Skip to content

Partial Wrist Fusion PDF Evidence

A hand-drawn illustration of a partial fusion of the carpal bones of the wrist.
X-ray after a partial wrist fusion: only the painful, arthritic joints are fused with screws, leaving the healthy joints free to move so the wrist keeps some bend and rotation. Kieran Hirpara 4.0

Patient-facing topic for four-corner and capitolunate (two-corner) fusion of the wrist — joint-preserving alternative to total wrist fusion that retains some bending motion.

Why this operation has been suggested

Your surgeon has suggested a partial wrist fusion, also known as a four-corner or capitolunate arthrodesis, to treat advanced wear-and-tear arthritis in your wrist. This procedure is typically offered when non-surgical treatments have not provided enough relief and your specific joint damage involves the capitolunate area. It is designed to relieve pain and provide stability by fusing the remaining healthy bones together.

The main goal of this operation is to give you reliable, resilient function that remains stable over time. By removing the damaged bone and joining the others, the surgery aims to stop the grinding that causes pain while preserving as much motion as possible. This approach offers a strong alternative to a total wrist replacement or a more extensive fusion, helping you return to daily activities with less discomfort.

Before the operation

Your surgeon will likely order X-rays, blood tests, or an MRI to check your wrist and overall health before surgery. You will need to fast for several hours before the procedure and stop taking certain medications as your surgeon instructs. Please arrange for a friend or family member to drive you home, as you cannot drive yourself. Bring a complete list of all current medicines and wear comfortable, loose clothing to the hospital. This operation is performed through a single open incision on the back of your wrist. Your surgical team will review all specific instructions with you directly.

On the day

You will arrive at the hospital and meet your anaesthetist to discuss your care. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief — the anaesthetist decides on the day based on your individual circumstances.

Your surgeon will perform the procedure through a single open incision over your wrist. You will then be moved to the recovery area to wake up safely. You will be monitored closely while the effects of the anaesthetic wear off.

What the operation involves

Your surgeon will make a single cut over the back of your wrist to reach the joint. This open approach allows direct access to the bones inside. Depending on your specific arthritis, your surgeon may remove the scaphoid bone or resurface the capitate bone with a special implant.

Next, your surgeon prepares the joint surfaces for fusion. If you are having a four-corner fusion, the surgeon removes the scaphoid bone and joins the remaining four wrist bones together. For a capitolunate fusion, only the capitate and lunate bones are joined. The surgeon uses screws, staples, or a metal plate to hold these bones firmly in place while they heal. Local bone graft may be added to help the bones grow together.

Finally, your surgeon closes the cut with stitches and applies a dressing. The goal is to create a stable, pain-free wrist while keeping as much motion as possible in the remaining joints. This procedure is designed for wrists with advanced arthritis where other treatments have not worked.

After the operation

You will wake up in a recovery ward where your team manages your pain. Your surgeon uses a single open incision over your wrist. You will leave with a bulky dressing and a sling or brace to protect your wrist. Most patients go home the same day, but some stay overnight. You must have someone stay with you for the first 24 hours to help you. You will start moving your fingers gently right away. Your surgeon will guide you on how to care for your wound and when to start using your hand again.

Recovery

After your open surgery, you will likely feel pain and swelling in your wrist and hand. This is normal as your body heals. Your surgeon will guide you on how to manage this discomfort with medication and ice. You will wear a cast or splint to protect the fused bones while they join together.

In the early days, you will keep your arm elevated to reduce swelling. You will use a sling for support when moving around the house. Simple tasks like eating or brushing your teeth are possible with care. Your physiotherapist will teach you gentle exercises to keep your fingers moving and prevent stiffness. As the swelling settles and movement returns, you will gradually start using your hand more.

Your surgeon and physio will guide you on when to stop using the brace and how to strengthen your grip. Your timeline may differ from others; your surgeon and physio will guide you based on your healing. You will feel more confident as the pain fades and your wrist becomes stable.

What can go wrong

Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.

Sometimes the bones do not heal together as planned. You might notice deep pain that does not ease with simple painkillers or a feeling that the wrist is still unstable. If this happens, call your surgeon to discuss the next steps.

There is a small chance the joint may need to be fully fused later. You might feel increasing stiffness or pain that returns after a period of improvement. Your surgeon will review your X-rays and talk to you about converting to a total wrist fusion if needed.

In some cases, the bone graft or screws may not work as intended. You could feel a clicking or grinding sensation in your wrist, or notice sudden swelling and tenderness. Bring this up at your next review so your surgeon can check the hardware.

If you have a pyrocarbon implant, the long-term results can be hard to predict. You might experience pain or loss of motion over time. If the implant fails, a fusion surgery remains an option to fix the problem.

The complications table on this page lists typical rates if you want the specifics.

When to call us

Call us if you have a fever, increasing redness, or discharge from your wound. Contact your surgeon immediately for sudden, severe pain or if you lose feeling in your hand. Go to emergency care if you notice calf swelling or shortness of breath. These signs may mean a blood clot or infection that needs urgent treatment.

Reviewed by AI synthesis (v2) — pending human review · 2026-05-18 19:02:24.992455+00:00.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

