Scaphoid Excision Research Articles

PRC with Double Interposition Arthroplasty for Failed Partial Wrist Arthrodesis

Abstract Background In patients with lunate fossa and proximal capitate degeneration, or failed scaphoid excision and partial wrist arthrodesis, double allograft interposition arthroplasty may allow patients to maintain wrist motion and improve pain. Description of Technique Following dorsal exposure of the carpus, a completion proximal row carpectomy is performed. Suture anchors are placed evenly along the perimeter of the distal radius and used to secure a precut sheet of allograft. Additional suture anchors are placed at the proximal aspect of the distal carpal row, securing a second piece of allograft to the proximal capitate and hamate. Patients, Methods, and Results We present the case of a female with osteogenesis imperfecta who failed prior partial wrist fusion for treatment of scapholunate advanced collapse. She declined wrist arthrodesis and was not a candidate for total wrist arthroplasty. Proximal row carpectomy with double interposition arthroplasty provided resolution of her pain and preserved her wrist range of motion. Conclusions Double interposition arthroplasty may provide reliable pain relief and wrist range of motion for patients with advanced wrist arthritis in whom traditional salvage procedures are contraindicated or have failed. Use of this technique offers benefits that may minimize complications and improve longevity compared with previously described allograft interposition techniques.

Proximal row carpectomy or scaphoid excision and four-corner arthrodesis for treatment of scapholunate advanced collapse arthritis.

Degenerative wrist conditions, such as scapholunate advanced collapse and scaphoid nonunion advanced collapse, often require salvage procedures to reduce pain and improve function. For early stages of disease, both proximal row carpectomy and scaphoid excision four-corner arthrodesis are viable motion-preserving options. There remains controversy on which technique is superior. Selection is a nuanced decision that requires consideration of patient characteristics and stage of disease. The traditional notion that proximal row carpectomy should be reserved for older individuals with low demands has been challenged; long-term studies in younger populations demonstrate similar patient-reported outcomes, pain relief and survivorship without conversion to total wrist arthrodesis between proximal row carpectomy and four-corner arthrodesis. The existing evidence suggests proximal row carpectomy has advantages of greater range of motion, fewer complications and lower costs. Advancements such as arthroscopic techniques for both procedures show potential, although mastery involves a steep learning curve.

Progression of arthritis after four-corner fusion in patients with calcium pyrophosphate deposition disease: a case series of eleven patients

Aim: The purpose of this study is to evaluate outcomes and radiographic progression of wrist arthritis after four-corner fusion (4CF) in patients with evidence of calcium pyrophosphate deposition disease (CPPD). The insights derived from this study are expected to improve the understanding of 4CF outcomes in the presence of CPPD, guiding clinical decisions, and management strategies. Methods: 11 patients with prior 4CF and evidence of CPPD were available for prospective follow-up and imaging, with a mean follow-up time of 5 years. Range of motion measurements, radiographs, and outcome data were collected at the follow-up visit and prior data and imaging were reviewed retrospectively. The chronological progression of arthritis was evaluated on standard three-view wrist radiographs using the Larsen scale. Results: All participants (11/11) deemed their wrist fusion a success, with an average satisfaction score of 8.8 out of 10.73% (8/11) patients were able to return to their original occupation after the procedure. The mean flexion of the affected wrist preoperatively was 43 degrees (SD: ±12 degrees) and 41 degrees (SD: ±7 degrees) at the final follow-up. The mean extension of the affected wrist was 35 degrees (SD: ±8 degrees) preoperatively and 40 degrees (SD: ±12 degrees) at the final follow-up. Radiographic analysis showed that 82% (9/11) of patients displayed progression of arthritis as per the Larsen scale by the final follow-up. All patients that showed radiographic progression had involvement of the radiolunate (RL) articulation, which is classically persevered in non-inflammatory wrist arthritis. Conclusions: Scaphoid excision with 4CF is a promising surgical option for managing CPPD-related wrist arthritis, offering significant functional improvements, motion preservation, and high patient satisfaction. However, it does not halt radiographic progression of arthritis for the majority of patients at a mean prospective long-term follow-up of 5 years.

