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FOUR-CORNER ARTHRODESIS

BY ALEXANDER Y. SHIN, MD

Although nearly every combination of intercarpal arthrodeses has been described,excision of the scaphoid and fusion of the remaining carpal bones in neutralalignment was a unique concept when it was introduced nearly 20 years ago. Thistime-tested and established procedure that is commonly known as the 4-corner or4-bone arthrodesis is based on the principle that the radiolunate articulation isoften spared from degenerative changes from conditions that result in rotatorysubluxations of the scaphoid. The 4-corner arthrodesis is a motion-sparing,limited arthrodesis that reliably results in pain relief, improved grip strength,and overall high patient satisfaction with low associated nonunion and compli-cation rates.

Copyright © 2001 by the American Society for Surgery of the Hand

Congenital carpal fusions or coalitions are of-ten discovered serendipitously on radiographstaken for other purposes.1-4 The wrists of these

individuals are often normal, without symptoms orconditions that can be recognized by clinical exami-nation. Because wrists with carpal coalitions oftenhave normal appearance and function without pain,disability, weakness, or instability, it was postulatedthat intercarpal arthrodesis could restore acceptablefunction to an injured wrist and obviate the need fortotal wrist arthrodesis, which results in complete lossof motion.5

One of the earliest descriptions of an intercarpalarthrodesis was in 1924 by Thornton,6 who excised

the base of the capitate and fused the hamate,trapezoid, scaphoid, lunate, and triquetrum. In1946, Sutro7 reported 4 cases of scaphoid nonunionstreated by intercarpal arthrodesis of the scaphoidfragments to the capitate. Similarly, in 1952Helfet8 reported 7 cases of scaphocapitate arthrode-sis for the treatment of scaphoid nonunions. By the1960s the concepts and indications of intercarpalarthrodesis were further refined. Graner and associ-ates9 described intercarpal arthrodesis with excisionof the lunate or proximal scaphoid fragment inpatients with Kienbock disease, scaphoid non-unions, or old carpal fracture-dislocations. Soonafter Graner’s report, Peterson and Lipscomb5 ofthe Mayo Clinic reported the successful outcomeof 8 patients treated with intercarpal arthrodesisperformed for degenerative arthritis secondary toscaphoid nonunion, posttraumatic scaphoid sub-luxations, scaphoid nonunion, and Kienbockdisease. One of the intercarpal arthrodeses theyperformed was the scaphoid-trapezium-trapezoidarthrodesis, subsequently popularized as the tri-scaphe arthrodesis by Watson.10-12

Early results of treatment of scaphoid nonunion byexcision of part or all of the scaphoid often resulted in

From the Division of Hand & Microsurgery, Department of Ortho-paedic Surgery, Naval Medical Center San Diego, San Diego, CA.The views expressed in this article are those of the authors and do notreflect the official policy or position of the Department of the Navy,Department of Defense, or the United States Government.Address reprint requests to Commander Alexander Y. Shin, MD,USN, c/o Clinical Investigations Department, Naval Medical CenterSan Diego, 34800 Bob Wilson Dr, San Diego, CA 92134-5000.

Copyright © 2001 by the American Society for Surgery of the Hand1531-0914/01/0102-0005$35.00/0doi:10.1053/jssh.2001.23905

JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND z VOL. 1, NO. 2, MAY 2001 93

weakness, pain, and loss of function of the wrist.7,13-15

As such, scaphoidectomy was generally not recom-mended for the treatment of scaphoid nonunions.7

However, when the scaphoid fragments were arthro-desed to the capitate, pain diminished and strengthimproved.5,7,8 Intercarpal arthrodesis of the scaphoidand capitate provided pain relief, stability, and thepreservation of some wrist motion. As intercarpalarthrodeses evolved, nearly every conceivable combi-nation of carpal bone fusion was described.