title: "Partial Wrist Fusion" slug: partial-wrist-fusion region: wrist audience: patient mesh_terms: ["Arthrodesis", "Carpal Bones"] article_count: 316 model_used: qwen3.5-35b-a3b-q8 generated_at: '2026-05-18T14:13:49+00:00' key_articles: - title: "How Much Scaphoid Can be Safely Resected? A Biomechanical Analysis of the Effects of Distal Scaphoid Resection" ref_num: 1 evidence_tier: paper evidence_level: 5 doi: 10.1177/1558944720966717 year: 2020 - title: "Vascularized Bone Graft to the Lunate Combined with Shortening of the Capitate and Radius for Treatment of Advanced Kienböck Disease After a Follow-Up for More Than 10 Years" ref_num: 2 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsg.2019.09.012 year: 2020 - title: "The use of a pyrocarbon capitate resurfacing implant in chronic wrist disorders" ref_num: 3 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193413501730 year: 2013 - title: "Midcarpal instability" ref_num: 4 evidence_tier: paper evidence_level: 5 doi: 10.1177/1753193415617756 year: 2015 - title: "Resilience of SLAC 4-Corner Fusion: Long-Term Follow-Up" ref_num: 5 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2014.06.118 year: 2014 - title: "The Outcome of Scaphoid Excision and Four-Corner Arthrodesis for Advanced Carpal Collapse at a Minimum of Ten Years" ref_num: 6 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2010.01.025 year: 2010 - title: "Reduction and Association of the Scaphoid and Lunate Procedure: Short-Term Clinical and Radiographic Outcomes" ref_num: 7 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2014.07.014 year: 2014 - title: "Ten-Year Minimum Follow-Up of 4-Corner Fusion for SLAC and SNAC Wrist" ref_num: 8 evidence_tier: paper evidence_level: 4 doi: 10.1177/1558944716681949 year: 2016 - title: "Pyrocarbon Interposition Arthroplasty for Proximal Capitate Avascular Necrosis" ref_num: 9 evidence_tier: paper evidence_level: 5 doi: 10.1007/s11552-014-9698-7 year: 2014 - title: "2007 IFSSH Committee Report of Wrist Biomechanics Committee: Biomechanics of the So-Called Dart-Throwing Motion of the Wrist" ref_num: 10 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2007.08.014 year: 2007 - title: "Radioscapholunate Arthrodesis With Compression Screws and Local Autograft" ref_num: 11 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2013.01.026 year: 2013 - title: "Three-dimensional analysis of the proximal articulating surfaces of the lunate and capitate" ref_num: 12 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193413488303 year: 2013 - title: "A new plate for partial wrist fusions: results in midcarpal arthrodesis" ref_num: 13 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193410395357 year: 2011 - title: "Radiocarpal fusion and midcarpal resection interposition arthroplasty: long-term results in severely destroyed rheumatoid wrists" ref_num: 14 evidence_tier: paper evidence_level: 4 doi: 10.1186/s12891-018-2172-x year: 2018 - title: "A Case of Implant Failure in Partial Wrist Fusion Applying Magnesium-Based Headless Bone Screws" ref_num: 15 evidence_tier: case_report evidence_level: 4 doi: 10.1155/2016/7049130 year: 2016 - title: "Surgical Treatments for Scapholunate Advanced Collapse Wrist: Kinematics and Functional Performance" ref_num: 16 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jhsa.2015.04.035 year: 2015 - title: "Interfragmentary Motion in Patients With Scaphoid Nonunion" ref_num: 17 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2008.03.008 year: 2008 - title: "Dart-Splint: An innovative orthosis that can be integrated into a scapho-lunate and palmar midcarpal instability re-education protocol" ref_num: 18 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jht.2015.01.007 year: 2015 - title: "Scaphocapitate Arthrodesis for Kienböck Disease" ref_num: 19 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2014.12.013 year: 2015 - title: "Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up" ref_num: 20 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jhsa.2017.06.016 year: 2017 - title: "Parallel K-Wire Placement Leads to Fusion and Midcarpal Settling in Scaphoid Excision Four-Corner Fusion" ref_num: 21 evidence_tier: paper evidence_level: 4 doi: 10.1177/15589447211057302 year: 2021 - title: "Scaphoid Excision with Four-Corner Fusion: A Biomechanical Study" ref_num: 22 evidence_tier: paper evidence_level: 5 doi: 10.1007/s11552-007-9048-0 year: 2007 - title: "“Off-Label” Use of Orthopedic Implants in the Wrist" ref_num: 23 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2012.10.050 year: 2013 - title: "Arthroscopic Resection of the Proximal Capitate With Tendon Interposition for Isolated Capitolunate Osteoarthritis: A Retrospective Series of Six Cases" ref_num: 24 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2025.06.004 year: 2026 - title: "Avascular necrosis of the capitate: report of six cases and review of the literature" ref_num: 25 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193414524876 year: 2014 - title: "Volar Capitate Dislocation: A Case Report" ref_num: 27 evidence_tier: case_report evidence_level: 5 doi: 10.1007/s11552-013-9545-2 year: 2013 - title: "Elongation of the Dorsal Carpal Ligaments: A Computational Study of In Vivo Carpal Kinematics" ref_num: 29 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2012.04.025 year: 2012 - title: "Force in the Scapholunate Interosseous Ligament During Active Wrist Motion" ref_num: 30 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2015.04.007 year: 2015 - title: "Radiocarpal and midcarpal kinematics in scapholunate instability: a four-dimensional CT study in vivo" ref_num: 31 evidence_tier: paper evidence_level: 3 doi: 10.1177/17531934241242676 year: 2024 - title: "Scapholunate and lunotriquetral joint dynamic stabilizers and their role in wrist neuromuscular control and proprioception" ref_num: 32 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jht.2023.09.011 year: 2024 - title: "Carpal Kinematics and Kinetics" ref_num: 33 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2016.07.105 year: 2016 - title: "In Vivo Kinematics of the Scaphoid, Lunate, Capitate, and Third Metacarpal in Extreme Wrist Flexion and Extension" ref_num: 34 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2012.10.035 year: 2013 - title: "Imaging in carpal instability" ref_num: 35 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193415610515 