The use of the 4 + 5 extensor compartmental vascularized bone graft for the treatment of Kienböck's disease

Pyrocarbon Lunate Arthroplasty: An Option for the Young Patient with Advanced Kienbock Disease

Kienbock disease, or avascular necrosis of the lunate, is an uncommon cause of a painful and stiff wrist. Management options range from conservative treatment in the form of immobilization and corticosteroid injections to a wide variety of surgical treatments that depend on the structural integrity of the lunate, intercarpal relationships, and the condition of the articular cartilage of the wrist. A particularly difficult problem lies in the management of young patient in whom vascularized bone grafting of the lunate has failed but in whom arthritis has not yet developed. Pyrocarbon lunate implant arthroplasty is a newer treatment option for such a patient, and allows the preservation of the remainder of the proximal carpal row while directly addressing the degenerative lunate. This article describes the evidence and surgical technique for lunate implant arthroplasty and presents an illustrative case example.

Kienböck's disease: preventing disease progression in early-stage disease

Currently Kienböck's disease remains an 'unsolved' problem in hand surgery. Different factors have been associated with the avascular necrosis of the lunate. Mechanical, vascular and biological factors, alone or in combination, may have an influence in the aetiopathogenesis and determine the progress of the disease and even the results of the treatment. This is especially relevant in the early stages, in which conservative or surgical treatment may modify the natural history of the disease, maintaining the lunate structure and thus preserving the joint surfaces. There are multiple surgical treatments for Kienböck's disease in the early stages, before lunate collapse; each one is based on one of the possible factors that can cause avascular necrosis of the lunate. The objective is not only to treat symptoms but to prevent progression. This article is a review of the most frequent treatments used in the early stages and a personal view of the authors.Level of evidence: V.

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review

Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.

Lunate Revascularization With Temporary Internal Radiocarpal Spanning Fixation for Kienböck Disease

BACKGROUND

The goal in the treatment of stages II and III Kienböck disease is to restore lunate vascularity and halt the progression of avascular necrosis.

METHODS

We report the outcomes for patients with stages II and III Kienböck disease treated with fourth extensor compartment artery vascularized bone grafting and temporary radiocarpal spanning internal fixation. Nine patients with a mean age of 28.8 years were included. Mean clinical and radiographic follow-up were 4.9 and 1.9 years, respectively.

RESULTS

Six patients had no change in Lichtman stage, 2 patients regressed 1 stage, and 1 patient progressed 1 stage. Mean postoperative quick disabilities of the arm, shoulder, and hand (QuickDASH) was 17.4. Mean postoperative visual analogue pain scale (VAS) was 1.8. Patients under age 25 trended toward improved clinical outcomes compared with patients over age 25. Two patients, aged 33 and 65, underwent proximal row carpectomy at a mean 30.5 months postoperatively.

CONCLUSIONS

In conclusion, the use of local vascularized bone graft with temporary internal radiocarpal spanning fixation provides a treatment option with outcomes comparable to existing literature with benefits inherent to internal immobilization.

Vascular Supply of the Wrist

The vascular anatomy of the wrist is vital in the development of multiple disorders at the carpus. Understanding this vascular network may prevent iatrogenic injury to the blood supply and can be used by surgeons through vascularized bone grafts. Multiple surgical techniques take advantage of the vascular network. This article reviews the blood supply of the distal radius, ulna, and carpal bones and its clinical implications.

Osteotomies, Core Decompression, and Denervation for the Treatment of Kienböck Disease

Various osteotomies, core decompression, and denervation all have demonstrated favorable outcomes in treatment of Kienböck disease. Given the rarity of this disease, there is a dearth of high-level comparative studies to direct treatment. In this article, the authors review the current literature surrounding these techniques, and provide summary recommendations for the procedure choice.

An Algorithmic Approach to the Treatment of Kienböck Disease

The algorithm and rationale described is a reflection of our own surgical experience for this challenging disorder and can be compared with other publications. Our algorithm has evolved from treatment of a large volume of patients with Kienböck disease in a referral practice. However, it is limited to the management that we have found logical, effective, and within our scope of experience. The treatment guidelines for our specialty as a whole will evolve as our understanding of the etiology and our ability to quantify efficacy improves.

Pathophysiology of Avascular Necrosis

Avascular necrosis is a complicated, multifactorial disease with potentially devastating consequences. Although the underlying root cause is a lack of appropriate vascular perfusion to affected bone, there are often varying patient-specific, anatomic-specific, and injury-specific predispositions. These factors generally fall into 3 categories: direct vascular disruption, intravascular obliteration, or extravascular compression. The initial stages of disease can be insidiously symptomatic because edematous bone marrow progresses to subchondral collapse and subsequent degenerative arthritis. Although much of the current literature focuses on the femoral head, other common areas of occurrence include the proximal humerus, knee, and the carpus. The low-incidence rate of carpal avascular necrosis poses a challenge in establishing adequately powered, control-based validated treatment options, and therefore, optimal surgical management remains a continued debate among hand surgeons. Appreciation for expectant fracture healing physiology may help guide future investigation into carpal-specific causes of avascular necrosis.

Vascularized Bone Flaps for the Treatment of Kienböck Disease

Of the many treatments for Kienböck disease, only lunate revascularization procedures provide a direct mechanism for reversing the process of osteonecrosis. Owing to the redundant blood supply of the distal radius and carpus, pedicled flaps are versatile solutions for patients with bone loss but intact cartilage. With the advent of free vascularized flaps, the indications for lunate revascularization procedures are expanding. These flaps can be used when the articular cartilage has been compromised and are suitable options to restore native anatomy in patients previously thought to have unreconstructible disease.

