SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original Article
APSI scaphoid hemiarthroplasty – long-term results 夽
Filipe Lima Santos
∗, Andreia Ferreira, Rita Grazina, David Sá, Pedro Canela, Rui Lemos
CentroHospitalardeVilaNovadeGaia,VilaNovadeGaia,Portugal
a r t i c l e i n f o
Articlehistory:
Received14April2017 Accepted8June2017
Availableonline2August2018
Keywords:
Hemiarthroplasty Scaphoidbone Necrosis Wrist
a bs t r a c t
Objective:This studyis aimedatevaluating thelong-termresults ofproximalscaphoid hemiarthroplastyforpost-traumaticavascularnecrosisatthisinstitution.
Methods:Twelvepatientswhounderwentthisprocedurewereidentified,and themean follow-uptimewas6.5years(range:5–8years).Allpatientsweremale,withameanage of39years(range:28–55years).Ineightpatients,thenon-dominant limbwasaffected.
Theprocedurewascarriedoutthroughadorsalapproachandallpatientsunderwentthe samerehabilitationprotocol.Caseswereevaluatedregardingcomplications,pain,rangeof motion,functionalstatus(MayoWristScore),anddisability(QuickDASHScore).
Results:Noimmediatepost-operativecomplications,suchasinfectionordislocationofthe implant,wereobserved.Allpatientspresentedwithperi-implantosteolysisatfollow-up,on aradiographstudy.Noneofthepatientswasforcedtoabandontheirpreviousprofessional activity,althoughabout50%requiredsometypeofadaptationattheirworkplace.Themean functionalcapacitywas,accordingtotheMayoWristScore,of67.5points(range:50–80), correspondingtoasatisfactorydegreeoffunction.TheQuickDASHdisabilityscorepresented ameanof25(range:3–47.7).
Conclusion:Theresultsofthisseriesareinlinewithpreviouslypublishedstudiesabout thistechnique.Hemiarthroplastywithapyrocarbonimplantisa safetechniqueforthe treatmentofpost-fractureavascularnecrosisofthescaphoidproximalpole.Thistechnique allowedforsatisfactoryfunctionalresultsatameanfollow-upof6.5years.
©2018PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
HemiartroplastiadoescafoidecomAPSI–resultadosfuncionaisemlongo prazo
Palavras-chave:
Hemiartroplastia
r e su m o
Objetivo:Avaliarosresultadosemlongoprazodahemiartroplastiadoescafoideproximal notratamentodaosteonecroseavascularpós-traumáticanainstituic¸ão.
夽StudyconductedatCentroHospitalardeVilaNovadeGaia,VilaNovadeGaia,Portugal.
∗ Correspondingauthor.
E-mail:santos.fi[email protected](F.L.Santos).
https://doi.org/10.1016/j.rboe.2018.07.011
2255-4971/©2018PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopediaeTraumatologia.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
rev bras ortop.2018;53(5):582–588
583
Ossoescafoide Necrose Punho
Métodos:Foramidentificados12pacientessubmetidosaesseprocedimento.Otempomédio deseguimentofoide6,5anos(entrecincoeoito).Todosospacienteseramdosexomas- culino,commédiade39anos(entre28e55).Emoitopacientesomembroafetadofoio nãodominante.Oprocedimentofoifeitopormeiodeumaabordagemdorsaletodosos pacientesforamsubmetidosaomesmoprotocolodereabilitac¸ão.Todososcasosforam avaliadosquantoàocorrênciadecomplicac¸ões,dor,amplitudedemovimento,capacidade funcional(MayoWristScore)eincapacidade(QuickDASHScore).
Resultados: Nãoforamobservadascomplicac¸õesnoperíodopós-operatórioimediato,como infec¸ãoouluxac¸ãodoimplante.Nofimdoperíododeseguimento,todososcasosapresen- tavamosteóliseperi-implantenoestudoradiográfico.Nenhumdospacientesabandonoua suaatividadeprofissionalpréviaàcirurgia,emboraemcercade50%doscasostenhasido necessárioalgumtipodeadaptac¸ãonolocaldetrabalho.Acapacidadefuncionalmédiafoi, deacordocomoMayoWristScore,de67,5pontos(entre50e80),correspondeuaumnívelde func¸ãosatisfatório.OescoredeincapacidadeQuickDASHapresentouumapontuac¸ãomédia de25(entre3e47,7).
Conclusão: Osresultadosdestasérieencontram-seemlinhacomosestudospublicados sobreessatécnica.Ahemiartroplastiadoescafoidecomimplantedepirocarbonoéuma técnicaseguraparaotratamentodanecroseavasculardopoloproximaldoescafoideapós fratura.Essatécnicapermitiuobterumresultadofuncionalsatisfatórioapósumamédiade 6,5anosdeseguimento.
