Rev. bras. ortop. vol.51 número5

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Randomized

clinical

trial

between

proximal

row

carpectomy

and

the

four-corner

fusion

for

patients

with

stage

II

SNAC

夽

Marcio

Aurelio

Aita

_,

_Edison

_Kenji

_Nakano,

_Henrique

_de

_Lazari

_{Schaffhausser,}

Walter

Yoshinori

Fukushima,

Edison

Noboru

Fujiki

FaculdadedeMedicinadoABC,DepartamentodeOrtopediaeTraumatologia,SantoAndré,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received2September2015 Accepted29January2016 Availableonline20August2016

Keywords:

Wrist Pain

Scaphoidbone Arthrodesis

a

b

s

t

r

a

c

t

Objective:TocomparetheoutcomesofpatientswithstageIISNACsubmittedtosurgical treatmentbyproximalrowcarpectomy(PRC)orfour-cornerfusion(FCF).

Method:Twenty-sevenpatientsaged18–59years(mean37.52years)wereincluded.Thirteen patientsunderwentPRCinGroupA,and14underwentFCFofthewristinGroupB. Evalua-tionsweremadebeforeandaftersurgerywithfollow-upbetween45and73months.Range ofmotion(ROM);painassessmentwithavisualanalogscale(VAS);gripstrength;disability ofthearm,shoulder,andhand(DASH);andreturntoworkwereevaluated.

Results:GroupApatientshad68.5%andGroupBpatients,58.01%oftheROMofthe con-tralateralside.TheVASscorewas2.3inGroupAand2.9inGroupB.Gripstrengthwas78.67% and65.42%,respectively,relativetothesidenotaffected.TheDASHscorewas11forPRC and13forFCF.InGroupA,9/13(69.23%)andinGroupB,8/14(57.14%)patientsarecurrently working.Complicationsweresymptomaticosteoarthritisinthemid-carpaljointinGroup AandlooseningofascrewinGroupB.

Conclusion:Theclinicalandfunctionalresultsdonotpresentstatisticallysignificant differ-encesforbothanalyzedmethods.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Ensaio

clínico

randomizado

entre

ressecc¸ão

da

fileira

proximal

(carpectomia)

e

artrodese

dos

quatro

cantos

nos

pacientes

portadores

de

SNAC

no

estágio

II

Palavras-chave:

Punho Dor

Ossoescafoide Artrodese

r

e

s

u

m

o

Objetivos:Compararosresultadosclínicosefuncionaisdospacientescomdiagnósticode

ScaphoidNonUnionAdvancedColapse(SNAC),noestágioII,submetidosàressecc¸ãodafileira proximaldocarpoouàartrodesedosquatrocantos.

Método:Foramincluídosnoestudo27pacientes,commédiade37,52anos(18-59).Treze foramsubmetidosàcarpectomiaproximalnoGrupoAe14àartrodesedosquatrocantos

夽

StudyconductedattheHandandMicrosurgeryGroup,DepartmentofOrthopedicsandTraumatology,FaculdadedeMedicinadoABC, SantoAndré,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](M.A.Aita).

http://dx.doi.org/10.1016/j.rboe.2016.08.008

noGrupoB.Oseguimentomédiofoide45a73meses.Foramavaliadososarcosde movi-mento,ador,aforc¸adepreensãopalmar,oDisabilityArmShoulderHand(DASH)escoreeo retornoaotrabalho.

Resultados: NoGrupoAospacientesapresentaram68,5%doarcodemovimentonolado nãoafetadoenoGrupoB,58,01%.Naavaliac¸ãosubjetivadador(VAS),obtivemos2,3no GrupoAe2,9noGrupoB.Aforc¸adepreensãopalmarfoide78,67%noGrupoAdolado nãoacometidoede65,42%noGrupoB.ODASHescorenoGrupoAfoi11enoGrupoB, 13.Quantoaotrabalho,69,23%(9/13)dospacientesnoGrupoAe57,14%(8/14)noGrupoB retornaramaalgumaatividadelaboral.Ataxadecomplicac¸õesnoGrupoAfoide(1/13)e noGrupoB,de7,1%(1/14).

