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Four-corner carpal ‘closing’ fusion technique increases stability and fusion rate
Pain scores and function significantly improved for 10 years.
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Incorporating a “closing” fusion technique to appose the surfaces during a four-bone carpal fusion procedure increases stability and improves fusion rate, according to a 10-year follow-up study.
“The results at 2 years were maintained out to 10 years,” said study author Gregory I. Bain, MD, of Australia. “Furthermore, the results at 10 years for the four corner (four-bone carpal) fusion are superior to published long-term results for proximal row carpectomy.”
Among the 31 patients followed to 10 years, there was no significant change in subjective or objective scores — pain, satisfaction, range of motion, union rates — from 1 year to 10 years, according to the investigation.
Early in his medical training, Bain was taught that a limited wrist fusion was a staged full-wrist fusion. “But we wanted to assess whether we could achieve good long-term results with a four corner fusion, which would disprove this point,” Bain told Orthopedics Today. “Although many papers in the literature report good medium-term results with a four-corner fusion, there is no other study in the literature with a minimum 10-year follow-up.”
Outcomes were presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans. Patients in the series were prospectively identified and independently followed at 1-, 2- and 10-years postsurgery.
“Fusion of the midcarpal joint and scaphoid excision is a salvage option for patients with advanced carpal collapse,” said Bain, who performed all surgeries, between 1994 and 1999. “It is important to ensure that the midcarpal joint is stable, thus we prefer a ‘closing’ fusion technique to provide better stability and likely a better union rate.”
Pain score improvement
Bain, who has performed a total of about 100 “closing” fusion procedures, said it is important to add local bone graft and to stabilize the joint. He prefers to use staples to provide stability.
The median pain score prior to surgery was 6, on a 0-to-10 scale, which improved to 0 at 1 year, and remained at 0 at 2 and 10 years. There was also a statistically significant improvement in functional scores at 1 year, which again was maintained at 2 years and 10 years.
However, there was a statistically significant reduction in the range of motion at 1 year, “which was expected, due to the limited refusion,” Bain said.
Two patients in the series required a total wrist fusion, three required bone grafting for nonunion and two had ulnar-sided wrist pain that warranted further surgery.
Three corner fusion
Since completing the prospective cohort, Bain and colleagues 2006, he has switched to memory staples for compression of the fusion site and a three-corner fusion (excising the triquetrum instead of leaving the bone intact) for a better range of motion.
“We have patients with three-corner fusions who are 10 years out, but not enough to present our results,” he said. “I believe three-corner fusion will eventually replace four-corner fusion because there should be a better range of motion. Our early results demonstrate better functional scores and quicker return to work.” Since using the memory staples, patients require only 1 week of a plaster splint vs. 8 weeks with the older staples. — by Bob Kronemyer
References:
- Bain, GI. Outcome of four bone carpal fusion procedure with a minimum 10 years follow up. Paper 083. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13. New Orleans.
- Bain GI, Sood A, Ashwood A, et al. Effects of scaphoid and triquetrum excision on limited arthrodesis of the wrist: A laboratory study. J Hand Surg Eur Vol. 2009;34E:614-617.
- Van Riet RP, Bain GI. Three corner wrist fusion using memory staples. Tech Hand Up Extrem Surg. 2006;10:259-264.
- Gregory I. Bain, MD, associate professor, Department of Orthopaedic Surgery and Trauma, University of Adelaide, can be reached at 196 Melbourne St., North Adelaide, SA 5006 Australia; 618-8361-8399; e-mail: greg@gregbain.com.au.
