Radial shortening for the treatment of Kienböck's disease--a 5- to 10-year follow-up

Pediatric Kienböck's Disease in an 11-Year-Old Boy: A Case Report

Kienböck's disease is a rare condition in the pediatric age group, with little agreement on its natural history and the best treatment option. Typically, these patients present with vague wrist pain and a variable degree of joint motion restriction. Diagnosis is mainly based on clinical suspicion and MRI findings, as radiographs do not show significant changes in the early stages of the disease. Prognosis is better in children than in adults due to the good healing capacity in this age group. This study will report on an 11-year-old boy diagnosed with Kienböck's disease who underwent surgical treatment to temporarily offload the diseased lunate. Clinical and radiographic recovery was observed at the six-month follow-up.

Sliding Plate System: A Novel Method and Device for Shortening Osteotomy

We report a novel sliding plate system (SPS) and its application for radial shortening osteotomy. We conceptualised, designed and introduced the SPS, which helps with precise shortening osteotomy in both radius and ulna. We implanted the SPS in a patient with Kienböck disease following a radius shortening osteotomy. The SPS was safe and efficient, and the surgical technique eliminated extra steps. The SPS affords precise shortening, optimum compression and anatomic alignment after radius shortening osteotomy. Level of Evidence: Level V (Therapeutic).

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.

Changes in wrist joint contact area following radial shortening osteotomy for Kienböck's disease

We hypothesized that the contact area of the articular surface of the wrist joint could be evaluated using a custom-designed analytical program. The aim of the study was to compare the articular contact area of the wrist joint before and after radial shortening osteotomy for Kienböck’s disease. Nine wrists of 9 patients underwent radial shortening osteotomy for Kienböck’s disease. Computed tomography (CT) images of the wrist joint were reconstructed using a 3D reconstruction software package. Radioscaphoid and radiolunate joint contact areas and translation of the joint contact area from preoperative to postoperative were calculated using customized software. The mean Modified Mayo Wrist Score was significantly improved from 50.6 preoperatively to 83.3 at final follow-up (p < .001). Preoperatively, the pain was reported as severe in five wrists and moderate in four wrists, while at final follow-up, five patients were free from pain and four patients had mild pain with vigorous activity. The preoperative radioscaphoid joint contact area was 133.4 ± 49.5 mm² and the postoperative radioscaphoid joint contact area was 156.4 ± 73.1 mm². The preoperative radiolunate joint contact area was 194.8 ± 92.1 mm² and the postoperative radiolunate joint contact area was 148.3 ± 97.9 mm². The radial translation distance was 0.4 ± 1.2 mm, the dorsal translation distance was 0.6 ± 1.2 mm, and the proximal translation distance was 0.2 ± 0.4 mm. CT-based analysis revealed that the center of the contact area translated radially following radial shortening.

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.

Lunate biomechanics: application to Kienböck's disease and its treatment

Kienböck's disease was initially considered as lunate osteomalacia due to lesions of its nutrient arteries during carpal ligament tears. It has also been suggested following primary fractures, or because of repeated microtrauma. It is only in the past 20 or 30 years that it has appeared as aseptic necrosis. Based on Hultén's hypothesis that a negative radioulnar index was the cause of Kienböck's disease, equalization osteotomies (shortening of the radius or lengthening of the ulna) were developed. The observation of Kienböck's disease in subjects with a positive index and the risk of ulnar abutment after osteotomy led to the introduction of new osteotomies to get around these difficulties, still in the hope of treating the cause of Kienböck's disease. While it has been confirmed that a negative radioulnar index promotes lunate fracture, it clearly does not induce the pathology in the form of necrosis. In this scenario, perilunar osteotomies produce durable decompression, limiting the risk of lunate fracture in case of necrosis by removing the compressive constraints. After comparing the different osteotomies used to treat Kienböck's disease, it seems that the Camembert osteotomy for radius shortening, combined with selective shortening of the ulnar head as described by Sennwald, decompresses the lunate maximally, and protects it long enough for potential natural revascularization to occur.

The 100 Top-Cited Articles about Kienböck’s Disease: A Bibliometric Analysis

Introduction The aim of this study was to analyze the 100 top-cited articles about Kienböck’s disease and their features.