Conclusões: Osresultadosclínico-funcionaisestudadosnãoapresentamdiferenc¸as estatís-ticasparaosdoismétodosanalisados.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Scaphoidfractureisacomplexinjury,representingthemost incidentinjuryamongcarpalbones;sometimes,itisnot diag-nosed and evolves with high rates of complications, such aspseudarthrosis, necrosisofthe proximalpole, and even osteoarthritisoftheentirewrist.Pseudarthrosis,ifuntreated, causes aburden on the radialside ofthe carpus, promot-ing degeneration ofthe radioscaphoid joint, mainly inthe radialstyloidprocess, which leadsto alocal impact. With evolution,theoutlineofthescaphoidisworndown,which affects the scaphocapitate and capitolunate joints, caus-ingproximalmigrationofthecapitateandpromotescarpal derangement,1–3_{describedasscaphoidnon-unionadvanced}

collapse(SNAC).Toguidetreatmentofthisdisease,the clas-sificationaccordingtothestagesofWatsonandRyu1_isused.

Thedevelopmentstagesaredescribedasfollows:

1. Stylo-scaphoidosteoarthritis–SNACstageI;

2. Stylo-scaphoid+radioscaphoidosteoarthritis–SNACstage II;

3. Stylo-scaphoid+lunocapitateosteoarthritis–SNACstage III;

4. Stylo-scaphoid+lunocapitate osteoarthritis+radiolunate osteoarthritis–SNACstageIV.

No published study has concluded which is the best method for treating this disease; arthrodesis carpectomy and four-corner fusion (FCF) are the most studied meth-ods.Thesesurveysshownoscientificevidence,4–8_sincethey

areretrospectivestudies,non-randomized,andincludeother degenerativediseasesofthecarpus,suchaspost-traumatic osteoarthritisofthe wrist,Kienböckdisease,and scapholu-nate advanced collapse(SLAC). Other randomizedstudies9

thataddressedthesameconditionsotherthanSNAC10_were

alsonon-conclusive.

Onlypatients withthe disease in stageII may undergo salvagesurgery,2,11–13_{whichpreservessomedegreeof}

move-ment, as do carpectomy14–18 _{and FCF.}1,19–21 _{Patients in}

stageI should undergo reconstructive surgery,such asthe correctionofthescaphoidnon-union3_and/orradial

styloidec-tomy.Thosewhohaveradiographicchangesoflunocapitate

joint (stage III) cannot undergo carpectomy, only partial wrist arthrodesis.11,19,22–24 _{Patients in stage IV have the}

best treatment option in salvage surgeries, such as total fusion,2,11,25_{or totalwristarthroplasty, whoseindicationis}

stillcontroversial.26

Bothforcarpectomy18,27,28 _{andFCF,29studiespresented}

satisfactory long-term clinical and functional results, with approximatelytenyearsoffollow-up.Buttherearestill ques-tionsaboutwhatisthebestmethodoftreatmentforpatients withpain,lossofhandgripstrength,andrangeofmotion lim-itationtoperformdailylifeorprofessionalactivities.Forthese reasons,theauthorsdecidedtoperformthisclinicaltrial.

Thisstudyaimedtocomparetheclinicalandfunctional outcomes ofpatients with stageII1 _{SNAC who underwent}

proximalrowcarpectomy(PRC)orFCF.

Methods

From2005toDecember2014,78patientstreatedinthe out-patientclinicsoftheHandandMicrosurgeryDepartmentand diagnosedwithSNACwereevaluated.Only27metinclusion criteriaandwereincludedinthestudy;theyunderwent physi-calexamination,plainradiographsinposteroanterior(PA)and lateral (P), computed tomography,and magnetic resonance imaging(MRI)oftheaffectedwrist.

Inclusioncriteriawereadultpatientsaged18–60years,of bothgenders, withclinical andimagingdiagnosis ofSNAC (Fig. 1), instageII, who signedtheinformed consentform andtheconflictofinterestprotocol,aspertheResearchEthics Committeedecision.Patientswithassociatedwristdiseases, suchasbonemetabolicdiseases,orwhohadundergoneany priorsurgicalprocedure,orthosewhohadbilateralconditions onthewrists,wereexcluded.

