Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion

Abstract

Proximal row carpectomy and four-corner fusion are commonly used in the patients with scaphoid nonunion advanced collapse or scapholunate advanced collapse. We compared activities of daily living of the 24 patients after proximal row carpectomy with 24 patients with four-corner fusion procedures using the modified Sollerman hand function test and Michigan Hand Questionnaire. Most tasks were performed significantly quicker by the patients after proximal row carpectomy. The patients after proximal row carpectomy reported better function during activities of daily living.

Level of Evidence: Level III, Therapeutic Study.

Keywords

Four-corner fusion hand function proximal row carpectomy scapholunate advanced collapse scaphoid nonunion advanced collapse

Introduction

Proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion are commonly used motion-preserving surgical techniques to manage stage 2 scaphoid nonunion advanced collapse (SNAC) or scapholunate advanced collapse (SLAC) wrists. In PRC, a new joint is created between the distal carpal row (capitate) and the radius (Blankenhorn et al., 2007; Imbriglia et al., 1990; Inglis and Jones, 1977). Four-corner fusion is a more technically demanding operation that restores midcarpal stability and preserves the anatomical joint (Baratz and Towsen, 1997; Merrell et al., 2008). Evaluating hand function is important to assess the ability to perform activities of daily living (ADL) (Jonsson and Larsson, 1990; Sollerman and Ejeskar, 1995). Previous studies compared the functional outcome of PRCs and four-corner fusions by assessing ranges of motion of the wrist and by using questionnaires.(Bain and Watts, 2010; Baumeister et al., 2005; Bisneto et al., 2011; Dacho et al., 2008; Mulford et al., 2009; Richou et al., 2010). To our knowledge, the ability to perform tasks of daily living in patients after two surgeries has not been assessed with an objective ADL test.

The Sollerman hand function test examines the ability to perform ADL using different handgrips (Blomgren et al., 1988; Brogardh et al., 2007; Draviaraj and Chakrabarti, 2004; Lindqvist et al., 2011; Sollerman and Ejeskar, 1995). Recently, the test was modified by timing all the subtasks separately, which gives a more precise overview of hand function (Singh et al., 2015). The timed Sollerman hand function test could give more information about which tasks and grips are more difficult for patients in each study group (Singh et al., 2015). This knowledge could assist surgeons in making a more informed choice between these salvage procedures and help counsel patients about the effects of the two procedures on ADL.

The aim of this study was to compare the effect of PRC and four-corner fusion on patients’ ability to perform ADL by comparing the time taken to perform the tasks in the timed Sollerman test and its related handgrips.

Methods

Study design

Data for this cross-sectional study were collected from patients who had undergone either a PRC or a four-corner fusion for SNAC or SLAC wrist stage 2 or 3 from two separate institutions in the Netherlands and the United Kingdom. The inclusion criteria were that the patients should be older than 20 years, they were treated for post-traumatic wrist osteoarthritis, they have never had any other surgical procedures on the wrist; and they had follow-up of more than 6 months. Exclusion criteria were a medical history of rheumatoid arthritis, osteoarthritis of digits of the hands, major surgical procedures or neuromuscular pathology affecting the ipsilateral upper extremity, or if the patient had learning disabilities.

Data were collected by two researchers who were not involved in direct patient care. A standard protocol was agreed for consistency and the second researcher (MB) was trained by the first researcher (HS) who had previous experience using the timed Sollerman test. Demographic data on operative procedures were collected by retrospective chart analysis.

Patients

Information on patients (n = 48) who had undergone a four-corner fusion with a spider plate or Hubcap in the period from 2005 to 2011, was retrieved from the database of the Orthopaedic Department of the Glenfield Hospital, Leicester, UK. All patients were treated with a technique described below. A total of 29 patients agreed to attend the research clinic. Two patients were excluded as they had had surgery on both wrists, three patients were excluded due to surgery on their ipsilateral shoulder. A total of 24 patients with a four-corner fusion were included in the analysis.