Evaluating inter- and intraobserver reliability in radiographic determination of wrist alignment following scaphoid excision and four-corner arthrodesis

BackgroundFour-corner arthrodesis is commonly performed for advanced collapse patterns of wrist arthritis. Reduction of the capitolunate (CL) angle during four-corner fusion is crucial to allow for the greatest radiocarpal joint arc of motion. Previous studies demonstrate variable inter- and intraobserver reliability of measuring the CL angle. However, in a four-corner fusion, hardware implementation and scaphoid excision can complicate carpal alignment measurements. The purpose of this study is to investigate inter- and intraobserver reliability of measuring carpal alignment parameters following scaphoid excision and four-corner arthrodesis. MethodsThree fellowship-trained orthopaedic hand surgeons evaluated 30 posteroanterior and lateral radiographs of wrists after scaphoid excision and four-corner fusion. Radiographic evaluation included analysis of the radiolunate angle (RL), CL angle, lunate posture, carpal height, carpal height ratio, hardware impingement, and arthrodesis technique. Intraclass correlation coefficients (ICCs) and kappa values were used to evaluate reliability of radiographic measurements. ResultsRL and CL angles demonstrated very good inter- (ICCs: 0.657 and 0.693, respectively) and intraobserver agreement (ICCs: 0.576 to 0.924 and 0.596 to 0.811, respectively). Hardware impingement metrics by dorsal prominence and radiocarpal prominence had excellent interobserver reliability of 0.821 and 0.803, respectively. ICC values for arthrodesis technique were equal to 1.00. The inter- and intraobserver ICC values for the number of screws/staples used were in excellent agreement ranging from 0.910 to 1.000. ConclusionsOur study demonstrated favorable intra- and interobserver reliability at assessing carpal alignment following scaphoid excision and four-corner arthrodesis and these metrics potentially could be used in future research to evaluate long-term surgical outcomes. Level of evidenceLevel III, retrospective cohort study.

Proximal row carpectomy versus four-corner arthrodesis: a retrospective comparative study.

Four-corner arthrodesis with scaphoid excision (FCA) and proximal row carpal resection (PRC) are frequently performed in wrists with post-traumatic Scaphoid Non- Union Advanced Collapse (SNAC)/Scapho-Lunate Advanced Collapse (SLAC) osteoarthritis. The aim of this study was to compare the clinical outcomes of these two procedures. This single-center, retrospective cohort study included all patients who had PRC or FCA between January 1st, 2009 and January 1st, 2019 and who were followed up. Follow-up included: mobility (radial deviation, ulnar deviation, flexion, extension), strength (grip test, pinch test), function (QuickDash, patient-rated wrist evaluation [PRWE]), subjective mobility, and global satisfaction scores. Among 25 patients included, 11 had PRC and 14 had FCA with a mean follow-up of 69.5 months [12-132]. Radial deviation was 18° versus 14° (p = 0.7), ulnar deviation was 21° versus 22° (p = 0.15), flexion was 39° versus 30° (p = 0.32), extension was 32.5° versus 29.5° (p = 0.09), grip test compared to the controlateral side was 72% versus 62% (p = 0.53), Quick Dash score was 12.5 versus 17.6 (p = 0.84), PRWE was 18.7 versus 17.6 (p = 0.38), subjective mobility was 7.8 versus 7.5 (p = 0.23), and satisfaction score was 8.7 versus 9 (p = 0.76), respectively, in the FCA group and the PRC group. Re-operation rates were 14% patients in the FCA group and 0% in the PRC group. This study found no significant difference between FCA and PRC on strength, mobility, and function in patients with post-traumatic SLAC or SNAC stage II wrist arthritis. Both FCA and PRC seem to be reliable surgical techniques with good outcomes with more revision in the FCA group.

