Proximal row carpectomy in advanced Kienbock's disease

Long-term Outcomes for Late-Phase Kienböck's Tenoarthroplasty

BACKGROUND

In late Kienbӧck's, the lunate is fully fragmented and nonreconstructible. Replacing the lunate with a pyrocarbon prosthesis preserves load distribution and avoids carpectomy or fusion, but leaves the wrist intrinsically unstable, requiring additional soft-tissue stabilization techniques.

METHODS

Five men and 7 women with a mean age of 43 (±15) years underwent prosthetic replacement of the lunate with dual bundle scaphoid-triquetrum tenodesis for carpal stabilization. The mean follow-up interval from initial surgery was 9.1 (±1.7) years. Outcomes were Disabilities of Arm, Shoulder, and Hand (DASH) score, revision or conversion surgery, and wrist range of motion.

RESULTS

The mean DASH score was 8.9 (±7.1). No patients reported any additional revision or conversion surgery. The mean wrist flexion was 60° (±14°); wrist extension was 45° (±21°).

CONCLUSIONS

Clinical outcomes proved more favorable than anticipated, particularly the self-rated outcomes scores and the absence of any revision or conversion surgery.

Clinical and radiographic results of lunate resection and vascularized os pisiform transfer for Kienböck's disease

Although various treatments for advanced stages of Kienböck's disease have been reported, clinical evidence demonstrating the efficacy of lunate resection and vascularized os pisiform transfer for Kienböck's disease is limited. Herein, we investigated the clinical and radiographic results of this procedure. We retrospectively investigated eight patients who were followed up for ≥1 year. The mean age at the time of surgery was 52 years. The mean follow-up period was 3.4 years. The preoperative and postoperative mean wrist flexion-extension ranges were 84° and 111°, respectively, and grip strengths were 18.5 and 26.3 kg, respectively. Pain decreased in five patients postoperatively. The mean preoperative and postoperative carpal height ratios were 0.47 and 0.46, respectively, and radio scaphoid angles were 63° and 65°, respectively. Osteoarthritic changes were observed in or around the transferred pisiform in all five patients who were surveyed using radiographs. Most patients demonstrated satisfactory clinical results, including pain relief and improved wrist motion and grip strength, regardless of osteoarthritic wrist changes on postoperative radiographs. In summary, this procedure was effective for treating Kienböck's disease, especially in the advanced stages. Level of evidence: Ⅳ.

Carpal bone replacement using personalized 3D printed tantalum prosthesis

Objective: Scaphoid and lunate fractures have a relatively high incidence rate. Traditional carpectomy and carpal arthrodesis in the treatment of carpal osteonecrosis will lead to many complications. Three-dimensional (3D) printed tantalum has good biocompatibility and can be designed to match the patient's personalized anatomical carpal structure. This study aims to investigate carpal function and prosthesis-related conditions after carpal bone replacement using 3D printed tantalum prostheses. Methods: From July 2020 to January 2022 at our center, seven patients with osteonecrosis of the carpus received carpal bone replacement using 3D printed tantalum prosthesis. The Disability of the Arm, Shoulder and Hand (DASH) score and patient satisfaction, as well as the Mayo Wrist Scores (Cooney method, modified Green, and O'Brien wrist score), were used to evaluate the preoperative and postoperative wrist function of patients. The Visual Analog Scale (VAS) pain scores were also recorded before and after surgery. The angles of flexion, dorsiflexion, ulnar deviation, and radial deviation were measured using an arthrometer. The grip strength and pinch strength of the operated hand after carpal bone replacement and the contralateral healthy carpus were measured using a dynamometer. Radiographs were taken to confirm the condition and complications of the tantalum prosthesis. Results: All seven patients were followed for 19.6 ± 2.7 months. At the last follow-up, the grip strength of the operated wrist joint after carpal bone replacement was 33.4 ± 2.3 kg, the pinch strength was 8.9 ± 0.7 kg, the flexion was 54.6° ± 0.8°, the dorsiflexion was 54.7° ± 1.7°, the ulnar deviation was 34.6° ± 1.9°, and the radial deviation was 25.9° ± 0.8°, all of which showed no statistically significant difference with the contralateral healthy carpus (p > 0.05). There were significant differences in the VAS, DASH, and MAYO scores between the preoperative and the last follow-up (p < 0.01). Patients had reduced postoperative pain and improved wrist function and range of motion (ROM), and the tantalum prostheses were stable. Conclusion: The 3D printed tantalum brings us new hope, not only for hip or knee replacement, but also for joint replacement of other complex anatomical structures, and patients with other irregular bone defects such as bone tumors and deformity, which could realize personalized treatment and precise medicine.

