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. 2021 Feb 24;24:102–110. doi: 10.1016/j.jor.2021.02.032

The effect of four-corner fusion and proximal row carpectomy on uniplanar and multiplanar wrist motion: A biomechanical study

Stacy Fan a, Clare Padmore b, Assaf Kadar c,d, Spencer Chambers a, G Daniel G Langohr b, Nina Suh a,b,c,∗
PMCID: PMC7930352  PMID: 33679035

Abstract

Purpose

To compare changes in wrist kinematics after scaphoidectomy and four-corner fusion (4CF), and proximal row carpectomy (PRC).

Methods

Six cadaveric specimens underwent flexion-extension, radial-ulnar deviation and circumduction in an active motion wrist simulator. Native state, “anatomic 4CF”, “radial 4CF”, and PRC were compared.

Results

Radial 4CF reduced wrist extension, while PRC reduced radial deviation. Fusion groups had similar motion profiles. 44%, 41%, and 32% of native circumduction was maintained in PRC, anatomic, and radial 4CF.

Conclusions

Both fusion positions resulted in comparable motion outcomes. Anatomic 4CF was restricted in wrist extension compared to PRC but provided favourable radial deviation.

Keywords: Four corner fusion, Proximal row carpectomy, Partial wrist arthrodesis, Circumduction

1. Introduction

The mainstay treatment of advanced wrist arthritis, caused by scaphoid non-union advanced collapse (SNAC) or scapholunate advanced collapse (SLAC), are salvage procedures including scaphoidectomy with four corner fusion (4CF) and proximal row carpectomy (PRC). These procedures provide reliable pain relief while preserving some degree of wrist motion.1 There is currently no consensus as to which of the two operations is clinically superior. Few studies have investigated biomechanical outcomes following these procedures to account for clinical findings. Those that have been conducted typically report uniplanar motion,2, 3, 4, 5 while a single study6 has reported multiplanar motion which is thought to be a more accurate indicator of wrist function when translating in vitro to in vivo results.7

Another topic of debate is the position of capitolunate fusion in the coronal plane in 4CF, of which two positions of fusion have been described. When looking at radiographic images of a native wrist, it can be seen that there are variable degrees of “capitate overhang”, whereby the radial border of the capitate sits more radially than that of the lunate.8 This anatomic relationship between the capitate and lunate corresponds to a fusion position in 4CF referred to as “anatomic 4CF”. Many groups strongly recommend performing anatomic 4CF to maintain this overhang, with the belief that doing so retains more physiologic anatomy of the carpus.8, 9, 10, 11 Four corner fusion can been also be performed with alignment of the radial capitolunate border in the coronal plane to improve osseous contact between the capitate and lunate, although this alters the relationship between the hamate and triquetrum.12, 13, 14, 15, 16, 17, 18, 19, 20 Additionally, arthrodesis in this radial-aligned position may be required in advanced SLAC with significant capitate proximal migration, as the capitate must be reduced onto the distal row to restore its native position. Recently, a biomechanical study questioned the practice of radial capitolunate alignment in 4CF, reporting that this fusion pattern results in a radially-deviated resting wrist position, altering normal wrist kinematics.4

The purpose of this in vitro biomechanical study was to quantify changes in wrist kinematics during wrist flexion-extension, radial-ulnar deviation, and circumduction for “anatomic 4CF”, “radial 4CF” and PRC conditions. We hypothesized that uniplanar and multiplanar wrist motion would be greater after PRC as compared to 4CF, and that biomechanics would be significantly altered after 4CF performed in the radial-aligned position compared to anatomic 4CF.

2. Material and methods

2.1. Specimen preparation

Six fresh-frozen cadaveric upper limbs (mean age: 57.8 years [range: 39–71]; 6 males; 5 right, 1 left) amputated at the mid-humeral level were used in the study. Computed tomography (CT) scans of each specimen were obtained prior to inclusion in the study to confirm lack of osseous or soft tissue pathology. Specimens were thawed for 18 h prior to testing. Passive range of motion (ROM) was assessed under fluoroscopy to confirm full wrist ROM.