Data on all patients (n = 59) who had a PRC from 2006 to 2010, were retrieved from the database of the Plastic Surgery Department of the Diakonessenhuis, Utrecht/Zeist, the Netherlands. These patients were treated by one of the two senior hand surgeons. The levels of expertise of both surgeons for these procedures were Level IV (Specialist – highly experienced) (Tang, 2009). A total of 37 patients agreed to attend the clinic, two patients were unable to attend due to illness, two patients were excluded as they had operations on both wrists, seven patients were excluded as they had PRC for Kienböck’s disease, and another two patients were excluded due to osteoarthritis at the base of the thumb on the affected hand. Therefore, 24 patients with a PRC were included in the analysis.

Verbal and written information was given to all patients before assessment. All patients gave signed consent.

Surgical techniques

Four-corner fusion

A longitudinal dorsal incision was made, followed by a ligament sparing approach to the wrist joint. The posterior interosseous nerve was dissected and divided proximal to the joint. It was confirmed that the cartilage over the lunate and the fossa lunate was intact. The Spider plate (Integra^® Spider™ Fusion System, Osteotec, UK) plate or Hubcap (Hubcap four-corner fusion plate, Acumed, UK) was placed so that each carpal bone was fixated with screws (2.4 mm, self-tapping). Patients stayed in a protective splint or cast for 6–8 weeks. Further mobilization was allowed under guidance of the Hand Therapy Department after confirmation of fusion by radiological assessment.

Proximal row carpectomy

A dorsal longitudinal incision was made followed by raising of the third and fourth extensor compartment. Neurectomy of the posterior interosseous nerve was performed in a standard fashion. The scaphoid, lunate and triquetrum were removed while protecting the palmar ligaments, cartilage on the surface of the capitate, and lunate fossa of the radius. The radial styloid was resected to avoid radial impingement if deemed necessary. Postoperatively, all patients stayed in a splint or cast for 7–10 days, followed by protective splinting and mobilization under guidance of a hand therapist.

The timed Sollerman hand function test

The Sollerman hand function test is a standardized hand function test consisting of 20 ADL based on seven of the eight handgrips (Supplementary Table 1, available online) (Sollerman and Ejeskar, 1995). We have combined subtasks 13–15 (writing, fold paper, and put in envelope, and put paperclip on envelope) and subtasks 18–20 (pack to jug, jug to cup, and cup to jug), because they consisted of similar wrist movements, resulting in a total of 16 subtasks (Supplementary Table 2). In the original Sollerman test, all subtasks were timed and after completion of the test every subtask was scored on a 5-point scale from 0 (task cannot be performed) to 4 (task was easily completed within 20 seconds with the prescribed handgrip) (Sollerman and Ejeskar, 1995). This may lead to the loss of useful information, as the original Sollerman test was designed for patients with tetraplegia.

In the present study, we used the modified timed Sollerman hand function test described by Singh et al. (2015). All patients were given verbal instructions before each task to explain the appropriate position, prescribed handgrip, and method of doing each task as described by Sollerman (1995). Both hands were assessed individually and all subjects performed the test once.

Patient reported outcome

The Michigan Hand Questionnaire (MHQ) and the Patient Evaluation Measure (PEM) were used to evaluate patient-reported outcome and hand function for the two patient groups. The MHQ evaluates overall hand function, ADL, pain, work performance, aesthetics, and patient satisfaction with hand function. It consists of 63 questions with five possible answers, divided into six scales (overall function, ADL, work, pain, appearance, and satisfaction). Both hands are assessed individually. A higher score indicates a better hand performance, except for the pain score where a higher score indicates more pain (Chung et al., 1998).

The PEM evaluates the process of treatment, the current state of the hand, and it provides an overall assessment of the wrist and hand. It consists of three parts with a total of 19 questions. The questions focus on symptoms, the impact of the disorder on the patient, the satisfaction, and general disability/handicap. A higher score indicates greater disability (Dias et al., 2001).

Data analysis

For the timed Sollerman test, we calculated the median and range of the time taken to complete each individual task with the affected and unaffected hand, and the total time. In addition, we normalized the time of the separate items and the total time by calculating a ratio of the affected hand divided by the unaffected hand and the total to complete the test was further adjusted for age based on our previous data obtained from 100 healthy volunteers (Singh et al., 2015). The Mann–Whitney U test was used to compare the data of the patients after two surgeries. Statistical significance was set at 0.05.