©2018PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Thescaphoidisthemostcommonlyfracturedcarpalbone.It presentsacomplexthree-dimensionalanatomyandaprecar- iousvascularsupply,especiallyproximally.1–5
Thelossofbonecontinuityresultsininjurytothescaphoid vascularizationand,consequently,impairsmechanismofres- olutionofthefracture.5Inproximal-thirdfractures,complete lossofvascularization ofthis segment can beobserved in upto40% ofthe cases,withosteonecrosisoftheproximal segment.6,7
Consolidationfractureatthescaphoidlevelgenerallypro- gressestoosteoarthrosis,accordingtothescaphoidnonunion advancedcollapse(SNAC)pattern,withpainandfunctional disabilityatwristlevel.Thereisnoconsensusonthetreat- mentoftheselesions.8–10
Thesurgicaltreatmentsclassicallyindicatedforthetreat- mentofSNAClesionsare:partialresectionofthescaphoid;
proximalcarpectomy;intracarpalarthrodesis(lunar-capitate- trapezium-trapezoid four-corner arthrodesis). These proce- dures present specific technical complications – scaphoid resection and proximal carpectomy are associated with an increased risk of progression to wrist osteoarthrosis and decreased grip strength; in turn, arthrodesis proce- dures are associated with a decrease in the range of motion.11–15
In more advanced cases, with generalized intercarpal and radiocarpal osteoarthrosis, arthrodesis or total wrist arthroplasty may be indicated. Radiocarpal arthrodesis is associatedwithanimportantlimitation inhand andwrist function. Total wrist arthroplasty is a technique without consistent results in the literature; short-term functional improvementshavebeenobserved,butlong-termhighrates of complications, such as aseptic detachment, have been observed.16–19
Partial or total scaphoid resection (proximal fragment) results in a collapse of the proximal row. Adaptive Prox- imal Scaphoid Implant (APSI – Tornier Cie., Montbonnot, Saint Martin,France)hemiarthroplastyuses amobilepyro- carboninterpositionimplanttoreplacetheproximalpoleof the scaphoid. This technique aimsat avoiding a proximal rowcollapse,maintaincarpalkinematicsduringwristmove- ments, and minimize the evolution to carpal collapse and osteoarthrosis.20
Moststudiespublishedinthescientificliteratureontheuse ofthistypeofimplantpresentonlyshort-termresults.20–23 The present study was aimed at evaluating the long-term resultsofinterpositionhemiarthroplastyofthescaphoidwith amobilepyrocarbonimplantinthepatientsfromthisinstitu- tion.Thecomplicationsassociatedwiththeprocedure,pain, range ofmotion,functional capacity,disability,and patient satisfactionwiththeprocedurewereassessedattheendofa meanfollow-uptimeof6.5years.
Material and methods
Twelvecasesofthistypeofhemiarthroplastywereretrieved atthisinstitution.Allpatientsweremale,withameanageof 39years(range:28–67years).
In eight patients, the non-dominant side was affected.
Of the 12 patientsevaluated, eightperformed professional activitieswithhighphysicalandfunctionaldemandsonthe wrist.
Preoperative imageswere collected in all patients,from simple wrist radiographs to computed tomography and nuclear magnetic resonance when the attending surgeon deemeditnecessary.
The biographic data and the classification of patients accordingtotheSNACdegree(accordingtotheclassification proposedbyVenderetal.8)observedintheinitialradiographic
Table1–BiographicdataandpreoperativedegreeofSNAClesion.
Patient Age Gender Follow-uptime Occupation Affectedlimb SNAC
1 46 Male 7 Metalworker Dominant 1
2 34 Male 5 Gravedigger Non-dominant 2
3 38 Male 6 Civilconstruction Dominant 1
4 33 Male 8 Civilconstruction Dominant 1
5 28 Male 7 Physicaltherapist Non-dominant 1
6 55 Male 5 Secretary Non-dominant 2
7 35 Male 7 Civilconstruction Non-dominant 1
8 44 Male 7 Secretary Non-dominant 1
9 37 Male 6 Electrician Non-dominant 2
10 40 Male 8 Metalworker Dominant 2
11 35 Male 5 Factoryworker Non-dominant 1
12 42 Male 7 Secretary Non-dominant 2
studyaredescribedinTable1.Thestudywasapprovedbythe EthicsCommitteeoftheinstitution,andallpatientssignedan InformedConsentFormforparticipationinthestudy.
