Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time.

PURPOSE: Scaphoidectomy and 4-corner arthrodesis (4CA) is an effective procedure for treating several degenerative conditions of the wrist. Recently, the arthroscopic approach to this operation was described. Although it is conceptually appealing, certain aspects make its application difficult. We present our technique for dry arthroscopic scaphoidectomy and 4CA, which reduces the operative time to less than 2 hours. METHODS: Four consecutive patients underwent scaphoidectomy and 4CA. In each case, we performed the operation with a dry arthroscopic technique using cannulated screws for rigid fixation. We performed bone grafting from the distal radius in 2 patients and from the scaphoid itself in the other two. The relevant operative details are the use of a scapholunate portal, the resection of the scaphoid with a pituitary rongeur, and the placement of bone graft in a dry arthroscopic environment. Range of motion exercises are started 2 to 3 weeks after the operation. RESULTS: The first operation took 4 hours. The last 2 were completed in 1 hour 45 minutes and 1 hour 55 minutes, respectively. No complications occurred. No operations were converted to an open procedure. CONCLUSIONS: Although the operation has a steep learning curve, it is conceptually appealing. It is too early to prove that the arthroscopic procedure has better results than the open 4CA; nevertheless, in our opinion it represents the future of wrist surgery.

Clinical and radiological outcomes of 40 cases of SLAC and SNAC wrist treated by four-corner arthrodesis with locking plate.

The treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist varies. No clear consensus exists on surgical indications. Scaphoid excision and four-corner arthrodesis with locking plate is one of preferred treatments for these lesions. The purpose of this study was to assess the clinical and radiological outcomes of locking plates for treating SNAC and SLAC wrist after a mean follow-up of 5 years and to compare these outcomes with the results reported in the literature. A retrospective study was conducted in two hospitals, involving 40 patients who underwent scaphoid excision and four-corner arthrodesis with locking plate between January 2006 and September 2016. All patients were reviewed as outpatients with clinical and radiographic measurements. At the last follow-up, the mean pain level on visual analog scale (VAS) was 2.5/10 [0-7] (SD: 1.7). Patients had a mean flexion of 46% and a mean extension of 46% compared to the contralateral side. An 18% gain was observed in grip strength. The mean postoperative QuickDASH score was 30 [0-57] (SD: 15.3). Seventy percent of patients were satisfied with the operation. Complete (all four joint interfaces) joint space fusion was achieved in 55% of patients. Only one patient (2.5%) had no joint fusion. The joint between the lunate and the capitate was fused in 38 patients (95%). Nine patients suffered complications; eight of them required surgical revision (20%). Four-corner arthrodesis with locking plate is a valuable surgical technique for treating SLAC and SNAC wrist because it preserve satisfactory range of motion and grip strength (64% compared to the non-operated side), maintains the height of the carpus and prevents the premature appearance of radiocarpal osteoarthritis, as long as the technical challenges of this procedure are mastered.

The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap.

Background: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion. Methods: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap. Results: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united. Conclusions: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.

Salvage of a post-traumatic arthritic wrist using the scaphoid as an osteochondral graft.

The authors describe a case of post-traumatic wrist arthritis with an osteochondral defect in the scaphoid fossa of the radius. The patient was treated with proximal row carpectomy, radial styloidectomy and reconstruction of the defect using the proximal half of the scaphoid as an autologous osteochondral graft. Pain relief was achieved while wrist motion and strength were improved. The carpal bones are a source of osteochondral grafts and can be used to expand the indications of motion-preserving wrist salvage procedures.

New surgical approach to advanced Kienböck disease: lunate replacement with pedicled vascularized scaphoid graft and radioscaphoidal partial arthrodesis.

