Scaphoid Excision Research Articles

Four-Corner Arthrodesis Using a Circular Plate and Distal Radius Bone Grafting: A Consecutive Case Series

Four-corner arthrodesis with scaphoid excision has been shown to be an acceptable method for treating wrist degenerative changes. Some recent studies have identified higher complication rates when circular plates are used. This study examined a consecutive case series with defined technique for outcome and complications. A retrospective assessment was performed in a consecutive cohort of 28 patients who underwent a standardized 4-corner arthrodesis with a 2nd-generation circular plate and distal radius bone grafting for a diagnosis of scapholunate advanced collapse, scaphoid nonunion advanced collapse, or midcarpal arthrosis. Complete data were obtained for 26 of the patients and partial data for the other 2. Follow-up examination included visual analog scale and activity scores, work status, posteroanterior and lateral radiographs, bone union status, grip strength, range of motion, and complications. Average follow-up was 46 months. Range of motion averaged 45% of the uninjured side (average extension, 35 degrees; average flexion, 26 degrees). Grip strength averaged 82% of the uninjured side. The mean visual analog scale pain and activity scores were 2.3/10 and 2.4/10. Only 1 patient required job modification because of wrist impairment. Radiographs demonstrated union of the primary capitolunate fusion mass in all of the cases. There was 1 case of probable but not certain peritriquetral nonunion and 1 case of asymptomatic loss of radiolunate joint space; in terms of hardware, there was screw back-out (of 1 screw) in 1 case the plate broke in 1 case. Two patients underwent reoperation, one for radial styloid impingement pain and the other for lack of flexion. Despite recent reports indicating a high nonunion rate with plate fixation, standardized 4-corner arthrodesis using a recessed, dorsal circular plate and distal radius bone grafting produced excellent and reproducible results in this consecutive series. Notably, there was no development of secondary arthritic changes at the radiolunate joint, indicating a reasonable durability to the procedure. Optimal results require exacting technique with quality bone graft.

Scaphoid Excision and Limited Wrist Fusion: A Comparison of K-Wire and Circular Plate Fixation

The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.

Scaphoid Excision with Four-Corner Fusion: A Biomechanical Study

Partial wrist arthrodesis is a commonly performed procedure for the treatment of posttraumatic wrist arthritis because of its ability to provide pain relief without sacrificing complete wrist motion. The purpose of this study was to evaluate the redistribution of force after four-corner fusion and scaphoid excision, and to correlate the findings with the reported clinical outcomes. Fifteen cadaveric wrists were used to study the biomechanics of the four-corner fusion. Pressure-sensitive film (super-low-pressure-indicating film-Pressurex, Sensor Products Inc, Madison, NJ) was inserted into the radiocarpal joint. Using the MTS 858 Mini Bionix (MTS System, Eden Prairie, MN), 50-kg loads (220 N) were applied to the wrists before and after simulated four-corner fusion and scaphoid excision. Statistically, we compared the pressure in the normal (intact) wrists versus four-corner fusion and scaphoid excision. The pressure measurements across the scaphoid fossa, lunate fossa, and triangular fibrocartilage complex (TFCC) were compared. There is a statistical significant difference between scaphoid, lunate, and TFCC mean total force when pre and post-fusion were compared (p = 0.0001). Our study revealed a statistical significant decrease in the mean scaphoid total force after scaphoid excision and four-corner fusion (p = 0.0001). We also found a subsequent increase in mean total force after scaphoid excision and four-corner fusion for the lunate fossa that did not reach statistical significance (p = 0.08), and no difference in load across the TFCC area (p = 0.995). Our findings suggest that load is preferentially transferred to the radiolunate joint after scaphoid excision with four-corner fusion.

Management of Non-United Four-Corner Fusions

Wrist degeneration, resulting from scaphoid nonunion or scapholunate ligamentous disruption, is widely managed with scaphoid excision with four-corner fusion. There are no specific details in the literature regarding "salvage" of nonunion after attempted "four-corner fusions" or the patient outcomes. The purpose of this paper is to present the results of patients who underwent treatment for nonunion after four-corner fusion, the subsequent surgeries done for wrist salvage and the functional results. We reviewed, retrospectively, 37 patients who underwent limited wrist fusion using circular plate fixation, of which eight cases (22%) went on to nonunion and necessitated revision surgeries with plate exchange and bone graft. (Table 1) Five of eight patients were available to return to the clinic, and the wrist range of motion and the disabilities of the arm, shoulder, and hand (DASH) score were recorded. The average DASH score was 46 (range, 15 to 60.8). Grip on the affected limb was, on the average, 62% of the contralateral limb. Average arc of wrist motion was 70 degrees (35.7 degrees of flexion and 34.3 degrees of extension). Three of the five patients were laborers, and two returned to the previous employment. The remaining two patients returned to their previous sedentary jobs. All patients reported difficulty with recreational activities involving heavy activity. Complications of four-corner arthrodesis using circular plate fixation were recorded, revealing a high number of nonunions and hardware failures. All nonunions were salvaged with allograft or autogenous grafting with plate revision; however, the patients did have considerable limitations.

