treated for STT arthritis by partial resection of the distal scaphoid pole with interposition of the abductor pollicis longus (APL) tendon. In the radiological classification of STT arthritis, 3 wrists were graded stage I (12%), 10 wrists were stage IIa (42%), 7 wrists were stage IIb (29%) and 4 wrists stage IIIa (16, 6%). In terms of surgical techniques, eight patients underwent partial scaphoidectomy with pyrocarbon implant, five patients underwent partial scaphoidectomy with tendon interposition (flexor carpi radialis or APL), four patients underwent partial scaphoidectomy alone and seven patients underwent total trapeziectomy. None had STT arthrodesis. The mean follow-up since surgery was 79 ± 46.8 months. The mean VAS for pain at the STT joint was 6.6 ± 1.17 preoperatively versus 1.25 ± 1.51 postoperatively. This reduction in pain levels, with a change of 5.35 points on average, was statistically significant (p=0.003). Regarding mobility, the mean wrist flexion was 65° ± 7.37 preoperatively vs 63.9° ± 7.97 postoperatively, a loss of 1.09° on average (p = 0.412). Mean wrist extension preoperatively was 58.75° ± 6.79 vs 54.37° ± 10.76 postoperatively, a loss of 4.38° on average (p = 0.124). The mean preoperative Kapandji score was 9.21 ± 0.93 compared to 9.04 ± 0.99 postoperatively, a loss of 0.17 points on average postoperatively (p = 0.527) (Table 2). The mean lunocapitate angle found preoperatively was 11.5° ± 6.2, whereas the postoperative angle was 14.34° ± 6.1. However this increase of 2.84° was not statistically significant (p=0.131). The postoperative mean QuickDASH score was 29.15 ± 8.46 out of 100. We also looked for potential predictive factors of a better functional QuickDASH score postoperatively through subgroup analyses. The criteria studied were the patient’s age at surgery (< 60 years or > 60 years), the radiological misalignment of the carpal bones according to the Crosby classification as modified by Goubier [7], the patient’s gender and the surgical technique used. The subgroup analysis of the "age" criterion showed no significant difference between the QuickDASH score of the under 60 group and that of the over 60 group: the average QuickDASH score was 30.2 ± 11.9 for those under 60 years of age compared to an average of 29.9 ± 5.2 for those over 60 years (p = 0.976). Regarding the
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subgroup analysis of carpal bone misalignment, no significant difference was found: the average QuickDASH score in the Crosby A group (aligned carpus) was 31.7 ± 8.8 while it was 25.8 ± 4.9 in the Crosby B group (DISI) (p = 0.0917). The subgroup analysis of the "gender" criterion also showed no significant difference: the average QuickDASH score was 30.6 ± 6.9 for women, compared to an average of 29 ± 11.7 for men (p = 0.455). Finally, the subgroup analysis of the surgical technique used revealed no significant difference in the mean QuickDASH score between patients who underwent a partial scaphoidectomy with placement of a pyrocarbon implant (29.9 ± 12.7) and other techniques (30.1 ± 6.5) (p = 0.759). There was also no significant difference between patients who underwent partial scaphoidectomy with tendon interposition (29.8 ± 8.6) and other techniques (30.05 ± 8.9) (p = 0.914). We also found no significant difference between patients who underwent partial scaphoidectomy (33.25 ± 5.6) and other surgeries (29.35 ± 9.2) (p=0.351) as well as patients who underwent trapeziectomy (24.1 ± 5.9) versus the other techniques (30.6 ± 9.5) (p = 0.588). These results are summarized in Tables 3 and 4. We also evaluated the impact of the surgical technique performed on the progression of radiographic carpal bone misalignment. For this, we compared the difference between the postoperative and preoperative lunocapitate angle (CL) based on the surgical technique to determine if one of them produced better carpal bone stability over time. Our analysis found no significant differences in carpal bone misalignment between patients who underwent partial scaphoidectomy with pyrocarbon implant (+2.83° ± 1.2) and other techniques (+2.64° ± 0.5) (p = 0.806). We found no significant difference between patients with partial scaphoidectomy plus tendon interposition (+2.46° ± 0.5) and other techniques (+2.77° ± 0.8) (p = 0.373). Similarly, we found no significant difference between patients who underwent partial scaphoidectomy alone (+3.01° ± 0.3) and other techniques (+2.63° ± 0.8) (p = 0.244), as well as for patients who underwent trapeziectomy (+2.52° ± 0.6) versus the other techniques (+2.78° ± 0.8) (p = 0.679). These results are summarized in Table 5. Finally, we evaluated the impact of surgical technique on the change in postoperative wrist ROM. We compared the difference between post and preoperative wrist flexion, as well as wrist extension, according to the surgical technique to determine whether one of the techniques contributed to better ROM over time. Our analysis revealed no significant difference in flexion between patients who underwent partial scaphoidectomy with pyrocarbon implant (+1.87° ± 1.1) and other surgical techniques (−2.81° ± 0.7) (p = 0.274), as well as for extension (−3.75° ± 1.2 vs. −4.68° ± 0.8; p = 0.873). We found no significant difference in flexion between patients with partial scaphoidectomy associated with tendon interposition (−6° ± 0.5) and other techniques (+ 0° ± 0.9) (p = 0.232), as well as for extension (−6° ± 1.2 vs. −3.95° ± 0.6, p = 0.99). Similarly, we found no significant difference in flexion between patients who had partial scaphoidectomy alone (+ 0° ± 0.4) and other techniques (−1.5° ± 0.7) (p = 0.654), as well as for extension (−7.5° ± 1.4 versus 3.75° ± 0.8, p = 0.493). Finally, we found no significant difference in flexion between the patients who underwent total trapeziectomy (−2.14° ± 0.5) and the other techniques (−0.88° ± 0.9) (p = 0.664) as well as for extension (−2.14° ± 1.2 vs. −5.29° ± 1.5. p = 0.467). Regarding complications, two cases of complex regional pain syndrome were found (one after partial scaphoidectomy with pyrocarbon implant and one after partial scaphoidectomy alone). One pyrocarbon implant surgical revision was needed due to malposition. 4. Discussion Our results are similar to those found in the literature, both in terms of pain reduction and functional outcomes (Table 6). There was a statistically significant reduction in pain after surgical management of 5.35 points of average on the VAS (p=0.003). This represents a significant improvement in the patient's quality of life, especially since pain is the main
