Merrell Gregory A, McDermott Erin M, Weiss Arnold-Peter C
Division of Hand Surgery, Department of Orthopaedics, Warren Alpert Medical School, Brown University, Providence, RI, USA.
J Hand Surg Am. 2008 May-Jun;33(5):635-42. doi: 10.1016/j.jhsa.2008.02.001.
Four-corner arthrodesis with scaphoid excision has been shown to be an acceptable method for treating wrist degenerative changes. Some recent studies have identified higher complication rates when circular plates are used. This study examined a consecutive case series with defined technique for outcome and complications.
A retrospective assessment was performed in a consecutive cohort of 28 patients who underwent a standardized 4-corner arthrodesis with a 2nd-generation circular plate and distal radius bone grafting for a diagnosis of scapholunate advanced collapse, scaphoid nonunion advanced collapse, or midcarpal arthrosis. Complete data were obtained for 26 of the patients and partial data for the other 2. Follow-up examination included visual analog scale and activity scores, work status, posteroanterior and lateral radiographs, bone union status, grip strength, range of motion, and complications.
Average follow-up was 46 months. Range of motion averaged 45% of the uninjured side (average extension, 35 degrees; average flexion, 26 degrees). Grip strength averaged 82% of the uninjured side. The mean visual analog scale pain and activity scores were 2.3/10 and 2.4/10. Only 1 patient required job modification because of wrist impairment. Radiographs demonstrated union of the primary capitolunate fusion mass in all of the cases. There was 1 case of probable but not certain peritriquetral nonunion and 1 case of asymptomatic loss of radiolunate joint space; in terms of hardware, there was screw back-out (of 1 screw) in 1 case the plate broke in 1 case. Two patients underwent reoperation, one for radial styloid impingement pain and the other for lack of flexion.
Despite recent reports indicating a high nonunion rate with plate fixation, standardized 4-corner arthrodesis using a recessed, dorsal circular plate and distal radius bone grafting produced excellent and reproducible results in this consecutive series. Notably, there was no development of secondary arthritic changes at the radiolunate joint, indicating a reasonable durability to the procedure. Optimal results require exacting technique with quality bone graft.
舟骨切除四角融合术已被证明是治疗腕关节退行性变的一种可接受的方法。最近的一些研究发现，使用环形钢板时并发症发生率较高。本研究对一系列连续病例进行了研究，采用明确的技术评估其疗效和并发症。
对连续28例因诊断为舟月骨高级塌陷、舟骨不愈合高级塌陷或腕中关节病而接受标准化四角融合术、使用第二代环形钢板和桡骨远端植骨的患者进行回顾性评估。26例患者获得了完整数据，另外2例获得了部分数据。随访检查包括视觉模拟评分和活动评分、工作状态、正位和侧位X线片、骨愈合情况、握力、活动范围和并发症。
平均随访46个月。活动范围平均为健侧的45%（平均伸展35度；平均屈曲26度）。握力平均为健侧的82%。视觉模拟评分的平均疼痛和活动评分为2.3/10和2.4/10。只有1例患者因腕关节损伤需要调整工作。X线片显示所有病例中主要的头月骨融合块均已愈合。有1例可能但不确定的三角骨周围不愈合，1例桡月关节间隙无症状性丢失；在硬件方面，1例出现螺钉退出（1枚螺钉），1例钢板断裂。2例患者接受了再次手术，1例因桡骨茎突撞击疼痛，另1例因屈曲受限。
尽管最近有报道表明钢板固定的不愈合率较高，但在本连续系列研究中，使用凹形背侧环形钢板和桡骨远端植骨的标准化四角融合术产生了优异且可重复的结果。值得注意的是，桡月关节未出现继发性关节炎改变，表明该手术具有合理的耐久性。最佳结果需要精确的技术和优质的骨移植。