year: 2015 - title: "Impact of scapholunate dissociation on human wrist kinematics" ref_num: 38 evidence_tier: paper evidence_level: 5 doi: 10.1177/1753193415600669 year: 2015 - title: "Imaging Recognition of Morphological Variants at the Midcarpal Joint" ref_num: 39 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2009.03.002 year: 2009 - title: "International Federation of Societies for Surgery of the Hand 2013 Committee's Report on Wrist Dart-Throwing Motion" ref_num: 40 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2014.02.035 year: 2014 - title: "Changes in Contact Site of the Radiocarpal Joint and Lengths of the Carpal Ligaments in Forearm Rotation: An In Vivo Study" ref_num: 41 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2013.01.021 year: 2013 - title: "Reconstruction of Both Volar and Dorsal Limbs of the Scapholunate Interosseous Ligament" ref_num: 42 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2013.05.026 year: 2013 - title: "Ulnar-sided Wrist Pain: Evaluation and Treatment of Triangular Fibrocartilage Complex Tears, Ulnocarpal Impaction Syndrome, and Lunotriquetral Ligament Tears" ref_num: 43 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2012.04.036 year: 2012 - title: "Influence of forearm rotation on the kinetic stabilizing efficiency of the muscles that control the scapholunate joint. Clinical application in proprioceptive and neuromuscular rehabilitation programs" ref_num: 44 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jht.2023.09.012 year: 2024 - title: "Carpal Kinematics After Proximal Row Carpectomy" ref_num: 45 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2006.10.014 year: 2007 - title: "Complex Carpal Dissociation With Open, Complete, and Divergent Trapezium, Capitate, and Hamate Dislocation: A Case Report" ref_num: 46 evidence_tier: case_report evidence_level: 4 doi: 10.1016/j.jhsa.2007.07.025 year: 2007 - title: "Exercise-based intervention as a nonsurgical treatment for patients with carpal instability: A case series" ref_num: 47 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jht.2023.08.010 year: 2024 - title: "Modified AO Arthrodesis of the Wrist (With Proximal Row Carpectomy)" ref_num: 48 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2012.11.010 year: 2013 - title: "Trigger wrist caused by avascular necrosis of the capitate: a case report" ref_num: 49 evidence_tier: case_report evidence_level: 4 doi: 10.1186/s12891-018-2010-1 year: 2018 - title: "Midcarpal instability after excision arthroplasty for scapho-trapezial-trapezoid (STT) arthritis" ref_num: 50 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193408098903 year: 2009 - title: "Radiocarpal Fusion: Indications, Technique, and Modifications" ref_num: 51 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2022.04.002 year: 2022 - title: "Vascular anatomy of the capitate determined by micro-computed tomography angiography" ref_num: 52 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193417714400 year: 2017 - title: "Relative Contributions of the Midcarpal and Radiocarpal Joints to Dart-Thrower’s Motion at the Wrist" ref_num: 53 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2017.10.017 year: 2018 - title: "The Crucial Role of Locking Screws in Total Wrist Arthroplasty: Should We Always Revise or Not?" ref_num: 55 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsg.2024.01.002 year: 2024 - title: "Lateral Femoral Trochlea Flap Reconstruction of the Proximal Capitate: An Assessment of Congruity and Description of Technique" ref_num: 56 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2022.04.015 year: 2023 - title: "Dynamic CT Scan of the Normal Scapholunate Joint in a Clenched Fist and Radial and Ulnar Deviation" ref_num: 57 evidence_tier: paper evidence_level: 4 doi: 10.1177/1558944717726372 year: 2017 - title: "Traumatic Nondissociative Carpal Instability: A Case Series" ref_num: 58 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2021.04.024 year: 2022 - title: "Simulated Radioscapholunate Fusion Alters Carpal Kinematics While Preserving Dart-Thrower's Motion" ref_num: 59 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2007.12.013 year: 2008 - title: "Effect of scaphoid and triquetrum excision after limited stabilisation on cadaver wrist movement" ref_num: 60 evidence_tier: paper evidence_level: 5 doi: 10.1177/1753193408094923 year: 2009 - title: "Arthroscopic Interposition Tendon Arthroplasty for Stage 2 Scapholunate Advanced Collapse" ref_num: 61 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.arthro.2018.10.134 year: 2019 - title: "The Benefit of Magnetic Resonance Imaging for Patients With Posttraumatic Radial Wrist Tenderness" ref_num: 62 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jhsa.2012.09.034 year: 2013 - title: "The Optimal Location to Measure Scapholunate Diastasis on Screening Radiographs" ref_num: 63 evidence_tier: paper evidence_level: 5 doi: 10.1177/1558944717729219 year: 2017 - title: "Common Radiographic Imaging Modalities Fail to Accurately Predict Capitate Morphology" ref_num: 64 evidence_tier: paper evidence_level: 4 doi: 10.1007/s11552-015-9743-1 year: 2015 - title: "Four-corner bone arthrodesis with dorsal rectangular plate: series and personal technique" ref_num: 66 evidence_tier: paper evidence_level: 4 doi: 10.1177/1753193409105684 year: 2009 - title: "Arthroscopic Partial Capitate Resection for Type Ia Avascular Necrosis: A Short-Term Outcome Analysis" ref_num: 67 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2015.09.010 year: 2015 - title: "Intercarpal Arthrodeses" ref_num: 68 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jhsa.2013.09.014 year: 2014 - title: "Proximal Row Carpectomy Versus 4-Corner Fusion: Incidence, Conversion to Fusion, and Cost" ref_num: 70 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jhsa.2019.12.010 year: 2020 - title: "A Comparative Analysis of Resource Utilization Between Proximal Row Carpectomy and Partial Wrist Fusion: A Population Study" ref_num: 71 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jhsa.2017.07.032 year: 2017 - title: "Treatment Outcomes of 4-Corner Arthrodesis for Patients With Advanced Carpal Collapse: An Average of 4 Years’ Follow-Up Comparing 2 Different Plate Types" ref_num: 74 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2017.10.036 year: 2018 synthesis_version: "v2" verifier_status: skipped