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symptom that pushes patients to consult. Moreover, there was no significant postoperative decrease in wrist ROM postoperatively: flexion (−1.09°) and extension (−4.38°). In addition, the Kapandji score for thumb mobility was almost unchanged (loss of 0.17 point, not significant). Finally, the surgical treatment did not cause statistically significant radiological carpal bone offsets with an average postoperative lunocapitate angle of 14.34° ± 6.1 (p = 0.131) which remained below the 15° threshold. However, a mean postoperative QuickDASH score of 29.15 out of 100 means that patients are still functionally impaired in daily life despite surgical management. There is therefore a global functional interest in the surgical management of STT osteoarthritis in case of failure of conservative treatment. We found no statistically significant predictors of improvement in the postoperative QuickDASH functional score, whether in terms of patient’s age, gender, radiological Crosby status, or surgical technique used. Regarding the impact of the surgical technique on the progression of carpal bones misalignment, no technique was statistically superior. Similarly, no surgical technique was statistically superior in terms of its impact on wrist flexion and extension. This lack of significant results can be attributed to the limitations of our study. Indeed, because of the scarcity of isolated STT osteoarthritis cases, only a small number of patients were included. However, with 24 patients included, our study is one of the largest case series published to date. In addition, with four different surgical techniques, our statistical analysis was less robust, with the need to perform subgroup analyses. Finally, from a pure methodological point of view, our study was retrospective. This potentially leads to publication bias and selective reporting within our study. Arthrodesis has long been the gold standard for treating isolated STT osteoarthritis. According to some authors, it helps to reduce pain, minimally affects the grip strength and prevents carpal bone misalignment in the long term [5-7]. However, this technique has a risk of significant complications, in particular of non-union, from 4% to 31% depending on the series [8,10,11]. This is a technically difficult procedure due to the need for bone supply and precise adjustment of the scaphoid position to minimize the consequences of its absence on mobility. In addition, Watson et al. [6] recommends that a partial radial styloidectomy be performed to reduce the risk of postoperative radioscaphoid osteoarthritis. Some authors feel it is illogical to eliminate the mobility of the scaphoid, essential to carpal kinematics [15]. In this context, new techniques have been developed, including partial resection of the distal pole of the scaphoid. This can be isolated or supplemented by an interposition (prosthetic or tendinous). Simple arthroplasty resection performed under arthroscopy [12-14] requires that 4 mm be resected from the distal pole of the scaphoid according to Mathoulin and Darin [16], in order to avoid any risk of residual impingement. And to avoid the risk of DISI, GarciaElias [12] recommends performing capsuloplasty and prohibits this intervention when DISI is present preoperatively. The interposition of a pyrocarbon implant restores the spatial configuration of carpal bones and prevents any secondary misalignment. The published studies report good results with less pain, a low impact on wrist mobility [15-19] and no implant dislocation (except for the case series by Mathoulin and Darin [16] in which two implants dislocated because of initial positioning defects). Finally, total trapeziectomy is another alternative and also has good functional results in the literature [20-22]. Ultimately, based on our findings, there is an functional benefit to surgically managing patients with isolated STT arthritis who do not respond to conservative treatment. However, whether through our series or in the literature, no surgical technique stands out as being the best for managing isolated STT osteoarthritis. This is the conclusion arrived at by Deans et al. [25] based on their systematic review of the literature. They also concluded that it is impossible at the moment to determine the best surgical technique but that STT arthrodesis
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should no longer be considered as the gold standard. It is now competing with other methods (STT arthroplasty or total trapeziectomy) that have good published outcomes. Given the low incidence of isolated STT osteoarthritis, only a multicenter randomized and prospective study would be able to identify any significant differences.
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Conflict of interest: The authors declare that they have no competing interest.
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5. Conclusion STT osteoarthritis is a functionally disabling condition that must be managed surgically when conservative treatment fails. Our study did not identify any predictive factors for better functional outcomes in isolated STT osteoarthritis surgery. Moreover, given our results, we cannot determine a gold standard surgical technique. However, current published data support the abandonment of arthrodesis in favor of other methods such as STT arthroplasty and total trapeziectomy.