Despite the historical recommendations againstscaphoidectomy, Watson and associates16 describedthe unique concept of combining the scaphoidectomy,neutral alignment of the remaining carpal bones, andarthrodesis of the capitate, hamate, lunate, and tri-quetrum to maintain the neutral alignment. Arthro-desis of the capitate and lunate was difficult toachieve, with nonunion rates reported as high as30%.17 Thus, to increase the union rates, the hamateand triquetrum were added to the capitolunate arth-rodesis.16 The resultant arthrodesis of the capitate,hamate, lunate, and triquetrum was termed a 4-cornerarthrodesis. In 1981, Watson and associates16 de-scribed the results of 2 patients (3 wrists) who under-went a 4-corner arthrodesis, excision of the scaphoid,and replacement with a silicone implant spacer fordegenerative arthrosis. Three years later, Watson andBallet18 described the scapholunate advanced collapse(SLAC) pattern of degenerative arthritis and reportedon the results of 16 patients who underwent scaph-oidectomy, neutral alignment, and 4-corner arthrode-sis.18 A decade later, Ashmead and associates19 re-ported 100 cases in which scaphoidectomy and4-corner arthrodesis were performed for SLAC wristsalvage.

Today, nearly 20 years after its formal introduction,scaphoidectomy and 4-corner arthrodesis with neutralalignment of the carpus has become an accepted andtime-tested procedure for the treatment of a variety ofcarpal maladies.

INDICATION FOR 4-CORNER ARTHRODESIS

In 1984, Watson and Ballet18 reviewed 4,000radiographs of the hand and wrist to determine thepatterns of sequential change in degenerative ar-thritis of the wrist. The most common pattern ofdegenerative arthritis of the wrist was described as

SLAC and represented a final common pathway fora variety of carpal conditions, of which the mostcommon were rotatory subluxations of the scaphoidand scaphoid nonunion.20-25 Most cases of SLACwrist represent the late sequelae of scapholunatedissociation, either traumatic or secondary to atten-uation of the scapholunate ligament.19 Scapholu-nate ligament attenuation by calcium pyrophos-phate dihydrate deposition disease or rheumatoidarthritis can also result in SLAC wrist.21,26 Chronicscaphoid nonunions can also lead to a SLAC patternof arthritis and have been more correctly termedscaphoid nonunion advanced collapse (SNAC) (Fig1).27 Despite the etiology, the pattern of SLACwrist shows a consistent progression of degenerativechanges that first occurs between the tip of theradiostyloid and the scaphoid (stage I) (Fig 2).18

The arthritic changes then progress along the ra-dioscaphoid articulation (stage II). The radiolunatejoint is spared, and the degenerative changesprogress to the capitolunate joint (stage III). De-spite the etiology, the SLAC pathway has consis-tently spared the radiolunate articulation, evenwhen there is severe or chronic dorsal intercalatedsegmental instability (DISI) stance of the lunate.This preservation of the radiolunate joint is thefoundation of the 4-corner arthrodesis.

Another group of patients who may benefit fromthe 4-corner arthrodesis includes those with chronicdynamic carpal instability, chronic perilunar insta-bility28 or nondissociative carpal instability.29,30

When soft tissue reconstruction or repair has failedor when soft tissue reconstruction would result in agreater limitation of motion than limited arthrode-sis, 4-corner arthrodesis with scaphoidectomy candecrease pain, improve strength, and preserve mo-tion.

The 4-corner arthrodesis is indicated in patientswith nondissociative carpal instability that has failedsoft tissue reconstructions and those with arthriticinvolvement of the radioscaphoid joint with or with-out capitolunate involvement, chronic dynamic carpalinstability, or chronic perilunar instability not ame-nable to soft tissue procedures. Absolute contraindi-cations to the 4-corner arthrodesis include ulnar trans-location of the carpus and radiolunate degenerativechanges, observed intraoperatively or in preoperativeradiographs.19

94 FOUR-CORNER ARTHRODESIS z SHIN

BIOMECHANICAL CONSIDERATIONS

Although a complete discussion of biomechanics ofthe wrist is beyond the scope of this article, basicunderstanding of the normal mechanics and the effectsof the 4-corner arthrodesis on overall wrist motion andforce transmission is essential in communicating theexpected outcome to patients.

In the normal wrist, there is a balanced synchronybetween the proximal and distal carpal rows.31,32

