Idiopathic osteonecrosis of the scaphoid (Preiser's disease) – MRI gives new insights into etiology and pathology

Atraumatic Scaphoid Avascular Necrosis After Repeated Steroid Injections

Atraumatic avascular necrosis of the scaphoid is an extremely rare pathology. We present a case of avascular necrosis of the scaphoid following repeat local glucocorticoid injections. A 70-year-old, right-handed woman presented to our clinic with 2 years of atraumatic, progressively worsening left wrist pain and loss of range of motion. Imaging demonstrated fragmentation and avascular necrosis of the scaphoid. The patient underwent uncomplicated scaphoid excision, pisiform excision, and intercarpal arthrodesis, with a good functional outcome. This case highlights both the risk of repeated intra-articular steroid injections and the importance of obtaining serial radiographs when providing intra-articular steroid injections. [Orthopedics. 2025;48(3):188-191.].

Treatment Selection and Characteristics of Patients With Preiser Disease

Purpose

Preiser disease is difficult to diagnose and treat because of its unclear pathophysiology. Although both nonsurgical treatment and surgical treatment for Preiser disease have been reported, there is no consensus on the optimal treatment because of its rarity. The purpose of this study was to investigate the relationship between treatment selection and characteristics of patients with Preiser disease.

Methods

This single-institution retrospective chart review included nine patients (two men and seven women) with Preiser disease who were treated at our hospital. We divided patients into two groups consisting of elderly (older than 65 years of age) and nonelderly patients. Herbert-Lanzetta classification, presence of dorsal intercalated segment instability (DISI), Watson classification based on plain radiography, Kalainov classification based on magnetic resonance imaging, and treatment modalities were investigated in both groups.

Results

In the elderly group, three of five cases were in advanced stages of Preiser disease according to the Herbert-Lanzetta classification. Three wrists had a DISI deformity. Three patients underwent conservative treatment. The two remaining cases classified as Herbert-Lanzetta stage II underwent closing radial wedge osteotomy. In the nonelderly group, three of four cases were in the early stages of Preiser disease according to the Herbert-Lanzetta classification. One wrist had a DISI deformity. Two patients were treated conservatively. The other two patients were surgically treated using closing radial wedge osteotomy in one case and vascularized bone graft from the second metacarpal base in another case, both classified as Herbert-Lanzetta stage II.

Conclusions

Most elderly patients with Preiser disease showed concurrent DISI at the time of initial presentation and advanced stage. Most elderly patients underwent nonsurgical treatment. Even when surgical treatment is implemented, our study suggests that the less invasive and optimal treatment is closing radial wedge osteotomy.

Type of study/level of evidence

Therapeutic IV.

A systematic review on the management of idiopathic avascular necrosis of the scaphoid (Preiser's disease)

BACKGROUND

Treatment options for patients with Preiser's disease are challenging and varied. This article thus provides a systematic review of existing studies on the outcomes of the treatments for patients suffering from Preiser's disease in order to investigate the most appropriate management of Preiser's in each stage of the disease.

METHODS

We followed PRISMA guidelines while performing the study, and reviewed 107 papers in all languages from 1981 till November 2020 and included 42 studies that met the eligibility criterion. Studies investigating the outcome of one or more treatment options for Preiser's disease were eligible. Besides, quantitative analysis on 130 individuals (135 wrists) of the included studies was performed.

RESULTS

The results show that in stages II and III, pain score reduces more in surgical approach than in conservative treatment. In stage II of the Preiser's, Vascularized Bone Grafting (VBG) was more effective in pain alleviation and improvement in wrist range of motion (ROM) and Mayo Modified Wrist Score (MMWS) than immobilization. Proximal Row Carpectomy (PRC) in stage III causes more pain relief and ROM improvement than VBG and conservative treatments like prescribing NSAIDs. Inconsistent evidence was found in case studies of stage IV; however, they generally favour PRC and SILASTIC implants. Surgical studies of stage I are not yet enough for making a conclusive assessment.

CONCLUSION

Surgical treatment outcomes seem more satisfactory in all Preiser's disease stages. Specifically, VBG for patients of stage II provided they have no scaphoid degenerative changes, and PRC seems more satisfactory for stage III.

LEVEL OF EVIDENCE

IV; systematic review of case reports and case series on Preiser's disease.

Preiser's Disease-Current Concepts of Etiology and Management

The term Preiser's disease typically is used to describe idiopathic avascular necrosis of the scaphoid, but there have been a number of putative etiologies considered. It is rare and the natural history is not fully understood. Management of the condition should be based on patient factors as well as the stage of disease with regard to the scaphoid and the surrounding wrist. This chapter appraises the available evidence and aims to provide the reader with a framework to manage this rare condition.