To control for the multiple testing of all timed Sollerman items, we used the Holm-Bonferroni correction to adjust P levels for multiple tests.

Approval by the medical ethical committees from both institutions was obtained (NL: MEC-2010-295 and UK: 08/H0406/221).

Results

The two groups were similar for hand dominance, gender, side of surgery, age at time of surgery, and age at follow-up (Supplementary Table 3). The mean follow-up was 23 months for the patient with PRC and 75 months for the patients with four-corner fusion. In the follow-up course, one patient in the four-corner fusion group reported prominence of the screws of the plate. This plate was removed after radiologically confirmed bone union. Two patients experienced a superficial infection, and one patient developed early signs of complex regional pain syndrome, which settled with exercise. No nonunion was reported. In the PRC group, one patient was treated for De Quervain’s tenosynovitis. In the four-corner fusion group, two patients (a truck driver and a computer assistant) stopped working after surgery. In comparison with the PRC group, all patients continued working after surgery.

The median time to complete the timed Sollerman hand function test with the affected hand was 241 seconds for patients with a four-corner fusion, which was significantly slower than the 221 seconds in patients with a PRC (P = 0.007). Patients with a PRC were significantly quicker in tasks 1, 2, 6, 9, 10, 12, 15, and 16 than the patients with a four-corner fusion (Table 1), which corresponds to better function of the pulp pinch, transverse volar grip, a combination of pulp and lateral pinch, combination of tripod and five-finger pinch, and a combination of tripod pinch and diagonal volar grip (Supplementary Table 1). The same result was found when the ratio compared with the unaffected wrist was calculated (Table 2). The patients with a four-corner fusion could unscrew the lids with their affected hand significantly quicker than patients with a PRC (Tables 1 and 2), which corresponds to a better spherical volar grip. No significant difference was found when comparing the unaffected hand in PRC patients with those of four-corner fusion patients. When adjusting for age and handedness, we found that the median time to complete the test was significantly lower (119%) in patients with a PRC than in patients with a four-corner fusion (135%, P = 0.005). The total time to complete the test with the unaffected hand was not significantly different (116% vs 112%, P = 0.90).

Table 1.

Results, in seconds, to complete the subtasks of the modified timed Sollerman hand function test for the affected hand.

Subtask		FCF (n = 24)		PRC (n = 24)		P value	Holm-Bonferroni P value
		Median	Range	Median	Range		Holm-Bonferroni P value
1	Put key into Yale lock, turn 90°	8	3–12	5	3–20	0.001	0.01*
2	Pick coins from flat surface, put into purses mounted on wall	6	4–10	4	3–6	<0.001	<0.001*
3	Open/close zip	11	6–16	12	8–33	0.56	0.56
4	Coins out of purse	9	4–17	8	5–16	0.24	1
5	Wooden blocks	6	3–10	4	2–8	0.03	0.17
6	Lift iron	5	3–7	3	2–6	0.003	<0.001*
7	Turn screwdriver	9	6–10	10	6–25	0.10	0.57
8	Nuts on bolts	29	16–40	24	17–85	0.42	0.84
9	Unscrew lids	14	9–17	19	11–51	<0.001	0.003*
10	Do up buttons	36	29–62	24	19–83	<0.001	<0.001*
11	Cut play-doh	20	10–30	16	10–29	0.02	0.17
12	Put on tubigrip on other hand	7	3–10	5	2–10	0.002	0.02*
13	Writing + fold paper put in envelope + paper clip	38	32–62	39	27–61	0.38	1
14	Pick up telephone	4	2–5	3	2–5	0.34	1
15	Turn door-handle	3	2–4	2	1–3	<0.001	0.001*
16	1 L pack to jug + jug to cup + cup to jug	34	24–49	29	20–41	0.001	0.006*
Total time to complete test		241	204–270	221	204–270	0.007

FCF: Four-corner fusion; PRC: Proximal row carpectomy.

Null hypothesis that the differences are only by chance rejected by Holm-Bonferroni test.

Table 2.

Ratio to complete the subtasks of the modified timed Sollerman hand function test.