When motion occurs in the flexion-extension plane,there is coordinated motion between the distal andproximal carpal rows. As the distal carpal row flexes,the proximal carpal row also flexes. Similarly, whenthe distal carpal row extends, the proximal carpal rowextends. The relative contributions of flexion and ex-tension of each of the carpal rows depends on theframe of reference evaluated. If the central portion of

the carpus (capitate-lunate-radius linkage) is consid-ered, radiocarpal and midcarpal motion are equallydivided in a third of wrists, with the remaining twothirds having approximately 60% of flexion at themidcarpal joint and 66% of extension at the radiocar-pal joint.33-35 However, when the frame of reference ischanged to the lateral portion of the carpus (radius-scaphoid-trapezium linkage), nearly two thirds of theglobal arc of motion occurs at the radioscaphoidjoint.33,36,37 With radial and ulnar deviation, there isa complex reciprocating motion of the proximal anddistal carpal rows. With radial deviation, the distalcarpal row inclines radialward, extends, and supinates.The proximal carpal bones principally flex and trans-late ulnarward. With ulnar deviation the oppositeoccurs: The distal carpal row inclines ulnarward,flexes, and pronates, while the proximal carpal bonesextend and translate radialward.37-39 Such complex

FIGURE 1. An anteroposterior (A) and lateral (B) radiograph of a wrist with a SNAC. The radiolunate articulation and theradioscaphoid articulation proximal to the nonunion site are preserved, and the distal radioscaphoid and capitolunate articulationshow significant degenerative arthritis.

FOUR-CORNER ARTHRODESIS z SHIN 95

motions are required to maintain the carpal congru-ency and spatial consistency in all wrist posi-tions.33,40,41

Because the proximal and distal carpal rows func-tion separately, procedures linking the rows will resultin profound effects on wrist range of motion and force

transmission across the radiocarpal joints. Simulationof intercarpal arthrodeses have shown that capitolu-nate arthrodesis resulted in the greatest reduction ofdorsiflexion, palmar flexion, and ulnar deviation com-pared to scaphoid-trapezium-trapezoid, scaphocapi-tate, and triquetrohamate arthrodesis.42 Specifically,

FIGURE 2. (A) SLAC follows a predictable pattern of degenerative arthrosis that starts at the radial styloid (stage I), advancesto the radioscaphoid articulation (stage II), and ends with midcarpal (capitolunate) arthrosis (stage III). An anteroposteriorradiograph illustrating (B) SLAC stage II and (C) SLAC stage III changes.


there was a reduction of 9° of ulnar deviation, 34° ofdorsiflexion, and 25° of palmar flexion.42 Gellman andassociates43 showed that intercarpal arthrodesis withina carpal row had minimal effects on wrist motion inall planes. However, when intercarpal arthrodesis oc-curred between rows, profound losses of motions wereobserved. Capitolunate arthrodesis resulted in thegreatest loss of motion in the flexion-extension plane(loss of 30% flexion and 41% extension) and less inthe radio-ulnar planes (loss of 11% ulnar deviationand 21% radial deviation).43

Elegant studies of load mechanics and forcetransmission across the radiocarpal by Viegas andassociates44-48 have allowed the determination ofnormal and abnormal radiocarpal joint loading me-chanics. By using pressure sensitive film, normalcadaver wrists were compared with the same wristswith simulated intercarpal arthrodeses. In the ra-diocarpal joint of the normal wrist, the scaphoidwas found to transmit 60% of the load, whereas thelunate accounted for 40%. Overall, the amount ofcontact in the radiocarpal joint accounted for only20% of the surface area but increased to 40% withincreased load.49 In capitolunate simulated arthrode-sis, in which the lunate was brought back into neutralalignment, there was improved loading across theradiocarpal joint that more closely approximated thenormal wrist model.47

TECHNICAL ASPECTS

Surgical Exposure and TechniqueThe exposure of the carpus should be planned to

afford maximal exposure of the carpal elements and toallow for future salvage procedures should the 4-cor-ner arthrodesis fail. A dorsal midline longitudinalincision centered over the third metacarpal-capitate-lunate-radius axis is the traditional approach thatallows for extensile exposure of the carpus. An alter-native to this is the T incision, in which the transverselimb is centered over the carpometacarpal joints andthe longitudinal limb is midline and extends proxi-mally (Fig 3).50 Excellent carpal exposure with thisincision can be obtained with no skin complicationswhen used in elective wrist surgery. Additionally,when future salvage procedures were required (ie, totalwrist arthrodesis), there have been no adverse woundproblems. When a total wrist arthrodesis is performedafter use of a T incision, a fusion plate that does notrequire exposure of the third metacarpal, such as theCobra wrist fusion plate (Kinetikos Medical Inc, SanDiego, CA), is preferred.

