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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 44  |  Issue : 2  |  Page : 208-211
Non-union scaphoid: Four-corner fusion of the wrist

Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India

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Date of Web Publication27-Mar-2010


Background: Four-corner fusion of the wrist is an option for management of non-union scaphoid with painful arthritis of the wrist. Various surgical techniques have been devised for four-corner fusion, with inconsistent results. We present our experience of four-corner fusion achieved using a standard H-plate, designed originally for anterior cervical plating.
Materials and Methods: The study is a retrospective analysis of six cases of painful wrist arthritis resulting from nonunion of scaphoid treated by four-corner fusion, between 1996 and 2004. The average duration of follow-up was 5.8 years. Each patient was evaluated clinically according to the rating scales described by Bach.
Results: The mean grip-strength calculated as a percentage of the uninvolved side was 47% pre-operatively, and 74% post-operatively at the final follow-up. The difference between the preoperative and postoperative 'pain ratings' and 'activity ratings' was found to be statistically significant (P<0.001). Mean time to fusion was 16.1 weeks. Dorsal impingement was the most common associated problem.
Conclusions: H-plate, used for four-corner fusion, provides rigid fixation, ensures fusion, and is a good alternative to the available options.

Keywords: Four corner fusion, Cervical H-plate, nonunion scaphoid

How to cite this article:
Gupta RK, Chauhan DS, Singh H. Non-union scaphoid: Four-corner fusion of the wrist. Indian J Orthop 2010;44:208-11

How to cite this URL:
Gupta RK, Chauhan DS, Singh H. Non-union scaphoid: Four-corner fusion of the wrist. Indian J Orthop [serial online] 2010 [cited 2018 May 21];44:208-11. Available from: http://www.ijoonline.com/text.asp?2010/44/2/208/61908

   Introduction Top

Untreated scaphoid non-union leads to arthritis accompanied by pain, weakness, and restriction of wrist motion. [1] Total wrist arthrodesis provides predictable pain relief in arthritic conditions of the wrist, but at the cost of elimination of all radio-carpal and inter-carpal motion. [2] Procedures that preserve some motion while providing pain-relief are therefore preferable. Two of the motion-preserving procedures commonly performed are proximal row carpectomy and four-corner arthrodesis. [3],[4] Proximal row carpectomy provides similar grip strength and better range of motion, and is technically less demanding in comparison to limited arthrodesis by four-corner fusion. [5] However, it is not useful when associated capito-lunate arthritis is present. Secondly, it has a long-term risk of developing radio-carpal arthritis. [5] Although consensus regarding ideal motion-preserving surgical procedure for painful arthritic wrist is lacking, Watson strongly advised limited arthrodesis with scaphoid excision. [6]

Various surgical techniques have been devised for four-corner fusion. Previously, four-corner arthrodesis has been attempted using staples or K-wires for fixation, but a less reliable fixation sometimes resulted in risk of failure of fusion. [7] More recently, implants such as spider plate and differential pitch cannulated screws have been used to achieve rigid fixation, with variable results. [8],[9] In a recent study, a high rate of non-union was reported using the spider plate, with fusion being achieved in only 16.67% of the cases. [9]

We present this study of achieving four-corner fusions by using a standard H-plate, designed originally for anterior cervical plating.

   Materials and Methods Top

This study is a retrospective follow-up analysis of six cases with painful arthritis of the wrist secondary to non-union of the scaphoid, treated by four corner fusions between 1996 and 2004 at our institute. None of the patients included in the study had undergone any previous surgical procedure on the wrist. Three patients were managed by prolonged immobilization; one by repeated massage around wrist and the remaining two did not take treatment before presenting.

The average time between injury and presentation was 3.27 years (1.2 to 4.82 years). The average duration of follow-up was 5.8 years (range 2.8 years-10 years) [Table 1].

Each patient was evaluated clinically pre-operatively and assigned a 'pain rating' and 'activity rating', as per the rating scale described by Bach [10] [Table 2].

Operative procedure

All surgeries were performed under general anesthesia, with the patient supine, and with a pneumatic tourniquet applied to obtain a clear field. Through a longitudinal incision dorsally, the third dorsal compartment was opened. The extensor pollicis tendon was retracted laterally, and the wrist extensors retracted medially. The dorsal capsule was opened, scaphoid excised, and articular surfaces between lunate, triquetral, capitate and hamate denuded of the hyaline cartilage. Cortico-cancellous dowel of bone graft harvested from the iliac crest was impacted in the center of the four bones, and additional cancellous bone was packed between the denuded surfaces of the bones. After aligning the bones into anatomical position, with special attention to maintain a neutral position of the lunate, fixation was achieved using 2.7 mm fully threaded cancellous screws inserted one into each bone through the H-plate. [Figure 1] and [Figure 2] Post-operatively, a removable splint was applied, usually for 3-4 weeks.

   Results Top

Average age was 35.5 years (range 27 to 49 years). The four injuries were to dominant side. The mean pre-operative and postoperative ranges of motion at the wrist are listed in [Table 3].

The mean grip-strength calculated as a percentage of the uninvolved side was 47% pre-operatively, and 74% post-operatively at final follow-up.

The pre-operative and postoperative Bach scores for the study population are listed in [Table 4], with the mean pre-operative pain rating being 5.66, and the mean postoperative pain rating being 2.16. The mean pre-operative activity rating was 5, while the mean postoperative activity rating was 2.2.