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References [1]. Carstam N, Eiken O, Andrén L. Osteoarthritis of the trapezio-scaphoid joint. Acta Orthop Scand. 1968;39:354–8. [2]. Brown GD 3rd, Roh MS, Strauch RJ, Rosenwasser MP, Ateshian GA, Mow VC. Radiography and visual pathology of the osteoarthritic scaphotrapezio-trapezoidal joint, and its relationship to trapeziometacarpal osteoarthritis. J Hand Surg Am 2003;28:739–43. [3]. Viegas SF, Patterson RM, Hokanson JA, Davis J. Wrist anatomy: incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. J Hand Surg Am 1993;18:463–75. [4]. Saffar P. Chondrocalcinosis of the wrist. J Hand Surg Br 2004;29:486-93. [5]. Fortin PT, Louis DS. Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis. J Hand Surg Am 1993;18:675–81. [6]. Watson HK, Wollstein R, Joseph E, Manzo R, Weinzweig J, Ashmead D 4th. Scaphotrapeziotrapezoid arthrodesis: a follow-up study. J Hand Surg Am 2003;28:397–404. [7]. Goubier JN, Bauer B, Alnot JY, Teboul F. [Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis]. Chir Main 2006;25:179-84. [8]. Minami A, Kato H, Suenaga N, Iwasaki N. Scaphotrapeziotrapezoid fusion: long-term follow-up study. J Orthop Sci 2003;8:319-22. [9]. Wollstein R, Watson HK. Scaphotrapeziotrapezoid arthrodesis for arthritis. Hand Clin 2005;21:539-43, vi. [10]. Ishida O, Tsai TM. Complications and results of scapho-trapezio-trapezoid arthrodesis. Clin Orthop Relat Res 1993;287:125–30. [11]. Frykman EB, Af Ekenstam F, Wadin K. Triscaphoid arthrodesis and its complications. J Hand Surg Am 1988;13:844–9. [12]. Garcia-Elias M. Excisional arthroplasty for scaphotrapeziotrapezoidal osteoarthritis. J Hand Surg Am 2011;36:516–20. [13]. Zimmermann MS, Weiss AP. Scaphotrapezium-trapezoid arthroses. J Hand Sur Am 2012;37:2139-41; quiz 2141. [14]. Normand J, Desmoineaux P, Boisrenoult P, Beaufils P. [The arthroscopic distal pole resection of the scaphoid: clinical results in STT osteoarthritis]. Chir Main 2012;31:13–7. [15]. Pequignot JP, D’asnieres de Veigy L, Allieu Y. [Arthroplasty for scaphotrapeziotrapezoidal arthrosis using a pyrolytic carbon implant. Preliminary results]. Chir Main 2005;24:148–52. [16]. Mathoulin C, Darin F. Arthroscopic treatment of scaphotrapeziotrapezoid osteoarthritis. Hand Clin 2011;27:319–22. [17]. Low AK, Edmunds IA. Isolated scaphotrapeziotrapezoid osteoarthritis: preliminary results of treatment using a pyrocarbon implant. Hand Surg 2007;12:73–7. [18]. Gauthier E, Truffandier MV, Gaisne E, Bellemère P. Treatment of scaphotrapeziotrapezoid osteoarthritis with the Pyrocardan(®) implant: Results with a minimum follow-up of 2 years. Hand Surg Rehabil 2017;36:113–21. [19]. Pegoli L, Zorli IP, Pivato G, Berto G, Pajardi G. Scaphotrapeziotrapezoid joint arthritis: a pilot study of treatment with the scaphoid trapezium pyrocarbon implant. J Hand Surg Br 2006;31:569-73. [20]. Langenhan R, Hohendorff B, Probst A. Trapeziectomy and ligament reconstruction tendon interposition for isolated scaphotrapeziotrapezoid osteoarthritis of the wrist. J Hand Surg Eur 2014;39:833–7. [21]. Andrachuk J, Yang SS. Modified total trapezial and partial trapezoidal excision and ligament reconstruction tendon interposition reduces symptoms in isolated scaphotrapezialtrapezoid arthritis of the wrist. J Hand Surg Eur. 2012;37:637–41.
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[22]. Wolf JM, Delaronde S. Current trends in nonoperative and operative treatment of trapeziometacarpal osteoarthritis: a survey of US hand surgeons. J Hand Surg Am 2012;37:77–82. [23]. Kapandji A. Clinical test of apposition and counter-apposition of the thumb. Ann Chir Main 1986;5;67-73. [24]. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44. [25]. Deans VM, Naqui Z, Muir LTSW. Scaphotrapeziotrapezoidal joint osteoarthritis: A systematic review of surgical treatment. J Hand Surg Asian Pac 2017;22:1–9.
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Table titles Table 1. Crosby classification as modified by Goubier et al. [7] Normal
Grade I
Joint space narrowing <50%
Grade II
Joint space narrowing > 50%
IIa
Without axial misalignment of carpal bones
IIb
With axial misalignment of carpal bones
Grade III
Erosions, sclerosis and irregularities
IIIa
Without axial misalignment of carpal bones
IIIb
With axial misalignment of carpal bones
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Grade 0
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Table 2. Analysis of range of motion measured pre- and postoperatively Table 2. Analysis of range of motion measured pre- and post-operatively
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Post-operative
Mann-Whitney (p)
Extension
Kapandji score
65° ± 7.37
58.75° ± 6.79
9.21 ± 0.93
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Pre-operative
Flexion
63.91° ± 7.97
54.37° ± 10.76 9.04 ± 0.99
p = 0412
p = 0.124
p = 0.527
Table 3. Analysis of the postoperative QuickDASH scores according to age, carpal bone misalignment and sex Quick DASH (out of 100) Mann Whitney (p Study Characteristics ) < 60 years 30.2 p = 0.976 > 60 years 29.9 Crosby A Crosby B
31.7 25.8
p = 0.0917
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Females Males
30.6 29.0
p = 0.455
Table 3. Analysis of the postoperative Quick DASH scores according to age, carpal bones misalignment and sex
Table 4. Analysis of the postoperative QuickDASH scores according to the surgical technique Table 4. Analysis of the postoperative Quick DASH scores according to the surgical technique
Quick DASH (/100)
Partial scaphoidectomy + pyrocarbon implant
29.9
Others
30.1
Partial scaphoidectomy + tendinous interposition
29.8
Others
30.05
33.25 29.35
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Others
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p = 0.914
p = 0.351
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Others
Total trapeziectomy
p = 0.759
Pr
Partial scaphoidectomy only
Mann Whitney (p)
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Surgical Technique
24.1
p = 0.588
Cases (n) 8
5
4
7
30.6
Table 5. Comparison of the post- and preoperative lunocapitate (LC) angle according to the type of surgery Table 5. Comparison of the post- and preoperative lunocapitate (LC) angle according to the type of surgery
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Surgical Technique
Preoperative LC angle