Materials and Methods A search through the Elsevier, Scopus database journal articles about Kienböck’s disease yielded 1,025 results. The 100 top-cited articles were identified and filtered again to exclude self-citations. The 100 top-cited articles without self-citations were analyzed for the number of citation, citation density, publishing journal, language, authorship, and geographic origin. The abstracts of the articles were obtained to review and determine the types of articles and levels of evidence.

Results The mean of the 100 top-cited articles’ absolute number of citations was 63.3 ± 34 (range: 23–199). Citation densities ranged from 1 to 8. A total of 97 (97%) articles were written in English. The leading countries were the United States with 50 (50%) articles followed by Japan with 16 (16%) articles. Forty (40%) articles have been published in the Journal of Hand Surgery American volume. Among the 100 top-cited articles, nine articles were devoted to basic science and 91 articles have dealt with clinical science. There were three articles with level II, 24 articles with level III, 46 articles with level IV, and 18 articles with level V of evidences.

Conclusion The current study presents an insight to the classic articles about Kienböck’s disease. The 100 top-cited articles have established a foundation that the science on Kienböck’s disease has been elaborated. The current study is likely helpful for educational purposes and further research about Kienböck’s disease.

Level of Evidence Economic and decision analysis/Level IV.

Varisized 3D-Printed Lunate for Kienböck's Disease in Different Stages: Preliminary Results

Objective

To evaluate the feasibility of arthroplasty with varisized three‐dimensional(3D) printing lunate prosthesis for the treatment of advanced Kienböck's disease (KD).

Methods

From 2016 November to 2018 September, a retrospective study was performed for the patients of KD in our hospital. Five patients (two males, three females) were included in this study. The mean age of the patients at the time of surgery was 51.6 years (range, 37–64 years). Varisized prosthesis identical to the live model in a ratio of 1:0.85, 1:1, and 1:1.1 were fabricated by 3D printing. All patients (one in Lichtman IIIA stage, two in Lichtman IIIB stage, one in Lichtman IIIC stage, and one in Lichtman IV stage) were treated with lunate excision and 3D printing prosthetic arthroplasty. Visual analog scale score (VAS), the active movement of wrist (extension, flexion) and strength were assessed preoperatively and postoperatively. The Mayo Modified Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) Score, and patient's satisfaction were evaluated during the follow‐up.

Results

Prosthesis identical to the live model in a ratio of 1:0.85 or 1:1 were chosen for arthroplasty. The mean operation time (range, 45 to 56 min) was 51.8 ± 4.44 min. Follow‐up time ranged from 11 months to 33 months with the mean value of 19.4 months. The mean extension range of the wrist significantly increased from preoperative 44° ± 9.6° to postoperative 60° ± 3.5° (P < 0.05). The mean flexion range of the wrist significantly increased from preoperative 40° ± 10.6° to postoperative 51° ± 6.5° (P < 0.05). The active movement of wrist and strength were improved significantly in all patients. VAS was significantly reduced from 7.3 preoperatively to 0.2 at the follow‐up visit (P < 0.05). The mean DASH score was 10 (range, 7.2–14.2), and the mean MMWS was 79 (range, 70–90). There were no incision infection. All patients were satisfied with the treatment.

Conclusions

For patients suffering advanced Kienböck's disease, lunate excision followed by 3D printing prosthetic arthroplasty can reconstruct the anatomical structure of the carpal tunnel, alleviate pain, and improve wrist movement.

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.

Evaluation of a shape memory staple (Qual®) in radial shortening osteotomy in Kienböck's disease: A retrospective study of 30 cases