Overview

  • Resection of over 25% of the scaphoid should be avoided or supplemented with partial wrist fusion due to induced instability and unpredictable kinematics [1].
  • Fusion of the proximal carpals developed in 3 of 7 patients who received vascularized bone graft with capitate shortening and radial shortening [2].
  • The use of a pyrocarbon capitate resurfacing implant may represent a good alternative to total and partial wrist arthrodesis [3].
  • Treatment options for midcarpal instability including partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage have been described in small case series with limited follow-up [4].
  • There are no comparative series or randomized studies for the treatment of midcarpal instability [4].
  • Scaphoid excision and four-corner fusion remains a viable option for patients with advanced wrist arthritis with reliable, resilient functional results that remain stable over time [5].
  • There is a low rate of conversion to total wrist arthrodesis following scaphoid excision and four-corner arthrodesis for advanced carpal collapse at a minimum of ten years [6].
  • The reduction and association of the scaphoid and lunate procedure should be abandoned due to a majority of patients experiencing early radiographic failure in the short term [7].
  • It is difficult to predict long-term survival of pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis, but the outcome so far is encouraging [9].
  • Conversion to midcarpal fusion remains a salvage option for pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis [9].
  • Radioscapholunate arthrodesis with compression screws and local autograft is an effective method to perform the procedure in appropriately selected patients with a preserved midcarpal joint [11].
  • Radioscapholunate arthrodesis with compression screws and local autograft achieves a 100% union rate at mean follow-up of 12 months with no complications [11].
  • Scaphoidectomy and midcarpal fusion is a useful salvage procedure in a variety of degenerative conditions [13].
  • The use of magnesium-based headless bone screws for partial wrist arthrodesis is not supported due to premature mechanical instability [15].
  • Radial wrist hemiarthroplasty implants are not approved by the FDA for use in humans in the United States [23].
  • Radial wrist hemiarthroplasty implants must be performed as off-label use with full patient understanding and appropriate institutional review board approval [23].

Anatomy & Pathophysiology

  • Resection of over 25% of the scaphoid induces instability and unpredictable kinematics [1].
  • A dart-throwing motion (DTM) at approximately 30° to 45° from the sagittal plane allows continued functional wrist motion while minimizing radiocarpal motion [10].
  • Surgical groups for scapholunate advanced collapse demonstrate decreased wrist kinematic motion and functional performance compared with individuals with normal wrists [16].
  • Scaphoid nonunions partially uncouple the proximal and distal carpal rows [17].
  • Computed fiber elongations of the dorsal carpal ligaments vary linearly with wrist position [29].
  • During simple unresisted wrist motions, force in the scapholunate interosseous ligament does not exceed 20 N [30].
  • Kinematic changes in scapholunate instability may predict the development of radioscaphoid arthritis [31].
  • Comprehending carpal dysfunctions and instabilities hinges on understanding carpal anatomy and normal biomechanics [32].
  • The distal carpal row has negligible intercarpal motion while the proximal row drives motion [33].
  • More than half the motion of the carpus when the wrist was loaded in extension occurred at the midcarpal joint [34].
  • Static imaging techniques may accurately depict major wrist ligamentous injury, while dynamic ultrasound and videofluoroscopy may demonstrate dynamic instability and kinematic dysfunction [35].
  • A pattern of kinematic changes was established after scapholunate ligament injury despite individual variance [38].
  • Accurate identification of carpal bone morphology is required to improve understanding of carpal mechanics and pathology [39].
  • A wide range of dart-throwing motion planes exists [40].
  • Midcarpal arthrodesis adversely affects dart-throwing motion compared with radiocarpal arthrodesis [40].
  • During forearm rotation, the contact site of the scaphoid and the lunate on the distal radial articular surface changed minimally [41].
  • Reconstruction of both volar and dorsal limbs of the scapholunate interosseous ligament aims to approximate original anatomy and restore normal carpal mechanics [42].

