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Four Corner Wrist Fusion

Planning

B

Preoperative Plan

1

Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • fusion plate and screws

2

Room setup and equipment

  • setup OR with standard operating table and radiolucent hand table
  • turn table 90° so that operative extremity points away from anesthesia machines
  • c-arm perpendicular to hand table with monitor in surgeon's direct line of site

3

Patient positioning

  • supine with shoulder at edge of bed centered at level of patient’s shoulder
  • hand centered on hand table, supinate arm
  • arm tourniquet placed on arm with webril underneath (optional)

Technique

D

Superficial Dissection Between 3rd and 4th Extensor Compartment

1

Mark incision and make the incision

  • make a standard dorsal longitudinal incision between the third and fourth extensor compartment
  • use the tubercle of Lister as a landmark

2

Divide the third and fourth compartments

  • incise the retinaculum over the third extensor compartment
  • incised the radial septum of the fourth extensor compartment

3

Retract tendons

  • retract the tendons ulnarly
E

Dorsal Wrist Capsulotomy and Joint Inspection

1

Expose the dorsal wrist capsule

  • elevate the fourth and fifth extensor compartments ulnarly
  • translocate the EPL tendon with the radial wrist extensor tendons radially

2

Expose the midcarpal joint and the radial half of the radiocarpal joint

  • longitudinally split the dorsal radiocarpal and dorsal intercarpal ligaments with the apex of the triquetrum

3

Elevate the flap radially

  • this will detach the dorsal capsule from the radius to the level of the styloid process

4

Expose the ulnocarpal joint

  • split the dorsal radiocarpal ligament longitudinally
  • incise the capsule along the ECU tendon subsheath proximally to the level of the TFCC with the apex of the triquetrum

5

Elevate this flap proximally

6

Inspect the radio lunate joint for articular cartilage wear

F

Scaphoid Excision

1

Excise the scaphoid

  • identify and excise the scaphoid either in a piecemeal fashion with a rongeur or sharply using a scalpel
  • take care to protect the volar radioscaphocapitate ligament
G

Fusion Preparation

1

Prepare the wrist for fusion

  • decorticate the opposing joint surfaces of the lunate, triquetrum, capitate and hamate
  • remove the volar third cartilage from the lunate and the capitate
  • this corrects the pre-existing DISI deformity but will shorten the intercarpal bone distance

2

Harvest distal radius bone graft and place into the fusion bed

H

Carpal Reduction

1

Place Kwires

  • place a .06 2K wire through the distal radius articular surface
  • place another Kwire in the lunate
  • use a separate K wire as a joystick to hold the lunate reduced and neutral alignment
  • advanced the K wire across the radio lunate joint from dorsal to volar

2

Verify Kwire placement

  • obtain images to verify the correction of the dorsally tilted lunate

3

Reduce the capitate

  • applied dorsal pressure to volarly translate the capitate on the lunate
  • this should fully correct the DISI deformity

4

Place 2 more Kwires

  • secure the triquetrum to the hamate and the lunate to the capitate with two additional K wire
  • place these K wire’s as volar as possible
  • this prevents interference with rasping and plate placement

5

Place the rasp

  • center the power rasp over the four bones in both the AP and lateral planes
  • bury the rasp down to subchondral bone

6

Pack bone graft

  • pack bone graft obtained from the distal radius between the four prepared bones
I

Plate Fixation

1

Position the plate

  • center the plate over the four bones in the AP and lateral planes
  • place the circular plate into the bony crater created by the rest
  • rotate the plate to maximize screw purchase into each of the four bones

2

Set the plate

  • place two screws in each of the four carpal bones
  • place the screws unicortically
  • place the first screw through the plate into the lunate
  • do not tighten the screw completely
  • place a second screw into the hole opposite the first screw
  • the plate position should now be set

3

Check imaging for placement of the plate

  • check a lateral x-ray to ensure the plate is well seated and there is no impingement with wrist extension

4

Fill the plate with screws

  • fill the remainder of the holes with screws
  • placing screws opposite one another and tightening them sequentially will help prevent Mal positioning of the plate

5

Obtain final imaging

  • obtain final images to check screw links position carpal reduction and construct stability
J

Wound Closure

1

Irrigation, hemostasis, and drain

  • irrigate wounds thoroughly and deflate tourniquet (if utilized)
  • coagulate any bleeders carefully

2

Deep closure

  • close the capsule with absorbable suture
  • repair the extensor retinaculum
  • leave the EPL tendon transposed subcutaneously

3

Superficial closure

  • close skin
  • close subcutaneous layer with 3-0 absorbable suture
  • 3-0 nylon vertical/horizontal mattress for skin
  • alternatively, can use running 4-0 or 5-0 Monocryl for subcuticular stitch

4

Dressing and splint

  • place a short arm cast

Patient Care

K

Preoperative H & P

1

Perform history and physical exam

  • check radial/ulnar artery patency of operative extremity with Allen’s test

2

Orders and interprets basic imaging studies

  • need biplanar films of wrist

3

Perform operative consent

  • describe complications of surgery including
  • neurovascular injury
  • superficial and deep infections
  • wound breakdown
  • implant failure
  • malunion and nonunion
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • prescribe outpatient physical therapy
  • non-weightbearing
M

Basic Outpatient Evaluation and Management (including Post Op Care)

1

Perform focused history and physical exam

  • recognizes implications of soft tissue injury

2

Orders/ interprets advanced imaging:

  • CT scan

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention
  • surgical indications
  • pain with motion
  • instability
  • end stage osteoarthritis of the wrist

4

Modify and adjust post-op plan when indicated

  • postop: 2-3 week postoperative visit
  • wound check and remove sutures
  • diagnose and management of early complications
  • continue immobilization for 8-10 weeks
  • continue non-weightbearing
  • postop:3 months
  • start strengthening exercises
  • postop: 1 year postoperative visit
 

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