Intracarpal arthrodesis or proximal row carpectomy in SNAC and SLAC wrist

Objective: To clarify the indications for the choice of operative intervention in patients with SLAC and SNAC wrist and to compare the functional results after proximal carpectomy (PRC) and partial intracarpal arthrodesis with scaphoid excision. Methods: A total of 20 patients underwent four corner fusion intracarpal arthrodesis with scaphoid excision, and 8 patients underwent proximal carpectomy in the period from 2016 to 2023. The mean postoperative follow-up period for patients with intracarpal arthrodesis was 3.2 years and for patients with proximal carpectomy was 3.5 years. Results: Regarding range of motion of the wrist in the flexion-extension axis, the proximal carpectomy patients in our series showed better results than the intracarpal arthrodesis patients, an average of 84% in the PRC patients and 75% in the intracarpal arthrodesis patients relative to the contralateral limb. In the patients with intracarpal arthrodesis, however, we recorded a greater preserved range of motion in the radial-ulnar deviation axis of the wrist. Grip strength was measured at 6 months postoperatively and averaged 72% for the PRC group compared with 83% for patients with intracarpal arthrodesis to the contralateral limb. Conclusion: Both proximal carpectomy and intracarpal arthrodesis are surgical interventions that achieve similar functional outcomes for the treatment of degenerative conditions of the wrist (SLAC/SNAC).

Outcomes after radioscapholunate arthrodesis for intra-articular malunion of distal radius fractures

PurposeTo study the clinical, radiological, and functional outcomes after of radioscapholunate (RSL) fusion for intra-articular malunion of the distal radius.MethodsThis retrospective study included 26 patients (17 males and 9 females) with intra-articular malunion of distal radius fractures who underwent RSL arthrodesis using locked miniplates (without distal scaphoid excision) between 2012 and 2020. Their mean age was 43 years (range, 32–56). Patients were assessed radiographically for union and clinically for range of motion, grip strength, and pain (assessed by Visual Analogue Scale (VAS) for pain). Functional evaluation was performed by using the Mayo modified wrist score (MMWS) and the Disabilities for the Arm, Shoulder, and Hand (DASH) questionnaire.ResultsAll patients showed complete healing at the fusion site after a mean of 8.7 weeks (range, 8–12). The mean follow-up period was 72 months (range, 60–84). The pinch strength improved from a mean of 6.2 kg (range, 3–12) to a mean of 9.8 kg (range, 5–18) which represents 80% of the contralateral side. The mean pinch strength was 7 kg (range, 5–18) which presents 80% of the other side. VAS for pain showed a mean improvement of 72.6%. The DASH score improved to a mean of 19.2 (range, 14–24). The MMWS improved to a mean of 68 (range, 45–86). At the final follow-up period, no degenerative changes were detected in the midcarpal joint.ConclusionRSL arthrodesis (using locked miniplates without distal scaphoid excision) is a reliable surgical procedure to manage cases of radiocarpal OA after intra-articular malunion of distal radius fractures with good clinical and radiological outcomes.Level of evidenceLevel IV- therapeutic.

Distal Scaphoid Excision for Chronic and Nonchronic Scaphoid Fracture Nonunion

PurposeThe indications for distal scaphoid excision are limited to localized wrist arthritis surrounding the scaphoid as a result of scaphoid nonunion advanced collapse or scapho-trapezio-trapezoid (STT) joint arthritis. The procedure historically has led to relief of symptoms and improvement in strength. Our aim was to examine the outcomes of this procedure in patients with scaphoid fracture nonunion. MethodsThis is a single-center retrospective case series of 12 consecutive patients who underwent distal scaphoid excision after scaphoid fracture nonunion. Patients were divided into two groups based on nonunion chronicity: chronic (more than a year) and non-chronic (less than a year). Clinical and radiographic data were examined using descriptive statistics. ResultsOur cohort consisted of 12 patients, 10 men (83%) and 2 women (17%), with a mean age 37.6±13.6 years. Eight patients had a chronic scaphoid fracture nonunion (6 had a neglected scaphoid fracture and 2 had a nonunion after scaphoid open reduction and internal fixation (ORIF) with bone graft) and 4 patients had non-chronic fracture non-union (2 had failed cast treatment and 2 had nonunion after scaphoid ORIF with bone graft). Pre-operatively, all patients complained of pain and 4 had numbness (all in chronic group). After an average 21 weeks post-operatively, 7 patients (58%) reported continued pain. Two patients reported ulnar side pain, one underwent arthroscopic synovectomy. All patients who started with normal radiolunate angle continued to have normal angle, whereas patients who had DISI prior to surgery persisted after surgery except for a patient who underwent midcarpal fusion and had their radiolunate angle corrected. ConclusionsDistal scaphoid excision is an effective procedure for carefully selected patients with periscaphoid wrist arthrosis. Patients with recent scaphoid fracture that failed treatment may also be treated with distal scaphoid resection.