A dorsal midline approach was used. Full-thickness subcutaneous skin flaps were raised, and the extensor retinaculum was incised along the third extensor compartment. The septae between the third and fourth, and fourth and fifth compartments were released. A Berger ligament-sparing dorsal approach to the wrist was used to access the carpus.21 Under fluoroscopic guidance, two 2.7-mm tracking bone screws were inserted into the dorsal lip of the lunate (just ulnar to the scapholunate ligament) in a retrograde fashion at 60° from the long axis of the lunate, to which optical tracking markers (Optotrak Certus, Northern Digital, Waterloo, ON, Canada) were mounted. Each specimen was subjected to complete wrist ROM under fluoroscopic guidance to ensure lack of impingement. Optical trackers were affixed to the third metacarpal, radius and ulna using 3.5-mm cortical bone screws.

Five 0.062” Kirschner wires (K-wires) were inserted in a retrograde fashion under fluoroscopic guidance to fuse the capitolunate joint,2 triquetrohamate joint,2 and lunotriquetral joint.1 Midcarpal fusion was confirmed clinically and radiographically (Fig. 1). A mark was made on each K-wire at the level of the skin to indicate the distance each K-wire had to be advanced for successful fusion. K-wires were then partially withdrawn to reverse the midcarpal joint fusion but left in situ to maintain trajectory.

Fig. 1.

Fig. 1

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Four corner fusion was performed with five retrograde K-wires. capitolunate joint,2 triquetrohamate joint,2 and lunotriquetral joint.1 Biplanar fluoroscopic images were obtained to confirm the position of the wires and the two 2.7 mm lunate tracking screws.

Flexor (flexor carpi radialis, flexor carpi ulnaris) and extensor tendons (extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris) were tagged, along with pronator teres and biceps brachii. Suture lines were passed through subcutaneous tunnels in the direction of muscle origin-insertion and epicondyle blocks were secured to maintain physiologic line of pull of tendons. Specimens were mounted on the active motion simulator22 with the elbow at 90° flexion.

2.2. Testing protocol

Baseline measurements for simulated active flexion (to 50°), extension (to 50°), radial (to 15°) and ulnar deviation (to 20°), and circumduction were taken in the native state without any interventions for all specimens.22 Circumduction motion was achieved by sequentially activating wrist flexion and ulnar deviation (FCU), followed by flexion and radial deviation (FCR), wrist extension and radial deviation (ECRL/ECRB), and extension and ulnar deviation (ECU), all while maintaining a minimum baseline load of 8.9 N on other tendons. Circumduction motion was restricted to 40° flexion and extension, and 20° radial and ulnar deviation. Each motion arc was repeated 3 times with the final simulation being recorded. Motion trials were performed at 5° per second following each stage of the protocol.

Next, scaphoidectomy was performed under direct visualization utilizing the previous dorsal incision, followed by 4CF in the anatomic position (“anatomic 4CF”), then with the radial border of the capitate and lunate aligned (“radial 4CF”), and finally PRC. The dorsal wrist capsule, extensor retinaculum and skin were repaired after each intervention.

2.3. Four corner fusion

During testing on the wrist simulator, K-wires were advanced to the level of the marker and midcarpal fusion was confirmed. This was repeated in anatomic 4CF (where fusion was performed with maintenance of the native capitate and lunate relationship, i.e. no reduction was performed) and radial-aligned 4CF (with fusion performed after ulnar translation of the distal row relative to the proximal row, aligning the radial border of the capitate and lunate in the coronal plane) (Fig. 2). The authors visually confirmed the lack of dorsal intercalated segment instability (DISI) or volar intercalated segment instability (VISI) deformity by assessing the amount of dorsal lunate relative to the dorsal rim of the radius, and by restoring the lunate trackers to their original position relative to the capitate. Successful fusion was verified by observing the capitate, lunate, hamate and triquetrum move as a single unit.

