Four-Corner Arthrodesis Employing the Native Scaphoid as the Principal Donor Graft and Kirschner-Wire Fixation for Advanced Collapse Deformity of the Wrist. Results in 40 Consecutive Cases

Purpose: To assess the outcome of four-corner arthrodesis (4CA) using the en bloc excised scaphoid as the principal source of bone graft coupled with secure Kirschner wire (K-wire) fixation employed for active persons with disabling collapse deformity of the wrist.

Materials and Methods: Between 2007 and 2014, 40 patients with a mean age 55 years (range, 22–76 years) underwent 4CA by the senior author (CPM) for progressive scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) deformity. In each case, the excised scaphoid was thoroughly débrided of cartilage and sclerotic subchondral bone, precisely sculptured to fit the realigned arthrodesis site, and securely fixed with K-wires. A solid cancellous wedge graft was fashioned to facilitate fusion and maintain carpal alignment. Supplemental local radial bone graft reinforced the fusion site in 28 cases. Cast immobilization was continued until radiographic union was clearly demonstrated. Range of wrist motion, grip strength, high-quality radiography, and the Michigan Hand Outcomes Questionnaire (MHOQ) were used to assess the objective and subjective outcomes. Results were statistically analyzed with the t-test for paired data, with a p-value < 0.05 considered significant.

Results: The average follow-up period was 4.4 years. Uncomplicated radiographic union was demonstrated in 38 cases within 6 to 8 weeks of surgery. In no case was fragmentation or collapse of the scaphoid graft observed, and in no case was radiolunate arthritis evident. Carpal height was maintained with postoperative indices averaging 0.452 ± 0.040 compared with preoperative values of 0.456 ± 0.044 (p = 0.76). Average grip strength postoperatively was 81.8% of the contralateral side. Average total active flexion-extension was 88° before surgery and 76° after surgery (p = 0.099). The total arc of wrist motion averaged 51% of the opposite side. The MHOQ demonstrated significant improvement in function, activities of daily living, work, pain, and satisfaction (p < 0.05). Two cases of radiographic malunion with dorsal carpal impingement occurred, but neither required revision, and, for the group, no additional operations proved necessary.

Summary Points:

• This review of 4CA indicates that the contoured native scaphoid provides a viable donor graft, promoting fusion while maintaining carpal alignment. The consistently rapid and successful fusion rate has resulted in relief of pain, restoration of function, and a high level of patient satisfaction for the active, high demand patient.

• This motion-preserving procedure is recommended for active persons, regardless of age, with advanced carpal collapse deformity.

References

References

1 Chung KC, Watt AJ, Kotsis, SV. A prospective outcomes study of four-corner wrist arthrodesis using a circular limited wrist fusion plate for stage II scapholunate advanced collapse wrist deformity. Plast Reconstr Surg 2006;118(2):433–442

2 Mantovani G, Mathoulin C, Fukushima WY, Cho AB, Aita MA, Argintar E. Four corner arthrodesis limited to the centre using a scaphoid one piece graft and a dorsal circular plate. J Hand Surg Eur Vol 2010;35(1):38–42

3 Bain GI, Watts AC. The outcome of scaphoid excision and four-corner arthrodesis for advanced carpal collapse at a minimum of ten years. J Hand Surg Am 2010;35(5):719–725

4 Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs. four-corner fusion for scapholunate (SLAC) or scaphoid nonunion advanced collapse (SNAC) wrist: a systematic review of outcomes. J Hand Surg [Br] 2009;34B 256–263

5 De Smet L, Deprez, P, Duerinckx, J, Degreef, I. Outcome of four-corner arthrodesis for advanced carpal collapse: circular plate versus traditional techniques. Acta Orthop Belg 2009;75(3):323–327

6 Vance MC, Hernandez, JD, Didonna ML, Stern PJ. Complications and outcome of four-corner arthrodesis: circular plate fixation versus traditional techniques. J Hand Surg Am 2005;30(6):1122–1127

7 Kendall CB, Brown TR, Millon SJ, Rudisill LE Jr, Sanders JL, Tanner SL. Results of four-corner arthrodesis using dorsal circular plate fixation. J Hand Surg Am 2005;30(5):903–907

8 Merrell GA, McDermott EM, Weiss AP. Four-corner arthrodesis using a circular plate and distal radius bone grafting: a consecutive case series. J Hand Surg Am 2008;33(5):635–642

9 Strauch RJ. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis—update on evaluation and treatment. J Hand Surg Am 2011;36(4):729–735

10 Kiefhaber TR. Management of scapholunate advanced collapse pattern of degenerative arthritis of the wrist. J Hand Surg Am 2009;34(8):1527–1530

11 Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am 1994;19(5):751–759

12 Ferreres A, Garcia-Elias M, Plaza R. Long-term results of lunocapitate arthrodesis with scaphoid excision for SLAC and SNAC wrists. J Hand Surg Eur Vol 2009;34(5):603–608

13 Gohritz A, Gohla T, Stutz N, , et al. Special aspects of wrist arthritis management for SLAC and SNAC wrists using midcarpal arthrodesis: results of bilateral operations and conversion to total arthrodesis. Bull Hosp Jt Dis 2005;63(1-2):41–48

14 Skie, MC, Gove, N, Ciocanel, DE, Smith, H. Management of non-united four-corner fusions. Hand (NY) 2007;2(1):34–38

15 Dacho, A, Grundel, J, Holle, G, Germann, G, Sauerbier, M. Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist). Ann Plast Surg 2006;56(2):139–144