A Prospective Outcomes Study of Four-Corner Wrist Arthrodesis Using a Circular Limited Wrist Fusion Plate for Stage II Scapholunate Advanced Collapse Wrist Deformity

Scapholunate advanced collapse wrist deformity is a common pattern of degenerative arthrosis of the wrist. This study prospectively evaluated a series of patients who underwent four-corner fusion using a circular plate internal fixation technique. Patients with symptomatic stage II scapholunate advanced collapse wrist deformity were treated with scaphoid excision and four-corner fusion using the Spider Limited Wrist Fusion Plate (KMI, San Diego, Calif.). Patients were prospectively evaluated at 6 months and 1 year using a standard study protocol with radiographs, functional tests, and an outcomes questionnaire. Outcomes were compared with those of historical series from the literature. Eleven patients were enrolled and 10 patients completed their 1-year follow-up. Grip strength, lateral pinch strength, and Jebsen-Taylor test scores at 1 year were not significantly different from preoperative values. Mean active range of motion was 87 degrees preoperatively and 74 degrees at 1-year follow-up (p = 0.19). The Michigan Hand Outcomes Questionnaire showed no significant improvement in function, activities of daily living, work, pain, or patient satisfaction. The mean pain scores decreased from 54 preoperatively to 42 1-year postoperatively (p = 0.30), indicating persistent wrist discomfort. Three patients had broken screws: one was asymptomatic, one required 3 months of strict wrist immobilization, and one was reoperated for symptomatic nonunion. Four-corner fusion using the first-generation Spider plate technique has the advantage of earlier mobility and more patient comfort from absence of protruding Kirschner wires; however, patients continued to have disabling pain, functional limitations, work impairment, and low satisfaction scores postoperatively. Although limited by a small patient sample, this series presents outcomes data that may be useful in counseling patients who are contemplating four-corner fusion using this internal fixation device. Further investigation is necessary to evaluate the biomechanical properties of the Spider plate. The data suggest that better implants should be designed to avoid implant failure, which occurred in three of the 11 patients in this series.

Experimental study of the biomechanical impact of limited intercarpal arthrodesis on the wrist

目的 探讨部分腕骨融合术后腕关节的活动范围、压力负荷及对腕关节生理状态的影响.方法选用12例新鲜腕关节标本随机分为3组,A组:舟大小融合术;B组:舟骨三角骨切除+头月融合术;C组:四角融合+舟骨切除术.通过CSS-44020系列生物力学试验机,用100 N力,以5mm/s的速度分别牵引腕关节被动掌屈、背伸、尺偏和桡偏,并测量A、B、C 3组标本的活动角度.然后,于腕关节内放置压敏片,用自制的实验架将腕关节固定于中立位,以5 N/s的压速对腕关节施压至200 N,维持60 s后测量压敏片上各组标本的受力面积和压力负荷.结果 (1) 活动范围:A组掌屈(68.4±5.2)°(±s,下同)、背伸(51.5±4.6)°、尺偏(24.5±2.3)°、桡偏(15.7±3.4)°.B组掌屈(64.5±7.1)°、背伸(60.0±5.2)°、尺偏(42.4±3.2)°、桡偏(26.9±5.2)°.C组掌屈(61.9±6.6)°、背伸(54.9±5.3)°、尺偏(27.1±3.9)°、桡偏(17.0±4.9)°.(2) 腕关节的受力面积:A组为(265.00±8.97)mm2.B组为(125.81±5.97)mm2.C组为(164.00±8.43)mm2.(3) 负荷压力:A组为(53.87±3.07)N/cm2.B组为(112.86±0.74)N/cm2.C组为(55.28±5.11)N/cm2.结论舟大小融合术、舟骨切除+四角融合术对腕关节应力负荷的影响与正常腕关节相比变化不大,而舟三角骨切除+头月融合术对腕关节的影响较大,其应力负荷的增加明显超出了正常腕关节所承受的压力负荷。

Complications and Outcome of Four-Corner Arthrodesis: Circular Plate Fixation Versus Traditional Techniques

