Abstract
Background Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are common patterns of wrist arthritis, and surgical treatment options include partial and total wrist arthrodesis and wrist denervation, which maintains the current anatomy while relieving pain.
Introduction The purpose of this study is to elucidate current practices within the hand surgery community with respect to the use of anterior interosseous nerve/posterior interosseous nerve (AIN/PIN) denervation in the treatment of SLAC and SNAC wrists.
Methods An anonymous survey was distributed to 3,915 orthopaedic surgeons via the American Society for Surgery of the Hand (ASSH) listserv. The survey collected information on conservative and operative management, indications, complications, diagnostic block, and coding of wrist denervation.
Results In total, 298 answered the survey. 46.3% ( N = 138) of the respondents used denervation of AIN/PIN for every SNAC stage, and 47.7% ( N = 142) of the respondents used denervation of AIN/PIN for every SLAC wrist stage. AIN and PIN combined denervation was the most common standalone procedure ( N = 185, 62.1%). Surgeons were more likely to offer the procedure ( N = 133, 55.4%) if motion preservation had to be maximized ( N = 154, 64.4%). The majority of surgeons did not consider loss of proprioception ( N = 224, 84.2%) or diminished protective reflex ( N = 246, 92.1%) to be significant complications. 33.5%, 90 respondents reported never performing a diagnostic block prior to denervation.
Conclusion Both SLAC and SNAC patterns of wrist arthritis can result in debilitating wrist pain. There is a wide range of treatment for different stages of disease. Further investigation is required to identify ideal candidates and evaluate long-term outcomes.
Keywords: SLAC, SNAC, wrist, denervation, arthritis
Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are common patterns of wrist arthritis. 1 SLAC wrist was initially described by Watson and Ballet in 1984. 3 Their analysis of over 4,000 wrist radiographs revealed a pattern of arthritic changes at the juncture between the scaphoid, lunate, and radius. Their findings also cataloged the progression of changes that occur in degenerative arthritis, which ultimately resulted in the classification scheme used for SLAC wrists. In 1987, Vender et al described a similar pattern of degeneration in their radiographic analysis of SNAC, albeit with sparing of the radiolunate joint as well as the proximal scaphoid fragment. 4
Both SLAC and SNAC wrist can occur in the setting of trauma, depositional disease, rheumatoid arthritis, or neuropathic disease. 3 These etiologies all result in the attenuation of the scapholunate ligament, the hallmark of SLAC wrist. 5 SNAC wrist typically occurs as a result of traumatic scaphoid fracture that progresses to nonunion. When a scaphoid fracture is untreated, it can lead to scaphoid pseudarthroses resulting in carpal collapse, possible symptoms arising including stress-related pain, swelling, and reduced strength and wrist mobility, leading to SNAC wrist. 6
The classifications of both SNAC and SLAC are derived from the progression of changes that occur between the distal radius, lunate, and scaphoid, described by Watson and Ryu 1 3 7 8 ( Table 1 ).
Table 1. Radiographic classification of SLAC/SNAC wrist.
| Stage | SLAC (Watson) 2 | SNAC (Vender) 5 |
|---|---|---|
| I | Narrowing and sclerosis predominantly on radial styloid tip or distal pole of scaphoid | Narrowing and sclerosis predominantly on radial styloid tip or distal pole of scaphoid |
| II | Narrowing and sclerosis extending to entire radioscaphoid joint | Narrowing and sclerosis of the scaphocapitate joint |
| III | Narrowing and sclerosis involving both the radioscaphoid and the capitolunate joints | Narrowing and sclerosis of the capitolunate joint |
| IV | Pan-carpal sclerosis and narrowing |
Abbreviations: SLAC, scapholunate advanced collapse; SNAC, scaphoid nonunion advanced collapse.
