Four Corner Fusion

Indications

• post-traumatic or degenerative mid carpal bone arthrosis

• carpal instability (SNAC or SLAC) - Stage 2 and 3

• failed partial arthrodesis

Aim

• Reduce pain• Maintain ROM• Maintain grip strength• Maintain activities of daily living (ADL)

contraindication for a 4CF

• Stiff wrist• Radio lunate arthritis• Erosive arthropathy

Consider Proximal row carpectomy

Prerequisites

• normal congruity without degenerative changes between the lunate fossa of the radius

• At least 40% of ROM in Radio carpal joint• Good bone stock of 4 bones

Complications of implant in 4CF

• Nonunion• Hardware failure• Dorsal wrist impingement

Approach

• Radially based capsular flap • allows a wide exposure of the

radiocarpal as well as the midcarpal joints

• dorsal capsule ligament sparing• Preserve volar radioscaphocapitate

ligament

Bone preparation• the articular surfaces of the four

bones to be fused must be decorticated

• bleeding cancellous bone• down to healthy cancellous bone• manipulate the lunate in a

neutral position (joystick)• K Wire temporarily fixes the two

bones(mini C-arm fluoroscopic),

Midcarpal joint in slight extension - to increase wrist functionality

Technique

12 screw holes,

4 cortical screws and 8 TriLock locking screws

reamer to create a recess for the four corner fusion plate

Seating recess

• Center the reamer on the proximal (medially oriented) pole of the hamate

• reamer perpendicularly, create recess by applying axial pressure

• Ream downward until the plate can be inserted a little beneath the dorsal bone surface

• 4 C filled with cancellous bone graft,

Plate alignment and fixation• 3 holes (1 fixation hole, 2 locking holes) per

bone to be fused• at least 2 holes per carpal bone• correctly aligned• fixation hole through one of the lower plate

holes 1.6mm drill• gold cortical screw Ø 2.0 mm (lag screw)• Remove the K-wires• blue TriLock locking screws Ø 2.0 mm are

inserted through the upper plate holesat least 1 locking screw per carpal bone

Results

Mulford, J. S., Ceulemans, L. J., Nam, D., & Axelrod, T. S. (2009). Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. The Journal of hand surgery, European volume, 34(2), 256–263.

•  both procedures give improvements in pain and subjective outcome • PRC may provide better postoperative range of movement and lacks the potential complications • risk of subsequent osteoarthritis is significantly higher in PRC • Grip strength, pain relief and subjective outcomes are similar in both treatment groups.

• Ball, B., & Bergman, J. W. (2012). Scaphoid excision and 4-corner fusion using retrograde headless compression screws. Techniques in hand & upper extremity surgery, 16(4), 204–209. doi:10.1097/BTH.0b013e3182688c6a

• Bisneto, E. N. F., Freitas, M. C., Paula, E. J. L. de, Mattar, R., Jr, & Zumiotti, A. V. (2011). Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study. Clinics (São Paulo, Brazil), 66(1), 51–55.

• Daruwalla, Z. J., Davies, K., Shafighian, A., & Gillham, N. R. (2013). An alternative treatment option for scaphoid nonunion advanced collapse (SNAC) and radioscaphoid osteoarthritis: early results of a prospective study on the pyrocarbon adaptive proximal scaphoid implant (APSI). Annals of the Academy of Medicine, Singapore, 42(6), 278–284.

• González Del Pino, J., Campbell, D., Fischer, T., Vázquez, F. N., Jupiter, J. B., & Nagy, L. (2012). Variable angle locking intercarpal fusion system for four-corner arthrodesis: indications and surgical technique. Journal of wrist surgery, 1(1), 73–78. doi:10.1055/s-0032-1323640

• Klausmeyer, M. A., Fernandez, D. L., & Caloia, M. (2012). Scaphocapitolunate arthrodesis and radial styloidectomy for posttraumatic degenerative wrist disease. Journal of wrist surgery, 1(1), 47–54. doi:10.1055/s-0032-1323846

• Korus, L. J., Ball, B., & Morhart, M. (2013). Exclusion of the hamate in 4-corner fusion: technique and outcomes of a novel approach to intercarpal arthrodesis. Techniques in hand & upper extremity surgery, 17(2), 102–105. doi:10.1097/BTH.0b013e31828d6070

• McBride, T. J., Jewell, D. P. A., & Deshmukh, S. C. (2012). Bone grafting in four-corner mid-carpal fusion. Hand surgery: an international journal devoted to hand and upper limb surgery and related research: journal of the Asia-Pacific Federation of Societies for Surgery of the Hand, 17(1), 143–144. doi:10.1142/S0218810412720173

• Mulford, J. S., Ceulemans, L. J., Nam, D., & Axelrod, T. S. (2009). Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. The Journal of hand surgery, European volume, 34(2), 256–263. doi:10.1177/1753193408100954

• Ozyurekoglu, T., & Turker, T. (2012). Results of a method of 4-corner arthrodesis using headless compression screws. The Journal of hand surgery, 37(3), 486–492. doi:10.1016/j.jhsa.2011.12.022

• Rhee, P. C., & Shin, A. Y. (2013). The rate of successful four-corner arthrodesis with a locking, dorsal circular polyether-ether-ketone (PEEK-Optima) plate. The Journal of hand surgery, European volume, 38(7), 767–773. doi:10.1177/1753193413475962

• Richards, A. A., Afifi, A. M., & Moneim, M. S. (2011). Four-corner fusion and scaphoid excision using headless compression screws for SLAC and SNAC wrist deformities. Techniques in hand & upper extremity surgery, 15(2), 99–103. doi:10.1097/BTH.0b013e3181f60fec

• Xu, Y., Qi, B., Fan, X., Xu, X., Lu, S., & Ding, J. (2012). Four-corner arthrodesis concentrator of nickel-titanium memory alloy for carpal collapse: a report on 18 cases. The Journal of hand surgery, 37(11), 2246–2251. doi:10.1016/j.jhsa.2012.07.040

• Xu, Y.-Q., Zhu, Y.-L., & Wang, Y. (2013). The memory plate for four-corner fusion of scaphoid non-union advanced collapse. Journal of plastic surgery and hand surgery. doi:10.3109/2000656X.2013.777844