To review the clinical and radiographic results of scaphoid excision and four-corner arthrodesis using a circular plate and screws compared with traditional fusion techniques (wires, staples, screws). Fifty-eight patients with four-corner arthrodesis (plate fixation, n = 27; traditional fixation, n = 31) were evaluated for radiographic and clinical success using wrist radiographs and functional assays. Patients were subjectively surveyed using the standardized Disabilities of the Arm, Shoulder, and Hand questionnaire and classification scales for pain and satisfaction. Objective measurements included grip-strength and range-of-motion measurements. Radiographic analysis showed 26% nonunion with loose hardware in the plate group compared with 3% in the traditional group and 22% hardware impingement in the plate group compared with 3% in the traditional group. Clinical evaluation yielded a mean grip strength of 31 kg (70% of opposite side) for plate fixation and 33 kg (79% of opposite side) for traditional fixation. The mean flexion-extension arc was 48% and 50% of the opposite wrist for plate and traditional patients, respectively. The mean adjusted Disabilities of the Arm, Shoulder, and Hand questionnaire scores were 27 out of 100 for plate patients and 8 out of 100 for traditional patients. Pain classification scores showed that only 2 patients in the plate group were pain free whereas there were 8 patients in the traditional group who were pain free. Overall patient satisfaction was 60% for the plate group whereas the traditional patient group reported 100% satisfaction. The rate of major complications (nonunion or impingement) was much greater with circular plate fixation (48%) versus traditional fixation techniques (6%). With the plate procedure the grip strength and arc of motion decreased approximately 30% and 52%, respectively, compared with decreases of 21% and 50%, respectively, for traditional fusion methods. Additionally, subjective patient dissatisfaction was 40% in the plate group compared with 0% in the traditional group. We postulate that the increased complication and dissatisfaction rates associated with plate fixation may be attributable to possible biomechanical imperfections or increased technical demands with this fusion system.

Results of Four-Corner Arthrodesis Using Dorsal Circular Plate Fixation

Four-corner arthrodesis with scaphoid excision has been used to reduce pain and preserve functional range of motion for patients with radioscaphoid arthritis. Early results of 4-corner arthrodesis with scaphoid excision using dorsal circular plate fixation are compared with reported results in the literature. We reviewed retrospectively the first 18 four-corner arthrodeses performed with this system by 4 hand surgeons. Two patients had revision surgery for nonunions before the study that were considered failures. Eight patients returned for final radiographs, objective examination, and functional questionnaire. The average follow-up period was 20 months (range, 13-33 mo). These results were compared with reported results in the literature using alternate fixation methods. Radiographic union was achieved in only 3 wrists. Range of motion was 46% that of the opposite normal wrist and grip strength compared with the opposite wrist was 56%. Five patients would have the procedure again and 6 of 8 have returned to their original employment. Four-corner arthrodesis with scaphoid excision using a circular internal fixation plate produced a high number of nonunions. Grip strength and range of motion results also were inferior to those reported in the literature.

Scaphoid excision and four-corner fusion in the slac/snac wrist

Scaphoid excision and four-corner fusion in the slac/snac wrist

Management of the scaphoid during four-corner fusion—a cadaveric study

Purpose To examine the effects of scaphoid retention, inclusion, and excision on wrist motion and radiolunate contact characteristics in a cadaveric model after simulated 4-corner fusion with rigid internal fixation. Methods Seven fresh-frozen cadaveric upper extremities were examined. For all surgical manipulations the motion was measured and contact characteristics were assessed using ultra-low prescale pressure-sensitive film. Results Compared with the intact specimen, simple 4-corner fusion with scaphoid retention led to a significant decrease in extension, radial deviation, and ulnar deviation, but no change in radiolunate contact characteristics. After 4-corner fusion there was no significant difference in motion or radiolunate contact characteristics between scaphoid retention and scaphoid inclusion. After 4-corner fusion scaphoid excision allowed significantly greater radial deviation compared with scaphoid retention and scaphoid inclusion. Compared with the intact specimen 4-corner fusion with scaphoid excision also led to a significant increase in radiolunate contact area and mean contact pressure. Conclusions When performing 4-corner arthrodesis in the absence of radioscaphoid arthritis, scaphoid excision may improve motion at the cost of increased mean radiolunate contact pressure.

Proximal row carpectomy and intercarpal arthrodesis for the management of wrist arthritis.

