Proximal Row Carpectomy with Interposition Arthroplasty using Both Capsular Flap and Acellular Human Dermal Matrix

doi:10.21203/rs.3.rs-3804596/v1

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Research Article

Proximal Row Carpectomy with Interposition Arthroplasty using Both Capsular Flap and Acellular Human Dermal Matrix

https://doi.org/10.21203/rs.3.rs-3804596/v1

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Journal Publication

published 05 Mar, 2024

Read the published version in BMC Musculoskeletal Disorders →

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Background

In cases of wrist arthritis, proximal row carpectomy (PRC) has been widely utilized and shown favorable long-term outcomes. However, its applicability is limited in cases where arthritis extends to the lunate fossa or capitate. Recently, surgical approaches combining various methods of interposition arthroplasty have been introduced to overcome these drawbacks. The purpose of this study was to perform PRC and interposition arthroplasty with dorsal capsule and acellular dermal matrix(ADM),and analyze the clinical outcomes of these procedures.

Methods

Thirteen cases who underwent PRC and interposition arthroplasty with ADM were retrospectively recruited. The researchers assessed the patients' Visual Analog Scale (VAS) pain score, Disabilities of the Arm, Shoulder and Hand (DASH) scores, range of motion (ROM), retear, and radiocarpal distance (RCD).

Results

One year post-surgery, both the VAS pain scores, DASH scores, and ROM showed statistically significant improvement compared to before the surgery. Upon reviewing the radiological results, the postoperative mean RCD was 4.8 ± 0.8 mm and one year follow up mean RCD was 3.6 ± 0.5 mm at one year post-surgery. Moreover, in the one year follow-up, there was no observed failure of the allodermis graft in any of the cases

Conclusion

The PRC and interposition arthroplasty with ADM demonstrated significantly improved clinical outcomes after surgery, showing a maintain of RCD without graft failure effectively.

Wrist arthritis

Proximal row carpectomy

Interposition arthroplasty

Acellular dermal matrix

Proximal row carpectomy (PRC) provides a beneficial surgical alternative for addressing wrist arthritis. PRC has demonstrated efficacy in treating arthropathy resulting from scapholunate advanced collapse, scaphoid nonunion advanced collapse, Keinböck’s disease, and the aftermath of perilunate dislocations. (1–3)

PRC is frequently juxtaposed with partial wrist arthrodesis involving scaphoid excision and four-corner fusion, given their analogous indications and favorable long-term outcomes.(1, 4)

Factors related to the patient, such as a younger age and occupation involving manual labor, tend to favor partial wrist arthrodesis over PRC. Studies have indicated that partial wrist arthrodesis is more effective in preserving wrist strength than PRC in such cases. In situations where motion-preserving alternatives and other treatments prove ineffective, total wrist fusion serves as a final option in salvage surgery.(2, 5)

Degenerative changes at the lunate fossa or capitate represent a significant limitation for PRC. A PRC with a capsular interposition flap between the radiocapitate articulation has been recently described with satisfactory results among 8 wrists with a mean follow up of 41 months.(5) However, the use of a capsular interpositioning flap is limited in cases where there is insufficient tissue due to advanced progression of the radiocarpal joint. Recently, to overcome these limitations, satisfactory results have been reported with the use of acellular human dermal matrix (ADM) for interposition arthroplasty in cases where the constraints were significant due to the advanced state of the radiocarpal joint.(6, 7)

Therefore, the authors conducted PRC with interposition arthroplasty using both capsular flap and ADM, aiming to report on the clinical outcomes of this approach.

After obtaining Institutional Review Board of our institution approval, a total of 17 cases who underwent PRC with interposition arthroplasty using both capsular flap and acellular human dermal matrix, procedures were retrospectively recruited as the study subjects (July 2020 - December 2022).

The study included patients with stage 3 or 4 scapholunate advanced collapse (SLAC), stage 2 or 3 scaphoid nonunion advanced collapse (SNAC), and those with arthritis progressing in the capitate head or lunate facet. Cases suspected of acute infection were considered a contraindication.

Surgical technique

Under regional anesthesia and via a dorsal midline cut, the extensor retinaculum was recognized and pivoted open from the second to the fifth extensor compartments. Following the withdrawal of the extensors, a capsular flap with a proximal origin was lifted from just above the second and fourth carpometacarpal joints to the distal articular edge of the radius (Fig. 1A). The lunate, triquetrum, and scaphoid were then gradually extracted using a ronguer, guided by a 1.8 mm Kirschner wire functioning as a joystick. After inserting 4 to 6 Q fix all-suture anchors (Smith & Nephew, London, United Kingdom) into the distal radius (Fig. 1B), each corner was secured by attaching acellular human dermal matrix (BellaCell; Hans Biomed Corporation, Daejeon, Korea) and sutures. Finally, capsular interposition was implemented by suturing the radial end of the capsule to the radioscaphocapitate ligament and the ulnar end to the ulnocarpal ligament (Fig. 1C).