A myriad of surgical options exists in the treatment of SLAC and SNAC. Partial and total wrist arthrodesis can limit wrist range of motion and strength. Wrist denervation, on the other hand, maintains the current anatomy while relieving pain. 2 Despite the growing body of literature supporting denervation, either as an isolated procedure or as an adjunct, the current extent of utilization of this procedure remains unknown. While there is yet to be a consensus on the appropriate technique and nervous targets for an isolated denervation, total wrist denervation has been shown to offer better long-term outcomes for pain relief. 9 The presence of persistent ulnar wrist pain for partial wrist denervation, 10 neuromas and decreased grip strength for complete wrist denervation are known complications, 11 although there still is a lack of research on the significance of these effects. Additionally, coding for the procedure has variability without a consensus. The purpose of this study is to elucidate current practices within the hand surgery community with respect to the use of anterior interosseous nerve/posterior interosseous nerve (AIN/PIN) denervation in the treatment of SLAC and SNAC wrists, including conservative treatment, indications for operation, operative treatment options, postoperative recovery, and coding for the procedure. We hypothesize that surgeons use denervation for all stages of SLAC and SNAC wrist with the goals of delaying more invasive treatment while retaining range of motion for patients.
Materials and Methods
Methods
Survey Population
After obtaining approval from our Institutional Review Board, an anonymous 29 question online survey was sent via email to 3,915 orthopaedic surgeons via the American Society for Surgery of the Hand (ASSH) research email listserv, with 298 respondents (response rate: 7.61%). The survey was distributed to the subset of the research mailing list composed of U.S. physician members only, which include candidate fellows, candidate, active, lifetime, and senior/retired members of ASSH. Resident candidate members were excluded. The survey received Institutional Review Board approval and was created and distributed using Qualtrics. Follow-up email was sent 4 weeks after initial communication to encourage participation.
All survey responses were categorized with anonymous identifiers. Categorical thresholds for questions involving Likert scales were analyzed by examining distributions of the raw data between different demographic groups of surgeons. Univariate analysis of categorical variables and multiple response sets were performed using the χ 2-test and analysis of dichotomous variables was done using Fischer exact test. Ordinal variables were also analyzed using the Mann-Whitney U test. A p -value <0.05 was considered statistically significant.
Results
Demographic information is outlined in Table 2 . Figs. 1 and 2 summarize the duration of conservative treatment. Non-academic surgeons recommended longer conservative treatment for SLAC wrist ( p <0.001) than academic surgeons, who recommended 3 to 5 months of treatment ( p <0.05).
Table 2. Demographic information.
| Current practice setting | |
|---|---|
| Academic | 96 (32.3) |
| Non-Academic | 201 (67.4) |
| Practice type | |
| Solo practice | 33 (11.1) |
| Group practice | 209 (70.1) |
| Hospital based | 55 (18.5) |
| Specialty training | |
| Orthopaedic surgery | 252 (84.6) |
| Plastic surgery | 36 (12.1) |
| General surgery | 10 (3.4) |
| Fellowship training | |
| Yes | 292 (98.0) |
| No | 1.7 (5) |
| Years in practice | |
| <5 | 51 (17.1) |
| 5–10 | 45 (15.1) |
| 11–20 | 67 (22.5) |
| 21–30 | 82 (27.5) |
| 31+ y | 53 (17.8) |
| Region of practice | |
| Pacific West | 50 (19.8) |
| Mountain West | 15 (5.0) |
| Central | 43 (14.4) |
| Midwest | 49 (16.4) |
| Mid-South | 13 (4.4) |
| South-East | 32 (10.7) |
| Mid-Atlantic | 54 (18.1) |
| North-East | 41 (13.8) |
Note: All data presented as total no (%) unless otherwise indicated. Some percentages may not add up to 100% because of rounding.
Fig. 1.
Duration of conservative treatment for SLAC (scapholunate advanced collapse) stages by percentage of surgeons.
Fig. 2.
Duration of conservative treatment for SNAC (scaphoid nonunion advanced collapse) stages by percentage of surgeons.
Surgical treatment for SLAC/SNAC stages is reported in Table 3 . AIN/PIN denervation was the second most popular adjunct treatment option for every stage of SLAC wrist. 47.7% ( N = 142) of respondents used denervation of AIN/PIN for every SLAC wrist stage in conjunction with other procedures, with the majority using it for stage I ( Table 4 ).