Recent Advances in Assessment and Treatment in Kienböck's Disease

Kienböck’s disease is a rare disease described as progressive avascular osteonecrosis of the lunate. The typical manifestations include a unilateral reduction in wrist motion with accompanying pain and swelling. Besides recent advances in treatment options, the etiology and pathophysiology of the disease remain poorly understood. Common risk factors include anatomical features including ulnar variance, differences in blood supply, increased intraosseous pressure along with direct trauma, and environmental influence. The staging of Kienböck’s disease depends mainly on radiographic characteristics assessed according to the modified Lichtman scale. The selection of treatment options is often challenging, as radiographic features may not correspond directly to initial clinical symptoms and differ among age groups. At the earliest stages of Kienböck disease, the nonoperative, unloading management is generally preferred. Patients with negative ulnar variance are usually treated with radial shortening osteotomy. For patients with positive or neutral ulnar variance, a capitate shortening osteotomy is a recommended option. One of the most recent surgical techniques used in Stage III Kienböck cases is vascularized bone grafting. One of the most promising procedures is a vascularized, pedicled, scaphoid graft combined with partial radioscaphoid arthrodesis. This technique provides excellent pain management and prevents carpal collapse. In stage IV, salvage procedures including total wrist fusion or total wrist arthroplasty are often required.

Vascularized Bone Grafts in Orthopaedic Surgery: A Review of Options and Indications

Vascularized bone grafts have demonstrated increased perfusion, structural integrity, and ability to achieve good outcomes in challenging clinical situations when compared with nonvascularized grafts. These grafts may be pedicled or free, and bring perfused, viable bone into areas of impaired healing. Although numerous grafts have been described, a few grafts have demonstrated particular usefulness and versatility. Pedicled grafts from the distal radius, medial femoral condyle, ribs, and fibula have improved outcomes in challenging situations without the need for microsurgery. Free grafts from the fibula and medial femoral condyle/trochlea, although they require microsurgical anastomosis, can be transferred to virtually any site in the body and have expanding indications. The capacity of these grafts to achieve favorable outcomes in difficult cases make them a powerful tool for orthopaedic surgeons to have in their armamentarium.

The free vascularized lateral femoral trochlea osteochondral graft: a reliable alternative for Stage III Kienböck's disease

Lunate reconstruction using a lateral femoral trochlea osteochondral graft was carried out in 27 patients with Stage III Kienböck's disease from 2012 to 2019. Twenty-three of these patients could be followed-up in this retrospective study. Ten were women and 13 men. Nine were Lichtman Stage IIIA, seven Stage IIIB and seven Stage IIIC. The mean follow-up was 39 months (range 12-86). Bony consolidation was found in 18 of the 23 patients, with no graft loss. The mean Disabilities of the Arm, Shoulder and Hand score (DASH score) was 11 and the Modified Mayo Wrist Score was 83. There were only two radiological deteriorations, with the same or improved Lichtman classifications in the other patients and a significant reduction in pain. Postoperative extension of the wrist (52°) and flexion (48°) were comparable with preoperative values and, respectively, 81% and 72% of the contralateral side. Grip strength and pinch grip were 32 kg and 12 kg, 88% and 94% of the other hand, respectively, and an insignificant increase compared with the preoperative values. The vascularized lateral femoral trochlea osteochondral graft yields good short- and mid-term results in Grade III Kienböck's disease.Level of evidence: IV.

Capitate shortening osteotomy with or without vascularized bone grafting for the treatment of early stages of Kienböck's disease

PURPOSE

The study evaluates the procedures of capitate shortening osteotomy with or without vascularized bone grafting (VBG) for the treatment of stage II or IIIA Kienböck's disease with neutral ulnar variance.

METHOD

Forty-five patients with stage II (n = 21) and IIIA (n = 24) Kienböck's disease were included in the study. Patients were classified into two groups; isolated capitate shortening (ICS) group included 21 patients (stage II [n = 10] and stage IIIA [n = 11]) treated by capitate shortening without VBG of the lunate. Combined capitate shortening (CCS) group includes 24 patients (stage II [n = 11] and stage IIIA [n = 13]) who treated by capitate shortening combined with VBG of the lunate from the dorsal distal radius based on the fourth + fifth extensor compartment artery. All patients were evaluated pre- and post-operative for pain as measured by visual analogue scale score (VAS), range of motion (ROM), grip strength, modified Mayo wrist score (MMWS), lunate height index (LHI) ratio, and carpal height index (CHI) ratio.

RESULTS

The mean operative time for CCS procedure was 85 min (76 to 120) and for ICS was 58 min (47 to 65). The mean follow-up period for all patients was 33 months (29 to 47). Patients with stage IIIA Kienböck's disease treated by CCS procedure had better post-operative VAS, ROM, grip strength, MMWS, LHI, and CHI ratio than patients treated by ICS procedure. ICS procedure reported 28% failure rate versus 8% for CCS. No differences were found between CCS and ICS procedures in patients with stage II Kienböck's disease in the term of clinical, radiographic outcomes, or failure rate.

CONCLUSION

Using CCS procedure for the treatment of stage IIIA Kienböck's disease (lunate height collapse) with neutral ulnar variance can restore height and dimensions of the collapsed lunate and subsequently improve the final outcomes with lower failure rate. However, in patients with stage II Kienböck's disease (maintained lunate height), no advantages were noticed for CCS over ICS procedure. Lunate height index might be considered a prognostic factor for the treatment outcomes of Kienböck's disease.

