“Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of SLAC/SNAC Wrist: A Cost-Utility Analysis”

Background: Two mainstay surgical options for salvage in scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) include proximal row carpectomy (PRC) and four-corner arthrodesis (4CA). This study evaluates the cost-utility of PRC versus three methods of 4CA for the treatment of SLAC/SNAC wrist. Methods: 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 analog scale survey of expert hand surgeons estimated 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. Decision tree analysis determined that both 4CA with screw fixation and PRC were cost-effective options, but 4CA with screw was the optimal treatment strategy. 4CA with K-wire fixation and 4CA with plate fixation were dominated (inferior) strategies and therefore not cost-effective. 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 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. 4CA with plate and K-wire fixation should be avoided from a cost-effective standpoint. Financial Disclosure Statement: The authors have no financial interest to declare in relation to the content of this work. Acknowledgements: None. Corresponding Author: David A. Daar MD, Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 305 East 33rd St. Lower Level, New York, NY 10016,. Daard01@nyumc.org, 847-276-1310 ©2019American Society of Plastic Surgeons

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