O243: The effect of midcarpal fusions on dart thrower’s motion: a cadaveric study

Abstract Introduction Midcarpal osteoarthritis can be managed with several types of partial wrist fusion. Limited information is available regarding their effects on functional movement. Many daily activities require a coupled wrist movement, from radial extension to ulnar flexion, termed dart thrower’s motion (DTM). This study aimed to compare the effect of four different midcarpal fusions on DTM. Methods Twelve fresh-frozen cadaveric specimens were dissected. Sequential loading of tendons into radial extension and ulnar flexion enabled full DTM to be measured using goniometry. Specimens were tested at baseline and following each fusion, performed sequentially using Kirschner wires: (1) scaphocapitate fusion, (2) lunocapitate fusion with scaphoid excision, (3) four-corner fusion with scaphoid excision and (4) three-corner fusion with scaphoid and triquetral excision. A one-way ANOVA and Tukey test established the significance of differences in range of motion. Results Each procedure significantly decreased DTM compared with intact wrists. Scaphocapitate fusion resulted in the smallest mean reduction in movement from 78°–70° (p=0.0014). Four-corner fusion produced the greatest reduction in DTM from 78°–63° (p<0.0001). There was a significant difference in DTM between four-corner and scaphocapitate fusions (p=0.0338). There was no significant difference in the range of postoperative DTM between lunocapitate, three-corner, or four-corner fusions. Conclusion DTM was minimally affected by scaphocapitate fusion and maximally affected by four-corner fusion, with a significant difference seen between these two operations. However, as a 44°–87° range of DTM was maintained for four-corner fusions, this is felt to be adequate for function. These results could aid preoperative decision-making.

Effect of Capitolunate Positioning on Outcomes in Scaphoid Excision and 4-Bone Fusion Patients.

Scaphoid excision and 4-bone fusion (4BF) is a surgical procedure to treat scapholunate advanced collapse. Some surgeons align the lunate over the capitates, whereas others leave the capitate in its uncovered native position. The capitolunate angle may affect long-term outcomes. This study examined whether postsurgical outcomes differed based on these differences in positioning. A retrospective analysis was performed for patients that underwent a 4BF between 2006 and 2020. Wrist range of motion; pain (0-10); and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were recorded. The width of the capitate, the width of the lunate contacting the capitate, and the capitolunate angle were measured. Pearson correlations and t tests were performed. For t tests of capitolunate uncovering, patients were divided into 2 groups: patients with 0% capitate uncovering and patients with >0% uncovering. For capitolunate angle, the 2 groups were patients with a capitolunate angle of ≤10° and patients with a capitolunate angle of >10°. There was a significant correlation between capitate coverage and wrist extension, but no correlation for flexion, pain, or DASH scores. Group 1 (0% uncovering) had increased wrist extension and decreased pain compared with group 2 (>0% uncovering). There were no significant correlations or differences in the analyses of capitolunate angle's impact on outcomes. In patients undergoing 4BF, those who had the lunate aligned to completely cover the capitate head had improved wrist extension and pain compared with patients where the capitate head was left partially uncovered. Capitolunate angle was not predictive of postsurgical outcomes.

Arthroscopic Resection Arthroplasty for Scapholunate Advanced Collapse Wrist.

Purpose Scapholunate advanced collapse (SLAC) wrist results from an untreated scapholunate dissociation and is the most common type of degenerative arthritis of the wrist. The most common surgical treatments for SLAC wrist are proximal row carpectomy and four-corner fusion with scaphoid excision. Arthroscopic surgical treatment for SLAC wrist has been reported; however, only limited data on functional outcomes are available. The purpose of this study is to report our 5-year follow-up clinical outcomes for arthroscopic treatment for SLAC wrist. Methods Thirty-one consecutive cases of arthroscopic resection arthroplasty for SLAC wrist were reviewed. Preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, grip strength, and pain (on 0-10 scale) as well as postoperative satisfaction (0 = not satisfied, 5 = completely satisfied) were recorded. Grip and range of motion were measured by an occupational therapist. Results The preoperative pain score was 7 and 0.18 postoperatively. The mean satisfaction at final follow-up was 4.8. Preoperative and final follow-up scores of the mean DASH was 48 and 3, respectively. The total arc of motion was 114 degrees preoperatively and 126.5 degrees postoperatively. Mean grip strength before surgery was 41 and 49 kg at final follow-up. Conclusion Arthroscopic resection arthroplasty for SLAC wrist results in significant improvement in patient function as measured by DASH and pain scores. Type of Study/Level of Evidence Therapeutic IV.