Capitate shortening osteotomy and vascularized bone grafting for Kienböck's disease in ulnar positive or neutral wrists

We report the short- to medium-term outcomes for patients with Kienböck's disease and ulnar positive or neutral wrists treated by capitate shortening osteotomy combined with a 4 + 5 extensor compartmental artery vascularized bone graft placed in the lunate. This is a retrospective study of seven consecutive patients with Lichtman Stage 2 to 3B. Radiological and clinical outcomes were evaluated. Six patients maintained their Lichtman stage, one progressed. Mean time to union of the capitate was 10 weeks. Five of six lunates were completely revascularized on MRI scans, with one partial revascularization. Mean follow-up for functional scores was 40 months (range 15 to 62). Mean pain score improved significantly from 7.4/10 preoperatively to 1.9/10 postoperatively, and patient satisfaction was 9.2/10. Mean postoperative Quick Disabilities of Arm, Shoulder and Hand, Patient Evaluation Measure and Patient-Rated Wrist Evaluation scores were improved. All patients returned to their previous work. We conclude that this procedure has good short- to medium-term outcomes.Level of evidence: IV.

Matching Kienböck's Treatment Options to Specific Features of Each Case

Kienböck's disease is best understood as a continuous interaction between compromised perfusion and structural deterioration that transitions from an early phase to a late phase. Existing literature has failed to identify any one superior treatment for Kienböck's; many studies even demonstrate no advantage for surgery compared with the natural history. Surgical interventions for early and transitional Kienböck's are designed to preserve or reconstruct the lunate. However, in most studies, the only tool used to assess the lunate itself has been plain radiography that neither reveals critical architectural details (demonstrated by computed tomographic scan) nor the vascular status (demonstrated by magnetic resonance imaging). Most articles, therefore, do not adequately define the preoperative status of the lunate or its alteration through surgical intervention. Critical preoperative features that are best demonstrated by these advanced imaging studies have specific anatomic and physiologic relationships that better correspond with certain surgical interventions, which also pair better with specific patient characteristics. This review explains how to identify, analyze, and strategically match these variables with the treatment interventions available for Kienböck's patients through the early, transitional, and late phases of the disease.

Improvement in lunate perfusion after radial closing-wedge osteotomy in patients with Kienböck's disease

Radial closing-wedge osteotomy is a widely accepted treatment for Kienböck's disease. However, despite favorable long-term clinical outcomes, its impact on lunate perfusion has not been documented. The purpose of this study was to determine whether radial closing wedge osteotomy improved lunate perfusion on gadolinium (Gd)-enhanced magnetic resonance imaging (MRI). We conducted a retrospective review of 12 patients with Kienböck's disease who received radial closing wedge osteotomy. Mean age at surgery was 25 years. Preoperative Gd-enhanced MRI was performed in 7 patients. After bone union, implants were removed and MRI was repeated. Two patients were classified as Lichtman stage IIIA, and 5 as stage IIIB. Percentage pre- to post-operative perfused lunate volume was compared on MRI. At last follow-up, mean QuickDASH score improved from 43.7 to 6.2. Pre- to post-operative lunate fragmentation, collapse and perfusion were compared qualitatively on MRI. On quantitative analysis, perfusion increased from 24% to 54% (p = 0.018) using our method of measuring percentage perfused lunate volume. The method showed satisfactory reproducibility. Investigation using Gd-enhanced MRI suggested that radial closing wedge osteotomy increases lunate perfusion.

Radial shortening, bone grafting and vascular pedicle implantation versus radial shortening alone in Kienböck's disease

We prospectively compared outcomes of two surgical procedures for Stage II and IIIa Kienböck's disease with negative ulnar variance. Group I (13 wrists) was treated with radial shortening alone, and Group II (14 wrists) with combined radial shortening, bone grafting and implantation of a vascular pedicle. At follow-up 3 to 7 years (mean 4.5) after operation, scores by the Quick version of the Disability of Arm, Shoulder and Hand questionnaire and scores for pain and grip strength were significantly better in Group II, but the differences were rather small. On MRI all patients in Group II had revascularization, but 11 patients in Group I had not. We conclude that combining radial shortening with the revascularization procedure improved revascularization. Clinically, both treatments were efficient, and the additional bone grafting and vascular pedicle insertion did not greatly improve function, although statistically there were differences in several follow-up variables. This study also could not identify the independent role of the three procedures (drilling, grafting and artery insertion) in Group II, because decompression or bone grafting alone may be effective.Level of evidence: II.

Medial femoral trochlea flap reconstruction: Clinical outcomes and perspectives

INTRODUCTION

We report our experience with use of the medial femoral trochlea (MFT) osteochondral flap for carpal applications.

METHODS

Outcomes of all patients treated with MFT flaps were reviewed. Healing, range of motion, grip strength, carpal alignment, pain, and complication data were collected.

RESULTS

MFT flaps were performed on seven patients with a mean age of 26.1 (range, 17-42) years. Indications included scaphoid proximal pole nonunion (n = 3), Kienböck's disease (n = 3), and Preiser's disease (n = 1). The mean follow-up was 32.3 (range, 5-70) months. Union was achieved in five patients at a mean of 12 (range 6-22) weeks. All five patients had increased grip strength and absence of pain at follow-up. There were two failures due to graft resorption.

CONCLUSIONS

The MFT osteochondral flap is a technically challenging yet powerful tool to replace the loss of both carpal articular cartilage and adjacent bone.

Update on the Use of Arthroscopy in Kienböck's Disease Management

Kienböck's disease is a clinical-radiological condition that can permanently affect wrist functionality and the patient's quality of life. Proper, pertinent diagnosis and treatment are required to avoid salvage procedures. Arthroscopic techniques have emerged as an important tool for the treatment of certain stages of the disease.

We present a review of the literature and propose a treatment algorithm according to the stage of the disease, including arthroscopic techniques. We detail the surgical technique of arthroscopic scaphocapitate arthrodesis, and the functional outcomes obtained by our group.

Osteonecrosis of the Lunate: Kienböck Disease

Kienböck disease, osteonecrosis of the lunate, is a well-known but poorly understood complication seen by hand surgeons. This review presents the background and important patient-specific parameters of the disease and reviews the numerous treatment options that exist for the disease.