Reconstructive procedures such as proximal row carpectomy or partial arthrodesis have been commonly proposed for advanced Kienböck disease (Lichtmann IIIB to IV). The purpose of this study is to evaluate an alternative surgical technique to advanced Kienböck disease: lunate excision and replacement with pedicled vascularized scaphoid graft and partial radioscaphoidal arthrodesis. The main advantage of the proposed intervention is to preserve mobility while not jeopardizing prime clinical outcomes such as pain. By replacing the devitalized lunate we aim at maintaining midcarpal range of motion, and preventing disease progression with carpal collapse and osteoarthritis of the wrist. Between 2002 and 2008, 13 patients of mean age 41 years (range, 25 to 57 y) were operated using this technique. The surgical act included 3 key steps. First, we excised the lunate, then, filled the generated gap with the rotated scaphoid, using it as a pedicled vascularized autograft. Finally, we performed a partial radioscaphoid arthrodesis. At the final follow-up, none of the intervened patients had pain at rest, and 6 patients could perform nonrestricted daily activities. The average postoperative range of motion in flexion/extension was 70 degrees (range, 55 to 90 degrees), 44% (range, 38% to 54%) of what could be achieved by the contralateral arm, and only 16% (range, 14% to 19%) or 25 degrees (range, 18 to 30 degrees) less than the preoperative range of motion of the same wrist. Grip strength improved by more than 30% (range, 24% to 36%). At an average follow-up of 4 years after surgery, 12 of 13 patients had no radiographic evidence of osteoarthritis or collapse of subchondral bone at the level of the new scaphocapitate joint. At follow-up evaluation, the average DASH score was 14 points (range, 6 to 20). The patients experienced a significant improvement in their functional abilities, achieving good results compared with the conventional techniques. The absence of carpal collapse and good functional results are encouraging.

Four corner arthrodesis limited to the centre using a scaphoid one piece graft and a dorsal circular plate.

We present 20 patients, who had a four corner arthrodesis, from July 2006 to March 2008, using a dorsal circular plate, to treat scaphoid nonunion and scapholunate dissociation with advanced collapse (SNAC, SLAC). The surgical technique was a fusion restricted to the central area filled with one piece of cancellous bone graft taken from the excised scaphoid. Wrist motion, grip strength, and Disabilities of Arm Shoulder and Hand (DASH) score improved after surgery at a mean follow-up of 20.2 months. Fusion occurred in 19/20 patients. Two patients (10%) had persistent pain. The rest had a good clinical result. We found that four-corner fusion using a dorsal circular plate using the specific technical modifications was successful.

Complications and outcome of four-corner arthrodesis: circular plate fixation versus traditional techniques.

PURPOSE: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Injerto óseo pediculado de pronador cuadrado en el tratamiento de la seudoartrosis de escafoides / Pronator quadratus pedicled bone graft in the treatment of scaphoid pseudoarthrosis

La pseudoartrosis del escafoides es un reto para el cirujano de mano. Dentro de los diferentes métodos de tratamiento quirúrgico de la no unión del escafoides se resalta la fijación interna acompañada de injertos óseos autólogos de corticoesponjosa y otras técnicas de injertos óseos vascularizados. El propósito de esta investigación es mostrar nuestra experiencia con el injerto óseo pediculado al pronador cuadrado. Se reportan 17 pacientes con pseudoartrosis del escafoides carpiano sin cambios osteoartríticos a nivel de la articulación radiocarpiana, los cuales fueron tratados mediante injerto óseo pediculado al pronador cuadrado y fijación interna. En todos los pacientes operados se obtuvo consolidación de la no unión. La técnica propuesta en nuestro trabajo también permitió realizar una corrección de la deformidad angular del escafoides.

Scaphoid pseudoarthrosis is a challenge for the surgeon specialized in hands. Among the different surgical methods to treat non-union of the scaphoid, one may underline the internal fixation accompanied by autologue bone grafts of corticospongious and other vascularized bone graft techniques. The objective of this research study was to show our own experience in pronator quadratus pedicled bone graft. Seventeen cases with carpal scaphoid pseudoarthrosis, but without osteoarthritic changes at radiocarpal joint, were reported; they were all treated with pronator quadratus pedicled bone graft and internal fixator. The non-union consolidation was seen in all the patients. The suggested technique also allowed making the angle deformity corrections of the scaphoid.

La pseudarthrose du scaphoïde est un défi pour le chirurgien orthopédique. Parmi les différentes méthodes de traitement chirurgical d'une fausse articulation du scaphoïde, on met l'accent sur la fixation interne accompagnée de greffes osseuses autologues de tissu corticospongieux et d'autres techniques de greffes osseuses vascularisées. Le but de cette étude est de montrer notre expérience avec la greffe osseuse pédiculée au niveau du muscle carré pronateur. Dix-sept patients atteints de pseudarthrose du scaphoïde carpien sans changements ostéo-arthritiques au niveau de l'articulation radio-carpienne ont été traités par greffe osseuse pédiculée du carré pronateur et par fixation interne. La consolidation de la fausse articulation est obtenue chez tous les patients opérés. La technique proposée dans notre travail a aussi permis de réaliser une correction de la difformité angulaire du scaphoïde.