Preiser's disease or avascular osteonecrosis of the scaphoid: An updated literature review

Avascular necrosis of the scaphoid, often referred to as Preiser's disease, is little known despite the scaphoid being the second most frequently involved location in avascular pathology of the carpal bones after the lunate (Kienböck's disease). Nonetheless, very few cases have been reported in the medical literature over the last century. Its pathophysiology is not completely elucidated although the unique vascularization of the scaphoid and several risk factors seem to be recurrently incriminated. Two new classifications based on modern imaging have appeared in the last decade and are now considered essential supplements to Herbert and Lanzetta's original radiographic classification. Because of the lack of formal treatment guidelines, a wide range of different treatments have been explored over time, contributing to the confusion around this pathology. Adding to this confusion, are the numerous terms used to designate the condition and lack of knowledge concerning its pathophysiology, risk factors, clinical and radiographic presentation. The aim of this review is therefore to explore and clarify Preiser's disease in terms of history, terminology, pathophysiology, clinical considerations and imaging and to propose a simple updated treatment algorithm based on the results provided by a thorough review of literature (53 publications, 170 patients) since Georg Preiser's original and controversial description in 1910.

Magnetic resonance imaging of the wrist and hand

The anatomy of the wrist and hand is complex and contains numerous small structures. Magnetic resonance imaging (MRI) is often an ideal imaging modality in the assessment of various traumatic and pathologic conditions of this region, and it is frequently performed after initial radiographs. In this manuscript we describe the normal anatomy, imaging techniques, and MRI findings of various traumatic and pathologic conditions of the wrist and hand including occult fractures, osteonecrosis, ligamentous and tendon injuries, and entrapment neuropathies.

Clinical outcomes of nonsurgical treatment for Preiser disease

To elucidate whether nonsurgical treatment for Preiser disease is effective.Eight patients with Preiser disease (median age 59 [47-69] years) underwent nonsurgical treatment (median symptom-onset-to-treatment interval 8 [9-180] months). At presentation, 7 patients complained of constant pain and 1 of motion-related pain. Pain restricted wrist range of motion (median modified Mayo wrist score [MMWS] 17.5 [range 10-30]). Radiography revealed stages 1 to 3 disease (Herbert-Lanzetta classification). Median scapholunate angle was 62° (54°-75°), with 3 wrists suffering dorsal intercalated segment instability (DISI). Magnetic resonance imaging showed (Kalainov criteria) 4 stage 1 wrists (complete necrosis) and 4 stage 2 (incomplete necrosis). Two had concomitant Kienböck disease. All patients underwent nonsurgical treatment (ie, oral pain killer, immobilization, rest) and were monitored via radiographic and clinical evaluations. Scapholunate angles and the scaphoid area reduction ratio were calculated using radiography. Response criteria were the patients' subjective and objective status. Endpoint was the time from start of non-surgical to surgical treatment.Immobilization lasting 0 to 24 months (median 1.8 months) did not relieve their symptoms. Follow-up radiography showed that the disease stage had progressed in 5 of 8 wrists, with 5 wrists having DISI. The median area reduction ratio of the scaphoid was 11% (4%-52%) on anteroposterior views and 4% (-23% to 17%) on lateral views. Compared with the contralateral wrist, the median wrist flexion-extension arc was 61% (50%-79%) and the median grip strength 39%. Median MMWS score was 17.5 (10-25) - poor in 6 of 8 patients. Surgery was thus necessary in all patients.Nonsurgical treatment for Preiser disease did not improve subjective or objective outcomes and did not prevent deterioration of radiographic findings.Type of study/level of evidence: Therapeutic, Level V.

Closing Radial Wedge Osteotomy for Preiser Disease: Clinical Outcomes

PURPOSE

To determine clinical outcomes of Preiser disease treated with closing radial wedge osteotomy (CRWO).

METHODS

Seven patients with Preiser disease underwent CRWO. Two wrists had stage 2 disease, 3 had stage 3, 2 had stage 4 (Herbert-Lanzetta classification). Magnetic resonance imaging (MRI) showed that 4 wrists had stage 1 and 3 had stage 2 indicating complete and incomplete necrosis, respectively (Kalainov criteria), before surgery. Two wrists had concomitant Kienböck disease. The range of motion (ROM) of the wrists was restricted owing to pain, and median Modified Mayo Wrist Score (MMWS) was 15 points. Patients were followed after surgery with radiography, MRI, and clinical evaluation (ROM, grip strength, MMWS). Radiolunate and scapholunate angles were calculated on lateral radiographs.