The skin flaps are raised, and the superficial branchof the radial nerve is identified and protected. Theextensor retinaculum over the extensor pollicis longusis divided in line with the tendon, and an ulnarlybased flap of extensor retinaculum is created by divid-

FIGURE 3. A T-shaped incision, with the distal transverselimb centered on the carpometacarpal joints and the longitu-dinal incision in line with the third metacarpal, is an alternativeincision that enables wide exposure of the carpus.

FIGURE 4. After the T incision is made, the skin flaps areelevated, the extensor retinaculum over the extensor pollicislongus is divided, and a ulnar-based flap of retinaculum iscreated by dividing the septations between the third andfourth and fourth and fifth extensor compartments.


ing the septations between the third, fourth, and fifthextensor compartments (Fig 4). The extensor tendonsare retracted, and the dorsal wrist capsule is exposed.A longitudinal incision in the capsule can be made onthe ulnar aspect of the fourth compartment to exposethe carpal bones, or alternatively, a ligament-sparingcapsulotomy can be made along the dorsal intercarpal,the dorsal radiotriquetral ligaments, and radioscaph-oid joint (Fig 5).51 The ligament-sparing capsulot-omy, when repaired, may prevent dorsal capsular con-tracture, and thus improve ultimate range of motion.A radial based flap of capsule is then raised, exposingthe carpal bones (Fig 6). The radiolunate articulationis inspected for degenerative wear and if normal, thescaphoid is excised either piecemeal with a rongeur orin its entirety sharply. Care is taken not to injure thevolar radiocarpal ligaments (radioscaphocapitate andlong radiolunate ligaments), because injury to thesestructures may result in ulnar translocation of theremaining carpals. The articular surfaces of the capi-tolunate, capitohamate, triquetrohamate and lunotri-quetral joints are denuded of articular cartilage, andfurther prepared by placement of 1-mm burr holesevenly spaced throughout the surfaces to be arthro-desed (Fig 7).

Neutral Alignment of the Capitolunate AxisReduction of the capitolunate axis in neutral posi-

tion is critical to the success of the 4-corner arthro-desis. Without reduction of the capitolunate axis,

dorsal impingement on the radius can occur, oftenresulting in pain and limitation of extension. Correc-tion of carpal alignment improves motion and pre-vents dorsal impingement. When significant DISIdeformity is associated with the carpal pathology,neutral alignment can be difficult to obtain. Use of aK wire placed into the lunate to act as a joystick canbe helpful; however, the K wire can often be in theway of future fixation methods. An alternative tech-nique, which we prefer, was described by Linscheid.52

Under fluoroscopy, a lateral view of the flexed wrist isobtained. The wrist is flexed and slightly ulnarly

FIGURE 5. (A, B) A ligament-sparing capsulotomy is made in the lines of the dorsal intercarpal ligament, the dorsal radiocarpalligament, and the radioscaphoid capsule.

FIGURE 6. A radial-based flap of capsule is elevated after theincisions are made in the dorsal scaphotriquetral ligament,the dorsal radiotriquetral ligament, and the radioscaphoidcapsule.


deviated until neutral alignment of the radius andlunate are seen. A 0.0625-inch K wire is then drilledfrom the dorsal distal radius into the lunate, with thelunate held in the reduced position. With the K wirein place, the wrist is extended, while the neutralalignment of the radiolunate joint is preserved.

Choice of Bone GraftAllograft or autologous bone graft obtained from

the distal dorsal radius or the anterior iliac crest ispacked into the interstices of the denuded articularsurfaces. Autologous cancellous grafts are the mosteffective grafting material, because they are osteocon-dutive and osteoinductive and contain living osteo-genic cells.53 Among the choices of autologous grafts,distal radius graft allows for a single incision forprocurement and carpal exposure; however, the graftis less dense, has fewer osteogenic cells, and contains

more fat.54,55 Autogenous iliac crest bone graft, on theother hand, is more dense and has greater numbers ofosteogenic cells, but it requires an additional surgerysite that is often more painful than the wrist sur-gery.54,55 Despite the histomorphogenic differences iniliac crest and distal radius bone graft, clinical studieshave not borne out these differences and have shownboth to be effective in affording arthrodeses.55 Allo-grafts become attractive, because their use avoids ad-ditional surgery. However, the lack of osteoinductiv-ity and osteogenic cells, in addition to the potentialfor disease transmission, tempers the decision to useallograft materials.53 The choice of bone graft and thesurgeon’s preference should be discussed with thepatient before surgery.

