SCIENTIFIC ARTICLE

Four-Corner Fusion Versus Proximal Row

Carpectomy for Scapholunate Advanced Collapse
and Scaphoid Nonunion Advanced Collapse
Wrist: A Systematic Review and Meta-Analysis
Keegan M. Hones, MD, MS,* Kevin A. Hao, BS,† Taylor R. Rakauskas, BS,‡ Sebastian Densley, BS,‡
Hailey Hampton, MD,* Jongmin Kim, MD,* Thomas W. Wright, MD,* Harvey Chim, MD§

Purpose Although proximal row carpectomy (PRC) has increasingly been shown to have superior features to
four-corner fusion (4CF), individual surgeons may remain convinced of the superiority of one procedure
based on personal experience and individual biases. Hence, we sought to perform an updated meta-analysis
with some of the largest studies to date to compare outcomes and complications between these procedures in
the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists.
Methods A systematic review and meta-analysis was performed per Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and
Cochrane were queried for articles on PRC and 4CF performed for scapholunate advanced collapse and
scaphoid nonunion advanced collapse wrist. Primary outcomes included wrist range of motion; grip
strength; outcome measures, including Disabilities of Arm, Shoulder, and Hand and Quick Disabilities of
Arm, Shoulder, and Hand scores, Patient-Rated Wrist and Hand Evaluation, and visual analog scale pain
scores; and surgical complications.
Results Sixty-one studies reported on 3,174 wrists, of which 54% were treated with PRC and 46% were
treated with 4CF. The weighted mean follow-up was 61 months (range, 12e216 months). Meta-analysis
comparing PRC and 4CF demonstrated that PRC had significantly greater postoperative extension; ulnar
deviation; postoperative improvement in extension, flexion, ulnar deviation; and visual analog scale score. No
comparisons showed significant differences in grip strength. The percentage of wrists requiring arthrodesis
was 5.2% for PRC and 11% for 4CF. There was an 8.9% (57/640 wrists) 4CF nonunion rate and 2.2% (17/789)
hardware removal rate after 4CF.
Conclusions In the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse
wrists, PRC results in better outcomes and a lower complication rate compared to 4CF. (J Hand Surg Am.
2024;-(-):1.e1-e6. Copyright Ó 2024 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Arthritis, four corner fusion, hand, meta-analysis, proximal row carpectomy, wrist.

patterns.1,2 Over time, 4CF was shown to demonstrate

A
advanced collapse
T THE TIME SCAPHOLUNATE
(SLAC) wrist was described by Watson and improvements in pain and grip strength with the
Ballet in 1984, four-corner fusion (4CF) with preservation of carpal height.3e5 Proximal row car-
or without silastic scaphoid implant was their treat- pectomy (PRC) offers another surgical option,
ment of choice in patients with advanced wear benefiting from the absence of hardware and

From the *Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Corresponding author: Harvey Chim, MD, Division of Plastic and Reconstructive Surgery,
Gainesville, FL; †College of Medicine, University of Florida, Gainesville, FL; ‡College of University of Florida College of Medicine, 4037 NW 86th Terrace, Gainesville, FL 32611;
Medicine, Florida Atlantic University, Boca Raton, FL; and the §Department of Plastic and e-mail: harveychim@yahoo.com.
Reconstructive Surgery, University of Florida, Gainesville, FL.
0363-5023/24/---0001$36.00/0
Received for publication September 18, 2023; accepted in revised form January 24, 2024. https://doi.org/10.1016/j.jhsa.2024.01.011

