Proximal Row Carpectomy Versus Four-Corner Arthrodesis for the Treatment of Slac/Snac Wrist: A Cost-Utility Analysis

Purpose:
Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) can cause persistent pain, weakened grip strength, and decreased range of motion. These factors can lead to a significant reduction in quality of life. Two mainstay surgical options for salvage include proximal row carpectomy (PRC) and four-corner arthrodesis (4CA). This study evaluates the cost-utility of PRC versus three methods of 4CA (K-wire fixation, plate fixation, or screw fixation) for the treatment of SLAC/SNAC wrist.

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

Results:
Forty studies yielding 1730 SLAC/SNAC wrists were identified. Overall complication rate was highest in the 4CA Plate group (11.3%), with malplacement of hardware requiring revision being the most prevalent (7.3%). Notably, PRC had the highest rate of persistent pain requiring conversion to total wrist arthrodesis (5.9%). Using a willingness to pay (WTP) threshold of $50,000 per QALY, decision tree analysis determined that both 4CA with screw fixation and PRC were cost-effective options. However, 4CA with screw was the optimal treatment strategy as it offered the greatest effectiveness at an incremental cost-utility ratio less than the WTP threshold. 4CA with K-wire fixation and 4CA with plate fixation were dominated (inferior) strategies and therefore not cost-effective. This was true for both societal and health care perspectives. One-way sensitivity analysis demonstrated that when the QALYs for a successful 4CA Screw are lower than 26.36, PRC becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis, which included acceptability curves and incremental cost-effectiveness scatter plots, confirmed the results of our model. 

Conclusions:
4CA with screw fixation and PRC are both cost-effective treatment options for SLAC/SNAC wrist due to their lower complication profile and high efficacy, with 4CA with screw as the most cost-effective treatment strategy. 4CA with plate and K-wire fixation should be avoided from a cost-effective standpoint. This study can serve as a framework for providers with regards to resource allocation and implementing policies consistent with efficiencies in both hospital and societal costs when treating patients with degenerative wrist disease.