	Subtask	FCF (n = 24)		PRC (n = 24)		P value	Holm-Bonferroni P value
		Median	Range	Median	Range		Holm-Bonferroni P value
1	Put key into Yale lock, turn 90°	1.5	0.5–3.5	1	0.5–4	0.035	0.35
2	Pick coins from flat surface, put into purses mounted on wall	1.6	0.9–3.2	1	0.7–1.5	<0.001	<0.001*
3	Open/close zip	1.1	0.6–1.9	1	0.6–2.7	0.31	1
4	Coins out of purse	1.3	0.4–2.7	1.1	0.5–2.8	0.09	0.70
5	Wooden blocks	1.2	0.6–3.0	1.2	0.8–1.7	0.09	0.55
6	Lift iron	1.6	0.9–3.4	1.2	6.6–1.6	<0.001	<0.001*
7	Turn screwdriver	0.9	0.5–1.2	1	0.5–2.1	0.14	0.72
8	Nuts on bolts	1	0.7–2.2	1	0.4–4.4	0.97	0.97
9	Unscrew lids	0.8	0.5–1.7	1.1	0.7–2.4	<0.001	<0.001*
10	Do up buttons	1.6	1–4.8	1.1	0.6–3.8	0.004	0.048*
11	Cut play-doh	1	0.5–2.5	0.8	0.3–2.2	0.09	0.61
12	Put on tubigrip on other hand	1.3	0.6–3	1.1	0.5–2.2	0.31	0.94
13	Writing + fold paper put in envelope + paperclip	1	0.7–1.7	0.7	0.5–1.6	0.022	0.24
14	Pick up telephone	1.2	0.4–3	1.2	5.8–1.9	0.34	1
15	Turn door-handle	1.3	0.8–2.9	1.1	0.6–2	0.06	0.55
16	1 L pack to jug + jug to cup + cup to jug	1.2	0.8–1.7	1	20–41	0.003	0.039*

Ratio = time affected hand/time unaffected hand.

Null hypothesis that the differences are only by chance rejected by Holm-Bonferroni test.

FCF: Four-corner fusion; PRC: Proximal row carpectomy.

The median total MHQ score for the affected hand (Table 3) in the PRC group was significantly higher than in the four-corner fusion group (P < 0.001), indicating better hand function in the PRC group. The ADL, pain, and satisfaction subscores of the PRC patient group showed better results (P < 0.001, <0.001, and 0.02, respectively). The median PEM score (Table 3) was lower in the PRC group compared with the four-corner fusion group (P < 0.001).

Table 3.

Results of the patient reported outcomes.

	Four-corner fusion		PRC
	Median	Range	Median	Range
Michigan Hand Questionnaire
Overall function	63	10–100	68	50–100
ADL	62	4–98	88	61–100
Pain	48	0–85	10	0–40
Aesthetics	100	13–100	100	75–100
Satisfaction	67	0–100	85	46–100
Total score	69	18–99	87	61–100
Patient Evaluation Measure
Total score	48	17–82	27	14–40

ADL: activities of daily living; PRC: proximal row carpectomy.

Discussion

Previous studies compared hand function of the patients with PRC and scaphoid excision with four-corner fusion by assessing grip strength and range of motion of the wrist (Baumeister et al., 2005; Bisneto et al., 2011; Dacho et al., 2008; Mulford et al., 2009). Here we compared ADL and its related hand grip after a four-corner fusion or a PRC.

The Sollerman test was originally developed for tetraplegic patients. Using the original test in our patient group would have given a limited view on the ability to complete ADL, because the patients in these groups are much quicker than tetraplegic patients. As a result, the Sollerman scores in both patient groups would have been the same. Recently, Singh et al. (2015) proposed a modification of the Sollerman hand function test. The modified test provided more detailed information about the ability to perform tasks in ADL swiftly, as well as to compare the scores of individual items and their related hand grips by looking at the time to complete a task compared with the original summarized score. As the patients could perform the tasks more quickly after a PRC compared with a four-corner fusion, the clinical impact could be reflected in greater satisfaction for patients as indicated by the questionnaires.