Functionalassessmentwasconductedbythe profession-alsfromtheHandOccupationalTherapyDepartmentofthe institution,whodidnothaveaccesstoinformationregarding thegrouptowhichthepatientbelonged.

Fig.1–Preoperativetests:(a)wristX-rayinposteroanterior(PA);(b)X-rayinprofile(P);(c)coronaltomographicsliceofthis wrist.

Clinicalanalysisofpain wasmadewiththe visual ana-log scale(VAS) from 0to10,forsubjectiveevaluation. The assessment of quality of life was made with the DASH questionnaire.13

Randomization was done by drawing lots with a coin: heads,thepatientwouldundergoPRC(Fig.2);tails,FCF(Fig.3). Therefore, patientswere dividedinto twogroups, Aand B. Group A(heads) underwent resection ofthe proximal row

(Table1),withinterpositionofthedorsalwristcapsule.14–18

PRC

surgical

technique

Dorsalandoblique surgicalapproach,usingthebaseofthe secondmetacarpalboneandthedistalradioulnarjoint,was thesameforbothgroups.

A single transverse opening of the dorsal capsule was made; a flap was created to contour the head of the capitate.15,16

Atthatmoment,proximalcarpectomywasmadewiththe removalofthescaphoid,lunate,andtriquetrum.

Aradiusstyloidectomy,ofatmost2mm,wasmandatory. Then,thedorsalcapsulewasinterposedandtheflapwas sutured in the palmar capsule, followed by sutures ofthe planesandskin.

Subsequently,postoperativefluoroscopyand radiographs ofthewristweremadeforpost-operativecontrol.

FCF

surgical

technique

Patients in Group B (Table 2) were treated using the FCF technique:theyunderwenttwodorsalarthrotomies,onefor resectionofthescaphoidboneandtheotherforfixationof thefourcorners.

Aftertheremovalofthescaphoidboneandthepreparation ofthegraftofthesamebone,thefourcornerswereopened.

Atthispoint,athickcavityofsimilarthicknesstocarpal boneswascreatedinthecenterofthefourcorners,wherethe scaphoidgraft wasplaced.Thefour cornerswereprepared withaspecialmillprovidedbythemanufacturer.Thelunate andtriquetrumwereappropriatelyreducedwithprovisional Kirschnerwires.

Allfourbones(lunate,capitate,hamate,andtriquetrum) were stabilized with a special plate (conventional carpal button®_bySBI®_{, orblockedcarpalbuttonbyBiotech}®_)and screws.15–17

Postoperative

period

of

Groups

A

and

B

Forcompletionoftheprocedure,wristfluoroscopyand radio-graphywereperformedtoassessthepositionoftheimplant andscrews.

A plastercast was made around the wrist, which was removedinthefirstweekaftersurgery.

Patients were clinically and radiographically evaluated beforesurgeryandthenonamonthlybasis.However,inthe presentstudy,onlythepreoperativeandcurrentvalueswere usedforstatisticalanalysis.Allpatientsunderwent rehabili-tationattheHandOccupationalTherapyDepartmentofthe institution,withthesameprotocol,fromthefirstweekafter thesurgery,whentheimmobilizationwasremoved,until dis-chargefromthedepartment.

GroupAcomprised13patientswithameanof32.38years, whounderwentPRC(Fig.2).

GroupBcomprised14patientswithameanof40.43years, whounderwentFCF(Fig.3).

Fig.2–Intraoperativeaspectofresectionoftheproximalcarpalrow.(a)Dorsalaccesstothewrist;(b)scaphoid,lunate,and triquetrumremoved;(c)makingoftheflapinthewristdorsalcapsule,whichwasusedtocoattheheadofthecapitate;(d) planningthewristaccessroute.

Table1–Epidemiologicaldistributionandpostoperativefollow-upofpatientsundergoingproximalcarpectomy(Group A).

Follow-up(months) Sex Age(years) Identification Returntowork Dominantside Affectedside

69 M 39 I Yes R R

68 M 28 II No R L

74 M 39 III Yes R L

73 M 30 IV Yes R R

75 M 18 V Yes R L

76 M 52 VI No R L

72 M 22 VII Yes R R

70 F 41 VIII Yes R R

74 M 30 IX No R L

78 M 26 X Yes R L

75 M 23 XI Yes R L

77 M 38 XII No R L

77 M 35 XIII Yes R R

Source:Hospital’sSAME.