For advanced noninflammatory wrist arthritis, the most common surgical treatments to preserve motion are proximal row carpectomy and scaphoid excision with capitohamate-lunotriquetral arthrodesis. Both procedures have documented successful outcomes. Proximal row carpectomy is simpler but typically is contraindicated when degeneration of the capitate head cartilage exists. Scaphoid excision with capitohamate-lunotriquetral arthrodesis is more complex but may provide greater grip strength and can be successful in the presence of capitate degeneration. Treatment selection should be based on surgeon preference and experience as well as on the patient's understanding of the possible complications and benefits of each procedure.

The radial portal for scaphotrapeziotrapezoid arthroscopy

The scaphotrapeziotrapezoidal (STT) joint is a complex joint in which the arthroscope and instruments can be used through the radial midcarpal and STT-ulnar portals. This report describes a new arthroscopic portal at the STT joint to complete and improve the evaluation and treatment of this joint by arthroscopy: The STT-radial (STT-R) portal is situated immediately radial to the abductor pollicis longus at the STT level. Five cadaveric wrist specimens were dissected immediately after the portal was established, and photographed to determine the proximity of neurovascular structures. Magnetic resonance imaging evaluation of 15 hands was performed to measure the proximity of the radial artery. A cadaveric distal scaphoid excision was also created arthroscopically to show the real usefulness of this portal. Results of the anatomic study showed that no lesions of nerves or vessels were seen at this portal. Magnetic resonance imaging showed that the radial artery was located at a safe distance from the portal. The distal scaphoid excision was performed 15 minutes after the STT portals were established. Our results suggest that this new portal is safe and effective.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: pp 547–553

Scaphoid excision and four-corner fusion in the SLAC/SNAC wrist

Scaphoid excision and four-corner fusion in the SLAC/SNAC wrist

INTERCARPAL FUSION FOR THE TREATMENT OF SCAPHOID NONUNION

Salvage of the ununited scaphoid may not always be feasible or advisable, hence the availability of a number of alternative techniques which prioritize restoration of pain relief and range of motion. The role of intercarpal fusion reflects the importance of midcarpal stabilization when the scaphoid is resected. While scaphocapitate and scaphocapitolunate fusions have been described, these techniques provide less pain relief than midcarpal fusion with scaphoid excision, and are associated with an increased risk of radioscaphoid arthritis. In this article, the author will address the rationale for, technique of, and outcome after midcarpal arthrodesis and scaphoid excision.

Functional results of medio-carpal partial arthrodesis with excision of the scaphoid

Midcarpal arthrodesis with excision of the scaphoid for the treatment of painful carpal collapse has been performed in our hospital since 1993. A clinical study was carried out to evaluate the results and determine special factors, which might influence the results. 26 out of 29 patients operated until 1999 were reexamined after an average follow-up of 27 months. The results were evaluated according to the Mayo-modified wrist score. The DASH score and the pain-disability index (PDI) were calculated postoperatively. Standard X-rays of the wrist were analyzed for alteration of the radio-lunate joint space, the position of the lunate with respect to the radius and the correction of the carpal height as calculated by the Youm index. Carpal collapse was due to scapholunate pathology (SLAC) in 12 cases, long-standing scaphoid nonunion (SNAC) in ten cases, perilunate dislocation, which was only simply reduced, in three cases, and calcium pyrophosphate deposition disease in two cases. The Mayo-modified wrist score improved significantly from an average of 46 points before to 76 points after surgery. The DASH score postoperatively was 22, the PDI 13. All patients reported improvement of their situation after the operation, eight were completely free of pain. The average range of motion from extension to flexion was 64 degrees, which was almost identical to the average preoperative value. The average grip strength before surgery was 24 kg, after surgery 34 kg. There was a correlation between the position of the lunate to the radius in the lateral X-ray and the range of extension. If the lunate was positioned correctly, wrist extension was significantly better. The radiolunate joint space was maintained during the period of observation with only two exceptions. Apparent subchondral sclerosis was seen in most of the cases. It was not possible to restore carpal height completely. Some results after perilunate luxations and one case of calcium pyrophosphate deposition disease were unsatisfactory. Midcarpal arthrodesis with scaphoid excision is a reliable method for treating radioscaphoid arthrosis caused by carpal collapse. Correction of the hyperextended position of the lunate is important to obtain optimum results. In our hospital, a wrist arthrodesis is only rarely performed nowadays, except in the rheumatoid patient.

PARTIAL EXCISION OF SCAPHOID: IS IT EVER INDICATED?

The carpal scaphoid cannot be partially or totally excised without paying a functional penalty, usually in the form of carpal instability. In selected conditions, however, a partial scaphoidectomy may be preferred over other less reliable alternatives. These include excision of a small fragment of a fractured proximal pole when there is no injury to the scapholunate ligaments; excision of the distal fragment of a nonunited, arthritic distal-third scaphoid fracture; resection-arthroplasty of isolated STT osteoarthritis; and distal scaphoid excision to improve midcarpal function after a radioscapholunate fusion. In this article, both the pathomechanics and clinical results of such techniques are discussed.