Fig. 2.

Fig. 2

Fig. 2

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Clinical visualization of A) Anatomic 4CF and B) Radial-aligned 4CF.

2.4. Proximal row carpectomy

As scaphoidectomy had already been performed for the 4CF stages, only the lunate and triquetrum remained to be excised. Care was taken not to disrupt the volar ulnocarpal and radioscaphocapitate ligaments.

2.5. Statistical analysis

A one-way repeated measures ANOVA was used to compare mean reductions in flexion-extension ROM, radial-ulnar deviation ROM, and circumduction area between native, anatomic 4CF, radial 4CF, and PRC conditions.

3. Results

3.1. Flexion-extension

Wrist extension was significantly reduced (−14.2 ± 12.6°) in radial 4CF compared to the native state (p = 0.04) (Fig. 3). The reduction in wrist extension after anatomic 4CF and PRC were similar to native state. Additionally, a greater reduction in wrist extension was noted for anatomic 4CF (−7.7 ± 10.5°) when compared to PRC (−1.5 ± 7.3°, p = 0.04). The reduction in wrist extension was similar between fusion groups, but no statistically significant difference was detected between groups.

Fig. 3.

Fig. 3

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Mean absolute change (°) in wrist flexion, extension, ulnar and radial deviation compared to native state. Asterisk indicates statistical significance (p < 0.05) between comparison groups. Asterisk at base illustrates significance compared to native state.

3.2. Radial-ulnar deviation

Radial deviation was significantly reduced in PRC compared to native state (−6.3 ± 4.4°) and anatomic 4CF conditions (p = 0.02, both) (Fig. 3). Ulnar deviation was similar between all groups.

3.3. Circumduction

Total circumduction area (mm2) was highest in native state at 2121 ± 1089 mm2, followed by PRC at 1248 ± 812 mm2, anatomic 4CF at 920 ± 525 mm2, and finally radial 4CF at 918 ± 311 mm2 (Fig. 4). Compared to the native state, circumduction area was significantly reduced in radial-aligned 4CF (p = 0.048), but not in anatomic 4CF (p = 0.11) or PRC (p = 0.07). Total circumduction area was similar between the two fusion positions (p = 0.99).

Fig. 4.

Fig. 4

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Total circumduction area (mm2). Asterisk indicates statistical significance (p < 0.05).

Circumduction pathways were recorded for each group and were compared to the circumduction pattern generated by the native state (Fig. 5). The percent overlap in circumduction pattern in each group was compared to native. PRC maintained the closest circumduction pattern to native, followed by anatomic 4CF, then radial-aligned 4CF, with 44 ± 24%, 41 ± 20%, and 32 ± 18% of the native circumduction area maintained, respectively. The percentage of each quadrant maintained from native state is shown in Fig. 6. Morphology of circumduction pattern was most congruent between PRC and native conditions.

Fig. 5.

Fig. 5

Fig. 5

Fig. 5

Fig. 5

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Circumduction pattern after anatomic 4CF (A), radial 4CF (B) and PRC (C), superimposed on native circumduction pattern.

Fig. 6.

Fig. 6

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Percent of maintained motion within each quadrant compared to native state.

4. Discussion

Presently, there is a paucity in biomechanical literature regarding the influence of scaphoidectomy with 4CF and PRC on multiplanar wrist kinetics. Additionally, there is a lack of consensus regarding the optimal position of fusion in the coronal plane in 4CF. This biomechanical study aims to delineate the motion pathways of the wrist after 4CF in anatomic and radial-aligned positions, and after proximal row carpectomy.

The results of this work can be summarized into 3 key findings. Firstly, no statistically significant relationships were identified when comparing uniplanar and multiplanar motion in anatomic 4CF and radial 4CF. However, radial-aligned 4CF resulted in reduced wrist extension (p = 0.04) and total circumduction area (p = 0.048) when compared to native state. Additionally, anatomic 4CF was noted to have reduced wrist extension compared to PRC (p = 0.04) but was superior in radial deviation (p = 0.02). Finally, total circumduction area was least compromised in PRC, with the highest percent retention of the native circumduction pattern.