Scaphoid excision and four corner fusion in treatment of scapholunate dissociation

The purpose of this study was to evaluate the clinical outcome, union rate, and complications of a consecutive series of scaphoid excision and four-corner arthrodeses performed by a three surgeon using distal radius bone graft Herbert screws or K-wires or cannulated Synthes screws or Flower plate fixation. Mean duration of follow-up was 16 months. The results of the present study revealed that, patient satisfaction is high, and the procedure offers well to excellent pain relief. Advances in surgical exposures, fixation techniques, and implants have allowed for rigid fixation that enables for rapid union and the commencement of early range of motion. Failure rates and complication rates are relatively low, and long-term outcomes have been promising

FOUR-DIMENSIONAL COMPUTED TOMOGRAPHY-DERIVED RADIOLUNATE ARTHROKINEMATICS WITH A CASE STUDY IN FOUR-CORNER ARTHRODESIS

The radiocarpal joint, which includes articulations between the radius and the proximal carpal row, transmits force through the central column of the wrist. Chronic disruptions to radiocarpal biomechanics are associated with the development of scapholunate advanced collapse (SLAC) pattern OA. While the radiolunate joint is thought to be typically spared in SLAC progression, degenerative changes can present on the proximal lunate. An investigation of radiolunate arthrokinematics may improve understanding of posttraumatic and postsurgical outcomes, including salvage procedures for SLAC wrist such as scaphoid excision with four-corner arthrodesis (SEFCA). Four-dimensional CT, which captures CT volumes over time or motion, has enhanced our ability to quantify arthrokinematics during functional tasks. We hypothesize that 4DCT-derived radiolunate arthrokinematics during flexion-extension and radioulnar deviation will differ between healthy, uninjured wrists and a wrist three years post-SEFCA. Data were collected from the uninjured wrists of ten participants enrolled in a prospective study of unilateral wrist injury and one participant following SEFCA (n=11, 36% female). The SEFCA arthrodesis was fixed using Kirschner wires prepositioned in the head of the capitate and subsequently advanced into the lunate. Included participants were aged between 18 and 60 years; exclusion criteria included history of injury, surgery, or congenital variant in the contralateral wrist; rheumatologic disease; or connective tissue disease. Static-neutral and dynamic CT data were collected using a dual-source scanner (SOMATOM Flash, Siemens, DE) and commercially-available cardiac sequential scan protocol. 4DCT data were collected over a 1.5-second period as signaled by an ECG simulator. CT volumes were collected at a temporal resolution of 66 ms as participants moved at a cadence of 70 beats per minute (voxel size: 0.234mm × 0.234mm × 0.600mm). Nearest mesh-vertex distances between vertices on the radius and lunate within distance (2.5 mm) and surface-normal angular (60°) thresholds were calculated to define interosseous proximity distributions. Median interosseous proximities at each time point were calculated. Ten participants were aged mean (SD) 30.3 (6.8) years at the time of imaging; the SEFCA participant was 52 years of age and three years postoperative. Median radiolunate interosseous proximities are presented during flexion-extension and radioulnar deviation (Fig. 1). 4DCT has advanced our understanding of wrist arthrokinematics during functional tasks. The current study reveals that radiolunate interosseous proximities in healthy, uninjured wrists remain relatively constant over wrist flexion-extension and radioulnar deviation, with greatest proximities occurring near the extrema of motion. In the SEFCA participant, interosseous proximities were closest in flexion and ulnar deviation; this may be associated with high articular contact pressures in these positions. Interosseous proximities reveal how restricting midcarpal motion in SEFCA impacts adjacent articulations during wrist motion. This study represents a novel use of 4DCT to assess post-arthrodesis outcomes.

