Four-corner arthrodesis using the Quad memory staple

Clinical efficacy of Ni-Ti memory alloy four-corner arthrodesis concentrator in the treatment of scaphoid nonunion advanced collapse: a follow-up of over 10 years

PURPOSE

Exploring the therapeutic effects of Ni-Ti shape memory alloy four-corner arthrodesis concentrator (NT-FCAC) in treating scaphoid nonunion advanced collapse (SNAC) and providing a decade-long follow-up report.

MATERIALS AND METHODS

Twenty-six patients with SNAC underwent scaphoidectomy, along with four-corner arthrodesis fusion involving the capitate, lunate, triquetrum, and hamate, using NT-MFCAC. Grip strength was measured using a Jamar dynamometer, while wrist joint mobility was assessed using a goniometer. Preoperative and postoperative assessments were conducted using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire to monitor limb functionality restoration. Pain levels at the wrist joint were evaluated using the visual analog scale (VAS). Postoperative wrist bone fusion status was assessed through anteroposterior and lateral radiographs of the wrist joint.

RESULTS

After a 3-month postoperative period, all 26 patients exhibited osseous union at the wrist joint. Over a follow-up spanning 10-15 years, no severe postoperative complications were observed in any patient. Grip strength in the affected side of all patients recovered to 81.96% compared to the healthy side, while wrist joint mobility in the affected side reached over 60% of the healthy side's functionality. VAS scores decreased significantly from 5.85 ± 0.73 preoperatively to 0.19 ± 0.40 at the final follow-up; Quick DASH scores reduced from 69.88 ± 5.12 preoperatively to 6.30 ± 1.25 at final follow-up. Statistically significant differences were noted in VAS and Quick DASH scores for all patients (p < 0.05). However, beyond 60 months postoperatively, subsequent follow-ups did not yield statistically significant differences in VAS and Quick DASH scores for all patients (p > 0.05).

CONCLUSIONS

Utilizing NT-FCAC for SNAC treated with four-corner arthrodesis fusion results in a high rate of wrist bone fusion, preserving a significant portion of wrist joint function and exhibiting favorable long-term outcomes. This approach is suitable for treating patients with SNAC requiring four-corner arthrodesis fusion.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 Arthrodesis With Differing Methods of Osteosynthesis: A Systematic Review

PURPOSE

The purpose of this study was to compare the union rates and clinical outcomes of 4-corner arthrodesis with different methods of osteosynthesis.

METHODS

A systematic review of studies published in Ovid, Medline, Embase, and PubMed was conducted. Primary studies that reported clinical and radiographic results following 4-corner arthrodesis for scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), or other types of wrist arthritis in human subjects were eligible. Biomechanical or cadaveric studies, case reports, studies that did not define and report a radiographic union rate, reviews and technical articles, studies that did not report the method of osteosynthesis, and studies that used multiple methods of osteosynthesis, but did not separate results for individual methods of osteosynthesis were excluded. Radiographic union rate, range of motion, and grip strength were analyzed.

RESULTS

We identified and reviewed 291 full texts, selecting 57 studies for coding. The radiographic union rate did not significantly differ between studies using K-wire, screw, staple, nonlocking plate, metal locking plate, and radiolucent locking plate osteosynthesis. Fixation method significantly affected flexion, but pairwise comparison did not reveal any significant differences between individual groups. Grip strength as a percentage of the contralateral limb was significantly lower in studies with metal locking plate fixation compared to K-wire fixation (63.2% vs 82.6%). There were no other statistically significant differences between groups with respect to flexion, extension, radial deviation, ulnar deviation, and grip strength.

CONCLUSIONS

All methods of osteosynthesis result in similar union rates, with no significant differences between methods. While there are some significant differences in range of motion and grip strength, these differences are unlikely to be clinically relevant.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Four-corner arthrodesis using the 4Fusion® quadripodal shape memory staple: a long-term review

We investigated the reliability of the 4Fusion® quadripodal memory staple in a consecutive series of 59 four-corner arthrodeses in a single centre. Forty-one patients (46 wrists) had a radiological and clinical assessment at a mean follow-up of 7.4 years. Thirteen patients (13 wrists) were lost to follow-up. Bone union was achieved in all but one patient. Seven patients were reoperated, six for device removal and one for nonunion. Most patients were satisfied, had a functional range of wrist mobility, good strength and were free of pain, comparable with the best previously reported series.Level of evidence: IV.