Postoperative rehabilitation

After surgery, a short arm splint was applied for four weeks. Finger movement was allowed immediately after the surgery. Wrist passive and active exercises, as well as daily activities, were permitted starting four weeks post-surgery. Weight-bearing tasks were allowed after 12 weeks post-surgery.

Clinical and radiological evaluation

Before the surgery and at one year post-surgery, the researchers assessed the patients' Visual Analog Scale (VAS) pain score, Disabilities of the Arm, Shoulder and Hand (DASH) scores, and range of motion (ROM).

Postoperative surgery and at one year post-surgery, plain radiography was used to measure the radiocarpal distance (RCD). The outcomes were measured through assessments performed by an orthopedic specialist (J.W.J.), and Radiological evaluations were conducted with measurements taken twice by two observers, and the mean values were used for analysis (D.H.L. and J.W.J.).

Fourteen cases were recruited and observed for a minimum of 1 year. The average age was 65.5 ± 7.5 years, with a gender distribution of 8 males and 6 females. The dominant arm occurred 5 cases, and the non-dominant arm occurred 9 cases. (Table 1)

Before surgery, the wrist flexion-extension ROM averaged 64.2 degrees with a standard deviation of 16.1 degrees. One year after surgery, the wrist flexion-extension ROM averaged 72.7 degrees with a standard deviation of 14.8 degrees. The wrist pronation-supination ROM before surgery averaged 123.8 degrees with a standard deviation of 15.7 degrees. One year after surgery, the wrist pronation-supination ROM averaged 137.7 degrees with a standard deviation of 18.5 degrees. Before surgery, the VAS pain score was 7.7 with a standard deviation of 2.8. One year after surgery, the VAS pain score was 1.7 with a standard deviation of 0.7. Before surgery, the DASH score was 66.1 with a standard deviation of 17.4. One year after surgery, the DASH score was 16.8 with a standard deviation of 10.9 (Table II). After surgery, the RCD was 4.8 mm with a standard deviation of ± 0.8 mm. One year after surgery, the RCD was 3.6 mm with a standard deviation of ± 0.5 mm (Fig. 2)

While positive outcomes have been documented following proximal row carpectomy, additional research suggests that extensive cartilage deterioration on both sides of the radiocapitate joint is prone to result in an unfavorable prognosis.(1, 8–10) Salomon and Eaton addressed these limitations by performing a combination of PRC and dorsal capsular interposition in a study involving 12 patients, reporting satisfactory outcomes with a flexion-extension range of motion of 94 degrees and pain relief.(11) In 2009, Kwon et al. also reported satisfactory results with a significant pain relief and an average flexion-extension ROM of 71.9 degrees after performing a combination of PRC and dorsal capsular interposition surgery.(5)

However, using only dorsal capsule interposition may not be sufficient to prevent adequate bone-to-bone contact in the radiocarpal joint, as there are cases where the amount or thickness of tissue is not enough. Therefore, recently, interposition arthroplasty using Dermal Allograft has been proposed as an alternative. In 2011, Carneiro (12) et al., and in 2018, Rabinovich and Lee(7) introduced the surgical technique of interposition arthroplasty using PRC and dermal allograft. In 2020, Lee et al. reported improved outcomes, including a flexion-extension ROM of 113 degrees, pronation supination ROM of 170.5 degrees, and a DASH score improving from 63.5 before surgery to 23.8 after surgery, based on a study involving 9 patients.(6)

In cases of joint disruption, the thickness and quality of the interposed tissue are crucial factors for achieving pain relief and functional improvement in terms of ROM.(13, 14) Therefore, the authors employed a combination of dorsal capsule tissue and dermal allograft to interposition sufficient tissue between the radiocarpal joint. In contrast to the traditional technique of folding the dermal allograft for insertion, they referred to Hartzler et al.'s method(14) and utilized suture anchors for robust fixation to ensure secure anchoring of the ADM. Through this surgical approach, the authors achieved satisfactory results in terms of VAS score, DASH scores, ROM, and maintenance of the radiocarpal joint distance.

This study holds significance as it reports satisfactory clinical and radiological outcomes after performing interposition arthroplasty with a combination of dorsal capsule and dermal allograft following PRC in 14 patients.

Limitation

Firstly, it is a non-randomized, retrospective level IV case study, which may introduce bias and limit the generalizability of the findings. Secondly, the sample size is relatively not much, with only 14 cases included, which may affect the statistical power and limit the ability to draw robust conclusions. Thirdly, the follow-up period is limited to one year, and a longer-term follow-up and randomized controlled study with a sufficient sample size would be beneficial to further evaluate the outcomes of the PRC with interposition arthroplasty using both capsular flap and ADM. Despite these limitations, this study holds significance as it reports satisfactory clinical and radiological outcomes after performing interposition arthroplasty with a combination of dorsal capsule and dermal allograft following PRC in 14 patients.

