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Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis

Daar, David A. M.D., M.B.A.; Shah, Ajul M.D.; Mirrer, Joshua T. M.D.; Thanik, Vishal M.D.; Hacquebord, Jacques M.D.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1432-1445
doi: 10.1097/PRS.0000000000005558
Hand/Peripheral Nerve: Original Articles
Coding Perspective
Outcomes: Cost

Background: Two mainstay surgical options for salvage in scapholunate advanced collapse and scaphoid nonunion advanced collapse are proximal row carpectomy and four-corner arthrodesis. This study evaluates the cost-utility of proximal row carpectomy versus three methods of four-corner arthrodesis for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist.

Methods: A cost-utility analysis was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A comprehensive literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analogue scale survey of expert hand surgeons estimated utilities. Overall cost, probabilities, and quality-adjusted life-years were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed.

Results: Forty studies yielding 1730 scapholunate advanced collapse/scaphoid nonunion advanced collapse wrists were identified. Decision tree analysis determined that both four-corner arthrodesis with screw fixation and proximal row carpectomy were cost-effective options, but four-corner arthrodesis with screw was the optimal treatment strategy. Four-corner arthrodesis with Kirschner-wire fixation and four-corner arthrodesis with plate fixation were dominated (inferior) strategies and therefore not cost-effective. One-way sensitivity analysis demonstrated that when the quality-adjusted life-years for a successful four-corner arthrodesis with screw fixation are lower than 26.36, proximal row carpectomy becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model.

Conclusions: Four-corner arthrodesis with screw fixation and proximal row carpectomy are both cost-effective treatment options for scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist because of their lower complication profile and high efficacy, with four-corner arthrodesis with screw as the most cost-effective treatment. Four-corner arthrodesis with plate and Kirschner-wire fixation should be avoided from a cost-effectiveness standpoint.

Evidence-Based Outcomes Article.Coding Perspective for this Article is on Page 1443.

New York, N.Y.; Saint Petersburg, Fla.; and Philadelphia, Pa.

From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopedic Surgery, New York University School of Medicine; All Florida Orthopedics; and the Department of Orthopaedic Surgery, University of Pennsylvania Health System.

Received for publication January 28, 2018; accepted October 26, 2018.

Disclosure:The authors have no financial interest to declare in relation to the content of this work.

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Jacques H. Hacquebord, M.D., Department of Orthopedic Surgery, New York University School of Medicine, 550 1st Avenue, Skirball 8U, New York, N.Y. 10016,

Copyright © 2019 by the American Society of Plastic Surgeons