Table2–Epidemiologicaldistributionandpostoperativefollow-upofpatientsundergoingfour-cornerarthrodesis(Group B).

Follow-up(months) Sex Age(years) Identification Returntowork Dominantside Affectedside

77 M 56 I Yes R R

77 M 25 II Yes R L

81 M 40 III Yes R L

71 F 39 IV No R L

75 F 30 V Yes R R

78 M 33 VI Yes R R

74 M 45 VII No R R

76 M 34 VIII Yes R L

68 M 54 IX No R L

69 M 48 X Yes R L

68 M 37 XI No R R

78 M 36 XII Yes R R

70 M 48 XIII Yes R R

67 M 41 XIV No R L

Source:Hospital’sSAME.

value(p)wasequaltoorgreater than5%(0.050),a statisti-callynon-significantdifferencewasobservedanditwasnot marked.Fornonparametricvariables,Fisher’sexacttestwas used.

Results

ThevaluesofGroupAforrangeofmotionwere68.50%,and forhandgripstrength,78.67%,bothcomparedwiththe unaf-fectedside;GroupB,whichunderwentFCF,presentedrangeof motionof58.01%,andhandgripstrengthof65.42%.The sub-jectiveassessmentofpainwas2.3inGroupAand2.9inGroup B.TheDASHscorewas11forGroupAand13forGroupB.In relationtoreturntowork,64.3%(9/14)and84.61%(11/13)of patientsinGroupsAandB,respectively,performsomework activity(Tables3–5).

The complication rate observed in Group A was 7.69% (1/13), a patient diagnosed with symptomatic osteoarthri-tis in the radiocarpal joint (Fig. 4) who required total wrist arthrodesis; in Group B, this rate was 7.1% (1/14),

composedbyasinglepatientwithdiagnosisof pseudarthro-sis of the four corners and loosening of the screws. This patient was satisfied with his wrist functional outcome (Fig.5).

Table3–Clinicalandfunctionalresults–comparative analysisbetweengroups.

Parameters Carpectomy Arthrodesis

(GroupA) (GroupB)

Pain(VAS) 2.3 2.9

DASH 11 13

Force(kgf) 78.67% 65.42

ROM(◦_{) 68.50% 58.01%}

Returntowork 84.61% 64.30%

Complications 7.69% 7.10%

VAS,VisualAnalogScore;DASH,DisabilitiesoftheArm,Shoulder andHand;ROM,rangeofmotion.

Table4–Statisticalresultsofparametricvariables.

Variable Group n Mean Standarddeviation Significance

(p)

Follow-uptime A 13 74 3.37 0.846

B 14 74.21 2.79

Age A 13 32.38 9.39 0.039*

B 14 40.43 8.94

Preoperativepain A 13 7.54 2.50 0.645

B 14 8.21 1.81

Postoperativepain A 13 2.3 3.55 0.769

B 14 2.9 3.45

PreoperativeDASH A 13 99.62 24.46 0.331

B 14 91.71 18.00

PostoperativeDASH A 13 47.62 15.47 0.697

B 14 45.00 10.93

Preoperativestrength A 13 40.38 17.11 0.827

B 14 40.64 19.88

Postoperativestrength A 13 78.5 18.89 0.145

B 14 56.0 11.69

PreoperativeROM A 13 80.54 54.75 0.132

B 14 50.64 28.55

PostoperativeROM A 13 108.85 36.29 0.593

B 14 118.36 39.76

n,numberofpatients;DASH,DisabilitiesoftheArm,ShoulderandHand;ROM,rangeofmotion.

Table5–Statisticalresultsofnonparametricvariables.

Group Returntowork Total

Yes No

A 11 2 13

84.61 15.38 100.00

B 9 5 14

64.29 35.71 100.00

Total 20 7 27

74.07 25.93 100.00

Group Complications Total

Yes No

A 1 12 13

7.69 92.31 100.00

B 1 13 14

7.14 92.86 100.00

Total 2 25 27

7.41 92.59 100.00

p=0.695. p=0.999.