Difference between post- and preoperative LC angle
Partial scaphoidectomy + pyrocarbon implant
15.13° ± 4.7
+ 2.83°
Others
9.7° ± 4.3
+ 2.64°
Partial scaphoidectomy + tendinous interposition
12.22° ± 3.1
+ 2.46°
Others
11.33° ± 5.2
+ 2.77°
Partial scaphoidectomy only
7.25° ± 0.64
+ 3.01°
Others
12.37° ± 4.1
+ 2.63°
Total trapeziectomy
9.31° ± 1.6
+ 2.52°
Cases (n) 8
p = 0.806
5
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p = 0.373
4
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12.42° ± 4.3
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p = 0.244
7 p = 0.679
+ 2.78°
Pr
Others
Mann Whitney (p)
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Table 6. Published outcomes after surgical STT arthritis treatment relative to the surgical technique
Preop Cases average flexion (°)
Postop average flexion (°)
Surgical Technique
Study
Total trapeziectomy
Andrachuk et 12 al. [21]
48° (38-60°) 53° (38-65°)
STT arthrodesis
Watson et al. 800 [6]
Not measured
54° ( 0-134°)
Preop Postop p value average average p valu extension (°) extension (°) p< 0.05
52° (45-65°) 55° (50-65°)
Not measured
p< 0.05
49° (0-130°)
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Minami et al. 30 [8]
43° ± 14°
Goubier et al. 13 [7]
51° (5-70°) 67° (20-80°)
Fortin et al. [5]
14
Not measured
68% contralateral side
Not measured
58% contralateral side
10
Not measured
71° (55-80°)
Not measured
55° (45-70°)
10
Not measured
Not measured
Not measured
Not measured
8
56°
58°
56°
45° ± 15°
p> 0.05
39° (15-60°) 26° (15-60°)
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p> 0.05
59°
p> 0.05
38° ± 16°
p> 0.05
p= 0.03
p> 0.05
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Partial scaphoidectomy + Normand et tendon al. [14] interposition
e-
Low et al. Partial [17] scaphoidectomy + pyrocarbon Pegoli et al. implant [19]
39° ± 14°
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PII:
S2468-1229(19)30367-6
DOI:
https://doi.org/doi:10.1016/j.hansur.2019.11.005
Reference:
HANSUR 1081
To appear in:
Hand Surgery and Rehabilitation
Received Date:
30 April 2019
Accepted Date:
4 November 2019
Please cite this article as: G. LafayeM. Rongi`eresP. MansatJ.L. GrolleauS. Riot Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: retrospective single-center 24-case series (2019), doi: https://doi.org/10.1016/j.hansur.2019.11.005
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: retrospective single-center 24-case series Évaluation fonctionnelle de la prise en charge chirurgicale de l’arthrose scapho-trapézotrapézoïdienne isolée : série rétrospective monocentrique de 24 patients Functional outcomes after surgical treatment of isolated scaphotrapeziotrapezoid osteoarthritis: retrospective single-center 24-case series Évaluation fonctionnelle de la prise en charge chirurgicale de l’arthrose scapho-trapézotrapézoïdienne isolée : série rétrospective monocentrique de 24 patients G. Lafaye1, M. Rongières2, P. Mansat2, J.-L. Grolleau1, S. Riot1
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1 : Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1, avenue du Professeur Jean Poulhès, 31400 Toulouse, France 2 : Chirurgie orthopédique-chirurgie de la main, Institut locomoteur Pierre-Paul Riquet, Hôpital Purpan, CHU de Toulouse, Place du Dr Baylac, 31059 Toulouse cedex, France
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Corresponding author : Dr Samuel RIOT, Interne des hôpitaux Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1 Avenue du Professeur Jean Poulhès, 31400 Toulouse , France Phone number : 0561322472 E-mail : [email protected]
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Other authors: Michel RONGIERES : Maître de Conférence des Universités, Chirurgie orthopédiquechirurgie de la main, Institut locomoteur Pierre-Paul Riquet, Hôpital Purpan, CHU de Toulouse, Place Baylac, 31059 Toulouse cedex, France Pierre MANSAT : Professeur des Universités, Chirurgie orthopédique-chirurgie de la main, Institut locomoteur Pierre-Paul Riquet, Hôpital Purpan, CHU de Toulouse, Place Baylac, 31059 Toulouse cedex, France Jean-Louis GROLLEAU : Professeur des Universités, Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1 Avenue du Professeur Jean Poulhès 31400 Toulouse, France Samuel RIOT : Chef de clinique des universités, Chirurgie Plastique, Esthétique et Reconstructrice - Chirurgie de la main, Hôpital Rangueil, CHU de Toulouse, 1 Avenue du Professeur Jean Poulhès 31400 Toulouse, France Conflict of interest: The authors declare that they have no competing interest.
Abstract Isolated scaphotrapeziotrapezoid (STT) osteoarthritis has functional consequences on the wrist. The main objective of our study was to evaluate the functional outcomes of patients managed surgically during the last 12 years at the Toulouse University Hospital, regardless of the surgical technique used, for isolated STT osteoarthritis. We performed a single-center
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retrospective observational study using the CCAM database. The inclusion criteria were patients treated surgically for isolated STT osteoarthritis who did not respond to conservative treatment, with at least 6 months of clinical and radiological follow-up. Twenty-four patients were treated between 2006 and 2018. Partial arthroplasty of the distal pole of the scaphoid with or without interposition and total trapeziectomy had been performed on these patients. The mean follow-up was 79 ± 46.8 months. The wrist range of motion (ROM) and the Kapandji score were not significantly reduced postoperatively. The mean postoperative QuickDASH score was 29.15 ± 8.46. The mean pain assessed using a visual analog scale was 6.6 ± 1.17 preoperatively versus 1.25 ± 1.51 postoperatively (p=0.003). Statistical subgroup analysis found no predictive factor for a better postoperative QuickDASH score, and no surgical technique was superior at halting the progression of intracarpal misalignment and postoperative ROM. Surgical treatment of isolated STT osteoarthritis resistant to conservative treatment leads to significant functional improvement, particularly in terms of pain, without altering the wrist’s overall mobility.