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

Purpose

This study aimed to report the outcomes of patients with stage III Kienböck disease after treatment with a vascularized bone graft (VBG) to the lunate combined with capitate shortening osteotomy (CS) after a more than 10-year follow-up.

Methods

A VBG to the lunate was combined with CS in 10 patients with stage III Kienböck disease (6 patients with stage IIIA and 4 with stage IIIB). We performed VBG, CS, and radial shortening osteotomy (RS) on 7 patients. Among them, 4 had undergone RS previously. The passive wrist extension angle and wrist flexion angle, grip strength (GS), carpal height ratio, Stahl index, visual analog scale of wrist pain, and Mayo modified wrist score were assessed before surgery and at the final follow-up.

Results

The flexion angle decreased markedly after surgery, when GS increased in all 10 patients. Radiographic examinations revealed that the carpal height ratio decreased in 9 of 10 patients, whereas the Stahl index increased in 8 patients and remained unchanged in 2. The oldest 3 of 7 patients who underwent VBG, CS, and RS exhibited fusion of the proximal carpals except the pisiform. The mean visual analog scale decreased from 27.6 before surgery to 5.7 afterward. The Mayo modified wrist score improved in 9 patients after surgery and remained unchanged in one.

Conclusions

In stage III Kienböck disease, VBG to the lunate combined with CS relieved wrist pain and increased GS and lunate height but was followed by severely restricted wrist motion. Fusion of the proximal carpals developed in 3 of 7 patients who received VBG with CS and RS.

Type of study/level of evidence

Therapeutic Ⅳ.

Use of 4+5 extensor compartmental vascularized bone graft and K-wire fixation for treating stage II-IIIA Kienböck's disease

Vascularized bone grafts have shown favorable outcomes in Kienböck's disease, preventing the progression of lunate collapse and avascular necrosis. Here we describe our experience using a 4+5 extensor compartmental artery (ECA) vascularized bone graft combined with K-wire fixation. Between September 2010 and June 2013, 9 patients with Lichtman stage II-IIIA disease underwent arthroscopy prior to 4+5 ECA graft placement combined with temporary fixation (scaphocapitate and triquetrum-capitate joints). The average follow-up was 69 months (range, 51-92 months). Changes in pain, range of motion, grip strength, and pinch strength were analyzed. All patients had satisfactory recovery, especially pain relief and grip strength improvement (both P<0.01). Furthermore, magnetic resonance imaging follow-up was critical for monitoring lunate revascularization, especially in the early postoperative period.

Vascularized pedicled bone graft from the distal radius supplied by the anterior interosseous artery for treatment of ulnar shaft nonunion: An anatomical study of cadavers and a case report

BACKGROUND

A vascularized distal radius graft can be a reliable solution for the treatment of refractory ulnar nonunion. The aim of this study is to establish the anatomical basis of a vascularized bone graft pedicled by the anterior interosseous artery and report its clinical application, using cadaveric studies and a case report.

METHODS

Fourteen fresh frozen cadaveric upper limbs were used. The branches of the anterior interosseous artery (the 2, 3 intercompartmental supraretinacular artery and the fourth extensor compartment artery) were measured at the bifurcation site. The anatomical relationship between the anterior interosseous artery and motor branches of the posterior interosseous nerve was investigated. An anterior interosseous artery pedicled bone flap was used in a 48-year-old woman with refractory ulnar nonunion.

RESULTS

There were two variations depending on whether the 2,3 intercompartmental supraretinacular artery branched off distally or proximally from the terminal motor branch of the posterior interosseous nerve. The proximal border of the graft was located at an average of 10.5 cm (range, 6.5-12.5 cm) from the distal end of the ulnar head in the distal type (57%) and 17.5 cm (range, 9.5-21.5 cm) in the proximal type (43%). In the clinical application, successfully consolidation was achieved 4 months post-surgery. The patient had not developed any postoperative complications until the 2-year postoperative follow-up.

CONCLUSIONS

The anterior interosseous artery-pedicled, vascularized distal radius bone graft would be a reliable alternative solution for the treatment of an ulnar nonunion located within the distal one-third of the ulna.

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.

Kienböck's disease: Where do we stand?

Avascular necrosis of the lunate, commonly known as Kienböck's disease is a disorder that can lead to carpal collapse and the need for surgeries, which can stabilize the wrist. There are different associations with the disease but the exact etiology is unknown. Kienböck's disease is believed to result from mechanical and vascular factors in genetically predisposed individuals. The newer classification based on advanced wrist arthroscopy and MRI help in a better understanding of the disease, early diagnosis, and treatment. A review of recent literature regarding newer treatment options has shown good results in the early stages of osteonecrosis. This article intends to review an update on the etiopathogenesis, classification, and the current advanced treatment options.

Is Joint Levelling Procedure Better than Temporary Scaphocapitate Pinning in Patients Undergoing Vascularized Bone Graft for Kienböck Disease?