The PRC with interposition arthroplasty using both capsular flap and ADM showed satisfactory clinical improvement, and the radiological results demonstrated the maintenance of a sufficient distance in the RCD after surgery.

Ethical approval and consent to participate: All methods were carried out in accordance with relevant guidelines and regulations, and approval from appropriate Institutional Review Board of the Dankook University Hospital. This study received informed consent from all participants consisted of this study cohort.

Consent for publication: Not applicable.

Availability of data: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests: The authors declare no competing interests.

Funding: There is no funding source.

Authors' contributions: Jae sung Yoo: Study design, data gathering, interpreting statistical results, and writing the manuscript. DaeHee Lee & JaeUk Jung: Data gathering and statistical analyses. Joongbae Seo: Participating in manuscript writing and reviewing.

JebsonPJ,HayesEP,EngberWD.Proximal row carpectomy: a minimum 10-year follow-up study.J Hand Surg Am.2003;28(4):561–9.
JebsonPJ,EngberWD.Proximal row carpectomy.Tech Hand Up Extrem Surg.1999;3(1):32–6.
DiaoE,AndrewsA,BeallM.Proximal row carpectomy.Hand Clin.2005;21(4):553–9.
HoganCJ,McKayPL,DegnanGG.Changes in radiocarpal loading characteristics after proximal row carpectomy.J Hand Surg Am.2004;29(6):1109–13.
KwonBC,ChoiSJ,ShinJ,BaekGH.Proximal row carpectomy with capsular interposition arthroplasty for advanced arthritis of the wrist.J Bone Joint Surg Br.2009;91(12):1601–6.
LeeSJ,RabinovichRV,KimA.Proximal Row Carpectomy Using Decellularized Dermal Allograft: Preliminary Results.J Wrist Surg.2021;10(2):116–22.
RabinovichRV,LeeSJ.Proximal Row Carpectomy Using Decellularized Dermal Allograft.J Hand Surg Am.2018;43(4):392e1- e9.
BegleyBW,EngberWD.Proximal row carpectomy in advanced Kienbock's disease.J Hand Surg Am.1994;19(6):1016–8.
InoueG,MiuraT.Proximal row carpectomy in perilunate dislocations and lunatomalacia.Acta Orthop Scand.1990;61(5):449–52.
TomainoMM,MillerRJ,ColeI,BurtonRI.Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision?J Hand Surg Am.1994;19(1):134–42.
SalomonGD,EatonRG.Proximal row carpectomy with partial capitate resection.J Hand Surg Am.1996;21(1):2–8.
Carneiro RdosS,DiasCE,BaptistaCM.Proximal row carpectomy with allograft scaffold interposition arthroplasty.Tech Hand Up Extrem Surg.2011;15(4):253–6.
SeoJB,KwakKY,ParkB,YooJS.Anterior cable reconstruction using the proximal biceps tendon for reinforcement of arthroscopic rotator cuff repair prevent retear and increase acromiohumeral distance.J Orthop.2021;23:246–9.
HartzlerRU,MelapiS,deBeerJF,BurkhartSS.Arthroscopic Joint Preservation in Severe Glenohumeral Arthritis Using Interpositional Human Dermal Allograft.Arthroscopy.2017;33(11):1920–5.

Table I. Demographic data

Variable	Combination PRC and interposition arthroplasty (n=14)
Mean age	65.5 ± 7.5
Gender (Male: Female)	8 : 6
Dominant arm: Non-dominant arm	6 : 8
Height (cm)	167.2 ± 12.3
Weight (kg)	66.3 ± 10.3
Body mass index	23.7 ± 3.6
Smoking: Non-smoking	4 : 10
ASA class (1:2:3)	11 : 3 : 0
Mean follow-up (month)	15.6 ± 4.8

Table II. Clinical outcomes

Variable	Preoperative	Final follow-up	p-value
VAS pain score	7.7 ± 2.8	1.7 ± 0.7	<0.001
DASH score	66.1 ± 17.4	16.8 ± 10.9	<0.001
Flexion Extension ROM	64.2 ± 16.1	72.7 ± 14.8	0.02
Pronation Supination ROM	123.8 ± 15.7	137.7± 18.5	0.003

VAS: Visual Analog Scales, DASH: Disabilities of the Arm, Shoulder and Hand, ROM: Range of Motion.

No competing interests reported.

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Journal Publication

published 05 Mar, 2024

Read the published version in BMC Musculoskeletal Disorders →

Editorial decision: Revision requested
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09 Jan, 2024
Editor invited by journal
31 Dec, 2023
Submission checks completed at journal
31 Dec, 2023
First submitted to journal
25 Dec, 2023

You are reading this latest preprint version

Proximal Row Carpectomy with Interposition Arthroplasty using Both Capsular Flap and Acellular Human Dermal Matrix

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Method

Surgical technique

Postoperative rehabilitation

Clinical and radiological evaluation

Results

Discussion

Limitation

Conclusion

Declarations

References

Tables

Additional Declarations

Status:

Journal Publication

Version 1