RESULTS

Although there were no usual postoperative complications (eg, infection, neuropathy, distal radius nonunion), 1 patient had an extensor pollicis longus tendon rupture, and another experienced osteoarthritis with deterioration of the distal radioulnar joint. Final follow-up radiography showed that 2 wrists were stage 3, 5 were stage 5 (Herbert-Lanzetta classification). At 1 year after surgery, T1-weighted MRI showed that 2 of 6 wrists had improved from stage 1 to stage 2 (Kalainov criteria). At the final evaluation, 5 wrists had no pain, and 2 had only mild pain. Compared with the contralateral wrist, the median ROM was 80% in extension, 73% in flexion. Median grip strength was 71%, median MMWS was 75 points, and clinical results were good in 1 patient, fair in 5, and poor in 1.

CONCLUSIONS

Although follow-up radiography showed that the disease stage had progressed in 4 of 7 patients, wrist pain alleviation, retention of ROM, and improvement of grip strength were obtained. The CRWO may be an option for reducing wrist pain and retaining ROM of the wrist owing to Preiser disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Review article: the differential diagnosis of bone marrow edema on wrist MRI

There is a large variety of conditions that can result in 'bone marrow edema' or 'bone marrow lesions' (BML) in the wrist on magnetic resonance imaging (MRI). The combination of clinical history and the distribution of the BML can serve as a valuable clue to a specific diagnosis. This article illustrates the different patterns of BML in the wrist to serve as a useful guide when reviewing wrist MRI studies. Imaging artefacts will also be briefly covered.

Preiser disease after repeated local glucocorticoid injections: A case report

RATIONALE

Preiser disease or avascular necrosis (AVN) of the scaphoid causes intolerable wrist pain and malalignment of the carpal bones. In previously reported cases, patients have had a history of steroid use for systemic illness such as autoimmune hemolytic anemia, systemic lupus erythematosus, or renal transplantation, or have had other risk factors, such as smoking, alcoholism, or infection. In particular, systemic glucocorticoid therapy has been most commonly associated with the disease. Although there are reports of AVN of the scaphoid induced by systemic glucocorticoids, no prior report has associated AVN of the carpal bones with repeated local injections of glucocorticoids.

PATIENT CONCERNS

We present a case in which it was strongly suspected that AVN of the scaphoid was induced by repeated local glucocorticoid injections. The patient had no history of excessive alcohol use, smoking, or trauma, except for local repeated steroid injections.

DIAGNOSES

Initially, she had diagnosed with de Quervain's disease and was treated by repeated local glucocorticoid injections followed by surgery for de Quervain's disease. Five years after surgery for de Quervain's disease, the patient presented at our hospital with sudden onset of intolerable pain in her right wrist without a history of trauma. In spite of nonsurgical treatment with rest, immobilization, analgesia, and surgery, her wrist pain was not improved. After further repeated local steroid injections in her wrist, radiographs, and magnetic resonance imaging of her wrist showed the AVN of the scaphoid.

INTERVENTIONS

Surgery was performed and the fragmented proximal scaphoid and the entire lunate were resected.

OUTCOMES

The diagnosis was confirmed according to the histopathological examination of the proximal scaphoid bone, which showed the characteristic of AVN of the scaphoid. At follow-up evaluation, radiographs of the right wrist showed no progression of osteoarthritis. The patient had no tenderness or residual pain at the wrist and had no desire to pursue additional surgery.

LESSONS

We have presented a case with AVN of the scaphoid, which was strongly suspected to be associated with the repeated local steroid injections. Further studies are required to more fully elucidate the association between AVN of the scaphoid and repeated local steroid injections.

On the history and definition of Preiser's disease

In 1910, Georg Preiser (1876-1913) described five cases of rarifying osteitis. Based on his imaging studies, he diagnosed post-traumatic avascular necrosis (AVN) of the scaphoid without any sign of primary fracture. This was followed by an article in 1911 in which Preiser related his findings to Kienböck's disease and Köhler's disease of the tarsal navicular. Upon searching the literature, we found descriptions and discussions of Preiser's imaging; however, the original images have never been published. We reproduce Preiser's original imaging in this current review. All of these appear to show a fracture and no signs of AVN, suggesting that Georg Preiser misinterpreted his findings. There is no apparent uniformity in the literature regarding the definition, description, or aetiology of Preiser's disease, and it is for this reason that we find the use of eponyms to be confusing.