Background: Although there have been many studies of the vascularized bone graft (VBG) or unloading procedures alone for the treatment of Kienböck disease, little information has been reported about patients treated with VBG combined with unloading procedures. The purpose of this study is to 1) describe the outcomes in patients treated with VBG combined with unloading procedures, 2) compare the outcomes according to the unloading procedures and 3) find any radiologic parameters affecting revascularization in Kienböck disease. Methods: A retrospective review was performed involving in 20 patients undergoing 4^th and 5^th extensor compartmental VBG with unloading procedures for Kienböck disease from 2010-2015. After VBG in all patients, unloading procedures were additionally performed depending on the ulnar variance. These additional operations included joint leveling procedures (radial and capitate shortening osteotomy) or temporary scaphocapitate pinning. Radiologic outcome was evaluated according to Lichtman stage and presence of revascularization evidence. Clinical evaluations included wrist range of motion, grip strength, visual analogue scale (VAS), and Mayo wrist score. Results: VBG with joint leveling procedures was performed in 11 patients (5 radial shortening and 6 capitate shortening) and VBG with temporary scaphocapitate pinning was performed in 9 patients. Although clinical outcomes were not significantly different according to the unloading procedures, there were significantly more patients with evidence of healing of osteonecrosis on radiographs in joint leveling procedure group than temporary scaphocapitate pinning group. Overall, evidence of healing of osteonecrosis was found on plain radiographs in 11 patients and was not found in 9 patients. However, there were no significant preoperative radiological parameters affecting revascularization on radiographs. Conclusions: Not all patients had evidence of revascularization on radiography after VBG combined with unloading procedures for Kienböck disease. However, among the unloading procedures, joint-leveling procedures positively influenced the revascularization process.

Extensor carpi radialis longus tendon ball interposition arthroplasty for treatment of late-stage Kienböck's disease: Short-term results of a novel technique

PURPOSE

The aim of this study was to evaluate short-term clinical and radiological results of extensor carpi radialis longus (ECRL) tendon ball arthroplasty for treatment of late-stage Kienböck's disease.

METHODS

We retrospectively reviewed data of 19 patients suffering from Kienböck's treated with ECRL tendon ball arthroplasty between December 2014 and December 2016. Patients' clinical functions were assessed using grip strength, range of motion (ROM) of the wrist, QuickDASH, Mayo wrist score, and visual analog scale score. Radiological examination was performed to assess carpal height ratio and progression of arthritis.

RESULTS

The median follow-up was 30 months (range, 12-36 months). At final follow-up, ROM of operated wrist was 71% of the nonoperated side. Thirteen (86.6%) patients were pain free. Carpal height ratio was statistically significantly reduced compared with preoperative values. All patients declared their satisfaction with the results due to their preoperative status.

CONCLUSIONS

ECRL tendon ball arthroplasty is a new and good option for treatment of late-stage Kienböck's disease with low complication rate.

Effects of Surgical Angiogenesis on Segmental Bone Reconstruction With Cryopreserved Massive-Structural Allografts in a Porcine Tibia Model

Cryopreserved bone allografts (CBA) used to reconstruct segmental bone defects provide immediate structural stability, but are vulnerable to infection, non-union and late stress fracture as the majority of the allograft remains largely avascular. We sought to improve the bone vascularity and bone formation of CBAs by surgical angiogenesis with an implanted arteriovenous (AV) bundle, using a porcine tibial defect model. Cryopreserved tibial bone allografts were transplanted in swine leukocyte antigen (SLA) mismatched Yucatan minipigs to reconstruct a 3.5 cm segmental tibial defect. A cranial tibial AV-bundle was placed within its intramedullary canal to induce angiogenesis. The AV bundle was patent in eight pigs and ligated in a control group of eight pigs. At 20 weeks neo-angiogenesis was evaluated by micro-angiography. Bone formation was measured by quantitative histomorphometry and micro-computed tomography. Seven of eight AV-bundles in the revascularized group were patent. One had thrombosed due to allograft displacement. Total vascular volume was higher in the revascularized allografts compared to the ligated group (p = 0.015). Revascularized allografts had increased levels of bone formation on the allograft endosteal surface compared to the ligated control group (p = 0.05). Surgical angiogenesis of porcine tibial CBAs by intramedullary implantation of an AV-bundle creates an enhanced autogenous neoangiogenic circulation and accelerates active bone formation on allograft endosteal surfaces. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1698-1708, 2019.

Treatment of Kienböck's Disease With Neutral Ulnar Variance by Distal Capitate Shortening and Arthrodesis to the Base of the Third Metacarpal Bone

PURPOSE

We evaluated whether a surgical technique combining distal capitate shortening and arthrodesis to the base of the third metacarpal bone for the treatment of the early stages (stages II and IIIA) of Kienböck's disease with neutral ulnar variance resulted in pain relief, improvement in wrist motion, or changes in the radiographic evaluation.

METHODS

This retrospective study reviewed 22 patients with early stages of Kienböck's disease with neutral ulnar variance, treated by distal capitate shortening and arthrodesis to the base of the third metacarpal bone. Patients were divided into 2 groups by disease stage: stage II (n = 12) and stage IIIA (n = 10). There were 8 women and 14 men, with an average age of 35.7 years. The following parameters were measured before and after surgery: visual analog scale (VAS) for pain evaluation, grip strength, range of motion (ROM), ulnar variance, carpal height index, lunate height index, and the scapholunate and scaphocapitate angles. The patients were evaluated in accordance with Modified Mayo Wrist Score (MMWS).

RESULTS

The average follow-up period was 30.5 months (range, 26-36 months). The stage II group showed significant improvements in the mean VAS (58-5), ROM (57% to 73%), grip strength (54% to 75%), and MMWS (51-78). Patients in the stage IIIA group showed nonsignificant changes in mean VAS score (64-42.5), ROM (52.5% to 55.5%), grip strength (46.5% to 57.5%), and MMWS (36-50.5). Significant decreases in the carpal height index and scaphocapitate angle, and an increase in scapholunate angle in all stage IIIA patients were observed.

CONCLUSIONS

Distal capitate shortening with capitometacarpal arthrodesis can alleviate pain and improve ROM and grip strength in patients with stage II Kienböck's disease, but not in those with stage IIIA. Moreover, it cannot prevent carpal collapse, especially in stage IIIA of the disease. We do not recommend this technique for treating stage IIIA patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Donor site morbidity of vascularized bone grafts from the medial femoral condyle for osseous revascularization

BACKGROUND

Vascularized bone grafts from the medial femoral condyle (MFC) are used to gain surgical revascularization of osseous defects. To date objective data regarding the donor site morbidity are limited. This study aims to evaluate the donor site associated outcome after MFC flap harvest.