Forthisprocedure,adorsalarthrotomyapproachwasused betweenthethirdandfourthextensorcompartments.Acare- fulpartialstyloidectomy(in ordertoavoidtheimpairment oftheextrinsicligaments)wasassociatedwithhemiarthro- plastyincasesofsignificantosteophytosis,orincasesofspace conflictforimplantplacement.
The procedure was performed with a tourniquet, after exsanguination;all patientswere operatedon bythe same surgeon,undergeneralanesthesiaandfluoroscopiccontrol.
Aftertheproximalpoleofthescaphoidwasresected,differ- entsizes(small,mediumorlarge)weretestedtodeterminethe appropriatesizeoftheimplanttobeused.Thetestsallowed thesurgeontoassessthelevelofboneresection,theneedfor astyloidectomy,andtherangeofmotionandstabilityofthe implantthroughtherangeofmotionofthejoint,underdirect vision.Theimplantsareavailableinthreesizes,whicharethe sameasthoseusedinthetests.
Attheendofthe procedure,thejointcapsulewascom- pletely repaired in order to maximize the stability of the implant.Nopostoperativedrainswere used.Afterthe pro- cedure,aforearmplastersplintwasmade.Allpatientswere dischargedfromhospitalonthedayafterthesurgicalproce- dure.
All cases were followed-up in outpatient consultations aftersurgery and underwent thesame protocol ofpostop- erative physical therapy for approximately three months.
In the immediatepostoperative period,finger mobilization wasencouraged.Betweenthesecondandthirdpostoperative weeks,theplastersplintwasremovedandthepatientsstarted activewristmobilization;theuseoftheoperatedwristwasnot allowedatthatmoment.
Onthe sixth postoperative week,patients were allowed toperformactivitiesofdailylivingwiththeoperatedlimb.
From that moment onwards, physiatric therapy treatment focused on improving the range of motion and muscle strength.
Themean follow-up time was5.5years (range: 4–7). At theendofthefollow-uptime,allpatientswereassessedfor pain,rangeofmotion,functionalcapacity,disability,andsat- isfactionwiththeprocedure.Painintensitywasdetermined
basedonthevisualanalogscale(VAS);rangeofmotionwas assessedusingagoniometer;gripstrengthwasmeasuredwith adynamometer.TheMayoWristScoreand theQuickDASH scorewereusedtoassessfunctionalcapacityandassociated disabilityattheendoffollow-uptime.Datawerecollectedand processedusingstatisticalsoftware(SPSS–IBM,NewYork, UnitedStates,2014).
Results
No cases of periprosthetic infection, instability of the implant, or complications related to the surgical incision wereobservedintheimmediateorlong-termpostoperative period.
Atthe endofthefollow-up time,all patientspresented correctimplant positioningintheproximalrow ofthe car- pus.Despitethegoodpositioning,intheradiographicstudy attheendofthefollow-uptimeallcasesshowedsomedegree ofperi-implantosteolysisandprogressionofthedegenera- tivewristalterations(osteophytosisanddecreasedjointline space;Fig.1).Theimplantpositioningintheproximalrowand thedegreeofosteolysisaroundtheimplant(especiallyatthe distalendofthecapitate)rendertheinterpretationofradio- graphicresults(suchastheinterruptionofGilulalines)less reliable(Fig.1).
Noneofthepatientshadtochangehisprofessionalactiv- ity afterthe lesion was surgically corrected, although half ofthepatients reportedaneedforadaptationtothe func- tions performed in the workplace after surgery. Prior to surgery, ineightofthe 12 cases,the patients’ professional activities were considered to be of high demand for the wrist.
All patients reported less pain after surgery; the mean intensitywas22.33(3)onVAS(0–100).Allpatientsreported thepersistenceofsomedegreeofpainaftersurgery,ofmild intensity(from5to41).
Allpatientshadadecreaseinrangeofmotionwhencom- paredwiththecontralateralsideattheendofthefollow-up time.Table2presentstherangeofmotionobservedattheend ofthefollow-uptime.
Themeanfunctionalcapacity,accordingtotheMayoWrist Score,was67.5points(range:50–80),whichisconsideredto
rev bras ortop.2018;53(5):582–588
585
Fig.1–Radiographicstudyattheendofthefollow-uptime–implantiswellpositionedintheproximalrow,with peri-implantosteolysis,andprogressionofdegenerativechanges.
be“fair.”ThemeanQuickDASHscorewas25(range:3–47.7).
ThecompleteresultsareshowninTable3.
Theareawhereallpatientspresentedmostdisabilitywas duringmoreintenseexerciseandintransportingorworking withheavyweights.