METHOD OF FIXATION

After bone graft is packed into the interstices of thedenuded articular cartilage, the capitolunate axis isreduced, and a 0.045-inch K wire placed across thecapitate and triquetrum maintains the alignment.Several methods of securing the 4-corner arthrodesishave been described and include fixation with K wires,staples, screws, and specially designed plates.

K-Wire FixationIn Watson’s original description of the 4-corner

arthrodesis, K wires were the method of fixation.16

After the carpal bones are temporarily held in neutralalignment and bone graft is placed, 0.045-inch Kwires are placed from the capitate to the lunate,hamate to lunate, triquetrum to capitate, and tri-quetrum to lunate (Fig 8). The placement of wires isconfirmed on fluoroscopy. The wires are cut and bur-ied under the skin or left protruding through the skin.Additional bone graft is placed to fill the gaps.

Staple FixationSince the advent of power staple fixation, the place-

ment of staples has increased in accuracy and biome-chanical properties.56 The 3M Staplizer (3M, Minne-apolis, MN) is an air-powered stapler/impactor thatuses staples in cartridges ranging from 7 mm to 16mm in width and depth. Power-driven staples showedincreased pullout strength compared with manuallydriven staples. When used in 4-corner arthrodesis,staples can be used in conjunction with K wires (Fig9) or by themselves. When used by themselves, one of

FIGURE 7. The articular surfaces of the 4-corner arthrodesisare denuded of cartilage down to subchondral bone. A high-speed burr is used to create evenly spaced burr holesthroughout the surfaces to be arthrodesed.


FIGURE 8. K-wire fixation of the 4-corner arthrodesis hasbeen a very common method of securing the carpal bones.Typically, 0.045-inch K wires are placed percutaneously, en-gaging the capitate-lunate, capitate-triquetrum, hamate-lu-nate, and hamate-triquetrum bones (A, B). Additional K wiresare placed as needed. After K-wire fixation, bone graft ispacked between the bones to be arthrodesed (C).


two configurations can be used. One configurationuses 4 staples in a “box” pattern (Fig 10). The staplesspan the capitolunate, capitohamate, triquetrohamate,and lunotriquetral articulations. The lunotriquetralstaple is difficult to place and may impinge on thedorsal lip of the radius if improperly positioned. Thesecond configuration, which avoids impingementon the radius, is placement of 3 staples that spanthe capitohamate, capitolunate, and triquetrohamatejoints (Fig 11). Typically, a 13-mm– wide by 10-mm–deep staple is used. Once the staples are placed,temporary K wires, which maintained carpal align-ment, are removed and wrist motion is evaluated;

careful fluoroscopic evaluation of the depth of thestaple is necessary in order to prevent irritation of thepisotriquetral joint or other volar structures.57 Addi-tional bone graft is placed in the 4-corner area.

Screw FixationScrew fixation of the 4-corner arthrodesis with

headless compression screws is a method of fixationthat results in immediate stable fixation that wouldallow for early range of motion. Use of the cannulatedAcutrak variable-pitched headless screw (Acumed,Beaverton, OR) or cannulated Herbert-Whipplescrew (Zimmer, Warsaw, IN) is ideal. The cannulated

FIGURE 9. (A, B) A combination of 3M Staples and K wires can be used for fixation of the 4-corner arthrodesis.


screw allows for accurate placement of the screw andallows the placement of multiple screws in a relativelyconfined space. Screws should be placed at a minimumacross the capitolunate, triquetrohamate, and capito-hamate joints when using screw fixation. A variety ofcombinations of screw placement can result in suc-cessful outcomes.

Plate FixationA specially designed plate for limited wrist ar-

throdesis called the Spider Limited Wrist FusionPlate (Kinetikos Medical Inc, San Diego, CA) wasintroduced in 1999. The Spider plate is a low-profile, conically shaped plate with 8 recessed screwholes that accept 2.4-mm screws (Fig 12). Aftercorrection of the DISI deformity with the radiolu-nate K wire, bone graft is packed into the inter-stices of the denuded carpal bones. A K wire is

placed from capitate to the triquetrum, provision-ally fixing the carpal bones (Fig 13). A specialconical rasp is used to create a recessed, acceptingbed for the Spider plate, which is centered at thejunction of the 4 corners (Fig 14). In the case of atype II lunate, the rasp is centered at the articula-tion of the lunate and hamate. The Spider plate isplaced in the accepting bed and rotated to allow theplacement of 2 screws into each of the carpal bones.A 1.5-mm drill is used to place the index screwhole, typically in the capitate. The screw length ismeasured, and a self-tapping 2.4-mm screw isplaced into the capitate. Subsequently, a screw isplaced in each of the remaining carpal bones, fol-lowed by placement of the second screw into each ofthe carpal bones (Fig 15). The provisional K wirefixation is removed; motion is evaluated, ensuringthat no plate impingement occurs; and screw