Lateral Approach for Scaphoid Excision and Capitolunate Arthrodesis in the Treatment of Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Wrists: A Case Series.

The dorsal approach is commonly used in open wrist arthrodesis. However, the extensor compartments and the dorsal wrist capsule need to be opened. We propose and evaluate a lateral approach using a small incision over the scaphoid anatomical snuffbox, which could be more straightforward for performing scaphoid excision and capitolunate arthrodesis in the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC). Between 2016 and 2021, 10 patients were enrolled retrospectively and underwent the lateral approach for scaphoid excision and capitolunate arthrodesis. We presented the radiographic outcomes, including fusion status, capitolunate angle, and carpal height ratio. The functional outcomes of wrist range of motion, grip strength, visual analog scale (VAS) score for pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Mayo wrist score were evaluated. The data obtained were analyzed and presented as the mean and standard deviation (SD). All 10 patients achieved solid bone fusion, and the mean follow-up period was 20.4 (range 12-38; SD 10.1) months. Postoperatively, the mean capitolunate angle and carpal height ratio improved from 18.1° (range 8-34°; SD 8.6°) to 2.9° (range 0-5°; SD 1.9°) and 0.45 (range 0.40-0.49; SD 0.03)% to 0.50 (range 0.46-0.54; SD 0.02)%, respectively. The average preoperative and final follow-up functional results were as follows: flexion-extension arc of 76.5° (range 50-110°; SD 20.0°) and 74.0° (range 65-90°; SD 9.1°); VAS pain score of 5.8 (range 4-7; SD 1.0) and 0.9 (range 0-2; SD 0.6); QuickDASH score of 55.9 (range 40.9-79.5; SD 11.4) and 26.1 (range 18.2-36.4; SD 6.0); and Mayo wrist score of 46.5 (range 25-60; SD 13.8) and 72.5 (range 70-80; SD 3.5), respectively. The lateral approach for scaphoid excision and capitolunate arthrodesis in treating SLAC and SNAC can provide a straightforward way for performance. This approach does not require disruption of the dorsal wrist capsule and extensor retinaculum. Bony healing can be achieved, and functional outcomes can be improved.

Treatment Outcomes of All Arthroscopic 4-Corner Arthrodesis Techniques With 2 Headless Screws

Scaphoid excision with 4-corner arthrodesis is a safe procedure that relieves pain while also preserving the functional movements of the wrist. Different techniques have been described with successful results. In this study, we present the midterm clinical outcomes of 17 patients who underwent treatment with our arthroscopic 4-corner arthrodesis technique. Patients with at least 1 year of follow-up were included in our study. Preoperative and postoperative radiologic, functional, and clinical results were compared. Radiologic and clinical union were achieved in all patients. Significant improvement was observed in Quick Disabilities of the Arm, Shoulder, and Hand, Mayo Wrist Score, visual analog scale, and Patient-Rated Wrist Evaluation scores. Although wrist range of motion increased in the radioulnar plane, no clinically important change was observed in the flexion-extension arc. The patients were able to return to work in an average of 10 weeks. The arthroscopic 4-corner arthrodesis technique is a method with satisfactory outcomes. The main disadvantage of this procedure is that it requires a lengthy operative time, and both specific expertise and equipment. Therapeutic IV.

Outcomes of Arthroscopic Scaphoid Excision and Lunocapitate Fusion for Advanced Traumatic Arthritis of the Wrist.