Distal scaphoid excision after radioscaphoid arthrodesis.

Radioscaphoid and radioscapholunate arthrodeses are effective surgical procedures for the treatment of nonsalvageable and isolated radiocarpal arthritis. These procedures, however, limit wrist motion significantly as the immobile scaphoid bridges the remaining midcarpal joint. A cadaver study of radioscaphoid arthrodesis followed by distal scaphoid excision was undertaken. Range of motion after radioscaphoid K-wire fixation alone demonstrated a 58% decrease in the preoperative flexion-extension arc to 60 degrees. After distal scaphoid excision (with the radioscaphoid pins still in place) the flexion-extension arc increased to 122 degrees or 86% of the preoperative range of motion; most of the increase in motion occurred at the midcarpal joint. Distal scaphoid excision releases the midcarpal joint following radioscaphoid fixation and results in a significantly greater wrist motion. If the results of this cadaver study are extrapolated to clinical practice the addition of this step to the previously described procedures of radioscaphoid or radioscapholunate arthrodesis addresses their major limitation, restricted motion.

A MODIFIED TECHNIQUE OF FOUR-BONE FUSION FOR ADVANCED CARPAL COLLAPSE (SLAC/SNAC WRIST)

This study reports the outcome of 16 patients treated with a modified four-bone fusion for symptomatic stage II and III advanced carpal collapse. The technique is based on fusion of the capitate, lunate, hamate and triquetrum using an autogenous corticocancellous bone-graft fixed with screws. The void left behind after scaphoid excision was filled with an extensor carpi radialis longus anchovy. After an average follow up of 3 years; there were 13 excellent and three good outcomes. In every patient pain relief was achieved with preservation of joint motion and grip strength. All the patients were able to return to their previous activities and jobs. Radiographic evaluation showed bone fusion in all 16 patients with a slight decrease in carpal height but a well preserved radiolunate joint space. In conclusion, this technique provides immediate stable fixation and early mobilization and assures bone fusion.

Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis.

Two cohort populations of 19 patients from separate institutions performing exclusively either a scaphoid excision and 4-corner arthrodesis (lunate, capitate, hamate, and triquetrum) or proximal row carpectomy (PRC) for scapholunate advanced collapse arthritis were compared. There were no preoperative differences with respect to age, gender, dominance, stage of arthritis, or preoperative measures of pain and function. The length of the follow-up period averaged 28 months for the 4-corner arthrodesis group compared with 19 months for the PRC patients. At the follow-up examination wrist motion revealed no significant differences in the flexion-extension arc, averaging 81 degrees in the PRC patients and 80 degrees following 4-corner arthrodesis, which was 62% and 58%, respectively, of the opposite wrist. The 4-corner arthrodesis patients maintained greater radial deviation and total percent radial-ulnar deviation of the wrist. Grip strength averaged 71% for the PRC group compared with 79% for the 4-corner arthrodesis patients. Pain relief was similar using a variety of measures and patient satisfaction was equivalent. Function was similar except that the 4-corner arthrodesis patients scored significantly higher on the mental health component of the short form-36 health status survey. No differences were seen on the physical health component or an outcome scale specifically designed for the wrist. Both PRC and scaphoid excision and 4-corner arthrodesis are motion-preserving options for the treatment of scapholunate advanced collapse arthritis with minimal subjective or objective differences in short-term follow-up evaluations.

MIDCARPAL ARTHRODESIS WITH COMPLETE SCAPHOID EXCISION AND INTERPOSITION BONE GRAFT IN THE TREATMENT OF ADVANCED CARPAL COLLAPSE (SNAC/SLAC WRIST): OPERATIVE TECHNIQUE AND OUTCOME ASSESSMENT

Thirty-six patients with stage II or III SNAC and SLAC wrists were treated by midcarpal arthrodesis and complete scaphoid excision. When assessed at a mean follow-up of 25 months, pain was significantly reduced both under resting and stress conditions. The active range of motion was 54% of the contralateral wrist and grip strength was 65% of the non-operated hand. The mean DASH score was 28 points, the Mayo wrist score was 63 points, and the Krimmer wrist score was 68. Correlation of the wrist scores with the DASH values demonstrated a significant correlation. Our data demonstrate that midcarpal fusion with complete excision of the scaphoid is a reliable procedure for treating advanced carpal collapse.