FIGURE 10. (A, B) 3M Staples used in a box configuration secure the capitolunate, lunotriquetral, capitohamate, andtriquetrohamate articulations. Care must be used in placing the lunotriquetral staple, because it can impinge on the dorsal distalradius.


FIGURE 11. (A, B) An alternative to the box configuration forplacement of staples is the use of 3 staples placed across thecapitohamate, capitolunate, and triquetrohamate joints. (C)Bone graft is placed between the bones before staple appli-cation and is further impacted between the bones after thestaples are placed.


lengths are confirmed with radiographs (Fig 16).Additional bone graft is packed into the center ofthe 4-corner region through the plate. The rigidfixation provided by the Spider plate allows forearly active range-of-motion exercises.

ClosureAfter the 4-corner arthrodesis is secured and the

temporary K wires removed, the radially based flap of

the ligament-sparing capsulotomy is replaced and re-paired with nonabsorbable sutures (Fig 17). The ex-tensor tendons are replaced, and the extensor retinac-ulum is repaired with the extensor pollicis longusdorsally transposed (Fig 18). Tourniquet is deflated,hemostasis is obtained, and the skin edges are reap-proximated (Fig 19). A bulky hand dressing with avolar plaster splint immobilizes the wrist in a neutralposition and the elbow at 90°.

POSTOPERATIVE CARE/REHABILITATION

Postoperative care and rehabilitation are contingenton the method of fixation used; however, all patientsare encouraged to commence digital range of motion,tendon-gliding exercises, and edema-control measuresstarting on the first postoperative day. Approximately1 week after surgery, the bulky hand dressing andsutures are removed. If K wires or staples are used, along arm cast with the elbow at 90° is applied for 3weeks, at which time a short arm cast is applied untilarthrodesis has occurred. When screw or Spider platefixation is used, a short arm cast can be placed for 3 to4 weeks, or alternatively, a removable custom-madeorthoplast short arm splint can be applied to allowearly active range-of-motion exercises. Serial intervalradiographs should be taken to ensure the arthrodesishas united before return to full normal activities.Based on our experience, the average time to arthro-desis for K wires is approximately 8 to 10 weeks, for

FIGURE 12. The Spider limited wrist fusion plate is a spe-cially designed plate for 4-corner arthrodesis. It is a low-profile, conical plate with 8 recessed screw holes (A), whichaccept 2.4-mm screws (B). (Courtesy of Kinetikos Medical,Inc)

FIGURE 13. K wires are used to maintain the reduction of thecapitolunate axis when applying the Spider plate, and theymust be placed volarly to avoid impinging on the rasp. Assuch, in addition to the radiolunate-reduction K wire used toreduce the DISI deformity, a K wire is used to secure thecapitate to the triquetrum.


staple fixation is approximately 6 to 8 weeks, and forSpider plate fixation is approximately 4 to 5 weeks.

A formalized hand therapy program emphasizingrange of motion, strengthening and endurance is oftenbeneficial following prolonged immobilization.

CLINICAL OUTCOMES

The earliest reported outcomes for 4-corner arthro-desis was by Watson and associates.16 They reported

on 2 patients with 3 wrists that underwent the 4-cor-ner arthrodesis, of which only the results of 1 patient(1 wrist) were reported. This patient had a follow-upof 2 years and 6 months and had 10° of extension (40°opposite wrist), 50° flexion (55° opposite), 20° radialdeviation (35° opposite), and 20° ulnar deviation (20°opposite) and reported that he was without pain.Three years later, Watson and Ballet18 reported on thetreatment of 19 patients treated for SLAC wrist. Ofthese, only 9 were treated with silicone scaphoidreplacement combined with the 4-corner arthrodesisand 1 with 4-corner arthrodesis. The average age ofthis subset of patients was 55 years, and the averagefollow-up was 17.5 months. Overall this cohort re-ported less pain, with the exception of 1 patient whoreported more pain. The average grip strength of theoperative wrist of this cohort was 73% of the unaf-fected wrist. The average flexion of the operative wristwas 30° (45% of the opposite), average extension was33° (54% of opposite), average radial deviation was11° (40% of opposite), and average ulnar deviationwas 26° (66% of opposite).