Table 3. Surgical treatment options for SLAC and SNAC wrist.
| Surgical procedure | SLAC 1 | SLAC 2 | SLAC 3 | SLAC 4 | SNAC 1 | SNAC 2 | SNAC 3 |
|---|---|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | |
| Total wrist arthrodesis SLAC | 7 (2.5) | 12 (4.2) | 64 (22.2) | 232 (80.8) | 7 (2.5) | 25 (8.80) | 151 (53.4) |
| Partial wrist arthrodesis (Four corner, three corner, capitolunate) | 78 (27.4) | 188 (65.70) | 233 (80.9) | 75 (26.1) | 87 (30.9) | 200 (70.4) | 173 (61.1) |
| Proximal row carpectomy (PRC) | 92 (32.3) | 219 (76.6) | 142 (49.3) | 67 (23.3) | 105 (37.2) | 179 (63.0) | 137 (48.4) |
| Denervation involving the AIN/PIN | 188 (66.0) | 194 (67.8) | 186 (64.4) | 167 (58.2) | 179 (63.5) | 181(63.7) | 158 (55.80) |
| Radial styloidectomy | 195 (68.4) | 76 (26.6) | 44 (15.3) | 24 (8.4) | 142 (50.4) | 54 (19.0) | 32 (11.30) |
| Distal scaphoid excision | 43 (15.1) | 16 (5.6) | 5 (1.7) | 4 (1.4) | 121 (42.9) | 43 (15.1) | 12 (4.20) |
Abbreviations: SLAC, scapholunate advanced collapse; SNAC, scaphoid nonunion advanced collapse.
Table 4. Use of Isolated AIN/PIN Denervation with SLAC and SNAC Wrist.
| SLAC | ( N = 233) | % |
|---|---|---|
| I | 196 | 84.1% |
| II | 170 | 73.0% |
| III | 152 | 65.2% |
| IV | 145 | 62.2% |
| SNAC | ( N = 233) | % |
| I | 195 | 83.7% |
| II | 165 | 70.8% |
| III | 148 | 63.5% |
Abbreviations: AIN, anterior interosseous nerve; PIN, posterior interosseous nerve; SLAC, scapholunate advanced collapse; SNAC, scaphoid nonunion advanced collapse.
For SNAC stage 3, more non-academic surgeons performed denervation of the AIN/PIN ( N = 110, 58.5%), while most academic surgeons performed a partial wrist arthrodesis ( N = 63, 68.5%), ( p = 0.035). The majority of surgeons ( N = 195, 86.3%) considered the use of AIN/PIN denervation alone with SNAC stage 1 ( Table 4 ). 46.3% ( N = 138) of respondents used denervation of AIN/PIN for every SNAC stage.
The majority of surgeons performed both AIN and PIN denervation as a standalone procedure ( N = 185, 75.2%), versus just AIN denervation alone ( N = 1, 0.4%) or PIN denervation alone ( N = 60, 24.4%). Most surgeons who performed AIN/PIN denervation as an adjunct procedure performed the denervation as well ( N = 242, 84.9%), and most commonly performed PIN denervation alone ( N = 183, 66.1%). Most performed the procedure by excising part of the nerve ( N = 214, 77.3%). All ( N = 281) of the respondents stated that the decision to add-on AIN/PIN denervation to another procedure (proximal row carpectomy, four-corner, styloidectomy, and total wrist arthrodesis) did not impact their postoperative care plan, and 78.8% ( N = 223) reported that the decision to perform AIN/PIN denervation in addition to a salvage procedure did not impact their surgical approach to the non-denervation surgical component.
The majority of surgeons reported they never performed a diagnostic nerve block ( N = 90, 33.5%). 66.8% ( N = 163) of surgeons stated that age did not play a role in their decision to perform the procedure, but 55.4% ( N = 133) of surgeons reported they were more likely to offer the procedure if motion preservation had to be maximized. 65.1% ( N = 153) of surgeons reported that a patient's concern about undergoing more invasive procedures factored into their decision to offer isolated AIN/PIN denervation. Most reported the goal of AIN/PIN denervation was to delay further surgical treatment ( N = 154, 64.4%).
