Objective: Four-corner fusion (4CF) is an accepted and effective procedure for managing several degenerative disorders of the wrist. This procedure consists of the excision of the entire scaphoid in association with midcarpal fusion of the remaining carpal bones (lunate, triquetrum, capitate, and hamate), and it is generally performed through an open approach. The combination of a minimal volar approach, for scaphoid excision, with arthroscopy preparation of midcarpal joint surfaces plus bone graft placing and percutaneous fixation techniques can, potentially, generate the best possible functional outcome by minimizing the effect of extra-articular adhesion related to open surgery. The purpose of this retrospective study is to present the arthroscopically assisted 4CF performed in our practice and to evaluate the clinical and radiographic results. Materials and Methods: Eleven patients underwent scaphoidectomy and 4CF. In each case, the scaphoidectomy was performed through a minimal volar approach, and the midcarpal joint surfaces were denuded through dry arthroscopy. The regular midcarpal portals were used. The bone graft was prepared from the excised scaphoid, and it was placed in midcarpal space using a 3.4 mm burr cannula. The fixation was achieved using headless cannulated compression screws. In the postoperative period, patients were put in a splint for 2 weeks. Range of motion exercises began 2 weeks after operation. Functional outcomes were assessed by objective and subjective measures: range of motion, grip strength, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, visual analogue scale (VAS) of pain, satisfaction, and return to work. The x-rays were evaluated for union. The mean follow-up was of 20 months. Results: Mean surgery time was 2 hours. There was no need for conversion to the classic open procedure in any patient. The average flexion was of 44° (range, 30°-70°) and extension was of 39° (range, 10°-50°). Grip strength averaged 23 kg (62% of the other hand). Terminal to terminal pinch averaged 5.8 kg and terminal to lateral pinch was 7.3 kg (89% and 88% of the other hand, respectively). The mean QuickDASH score improved postoperatively from 40 to 10. Mean VAS postoperative pain rating was 2, compared with 7 preoperatively. All the patients were satisfied and were able to return to their previous activities. Fusion was achieved in every patient, confirmed by x-rays taken at 10 months postoperative. We had a surgery-related complication, a second-degree burn related with the use of the burr, which resolved with dressings, and there was a breakage of a screw in 1 patients, but in both cases fusion was achieved. Conclusion: Although technically demanding, in our opinion, the arthroscopically assisted 4CF seems a valid alternative to the classic 4CF procedure. The preliminary results seem promising, but longer follow-up is needed to confirm the benefits of this technique.