Classification

  • Resection of over 25% of the scaphoid should be avoided or supplemented with partial wrist fusion due to induced instability and unpredictable kinematics [1].
  • Fusion of the proximal carpals developed in 3 of 7 patients who received vascularized bone graft with capitate shortening and radial shortening [2].
  • The use of a pyrocarbon capitate resurfacing implant may represent a good alternative to total and partial wrist arthrodesis [3].
  • Treatment options for midcarpal instability including partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage have been described in small case series with limited follow-up [4].
  • There are no comparative series or randomized studies for midcarpal instability treatment options including partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage [4].
  • Scaphoid excision and four-corner fusion remains a viable option for patients with advanced wrist arthritis with reliable, resilient functional results that remain stable over time [5].
  • There is a low rate of conversion to total wrist arthrodesis following scaphoid excision and four-corner arthrodesis for advanced carpal collapse at a minimum of ten years [6].
  • Functional results were good at long-term follow-up for 4-corner fusion for SLAC and SNAC wrist despite radiographic changes in the radiolunate joint in 73% of patients [8].
  • Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows [17].
  • Simulated radiocarpal fusion and simulated partial carpal fusion decreased range of motion compared with the intact wrist [53].
  • The principal direction of wrist motion along the path of dart-thrower's motion was not significantly altered by simulated radiocarpal fusion or partial carpal fusion [53].
  • The LFT and MFT demonstrate similar congruity to the proximal capitate in the sagittal and coronal planes of the wrist [56].
  • Simulated radioscapholunate fusion confirmed the dart-thrower's hypothesis as wrist motion was primarily preserved from radial-extension toward ulnar-flexion [59].
  • Midcarpal stabilisation and scaphoid and triquetrum excision retains most wrist motion [60].

Clinical Presentation

  • Resection of over 25% of the scaphoid induces instability and unpredictable kinematics [1].
  • Fusion of the proximal carpals developed in 3 of 7 patients who received vascularized bone graft with capitate shortening and radial shortening [2].
  • Treatment options for midcarpal instability include partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage [4].
  • There are no comparative series or randomized studies regarding treatment options for midcarpal instability [4].
  • Scaphoid excision and four-corner fusion remains a viable option for patients with advanced wrist arthritis with reliable, resilient functional results that remain stable over time [5].
  • There is a low rate of conversion to total wrist arthrodesis following scaphoid excision and four-corner arthrodesis for advanced carpal collapse [6].
  • The reduction and association of the scaphoid and lunate procedure experiences early radiographic failure in the majority of patients in the short term [7].
  • Functional results for 4-corner fusion for SLAC and SNAC wrist are good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients [8].
  • It is difficult to predict long-term survival for pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis, though outcomes are currently encouraging [9].
  • Conversion to midcarpal fusion remains a salvage option for pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis [9].
  • A dart-throwing motion (DTM) at approximately 30° to 45° from the sagittal plane allows continued functional wrist motion while minimizing radiocarpal motion [10].
  • Lunate excision without midcarpal fusion resulted in a disease-free state with good painless range of motion at 6 years [12].
  • Scaphoidectomy and midcarpal fusion is a useful salvage procedure in a variety of degenerative conditions [13].
  • Radiographic carpal collapse and ulnar translocation occurred in scaphocapitate arthrodesis for Kienböck disease, but patients were not symptomatic [19].
  • From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength [20].
  • Parallel K-wire placement across the midcarpal joints with scaphoid leads to a high rate of fusion with good patient outcomes long term [21].
  • Ulnar-sided wrist pain is a common cause of upper extremity disability with a complex differential diagnosis [43].
  • Both trigger wrist and avascular necrosis of the capitate are rare disorders [49].
  • Excision arthroplasty for scapho-trapezial-trapezoid (STT) arthritis can provoke severe malalignment and midcarpal instability [50].
  • Midcarpal instability following excision arthroplasty for STT arthritis can lead to an intercarpal arthrodesis with an outcome potentially worse than STT fusion [50].

Investigations

  • Resection of over 25% of the scaphoid should be avoided or supplemented with partial wrist fusion due to induced instability and unpredictable kinematics [1].
  • Treatment options for midcarpal instability including partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage have been described in small case series with limited follow-up [4].
  • There are no comparative series or randomized studies regarding treatment options for midcarpal instability [4].
  • A dynamic CT scan of the wrist is a user-friendly way of measuring the scapholunate distance, which is minimal in the normal wrist below 40 years of age [57].
  • Measurements in the middle of the scapholunate joint in neutral and 30° of ulnar deviation under fluoroscopic imaging best capture all stages of ligamentous disruptions [63].
  • Plain radiographs, CT, 3D-CT, and MRI are suboptimal modalities to assess capitate type [64].
  • A scaphoid fracture was by far the most common injury in patients with posttraumatic radial wrist tenderness, but it is not clear whether diagnosis of subtle injuries only demonstrated on MRI improves outcomes [62].
  • Delayed diagnosis and late reconstructive surgery for traumatic nondissociative carpal instability were associated with no improvement in radiolunate angle [58].
  • Delayed diagnosis of intercarpal injuries can result in persistent median nerve dysfunction [27].

