Scaphoid excision and four-corner fusion in the treatment of scaphoid nonunion advanced collapse

Abstract

Background Four-corner arthrodesis with scaphoidectomy is a time-tested, motion-sparing wrist procedure and biomechanically sound intercarpal fusion that results in near-normal load transmission through the radiolunate articulation that has evolved over the past 20 years. Aim The aim of the present study was to evaluate the results of scaphoid excision and four-corner fusion with fixation by K wires in the treatment of stage II and III scaphoid nonunion advanced collapse. Patients and methods A prospective study was conducted from March 2013 to November 2014 at the Al-Azhar University Hospital in Damietta. The study included 20 patients with established scaphoid nonunion advanced collapse grade II and III. All patients were males, and all cases involved the dominant hand (right hand). Their average age was 35 (25–48) years. Their occupations in terms of wrist loading were as follows: 10 patients were heavy manual workers and 10 patients were light manual workers. The mechanism of injury was ‘fall on an outstretched hand’ in 16 cases and ‘hit by heavy object’ in four cases. Results A total of 20 cases were included in this study − 14 of them had good results, four patients had fair results, and two patients had poor results. On reviewing all patients, the following points were checked with each patient: pain and tenderness, range of motion, grip strength, and patient satisfaction. In all patients, we found that there was soft tissue (synovium) interposition, instability, and deformity. Ten patients had 40–100% satisfaction, four patients had 0–100% satisfaction, four patients had 0–80% satisfaction, and the last two patients had 0–40% satisfaction. All patients showed radiological solid fusion by the end of the follow-up period. The mean time to achieve fusion was 10 (9–12) weeks. There were no intraoperative complications. Postoperatively, two patients presented with superficial wound infection that resolved completely with local measures and IV antibiotics (third generation cephalosporin). Two patients showed dorsal impingement of the capitate and the radius. Four patients developed reflex sympathetic dystrophy that also resolved within 6 months after cast removal with physiotherapy and active hand exercise. None of the patients showed deep infection, nonunion, or de Quervain tenosynovitis. Conclusion Patient satisfaction was high, and the procedure offered good-to-excellent pain relief. Advances in surgical exposures, fixation techniques, and implants have allowed for rigid fixation that enables rapid union and commencement of early range of motion. Failure rates and complication rates are relatively low, and the long-term outcomes are promising.