In 1993, Voche and Merle58 reported on 12 pa-tients who underwent 4-corner arthrodesis that werefollowed up for an average of 18.8 months. Theyreported that 75% had pain relief and an average gripstrength of 57% of the opposite, unaffected wrist. Theaverage flexion of the operated wrist was 27°, exten-sion was 18°, radial deviation was 4°, and ulnardeviation was 13°.

FIGURE 14. A conical rasp is used to burr out an accepting bed for the Spider plate to lie in. The rasp is placed deep enoughto allow the plate to sit flush with the dorsal cortex of the carpal bones.

FIGURE 15. The plate is situated such that each carpal bonewill accept 2 screws. The initial screw is placed into thecapitate and then into each of the remaining carpal bones.The remainder of the screws are then placed. The screws areself-tapping and vary in length from 8 mm to 14 mm in 2 mmincrements.


The first large series to evaluate the outcome of scaph-oidectomy and 4-corner was done by Ashmead and as-sociates in 1994.19 These authors reported on 100 casesfollowed up for an average of 44 months. 85% of patientsreported excellent or good pain relief. The average gripstrength was 81% of the opposite unaffected wrist. Theaverage flexion of the operated wrist was 32°, extensionwas 42°, radial deviation was 15°, and ulnar deviationwas 22°. The average total flexion-extension arc of mo-tion was 53% of that of the opposite wrist.

Watson and associates12 reported their results of252 patients who underwent the 4-corner arthrodesisfor SLAC wrist. This report appears to include thepatients in Ashmead’s series.19 Despite this, the aver-age flexion-extension arc was 88° (53% of opposite

wrist), with 91% of patients reporting pain relief. Theaverage grip was 80% of the opposite grip.

COMPLICATIONS

Of the 431 cases reported in 8 series of 4-cornerarthrodesis, the overall complication rate was13.5%.12,16,18,19,27,57-60 Dorsal impingement of thecapitate and radius occurred in 4.4% (Fig 20), reflexsympathetic dystrophy occurred in 3%, superficialinfections occurred in 3%, nonunions occurred in 2%,deep infections occurred in 0.5%, and deQuervain’s te-nosynovitis occurred in 0.5%. Only 7 failures of 4-cornerarthrodesis that required conversion to total wrist arth-rodesis were reported, representing a 2% incidence.

FIGURE 16. (A, B) After the plate is applied and provisional fixation is removed, radiographs of the wrist are obtained. Theradiographs of the Spider plate for which the intraoperative photographs are illustrated in Figures 13, 14, and 15 are shown here.


ALTERNATIVE PROCEDURES

Capitolunate ArthrodesisThe 4-corner arthrodesis was innovated secondary

to the difficulties in obtaining union in capitolunatearthrodesis.16 Several authors have described scaphoid-ectomy and capitolunate arthrodesis for the treatmentof radioscaphoid arthritis.11,16,17,61 The average rangeof motion obtained with capitolunate arthrodesis was48% of normal extension, 59% of normal flexion,59% of normal radial deviation, and 59% of normalulnar deviation.17 Grip strength averaged 67% of the

normal grip strength.17 A comparison of clinical re-sults shows that the addition of the hamate and tri-quetrum to the capitolunate arthrodesis does not di-minish motion.17,27,57,59 Despite the advantages ofrequiring a less extensive exposure, less bone graft andless surgical time compared with 4-corner arthrodesis,this procedure is not without complications. Kirshen-baum and associates reported a 33% nonunion rateand 33% pin tract infection rate.17

Another variant of a capitolunate arthrodesis wasdescribed by Calandruccio and associates,62 who de-scribed a capitolunate arthrodesis combined with ex-cision of the scaphoid and triquetrum. In 14 wriststreated with this technique, they showed range ofmotions and grip strengths similar to those of othermotion-sparing procedures (53° flexion-extension arc;71% normal grip strength). The lower nonunion rateof 14% most likely represents the results of screwfixation compared with the K-wire fixation used byKirshenbaum et al.17,62