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Résumé L’arthrose scapho-trapézo-trapézoïdienne (STT) isolée engendre un retentissement fonctionnel sur le poignet. L’objectif principal de notre étude était d’évaluer les résultats fonctionnels des patients pris en charge chirurgicalement au CHU de Toulouse durant les douze dernières années, quelle que soit la technique chirurgicale utilisée, pour une arthrose STT isolée. Nous avons réalisé une étude observationnelle rétrospective monocentrique en utilisant la base de données CCAM. Les critères d’inclusion étaient : patient pris en charge chirurgicalement pour une arthrose STT isolée résistant au traitement médical, avec un suivi clinique et radiologique supérieur à 6 mois. Vingt-quatre patients ont été pris en charge chirurgicalement entre 2006 et 2018. La résection arthroplastique partielle du pôle distal du scaphoïde avec ou sans interposition et la trapézectomie totale avaient été utilisées. Le recul moyen était de 79±46,8 mois. Les mobilités articulaires du poignet et le score de Kapandji n’étaient pas diminués de manière significative en postopératoire. Le score QuickDASH moyen postopératoire était de 29,15±8,46. La douleur moyenne appréciée sur une échelle visuelle analogique était de 6,6±1,17 en préopératoire contre 1,25±1,51 en postopératoire (p=0,003). Une analyse statistique en sous-groupes n’a pas permis de mettre en évidence de facteur prédictif d’un meilleur score QuickDASH postopératoire, ni la supériorité d’une technique chirurgicale sur l’évolution de la désaxation intracarpienne et les mobilités postopératoires. Le traitement chirurgical de l’arthrose STT isolée résistant au traitement médical apporte une amélioration fonctionnelle non négligeable, notamment sur la douleur sans altérer les mobilités globales du poignet. Keywords: Osteoarthritis; Scaphoid; Trapezium; Trapezoid; Carpal bones Mots-clés : Arthrose ; Scaphoïde ; Trapèze ; Trapézoïde ; Carpe
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1. Introduction Osteoarthritis of the scaphotrapeziotrapezoid (STT) joint was initially described by Carstam et al. in 1968 [1]. Unlike trapeziometacarpal osteoarthritis, STT osteoarthritis affects the biomechanics of the carpal bones with the development of intracarpal misalignment of the lunate (dorsal intercalated segment instability DISI, non-dissociative). This causes significant functional repercussions over time in the carpus. Its isolated form is rare. In fact, in general, it is part of peritrapezial osteoarthritis, which is associated with trapeziometacarpal osteoarthritis [2]. At the epidemiological level, it mainly affects women over 50 years in a bilateral form. As for prevalence, Viegas et al. [3] who found degeneration of the STT joint on 15% of wrist X-rays and in 21% of cadaver wrists. In addition, it is frequently associated with chondrocalcinosis. In his study, Saffar [4] found STT osteoarthritis in 61% of patients with chondrocalcinosis. We will focus on its isolated form here. After failure of well-conducted conservative treatment, several surgical options can be proposed: arthrodesis [5-11], partial arthroplasty resection of the distal pole of the scaphoid with or without tendon interposition [12-14], partial arthroplasty resection of the distal pole of the scaphoid with prosthetic interposition [15-19] or trapeziectomy with tendon interposition [20-22]. Few studies have documented the long-term functional outcomes of surgical management of isolated STT osteoarthritis. The main objective of our study was to evaluate the functional outcomes of patients with isolated STT osteoarthritis managed surgically at the Toulouse University Hospital, regardless of the surgical technique used, during the last 12 years. The secondary objectives were to find predictive factors for a better postoperative QuickDASH functional score, as well as to evaluate the impact of the chosen surgical technique on radiological intracarpal misalignment and postoperative mobility of the wrist.
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2. Patients and methods We performed a single-center retrospective observational study at the University Hospital of Toulouse (France). The inclusion criteria were patients treated surgically for isolated STT osteoarthritis resistant to conservative treatment with at least 6 months of clinical and radiological follow-up. The outcomes related to our principal objective were pain level, range of motion (ROM) in flexion and extension of the wrist, Kapandji score [23], radiological lunocapitate angle, as well as the QuickDASH functional score [24]. These outcomes were determined pre- and postoperatively. We identified eligible patients through the CCAM coding database (Common Classification of Medical Procedures). This French nomenclature gathers all the specific codes associated with each surgical technique. At the follow-up, all patients were reviewed in consultation by an independent surgeon. At each consultation, administrative, clinical and paraclinical data were collected pre- and postoperatively. In the medical history, the investigators inquired specifically about the history of wrist trauma, dominant hand, affected side, occupation (manual or not) as well as pre- and postoperative pain assessed using a visual analog scale (VAS) from 1 to 10. The QuickDASH functional score [24] assessed the patient’s pain and functional limitations over the prior 7 days pre- and postoperative. During the clinical examination, wrist flexion and extension were evaluated. The Kapandji score was also calculated to evaluate the overall mobility of the thumb [23]. Paraclinically, anteroposterior and lateral X-rays of the wrist were made. Staging of STT osteoarthritis was done using the Crosby classification as modified by Goubier et al. [7] (Table 1). Carpal bone misalignment was evaluated by measuring the lunocapitate angle on a lateral X-ray view. A lunocapitate angle greater than 15° was
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considered "pathological" and the wrist was classified in category B (misaligned wrist). Finally, postoperative complications were recorded. We used the “Numbers 4.3.1” software to calculate the mean, median, standard deviation, minimum and maximum values. The statistical analysis was carried out using R software. Student’s t test was used to compare the measurements of a quantitative variable between two groups when the studied population followed a normal distribution; if it did not follow a normal distribution, a Mann-Whitney test was used. The threshold value of significance was 5% (p < 0.05).