PATIENTS AND METHODS

From 2008 to 2016, 22 patients who underwent MFC bone flap harvest for osseous revascularization of 9 talus, 8 scaphoids, 2 metacarpals, 1 phalanx, 1 pilon tibiale, and 1 distal femur were included. Outcome analysis was performed for the whole cohort as well as for two subgroups (recipient site upper [group A] and lower extremity [group B]) by the lower extremity functional scale (LEFS), the OAK-score of the Swiss Orthopedic Society and the visual analog scale (VAS). Additionally, a 3D gait analysis was performed for four patients.

RESULTS

The mean flap size was 1 × 1 × 3 cm. No flap loss was observed. One minor surgical revision was performed due to donor site hematoma. Mean follow-up was 35.8 (12-98) months. Mean LEFS-score was 74.9 ± 9.5 (A: 74.3 ± 7.9; B: 75.6 ± 11.2, p > .05) and OAK-score was 92.8 ± 9.4 (A: 93.2 ± 5.8; B: 92.4 ± 12.3, p > .05). At follow-up examination, pain at rest was stated with 0.1 ± 0.2 (A: 0.1 ± 0.3; B 0 ± 0, p > .05) and with activity 0.6 ± 1.4 (A: 1.2 ± 1.8; B: 0 ± 0, p > .05) on VAS. The 3-D gait analysis showed normative walking patterns.

CONCLUSION

After MFC flap harvest knee function and gait pattern were almost unimpaired. Donor site morbidity can be considered as being of minor concern in the decision-making for this microvascular procedure.

The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients

Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.

Vascularized Bone Graft to the Lunate Combined With Temporary Scaphocapitate Fixation for Treatment of Stage III Kienböck Disease: A Report of the Results, a Minimum of 2 Years After Surgery

PURPOSE

To report the outcomes of patients with stage III Kienböck disease treated by vascularized bone graft (VBG) followed by temporary scaphocapitate (SC) fixation, a minimum of 2 years after surgery.

METHODS

Twenty-six patients (mean age, 35 years) with stage III Kienböck disease (16 with stage IIIA and 10 with stage IIIB), treated with VBG followed by SC fixation for 4 months, were retrospectively followed for at least 2 years (range, 24-121 months; mean, 61.8 months). The preoperative and postoperative assessments included range of motion (ROM) of the wrist, grip strength (GS), wrist pain, the modified Mayo wrist score (MMWS), carpal height ratio (CHR), Ståhl index (STI), and radioscaphoid angle (RSA). The outcomes of each assessment of the stages IIIA and IIIB groups at the final examination were compared with those before surgery.

RESULTS

In both stages IIIA and IIIB groups, GS increased after surgery. Decrease of CHR and STI was associated with the increase of RSA in the stage IIIA group after surgery, while RSA decreased, although neither CHR nor STI significantly increased in the stage IIIB patients. No patient demonstrated deterioration of the wrist pain after surgery. Twenty-one of 26 patients had an improved MMWS grade at the final follow-up.

CONCLUSIONS

Vascularized bone graft combined with SC fixation for 4 months provided greater GS, pain relief, and functional improvement compared with before surgery in both stages IIIA and IIIB groups.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Reconstruction of Extended Bone Defects Using Massive Allografts Combined with Surgical Angiogenesis: A Case Report

CASE

A 20-year-old patient presented with an extended composite knee defect with destruction of the medial femoral condyle, including the medial collateral ligament. Treatment included using an anterolateral thigh flap for soft-tissue reconstruction, tensor fasciae latae muscle for ligament repair, and a massive allogenic bone graft of the medial femoral condyle that was revascularized with an osteocutaneous composite free flap from the contralateral femur. At 17 months postoperatively, the outcome was evaluated with scores on several established scales and radiographic assessment.

CONCLUSION

The combination of vascularized soft-tissue reconstruction and osseous reconstruction using allogenic bone along with surgical angiogenesis proved to be effective. Complex extremity reconstruction should be discussed with interdisciplinary specialists.

Kienböck's disease: Role of cross-sectional imaging in treatment choice and patient follow-up

The management of Kienböck's disease is complex and constantly evolving in parallel with progress in the understanding of the pathophysiological mechanisms of this condition. Cross-sectional imaging techniques have an essential role in the diagnosis and prognostic assessment of this disease. CT allows the optimal study of the morpho-structure of lunate bone. MRI makes it possible to study bone marrow viability. As for CT arthrography, it allows to evaluate accurately articular cartilage of the different carpal joints. The evaluation of these different aspects of Kienböck's disease is essential for optimal treatment selection. Cross-sectional imaging also has an interest in post-treatment follow-up, by having a prognostic value and allowing the identification of post-operative complications. The purpose of this article is to review the contribution of cross-sectional imaging in the assessment of Kienböck's disease before and after treatment according to the most common surgical procedures. Pathophysiological mechanisms, predisposing factors, the different classifications and their interests will be discussed.

[Treatment of necrosis of the lunate bone]

BACKGROUND

There still is no standard therapy that predictably results in healing of avascular necrosis of the lunate bone. Nevertheless, there exists a wide spectrum of operative treatment options for different stages.

OBJECTIVE

This article reviews the treatment options for necrosis of the lunate bone and proposes algorithms based on the age of the patient and condition of the lunate bone and the wrist.

METHODS

Surgical treatment options for necrosis of the lunate bone can be divided into relieving or revascularization procedures and salvage procedures.