Ó 2024 ASSH r Published by Elsevier, Inc. All rights reserved. r 1.e1

1.e2 PROXIMAL ROW CARPECTOMY VERSUS FOUR-CORNER FUSION
avoidance of complications, such as nonunion and
hardware prominence, seen with 4CF.5,6 Theoretically,
range of motion (ROM) should favor PRC over 4CF at
the expense of increased contact forces; however,
multiple prior studies have failed to demonstrate a
difference in ROM or grip strength between the
procedures.5,7e12
Interest in the optimal treatment of SLAC and
scaphoid nonunion advanced collapse (SNAC) wrist
remains of great importance to hand surgeons
considering these conditions are the two most com-
mon patterns of posttraumatic arthritis.13 Both lead to
abnormal joint kinematics, with the lunate unre-
strained by the distal scaphoid and subsequently
extended, over time leading to dorsal intercalated
segment instability deformity, which generally pro-
gresses to further degeneration, carpal collapse and
midcarpal arthritis.14 In studies evaluating PRC
versus 4CF for SLAC and SNAC wrist, some have
showed superiority of PRC, whereas others have
showed many postoperative similarities between the
two interventions.5,8,15,16
Some surgeons remain individually convinced of
the superiority of one procedure over the other based
on personal experience. This systematic review and
meta-analysis sought to compare PRC versus 4CF
performed specifically for patients with SLAC and
SNAC wrist using the largest number of patients
analyzed to date to guide evidence-based practice.
We hypothesized that PRC would provide patients
with significantly better clinical outcomes and fewer
complications compared to 4CF, with superior ROM,
patient-reported outcomes, and strength.
MATERIALS AND METHODS
This systematic review was performed in accordance
with the guidelines for Preferred Reporting Items for
Systematic Reviews and Meta-Analyses.17
Eligibility criteria
We included original studies written in English and
published from inception to March 2023 evaluating
the use of 4CF and PRC. Studies were excluded for
being a duplicate, non-English text, abstract only,
review or meta-analysis, commentary or editorial,
pure radiographic or surgical technique, nonhuman,
biomechanical or without clinical variables, and not
including 4CF or PRC performed for SLAC or
SNAC wrist (ie, Kienbock’s and rheumatoid arthritis
were excluded). Proximal row carpectomy with
interposition was excluded. If we were unable to
stratify results to include only patients with a
J Hand Surg Am.
diagnosis of SLAC and SNAC wrist, that is, other
diagnoses, the study was excluded (Fig. 1).
Search strategy
We queried the PubMed/MEDLINE, Embase, Web
of Science, and Cochrane databases using the
following search terms: “four corner fusions” or “four
corner arthrodesis” or “SLAC arthrodesis” or “SNAC
arthrodesis” or “proximal row carpectomy” or
“capitate resurfacing.” Exclusion criteria were
applied during title and abstract screening, and when
uncertain, we erred on the side of inclusion. Subse-
quently, full texts of the remaining articles were
reviewed, which was performed by multiple authors
(K.M.H., T.R.R., and S.D.); expert opinion from se-
nior hand surgeons was available when necessary.
Study outcomes
Wrist flexion, extension, radial and ulnar deviation,
and grip strength, as well as patient-reported outcome
scores, including Disabilities of Arm, Shoulder, and
Hand (DASH) and QuickDASH scores, Patient-Rated
Wrist and Hand Evaluation, and visual analog scale
(VAS) pain scores, were the outcomes of interest. To
assess postoperative complications, we determined
complications of interest to be progression to wrist
arthrodesis, nonunion, infection, neurapraxia or nerve
injury, hardware removal, and implant complication.
Data extraction
Data extraction was completed using a standardized
data collection form by multiple authors (K.M.H.,
T.R.R., and S.D.). For the articles included in the
final review, data extracted included whether the
study was retrospective or prospective and compar-
ative versus a case series, number of wrists, mean
length of follow-up, average age, sex, percentage of
laborers included in the study, preoperative and
postoperative active ROM, grip strength, outcome
scores, and the complications of interest.
Data analysis and synthesis
Study characteristics were summarized descriptively.
Weighted means, based on the number of wrists in
each study, were calculated for study and patient
characteristics of interest. Although not every study
included each outcome, the individual variables of
interest were separately evaluated based on the
number of total wrists for which the variables were
reported, that is, studies that reported DASH scores
were only compared to studies reporting DASH
scores. Studies that reported outcomes of multiple
treatment strategies that we defined to be of interest
r Vol. -, - 2024
 PROXIMAL ROW CARPECTOMY VERSUS FOUR-CORNER FUSION 1.e3

Identification of studies via databases and registers

Identification
Records removed before screening:
Records identified from: Duplicate records removed
n = 2,837 n = 1,922

Records excluded based on title or

Records screened: abstract:
n = 915 n = 746

Reports excluded from clinical outcomes

analysis:
n = 104
Screening

Less than five patients (n = 4)