Comparison of Clinical Outcomes in Open and Arthroscopically-Assisted Mini Open Proximal Row Carpectomy for Lichtman Stage IIIB and IIIC Kienböck Disease

PURPOSE

Proximal row carpectomy (PRC) can be performed in the late stages of Kienböck disease using the traditional open technique or arthroscopically. In this study, we describe the arthroscopically-assisted mini-open PRC technique. The aim of the study was to compare the functional results with the open PRC technique in advanced-stage Kienböck disease.

METHODS

The medical records of patients with Kienböck disease who underwent open PRC between 2006-2010 (Cohort A) and arthroscopically-assisted PRC (AAPRC) between 2010-2018 (Cohort B) were analyzed. The Quick Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale, and Modified Mayo Wrist Scores were compared, which were obtained at the early postoperative (third month) and final follow-up.

RESULTS

Cohort A had 14 and Cohort B 21 patients. The preoperative, early, and final mean visual analog scale scores were 7, 3, and 0.3, respectively, for Cohort A, and 7, 0.3, and 0.1, respectively, for Cohort B. The preoperative mean Quick Disabilities of the Arm, Shoulder, and Hand scores decreased from 69 to 34 at the third-month and 6.1 on the final follow-up visit for Cohort A and from 77 to 18, and 5 for Cohort B. The final Mayo wrist scores were excellent in 4, good in 4, and moderate in 6 of the Cohort A patients, and excellent in 11, good in 8, and moderate in 2 of the Cohort B patients. Mean flexion increased to 52° from 43° for Cohort A and to 62° from 41° for Cohort B.

CONCLUSIONS

AAPRC, compared to the open PRC, resulted in increased wrist motion and increased Mayo wrist scores in the long-term. Also, the third-month patient-related outcomes revealed favorable results in the AAPRC group. We attribute these findings to the earlier initiation of postoperative wrist motion and the less invasive character of the AAPRC procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Wrist Salvage Procedures for the Treatment of Kienbock's Disease

Kienbock's disease is a progressive condition characterized by lunate collapse, carpal instability, and eventually perilunate arthritis. Etiology is likely multifactorial, including vascular and anatomic or osseus causes. In cases of advanced disease, disabling pain, limited motion, and decreased grip strength may be present. The preferred treatment options for the nonreconstructable wrist are proximal row carpectomy (PRC), total wrist arthrodesis, and total wrist arthroplasty (TWA). In the following chapter, we will discuss various surgical options for patients with advanced Kienbock's disease.

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.

Fixation of the Fractured Lunate in Kienböck Disease

PURPOSE

To describe an uncommon subset of fractured lunates in Kienböck disease that is salvageable by internal fixation.

METHODS

We performed a retrospective review for patients with Kienböck disease treated by internal fixation. Demographic data, objective and radiographic measurements, patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and pain (visual analog scale) scores were collected.

RESULTS

Of the 7 patients treated, 5 were available for review. At an average follow-up of 7.1 years (range, 1.5-15 years), all patients had activity-related wrist pain but were pain-free at rest. Radiographic assessment showed union in all lunates and a normal radioscaphoid angle and Stahl index. The modified carpal height ratio was reduced in 4 patients and normal in one. There was no observed narrowing or irregularity of the radiocarpal or midcarpal joints. Patient-reported outcome measures in 2 patients were unsatisfactory.