The QUAL^® (Memometal, Stryker) device is a shape memory staple used for bone fixation during distal radius shortening osteotomy in the context of Kienböck's disease. The present study is a retrospective, single-center and multisurgeon study of 30 patients with a mean follow-up of 8 years. Clinical criteria (range of motion (ROM), strength, pain and functional score) and radiographic data (ulnar variance, distal radius articular surface inclination, Lichtman stage, carpal height and bone healing) were evaluated pre- and post-operatively. We found satisfactory results with the mean grip strength of 22 kg/F before surgery and 24 kg/F after surgery. The mean ROM was 88° preoperatively and 82° postoperatively and the mean ulnar deviation was 23° preoperatively and 21° post-operatively. There was no change in radial deviation and pronation-supination after surgery. The average ulnar variance was 1 mm before surgery and 0.2 mm after surgery. The inclination of the distal radius articular surface on lateral and anteroposterior views and the mean carpal height were similar to the pre-operative ones. There was no delay in bone healing. The mean pain score was 2 at rest on a visual analogue scale after surgery. Seven patients experienced an increase in their Lichtman stage at the follow-up, and two patients were waiting for conversion to a non-conservative surgical treatment. Seven staples were removed postoperatively. Seventy-eight percent of patients returned to work after 3 months on average. Seventy-five percent of patients were at least satisfied with the outcome of their surgery. The QUAL^® staple is a reliable option for fixation during shortening osteotomy of the radius in Kienböck's disease.

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.

Radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease

We carried out a retrospective study to analyse the long-term outcome of 36 patients after radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease at a mean follow-up of 12.1 years (range 5.4-17.5). At review, seven wrists had progressed to Stage IIIB, eight wrists to Stage IV and 21 remained in Stage IIIA. Motion and grip strength were significantly improved. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score at review was 12 points (range 0-52), and patient satisfaction was high. Apart from plate removals in 14 patients and one wrist denervation, no subsequent surgical procedures were done. Radial shortening yields good long-term clinical results, but does not prevent radiographic progression of disease in some patients.

LEVEL OF EVIDENCE

Therapeutic IV.

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.

Outcome of Kienböck's disease in twelve cases: a mid-term follow-up study

INTRODUCTION

No single study has established the superiority of one treatment of Kienböck's disease over the other. Pooled outcome data is presently considered the best way to add to the knowledge and understanding of Kienböck's disease.

METHODS

A total of 12 patients (9 male and 3 female) with Kienböck's disease were included in the present case series. The mean age of the 12 patients was 28 years. One patient presented in Lichtman stage I, five in Lichtman stage II, five in Lichtman stage IIIa, and one in Lichtman stage IV. Univariate and multivariate analyses of the obtained data were performed to identify any correlations.

RESULTS

The mean follow-up time was 62 months, and the mean modified Mayo wrist score improved from the preoperative value of 29.5 to the final value of 89.6. Lichtman stage at presentation showed moderate positive correlation with the duration of symptoms (r = 0.56), and a strong negative correlation with the preoperative and final modified Mayo scores (r = -0.89 and r = -0.77, respectively). The final modified Mayo score showed moderate negative correlation with the duration of the symptoms (r = -0.55). There was a significant difference in the preoperative modified Mayo scores of patients who presented in stage II and those of patients who presented in stage IIIa (p = 0.03). However, the difference in the final modified Mayo scores of the patients in these stages was not significant (p = 0.14).

CONCLUSION

Lichtman's stage is moderately related to the duration of symptoms, suggesting natural progression of the disease. The final outcomes of stages II and IIIa were the same irrespective of the surgical treatment (radial shortening and/or vascularised bone grafting).

Characteristic features and natural evolution of Kienböck's disease: five years' results of a prospective case series and retrospective case series of 106 patients

OBJECTIVES

Scientific databases index numerous references related to the treatment of Kienböck's disease; yet little is known about the nature of the disease and its pathognomonic features. This study provides a cross-sectional analysis of the pattern and extent of osteonecrosis in a large cohort and a longitudinal analysis to determine the spontaneous disease progression in single patients who have not had surgical management until fragmentation of the lunate.

METHODS

In a prospective case series, the pattern and extent of osteonecrosis were correlated with the duration of symptoms in all patients with Kienböck's disease confirmed using high-resolution 3-T magnetic resonance imaging (MRI) and ultra-thin section computed tomographic (CT) scan since 2009. Furthermore, a retrospective consecutive case series study was conducted to determine the rate of spontaneous evolution in all consecutive patients treated conservatively in our university hospital since 1990.