Discussion

The present authors agree with Mulford and Krimmer7,11_:

thesearethetwomostcommonlyusedmethodsinthe treat-mentofSNAC.Thus,bothhavetheiradvantages.

Accordingtotheliterature,4–7,18,19,29_{FCFhasasadvantages}

inrelationshiptoPRCthemaintenanceofcarpalheightand preservationoftheradiolunatejointand,asdisadvantages, thesteeperlearningcurve,greaterincidenceofcomplications withtheuseofcircularplates,19–21_{andhighercost.}

AccordingtoImbriglia,18_{PRCdoesnotpreservethe}

mid-carpaljoint,andcanleadtodegenerationoftheradiusorthe headofthecapitate.

In order to protect the radio-capitate joint space, the authorschosetoperformaninterpositionofthedorsalwrist capsule15,16 _{and earlier joint mobility, with the removalof}

immobilization aftera periodnot longer than oneweek.17

However,otherauthors27,28 _{haveobservedlong-termresults}

ofdegenerativeradiographicalterationontheradiusoreven onthe headofthecapitate, withoutclinicalconsequences. In the present study, one patient from Group Apresented radiographicalterationsoftheradiallunatefossa,withclinical repercussionsoneyearaftersurgery.

Inthepresentstudy,carpalbutton®_{andbonegraftinblock} were usedforFCF.Mantovannietal.,19 _{andMerrelletal.,}20

whoalsousedcircularplatesintheirresearch,andsuggested modificationstothetechnique,suchasusingblockgraft har-vest from the scaphoidor metaphysis ofthe distalradius, showedsuperiorresultswithlowerrateofcomplicationthan thatobservedbyKendalletal.21 _{Therewere nostatistically}

significantdifferencesinfunctionalparametersafteroneor tenyearspostoperativeinpatientswhounderwentFCF.29_In

thepresentstudy,therewasonlyonecaseofpseudarthrosisof thefourcorners,withreleaseofascrewinthecarpalbutton. TherangeofmotioninGroupA(PRC)was68.50%in rela-tiontothecontralateralsideinthepresentstudy;Tomaino et al.4_{observed64%;Wryicketal.,}5_{7%;Cohenand Kozin,}6

57%;DiDonnaetal.,27_{61%;andJebsonetal.,}28_{63%.InGroupB,}

58.01%ofwristrangeofmotioncomparedtothenon-affected side was observed; Tomaino et al.4 _{observed 41%; Wryick}

etal.,5_{47%;CohenandKozin,}6_{64%;andKendalletal.,}21_;46%.

Fig.4–Additionalpreoperativeexamsandintraoperativeaspects(complication)ofthesecondproceduretocorrect radio-capitateosteoarthritis.(a)coronalMRIofthewrist;(b)axialMRIofthewrist;(c)intraoperativeimageofradial osteoarthritisandtheintegrityofthecartilageoftheheadofthecapitatebone;(d)sagittalMRIofthewrist;(e)X-rayofthe wrist,inposteroanterior(PA);(f)X-rayofthewristinprofile(P)–totalarthrodesisprocedure.

GroupAinthepresentstudy(78.67%ofthenormalside)are comparedwiththeliterature,Tomainoetal.4_observed96%;

Wryicketal.,5_{94%;CohenandKozin,}6 _{71%;Bisnetoetal.,}9

47%;Imbriglia,18_{80%;Didonnaetal.,}27_{91%;andJebsonetal.,}28

83%.InGroupB,thehand gripstrength was65.42%ofthe unaffectedside;Tomainoetal.,4_{observed81%;Wryicketal.,}5

74%;CoheneKozin,6_{79%;Bisnetoetal.,}9_{73%;andKendall}

etal.,21_{56%.Therewerenosignificantdifferencesinclinical}

andfunctionalresults.

