World J Surg Surg Res | Volume 2, Issue 1 | Research Article | Open Access

Smoking Increases Risk of Symptomatic Nonunion after Four-Corner Arthrodesis

Kyle Andrews1, Margaret Jain2, Joshua Schwind1, Megan Mooney1*, Phillip Stokey1, Briana Stirling1, Abdu l Azim Mustapha1 and Martin Skie1

1Department of Orthopedic Surgery, The University of Toledo Medical Center, Toledo, USA 2Department of Orthopedic Surgery, Salmon Medical Center, Silverdale, USA

*Correspondance to: Megan Mooney 

Fulltext PDF


Background: Nonunion remains prevalent among patients undergoing scaphoidectomy and Four-
Corner Arthrodesis (FCA) despite advances in patient selection and surgical technique. This study
examined smoking along with other patient and surgical factors to determine their effect on union
in patients undergoing FCA.
Methods: A retrospective review was conducted of consecutive cases of FCA completed at our
tertiary referral institution between 2001 and 2016. Two-hundred twelve cases were identified. After
exclusion criteria applied, 148 procedures performed in 146 patients (111 men, 35 women; mean
age 50.8 years) with an average follow-up of 26.2 months (4 to 154 months) were included for
analysis. Charts were reviewed for smoking status and other patient and surgical characteristics. The
primary outcome measure was symptomatic nonunion. Subjects were separated by outcome, group
1 (union) and group 2 (symptomatic nonunion) and analyzed.
Results: Thirty-seven of the 148 wrists (25.0%) developed symptomatic nonunion. Group 1 (union)
and group 2 (nonunion) subjects consisted of 111 and 37 wrists, respectively. Smoking status
differed significantly between the two groups (24.3% and 43.2%, respectively). Sixteen of 43 (37.2%)
smokers developed symptomatic nonunion compared to 21 of 105 (20%) nonsmokers. Union did
not differ significantly with respect to age, gender, diabetes mellitus, indication, fixation construct,
or source of bone graft.
Conclusion: Perioperative smoking is a significant risk factor for development of symptomatic
nonunion following FCA. We recommend all patients considering four-corner arthrodesis be
counseled regarding the high risk of nonunion in smokers.


Arthrodesis; Four-corner fusion; Nonunion; Tobacco; Wrist


Andrews K, Jain M, Schwind J, Mooney M, Phillip Stokey, Stirling B, et al. Smoking Increases Risk of Symptomatic Nonunion after Four-Corner Arthrodesis. World J Surg Surgical Res. 2019; 2: 1177..

Subscribe to Our Newsletter