Treatment

  • Resection of over 25% of the scaphoid should be avoided or supplemented with partial wrist fusion due to induced instability and unpredictable kinematics [1].
  • Fusion of the proximal carpals developed in 3 of 7 patients who received vascularized bone graft with capitate shortening and radial shortening [2].
  • The use of a pyrocarbon capitate resurfacing implant may represent a good alternative to total and partial wrist arthrodesis [3].
  • Treatment options for midcarpal instability including partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage have been described in small case series with limited follow-up, but there are no comparative series or randomized studies [4].
  • Scaphoid excision and four-corner fusion remains a viable option for patients with advanced wrist arthritis with reliable, resilient functional results that remain stable over time [5].
  • There is a low rate of conversion to total wrist arthrodesis following scaphoid excision and four-corner arthrodesis for advanced carpal collapse at a minimum of ten years [6].
  • The reduction and association of the scaphoid and lunate procedure should be abandoned due to a majority of patients experiencing early radiographic failure in the short term [7].
  • It is difficult to predict long-term survival of pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis, but the outcome so far is encouraging, and conversion to midcarpal fusion remains a salvage option [9].
  • Radioscapholunate arthrodesis with compression screws and local autograft is an effective method in appropriately selected patients with a preserved midcarpal joint, achieving a 100% union rate at mean follow-up of 12 months with no complications [11].
  • Lunate excision without midcarpal fusion resulted in a disease-free state with good painless range of motion at 6 years, avoiding the recurrence associated with curettage and the motion loss associated with fusion [12].
  • Scaphoidectomy and midcarpal fusion is a useful salvage procedure in a variety of degenerative conditions [13].
  • The results after total wrist joint arthroplasty vary probably as the result of different patient groups, implant types and evolution of prosthetic designs, and are not comparable with the present study [14].
  • The authors cannot support the use of magnesium-based screws for partial wrist arthrodesis due to premature mechanical instability [15].
  • Load is preferentially transferred to the radiolunate joint after scaphoid excision with four-corner fusion [22].
  • Radial wrist hemiarthroplasty implants are not approved by the FDA for use in humans in the United States and must be performed as off-label use with full patient understanding and appropriate institutional review board approval [23].
  • Arthroscopic resection of the proximal capitate with tendon interposition for isolated capitolunate osteoarthritis does not preclude the possibility of secondary arthrodesis in case of failure [24].
  • Better results were seen when arthrodesis fused in cases of avascular necrosis of the capitate [25].
  • The technique of wrist arthrodesis combining proximal row carpectomy and rigid internal fixation has proved to be a highly predictable operation with much less morbidity and fewer complications than with older techniques using distant bone graft [48].
  • Radiocarpal fusion aims to alleviate pain and improve range of motion in patients with isolated radiolunate or radioscapholunate arthritis who have failed non-surgical treatment [51].
  • Pyrocarbon interposition arthroplasty is an alternative to total wrist arthrodesis when marked degenerative changes exist at the radiolunate joint, capitate head or both, and increases operative options for challenging clinical scenarios [52].
  • Locking screws are important in improving the longevity of total wrist arthroplasty by imitating external or internal fixation for bridging large bony defects, allowing the carpal component to remain stable despite complete asymptomatic avascular bone necrosis around the capitate peg [55].
  • Arthroscopic interposition tendon arthroplasty for stage 2 scapholunate advanced collapse preserves motion, yields acceptable functional outcome, and reduces pain [61].
  • Arthroscopic partial capitate resection for type Ia avascular necrosis provided adequate pain relief and improved the range of wrist motion and grip strength during short-term follow-up [67].

Complications

  • Resection of over 25% of the scaphoid induces instability and unpredictable kinematics [1].
  • Fusion of the proximal carpals developed in 3 of 7 patients receiving vascularized bone graft with capitate shortening and radial shortening [2].
  • Treatment options for midcarpal instability, including partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage, are described in small case series with limited follow-up without comparative series or randomized studies [4].
  • There is a low rate of conversion to total wrist arthrodesis following scaphoid excision and four-corner arthrodesis for advanced carpal collapse [6].
  • The reduction and association of the scaphoid and lunate procedure experiences early radiographic failure in the majority of patients in the short term [7].
  • Radiographic changes in the radiolunate joint occur in 73% of patients at long-term follow-up despite good functional results after 4-corner fusion for SLAC and SNAC wrist [8].
  • Long-term survival of pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis is difficult to predict, though conversion to midcarpal fusion remains a salvage option [9].
  • Radioscapholunate arthrodesis with compression screws and local autograft achieves a 100% union rate at a mean follow-up of 12 months with no complications in appropriately selected patients [11].
  • Magnesium-based headless bone screws can result in premature mechanical instability and implant failure in partial wrist fusion [15].
  • Parallel K-wire placement across the midcarpal joints with scaphoid leads to a high rate of fusion with good long-term patient outcomes [21].
  • Arthroscopic resection of the proximal capitate with tendon interposition does not preclude the possibility of secondary arthrodesis in case of failure [24].
  • While some intercarpal arthrodeses yield good, predictable outcomes, others are infrequently used due to unpredictable results and high complication rates [68].
  • Wrist fusion rates are higher in the 4-corner fusion group compared to proximal row carpectomy without a significant difference in readmission rates [70].
  • Conversion rates to total wrist arthrodesis are significantly higher with partial wrist arthrodesis (19.2%) than with proximal row carpectomy (4.9%) [71].
  • Partial wrist arthrodesis has a greater associated direct cost than proximal row carpectomy [71].
  • High complication rates following four-corner arthrodesis with a nonlocking plate have led to the recommendation for fixation with a locking screw plate [74].

Recovery

  • Resection of over 25% of the scaphoid induces instability and unpredictable kinematics [1].
  • Fusion of the proximal carpals developed in 3 of 7 patients who received vascularized bone graft with capitate shortening and radial shortening [2].
  • Pyrocarbon capitate resurfacing may represent a good alternative to total and partial wrist arthrodesis [3].
  • Scaphoid excision and four-corner fusion remains a viable option for patients with advanced wrist arthritis with reliable, resilient functional results that remain stable over time [5].
  • There is a low rate of conversion to total wrist arthrodesis following scaphoid excision and four-corner arthrodesis for advanced carpal collapse at a minimum of ten years [6].
  • The reduction and association of the scaphoid and lunate procedure should be abandoned due to a majority of patients experiencing early radiographic failure in the short term [7].
  • Functional results were good at long-term follow-up for 4-corner fusion for SLAC and SNAC wrist despite radiographic changes in the radiolunate joint in 73% of patients [8].
  • It is difficult to predict long-term survival of pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis, but the outcome so far is encouraging [9].
  • Conversion to midcarpal fusion remains a salvage option for pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis [9].
  • A dart-throwing motion at approximately 30° to 45° from the sagittal plane allows continued functional wrist motion while minimizing radiocarpal motion [10].
  • Both surgical groups demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists [16].
  • Further studies need to be performed to address differences in anatomy and wrist movement among patients with different lunate shapes regarding the dart-splint [18].
  • From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength [20].
  • Delayed diagnosis of intercarpal injuries can result in persistent median nerve dysfunction [27].
  • Research underscores the importance of considering forearm rotation when developing rehabilitation protocols for scapholunate joint instability [44].
  • Radiocapitate range of motion after proximal row carpectomy was sufficient for activities of daily living [45].
  • A patient with complex carpal dissociation regained satisfactory function and returned to work at six months with stable carpus on radiographs [46].
  • Multicomponent exercise is important in the treatment of wrist instability [47].
  • Four-corner bone wrist arthrodesis by dorsal rectangular plating achieves an acceptable preservation of range of motion with good pain relief, an excellent consolidation rate and minimal complications [66].