Proximal Row CarpectomyAn alternative to 4-corner arthrodesis in the treat-

ment of stage I or II SLAC is the proximal rowcarpectomy (PRC), which involves the removal of theproximal carpal row and allows the capitate to artic-ulate in the lunate fossa. Although concerns regardingthe differential radius of curvature between the lunatefossa and capitate and the subsequent development ofprogressive degenerative arthritis have been discussed,long-term studies have not borne this out.63-66

Several studies have compared 4-corner arthrod-esis to PRC in the treatment of SLAC wrist (Ta-

FIGURE 17. After fixation of the 4-corner arthrodesis with Kwires, staples, screws or plates, the radially based flap of theligament-sparing capsulotomy is closed with nonabsorbablesutures, with care taken not to overtighten the capsule.

FIGURE 19. After tourniquet is released and hemostasis isobtained, the wound edges are reapproximated. The T inci-sion has led to very few skin/wound complications when usedfor elective surgical procedures.

FIGURE 18. The extensor retinaculum is repaired, transpos-ing the extensor pollicus longus dorsally, with nonabsorbablesuture.


ble 1).27,57,59 Tomaino and associates59 reported aretrospective comparison of 15 patients with SLACwrist treated by PRC and 7 treated with 4-cornerarthrodesis with an average follow-up of 5.5 years. Allpatients but 3 with PRC had satisfactory pain relief,grip strength, and functional performance. There wereno statistical differences in subjective or objective

results with the exception of motion, where PRC hadimproved motion over 4-corner arthrodesis. Tomainoand associates concluded that for stage III SLAC, 4-cor-ner arthrodesis is the motion-preserving treatment ofchoice but that for stage I and II SLAC, PRC is moreappealing, because it avoids complications of nonunion,pin tract infections, and lengthy immobilization.

FIGURE 20. (A) Dorsal impingement of the capitate andradius can occur if the capitolunate axis is not arthrodesed inneutral alignment. (B) Radiograph of a patient with dorsalimpingement secondary to failure to completely reduce theDISI deformity of the lunate in addition to excessive bonegraft being placed.


Wyrick and associates57 showed statistically signifi-cant differences with respect to total arc of wrist motionand grip strength. Specifically, in their retrospectivecomparison, they noted a total arc of motion of 64% inPRC compared with 47% in 4-corner arthrodesis andimproved grip in PRC (94% of opposite wrist) comparedwith 4-corner arthrodesis (74% of opposite). These re-searchers recommended PRC for SLAC stage I or II.

In a retrospective evaluation of treatments for SLACwrists, Krakauer and associates27 compared 23 pa-tients treated with 4-corner arthrodesis to 12 patientswith PRC. Similar to the findings of the previousstudies, they concluded that PRC best preserved wristmobility and that 4-corner arthrodesis was reliable indiminishing pain in SLAC stage III wrist while main-taining a functional arc of motion.

CONCLUSIONS

Four-corner arthrodesis with scaphoidectomy is atime-tested, motion-sparing wrist procedure thathas evolved over the past 20 years. The indications

for 4-corner arthrodesis include radioscaphoid ar-thritis with or without midcarpal arthritis, failedintercarpal ligament reconstruction, or perilunarinstabilities not amenable to soft tissue reconstruc-tion. The absolute contraindication for 4-cornerarthrodesis is radiolunate arthritis or ulnar translo-cation of the carpus. Four-corner arthrodesis is abiomechanically sound intercarpal fusion that re-sults in near-normal load transmission through theradiolunate articulation. Patient satisfaction ishigh, and the procedure offers good to excellentpain relief. The range of motion after 4-cornerarthrodesis ranges from 41% to 53% of the normalopposite wrist, and up to 76% of normal gripstrength can be expected. Advances in surgicalexposures, fixation techniques, and implants haveallowed for rigid fixation that enables for rapidunion and the commencement of early range ofmotion. Failure rates and complication rates arerelatively low, and long-term outcomes have beenpromising.

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TABLE 1A Comparison of Proximal Row Carpectomy and 4-Corner Arthrodesis in the Treatment of SLAC Wrist

Tomaino et al59 Wyrick et al57 Krakauer et al27

PRC(n 5 15)

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Total flexion-extension arc of motion(degrees) 77 52 85 67 71 54

Total flexion-extension arc of motion(percent opposite wrist) 64 41 64 47 — —

Grip strength (percent opposite) 77 76 94 74 — —Failure (percent) 20 0 0 30 17 9


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