Four Corner Fusion is a surgical procedure used to treat carpal instability and arthritis. It involves fusing together the four small carpal bones (scaphoid, lunate, triquetrum, and pisiform) through bone preparation, temporary fixation with K-wires, and permanent fixation with a plate and screws. The procedure aims to reduce pain, maintain range of motion and grip strength, and allow activities of daily living. Contraindications include a stiff wrist, radiolunate arthritis, or erosive arthropathy, which may be better treated with proximal row carpectomy.
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
7. Approach
• Radially based capsular flap
• allows a wide exposure of the
radiocarpal as well as the
midcarpal joints
• dorsal capsule ligament 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,
4 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
• 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.
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.
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 fourcorner 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