These scores were compared statistically using the paired t-test, and the difference between the pre-operative and postoperative 'pain ratings' (P<0.001) and 'activity ratings' (P<0.001) was found to be statistically significant. Mean time to fusion was 16.1 weeks. In one of the patient, the fusion was delayed up to 22 weeks

   Discussion Top

Cervical H-plate is universally available implant. Being a relatively rigid method of fixation, it ensures fusion more reliably as compared to staples and K-wires, and the spider plate. In our series satisfactory fusion and pain relief was achieved in all the patients. The amount of wrist motion (total arc) obtained (42% of the uninvolved side) and grip strength (more than 70% of the uninvolved side) was acceptable to the patients.

A number of authors have shown satisfactory results of four-corner fusion performed as a salvage of non union scaphoid. [4],[5],[11],[12] Our results are comparable to those studies corroborating the fact that, with proper indication, the procedure of four corner fusion gives optimum results.

El-Mowafi et al. successfully achieved the four-corner fusion by using K wires with further immobilization of the wrist with cast. [12] Garcia-López et al. achieved four-corner fusion by using the screw fixation. [13] In order to prevent the collapse of the fused bones, however, they filled the void of the excised scaphoid by using the anchovy of extensor carpi radialis longus tendon. [13] Chung et al. [8] used a spider web plate for stabilization and concluded that four-corner fusion using the first-generation Spider plate technique had the advantage of earlier mobility and more patient comfort from absence of protruding Kirschner wires; however, patients continued to have disabling pain, functional limitations, work impairment, and low satisfaction scores postoperatively. Commenting on the failures seen in 3 of the 11 of their patients, they also felt the need for a better implant designed to avoid implant failure. In a comparative study of using traditional implants (K wires, screws and staples) and the circular plate, Vance et al. [14] observed 26% nonunion with loose hardware in the plate group compared with 3% in the traditional group and 22% hardware impingement in the plate group compared with 3% in the traditional group. They concluded that the increased complication and dissatisfaction rates associated with plate fixation was attributable to possible biomechanical imperfections or increased technical demands with the circular plates.

The procedure of four-corner fusion results in loss of motion at the wrist almost to the tune of 50%, which is significant. However, the other options of proximal row carpectomy and total wrist fusion are relatively inferior options as compared to the four corner fusion with the former one having a long term risk of wrist arthritis and the latter one with disadvantage of total loss of motion. [2],[5]

The usual complications of donor site morbidity in case of harvesting of graft from the iliac crest were not seen in any of our patients probably due to a small amount of graft required for the procedure. We feel 'H' plate, originally designed for the stabilization of cervical vertebral bodies is able to tolerate significant loads. We did not find any of the problems related to tendon impingement, due to the low profile design of the plate. Further, as per our per-operative observations, the four holes in the four limbs of the 'H' have almost exact fit onto the bodies of the four bones constituting four corners (lunate, capitate, hamate, triquetrum). The central hole in the 'H' can be additionally used for passing an additional screw into the dowel graft placed in the center of the four corners; however, we have not used it in any of our patients.

All the patients in our series successfully achieved fusion without any failure of the implant. The functional scores seen in all of our patients were also satisfactory, thus implying that 'H' plate may prove to be a reasonable alternative to the traditional implants like K wires, screws or spider plate.

The low cost stainless steel indigenously produced 'H' plate is likely to make it a favored implant for the surgeons working in developing countries. However, the sample size of our study being small, further larger and controlled multicentric studies are required to know the more detailed results of this technique.

   References Top

1.Enna M, Hoepfner P, Weiss AP. Scaphoid excision with four-corner fusion. Hand Clin 2005;21:531-8.  Back to cited text no. 1      
2.Abbot LC, Saunders CM, Bost FC. Arthrodesis of the wrist with the use of grafts of cancellous bone. J Bone Joint Surg 1942;24:883-98.  Back to cited text no. 2      
3.Inglis AE, Jones EC. Proximal row carpectomy for diseases of the proximal row. J Bone Joint Surg Am 1977;59:460-3.  Back to cited text no. 3      
4.Lukas B, Herter F, Englert A, Backer K. The treatment of carpal collapse: Proximal row carpectomy or limited midcarpal arthrodesis? A comparative study. Handchir Mikrochir Plast Chir 2003;35:304-9.  Back to cited text no. 4      
5.Wyrick J, Stern P, Kiefhaber T. Motion preserving procedures in the treatment of scapholunate advanced collapse wrist: Proximal row carpectomy versus four corner arthrodesis. J Hand Surg Am 1995;20:965-70.  Back to cited text no. 5      
6.Watson KH, Ballet FL. The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984;9:358-65.  Back to cited text no. 6      
7.Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am 1994;19:751-9.  Back to cited text no. 7      
8.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;118:433-42.  Back to cited text no. 8      
9.Kendall CB, Brown TR, Millon SJ, Rudisill LE, Sanders JL, Tanner SL. Results of four-corner arthrodesis using dorsal circular plate fixation. J Hand Surg Am 2006;31:327-8.  Back to cited text no. 9      
10.Bach AW, Almquist EE, Newman DM. Proximal row fusion as a solution for radiocarpal arthritis. J Hand Surg Am 1991;16:424-31.  Back to cited text no. 10      
11.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;56:139-44.   Back to cited text no. 11      
12.El-Mowafi H, El-Hadidi M, Boghdady GW, Hasanein EY. Functional outcome of four-corner arthrodesis for treatment of grade IV scaphoid non-union. Acta Orthop Belg 2007;73:604-11.   Back to cited text no. 12      
13.Garcia-López A, Perez-Ubeda MJ, Marco F, Molina M, López-Duran L. A modified technique of four-bone fusion for advanced carpal collapse (SLAC/SNAC wrist). J Hand Surg Br 2001;26:352-4.   Back to cited text no. 13      
14.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;30:1122-7.  Back to cited text no. 14      

Correspondence Address:
Ravi K Gupta
Department of Orthopedics, Government Medical College Hospital, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5413.61908

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]

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