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Area of Focus: Hand & Wrist
Scaphoidectomy and four-corner fusion is a widely accepted treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) in wrists. With the introduction of circular plates in 1999, the expectation was that they would effectively bind the carpal bones together until solid fusion could be achieved. However, early reports suggested higher complication rates including nonunion, dorsal hardware impingement, and screw breakage or back-out. More recent studies have demonstrated superior results with few complications. This video demonstrates several technical steps that are necessary to achieve consistent success with circular plates.
Proper seating of the plate is important. To avoid hardware prominence, the surgeon should seat the plate entirely below the dorsal cortices. Even with relatively generous reaming, deep seating requires removal of only a small percentage of the surface area between the carpal bones. Another advantage of deep seating the plate is that it facilitates proper screw placement. With superficial plate placement, the surgeon can only achieve adequate screw fixation by using a horizontal trajectory, which may shift the bone away from the center and increase the gap at the fusion site. Deep seating permits vertical screw orientation and excellent fixation. The bone will draw toward the center of the plate, thus decreasing the gap at the fusion site.
Other details that will promote a successful outcome include: taking care to preserve congruent bony surfaces, performing complete decortication of the volar and dorsal portions of the articular surfaces, and undertaking external compression of the bone during provisional fixation. Following these dictates can lead to a stable construct with excellent potential for solid fusion.
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