Key Evidence

  • [L5] Resection of over 25% of the scaphoid should be avoided or supplemented with partial wrist fusion due to induced instability and unpredictable kinematics. (10.1177/1558944720966717)
  • [L4] Fusion of the proximal carpals developed in 3 of 7 patients who received vascularized bone graft with capitate shortening and radial shortening. (10.1016/j.jhsg.2019.09.012)
  • [L4] This surgical procedure may represent a good alternative to total and partial wrist arthrodesis. (10.1177/1753193413501730)
  • [L5] Treatment options including partial wrist fusions, tenodesis stabilizations, and arthroscopic capsular shrinkage have been described in small case series with limited follow-up, but there are no comparative series or randomized studies. (10.1177/1753193415617756)
  • [L4] Scaphoid excision and four-corner fusion remains a viable option for patients with advanced wrist arthritis with reliable, resilient functional results that remain stable over time. (10.1016/j.jhsa.2014.06.118)
  • [L4] There is a low rate of conversion to total wrist arthrodesis. (10.1016/j.jhsa.2010.01.025)
  • [L4] With a majority of patients experiencing early radiographic failure of the procedure in the short term, our experience suggests that the reduction and association of the scaphoid and lunate procedure should be abandoned despite the relatively low outcomes measures scores. (10.1016/j.jhsa.2014.07.014)
  • [L4] Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. (10.1177/1558944716681949)
  • [L5] It is difficult to predict long-term survival, but the outcome so far is encouraging, and conversion to midcarpal fusion remains a salvage option. (10.1007/s11552-014-9698-7)
  • [L5] Clinically, a DTM at approximately 30° to 45° from the sagittal plane allows continued functional wrist motion while minimizing radiocarpal motion. (10.1016/j.jhsa.2007.08.014)
  • [L4] This technique is an effective method to perform radioscapholunate arthrodesis in appropriately selected patients with a preserved midcarpal joint, achieving a 100% union rate at mean follow-up of 12 months with no complications. (10.1016/j.jhsa.2013.01.026)
  • [L4] Lunate excision without midcarpal fusion resulted in a disease-free state with good painless range of motion at 6 years, avoiding the recurrence associated with curettage and the motion loss associated with fusion. (10.1177/1753193413488303)
  • [L4] Scaphoidectomy and midcarpal fusion is a useful salvage procedure in a variety of degenerative conditions. (10.1177/1753193410395357)
  • [L4] The results after total wrist joint arthroplasty vary probably as the result of different patient groups, implant types and evolution of prosthetic designs, and are not comparable with the present study. (10.1186/s12891-018-2172-x)
  • [Case_report] Due to this disappointing result of the operation with premature mechanical instability, the authors cannot support the use of magnesium-based screws for partial wrist arthrodesis, at least not in dual use. (10.1155/2016/7049130)
  • [L2] Both surgical groups demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists. (10.1016/j.jhsa.2015.04.035)
  • [L4] Scaphoid nonunions have a dramatic impact on carpal kinematics, partially uncoupling the proximal and distal carpal rows. (10.1016/j.jhsa.2008.03.008)
  • [L5] Further studies need to be performed to address differences in anatomy and wrist movement among patients with different lunate shapes. (10.1016/j.jht.2015.01.007)
  • [L4] Although radiographic carpal collapse and ulnar translocation occurred, patients were not symptomatic. (10.1016/j.jhsa.2014.12.013)
  • [L2] From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength. (10.1016/j.jhsa.2017.06.016)
  • [L4] Parallel K-wire placement across the midcarpal joints with scaphoid leads to a high rate of fusion with good patient outcomes long term. (10.1177/15589447211057302)
  • [L5] Our findings suggest that load is preferentially transferred to the radiolunate joint after scaphoid excision with four-corner fusion. (10.1007/s11552-007-9048-0)
  • [L5] Radial wrist hemiarthroplasty implants are not approved by the FDA for use in humans in the United States and must be performed as off-label use with full patient understanding and appropriate institutional review board approval. (10.1016/j.jhsa.2012.10.050)
  • [L4] This approach does not preclude the possibility of secondary arthrodesis in case of failure. (10.1016/j.jhsa.2025.06.004)
  • [L4] Better results were seen when the arthrodesis fused. (10.1177/1753193414524876)
  • [Case_report] This case illustrates the importance of careful review of radiographs for evidence of intercarpal injuries, as delayed diagnosis resulted in persistent median nerve dysfunction. (10.1007/s11552-013-9545-2)
  • [L5] Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position. (10.1016/j.jhsa.2012.04.025)
  • [L5] However, during simple unresisted wrist motions, the force did not exceed 20 N. (10.1016/j.jhsa.2015.04.007)
  • [L3] These kinematic changes may predict the development of radioscaphoid arthritis and help identify a kinematically abnormal wrist. (10.1177/17531934241242676)
  • [L4] Comprehending carpal dysfunctions and instabilities hinges on understanding carpal anatomy and normal biomechanics. (10.1016/j.jht.2023.09.011)
  • [L5] Advances in 3-dimensional and 4-dimensional imaging have provided clearer insight into carpal kinematics, establishing that the distal carpal row has negligible intercarpal motion while the proximal row drives motion. (10.1016/j.jhsa.2016.07.105)
  • [L4] More than half the motion of the carpus when the wrist was loaded in extension occurred at the midcarpal joint. (10.1016/j.jhsa.2012.10.035)
  • [L4] Static imaging techniques may accurately depict major wrist ligamentous injury, while dynamic ultrasound and videofluoroscopy may demonstrate dynamic instability and kinematic dysfunction. (10.1177/1753193415610515)
  • [L5] Despite individual variance, a pattern of kinematic changes was established after scapholunate ligament injury. (10.1177/1753193415600669)
  • [L5] Accurate identification of carpal bone morphology is required to improve our understanding of carpal mechanics and pathology. (10.1016/j.jhsa.2009.03.002)
  • [L5] This report updates information on wrist dart-throwing motion based on recent research regarding its kinematics, kinetics, and clinical applications, noting that a wide range of DT planes exists and that midcarpal arthrodesis adversely affects DT motion compared with radiocarpal arthrodesis. (10.1016/j.jhsa.2014.02.035)
  • [L5] During forearm rotation, the contact site of the scaphoid and the lunate on the distal radial articular surface changed minimally. (10.1016/j.jhsa.2013.01.021)
  • [L4] The technique aims to approximate the original anatomy and restore normal carpal mechanics to prevent progression to scapholunate advanced collapse arthritis. (10.1016/j.jhsa.2013.05.026)
  • [L5] Ulnar-sided wrist pain is a common cause of upper extremity disability with a complex differential diagnosis. (10.1016/j.jhsa.2012.04.036)
  • [L5] This research underscores the importance of considering forearm rotation when developing rehabilitation protocols for scapholunate joint instability and provides a valuable perspective in line with current rehabilitation principles. (10.1016/j.jht.2023.09.012)
  • [L5] Radiocapitate range of motion after PRC was sufficient for activities of daily living. (10.1016/j.jhsa.2006.10.014)
  • [Case_report] The patient regained satisfactory function and returned to work at six months with stable carpus on radiographs. (10.1016/j.jhsa.2007.07.025)
  • [L4] These results highlight the importance of multicomponent exercise in the treatment of wrist instability. (10.1016/j.jht.2023.08.010)
  • [L4] This technique of wrist arthrodesis combining proximal row carpectomy and rigid internal fixation has proved to be a highly predictable operation with much less morbidity and fewer complications than with older techniques using distant bone graft. (10.1016/j.jhsa.2012.11.010)
  • [Case_report] Both trigger wrist and avascular necrosis of the capitate are rare disorders. (10.1186/s12891-018-2010-1)
  • [L4] The procedure can provoke severe malalignment and midcarpal instability, leading to an intercarpal arthrodesis with an outcome potentially worse than STT fusion. (10.1177/1753193408098903)
  • [L5] The procedure aims to alleviate pain and improve range of motion in patients with isolated radiolunate or radioscapholunate arthritis who have failed non-surgical treatment. (10.1016/j.jhsa.2022.04.002)
  • [L4] Pyrocarbon interposition arthroplasty is an alternative to total wrist arthrodesis when marked degenerative changes exist at the radiolunate joint, capitate head or both, and increases operative options for challenging clinical scenarios. (10.1177/1753193417714400)
  • [L5] Although both simulated fusion types decreased ROM compared with the intact wrist, the principal direction of wrist motion along the path of DTM was not significantly altered by simulated RCF or PCF. (10.1016/j.jhsa.2017.10.017)
  • [L4] The case highlights the importance of locking screws in improving the longevity of total wrist arthroplasty by imitating external or internal fixation for bridging large bony defects, allowing the carpal component to remain stable despite complete asymptomatic avascular bone necrosis around the capitate peg. (10.1016/j.jhsg.2024.01.002)
  • [L4] The LFT and MFT demonstrate similar congruity to the proximal capitate in the sagittal and coronal planes of the wrist. (10.1016/j.jhsa.2022.04.015)
  • [L4] This novel dynamic CT scan of the wrist is a user-friendly way of measuring the scapholunate distance, which is minimal in the normal wrist below 40 years of age. (10.1177/1558944717726372)
  • [L4] Delayed diagnosis and late reconstructive surgery were associated with no improvement in radiolunate angle. (10.1016/j.jhsa.2021.04.024)
  • [L5] The fusion model confirmed the dart-thrower's hypothesis as wrist motion was primarily preserved from radial-extension toward ulnar-flexion. (10.1016/j.jhsa.2007.12.013)
  • [L5] Results suggest that midcarpal stabilisation and scaphoid and triquetrum excision retains most wrist motion. (10.1177/1753193408094923)
  • [L4] This procedure preserves motion, yields acceptable functional outcome, and reduces pain. (10.1016/j.arthro.2018.10.134)
  • [L2] A scaphoid fracture was by far the most common injury, but it is not clear whether diagnosis of subtle injuries only demonstrated on MRI improves outcomes. (10.1016/j.jhsa.2012.09.034)
  • [L5] Measurements in the middle of the scapholunate joint in neutral and 30° of ulnar deviation under fluoroscopic imaging best capture all stages of ligamentous disruptions. (10.1177/1558944717729219)
  • [L4] Plain radiographs, CT, 3D-CT, and MRI are suboptimal modalities to assess capitate type. (10.1007/s11552-015-9743-1)
  • [L4] Four-corner bone wrist arthrodesis by dorsal rectangular plating achieves an acceptable preservation of range of motion with good pain relief, an excellent consolidation rate and minimal complications. (10.1177/1753193409105684)
  • [L4] It provided adequate pain relief and improved the range of wrist motion and grip strength during short-term follow-up. (10.1016/j.jhsa.2015.09.010)
  • [L5] While some procedures yield good, predictable outcomes, others are infrequently used due to unpredictable results and high complication rates. (10.1016/j.jhsa.2013.09.014)
  • [L3] Wrist fusion rates and average costs are higher in the 4CF group without a significant difference in readmission rates. (10.1016/j.jhsa.2019.12.010)
  • [L3] Conversion rates to total wrist arthrodesis are significantly higher with PWA (19.2%) than with PRC (4.9%) and have a greater associated direct cost. (10.1016/j.jhsa.2017.07.032)
  • [L4] Based on the high complication rate following FCA with a nonlocking plate, the authors no longer use this implant and recommend fixation with a locking screw plate. (10.1016/j.jhsa.2017.10.036)