When anatomic and radial 4CF were compared to native state, only the reduction in wrist extension and total circumduction area after radial 4CF reached statistical significance. However, no statistically significant differences were noted upon comparison between anatomic and radial 4CF. In general, the restriction in motion after 4CF may be explained by elimination of the midcarpal joint leaving a single articulation (radiolunate joint). The reduction in wrist flexion and ulnar deviation with radial 4CF compared to native state approached significance (p = 0.07). In the biomechanical study by Hernandez-Soria et al., the authors noted the wrist assumed a radially-deviated position after 4CF in a radially-aligned position.4 These results are consistent with our finding of reduced ulnar deviation. We hypothesize that these changes may be secondary to tensioning of the radioscaphocapitate (RSC) ligament when the capitate is translated ulnarly. Increased tension on this strong ligament may tether the wrist into radial deviation and ultimately limit ulnar deviation.4 Total circumduction area was also significantly reduced in radial 4CF compared to native state, with a 32% retention of native circumduction area. Again, a lack of statistical significance was noted when comparing both fusion positions, although anatomic 4CF maintained 41% native circumduction area. In this study, the lack of statistical significance in our results may have been a result of the large variance in our sample and the small number of specimens.

When comparing the results of 4CF and PRC, anatomic 4CF demonstrated increased restriction in wrist extension, while the latter was more restricted in radial deviation. PRC was also noted to have significantly reduced radial deviation compared to native state. Restricted radial deviation in PRC is reported consistently in clinical studies23,24 and has been shown to be secondary to impingement of the trapezium on the distal radius.25 The loss of both the radiocarpal and midcarpal joints, and replacement with a single new articulation of the capitate on the radius likely explains the reduction in motion with PRC.5 Additionally, the ROM values we report are consistent with clinical studies after 4CF and PRC,2, 3, 4,26 all of which are reduced but lie within an acceptable range of functional motion.

Some surgeons advocate for radially aligned 4CF over anatomic fusion and report good outcomes for this procedure.12, 13, 14, 15, 16, 17, 18, 19, 20 A retrospective cohort study by Bain et al. looking at long term (10-year minimum follow-up) outcomes in 31 patients after radial 4CF found that grip strength was maintained post-operatively, but wrist flexion was reduced by 22%. They reported mean radial deviation of 10° and ulnar deviation of 20°. Average patient satisfaction was 8/10, and reports of pain, wrist function and satisfaction were stable at 1–10 years. In another similar study, Traverso et al. reported a mean flexion-extension arc of 68.6°, and radial-ulnar deviation arc of 32.9°.18 Despite the fact that the majority of patients (73%) were noted to have radiographic changes at the radiolunate joint, patients were highly satisfied with the procedure and reported low functional impairment.

Clinical studies comparing function after 4CF and PRC have also been conducted. A study by Brinkhorst et al. compared the functional abilities in 48 patients at more than 6 months post-operatively and found that patients who underwent PRC competed tasks more expeditiously than those who underwent 4CF.27 Another functional study by Wolff et al. compared kinematics of dart throw and hammering in those who underwent PRC and 4CF.28 Similarly, this group found that patients performed better after PRC on kinematic and performance variables.