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3. Results Between 2006 and 2018, 623 patients met the search criteria in the CCAM database. Of these, only 26 patients were surgically treated for isolated STT osteoarthritis after failure of conservative treatment. Two patients were lost to follow-up before 6 months. In the end, 24 patients were included in our study. The patients had been operated by seven senior surgeons. Our case series included 15 women (62.5%) and 9 men (37.5%) with an average age of 62 ± 9.3 years at the time of surgery. None of these patients responded to well-conducted conservative treatment including brace immobilization, NSAIDs for analgesic purposes, intraarticular injections of corticosteroids as well as physical therapy. Our series was composed of 21 right-handed (87.5%) and 3 left-handed (12.5%) individuals; the dominant hand was operated in 16 patients (66.6%). Seventeen patients performed manual work (70.8%). Two patients had a history of wrist trauma (scaphoid fracture of the distal pole treated surgically, and fracture of the distal radius treated by intramedullary fixation) and three patients with a history of chondrocalcinosis. One patient had been treated for STT arthritis by partial resection of the distal scaphoid pole with interposition of the abductor pollicis longus (APL) tendon. In the radiological classification of STT arthritis, 3 wrists were graded stage I (12%), 10 wrists were stage IIa (42%), 7 wrists were stage IIb (29%) and 4 wrists stage IIIa (16, 6%). In terms of surgical techniques, eight patients underwent partial scaphoidectomy with pyrocarbon implant, five patients underwent partial scaphoidectomy with tendon interposition (flexor carpi radialis or APL), four patients underwent partial scaphoidectomy alone and seven patients underwent total trapeziectomy. None had STT arthrodesis. The mean follow-up since surgery was 79 ± 46.8 months. The mean VAS for pain at the STT joint was 6.6 ± 1.17 preoperatively versus 1.25 ± 1.51 postoperatively. This reduction in pain levels, with a change of 5.35 points on average, was statistically significant (p=0.003). Regarding mobility, the mean wrist flexion was 65° ± 7.37 preoperatively vs 63.9° ± 7.97 postoperatively, a loss of 1.09° on average (p = 0.412). Mean wrist extension preoperatively was 58.75° ± 6.79 vs 54.37° ± 10.76 postoperatively, a loss of 4.38° on average (p = 0.124). The mean preoperative Kapandji score was 9.21 ± 0.93 compared to 9.04 ± 0.99 postoperatively, a loss of 0.17 points on average postoperatively (p = 0.527) (Table 2). The mean lunocapitate angle found preoperatively was 11.5° ± 6.2, whereas the postoperative angle was 14.34° ± 6.1. However this increase of 2.84° was not statistically significant (p=0.131). The postoperative mean QuickDASH score was 29.15 ± 8.46 out of 100. We also looked for potential predictive factors of a better functional QuickDASH score postoperatively through subgroup analyses. The criteria studied were the patient’s age at surgery (< 60 years or > 60 years), the radiological misalignment of the carpal bones according to the Crosby classification as modified by Goubier [7], the patient’s gender and the surgical technique used. The subgroup analysis of the "age" criterion showed no significant difference between the QuickDASH score of the under 60 group and that of the over 60 group: the average QuickDASH score was 30.2 ± 11.9 for those under 60 years of age compared to an average of 29.9 ± 5.2 for those over 60 years (p = 0.976). Regarding the
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subgroup analysis of carpal bone misalignment, no significant difference was found: the average QuickDASH score in the Crosby A group (aligned carpus) was 31.7 ± 8.8 while it was 25.8 ± 4.9 in the Crosby B group (DISI) (p = 0.0917). The subgroup analysis of the "gender" criterion also showed no significant difference: the average QuickDASH score was 30.6 ± 6.9 for women, compared to an average of 29 ± 11.7 for men (p = 0.455). Finally, the subgroup analysis of the surgical technique used revealed no significant difference in the mean QuickDASH score between patients who underwent a partial scaphoidectomy with placement of a pyrocarbon implant (29.9 ± 12.7) and other techniques (30.1 ± 6.5) (p = 0.759). There was also no significant difference between patients who underwent partial scaphoidectomy with tendon interposition (29.8 ± 8.6) and other techniques (30.05 ± 8.9) (p = 0.914). We also found no significant difference between patients who underwent partial scaphoidectomy (33.25 ± 5.6) and other surgeries (29.35 ± 9.2) (p=0.351) as well as patients who underwent trapeziectomy (24.1 ± 5.9) versus the other techniques (30.6 ± 9.5) (p = 0.588). These results are summarized in Tables 3 and 4. We also evaluated the impact of the surgical technique performed on the progression of radiographic carpal bone misalignment. For this, we compared the difference between the postoperative and preoperative lunocapitate angle (CL) based on the surgical technique to determine if one of them produced better carpal bone stability over time. Our analysis found no significant differences in carpal bone misalignment between patients who underwent partial scaphoidectomy with pyrocarbon implant (+2.83° ± 1.2) and other techniques (+2.64° ± 0.5) (p = 0.806). We found no significant difference between patients with partial scaphoidectomy plus tendon interposition (+2.46° ± 0.5) and other techniques (+2.77° ± 0.8) (p = 0.373). Similarly, we found no significant difference between patients who underwent partial scaphoidectomy alone (+3.01° ± 0.3) and other techniques (+2.63° ± 0.8) (p = 0.244), as well as for patients who underwent trapeziectomy (+2.52° ± 0.6) versus the other techniques (+2.78° ± 0.8) (p = 0.679). These results are summarized in Table 5. Finally, we evaluated the impact of surgical technique on the change in postoperative wrist ROM. We compared the difference between post and preoperative wrist flexion, as well as wrist extension, according to the surgical technique to determine whether one of the techniques contributed to better ROM over time. Our analysis revealed no significant difference in flexion between patients who underwent partial scaphoidectomy with pyrocarbon implant (+1.87° ± 1.1) and other surgical techniques (−2.81° ± 0.7) (p = 0.274), as well as for extension (−3.75° ± 1.2 vs. −4.68° ± 0.8; p = 0.873). We found no significant difference in flexion between patients with partial scaphoidectomy associated with tendon interposition (−6° ± 0.5) and other techniques (+ 0° ± 0.9) (p = 0.232), as well as for extension (−6° ± 1.2 vs. −3.95° ± 0.6, p = 0.99). Similarly, we found no significant difference in flexion between patients who had partial scaphoidectomy alone (+ 0° ± 0.4) and other techniques (−1.5° ± 0.7) (p = 0.654), as well as for extension (−7.5° ± 1.4 versus 3.75° ± 0.8, p = 0.493). Finally, we found no significant difference in flexion between the patients who underwent total trapeziectomy (−2.14° ± 0.5) and the other techniques (−0.88° ± 0.9) (p = 0.664) as well as for extension (−2.14° ± 1.2 vs. −5.29° ± 1.5. p = 0.467). Regarding complications, two cases of complex regional pain syndrome were found (one after partial scaphoidectomy with pyrocarbon implant and one after partial scaphoidectomy alone). One pyrocarbon implant surgical revision was needed due to malposition. 4. Discussion Our results are similar to those found in the literature, both in terms of pain reduction and functional outcomes (Table 6). There was a statistically significant reduction in pain after surgical management of 5.35 points of average on the VAS (p=0.003). This represents a significant improvement in the patient's quality of life, especially since pain is the main
