Proximal Migration of Hardware in Patients Undergoing Midcarpal Fusion with Headless Compression Screws

Abstract

Background Scaphoid excision and limited intercarpal fusion is a common surgical procedure performed for degenerative disorders of the wrist including scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist deformities. Postoperative screw migration is a rare but devastating complication that can result in severe degenerative changes in the radiocarpal joint.

Questions/Purposes The purpose of this study is to report on a series of patients who developed proximal migration of their hardware following limited intercarpal fusions with headless compression screws.

Patients and Methods Four patients were identified between 2001 and 2012 who were indicated for and underwent scaphoid excision and midcarpal fusions with headless compression screw fixation and subsequently developed hardware migration with screw protrusion into the radiocarpal joint. Detailed chart review was performed.

Results Mean age at surgery was 64 years (57–69 years). All patients had the diagnosis of SLAC wrist. Mean time to detection of failure was 6 months (4–8 months). All patients demonstrated radiographic union prior to failure based on plain films. Radiographs revealed screw backout with erosion of the radial lunate facet in all patients. Calculated carpal height ratios demonstrated a drop from an average 44.2% to 39.5% at the time of hardware migration. All four patients underwent hardware removal. One patient was not indicated for any further surgery, and two patients underwent further revision surgery. All three patients reported complete pain relief. One patient refused a salvage procedure and had subsequent persistent pain.

Conclusions This study reports a serious complication of scaphoid excision and midcarpal fusion performed with headless compression screws. We advise surgeons to be aware of this potential complication and consider employing methods to reduce the risk of hardware migration. Additionally, we recommend at least 8 months of clinical and radiographic follow-up postoperatively to enable early intervention if necessary.

Level of Evidence Level IV, therapeutic study.

Keywords

headless compression screws - hardware failure - SLAC wrist

Note

Each author certifies that he has no commercial associations (e.g., consultancies, stock ownership, equity interest, or patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article.
No funding was necessary for this submission.
This was an institutional review board–approved study.

• References

• 1 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 (6) 1122-1127
• 2 Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg Am 1994; 19 (5) 751-759
• 3 Shindle MK, Burton KJ, Weiland AJ, Domb BG, Wolfe SW. Complications of circular plate fixation for four-corner arthrodesis. J Hand Surg Eur Vol 2007; 32 (1) 50-53
• 4 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 (2) 433-442
• 5 Collins ED, Nolla J. Spider plate fixation: no significant improvement in limited wrist arthrodesis. Tech Hand Up Extrem Surg 2008; 12 (2) 94-99
• 6 Ashmead IV D, Watson HK, Damon C, Herber S, Paly W. Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994; 19 (5) 741-750
• 7 Richards AA, Afifi AM, Moneim MS. Four-corner fusion and scaphoid excision using headless compression screws for SLAC and SNAC wrist deformities. Tech Hand Up Extrem Surg 2011; 15 (2) 99-103
• 8 Ozyurekoglu T, Turker T. Results of a method of 4-corner arthrodesis using headless compression screws. J Hand Surg Am 2012; 37 (3) 486-492
• 9 Gaston RG, Greenberg JA, Baltera RM, Mih A, Hastings H. Clinical outcomes of scaphoid and triquetral excision with capitolunate arthrodesis versus scaphoid excision and four-corner arthrodesis. J Hand Surg Am 2009; 34 (8) 1407-1412
• 10 McMurtry RY, Youm Y, Flatt AE, Gillespie TE. Kinematics of the wrist. II: clinical application. J Bone Joint Surg 1978; 60: 955-961
• 11 Ball B, Bergman JW. Scaphoid excision and 4-corner fusion using retrograde headless compression screws. Tech Hand Up Extrem Surg 2012; 16 (4) 204-209
• 12 Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four-corner fusion for scapholunate (SLAC) or scaphoid nonunion (SNAC) advanced collapse wrists: a systematic review of outcomes. J Hand Surg Eur 2009; 34 (2) 256-263
• 13 Merrell GA, McDermott EM, Weiss AP. Four-corner arthrodesis using a circular plate and distal radius bone grafting: a consecutive case series. J Hand Surg Am 2008; 33 (5) 635-642
• 14 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 (5) 604-611
• 15 Enna M, Hoepfner P, Weiss AP. Scaphoid excision with four-corner fusion. Hand Clin 2005; 21 (4) 531-538