Arthroscopic lunocapitate (LC) fusion can be an alternative surgical treatment for scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) of the wrist. We retrospectively reviewed patients who had arthroscopic LC fusion to estimate clinical and radiological outcomes. From January 2013 to February 2017, all patients with SLAC (stage II or III) or SNAC (stage II or III) wrists, who underwent arthroscopic LC fusion with scaphoidectomy and were followed up for a minimum of 2 years, were enrolled in this retrospective study. Clinical outcomes included visual analog scale (VAS) pain, grip strength, active range of wrist motion, Mayo wrist score (MWS), and the Disabilities of Arm, Shoulder and Hand (DASH) score. Radiologic outcomes included bony union, carpal height ratio, joint space height ratio, and loosening of screws. We also performed group analysis between patients with 1 and 2 headless compression screws to fix the LC interval. Eleven patients were assessed for 32.6 ± 8.0 months. Union was achieved in 10 patients (union rate, 90.9%). There was improvmenet in mean VAS pain score (from 7.9 ± 1.0 to 1.6 ± 0.7, p = 0.003) and grip strength (from 67.5% ± 11.4% to 81.8% ± 8.0%, p = 0.003) postoperatively. The mean MWS and DASH score were 40.9 ± 13.8 and 38.3 ± 8.2, respectively, preoperatively and improved to 75.5 ± 8.2 and 11.3 ± 4.1, respectively, postoperatively (p < 0.001 for all). Radiolucent screw loosening occurred in 3 patients (27.3%), including 1 nonunion patient and 1 patient who underwent screw removal due to the screw migration encroaching the lunate fossa of radius. In group analysis, only the frequency of radiolucent loosening was higher in 1 screw (3 of 4) than 2 screw fixation (0 of 7) (p = 0.024). Arthroscopic scaphoid excision and LC fusion for patients with advanced SLAC or SNAC of the wrist was effective and safe only in cases fixed with 2 headless compression screws. We recommend arthroscopic LC fusion using 2 screws rather than 1 to decrease radiolucent loosening, which might affect complications such as nonunion, delayed union, or screw migration.

Parallel K-Wire Placement Leads to Fusion and Midcarpal Settling in Scaphoid Excision Four-Corner Fusion.

Scaphoid excision 4-corner fusion is a motion-sparing procedure in patients with advanced radioscaphoid arthritis. This study introduces an alternate technique for scaphoid excision 4-corner fusion using a parallel Kirschner wire (K-wire) construct across the midcarpal joints that leads to reliable fusion rates, and good patient outcomes. This is a single-surgeon, retrospective study of patients who underwent scaphoid excision 4-corner fusion, using a parallel K-wire construct across the midcarpal joints. Once fusion was achieved, K-wires were removed. Radiographic union rate, time to union, capitolunate angle, capitolunate coverage, and amount of midcarpal settling are measured. Patient-reported outcome measures and descriptive statistics are presented. Sixty-five wrists were included in this study with a mean age of 50.1 years. One patient was lost to follow-up. All 64 wrists (100%) fused at an average of 2.6 months. The mean capitolunate angle was 7°, and capitolunate coverage was 99.2%. Fifty-two patients (81%) had adequate radiographs for measurement. Average midcarpal settling was 1.1 mm. Thirty-two patients (51%) were available for long-term follow-up at an average of 5.3 years (0.7-10.2 years), and participated in patient reported outcomes (PRO) surveys. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 16.6, and numeric pain rating scale score was 1.8. Parallel K-wire placement across the midcarpal joints with scaphoid leads to a high rate of fusion with good patient outcomes long term. Midcarpal settling that occurs through dynamic compression around the K-wires may have contributed to bony fusion. This technique may provide an alternative approach to achieving reliable fusion across the midcarpal joints.

Four-Corner Fusion with Locking Dorsal Circular Plate versus Headless Compression Screws: A Clinico-Radiological Comparative Study