RECOMMENDATIONS

For patients under 20 years old the treatment of choice is prolonged immobilization, in cases of non-response or progression, minimally invasive and relieving procedures are used. In adult patients with limited affection of the lunate bone the first therapeutic approach should also be immobilization. If in progressive disease or advanced stages only the lunate bone is compromised but reconstructable, restoration should be considered. In progressive collapse of a non-reconstructable lunate bone the therapeutic efforts shift to mobility-preserving procedures utilizing still functional articulations of the wrist. If all functional articulations are lost only classical salvage procedures are feasible.

CONCLUSION

According to the presented algorithms a stage-dependent therapy of necrosis of the lunate bone is possible. It should not be ignored that there are still no scientific and evidence-based arguments for some of these treatment options. This is also true for maximally invasive procedures, where superiority to more simple procedures have not been proven. Therefore, their application should be restricted and based on an individual decision.

The Fourth Extensor Compartment Artery Vascularized Bone Graft of the Distal Radius for CMC Fusion in the Treatment of Carpal Boss: A Case Report

BACKGROUND

Carpometacarpal joints can be affected by traumatic or degenerative pathology. Although different techniques have been described to treat these conditions, most authors agree that arthrodesis is an effective treatment modality. Vascularized bone grafts of the distal radius have been used to treat carpal conditions, such as scaphoid nonunion or Kiënbock disease, and they have been shown to have several advantages over nonvascularized bone grafts.

METHODS

We report a case of a carpal boss in a female patient treated with an arthrodesis of the second and third carpometacarpal joints by using the fourth extensor compartment artery vascularized bone graft.

RESULTS

At 6 weeks postoperative bone union was achieved. At 2 years follow-up the patient was able to perform daily life activities without pain.

CONCLUSIONS

The fourth ECA VBG with reverse blood flow from the dorsal intercarpal arch allowed the graft to reach the CMC. A solid fusion was obtained at 6 weeks due to the biological advantage of the VBG.

Regeneration of Osteonecrosis of Canine Scapho-lunate Using Bone Marrow Stromal Cells: Possible Therapeutic Approach for Kienböck Disease

We evaluated the ability of canine bone marrow stromal cells (cBMSCs) to regenerate bone in a cavity of the scapholunate created by curretage and freeze–thawing with liquid nitrogen (LN). Autologous BMSCs were harvested from the iliac crest and expanded in vitro. Their potential to differentiate into osteo-, chondro-, and adipogenic lineages was confirmed using a standard differentiation induction assay. LN-treated scapholunates showed no regeneration of bone tissue when the cavity was left alone, demonstrating severe collapse and deformity as observed in human Kienböck disease. A combination of β-tri-calcium phosphate and a vascularized bone graft with autologous fibroblasts failed to regenerate bone in the LN-treated cavity. When the same procedure was performed using BMSCs, however, LN-treated scapholunates showed no collapse and deformity, and the cavity was completely filled with normal cancerous bone within 4 weeks. These results suggested the potential of using BMSCs to treat Kienböck disease.

Radiologic Guide to Surgical Treatment of Kienbock's Disease

Kienbock's disease, or avascular necrosis of the lunate, is a progressive disease ultimately resulting in end-stage arthrosis of the wrist. Various surgical treatments are available for different Lichtman stages of disease. We review the surgical options and indications, expected radiologic post-operative appearance, as well as detail potential surgical complications, as they relate to Kienbock's disease.

Keyhole Revascularization for Treatment of Coronal Plane Fracture of the Lunate in Kienböck Disease

Coronal plane fracture of lunate in Kienböck disease is a challenging problem with no proven treatment. We present a technique for the treatment. A vascularized bone graft from the distal radius employing the fourth and fifth extracompartmental artery pedicles is used as a mechanical support in order to enable fracture union. The technical pearls and pitfalls are described and a clinical case is presented.

Bilateral Legg-Calve-Perthes Disease and Kienbock's Disease in a Child With Factor V Leiden Thrombophilia: A Case Report

Background: The etiology of multifocal osteonecrosis is not definitively known; however, hypercoagulable state is a very plausible cause. Methods: We present an unusual case of a 12-year-old boy with a history of Legg-Calve-Perthes disease presenting with right wrist pain who was subsequently diagnosed with Kienbock's disease. The finding of multifocal osteonecrosis prompted testing for a hypercoagulable state that was positive for Factor V Leiden thrombophilia. A thorough literature review using Medline database was conducted to investigate associations between inherited hypercoagulable states and multifocal osteonecrosis. Results: Our literature review identified 2 similar cases of multifocal osteonecrosis associated with a hypercoagulable disorder in adult patients. There were no reports among the pediatric patient population. Meta-analysis has demonstrated a potential link between Legg-Calve-Perthes disease and Factor V Leiden thrombophilia. Conclusions: This study offers further evidence to support the theory that multifocal osteonecrosis may be linked to a hypercoagulable state. Patients presenting with multifocal osteonecrosis should undergo screening for hypercoagulable states. Further investigation is needed to ascertain the potential benefit of prophylactic anticoagulation in patients with a known hypercoagulable state and multifocal osteonecrosis.

Treatment of Kienböck's disease using a fourth extensor compartmental artery as a vascularized pedicle bone graft

BACKGROUND

Vascularized bone grafts for the treatment of Kienböck's disease may facilitate revascularization and remodeling of the avascular lunate. The aim of this study was to evaluate the radiological and clinical results obtained when a fourth extensor compartmental artery (ECA) bone graft was used to treat Kienböck's disease.

METHODS

Between May 2009 and June 2012, 13 patients (6 men, 7 women) with Kienböck's disease were treated with placement of fourth ECA vascularized bone grafts. The mean patient age was 39.2 (20-58) years, and the mean follow-up period was 32.5 (12-72) months. At the time of surgery, One patient had Lichtman's stage II Kienböck's disease, 11 stage IIIA disease, and one stage IIIB disease. We measured the pre- and post-operative ranges of motion, pain, grip strength, and radiological parameters, including the carpal height ratio and the radioscaphoid angle.