Regarding the degree of satisfaction with the surgery, 11 patients reported being satisfied or very satis- fied with the surgery and only one patient reported dissatisfaction.
Discussion
Thetreatment ofSNAC lesions is still a matterof debate;
severaltechniqueshavebeenproposedforthetreatmentof this pathology.Mostinvolve sometypeofcarpal arthrode- sis (with a consequently decreased range of motion) or proximalcarpectomy(typicallywithlossofwristandhand strength).Inmoreadvancedcases,wristarthrodesismaybe indicated.8–15
When compared with hemiarthroplasty, arthrodesis is associatedwithaconsiderableperiodofpostoperativeimmo- bilizationtoachievecompleteboneunion.Thesetechniques alsopresent their unique complications, which are associ- atedwiththematerialusedtoachievearthrodesis–infection, migration,ormaterialfailure;jointprominenceofthematerial –andthebiologicalprocessofarthrodesis–delayedconsoli- dation,nonunion,andpseudoarthrosis.8–15
The goal of hemiarthroplasty of the proximal pole of the scaphoid isto replace the proximal pole ofthe carpal scaphoidandtherebypreventproximalrowcollapse.Theuse ofimplants madeofsilastic, metal,or ceramicwas notan effectiveoptionsincetheywereassociatedwithasignificant rateoffailureorassociatedsynovitis.24,25
TheAPSIimplantismadeofpyrocarbon,amaterialthat isbiochemicallyinert,biocompatible,andhighlyresistantto abrasivewear.Thismaterialpresentsamodulusofelasticity and densityequaltothatofthecorticalbone,whichmini- mizestheriskofstressshielding.26
Withthisimplant,proximalpolehemiarthroplastycanbe performedbyarthrotomyorthrougharthroscopy,asdescribed byGrasetal.23
Theuseoffluoroscopicimagingcontrolduringthesurgi- calprocedureallowsanassessmentofthescaphoidresection levelandofthecongruenceoftheimplant,itsbehavior,and itsstabilitywithwristmovements.
The complications described with this technique are implantdislocation(volarordorsal),peri-implantosteolysis, inadequate implant sizing(which maypredisposetoradial styloidconflictordislocation),persistentpainandlimitation, andprogressionofthedegenerativealterationsatthewrist level.23
Todate,fewfollow-upstudiesonthistypeofarthroplasty have been conducted. In the series of cases published by Pequignotetal.,20APSIprosthesisinterpositionarthroplasty allowedtherestorationofasatisfactorylevelofwristfunc- tion,withoutmechanicalcomplications;attheendofsixyears offollow-up, carpalheightwas maintained.Theretrospec- tivestudybyGrandisetal.21presentedsimilarresults,with a satisfactory functional outcome, including improvement of pain, range of motion, strength, and return to profes- sional activity, with a high rate of satisfaction with the procedure.
A prospective study by Daruwalla et al.,22 with a mean follow-up of 18 months, showed similar results – improvement of pain, range of motion, strength, return to work activity, and functional disability assessed by the DASH Score – without complications associated with the
revbrasortop.2018;53(5):582–588 Table2–Assessmentofmobilityattheendoffollow-uptime.
Patient Flexion(◦) Contralateral (◦)
%
Contralateral
Extension (◦)
Contralateral (◦)
%
Contralateral Radial deviation(◦)
%Contralateral (◦)
%
Contralateral
Cubital deviation(◦)
Contralateral (◦)
%
Contralateral
1 27 50.94 0.53 35 58.33 0.6 10 23.81 0.42 13 34.21 0.38
2 8 50.00 0.16 13 61.90 0.21 6 22.22 0.27 8 21.62 0.37
3 69 84.15 0.82 57 72.15 0.79 17 26.98 0.63 28 32.94 0.85
4 43 69.35 0.62 39 68.42 0.57 12 23.08 0.52 26 39.39 0.66
5 50 83.33 0.6 48 82.76 0.58 19 44.19 0.43 32 78.05 0.41
6 42 79.25 0.53 37 72.55 0.51 21 40.38 0.52 27 44.26 0.61
7 20 62.50 0.32 23 82.14 0.28 9 30.00 0.3 11 31.43 0.35
8 26 81.25 0.32 32 86.49 0.37 8 34.78 0.23 22 53.66 0.41
9 41 61.19 0.67 43 58.90 0.73 14 21.88 0.64 31 46.27 0.67
10 28 50.91 0.55 37 60.66 0.61 12 20.00 0.6 17 28.81 0.59
11 31 72.09 0.43 36 97.30 0.37 8 25.81 0.31 19 65.52 0.29
12 40 78.43 0.51 38 80.85 0.47 10 25.64 0.39 27 50.00 0.54
Mean 35.42 68.62 0.51 36.50 73.54 0.51 12.17 28.23 0.44 21.75 43.85 0.51
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587
Table3–Painassessment,MayoWristScore,and QuickDASHattheendoffollow-uptime.