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symptom that pushes patients to consult. Moreover, there was no significant postoperative decrease in wrist ROM postoperatively: flexion (−1.09°) and extension (−4.38°). In addition, the Kapandji score for thumb mobility was almost unchanged (loss of 0.17 point, not significant). Finally, the surgical treatment did not cause statistically significant radiological carpal bone offsets with an average postoperative lunocapitate angle of 14.34° ± 6.1 (p = 0.131) which remained below the 15° threshold. However, a mean postoperative QuickDASH score of 29.15 out of 100 means that patients are still functionally impaired in daily life despite surgical management. There is therefore a global functional interest in the surgical management of STT osteoarthritis in case of failure of conservative treatment. We found no statistically significant predictors of improvement in the postoperative QuickDASH functional score, whether in terms of patient’s age, gender, radiological Crosby status, or surgical technique used. Regarding the impact of the surgical technique on the progression of carpal bones misalignment, no technique was statistically superior. Similarly, no surgical technique was statistically superior in terms of its impact on wrist flexion and extension. This lack of significant results can be attributed to the limitations of our study. Indeed, because of the scarcity of isolated STT osteoarthritis cases, only a small number of patients were included. However, with 24 patients included, our study is one of the largest case series published to date. In addition, with four different surgical techniques, our statistical analysis was less robust, with the need to perform subgroup analyses. Finally, from a pure methodological point of view, our study was retrospective. This potentially leads to publication bias and selective reporting within our study. Arthrodesis has long been the gold standard for treating isolated STT osteoarthritis. According to some authors, it helps to reduce pain, minimally affects the grip strength and prevents carpal bone misalignment in the long term [5-7]. However, this technique has a risk of significant complications, in particular of non-union, from 4% to 31% depending on the series [8,10,11]. This is a technically difficult procedure due to the need for bone supply and precise adjustment of the scaphoid position to minimize the consequences of its absence on mobility. In addition, Watson et al. [6] recommends that a partial radial styloidectomy be performed to reduce the risk of postoperative radioscaphoid osteoarthritis. Some authors feel it is illogical to eliminate the mobility of the scaphoid, essential to carpal kinematics [15]. In this context, new techniques have been developed, including partial resection of the distal pole of the scaphoid. This can be isolated or supplemented by an interposition (prosthetic or tendinous). Simple arthroplasty resection performed under arthroscopy [12-14] requires that 4 mm be resected from the distal pole of the scaphoid according to Mathoulin and Darin [16], in order to avoid any risk of residual impingement. And to avoid the risk of DISI, GarciaElias [12] recommends performing capsuloplasty and prohibits this intervention when DISI is present preoperatively. The interposition of a pyrocarbon implant restores the spatial configuration of carpal bones and prevents any secondary misalignment. The published studies report good results with less pain, a low impact on wrist mobility [15-19] and no implant dislocation (except for the case series by Mathoulin and Darin [16] in which two implants dislocated because of initial positioning defects). Finally, total trapeziectomy is another alternative and also has good functional results in the literature [20-22]. Ultimately, based on our findings, there is an functional benefit to surgically managing patients with isolated STT arthritis who do not respond to conservative treatment. However, whether through our series or in the literature, no surgical technique stands out as being the best for managing isolated STT osteoarthritis. This is the conclusion arrived at by Deans et al. [25] based on their systematic review of the literature. They also concluded that it is impossible at the moment to determine the best surgical technique but that STT arthrodesis
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should no longer be considered as the gold standard. It is now competing with other methods (STT arthroplasty or total trapeziectomy) that have good published outcomes. Given the low incidence of isolated STT osteoarthritis, only a multicenter randomized and prospective study would be able to identify any significant differences.
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Conflict of interest: The authors declare that they have no competing interest.
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5. Conclusion STT osteoarthritis is a functionally disabling condition that must be managed surgically when conservative treatment fails. Our study did not identify any predictive factors for better functional outcomes in isolated STT osteoarthritis surgery. Moreover, given our results, we cannot determine a gold standard surgical technique. However, current published data support the abandonment of arthrodesis in favor of other methods such as STT arthroplasty and total trapeziectomy.
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References [1]. Carstam N, Eiken O, Andrén L. Osteoarthritis of the trapezio-scaphoid joint. Acta Orthop Scand. 1968;39:354–8. [2]. Brown GD 3rd, Roh MS, Strauch RJ, Rosenwasser MP, Ateshian GA, Mow VC. Radiography and visual pathology of the osteoarthritic scaphotrapezio-trapezoidal joint, and its relationship to trapeziometacarpal osteoarthritis. J Hand Surg Am 2003;28:739–43. [3]. Viegas SF, Patterson RM, Hokanson JA, Davis J. Wrist anatomy: incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. J Hand Surg Am 1993;18:463–75. [4]. Saffar P. Chondrocalcinosis of the wrist. J Hand Surg Br 2004;29:486-93. [5]. Fortin PT, Louis DS. Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis. J Hand Surg Am 1993;18:675–81. [6]. Watson HK, Wollstein R, Joseph E, Manzo R, Weinzweig J, Ashmead D 4th. Scaphotrapeziotrapezoid arthrodesis: a follow-up study. J Hand Surg Am 2003;28:397–404. [7]. Goubier JN, Bauer B, Alnot JY, Teboul F. [Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis]. Chir Main 2006;25:179-84. [8]. Minami A, Kato H, Suenaga N, Iwasaki N. Scaphotrapeziotrapezoid fusion: long-term follow-up study. J Orthop Sci 2003;8:319-22. [9]. Wollstein R, Watson HK. Scaphotrapeziotrapezoid arthrodesis for arthritis. Hand Clin 2005;21:539-43, vi. [10]. Ishida O, Tsai TM. Complications and results of scapho-trapezio-trapezoid arthrodesis. Clin Orthop Relat Res 1993;287:125–30. [11]. Frykman EB, Af Ekenstam F, Wadin K. Triscaphoid arthrodesis and its complications. J Hand Surg Am 1988;13:844–9. [12]. Garcia-Elias M. Excisional arthroplasty for scaphotrapeziotrapezoidal osteoarthritis. J Hand Surg Am 2011;36:516–20. [13]. Zimmermann MS, Weiss AP. Scaphotrapezium-trapezoid arthroses. J Hand Sur Am 2012;37:2139-41; quiz 2141. [14]. Normand J, Desmoineaux P, Boisrenoult P, Beaufils P. [The arthroscopic distal pole resection of the scaphoid: clinical results in STT osteoarthritis]. Chir Main 2012;31:13–7. [15]. Pequignot JP, D’asnieres de Veigy L, Allieu Y. [Arthroplasty for scaphotrapeziotrapezoidal arthrosis using a pyrolytic carbon implant. Preliminary results]. Chir Main 2005;24:148–52. [16]. Mathoulin C, Darin F. Arthroscopic treatment of scaphotrapeziotrapezoid osteoarthritis. Hand Clin 2011;27:319–22. [17]. Low AK, Edmunds IA. Isolated scaphotrapeziotrapezoid osteoarthritis: preliminary results of treatment using a pyrocarbon implant. Hand Surg 2007;12:73–7. [18]. Gauthier E, Truffandier MV, Gaisne E, Bellemère P. Treatment of scaphotrapeziotrapezoid osteoarthritis with the Pyrocardan(®) implant: Results with a minimum follow-up of 2 years. Hand Surg Rehabil 2017;36:113–21. [19]. Pegoli L, Zorli IP, Pivato G, Berto G, Pajardi G. Scaphotrapeziotrapezoid joint arthritis: a pilot study of treatment with the scaphoid trapezium pyrocarbon implant. J Hand Surg Br 2006;31:569-73. [20]. Langenhan R, Hohendorff B, Probst A. Trapeziectomy and ligament reconstruction tendon interposition for isolated scaphotrapeziotrapezoid osteoarthritis of the wrist. J Hand Surg Eur 2014;39:833–7. [21]. Andrachuk J, Yang SS. Modified total trapezial and partial trapezoidal excision and ligament reconstruction tendon interposition reduces symptoms in isolated scaphotrapezialtrapezoid arthritis of the wrist. J Hand Surg Eur. 2012;37:637–41.
