Four-Corner Arthrodesis With Differing Methods of Osteosynthesis: A Systematic Review


      The purpose of this study was to compare the union rates and clinical outcomes of 4-corner arthrodesis with different methods of osteosynthesis.


      A systematic review of studies published in Ovid, Medline, Embase, and PubMed was conducted. Primary studies that reported clinical and radiographic results following 4-corner arthrodesis for scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), or other types of wrist arthritis in human subjects were eligible. Biomechanical or cadaveric studies, case reports, studies that did not define and report a radiographic union rate, reviews and technical articles, studies that did not report the method of osteosynthesis, and studies that used multiple methods of osteosynthesis, but did not separate results for individual methods of osteosynthesis were excluded. Radiographic union rate, range of motion, and grip strength were analyzed.


      We identified and reviewed 291 full texts, selecting 57 studies for coding. The radiographic union rate did not significantly differ between studies using K-wire, screw, staple, nonlocking plate, metal locking plate, and radiolucent locking plate osteosynthesis. Fixation method significantly affected flexion, but pairwise comparison did not reveal any significant differences between individual groups. Grip strength as a percentage of the contralateral limb was significantly lower in studies with metal locking plate fixation compared to K-wire fixation (63.2% vs 82.6%). There were no other statistically significant differences between groups with respect to flexion, extension, radial deviation, ulnar deviation, and grip strength.


      All methods of osteosynthesis result in similar union rates, with no significant differences between methods. While there are some significant differences in range of motion and grip strength, these differences are unlikely to be clinically relevant.

      Type of study/level of evidence

      Therapeutic IV.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Watson H.K.
        • Goodman M.L.
        • Johnson T.R.
        Limited wrist arthrodesis. Part II: intercarpal and radiocarpal combinations.
        J Hand Surg Am. 1981; 6: 223-233
        • Jackson J.L.
        • Kuriyama A.
        • Anton A.
        • et al.
        The accuracy of Google Translate for abstracting data from non-English-language trials for systematic reviews.
        Ann Intern Med. 2019; 171: 677-679
        • Wang N.
        How to Conduct a Meta-Analysis of Proportions in R: A Comprehensive Tutorial Conducting Meta-Analyses of Proportions in R.
        • Schwarzer G.
        • Chemaitelly H.
        • Abu-Raddad L.J.
        • Rücker G.
        Seriously misleading results using inverse of Freeman-Tukey double arcsine transformation in meta-analysis of single proportions.
        Res Synth Methods. 2019; 10: 476-483
        • Lin L.
        • Xu C.
        Arcsine-based transformations for meta-analysis of proportions: pros, cons, and alternatives.
        Health Sci Rep. 2020; 3: 1-6
        • Ekelund L.
        • Hagberg L.
        • Hörberg L.
        • Jörgsholm P.
        • Gunnarsson M.
        Imaging of four-corner fusion (SLAC arthrodesis) of the wrist with 64-slice computed tomography.
        Acta radiol. 2007; 48: 76-79
        • Kendall C.B.
        • Brown T.R.
        • Millon S.J.
        • Rudisill L.E.
        • Sanders J.L.
        • Tanner S.L.
        Results of four-corner arthrodesis using dorsal circular plate fixation.
        J Hand Surg Am. 2005; 30: 903-907
        • Sadun R.
        • Pagnotta A.
        • Genzini A.
        • Mastrantuono M.
        Clinical and CT evaluation of four corner arthrodesis with Spider circular plate in the treatment of SLAC/SNAC wrist.
        J Hand Surg. 2006; 31: 43
        • Shindle M.K.
        • Burton K.J.
        • Weiland A.J.
        • Domb B.G.
        • Wolfe S.W.
        Complications of circular plate fixation for four-corner arthrodesis.
        J Hand Surg Eur Vol. 2007; 32E: 50-53
        • Vance M.C.
        • Hernandez J.D.
        • DiDonna M.L.
        • Stern P.J.
        Complications and outcome of four-corner arthrodesis: circular plate fixation versus traditional techniques.
        J Hand Surg Am. 2005; 30: 1122-1127
        • Watson H.K.
        • Weinzweig J.
        • Guidera P.M.
        • Zeppieri J.
        • Ashmead D.
        One thousand intercarpal arthrodeses.
        J Hand Surg Am. 1999; 24: 307-315
        • Pauchard N.
        • Lecoanet-Strugarek C.
        • Segret J.
        • De Gasperi M.
        • Dap F.
        • Dautel G.
        Dorsal locking plates versus staples in four-corner fusion: A comparative clinical and radiological study.
        Orthop Traumatol Surg Res. 2014; 100: 593-597
        • Van Amerongen E.A.
        • Schuurman A.H.
        Four-corner arthrodesis using the quad memory staple.
        J Hand Surg Eur Vol. 2009; 34: 252-255
        • Bain G.I.
        • Watts A.C.
        The outcome of scaphoid excision and four-corner arthrodesis for advanced carpal collapse at a minimum of ten years.
        J Hand Surg Am. 2010; 35: 719-725
        • Le Corre A.
        • Ardouin L.
        • Loubersac T.
        • Gaisne E.
        • Bellemère P.
        Retrospective study of two fixation methods for 4-corner fusion: shape-memory staple vs. dorsal circular plate.
        Chir Main. 2015; 34: 300-306
        • Ozyurekoglu T.
        • Turker T.
        Results of a method of 4-corner arthrodesis using headless compression screws.
        J Hand Surg Am. 2012; 37: 486-492
        • Iordache S.D.
        • Nam D.
        • Pylan J.
        • Axelord T.
        Four-corner arthrodesis using two headless compression screws.
        Acta Orthop Belg. 2016; 82: 332-338
        • Zeplin P.
        • Kuhfuß I.
        Mediokarpale Teilarthrodese mit kortikospongiösem Beckenkammspan zur Behandlung des karpalen Kollaps im Stadium II/III nach Skaphoidpseudarthrose oder skapholunärer Dissoziation.
        Handchirurgie Mikrochirurgie Plast Chir. 2009; 41: 183-185
        • Zeplin P.
        • Meffert R.
        • Kuhfuß I.
        Mid-term results after midcarpal arthrodesis using an iliac crest cortical chip for grade II/III SLAC/SNAC-wrists.
        GMS Ger Plast Reconstr Aesthetic Surg. 2013; 3: 1-6
        • Kraisarin J.
        • Dennison D.G.
        • Berglund L.J.
        • An K.N.
        • Shin A.Y.
        Biomechanical comparison of three fixation techniques used for four-corner arthrodesis.
        J Hand Surg Eur Vol. 2011; 36: 560-567
        • Rhee P.C.
        • Shin A.Y.
        The rate of successful four-corner arthrodesis with a locking, dorsal circular polyether-ether-ketone (PEEK-Optima) plate.
        J Hand Surg Eur Vol. 2013; 38: 767-773
        • MacDermid J.C.
        Development of a scale for patient rating of wrist pain and disability.
        J Hand Ther. 1996; 9: 178-183
        • Beleckas C.M.
        • Padovano A.
        • Guattery J.
        • Chamberlain A.M.
        • Keener J.D.
        • Calfee R.P.
        Performance of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) versus physical function (PF) computer adaptive tests (CATs) in upper extremity clinics.
        J Hand Surg Am. 2017; 42: 867-874