CONCLUSIONS

Computed tomography of the lunate in Kienböck disease is an important investigative tool. A coronal split fracture of these lunates can be salvageable by internal fixation. Revascularization of the lunate can be performed when the fragment is of sufficient size.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Long-Term Clinical Outcome After Titanium Lunate Arthroplasty for Kienböck Disease

PURPOSE

Titanium lunate arthroplasty (TLA) for Kienböck disease was introduced in 1984 to address the silicone-wear particle problem common to silicone lunate implants. We sought to study the outcome of TLA.

METHODS

We identified 11 patients from our hospital database who had undergone TLA between 2001 and 2010. We evaluated pain, range of motion (ROM), function, and radiological outcome at a mean 11 years after surgery. We compared preoperative ROM and radiological findings with final follow-up in the ipsilateral wrist and also made comparisons with the contralateral wrists.

RESULTS

No implants were removed, and no wrist joints were fused. Pain on the visual analog scale averaged 0.5 at rest, 0.3 at night, and 2.7 during heavy exertion. Seven patients had no pain at rest and 9 had no pain at night. Range of motion reached 70% of that of the contralateral wrist, and strength reached 81%. The Disabilities of the Arm, Shoulder, and Hand (DASH) score averaged 9.6, optional DASH 9.7, and Mayo wrist score 67.7. Radiologically, only Ståhl and arthrosis indexes differed significantly between affected and unaffected wrists. Two patients had a dorsally dislocated implant, meaning that around 20% of our cases probably meet the criteria for failure.

CONCLUSIONS

The longer-term results of TLA for stage III Kienböck disease are promising.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Factors associated with improved outcomes following proximal row carpectomy: a long-term outcome study of 144 patients

We conducted a review of 144 consecutive patients who underwent proximal row carpectomy from 1967 to 2010 for the diagnosis of wrist arthritis. At a mean follow-up of 13.4 years, patients experienced good pain relief with preservation (but not improvement) of wrist motion. A total of 17 patients (12%) required revision surgery at an average of 44.6 months. Improved pain, function, and survival outcomes were seen in those who underwent proximal row carpectomy after the age of 40, had a preoperative diagnosis of Kienbock's disease, who underwent a concomitant neurectomy procedure, patients who were non-labourers, and patients who underwent surgery after 1990. Although 45% of patients developed moderate to severe radiocapitate arthrosis postoperatively, these findings did not correlate with clinical outcomes or risk of revision surgery. Patients with type II lunate and type II and III capitate shapes had higher rates of postoperative radiocapitate arthrosis.

LEVEL OF EVIDENCE

III, Prognostic.

Current Trends in Treatment of Kienböck Disease: A Survey of Hand Surgeons

BACKGROUND

The cause and treatment of Kienböck disease is controversial. No treatment algorithm has been accepted. We surveyed US hand surgeons to determine trends and attitudes regarding the treatment of Kienböck disease.

METHODS

An online questionnaire was created focusing on specific treatments of Kienböck disease. The survey included 6 questions regarding the cause of disease, preferred vascularized bone grafting (VBG) procedure, and treatment of stages I, II, IIIA, and IIIB. Respondents were also asked to specify their geographic location of practice and the approximate number of years in practice.

RESULTS

A total of 338 of the 2781 surgeons contacted completed the survey for a response rate of rate of 12%. The majority of respondents believe ulnar-negative variance alone contributes to the development of Kienböck disease. For treatment of a young ulnar-neutral male with stage I disease who had failed immobilization and nonsteroidal anti-inflammatory drugs, most hand surgeons chose distal radius core decompression. There was no preferred treatment among respondents for treatment of a young ulnar-neutral female with stage II disease. For treatment of a 40-year-old ulnar-negative male with stage IIIA disease, most hand surgeons chose a radial shortening osteotomy. The preferred treatment among respondents for treatment of stage IIIB disease is a proximal row carpectomy.