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[22]. Wolf JM, Delaronde S. Current trends in nonoperative and operative treatment of trapeziometacarpal osteoarthritis: a survey of US hand surgeons. J Hand Surg Am 2012;37:77–82. [23]. Kapandji A. Clinical test of apposition and counter-apposition of the thumb. Ann Chir Main 1986;5;67-73. [24]. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44. [25]. Deans VM, Naqui Z, Muir LTSW. Scaphotrapeziotrapezoidal joint osteoarthritis: A systematic review of surgical treatment. J Hand Surg Asian Pac 2017;22:1–9.
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Table titles Table 1. Crosby classification as modified by Goubier et al. [7] Normal
Grade I
Joint space narrowing <50%
Grade II
Joint space narrowing > 50%
IIa
Without axial misalignment of carpal bones
IIb
With axial misalignment of carpal bones
Grade III
Erosions, sclerosis and irregularities
IIIa
Without axial misalignment of carpal bones
IIIb
With axial misalignment of carpal bones
pr
oo f
Grade 0
Pr
e-
Table 2. Analysis of range of motion measured pre- and postoperatively Table 2. Analysis of range of motion measured pre- and post-operatively
Jo ur n
Post-operative
Mann-Whitney (p)
Extension
Kapandji score
65° ± 7.37
58.75° ± 6.79
9.21 ± 0.93
al
Pre-operative
Flexion
63.91° ± 7.97
54.37° ± 10.76 9.04 ± 0.99
p = 0412
p = 0.124
p = 0.527
Table 3. Analysis of the postoperative QuickDASH scores according to age, carpal bone misalignment and sex Quick DASH (out of 100) Mann Whitney (p Study Characteristics ) < 60 years 30.2 p = 0.976 > 60 years 29.9 Crosby A Crosby B
31.7 25.8
p = 0.0917
Page 10 of 13
Females Males
30.6 29.0
p = 0.455
Table 3. Analysis of the postoperative Quick DASH scores according to age, carpal bones misalignment and sex
Table 4. Analysis of the postoperative QuickDASH scores according to the surgical technique Table 4. Analysis of the postoperative Quick DASH scores according to the surgical technique
Quick DASH (/100)
Partial scaphoidectomy + pyrocarbon implant
29.9
Others
30.1
Partial scaphoidectomy + tendinous interposition
29.8
Others
30.05
33.25 29.35
Jo ur n
Others
pr e-
p = 0.914
p = 0.351
al
Others
Total trapeziectomy
p = 0.759
Pr
Partial scaphoidectomy only
Mann Whitney (p)
oo f
Surgical Technique
24.1
p = 0.588
Cases (n) 8
5
4
7
30.6
Table 5. Comparison of the post- and preoperative lunocapitate (LC) angle according to the type of surgery Table 5. Comparison of the post- and preoperative lunocapitate (LC) angle according to the type of surgery
Page 11 of 13
Surgical Technique
Preoperative LC angle
Difference between post- and preoperative LC angle
Partial scaphoidectomy + pyrocarbon implant
15.13° ± 4.7
+ 2.83°
Others
9.7° ± 4.3
+ 2.64°
Partial scaphoidectomy + tendinous interposition
12.22° ± 3.1
+ 2.46°
Others
11.33° ± 5.2
+ 2.77°
Partial scaphoidectomy only
7.25° ± 0.64
+ 3.01°
Others
12.37° ± 4.1
+ 2.63°
Total trapeziectomy
9.31° ± 1.6
+ 2.52°
Cases (n) 8
p = 0.806
5
oo f
p = 0.373
4
e-
12.42° ± 4.3
pr
p = 0.244
7 p = 0.679
+ 2.78°
Pr
Others
Mann Whitney (p)
Jo ur n
al
Table 6. Published outcomes after surgical STT arthritis treatment relative to the surgical technique
Preop Cases average flexion (°)
Postop average flexion (°)
Surgical Technique
Study
Total trapeziectomy
Andrachuk et 12 al. [21]
48° (38-60°) 53° (38-65°)
STT arthrodesis
Watson et al. 800 [6]
Not measured
54° ( 0-134°)
Preop Postop p value average average p valu extension (°) extension (°) p< 0.05
52° (45-65°) 55° (50-65°)
Not measured
p< 0.05
49° (0-130°)
Page 12 of 13
Minami et al. 30 [8]
43° ± 14°
Goubier et al. 13 [7]
51° (5-70°) 67° (20-80°)
Fortin et al. [5]
14
Not measured
68% contralateral side
Not measured
58% contralateral side
10
Not measured
71° (55-80°)
Not measured
55° (45-70°)
10
Not measured
Not measured
Not measured
Not measured
8
56°
58°
56°
45° ± 15°
p> 0.05
39° (15-60°) 26° (15-60°)
pr
oo f
p> 0.05
59°
p> 0.05
38° ± 16°
p> 0.05
p= 0.03
p> 0.05
Jo ur n
al
Pr
Partial scaphoidectomy + Normand et tendon al. [14] interposition
e-
Low et al. Partial [17] scaphoidectomy + pyrocarbon Pegoli et al. implant [19]
39° ± 14°
Page 13 of 13