AbstractIntroduction Four-corner fusion is a technique for the treatment of carpal advanced collapse. It consists of scaphoid excision and arthrodesis of the lunate, triquetrum, hamate, and capitate bones. This can be accomplished with different kinds of osteosynthesis. In the first reports of the use of a circular plate, poor outcomes are described, with high rates of non-union, which decreased in later studies, which highlight certain aspects of the surgical technique.Objective To report our experience with four-corner fusion with the use of a dorsal locking plate (Xpode, Trimed Inc., Santa Clarita, CA, US), and compare it with another traditional fixation method (3.0-mm headless compression screws [HCSs], Synthes, Slothurn, Switzerland), with an emphasis on union, an assessment of the fincitonal outcomes, and the presence of complications.Material and Methods A comparative study of two prospective series of patients operated on through two fixation techniques for four-corner fusion using autologous bone graft from the iliac crest.The first group of patients, evaluated between 2010 and 2012, underwent osteosynthesis with 2 HCSs, with a minimum follow up of 18 months. The second group, evaluated between 2011 and 2014, underwent osteosynthesis with a dorsal locking plate, with a minimium foloow up of 12 months. The patients were operated on by four different surgeons in four centers.The patients were evaluated with radiographs to establish the presence of union and the time it took to occur. In case of doubt, union was confirmed through a computed tomography (CT) scan at 8 weeks postoperatrively. We also assessed the range of motion, the presence of complications, and function through the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a grip strength score.Results We achieved a union rate of 100% in both groups at similar times. In the dorsal locking plate group, we obtained better full range of motion, particularly in wrist extension, which was statistically significant (p = 0.0016), as well as lower DASH scores, which was also statistically significant (p = 0.0066). Complications were only present in two patients in the HCS group.Conclusion Both techniques are valid and reproducible for the treatment of wrists with scapholunate advanced collapse (SNAC) and scaphoid non-union advanced collapse (SLAC). Based on the outcomes, with the Xpode plate, the patients presented better ranges of motion and DASH scores; therefore it may be an excellent fixation option in the open four-corner fusion surgical technique. The entry point and configuration of the HCS are fundamental variables to analyze.The union rate of 100% obtained in the present study contrasts with the high rates of non-union reported in the literature published in the early 2000s.

Arthroscopic three-corner or lunocapitate arthrodesis: technical tips and early outcomes

The purpose of the study is to present a technical approach for arthroscopic three-corner or lunocapitate arthrodesis with mini-open scaphoid excision and to report about the early clinical and functional results. The median surgery time was 112 min with shorter times achieved once mastering the technique. Radiological and clinical union was observed in 11 out of 12 patients in a median time of five months. For final assessments nine patients were included with a median follow-up of 15 months. Wrist extension and flexion after surgery decreased to 58 and 62% of preoperative measurements and represented 37 and 42% of the unaffected side. Grip strength also decreased to 80% of the preoperative value and 57% of the unaffected side. All patients reported significant pain relief and functional improvement. Arthroscopic three-corner or lunocapitate arthrodesis was a safe, reliable and minimally invasive technique for treating wrist osteoarthritis, while it was technically demanding and time-consuming during learning curve.

The Biomechanical Effects of Simulated Radioscapholunate Fusion With Distal Scaphoidectomy, 4-Corner Fusion With Complete Scaphoidectomy, and Proximal Row Carpectomy Compared to the Native Wrist

To determine the effect of simulated radioscapholunate fusion with distal scaphoid excision (RSLF+DSE), 4-corner fusion with scaphoidectomy (4-CF), and proximal row carpectomy (PRC) on the wrist's range of motion (ROM), contact pressure, and contact force in a cadaveric model. Ten freshly frozen cadaveric wrists were tested under 4 sequential conditions: native wrist, RSLF+DSE, 4-CF, and PRC. The simulated fusions were performed using two 1.6-mm Kirschner wires. The ROM in the flexion-extension and radioulnar deviation planes was evaluated. Contact area, contact pressure, and contact force were measured at the scaphocapitolunate joint for the RSLF+DSE simulation and radiocarpal joint for the 4-CF and PRC simulations. Mechanical testing was performed using a 35-N uniaxial load and pressure-sensitive film. The RSLF+DSE and 4-CF groups had a decreased wrist arc ROM compared with the native wrist. The PRC group had a greater wrist arc ROM compared with the RSLF+DSE and 4-CF groups, but compared to the native wrist, it demonstrated a mildly decreased wrist arc ROM. The carpal pressure and contact force were significantly increased in the RSLF+DSE, 4-CF, and PRC groups compared with those in the native wrist. The RSLF+DSE group had the smallest increase in the carpal pressure and contact force, whereas the PRC group had the greatest increase. Our study validates previous findings that PRC is motion-conserving but has the greatest contact force, whereas RSLF-DSE and 4-CF may cause a decrease in the ROM but have lower contact forces. Understanding the underlying native wrist biomechanics and alterations following different surgical treatments may assist hand surgeons in their clinical decision making for the treatment of stage II scapholunate advanced collapse.