CONCLUSIONS

Our study demonstrated that most hand surgeons believe ulnar-negative variance largely contributes to Kienböck disease and the most commonly preferred VBG technique utilizes the fourth and fifth extensor compartment arteries.

In vivo 3-dimensional analysis of stage III Kienböck disease: pattern of carpal deformity and radioscaphoid joint congruity

PURPOSE

To examine 3-dimensional carpal alignment and radioscaphoid joint (RSJ) congruity among normal wrists and those with Lichtman stage III Kienböck disease or scapholunate dislocation (SLD).

METHODS

We conducted 3-dimensional analysis based on computed tomographic data to compare 10 wrists of stage III Kienböck disease (5 IIIa and 5 IIIb) with 5 normal wrists and 3 wrists with SLD. A markerless bone registration technique was used to investigate the 3-dimensional position of the scaphoid relative to the radius. To evaluate RSJ congruency, the inferred contact area between the scaphoid proximal pole and the distal radius was calculated from 3-dimensional bone models.

RESULTS

The scaphoid position was not significantly different from normal wrists in stage IIIa Kienböck disease. Stage IIIb Kienböck disease was meaningfully associated with a flexed scaphoid and proximal translation of the centroid, but not dorsal translation of the scaphoid proximal pole, where RSJ congruity was preserved. With SLD, the scaphoid flexed to the same extent as that in stage IIIb Kienböck disease, and the proximal pole translated dorsally together with the capitate, producing RSJ incongruity.

CONCLUSIONS

The patterns of carpal collapse differed between stage IIIb Kienböck disease and SLD in terms of RSJ congruity. Our study showed that stage IIIb Kienböck disease did not involve dorsal subluxation of the scaphoid proximal pole and that RSJ congruity was retained, unlike SLD.

CLINICAL RELEVANCE

Our results suggest that carpal collapse in Kienböck disease is not associated with RSJ incongruity, which may explain why there are asymptomatic patients with Kienböck disease and carpal collapse.

Outcomes assessment of lunate replacement arthroplasty with intrinsic carpal ligament reconstruction in Kienböck's disease

BACKGROUND

With advanced Kienböck's disease, hyaline cartilage delamination or bone fragmentation render the lunate unsalvageable. Common surgical options are proximal row carpectomy, scaphotrapeziotrapezoid fusion, scaphocapitate fusion, or total wrist fusion. The purpose of this study was to prospectively evaluate the clinical and radiographic outcomes of one alternative: lunate prosthetic replacement arthroplasty combined with reconstruction of the scapholunate and lunotriquetral interosseous ligaments using the flexor carpi radialis tendon.

METHODS

Eligible patients with advanced Kienböck's disease and an unsalvageable lunate were included in this prospective study on a self-selected basis, forming a study group of 13 consecutive patients, 6 males and 7 females with a mean age of 40. Clinical and radiographic measurements were compared at a mean follow-up of 30.3 months from surgery with a paired, single-tailed, Student's t test using a p value of 0.05 as statistically significant.

RESULTS

Mean preoperative/postoperative clinical measurements were as follows: wrist flexion 29.2°/43.3°, wrist extension 24.2°/53.3°, absolute value grip strength 12.3/31.5 kg, grip strength vs. contralateral 36.5/85.2 %, and DASH scores 39.1/7.7. Mean initial/immediate postoperative/final radiographic measurements were the following: scapholunate angle 64.2°/46.7°/46.4°, radioscaphoid angle 64.6°/42.1°/45°, and modified carpal height ratio 1.20/1.62/1.59. Preoperative to postoperative differences were all statistically significant.

CONCLUSIONS

Although these subjective and objective results reflect substantial improvement, there remain recognizable deficiencies in both prosthetic design and surgical strategy that require further modification.

