Four corner fusion

Arthrodesis for mid carpal arthritis and SLAC and SNAC wrist

1. Four Corner Fusion

2. Indications post-traumatic or degenerative mid carpal bone arthrosis carpal instability (SNAC or SLAC) - Stage 2 and 3 failed partial arthrodesis

3. Aim Reduce pain Maintain ROM Maintain grip strength Maintain activities of daily living ( ADL)

4. contraindication for a 4CF Stiff wrist Radio lunate arthritis Erosive arthropathy Consider Proximal row carpectomy

5. 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

6. Complications of implant in 4CF Nonunion Hardware failure Dorsal wrist impingement

7. Approach Radially based capsular flap allows a wide exposure of the radiocarpal as well as the midcarpal joints dorsal capsule l igament sparing Preserve volar radioscaphocapitate ligament

8. 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

9. Technique 12 screw holes, cortical screws and 8 TriLock locking screws reamer to create a recess for the four corner fusion plate

10. 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,

11. 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 holes at least 1 locking screw per carpal bone

12. 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.

13. 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