Records sought for retrieval: No outcomes of interest (n = 9)
n = 169 Same patient cohort used as another
included study (n = 1)
Could not stratify to include only
PRC, 4CF for SLAC or SNAC wrist
(n = 85)
Less than 12 months follow-up (n =
1)
Interposition or RCPI included (n =
8)
Included

Studies included in
analysis:
n = 61

*PRC, proximal row carpectomy; 4CF, four corner fusion; SLAC, scaphoid lunate advanced collapse; SNAC,
scaphoid nonunion advanced collapse; RCPI, resurfacing capitate pyrocarbon implant

FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram depicting article identification, sub-
sequent exclusion, and analysis for clinical outcomes and complications. RCPI, resurfacing capitate pyrocarbon implant.

for comparison a priori (ie, both 4CF and PRC) were
recorded as separate cohorts to enable meta-analysis
where possible. Thus, analysis was performed on
23 PRC cohorts and 62 4CF cohorts reported in 61
studies. Further, given that complications were not
reported or stratified in each study, we extracted these
separately, and the total number of wrists included in
the outcomes and complications analyses were
different. We also completed a risk of bias assess-
ment using the Methodological Index for Non-
randomized Studies (MINORS) criteria.18
Meta-analysis was performed to compare both
patient- and clinician-reported outcomes based on
treatment modality. Studies were included for meta-
analysis if they reported one or more of the out-
comes of interest and provided stratum-specific data.
Therefore, studies that used multiple treatment mo-
dalities or mixed cohorts with diagnoses not stratified
without reporting separate outcomes for the
aforementioned strata were not included. We antici-
pated that the design of the included studies and
methodology involved in data collection would result
in substantial heterogeneity; thus, we elected to use a
random-effects model a priori.19 The I2 statistic was
used to assess the heterogeneity of results. The true
effect size in 95% of the population (95% prediction
interval) was calculated using the variance of true ef-
fects (T2) and thus the SD of true effects (T). Meta-
analysis was performed using the metafor package.20
All statistical analyses were performed using R Soft-
ware (version 4.2.0, R Core Team) with an a of 0.05.
RESULTS
Search results
Our search strategy returned 2,837 publications, of
which 915 were found to be unique following
duplicate exclusion. We additionally excluded 746

J Hand Surg Am. r Vol. -, - 2024

1.e4 PROXIMAL ROW CARPECTOMY VERSUS FOUR-CORNER FUSION
articles during title and abstract screening, leaving 169
articles for full-text review. During full-text screening,
61 unique articles were included. MINORS analysis
revealed that noncomparative studies had an average
score of 12/16, whereas comparative studies had an
average score of 17/24. Based on previous reporting,
this indicated a moderate quality of evidence.21e23 See
Supplementary Table 1 (available online on the
Journal’s website at www.jhandsurg.org) for individ-
ual studies and methodological index for non-
randomized studies scores.
Study characteristics
Of the 61 included articles, the largest proportion
were authored in the United States (16/61, 26%). Of
the studies, 3/61 (4.9%) were prospective randomized
control trials, 2/61 (3.3%) were prospective compar-
ative studies, 20/61 (33%) were retrospective
comparative studies, and 36/61 (59%) were retro-
spective case series.
Patient characteristics
Our review included 3,174 wrists, 61% of which
were the patients’ dominant side. The weighted mean
follow-up was 61 months (range, 12e216 months);
15% of patients were women, and the weighted mean
age was 54 years (40e68 years). Of the included
wrists, 54% were treated with PRC (1,718/3,714),
and 46% were treated with 4CF (1,456/3,174).
Thirty-two cohorts (23 studies) reported the per-
centage of their cohorts that were laborers. The
weighted mean percentage of laborers was 49%. Of
these 32 cohorts, eight reported on PRC (weighted
mean, 39%), and 24 reported on 4CF (weighted
mean, 50%).
PRC versus 4CF
There were 1,718 PRCs with a weighted mean
follow-up of 66 months (range, 12e155 months);
9.1% were women, and the weighted mean age was
56 years (range, 12e80 months). There were 1,456
4CFs, with a weighted mean follow-up of 56 months
(range, 12e216 months); 16% of 4CFs were female,
and the weighted mean age was 52 years.
Range of motion was superior for PRC compared
to 4CF in extension (42
vs 34
; P ¼ .030,
Supplementary Fig. 1A, available online on the
Journal’s website at www.jhandsurg.org) and ulnar
deviation (29
vs 20
; P < .001, Supplementary
Fig. 2A, available online on the Journal’s website
at www.jhandsurg.org). No difference was found in
postoperative flexion (Supplementary Fig. 3A,
available online on the Journal’s website at www.
J Hand Surg Am.
jhandsurg.org), radial deviation (Supplementary
Fig. 4A, available online on the Journal’s website
at www.jhandsurg.org), or grip strength between
PRC and 4CF (Supplementary Fig. 5A, available
online on the Journal’s website at www.jhandsurg.
org). Postoperative DASH score was better, that is,
a lower disability score, for PRC compared to 4CF
(15 vs 26; P ¼ .002, Supplementary 6A, available
online on the Journal’s website at www.jhandsurg.
org). There was no difference between PRC and
4CF for postoperative QuickDASH (Supplementary
Fig. 7, available online on the Journal’s website at
www.jhandsurg.org), Patient-Rated Wrist and Hand
Evaluation (Supplementary Fig. 8A, available online
on the Journal’s website at www.jhandsurg.org), or
VAS scores (Supplementary Fig. 9A, available online
on the Journal’s website at www.jhandsurg.org).
There was greater preoperative to postoperative
improvement for PRC than 4CF in extension (11