New surgical approach to advanced Kienböck disease: lunate replacement with pedicled vascularized scaphoid graft and radioscaphoidal partial arthrodesis

Reconstructive procedures such as proximal row carpectomy or partial arthrodesis have been commonly proposed for advanced Kienböck disease (Lichtmann IIIB to IV). The purpose of this study is to evaluate an alternative surgical technique to advanced Kienböck disease: lunate excision and replacement with pedicled vascularized scaphoid graft and partial radioscaphoidal arthrodesis. The main advantage of the proposed intervention is to preserve mobility while not jeopardizing prime clinical outcomes such as pain. By replacing the devitalized lunate we aim at maintaining midcarpal range of motion, and preventing disease progression with carpal collapse and osteoarthritis of the wrist. Between 2002 and 2008, 13 patients of mean age 41 years (range, 25 to 57 y) were operated using this technique. The surgical act included 3 key steps. First, we excised the lunate, then, filled the generated gap with the rotated scaphoid, using it as a pedicled vascularized autograft. Finally, we performed a partial radioscaphoid arthrodesis. At the final follow-up, none of the intervened patients had pain at rest, and 6 patients could perform nonrestricted daily activities. The average postoperative range of motion in flexion/extension was 70 degrees (range, 55 to 90 degrees), 44% (range, 38% to 54%) of what could be achieved by the contralateral arm, and only 16% (range, 14% to 19%) or 25 degrees (range, 18 to 30 degrees) less than the preoperative range of motion of the same wrist. Grip strength improved by more than 30% (range, 24% to 36%). At an average follow-up of 4 years after surgery, 12 of 13 patients had no radiographic evidence of osteoarthritis or collapse of subchondral bone at the level of the new scaphocapitate joint. At follow-up evaluation, the average DASH score was 14 points (range, 6 to 20). The patients experienced a significant improvement in their functional abilities, achieving good results compared with the conventional techniques. The absence of carpal collapse and good functional results are encouraging.

Graner's procedure in Kienböck disease: a series of four cases with 25years of follow-up

Advanced stages of Kienböck's disease are treated by several techniques, one of which is Graner's procedure, nearly abandoned nowadays. The results of long-term follow-up of a series of four cases Graner's procedure are presented. Four patients were reviewed with a follow-up of 25years. There were two women and two men mean aged 37years at the time of surgery. Two of them were manual workers. Graner's procedure was the first surgery in three cases and secondary to failure of radius shortening in one case of Stage IIIa. Three patients underwent bone healing and the fourth benefited secondarily from radiocarpal arthrodesis. At maximal follow-up, the mean DASH score was 36.6 and pain assessed by visual analogic scale was 3.25 out of 10; the range of movement was half of the opposite side; the wrist strength was 80.9% of the opposite side. In the three consolidated cases, a spontaneous remodeling of the radiocarpal articular surfaces was noted. Graner's procedure is logical as it aims at creating a new radiocarpal articulation, either by the fusion of the lunate with the capitate (Graner I) or by replacing the lunate with the head of the capitate (Graner II and III). However, this old procedure should no longer be one of the surgical procedures for Kienböck disease due to its drawbacks: necrosis or non-union of the head of the capitate, necessity to perform a wrist fusion in the long-term and side effects of bone graft harvesting.

LEVEL OF EVIDENCE

II. Retrospective study.

Kienböck disease

Kienböck disease, or osteonecrosis of the lunate, is a progressive disease process that can lead to wrist pain and dysfunction. Although it was described over 100 years ago, and advances have been made in understanding this disease, the precise etiology remains uncertain. Anatomic, mechanical, vascular, and traumatic factors have been suggested to contribute to the disease. The natural history is unknown, and radiographic and clinical findings do not always correlate. Progress has been made in recognizing the progression of the avascular process and its deleterious effects on wrist mechanics. Initial treatment is nonsurgical, and it remains unclear whether surgical intervention results in improved outcomes over nonoperative treatment. Traditional surgical procedures such as radial shortening osteotomy and proximal row carpectomy have been shown to be reliable treatment options for relieving pain and improving function. Newer procedures such as pedicled bone grafts from the distal radius may improve direct revascularization of the lunate in earlier stages of the disease, potentially arresting the progression of collapse. Additional data are necessary to determine with certainty whether this type of procedure represents an improvement over the traditional treatment alternatives. Kienböck disease remains a challenging problem for hand surgeons.