Patient VAS Mayo QuickDASH
1 21 75 20
2 41 50 47.7
3 5 80 3
4 23 65 35
5 35 65 20
6 23 70 15
7 17 65 35
8 15 70 35
9 9 80 20
10 29 60 35
11 31 65 15
12 19 65 20
Mean 22.33(3) 67.5 21.975
procedure.Thecaseofvolardislocationoftheimplantafter trauma,due toafall,which requiredrevisionsurgery,was noteworthy.
Anotherprospective,arthroscopicprocedurepublishedby Grasetal.23reportedimprovementsinpain,rangeofmotion, strength,functionalcapacity(MayoWristScore),anddisabil- ity(DASHScore),withafollow-upof8.7years.However,six complicationswereobserved:onecaseofacuteimplantsub- luxation,twocasesofvolarsubluxationoftheimplant,and threecasesofconflictwiththestyloidprocess,requiringrevi- sionsurgery.
Thepresent results demonstrated improvements inthe degree of pain, although with persistence of slight pain (meanof22.33[3]).Theseresultsareinlinewiththosepub- lished byDaruwalla et al., but lower than those observed by Gras et al.,23 that may suggest that the use of an arthroscopic approach can be associated with lower post- operativepain,eveninthelong-term.Paincomplaintsmay beduetobiomechanicalalterationsafterhemiarthroplasty, progression of the degenerative process despite surgical treatment, the peri-implant osteolysisprocess, or to other causes.
Atthe end of the follow-up time, patients presented a decreased wrist range of motion in flexion/extension and inradialandulnardeviationwhencomparedwiththecon- tralateraljoint.Theseresultsaresimilartothosereportedby Daruwallaetal.,22althoughwithalongerfollow-uptime.The decreaseintherangeofmotionmaybeassociatedwithbiome- chanicalalterationsinthejointafterhemiarthroplasty,scar tissueretractionafterthe fracture and aftersurgical treat- ment,and progressionofthe degenerative process,among others.
Inthepresentstudy,themeandisabilityaccordingtothe QuickDASH score was 25, similar to that observed in the seriesbyDaruwallaetal.22(20),despitethelongerfollow-up time.ThestudybyGrasetal.23presentedbetterresultsthan thoseobservedinthepresentseries,whichmayindicatethat thearthroscopicprocedureisassociatedwithalowerdegree ofdisability. The higher disability observed in the present study may also bedue tothe fact that a significant num- berofpatients(eightoutof12cases)performedprofessional activitieswithhighphysicalandfunctionaldemandonthe wristjoint.High-demandprofessionalactivitiesarepossibly
associatedwithincreasedwear-outofthejoint,withafaster progressiontodegenerativealterationsanddecreasedfunc- tionalcapacity.
ThemeanMayoWristScoreof67.5points(range:50–80) observedinthepresent studycorrespondstoa“fair”func- tion,whichisinlinewiththestudies byPequignotetal.20 and Grandiset al.21 TheresultspresentedbyGras et al.,23 with a mean score of 79.6 points on that same scale, although in the “fair” range of function, are superior to those observed inthe present study. Thebetterfunctional results observedin the series byGras et al.23 may be due tothelower surgicalaggression (arthroscopicprocedure)or to the fact that cases with the worse functional outcome andgreaterpainintensity(twocases)underwentfour-corner fusion.
Pyrocarbonimplantswereshowntobeasafealternative, withlowriskofinfection,implant failure,ordislocation.It isalsoimportanttomentionthattheinformationregarding salvageproceduresinthecasesoffailureofthistypeofarthro- plastyisscarce,onlypresentedinthestudybyGrasetal.,23 whodidnotreportonthedifficultiesorcomplicationsinher- enttotheprocedure.
Conclusion
APSI arthroplasty is a safe technique forthe treatment of SNAC-typescaphoidlesions.Inthepatientsstudied,aftera meanfollow-upof6.5years,thistreatmentallowedthemain- tenanceofwristfunctionata“fair”level,inaccordancewith theMayoWristScore,andwithafunctionaldisabilityscoreof 25(QuickDASHscore).Theseresultsareinlinewithstudies published todate,despitebeinglimited bythe smallsam- plesize.Moreprospectivestudieswithagreaternumberof casesareneededtovalidatethistechniqueforthetreatment ofSNAClesions.
Conflicts of interest
Theauthorsdeclarenoconflictsofinterest.
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