[Preiser's disease. A case study]

The idiopathic avascular necrosis of the scaphoid or Preiser's disease is condition about which few cases have been described. In the majority of cases, it is debatable whether it is actually a spontaneous osteonecrosis, or a pathological process secondary to a systematic disease, or a result of chemotherapy treatment, or associated with taking steroids. We present the case of a 20-year old woman, with no previous trauma, with pain in her right wrist, which progressed over a period of four years. It was wrongly diagnosed as a tendinitis, and was treated conservatively without any improvement. A simple X-ray was requested that showed an abnormality of the proximal pole of the scaphoid that was beginning to fragment; a fact which was confirmed later by performing a CT scan. This was followed by nuclear magnetic resonance spectroscopy (NMR), which showed signs of ischaemia, mainly in the proximal pole. There were signs of viability in the distal fragment in the NMR using paramagnetic contrast. After the imaging tests, idiopathic avascular necrosis of the scaphoid was diagnosed. The surgical treatment consisted of the removal of necrotic fragments of the proximal pole and removal of the posterior interosseous-nerve. Two years after the intervention, the patient is asymptomatic and with a complete range of movement in the operated wrist.

Idiopathic avascular necrosis of the scaphoid: 10 new cases and a review of the literature. Indications for Preiser's disease

INTRODUCTION

Avascular necrosis of the scaphoid (Preiser's disease) is a rare entity for which there are no treatment guidelines to date. The aim of this study was to delineate the optimal treatment at different stages of this disease, based on an analysis of the cases treated in our department.

MATERIALS AND METHODS

Ten wrists (nine patients) were retrospectively reviewed after a mean 92 months of follow-up. The initial diagnosis was stage II avascular necrosis in four cases, stage III in four cases and stage IV in two cases. These patients were treated by conservative treatment (non surgical) in three cases, vascularized bone graft in two and palliative treatments (proximal row carpectomy or partial fusion) in five. Radiological examination, sometimes completed by MRI, and functional assessment of range of motion, grip strength and Mayo Wrist Score were performed.

RESULTS

Completely different results were obtained in the two stage II cases treated by conservative treatment, while functional results improved in the two cases treated by vascularized bone graft with regression of necrosis on MRI. Pain improved following palliative treatment in 4/5 stage III and IV wrists. Functional results were satisfactory with conservative treatment in one stage IV case for 13 years but worsened at the final follow-up assessment.

DISCUSSION

A review of the literature, including 126 cases in 29 articles clarified the role of conservative treatment, vascularized bone grafts and proximal row carpectomy in the treatment of avascular necrosis of the scaphoid. Conservative treatment is ineffective in the early stages and nearly always results in disease progression. In contrast vascularized bone grafts can stop or even reverse damage at stage II. Palliative treatment is indicated when facing irreversible lesions.

LEVEL OF EVIDENCE

Level IV - Retrospective study.

Atraumatic osteonecrosis of the distal radius and ulna: case series and review

PURPOSE

Atraumatic multifocal osteonecrosis is defined as the occurrence of atraumatic osteonecrosis in 3 or more anatomic locations, and it is rare. We identified 6 patients with osteonecrotic lesions in the distal ulna, radius, or both. The purposes of this study were to describe the clinical manifestations of atraumatic multifocal osteonecrosis affecting these bones, to identify risk factors for developing the disease in these locations, and to evaluate the success of treatment by percutaneous drilling.

METHODS

A total of 10 wrists in 6 women with a mean age of 41 years had symptomatic osteonecrosis. Patients were treated by percutaneous drilling after they had failed nonoperative modalities. Clinical evaluation included preoperative and postoperative Michigan Hand Questionnaire scores plain radiographs, and MRI evaluations were performed to characterize the disease. The incidence of risk factors was recorded.

RESULTS

There was disease occurrence in the radius in all 10 wrists and in the ulnas of 4 wrists. All patients presented with symptomatic osteonecrosis of the large joints (primarily knee or hip), presumably secondary to corticosteroid use. These patients later developed symptomatic pain in the distal ulna, radius, or both that impaired daily activities. Other risk factors included alcohol or tobacco use, blood dyscrasias, and systemic lupus erythematosus. Treatment consisted of percutaneous drilling of the distal radius (and ulna when affected). One patient required additional bilateral drillings and had further improvement in her Michigan Hand Questionnaire scores. At a mean follow up of 35 months, there was no disease progression as evident radiographically.

CONCLUSIONS

The distal radius and ulna are rare sites of osteonecrosis associated with multifocal disease. The clinical presentation and risk factors are similar to osteonecrosis in the large joints. Magnetic resonance imaging identifies necrotic lesions. The present study suggests that disease in these sites can be safely and effectively treated with percutaneous drilling.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.