Four-corner fusion of the wrist: clinical and radiographic outcome of 31 patients.

BACKGROUND: Four-corner fusion is a rational surgical option for the management of degenerative conditions of the wrist. Most related studies have compared four-corner fusion with scaphoid excision or proximal row carpectomy, with a variety of reported results. To enhance the literature, we performed this study to evaluate a series of patients with degenerative conditions of the wrist treated with four-corner fusion using 3 surgical techniques and to discuss the clinical and radiographic outcome of the patients. MATERIALS AND METHODS: We retrospectively studied 31 patients (24 men, 7 women; mean age, 43 years; 9 heavy manual laborers) who underwent four-corner fusion of their wrists for degenerative conditions from 2005 to 2015. Internal fixation was done using multiple Kirschner wires (14 patients), headless compressive screws (8 patients), or a circular plate (9 patients). Mean follow-up was 4 years (1-11 years). We evaluated the clinical outcome with the Patient-Rated Wrist Evaluation (PRWE) score and fusion with radiographs. RESULTS: All patients experienced improvement of their pain, function, range of motion and grip strength (p < 0.05). Twenty-three patients (74 %) reported no pain, and eight patients reported mild, occasional pain. Twenty-one patients (68 %) were able to do usual and specific activities. Mean wrist motion improved to 70 % and mean grip strength improved to 85 % of opposite wrist. Two heavy manual labor patients requested a job modification because of wrist impairment. Radiographs of the wrist showed fusion of all fused joints in 28 (90.3 %) patients and partial fusion in three patients (9.7 %). No patient with partial fusion required a reoperation for symptomatic nonunion until the period of this study. Three patients experienced complications (10 %). Two patients treated with a circular plate experienced complex regional pain syndrome and painful implant impingement; another patient treated with Kirschner wires and headless compression screws experienced radiolunate arthritis from impingement of the lunate screw to the radius. CONCLUSIONS: Four-corner fusion is a reliable limited wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation.

Distal Radioulnar Joint Replacement in the Scarred Wrist.

Background Radiocarpal or midcarpal arthritis can occur simultaneously with arthritis of the distal radioulnar joint (DRUJ), leading to functional impairment of the wrist. Treatment often involves wrist arthroplasty or arthrodesis, either with simultaneous or secondary procedures, addressing the DRUJ. Successful treatment of solitary DRUJ arthritis with DRUJ replacement has been reported. However, outcomes in patients with multiple prior wrist surgeries are lacking. Surgery in these wrists is challenging because surgical scarring and advanced bone deformities make implant positioning more difficult. Therefore, the aim of this study was to evaluate the outcomes in patients that underwent total wrist arthrodesis and DRUJ replacement after multiple prior wrist surgeries. Methods We prospectively enrolled patients that underwent total wrist arthrodesis and replacement of the DRUJ, either simultaneously or during separate procedures from 1999 to 2012. We included 14 patients with a median age of 43 years (interquartile range [IQR]: 35-47). As objective outcomes range of motion, weight-bearing ability, grip strength, was measured. For the subjective outcomes, we used an analogue pain score and the disabilities of the arm shoulder and hand (DASH) scores. Results At a median follow-up of 5.6 years (IQR: 3.2-7.1). The average DRUJ range of motion and weight lifting ability significantly improved. As for the subjective evaluations, postoperative pain scores improved significantly, as did the DASH scores. Four of the patients had a postoperative complication, including infection and heterotopic ossification, of which two required reoperations. Additionally, 5 patients developed pisotriquetral arthritis requiring, pisiform excision, triquetrum excision, or the combination of both. Conclusion Distal radioulnar joint replacement with a semiconstrained prosthesis was an effective method to restore the function of the wrist and forearm. As the surgical anatomy and soft tissue envelope were compromised in these patients, additional surgical exposure is necessary, adding to the complexity in these patients. No radiographic loosening Level of Evidence This is a therapeutic level IV study.

Flexor Tendon Ruptures After Distal Scaphoid Excision for Scaphotrapeziotrapezoid Osteoarthritis.

BACKGROUND: Distal scaphoid excision is one treatment option for osteoarthritis of the scaphotrapeziotrapezoid (STT) joint following failure of conservative measures. Potential complications of this procedure include injury to the carpal ligaments, cartilage, and radial artery. METHODS: A single case was identified by the senior author, and the medical record was reviewed for surgical notes, progress notes, and radiographs. RESULTS: A 68-year-old male sustained ruptures of the flexor digitorum superficialis (FDS) and flexor digitorum profundus to the index finger 3 years following a distal scaphoid excision for symptomatic STT osteoarthritis. He required a flexor tendon reconstruction using the remaining FDS tendon for graft incorporated with a Pulvertaft weave. His midcarpal pain continued after recovery of his index finger function, eventually requiring a 4-corner fusion of the wrist. CONCLUSIONS: Flexor tendon rupture is a previously unreported complication of distal scaphoid excision for STT arthritis.

Radial Column Excision and Four-Corner Fusion for the Treatment of Basal Thumb Arthritis and Scapholunate Advanced Collapse Wrist or Midcarpal Arthritis.

Background The combination of trapeziometacarpal arthritis and intercarpal pattern of degenerative wrist arthritis is uncommon. Purpose To report on the clinical and radiologic results of patients who have undergone radial column excision (scaphoidectomy and trapeziectomy) (RCE) and four-corner fusion (4CF). We describe the patterns of disease that present with basal thumb and midcarpal arthritis and treatment outcomes of a single-surgeon series. Patients and Methods A consecutive series of seven patients underwent RCE and 4CF over a 2-year period, for basal thumb osteoarthritis with concurrent degenerative midcarpal wrist arthritis. Six patients were available for review. All six patients were women with a mean age of 73 years (range: 67-78; SD 4.6). Mean follow-up time was 48.2 months (34-59 months). Radiographic and clinical outcomes were recorded for all patients, to include wrist range of motion, key pinch, grip strength, and patient-rated wrist evaluation (PRWE). Results There were no failures or revision procedures. The mean range of motion was flexion of 40 degrees (range: 30-40 degrees), extension of 30 degrees (range: 20-42 degrees), radial deviation of 18 degrees (range: 10-30 degrees), and ulnar deviation of 15 degrees (range: 0-25 degrees). The mean key pinch was 4.2 kg (range: 0.5-10, SD ± 3.5) and mean grip strength was 9.4 kg (range: 0-19, SD ± 8.9). The PRWE results in four patients were within normal values. Conclusion RCE with 4CF resulted in acceptable clinical outcomes in four of six patients treated, with no failures at a mean follow-up of 48.2 months. Level of Evidence Level IV, therapeutic study.