Four corner arthrodesis a retrospective review

1. Four Corner Arthrodesis: a
retrospective review
S L Carter, M Solomons.
Hand Surgery, Groote Schuur and Vincent Pallotti Hospitals,
Cape Town

2. Introduction
• Four Corner arthrodesis is a
well described salvage
procedure used to treat SLAC
and SNAC arthritis
• It maximizes wrist motion and
strength while eliminating pain
and instability

3. Introduction
• Scaphoid in wrist biomechanics
• Staging of SNAC/SLAC arthritis*
• Stage 1 radiostyloid OA
• Stage 2 radioscaphoid OA
• Stage 3 midcarpal OA
• Stage 4 Generalized radiocarpal OA
• Role of the 4 corner fusion
*Watson HK. J Hand Surg. 1984:9:358-365

4. Introduction
• Four corner arthrodesis
Watson 1999: 252 cases
- 97% union
- 90% pain reduction
- 80% improved grip strength
• Proximal row carpectomy
Jensen 2003: 20 patients (minimum 10 year follow-up)
- 80% pain reduction
- 80% improved grip strength
• Excision distal pole of scaphoid
Malerich 1999: 19 patients
- 85% improved ROM
- 135% improved grip strength

5. Aim
• To describe and analyze the Groote Schuur Hospital and Vincent
Pallotti Hospital experience of 10 cases of four corner
arthrodesis (2001-2004).
• To identify the indications, complications and intermediate
outcome of the procedure.

6. Method
• A retrospective review
- patient case notes
- Xrays
- operative notes
• All patients with 4-corner arthrodesis
- January 2001- April 2004
- Clinical and telephonic follow up

7. Surgical technique
• Dorsal midline ¾ compartment
• PIN denervation
• Trapdoor capsular incision
• Scaphoid removed
• Decortication of bony surfaces

8. Surgical Technique
•Correction of subluxed Capitate and Lunate extension
•Kwired in corrected position, reamed plate applied
•Bone grafting
•Closure in layers
•Drain / volar slab

9. Surgical Technique

10. Results
10 patients
• 7 (70%): male
• Mean age : 41 ± 15.4 years (22 – 65 years)
• Mean follow-up post arthrodesis: 16.3 ± 11.6 months
• Indication:
- SNAC: 6 (60%)
- SLAC: 2 (20%)
- trans scaphoid perilunate: 1(10%)
- Mid-carpal OA: 1(10%)

11. Results
• Right wrist: 7 (70%)
• Mean time trauma to surgery: 18 ± 9.6 months
• Technique: Spider: 9 (90%)
Screws: 1 (10%)
• Mean time to union: 6.2 ± 0.44 months
• 1 complication: sepsis ( repeat surgery)
• Overall rate of union at analysis: 90%

12. Intermediate outcomes
7 patients analysed (2: no data, 1: ankylosis post sepsis)
Pain: - 1: severe pain
- 1: pain free
- 5: moderate pain
ROM: mean 40% arc
Overall satisfaction: 13%
Grip strength: data incomplete

13. Conclusion
• Intermediate results poor compared to the literature
• Is one SNAC the same as another SNAC
• Is the SLAC a SNAC ?

14. Conclusion
• Functional wrist extension & no capitolunate
arthrosis in stage1/2 SNAC:
= distal pole resection
• Inadequate fuctional wrist extension & no
capitolunate arthrosis in stage1/2 SNAC:
= proximal row carpectomy
• Inadequate functional wrist extension with
caitolunate arthrosis in stage 1/2/3:
= four corner fusion

15. Conclusion

16. References
1. Jensen P et al . J Hand Surg.2003:28A;561-569
2. Malerich MM et al. J Hand Surg(Am). 1999:24:1196-12057
3. Watson HK et al. J Hand Surg(Am). 1984:9:358-365
4. Watson HK et al. J Hand Surg. 1999: 24B:3:307-315

17. Denial is not just another river in
Africa