Different studies showed that the ability to perform ADL is related to specific arcs of wrist motion (Brumfield and Champoux, 1984; Murgia et al., 2004; Ryu et al., 1991). Four-corner fusion provides a larger radioulnar deviation arc compared with the PRC (Singh et al., 2014). Patients with a PRC have a better flexion–extension arc and the position of the ellipse of circumduction is more similar to an unaffected hand. Nichols et al. (2013) examined the torque needed to maintain functional postures by comparing kinematic computer models of the wrists with PRC or four-corner fusion. They found that a PRC wrist required less torque than a four-corner fusion wrist even compared with normal wrists. Patients with a PRC are therefore expected to be less limited in performing most ADL than patients with a four-corner fusion. Wolff et al. (2015) compared kinematic coupling and performance during two functional tasks (dart throwing motion and hammering) in patients following four-corner fusion and PRC. They concluded that PRC subjects performed better on kinematic and performance variables. The above mechanical data suggest that PCR may favour wrist function than four-corner fusion.

Debottis et al. (2013) found that larger peak tendon forces were required in the wrists after four-corner fusion compared with those after PRC to achieve identical wrist motions. In our study, we found that most ADL were indeed performed more quickly by the patients with a PRC compared with patients after four-corner fusion. An exception was the ‘opening jars’ task, which was performed more quickly by the patients after four-corner fusion. For this task, a large wrist torque is required. The tests using MHQ and PEM show that patients experienced fewer disabilities in ADL and greater satisfaction after PRC compared with four-corner fusion. The pain reported in the two groups was also less after a PRC.

This study has its limitations. The number of patients in both groups is small, as around 50% of each intervention group were reviewed. This was because of restrictions imposed by our Ethics Committee. However, patients not reviewed were demographically similar to the patients reviewed. A second limitation is that the modified Sollerman test is relatively new, which has not been tested for its reliability and reproducibility. The third limitation is that the PRC group was retrieved from different institutions, but the patients with the four-corner fusion were from a single institute. A greater number of surgeons have involved in the care of patients with PRC. Furthermore, difference in ADL might have resulted from a longer immobilization period after four-corner fusion (6 weeks versus 1 week in the PRC group) and the mean length of follow-up was longer in the patients with four-corner fusion. However, the results of all patients were determined with a minimal follow-up of 6 months.

Overall, the results of this study show that patients with PRC had better functional outcome compared with patients with four-corner fusion using the modified Sollerman test. ADL were performed more quickly by patients with PRC than patients with four-corner fusion, except for activities requiring wrist torque strength, such as opening a jar.

Supplemental Material

sj-doc-1-jhs-10.1177_1753193416638812 – Supplemental material for Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion

Supplemental material, sj-doc-1-jhs-10.1177_1753193416638812 for Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion by M.E. Brinkhorst, H.P. Singh, J.J. Dias, R. Feitz and S.E.R. Hovius in Journal of Hand Surgery (European Volume)

Supplemental Material

sj-doc-2-jhs-10.1177_1753193416638812 – Supplemental material for Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion

Supplemental material, sj-doc-2-jhs-10.1177_1753193416638812 for Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion by M.E. Brinkhorst, H.P. Singh, J.J. Dias, R. Feitz and S.E.R. Hovius in Journal of Hand Surgery (European Volume)

Supplemental Material

sj-doc-3-jhs-10.1177_1753193416638812 – Supplemental material for Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion

Supplemental material, sj-doc-3-jhs-10.1177_1753193416638812 for Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion by M.E. Brinkhorst, H.P. Singh, J.J. Dias, R. Feitz and S.E.R. Hovius in Journal of Hand Surgery (European Volume)

Footnotes

Acknowledgements

We acknowledge the grants provided by the University Hospitals of Leicester NHS Trust Foxtrot Charity, Fonds NutsOhra, the Federation of European Societies for Surgery of the Hand (FESSH) and the British Orthopaedic Association (BOA) for the travelling fellowship grants. We acknowledge Mr Thybout Moojen of the Xpert clinic, the Netherlands, and Mr Aamer Ullah and Mr Bhaskar Bhowal of University Hospitals of Leicester, NHS Trust, UK, for allowing us to assess their patients. We acknowledge Mr Ruud Selles for all his help during this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

Both medical ethics committees approved this study (NL: MEC-2010-295 and UK: 08/H0406/221).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by the Fonds NutsOhra [grant number 1301-030]. The Federation of European Societies for Surgery of the Hand and the British Orthopedic Association.

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