The Long-Term Outcome of Four-Corner Fusion

Abstract

Introduction Four-corner arthrodesis with excision of the scaphoid is an accepted salvage procedure for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) and has been performed in our unit for over 20 years. We have undertaken a retrospective review of 116 of these procedures performed in 110 patients between 1992 and 2009. Fifty-eight patients attended for a clinical evaluation, and 29 responded by postal questionnaire. Methods The surgical technique undertaken was standard. That is, through a dorsal approach the scaphoid and tip of the radial styloid were excised. The capitate, lunate, triquetrum, and hamate articular surfaces were then prepared down to bleeding bone. Bone grafts from the scaphoid and radial styloid were then inserted and fixation undertaken. For the latter, various methods were used, including Kirschner (K-)wires, staples, bone screws, but predominantly the Spider plate (Integra Life Sciences, USA). Thereafter the wrist was immobilized for a minimum period of 2 weeks prior to rehabilitation. Results Follow-up was done at a mean of 9 years and 4 months (range 3-19 years). All patients reported a significant improvement in pain relief and $50% of flexion extension, although only 40% of radioulnar deviation. Grip strength was again $50% of the contralateral side. Most patients reported a significant improvement in function with 87% returning to work. In addition, radiologic evaluation identified 28 patients (31%) who demonstrated ongoing signs of nonunion, particularly around the triquetrum. Fourteen of these (15%) underwent a further procedure, generally with success. Finally, none of the patients demonstrated any arthritic changes in the lunate fossa on follow-up X-ray, and all secondary procedures were undertaken within 2 years of the primary. Discussion This research has demonstrated that four-corner fusion fixed with a circular plate can result in a satisfactory outcome with a reduction in pain, a functional range of motion, and a satisfactory functional outcome. The bulk of the complications appear to occur in the first 2 years after surgery. Thereafter, analysis shows long-term satisfaction with little deterioration. Nonunion, particularly around the triquetrum, continues to be a problem, but it may be that this bone should be excised along with the scaphoid, resulting in a three-part fusion only. Alternatively, a simple capitolunate fusion may be satisfactory.

Scapholunate Advanced Collapse: Four-Corner Fusion and Proximal Row Carpectomy

“…20 Most complications arise within the first 2 years after surgery, commonly related to nonunion. Grip strength, flexion, and wrist deviation are all decreased relative to the normal contralateral wrist, but functional results are favorable with a reported 87% return-to-work rate.…”

“…Grip strength, flexion, and wrist deviation are all decreased relative to the normal contralateral wrist, but functional results are favorable with a reported 87% return-to-work rate. 20 A systematic review found grip strengths of 75% when compared with the contralateral side. However, most studies reportpreoperative grip strength improvements postoperatively.…”

“…17 Despite concerns, there is no significant progression of radiolunate arthritis at minimum 3-year follow-up. 20 The PRC also provides reliable pain relief with fewer complications than FCF. 17,20 Grip strength is reported at 70%; however, as is seen in FCF, there is likely an improvement from preoperative strength.…”

“…20 The PRC also provides reliable pain relief with fewer complications than FCF. 17,20 Grip strength is reported at 70%; however, as is seen in FCF, there is likely an improvement from preoperative strength. 17 Postoperative flexionextension and radial-ulnar deviation are similar to preoperative ROM.…”

Four-corner arthrodesis of the wrist using Variable Angle Locking Compression Intercarpal Fusion Plate (VA LCP ICF Plate; Synthes ® ): pre- and postoperative radiological analysis and clinical outcome in long-term evaluation

“…Most commonly and best described in literature are the 4-corner fusion of the wrist and the proximal row carpectomy [1], [2], [3], [4], [5], [6], [7], [9], [10], [11], [13], [16], [18], [19], [31], [32], [33], [34], [35]. Nonetheless, some authors recommend the 3-corner fusion, bicolumnar intercarpal arthrodesis or other modifications as better options for treating wrist instabilities [14], [15].…”