Four-corner fusion method using a bioabsorbable plate for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists: a case series study

Background

Scaphoid excision and four-corner arthrodesis is an acceptable salvage procedure for the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists, since first popularized in the 1980s. We investigated the potential application of novel bioabsorbable plates and screws made of un-sintered hydroxyapatite/poly-L-lactide composite for the treatment of metacarpal fractures. We used this material for the fixation of four-corner fusions for SLAC or SNAC wrists commencing from April 2009. The purpose of this study was to clarify the controversy in the literature regarding the use of these plates.

Methods

The surgical procedures and clinical outcomes of four-corner fusions using a bioabsorbable (poly-L-lactic acid and hydroxyapatite) plate were reported. Ten patients (mean age, 59.2 years) with SLAC or SNAC wrists underwent fusions between April 2009 and June 2016. The primary diseases were scapholunate ligament injury, Preiser disease, and scaphoid pseudarthrosis. The mean postoperative follow-up period was 45.9 months (range, 12–86).

Results

In all patients, bone union was achieved without dislocation or pain. The mean wrist flexion and extension arc improved from 78.5 degrees before surgery to 90.5 degrees after surgery. Mean grip strength improved from 51 to 69% after surgery, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score improved from 53.5 to 14.3. No complications such as infection, avascular swelling, or tendon adhesion were observed. This implant requires no removal of internal fixation devices, produces stable outcomes, and is an effective fusion technique.

Conclusions

We summarized the outcomes of four-corner arthrodesis using bioabsorbable plates. Satisfactory clinical results were shown, with no obvious complications. This novel plate also serves as a good alternative for patients who are allergic to metals. Furthermore, bioabsorbable plates are advantageous as they do not require removal.

Cerclage Fusion Technique for 4-Corner Arthrodesis

Four-corner arthrodesis is commonly performed for symptomatic scapholunate advanced collapse and scaphoid nonunion advanced collapse. Potential complications associated with current techniques include nonunion, hardware issues, and dorsal impingement. A method for achieving 4-corner arthrodesis with strong internal fixation and effective compression while avoiding dorsal and cartilage-bearing surfaces can maximize the benefits of the fusion while minimizing the aforementioned complications. We present a cerclage fusion technique for achieving 4-corner arthrodesis. Proposed benefits of this technique include ease of fixation placement in the coronal plane, inclusion of a large surface area for compression, avoidance of dorsal and cartilage-bearing surfaces, and the ability to adjust sagittal alignment in the midcarpal joint.

Four-Corner Arthrodesis: Description of Surgical Technique Using Headless Retrograde Crossed Screws

BACKGROUND

Four-corner fusion has been shown to be a reliable option of treatment of wrist arthritis, but there is no consensus about which implant and surgical procedure should be used in the arthrodesis. The present study aimed to describe a surgical technique using 2 crossed screws as implants, inserted in a retrograde manner, and to demonstrate preliminary results of the use of the technique.

METHODS

A retrospective study was conducted using medical records and imaging tests (radiographs and computed tomography) of all 15 patients who underwent a standardized 4-corner fusion technique, between December 2011 and July 2015, in the Department of Hand Surgery of Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, Brazil. We collected data on the following variables: fusion rate, time to fusion, and percentage of patients who had any complications or needed another surgical procedure on the same wrist.

RESULTS

All but one patient achieved fusion of arthrodesis. The average time to union was 5.54 months (SD = 3.84). Only the patient who developed nonunion of the 4-corner fusion required another surgery on the same wrist.

CONCLUSIONS

The procedure described in this study demonstrated a low complication rate and high fusion rate, and can therefore be considered a reliable surgical technique for 4-corner fusion.

Update on the operative treatment of scapholunate instability for radiologists. II. Salvage procedures, total wrist arthrodesis, and total wrist arthroplasty

Scapholunate (SL) instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management, and postoperative follow-up of SL instability. In the final stage of SL instability, known as scapholunate advanced collapse, progressive degenerative changes occur at the carpal level. The goals of this article are to review the surgical options available for addressing the different stages of scapholunate advanced collapse, along with an emphasis on normal postoperative imaging and complications associated with each surgical option.