RESULTS

At the last follow-up, pain was significantly reduced, and grip strength had improved from 60.5% to 87.8% relative to that of the contralateral side. The mean range of motion for flexion had improved from 39° to 53° while that of wrist joint extension improved from 41° to 56°. There were little or no changes in either the carpal height ratio or the radioscaphoid angle (both p values > 0.05).

CONCLUSIONS

Placing of a fourth ECA vascularized bone graft is a reliable alternative to other revascularization procedures for treatment of Kienböck's disease. Such grafting is effective, minimally invasive, and associated with a low risk of pedicle kinking.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic/IV.

Vascularized Bone Grafts from the Dorsal Wrist for the Treatment of Kienböck Disease

Purpose The objective of this article is to evaluate functional and radiological outcomes of vascularized bone grafts for stage 2 and 3 Kienböck disease. The outcomes of three different donor sites via dorsal approach of the wrist were compared. Pearls and pitfalls in surgical technique were discussed. Methods There were 28 patients who underwent vascularized bone grafts, including the extensor fourth and fifth compartmental artery graft of distal radius in 8 patients, the first and second supraretinacular intercompartmental artery graft of distal radius in 12 patients, and the second dorsal metacarpal neck graft in 8 patients. Average age was 32 years, and radiological grading according to Lichtman classification was stage 2 in 8 patients, stage 3A in 10 patients, and stage 3B in 10 patients. Temporary pinning fixing the midcarpal joint was conducted for 10 weeks postoperatively. Results Follow-up periods averaged 70 months. Pain reduced in 27 patients, and visual analog scale for pain of pre- and postoperative level averaged 59 and 18. Range of wrist flexion and extension motion improved from 87 to 117 degrees, and average grip strength improved from 21 kg preoperatively to 33 kg postoperatively. Carpal height ratio had almost no change from 0.52 to 0.53. Fragmentation of necrotic bone healed in 7 of the 14 cases. Comparative analyses of functional and radiological outcomes between three donor sites found no significant difference. Conclusion Three different vascularized bone grafts from the dorsal wrist and hand area demonstrated favorable and comparable functional outcomes. It was technically important to elevate vascular bundle with surrounding retinaculum or fascia, to include sufficient periosteum, and to insert the vascularized bone as the cortex aligned longitudinally.

Surgical Revascularization-An Innovative Approach to the Treatment of Talar Osteonecrosis Dissecans Stages II and III

Talar osteonecrosis dissecans is caused by osseous malperfusion, leading to destruction of the talar bone. The current reference standard for advanced stages lacking arthrosis is core decompression, followed by autologous cancellous bone grafting. However, talar revascularization has not been observed in a subset of patients after this procedure. Microsurgical vascularized bone grafting can improve outcomes by the induction of angiogenesis. We present the 1-year follow-up data from 3 patients with talar osteonecrosis dissecans, who had undergone free vascularized medial femoral condyle autotransplantation. The patients were evaluated preoperatively and 3, 6, and 12 months postoperatively. The active range of motion, pain (visual analog scale [VAS]), and American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and lower extremity functional scale were used. Osteonecrosis dissecans stage II was seen in patient 1 (aged 27 years) and stage III in patients 2 (aged 18 years) and 3 (aged 41 years). Preoperative pain of the ankle was recorded as VAS score of 3 by patients 1 and 2 and VAS score of 6 by patient 3. At 12 months postoperatively, patients 1 and 2 recorded a VAS score of 2 and patient 3, a VAS score of 0. All patients showed improvement in the lower extremity functional scale and American Orthopaedic Foot and Ankle Society scale scores. After 6 and 12 months, magnetic resonance imaging showed a well-vascularized femoral condyle incorporated into the talus in all the patients. Autotransplantation of vascularized bone grafts from the medial femoral condyle is a promising technique for surgical revascularization of talar osteonecrosis dissecans stage II and III.

Comparison of clinical and radiologic treatment outcomes of Kienböck's disease

Purpose

The clinical outcomes of scaphotrapeziotrapezoid (STT) arthrodesis were compared to radial shortening osteotomy (RSO) to determine if any of the treatment methods was superior. The impact of RSO and vascularized bone grafts (VBG) on disease progression were measured based on X-rays to evaluate if a difference in Kienböck’s disease (KD) progression exists.

Methods

Out of 98 consecutive patients treated between 1991 and 2013, 46 had STT arthrodesis, 21 had RSO, 7 had VBG, and 3 had VBG and RSO. Patients treated with STT arthrodesis were compared to RSO regarding post-operative range of motion (ROM), wrist pain on the Numeric Rating Scale (NRS), grip strength, duration of incapacity for work, the Disabilities of the Arm, Shoulder, and Hand (DASH), and the Modified Mayo Wrist scores (MMWS). Radiographic assessment (Nattrass index, radioscaphoid angle, and Ståhl index) was performed to determine disease progression following RSO or VBG. Baseline patient characteristics were comparable in all treatment groups.

Results

There were no significant differences in post-operative ROM, wrist pain, grip strength, duration of incapacity, DASH score, or MMWS score following STT arthrodesis (n = 27) or RSO (n = 14). The Ståhl index, the Nattrass index, and the radioscaphoid angle suggested disease progression following RSO (n = 14) and/or VBG (n = 6) although the changes were not significant.

Conclusions

The study failed to demonstrate clinically relevant differences between STT arthrodesis compared to RSO. No evidence was found that decompression or revascularization, or the combination of the two, can reverse or halt the course of the disease.

Level of evidence

Therapy, level III, retrospective comparative study with prospectively collected data.