Abstract
Introduction Four-corner arthrodesis with excision of the scaphoid is an accepted salvage procedure
for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse
(SNAC) and has been performed in our unit for over 20 years. We have undertaken a
retrospective review of 116 of these procedures performed in 110 patients between
1992 and 2009. Fifty-eight patients attended for a clinical evaluation, and 29 responded
by postal questionnaire.
Methods The surgical technique undertaken was standard. That is, through a dorsal approach
the scaphoid and tip of the radial styloid were excised. The capitate, lunate, triquetrum,
and hamate articular surfaces were then prepared down to bleeding bone. Bone grafts
from the scaphoid and radial styloid were then inserted and fixation undertaken. For
the latter, various methods were used, including Kirschner (K-)wires, staples, bone
screws, but predominantly the Spider plate (Integra Life Sciences, USA). Thereafter
the wrist was immobilized for a minimum period of 2 weeks prior to rehabilitation.
Results Follow-up was done at a mean of 9 years and 4 months (range 3–19 years). All patients
reported a significant improvement in pain relief and ∼50% of flexion extension, although
only 40% of radioulnar deviation. Grip strength was again ∼50% of the contralateral
side. Most patients reported a significant improvement in function with 87% returning
to work. In addition, radiologic evaluation identified 28 patients (31%) who demonstrated
ongoing signs of nonunion, particularly around the triquetrum. Fourteen of these (15%)
underwent a further procedure, generally with success. Finally, none of the patients
demonstrated any arthritic changes in the lunate fossa on follow-up X-ray, and all
secondary procedures were undertaken within 2 years of the primary.
Discussion This research has demonstrated that four-corner fusion fixed with a circular plate
can result in a satisfactory outcome with a reduction in pain, a functional range
of motion, and a satisfactory functional outcome. The bulk of the complications appear
to occur in the first 2 years after surgery. Thereafter, analysis shows long-term
satisfaction with little deterioration. Nonunion, particularly around the triquetrum,
continues to be a problem, but it may be that this bone should be excised along with
the scaphoid, resulting in a three-part fusion only. Alternatively, a simple capitolunate
fusion may be satisfactory.
Keywords
four-corner fusion - spider plate - long term follow-up - complications