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienböck's disease: first results of an ongoing observational study

INTRODUCTION

Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienböck's disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienböck's disease.

MATERIALS AND METHODS

Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients.

RESULTS

In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39 % of the opposite hand. Grip strength improved from 52.9 to 62.1 %. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0 % of the opposite hand. Grip strength improved from 38.6 to 69.0 %, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0.

CONCLUSION

One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.

The Use of MRI Modeling to Enhance Osteochondral Transfer in Segmental Kienböck's Disease

Kienböck's disease, defined as avascular necrosis of the lunate, is a relatively rare condition with a poorly understood etiology. Conservative and invasive treatments for Kienböck's disease exist, including wrist immobilization, surgical joint-leveling procedures, vascularized bone grafting, proximal row carpectomy, and total wrist arthrodesis. Staging Kienböck's disease using radiography assumes near complete avascularity of the lunate. The staging distinguishes only the "state of collapse" in an ordinal classification scheme and does not allow localization or indicate partial involvement of the lunate, which the image contrast from MRI may provide. In this short communication, we report the treatment of a patient's Kienböck's disease by combining MRI with mathematical modeling to optimize the congruency between the curvature of donor and recipient sites of an autologous osteoarticular plug transfer. Follow-up MRI and radiographs at 1 year postoperatively demonstrated gradual graft incorporation and bone healing. The purpose of this study was to describe the feasibility of a novel surgical technique. The results indicate that donor site selection for autologous osteoarticular transfer using a quantitative evaluation of articular surface curvature may be beneficial for optimizing the likelihood for restoring the radius of curvature and thus joint articulation following cartilage repair.

The arthritic wrist. II--the degenerative wrist: indications for different surgical treatments

For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined.

[New treatment of advanced Kienböck disease: replacement of lunate with costochondral autograft]

Treatment of advanced Kienböck's disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböck's disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32-51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6-36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.

Systematic review of the treatment of Kienböck's disease in its early and late stages

PURPOSE

To perform a systematic review of the treatment of Kienböck's disease to test the hypothesis that none of the reported treatments for Kienböck's disease is superior with respect to outcomes of pain, motion, grip strength, and radiographic measures.

METHODS

We searched PubMed, Medline, and the Cochrane Review for articles published between 1998 and 2008 reporting outcomes of treatment for Kienböck's disease. Patients were grouped by stage of disease. Early stages were defined as Lichtman stage I, II, and IIIa, and 'late' stages as IIIb and IV. The groups were then analyzed on the basis of treatment; procedures performed on subjects in the early group included vascularized bone grafting (VBG), metaphyseal core decompression, and radial osteotomy, whereas the procedures performed on subjects in the late group included VBG, radial osteotomy, partial arthrodesis, proximal row carpectomy, tendon ball arthroplasty, and nonsurgical treatment.

RESULTS

We found no statistically significant difference between any of the treatment groups for subjective pain outcomes. In terms of objective measures, statistically significant improvement (p<.05) was seen in range of motion after radial osteotomy and VBG in early-stage patients and after all interventions, except partial arthrodesis and nonsurgical treatment, for late-stage patients. Grip strength was significantly improved in early-stage patients after radial osteotomy and VBG and for all late-stage patients, except among those managed nonsurgically. Changes in Stahl and carpal height index scores were not statistically significant regardless of intervention, except after radial osteotomy in the early group, where they statistically worsened.

CONCLUSIONS

Based on retrospective data from uncontrolled studies, no active treatment is superior in the treatment of Kienböck's disease and there are insufficient data to determine whether the outcomes of any intervention are superior to placebo or the natural history of the disease.