A significant strength of this study relative to prior investigations was the evaluation of multiplanar motion. We report a 57% reduction in total circumduction area in 4CF compared to a 41% reduction in PRC relative to the native state. We also provide further insight in that 44%, 41%, and 32% of the native circumduction area was maintained with PRC, anatomic 4CF, and radial 4CF, respectively. Although we were unable to identify any biomechanical studies comparing circumduction after 4CF or PRC, a prospective cohort study by Singh et al. compared circumduction in these groups.29 They found the mean circumduction area was similar after both procedures but was reduced by 30% relative to the non-operative side. They also report that the centre of the circumduction ellipse was closer to that of the non-operative wrist. The greater reduction in circumduction area noted in our study may be attributed to the intervention being performed on non-pathologic specimens. Clinically, patients have months to years after surgery to compensate for the loss in midcarpal motion, when these clinical outcomes are usually reported. Consistent with these results, we found that PRC exhibits a circumduction pattern more congruent with the native state in comparison to 4CF.

Limitations to this study include the use of healthy, non-arthritic cadaveric specimens rather than those with SLAC or SNAC pathology. This cadaveric model also lacked the potential for ligament adaptation during healing, which would occur in clinical scenarios. Although K-wire fixation is less rigid compared to screw or plate fixation, we attempted to improve construct rigidity with multiple large caliber K- wires (five 0.062”). K-wires were used in our study to allow for a repeated-measures study design, which improves statistical power by comparing procedures within specimens. As the capitate is shifted ulnarly relative to the lunate, the bony defect created from a headless compression screw in anatomic fusion would be shifted proportionally, leaving a very limited amount of bone stock at the radial aspect for radial-aligned fusion. As such, fixation may not have been maintained in the second (radial-aligned) procedure had screw fixation been chosen. Further, as there was a lack of access to fluoroscopy in the laboratory, we were unable to confirm correction of any DISI deformity radiographically, but this was confirmed visually. Finally, although the study was sufficiently powered, there was high variance in the results (standard deviation) which is expected due to the variable size and shape of normal wrists.

Between the two fusion positions, total circumduction area and wrist extension were significantly reduced in radial 4CF but not anatomic 4CF in comparison to native state, although no statistically significant differences were noted upon comparison of both fusion positions. With these biomechanical findings in mind, anatomic 4CF appears to provide superior motion outcomes compared to radial 4CF (particularly with circumduction area at 41% vs. 32%), although no statistically significant difference was detected, and as such, further clinical investigation is warranted. Anatomic 4CF may be suitable if there is sufficient pre-existing osseous contact between the capitate and lunate to achieve fusion, to maximize circumduction area, and to minimize restriction in wrist extension. However, in other circumstances, radial 4CF may be appropriate. For instance, in cases of SLAC with significant capitate proximal migration or minimal bone stock between the capitate and lunate, the fusion in the radial-aligned position may be required to obtain adequate fixation and bony apposition. Increasing contact between the capitate and lunate may reduce rates of non-union.8

Deciding between the two common salvage procedures is a clinical challenge for many hand surgeons. PRC is technically simpler and lacks hardware and osseous complications. However, the non-anatomical articulation between the capitate and radius invariably predisposes patients to post-operative arthritis. Our study provides additional insight suggesting that PRC results in greater native circumduction retention of 44% compared to 41% in anatomic 4CF and 32% in radial 4CF. These results may assist clinicians during the decision-making process, although the clinical significance of this finding is unknown at this time. Further clinical investigations comparing patient-reported outcomes, motion outcomes, and complication rates in anatomic 4CF, radial 4CF and PRC are required.

Declaration of competing InterestCOI

None.

Author role/Involvement

Stacy Fan – experimental design, laboratory testing, data analysis, manuscript preparation, manuscript review for publication.

Clare Padmore – experimental design, laboratory testing, data analysis, manuscript preparation, manuscript review for publication.

Assaf Kadar - experimental design, laboratory testing, data analysis, manuscript preparation, manuscript review for publication.

Spencer Chambers – experimental design, laboratory testing, data analysis, manuscript preparation, manuscript review for publication.

Daniel Langohr-experimental design, laboratory testing, data analysis, manuscript preparation, manuscript review for publication.

Nina Suh - experimental design, laboratory testing, data analysis, manuscript preparation, manuscript review for publication.

Funding

Lawson Health Research Institute Internal Research Fund.

Acknowledgements

None.

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