Four corner arthrodesis a retrospective review
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(1) The document reviews a retrospective study of 10 cases of four corner arthrodesis performed between 2001-2004 to treat various stages of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) arthritis. (2) Results found a 90% union rate but intermediate outcomes were poor compared to literature, with most patients reporting only moderate pain relief and 40% average range of motion recovery. (3) The conclusion discusses that patient factors like the specific stage of arthritis and degree of wrist extension may determine whether four corner fusion or alternative procedures like proximal row carpectomy or scaphoid resection are most appropriate in individual cases.
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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
- 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
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