References

[1] How Much Scaphoid Can be Safely Resected? A Biomechanical Analysis of the Effects of Distal Scaphoid Resection. HAND. 2020. DOI: 10.1177/1558944720966717 [2] Vascularized Bone Graft to the Lunate Combined with Shortening of the Capitate and Radius for Treatment of Advanced Kienböck Disease After a Follow-Up for More Than 10 Years. Journal of Hand Surgery Global Online. 2020. DOI: 10.1016/j.jhsg.2019.09.012 [3] The use of a pyrocarbon capitate resurfacing implant in chronic wrist disorders. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413501730 [4] Midcarpal instability. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415617756 [5] Resilience of SLAC 4-Corner Fusion: Long-Term Follow-Up. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.118 [6] The Outcome of Scaphoid Excision and Four-Corner Arthrodesis for Advanced Carpal Collapse at a Minimum of Ten Years. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.01.025 [7] Reduction and Association of the Scaphoid and Lunate Procedure: Short-Term Clinical and Radiographic Outcomes. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.014 [8] Ten-Year Minimum Follow-Up of 4-Corner Fusion for SLAC and SNAC Wrist. HAND. 2016. DOI: 10.1177/1558944716681949 [9] Pyrocarbon Interposition Arthroplasty for Proximal Capitate Avascular Necrosis. HAND. 2014. DOI: 10.1007/s11552-014-9698-7 [10] 2007 IFSSH Committee Report of Wrist Biomechanics Committee: Biomechanics of the So-Called Dart-Throwing Motion of the Wrist. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.08.014 [11] Radioscapholunate Arthrodesis With Compression Screws and Local Autograft. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.01.026 [12] Three-dimensional analysis of the proximal articulating surfaces of the lunate and capitate. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413488303 [13] A new plate for partial wrist fusions: results in midcarpal arthrodesis. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193410395357 [14] Radiocarpal fusion and midcarpal resection interposition arthroplasty: long-term results in severely destroyed rheumatoid wrists. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2172-x [15] A Case of Implant Failure in Partial Wrist Fusion Applying Magnesium-Based Headless Bone Screws. Case Reports in Orthopedics. 2016. DOI: 10.1155/2016/7049130 [16] Surgical Treatments for Scapholunate Advanced Collapse Wrist: Kinematics and Functional Performance. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.04.035 [17] Interfragmentary Motion in Patients With Scaphoid Nonunion. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.03.008 [18] Dart-Splint: An innovative orthosis that can be integrated into a scapho-lunate and palmar midcarpal instability re-education protocol. Journal of Hand Therapy. 2015. DOI: 10.1016/j.jht.2015.01.007 [19] Scaphocapitate Arthrodesis for Kienböck Disease. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.12.013 [20] Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.016 [21] Parallel K-Wire Placement Leads to Fusion and Midcarpal Settling in Scaphoid Excision Four-Corner Fusion. HAND. 2021. DOI: 10.1177/15589447211057302 [22] Scaphoid Excision with Four-Corner Fusion: A Biomechanical Study. HAND. 2007. DOI: 10.1007/s11552-007-9048-0 [23] “Off-Label” Use of Orthopedic Implants in the Wrist. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.050 [24] Arthroscopic Resection of the Proximal Capitate With Tendon Interposition for Isolated Capitolunate Osteoarthritis: A Retrospective Series of Six Cases. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.06.004 [25] Avascular necrosis of the capitate: report of six cases and review of the literature. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414524876 [27] Volar Capitate Dislocation: A Case Report. HAND. 2013. DOI: 10.1007/s11552-013-9545-2 [29] Elongation of the Dorsal Carpal Ligaments: A Computational Study of In Vivo Carpal Kinematics. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.04.025 [30] Force in the Scapholunate Interosseous Ligament During Active Wrist Motion. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.04.007 [31] Radiocarpal and midcarpal kinematics in scapholunate instability: a four-dimensional CT study in vivo. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241242676 [32] Scapholunate and lunotriquetral joint dynamic stabilizers and their role in wrist neuromuscular control and proprioception. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.09.011 [33] Carpal Kinematics and Kinetics. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.105 [34] In Vivo Kinematics of the Scaphoid, Lunate, Capitate, and Third Metacarpal in Extreme Wrist Flexion and Extension. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.035 [35] Imaging in carpal instability. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415610515 [38] Impact of scapholunate dissociation on human wrist kinematics. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415600669 [39] Imaging Recognition of Morphological Variants at the Midcarpal Joint. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.03.002 [40] International Federation of Societies for Surgery of the Hand 2013 Committee's Report on Wrist Dart-Throwing Motion. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.02.035 [41] Changes in Contact Site of the Radiocarpal Joint and Lengths of the Carpal Ligaments in Forearm Rotation: An In Vivo Study. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.01.021 [42] Reconstruction of Both Volar and Dorsal Limbs of the Scapholunate Interosseous Ligament. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.05.026 [43] Ulnar-sided Wrist Pain: Evaluation and Treatment of Triangular Fibrocartilage Complex Tears, Ulnocarpal Impaction Syndrome, and Lunotriquetral Ligament Tears. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.04.036 [44] Influence of forearm rotation on the kinetic stabilizing efficiency of the muscles that control the scapholunate joint. Clinical application in proprioceptive and neuromuscular rehabilitation programs. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.09.012 [45] Carpal Kinematics After Proximal Row Carpectomy. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.10.014 [46] Complex Carpal Dissociation With Open, Complete, and Divergent Trapezium, Capitate, and Hamate Dislocation: A Case Report. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.07.025 [47] Exercise-based intervention as a nonsurgical treatment for patients with carpal instability: A case series. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.08.010 [48] Modified AO Arthrodesis of the Wrist (With Proximal Row Carpectomy). The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.11.010 [49] Trigger wrist caused by avascular necrosis of the capitate: a case report. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2010-1 [50] Midcarpal instability after excision arthroplasty for scapho-trapezial-trapezoid (STT) arthritis. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408098903 [51] Radiocarpal Fusion: Indications, Technique, and Modifications. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2022.04.002 [52] Vascular anatomy of the capitate determined by micro-computed tomography angiography. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417714400 [53] Relative Contributions of the Midcarpal and Radiocarpal Joints to Dart-Thrower’s Motion at the Wrist. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.10.017 [55] The Crucial Role of Locking Screws in Total Wrist Arthroplasty: Should We Always Revise or Not?. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.01.002 [56] Lateral Femoral Trochlea Flap Reconstruction of the Proximal Capitate: An Assessment of Congruity and Description of Technique. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.04.015 [57] Dynamic CT Scan of the Normal Scapholunate Joint in a Clenched Fist and Radial and Ulnar Deviation. HAND. 2017. DOI: 10.1177/1558944717726372 [58] Traumatic Nondissociative Carpal Instability: A Case Series. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.04.024 [59] Simulated Radioscapholunate Fusion Alters Carpal Kinematics While Preserving Dart-Thrower's Motion. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.12.013 [60] Effect of scaphoid and triquetrum excision after limited stabilisation on cadaver wrist movement. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408094923 [61] Arthroscopic Interposition Tendon Arthroplasty for Stage 2 Scapholunate Advanced Collapse. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.10.134 [62] The Benefit of Magnetic Resonance Imaging for Patients With Posttraumatic Radial Wrist Tenderness. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.09.034 [63] The Optimal Location to Measure Scapholunate Diastasis on Screening Radiographs. HAND. 2017. DOI: 10.1177/1558944717729219 [64] Common Radiographic Imaging Modalities Fail to Accurately Predict Capitate Morphology. HAND. 2015. DOI: 10.1007/s11552-015-9743-1 [66] Four-corner bone arthrodesis with dorsal rectangular plate: series and personal technique. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409105684 [67] Arthroscopic Partial Capitate Resection for Type Ia Avascular Necrosis: A Short-Term Outcome Analysis. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.09.010 [68] Intercarpal Arthrodeses. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.09.014 [70] Proximal Row Carpectomy Versus 4-Corner Fusion: Incidence, Conversion to Fusion, and Cost. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.12.010 [71] A Comparative Analysis of Resource Utilization Between Proximal Row Carpectomy and Partial Wrist Fusion: A Population Study. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.07.032 [74] Treatment Outcomes of 4-Corner Arthrodesis for Patients With Advanced Carpal Collapse: An Average of 4 Years’ Follow-Up Comparing 2 Different Plate Types. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.10.036

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.