Dealer’s Choice on Surgical Approach for 4-Corner Fusion

No efficacy differences among many approaches to wrist fusion in large systematic review — and that creates options

What’s the Claim?

A systematic review of 29 studies found no differences in any key endpoints among the many commonly used approaches for four-corner wrist fusions. But don’t hit “delete” — this no-difference study holds a lesson worth your time. The most-common indications for fusion in these studies were SNAC or SLAC wrist (20 of 29 studies), with the remainder looking at a variety of indications you’d expect (AVN, midcarpal arthritis, instability, failed scapholunate ligament surgery, and perilunate injury). The most-common approaches used (24 of 29 studies) were K-wires, nonlocking plates, and locking plates. With few exceptions, studies of all techniques resulted in fusions in over 90% of patients, with no obvious differences in grip strength (which was generally good) or revision surgery (which was generally uncommon, occurring in about 12% of patients).

How’s It Stack Up?

Since systematic reviews are made up of the available evidence, they generally comport well with it. So let’s talk instead about caveats on that evidence so no one gets misled. The most-important one is that the actual findings here — percentages of patients achieving fusion or undergoing revision, and grip strength — must be considered best-case estimates. While this systematic review required a “minimum average” follow-up of 2 years, the authors placed no restriction on the proportion of patients lost to follow-up in the source study. Patients accounted for in the kinds of case series in this systematic review are almost always doing better than those missing. Unsure about that? Compare the happiness level of patients who had surgery with your crosstown competition and who present to you for follow-up after a complication (the missing, to the other surgeon) with the happiness level of patients you’ve operated on and who stay with you (the accounted for, who come bearing gifts at Christmastime). Because of this, we recommend discounting the percentages presented for each treatment approach, which, for the endpoint of fusion, generally were in the low- to mid-90% range, with no obvious differences among the treatments compared. In actual practice, that percentage is likely to be lower, grip strength results not as good, and revisions more frequent. Nonetheless, since these authors found only one randomized trial to include (and that one had only 14 patients in it), this systematic review is likely to be as good as it gets for awhile.

What’s Our Take?

Since this is a no-diff study, we can answer a key question about studies with no-difference findings: “Who cares?” For this, we consulted CORRelations’ advisor in Hand Surgery, Desirae McKee, MD, who shared: “This article basically says it’s dealers choice, which may reassure folks about the method they are currently using. Alternatively, it may entice surgeons to try alternative or easier fixation techniques, for those who’d wanted to try something different.” Just don’t overpromise when you do so — real-world fusion rates likely are lower than those reported here for all approaches they studied, and complications more frequent.


Andronic O, Labèr R, Kriechling P, et al. Surgical Fixation Techniques in Four-corner Fusion of the Wrist: A Systematic Review of 1103 Cases. J Plast Surg Hand Surg. 2023;57:29-37.