The complication rate was 7.69% in Group A and 7.1% in Group B; Tomaino et al.4 _{observed 0%; Jebson et al.,}28

10%; Didonna et al.,27 _{18%; Cohen and Kozin,}6 _0%;

Wry-ick et al.,5 _{11%; Kendall et al.,}21 _{62.5%; and Imbriglia,}18

3.7%.Radio-capitatejointdegenerationisfrequent7,27,28_(12/26

patients after ten years of follow-up) and asymptomatic in most patients,18 _{but one patient, an active adult who}

returned to work, evolved poorly with radio-capitate joint degeneration,7,12,18_{andunderwenttotalwristarthrodesis.}18,25

Althoughnotstatisticallysignificant,theindicationof carpec-tomy in young adult patients should beavoided. Group B presentedinferiorresultswhencomparedwithstudiesthat used circular plates, and similar results when compared with studies that used Kirschner wires and screws, per-hapsduetheimprovementofthemethodandsafetyofthe technique.7,12,19,20_{Thecomplicationobservedinthepresent}

trial was pseudarthrosis of the four corners; this patient declinedrevisionsurgery,ashewassatisfiedwithhisclinical andfunctionaloutcome.

Asforthereturntowork,resultswereverysimilartothose from theliterature.Return towork activitieswas observed in 69.23% of patients who underwent PRC in the present study;86%inthestudybyCohenandKozin6_and80%,inthe

studybyTomainoetal.4_{OfthepatientswhounderwentFCF}

inthepresent study,57.14%returnedtowork;100%inthe studybyTomainoetal.4_{and86%inthestudybyCohenand}

Kozin.6

Therewasnostatisticaldifferencebetweenthegroupsfor this variable.However,the authors believe that the above-mentioned data presentedobjective and subjective values; therefore,theydonotconsidertheresultofthevariable of returntoworktobereliable.

When comparing both methods, the literature4–8,12

presentsaslightsuperiorityinallanalyzedfunctional param-etersofpatientsundergoingPRC,exceptforthestudies by CohenandKozin6_{andbyBisnetoetal.,}9_{whoobservedbetter}

handgripstrengthresultsforpatientsundergoingFCF. Todate,noarticlefeaturesonlypatientswiththe same initialconditionofSNAC,whichleadstowristosteoarthritis. MoststudiesusingFCFforthetreatmentofosteoarthritisdid notstandardizethewristosteosynthesistechniquefor fixa-tionofthefourcorners(whichcombinestheuseofKirschner wires,compressionbolts,orcircularplates).Ofthe aforemen-tionedstudies,onlyonewasrandomized9_{;nevertheless,itdid}

notstandardizetheinitialpathologythatprogressedtocarpal collapse.Onestudy10_{includedonlypatientswithSLACand}

hadshorterhospitalstayandlowercomplicationrateinfavor ofPRC; those authors suggested the use ofthis procedure forstagesIand II. ThestudybyMulford et al.,7 _a

system-aticreviewof52articles,alsosuggestedPRCastheprocedure withthe lowest complicationrate; the authors highlighted

radio-capitateosteoarthritis,whichinmostpatientsis asymp-tomatic.

Forthesereasons,somedifferencesinthevariablesstudied maybeobservedwhencomparedwiththoseofthepresent study.

Both are salvage surgeries that present functional and sociallimitations,withdecreasingvaluesinallcriteria ana-lyzedwhencomparingthesewristswiththeuninvolvedside. Inthecomparisonwithothermethodsofsurgicalsalvage treatment, suchasarthroplastyandtotalwristarthrodesis, thepresentstudypresentedsuperiorDASHscoreswhen com-paredwiththestudybyAndersonandAdams26_andsuperior

returnwhencomparedwiththatbyWeissandHastings.25

When compared to other procedures of partial wrists arthrodesis,suchasradioscapholunatefusion,whichallows forwristmobilityinthe midcarpaljoint,the resultsofthe presentstudyarealsosuperiortothatobservedbySaffar,22

who observed 57% hand grip strength. Beyermann et al.23

observed aDASHscore24 _{of25.7.Dimitrios et al.}24 _showed

good resultsinaretrospectivestudy ofmodifiedmidcarpal arthrodesis,whereinaniliacgraftwasusedtomaintainthe carpal height,observing consolidationinallcases, without complications.

Conclusion

Patientshadclinicalandfunctionalimprovementofthewrist, increased hand grip strength,reduced pain, and improved qualityoflifeaftertreatmentofthisdiseasewithboth meth-odsusedinthistrial.

Clinicalandfunctionalresultsshowednostatistical differ-encesbetweenthetwomethods.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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