Four Corner Arthrodesis: a retrospective review

S L Carter, M Solomons.Hand Surgery, Groote Schuur and Vincent Pallotti Hospitals,

Cape Town

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

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

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

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.

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

Surgical technique

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

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

Surgical Technique

Results10 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%)

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%

Intermediate outcomes7 patients analysed (2: no data, 1: ankylosis post sepsis)

Pain: - 1: severe pain - 1: pain free - 5: moderate pain ROM: mean 40% arcOverall satisfaction: 13%Grip strength: data incomplete

Conclusion

• Intermediate results poor compared to the literature

• Is one SNAC the same as another SNAC

• Is the SLAC a SNAC ?

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

Conclusion

References

1. Jensen P et al . J Hand Surg.2003:28A;561-569 2. Malerich MM et al. J Hand Surg(Am). 1999:24:1196-120573. Watson HK et al. J Hand Surg(Am). 1984:9:358-3654. Watson HK et al. J Hand Surg. 1999: 24B:3:307-315

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