Biomechanics of the wrist after proximal row carpectomy in cadavers

We investigated the biomechanics of the radiocapitate joint after a proximal row carpectomy in six fresh-frozen cadaver wrists using super-low-pressure-sensitive film on a material testing system. The average pressure within the lunate fossa increased significantly from 23.2 to 136.4 N/cm(2) with a sharp decrease in the contact area from 2.08 to 0.30 cm(2) after a proximal row carpectomy. The cartilage of the proximal capitate had four sub-facets and therefore was not as smooth as the normal proximal lunate. We found that the wrist was overloaded after a proximal row carpectomy and the main cause was the anatomical mismatch of the radiocapitate articulation.

Proximal row carpectomy with capsular interposition arthroplasty for advanced arthritis of the wrist

Advanced osteoarthritis of the wrist or the distal articulation of the lunate with the capitate has traditionally been treated surgically by arthrodesis. In order to maintain movement, we performed proximal row carpectomy with capsular interposition arthroplasty as an alternative to arthrodesis in eight patients with advanced arthritis and retrospectively reviewed their clinical and radiographic outcomes after a mean follow-up of 41 months (13 to 53). The visual analogue scale (VAS) for pain at its worst and at rest, and the patient-rated wrist evaluation score improved significantly after surgery, whereas ranges of movement and grip strength were maintained at the pre-operative levels. Progression of arthritis in the radiocapitate joint was observed in three patients, but their outcomes were not significantly different from those without progression of arthritis.

Proximal row carpectomy with capsular interposition arthroplasty is a reasonable option for the treatment of patients with advanced arthritis of the wrist.

Proximal row carpectomy: long-term results

OBJECTIVES

To evaluate long-term clinical outcome of proximal carpectomy. Our assumption was that this intervention should result in long-term benefit, making a wrist painless, mobile, and functional, compatible with social and professional life, whatever the initial etiology of the degenerative wrist.

METHODS

We report a continuous single centre retrospective series of 24 patients. Objective (mobility, strength, radiographic evaluation) and subjective (pain, subjective wrist value, functional scores) functions were assessed by an independent observer. Surgery was performed mainly for Kienbock's disease, scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists.

RESULTS

The follow-up lasted 116 months in average, during which pain was improved in all cases; 83% of the patients were satisfied with a mean score of 1.2 on a visual analogue scale (VAS) and 76% subjective wrist value (SWV) (disabilities of the arm, shoulder and hand [DASH]: 31). Wrist flexion-extension arc averaged 76 degrees , and the grip strength equivalent to 78% of the contralateral limb. Radiographic modification developed in 52% without any clinical impact. Three patients required arthrodesis and never felt comfortable with their carpectomy.

CONCLUSIONS

Our study shows a long-term efficacy of proximal row carpectomy. This treatment must be considered in the therapeutic arsenal for a degenerative and painful wrist, and it should no longer be regarded as a salvage procedure. Advantages of this intervention are obvious: technical simplicity, short rehabilitation, immediate functionality of the wrist and few complications.

Kienböck's disease

Osteonecrosis of the lunate, Kienböck's disease, is a progressive, debilitating disease process that can lead to chronic pain and dysfunction. Despite its recognition almost 100 years ago, the etiology remains unidentified, although mechanical, vascular, and traumatic factors have been implicated. The natural history of this disease is poorly defined, and the radiographic appearance does not always correlate with the clinical findings. Some progress has been made in the identification and an understanding of the progression of the avascular process and its deleterious effects on wrist mechanics. Initial treatment is nonsurgical. Advances in surgical techniques with vascularized pedicled grafts from the distal radius may lead to an improvement in outcomes for patients in the earlier stages of disease, although much more work is needed to determine whether this surgical option represents an improvement over conventional treatment alternatives. Recent reports of long-term outcomes of radial shortening osteotomy for earlier stages of osteonecrosis and proximal row carpectomy for advanced Kienböck's disease reveal that these procedures provide reliable options for the long-term management of this difficult clinical problem.