Four corner fusion using a multidirectional angular stable locking plate

AIM

To review the results of our experience with the Medartis Aptus plating system for four corner arthrodesis of the wrist, which uses a combination of compression screws and variable angle locking screws.

METHODS

We reviewed the results of 17 procedures in 16 patients that underwent scaphoid excision and four corner fusion using the Medartis Aptus system between May 2010 and June 2014. The primary outcome measure was radiographic and clinical union.

RESULTS

The mean clinical follow up time was 20.6 mo. The mean union time was 6 mo. Two non-unions required revision procedures. The mean disabilities of the arm, shoulder and hand score taken after union was 36. The mean final grip strength was 27 kg. The mean final range of movement was 30° flexion and 31° of extension. All patients had a restored scapholunate angle on postoperative radiographs. There were no incidences of dorsal impingement.

CONCLUSION

Overall our experience with the Aptus plating system shows comparable results to other methods of fixation for four corner fusion, in the short to medium term.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions

PURPOSE

To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.

METHODS

A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.

RESULTS

Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.

CONCLUSIONS

Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

The memory plate for four-corner fusion of scaphoid non-union advanced collapse

The aim of this study was to evaluate the clinical outcomes of the memory plates for four-corner fusion (FCF) of scaphoid non-union advanced collapse (SNAC). From 2005-2010, 11 cases of SNAC received FCF with the memory plate designed by the authors. At an average follow-up of 21 months, there were no non-unions and postoperative infections. One patient complained of dorsal impingement. The pain relief rate was 100% and the average grip strength increased from 11.3% preoperatively to 56.3% postoperatively of the contralateral side. The primary results of FCF with memory plates are promising. By its compressive property, the memory plate facilitates the arthrodesis with a lower complication rate.

Four-corner arthrodesis concentrator of nickel-titanium memory alloy for carpal collapse: a report on 18 cases

PURPOSE

To evaluate the treatment of carpal collapse using a four-corner arthrodesis concentrator of nickel-titanium memory alloy.

METHODS

From August 2006 to August 2010, 18 patients with carpal collapse had scaphoid excision and four-corner (capitate, lunate, triquetrum, and hamate) arthrodesis using a nickel-titanium memory alloy four-corner arthrodesis concentrator. The mean follow-up time was 30 months (range, 12-48). Various wrist parameters, including grip strength, wrist motion, and degree of pain were recorded and compared before and after surgery.

RESULTS

The average fusion time was 2.3 months (range, 2-4). Neither nonunion nor wound infection was found in any of the patients. At one year follow-up, the grip strength had reached 80% of that of the healthy side, whereas the range of motion was greater than 50% of the contralateral side. After the surgery, the mean pain scores were improved.

CONCLUSIONS

Four-corner arthrodesis using a nickel-titanium memory alloy four-corner arthrodesis concentrator effectively treated carpal collapse and preserved most wrist function.

Four-corner arthrodesis concentrator of Ni-Ti memory alloy for carpal collapse

OBJECTIVE

To evaluate the treatment outcomes of a four-corner arthrodesis concentrator of Ni-Ti memory alloy for carpal collapse.

METHODS

From August 2006 to November 2009, 13 patients with carpal collapse underwent scaphoid excision and four-corner (capitate, lunate, triquetrum and hamate) arthrodesis using a four-corner arthrodesis concentrator of Ni-Ti memory alloy. The mean follow-up time was 26.5 months (range, 7-38 months). Various wrist parameters, including the grip strength, range of wrist movements and degree of pain (visual analogue scales) were recorded and compared before and after surgery.

RESULTS

The average fusion time was 2.3 months (range, 2-4 months). Neither non-union nor wound infection was found in any of the patients. By the sixth month postoperatively, the grip strength had reached an average of 32.49 ± 6.21 kg with a range of 22.3-39.7 kg, this being 80.8% of that found on the healthy side. The range of motion reached over 53.0% of that of the healthy side. Preoperatively and at 6 months postoperatively, the mean pain scores were (4.46 ± 1.27) and 1.31 ± 0.95, respectively, when resting (P < 0.05), and 7.00 ± 1.41 and 2.62 ± 1.26, respectively, when weight-bearing (P < 0.05). The mean value of the Krimmer wrist score was 79.2 (range, 64-84). The rate of excellent and fine results was 84.6% (11/13), being excellent in three cases, good in eight and fair in two.