vs 6.8
; P ¼ .016, Supplementary Fig. 1B), ulnar
deviation (8.0
vs 4.7
; P ¼ .011, Supplementary
Fig. 2B), and flexion (21
vs 6.0
; P < .001,
Supplementary Fig. 3B). No difference was found in
preoperative to postoperative improvement in radial
deviation (Supplementary Fig. 4B), or grip strength
between PRC and 4CF (Supplementary Fig. 5B).
There was greater preoperative to postoperative
improvement for PRC than 4CF for VAS score (6.2
vs 4.6; P < .001, Supplementary Fig. 9B). No
difference was found in preoperative to postoperative
improvement in DASH (Supplementary Fig. 6B,
available online on the Journal’s website at www.
jhandsurg.org) or Patient-Rated Wrist and Hand
Evaluation (Supplementary Fig. 8B). Meta-analysis
for improvement in QuickDASH was unable to be
performed due to lack of SDs reported.
Complications
The percentage of conversion to a wrist arthrodesis
was 8.0% overall (169/2,111 wrists), 5.2% for PRC
(59/1,125 wrists), and 11% for 4CF (110/986 wrists).
The overall weighted mean time to arthrodesis was
36 months (range, 4e120 months), 37 months for
PRC, and 16 months for 4CF.
There was an 8.9% (57/640 wrists) 4CF nonunion
rate; 63% (36/57) nonunions occurred with fixation
using a plate, 7.0% (4/57) with screws, 11% (6/57)
with staples, and 7.0% (4/57) with K-wires, and in
8.8% (5/57), it was unclear what fixation method was
used. Further, there was a 2.2% (17/789) hardware
removal rate in 4CF, with 15/17 being plate removal,
1/17 staple removal, and 1/17 screw removal. There
was a 5.1% (13/256 wrists) infection rate—2.6% (2/
r Vol. -, - 2024
 PROXIMAL ROW CARPECTOMY VERSUS FOUR-CORNER FUSION
56 wrists) of wrists treated with PRC and 5.5% (11/
200 wrists) of wrists treated with 4CF. Further, there
were neuropraxias in 8.3% (9/109 wrists) of cases, all
of which were treated with 4CF.
DISCUSSION
This systematic review sought to evaluate PRC and
4CF for SLAC and SNAC wrist to provide further
rationale for evidence-based practice given persistent
individual surgeon biases toward preferred surgical
treatment for these conditions and the prevalence of
these specific conditions when evaluating wrist
arthritis. Further, we analyzed postoperative ROM,
strength, and outcome scores as well as preoperative
to postoperative improvement. Our meta-analysis
found that PRC demonstrated greater postoperative
improvement in extension and ulnar deviation
compared to 4CF. Additionally, PRC demonstrated
greater improvement in VAS. Furthermore, compared
to PRC, the complication profile was less favorable
for 4CF with a higher rate of wrist arthrodesis (11%
vs 5.2%), risk of nonunion (8.9%) and need for
hardware removal (2.2%). These findings further
support many of the potential benefits of PRC over
4CF when appropriate for SLAC and SNAC wrists.
We found that patients who received PRC achieved
greater extension and preoperative to postoperative
improvement in extension and flexion compared to
patients who underwent 4CF. This is notable given the
lack of extension seen in patients with SLAC and
SNAC wrist pathology secondary to altered wrist
biomechanics. However, as shown in previous studies,
motion is less after these salvage procedures compared
to preoperative ROM.8,9,11,12 Further, PRC demon-
strated greater ulnar deviation than 4CF and greater
improvement in ulnar deviation. This may be func-
tionally relevant because previous biomechanical
studies have shown wrist motion relies more heavily
on ulnar deviation than radial deviation.24 However,
further research is needed to elucidate the minimal
clinically important difference and substantial clinical
benefit in wrist ROM to establish whether these dif-
ferences of 10
and less are meaningful. Further,
similar to prior analyses, we found no difference in
grip strength between groups. Further, there were