[Kienböck's disease. Diagnosis and therapy]

Kienböck's disease (carpal lunate necrosis or lunatomalacia) is the most common aseptic osteonecrosis of the upper extremity. Other bone necroses in the hand occur less frequently. The name indicates a disease with unclear etiology which eventually always leads to necrosis of the lunate bone. It usually affects the dominant hands of males between 20 and 40 years of age. Treatment methods extend from immobilization to revascularization surgery on the affected bone. There is still no gold standard for the treatment of Kienböck's disease.

Proximal row carpectomy for advanced Kienböck's disease: average 10-year follow-up

PURPOSE

To evaluate the clinical and radiographic results after a proximal row carpectomy for Lichtman stage III and IV Kienböck's disease at an average 10-year follow-up.

METHODS

Twenty-one patients with either Lichtman stage IIIA, IIIB, or IV Kienböck's disease were treated surgically at an average age of 38 years. At follow-up evaluation, each patient was evaluated subjectively with the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Related Wrist Evaluation questionnaires (both are validated, patient-reported questionnaires assessing pain and function) and objectively with an assessment of range of motion and grip strength. Radiographs were obtained to assess the radiocapitate articulation.

RESULTS

Three patients had persistent pain after a proximal row carpectomy requiring a radiocapitate arthrodesis at a mean of 23 months (range, 5-53 months). Two of these 3 patients had preoperative stage IV disease. The remaining 18 patients were evaluated at an average follow-up of 10 years (range, 4-17 years). The average wrist flexion-extension arc was 105 degrees, which averaged 78% of that of the contralateral wrist. Average maximal grip strength was 35 kg, which averaged 87% of that of the contralateral wrist. Average Quick Disabilities of the Arm, Shoulder, and Hand score was 12 points and average Patient-Related Wrist Evaluation score was 17 points, each representing minimal functional limitation. Radiographic analysis at final follow-up demonstrated degeneration of the radiocapitate articulation in 16 patients. Narrowing of the joint space was rated as none in 2 wrists, partial in 10 wrists, and complete in 4 wrists. There was no significant association between the radiographic findings and the subjective and objective outcome.

CONCLUSIONS

At an average follow-up of 10 years, proximal row carpectomy is a reliable and durable procedure for patients with Lichtman stage IIIA or IIIB Kienböck's disease. Caution should be exercised in performing the procedure in patients with stage IV disease because of risk of early symptomatic radiocapitate degeneration.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-term follow-up of radial shortening osteotomy for Kienbock disease

BACKGROUND

Three previous studies have investigated the long-term outcome of radial osteotomy in the treatment of Kienböck disease. However, none used patient-based assessment. The purpose of this study was to investigate the long-term clinical and radiographic outcomes of this osteotomy, including the subjective evaluation of the patient with use of the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire.

METHODS

A DASH questionnaire was sent to nineteen patients with Kienböck disease who had undergone a radial shortening osteotomy, and thirteen replied. The mean age at the time of surgery was thirty-nine years. On the basis of the Lichtman classification, six patients had stage-II, four had stage-IIIA, and three had stage-IIIB disease. Prior to surgery, ulnar variance was positive in six patients, neutral in four, and negative in three. The mean duration of follow-up was twenty-one years. Clinical evaluation, including calculation of the modified Mayo wrist score, and radiographic evaluation were also performed on twelve of the thirteen patients.

RESULTS

The mean DASH score was 8 points (range, 0 to 23 points), and patient satisfaction was high. Compared with the findings in the contralateral wrist, the mean range of motion was 81% in flexion and 82% in extension and mean grip strength was 88%. The mean modified Mayo wrist score was 83 points, and the clinical results were excellent in six patients, good in five, and moderate in one. The DASH scores tended to be worse in patients with Lichtman stage-IIIB disease. Follow-up radiographs revealed that the Lichtman stage had progressed in six of the twelve patients.

CONCLUSIONS

Although most patients had mild wrist pain, patient satisfaction and the clinical results were satisfactory following a radial shortening osteotomy. This procedure is a reliable long-term treatment for Lichtman stage-II and IIIA disease and may be a reasonable option for patients with stage-IIIB disease.