CONCLUSION

Four-corner arthrodesis using a four-corner arthrodesis concentrator of Ni-Ti memory alloy is an effective method for treating carpal collapse and preserving most wrist function.

[Midcarpal fusion using break-away compression screw]

Indication of midcarpal fusion is SNAC or SLAC wrist grade 3. The main complication of circular plate (most common technique) is non-union. In this context, the purpose of our work was to propose the use of break-away compression screws to decrease the rate of non-union. Our series included ten patients. The fusion was fixed using two break-away compression screws (2mm diameter). No bone graft was used. As assessment, subjective (pain, Quick-DASH) and objective (strength, mobility) criteria were reviewed at follow-up. All the criteria were significantly improved after operation except mobility. Among the complications, we noticed one delayed bone-healing with a good outcome and a radiological consolidation. Midcarpal fusion by dorsal approach using break-away compression screws appears to us a technique of interest, not requiring a bone graft, with good cost effectiveness.

Clinical outcome of rearthrodesis in cases of non-union following four-corner fusion

PURPOSE

Four-corner fusion is a proven treatment option for degenerative arthritis of the wrist (SLAC/SNAC); however, in some cases, non-union occurs. The purpose of this study was to evaluate the clinical outcome of rearthrodesis in cases of non-union following four-corner fusion. Furthermore, the goal was to identify the cause of non-union and the location of pseudarthrosis within the fusion.

METHODS

Seven patients (5 males, 2 females) who experienced pseudarthrosis following a four-corner fusion procedure and subsequently elected a rearthrodesis procedure were clinically and radiologically examined. The average age was 58 years (range 48-71 years). Average follow-up after rearthrodesis was 27 months (range 4-60 months). All patients experienced persistent wrist pain and non-union was diagnosed via radiography or CT scan. Range of motion, grip strength, the Modified Mayo Wrist score, and the DASH score were evaluated. The level of pain was determined by using a visual analogue scale. Patients were also asked whether they were satisfied with the procedure and if they would elect it again.

RESULTS

In all patients, the rearthrodesis procedure led to proper bone consolidation, which was verified by radiological examination. Due to persistent wrist pain, one patient required additional procedures (denervation, wrist arthroscopy). In four cases, the location of pseudarthrosis occurred between the triquetrum and hamate. In three cases, the location of pseudoarthrosis was between the capitate and lunate and, additionally, between the triquetrum and hamate. The average DASH score value was 38 and the average Modified Mayo Wrist score was 66. Grip strength was reduced to 85 percent of the contralateral, unaffected side. Three patients indicated that they are dissatisfied with the results and would not elect the procedure again.

CONCLUSIONS

The most frequent location of pseudarthrosis was between the triquetrum and the hamate, which was caused by incomplete cartilage debridement. Proper bone consolidation could be attained by means of rearthrodesis in cases of non-union following four-corner fusion. However, clinical results remain only moderate.

Treatment of post-traumatic degenerative changes of the radio-carpal and distal radio-ulnar joints by combining radius, scaphoid, and lunate (RSL) fusion with ulnar head replacement

Distal radial fractures are a common type of fracture. In the case of intra-articular fractures, they often result in post-traumatic arthrosis. The objective of this study is to describe a novel alternative to the established salvage techniques for the treatment of post-traumatic arthrosis of the radio-carpal and distal radio-ulnar joints (DRUJ). Six patients with radio-carpal and DRUJ arthrosis were treated with a combined radius, scaphoid, and lunate (RSL) arthrodesis and as a Herbert ulnar head prosthesis. Follow-up consisted of both radiographic and functional assessments. Functional measurements were noted both pre- and postoperatively. No non-union or pseudoarthrosis was seen; neither did any of the ulnar head prostheses show loosening. Clinical examination showed an improvement in strength, pain, and range of movement, as well as a decrease in disability. Combining RSL arthrodesis with a Herbert ulnar head prosthesis, which deals with pain while retaining partial wrist movement, can be an alternative to established salvage procedures.