When asked about postoperative care, 43.0% ( N = 128) of surgeons reported they did not splint patients undergoing isolated AIN/PIN denervation and did not consider loss of proprioception ( N = 224, 84.2%) or diminished protective reflex ( N = 246, 92.1%) to be risk factors. Surgeons that wrote in responses cited “avoiding Charcot joint,” “painful neuroma formation” and “CRPS” (complex regional pain syndrome).
In total, 166 of 239 surgeons [69.5%]) used the code 64772 “Transection or avulsion of other spinal nerve, extradural” to bill for the AIN/PIN denervation procedure, while the remainder used 64782 “excision of neuroma, hand or foot, except digital nerve.” 71.1% ( N = 165) of surgeons coded for both nerves, and 68.2% ( N = 176) included AIN/PIN denervation in their consent process if the denervation was adjunct to other surgical treatments.
Discussion
SLAC and SNAC wrist are two common patterns of wrist arthritis seen by hand surgeons. 3 Presentation can range from asymptomatic to debilitating wrist pain and/or limited motion and strength. 2 Denervation of the sensory branches of the AIN or PIN has been used in isolation or adjunct procedure to treat pain. 12 We aimed to elucidate current practices within the hand surgery community with respect to the use of AIN/PIN denervation for SLAC and SNAC wrists, indication for operation, operative treatment, and postoperative recovery.
Surgeons performing procedures to address SLAC and SNAC wrist are mostly non-academic orthopaedic surgeons fellowship trained in hand surgery, which is consistent with reports of the prevalence and training of hand surgeons in the United States. 3 Most recommended a longer duration of conservative treatment for earlier stage disease (up to 12 months), but for stage 2 and above, the recommended duration of conservative treatment was 3 to 5 months, despite the increasing degree of arthritis between stages. This supports previous findings that conservative management such as splinting or corticosteroid injections can be effective for early stage SNAC/SLAC wrist, but for later stages, debilitating pain or limited function dictates that only denervation or salvage operations are available. 13 14 15 16 Rothe et al found that denervation in patients with advanced SLAC/SNAC stages helped achieve long-term reduction and elimination of pain, and it should be favored over other procedures such as wrist arthrodesis or proximal row carpectomy. 17 Mid-term outcomes of denervation, as evaluated by Hassebrock et al, showed 28 out of 30 patients free from additional wrist procedures at an average of 47 months of follow-up. 18 Dellestable et al demonstrated a surgery free survival median of 8.8 years in a long-term study. 19 Wrist denervation has variability in providing long-term pain relief and although pain can recur, the treatment can provide years of relief without undergoing more invasive surgery.
Riches et al compared PIN denervation to wrist arthrodesis in 22 patients with rheumatoid arthritis and found patients reported low rates of complication, decreased pain, increased functionality, and overall high patient satisfaction in both groups (87% were satisfied with wrist arthrodesis compared with 78% in the denervation group), with no statistically significant difference in response between the two groups. 20 Thus, denervation for the management of late stage SLAC/SNAC is an overall less invasive option compared with procedures such as wrist arthrodesis, with similar patient reported pain outcomes, low complication rates, and overall high satisfaction with the procedure.
Our survey found that preservation of motion and delaying further surgical treatment were primary considerations in performing AIN/PIN denervation for SLAC and SNAC wrist. As a primary procedure, isolated wrist denervation performed for chronic wrist pain is somewhat controversial and should be performed only after failure of conservative treatment for at least 6 to 12 months. 21 Denervation is frequently combined with other procedures as a method of treating pain or alleviating future wrist pain from conditions such as wrist fractures, cysts, or ulnar-sided wrist pain, and our results show it is often standard practice to perform PIN denervation during other salvage procedures. The majority of surgeons performed isolated PIN denervation as an adjunct, but combined AIN/PIN as a standalone procedure. Further research is required to elucidate whether the addition of AIN denervation to adjunct procedures improves outcomes. An advantage of denervation is that salvage procedures such as wrist arthrodesis can still be safely performed utilizing the same incisions. Although literature shows that lack of proprioception due to denervation may speed the progression of wrist arthrosis, 22 the majority of our respondents did not feel that this was of significant concern.