essentially no differences in patient-reported outcome
scores between PRC and 4CF.10e12
Although the ongoing debate of PRC versus 4CF
has failed to establish consistent and significant
differences in motion, complication differences
remain substantial. Wrist arthrodesis remains one of
the final options after failed PRC and 4CF, with
J Hand Surg Am.
1.e5
patients generally experiencing pain improvements
at the cost of a complete loss in ROM.25 In our
review, the percentage of patients who were con-
verted to wrist arthrodesis was 5.2% for PRC and
11% for 4CF. Further, 4CF has specific complica-
tions that do not arise in PRC, with our review
demonstrating an 8.9% 4CF nonunion rate and
2.2% hardware removal rate. The nonunion and
hardware removal rates were especially notable in
4CF performed with a plate. It is a possibility that
this disproportionally high rate of removal with
plates is secondary to the use of plates that were
subsequently removed from the market due to a
high proportion of nonunions.26,27 Van Hernen
et al,28 in a study of 266 patients undergoing PRC
or 4CF for SNAC and SLAC wrists, reported that
reoperation was more commonly performed in 4CF
(34%) than in PRC (11%). Inevitably, the risk of
complications and conversion to wrist arthrodesis
are multifactorial in nature, though PRC appears to
be associated with a lower complication rate.
This study has several limitations. To capture all
relevant articles, we queried highly used databases
using broad search terms, but relevant articles still may
have been missed. The analysis of many retrospective
studies compounds individual and reporting bias, and
the overall quality is dictated by the individual studies.
Follow-up was set a minimum of 12 months but
ranged from 12 to 216 months across studies. We did
not set a minimum level of evidence as part of our
inclusion criteria. Although the MINORS scores
indicated moderate quality, this scoring system may
still have limitations, and many of the included studies
were level IV evidence.18 Further, reporting of certain
ROM and outcome score measures varied by study
and limited analysis in some situations. Although
limiting our inclusion to only SLAC and SNAC wrists
allows drawing of a stronger conclusion regarding
these pathologies, our findings may not apply to other
conditions. Additionally, selection bias may be present
in determining which procedure was performed in
patients, and 4CF may be the only option prior to wrist
arthrodesis for patients with advanced arthritis or those
who are not candidates for PRC. The inability to
identify how this affected the observations is one of
the main limitations of the study. We also could not
compare 4CF techniques or capsular interposition due
to reporting heterogeneity and inability to stratify. This
heterogeneity in reporting extended to the fact that not
all studies provided outcome scores or complications.
Although patient-reported outcomes and satisfaction
have become a contemporary focus, attempts to
compare these across procedures is currently limited.
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1.e6 PROXIMAL ROW CARPECTOMY VERSUS FOUR-CORNER FUSION
In this meta-analysis, PRC was associated with
favorable outcomes when performed for SLAC and
SNAC wrist compared to 4CF, demonstrating slight
ROM benefits and a lower complication rate. Notably,
both procedures provide some relief to patients,
although in some cases, this may be at the cost of ROM.
CONFLICTS OF INTEREST
K.A.H. is a paid consultant for LinkBio Corp.
T.W.W. is a consultant for and receives royalties
from Exactech, Inc. No benefits in any form have
been received or will be received by the other authors
related directly to this article.
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