Literature also supports the use of denervation procedures for painful wrist conditions as adjunct procedures, or as an alternative to a salvage procedure. For example, while isolated causes of ulnar-sided wrist pain (e.g., triangular fibrocartilage tears) are not typically treated with stand-alone wrist denervation, this may serve as an adjunct procedure as well. 23 46.3% of respondents used AIN/PIN denervation for every stage of SNAC, and 47.7% of respondents used AIN/PIN denervation for every stage of SLAC. This supports existing literature that denervation involving AIN/PIN is often used in all stages of SLAC wrist and SNAC wrist. 24 This is likely because denervation has been proven to be an effective surgical procedure for pain relief. 10 Storey et al, which looked at patient outcomes of 37 patients who underwent partial AIN/PIN denervation, found a significant decrease in median pain scores and improved range of motion and activity at 18 months follow-up. 25 Hassebrock et al examined 30 patients who underwent wrist denervation for stage 1 to 4 symptomatic SLAC arthritis that had failed nonoperative treatment, and found overall decreased pain and increased total arc of wrist motion. 18 Wrist denervation for pain relief is an effective noninvasive technique to decrease patient pain and also restore motion and functionality, which are often important factors for patients who are considering surgical intervention. 26
However, while our survey found that most surgeons performed isolated denervation in earlier stages of SLAC/SNAC wrist ( Table 4 ), performing wrist denervation in earlier stages does not slow down the progression of disease. In later stages of arthritis, the surgical plan is likely predetermined, and performing denervation would be considered an adjunct procedure to decrease pain and buy time prior to undergoing the salvage procedure 21
Diagnostic block of the AIN/PIN prior to proceeding with denervation can be informative regarding the potential success of the procedure. Only 19%, (51 respondents) reported always using a block. Success may be predicated by a significant reduction in pain with the block. Storey et al evaluated denervation in wrists and demonstrated improved outcomes in patients with less preoperative pain and higher reduction of pain after a block. 25 Further research is required to assess the predictive value of blocks in denervation.
Several CPT codes (64732–64772) are used to code the excision/transection of the AIN/PIN nerve. Excision is usually indicated for postoperative pain control, as Centers for Medicare and Medicaid Services have stated that global surgical care packages include postoperative pain management care by the surgeon (100–04 Claims Processing Section 40). The American Academy of Orthopaedic Surgeons (AAOS) published that AIN/PIN denervation should not be reported when performed for postoperative pain management in conjunction with other procedures. 27 However, if there is another reason for excision of the nerves, they recommended using CPT 64772, which the majority of surgeons in our survey (69.5%) used. AAOS guidelines state the origin of the nerve root must reference proper CPT code, and the majority surgeons in our survey (71.1%) coded for both nerves if they transected both the AIN and PIN.
Sample size was an inherent limitation: our survey had 298 responses and a response rate of 7.61%. Poor response rate was likely due to length of the survey. Furthermore, our study was limited to members of the ASSH. It is not known if surgeons not in the ASSH would consider isolated denervation to treat SNAC or SLAC wrist. This survey also focused largely on the subjective views of the ASSH membership toward a set of procedures, rather than objective treatment outcomes. As such, these results should not be taken as guidance for future treatment decisions, but rather should be viewed as the current state of attitudes toward denervation in the hand surgery community.
Both SLAC and SNAC patterns of wrist arthritis can result in debilitating wrist pain, and there is a wide range of treatment for different stages of disease. Our survey found that preservation of motion and delaying further surgical treatment were primary considerations in performing AIN/PIN denervation for SLAC and SNAC wrist. Further research is required to elucidate whether AIN/PIN as an isolated or adjunctive procedure is effective in treating pain caused by these conditions.
Conflict of Interest None declared.
Note
The authors whose names are listed immediately below certify that they have no affiliations or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.
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