RESULTS

Among the 35 consecutive patients with Kienböck's disease diagnosed in high-resolution 3-T MRI and ultra-thin section CT, 46% (16/35) presented degeneration of lunate cartilage on CT scan in the first 12 months following the onset of symptoms. Median wrist pain duration of patients presenting a fracture of the lunate was 14 months. Thirty-one percent (11/35) of the patients had arthritis of the lunate, yet no fractures at the time of examination. Of 106 consecutive patients with Kienböck's disease and complete records, who did not have surgical intervention until fragmentation of the lunate, three cases were identified with well-documented spontaneous courses from apparently intact lunate morphology until fragmentation within 6 months.

CONCLUSIONS

Kienböck's disease progresses substantially faster than previously described and, contrary to current classifications, the articular cartilage of the lunate degenerates in early stages.

LEVEL OF EVIDENCE

Diagnostic accuracy, Level IV.

Radial shortening osteotomy for Kienböck disease: minimum 10-year follow-up

PURPOSE

To clarify long-term clinical and radiological results more than 10 years after radial shortening osteotomy for Kienböck disease.

METHODS

Eleven wrists of 10 patients that had been classified as Lichtman stages 3A (2 wrists), 3B (8 wrists), and 4 (1 wrist) underwent radial shortening for Kienböck disease. The mean follow-up period was 14.3 years (range, 10-21 y). Clinical outcomes were quantified using the Japanese version of the Disabilities of the Arm, Shoulder, and Hand questionnaire and the modified Mayo wrist score. Radiographic and magnetic resonance imaging studies were performed for 9 of the 10 patients preoperatively and all 10 patients at follow-up.

RESULTS

At follow-up, 6 wrists were asymptomatic and the remaining 5 had mild occasional pain. The mean range of extension and grip strength significantly improved. The mean modified Mayo wrist score and Disabilities of the Arm, Shoulder, and Hand scores were 92 (range, 80-100) and 5 (range, 0-18), respectively. At follow-up, no progression of the Lichtman stage was found in any patient. There was no significant progressive lunate collapse in any patient. The magnetic resonance imaging in 7 wrists showed increased signal intensity of the lunate; the remaining 3 wrists had no alteration in signal intensity of the bone.

CONCLUSIONS

Our study demonstrated satisfactory clinical results after 10 or more years in patients who underwent radial shortening for Kienböck disease. Although we found no improvement in signal intensity of the lunate in 3 wrists, unloading of the diseased lunate after radial shortening gives long-lasting symptom relief and may prevent lunate collapse.

TYPE OF STUDY/LEVEL OF DISEASE

Therapeutic IV.

Radial shortening osteotomy in advanced stages of Kienbock disease

Radial shortening osteotomy is a well-accepted treatment for Kienbock disease in stages I to IIIA. The usefulness of this procedure in more advanced stages of the disease is controversial. In this study, 27 cases of stage IIIB and IV of Kienbock disease underwent radial shortening osteotomy and were followed for a mean period of 54.9 months (9 to 117 mo). Twenty-four patients had stage IIIB and 3 patients had stage IV disease. Sixteen of the affected wrists were on the dominant side. All patients were evaluated clinically and radiologically at last follow-up. Modified Mayo Score was used for clinical evaluation. The measured radiologic parameters included carpal height ratio, Stahl index, and radioscaphoid angle. In stage IIIB, 41.6% of cases had good, 54.2 had fair, and 4.2 had poor result, whereas in stage IV all patients showed poor result. The mean range of flexion-extension was 84.4% of the unaffected side. Considering the percentage of preserved motion, this procedure seems to be a good alternative to partial fusion for stage IIIB when the patient is willing to preserve more degrees of motion. Although the number of patients with stage IV disease was limited in this study, poor result in all of them may show the uselessness of this procedure in stage IV.

Long-term results of vascularized bone graft for stage III Kienböck disease

PURPOSE

Vascularized bone grafting (VBG) is one of the therapeutic approaches for treating advanced Kienböck disease; however, few reports on long-term outcomes are available for this technique. The purpose of this study is to evaluate long-term results by following up patients with stage III Kienböck disease for more than 10 years after VBG.

METHODS

The study included 18 patients with advanced Kienböck disease (Lichtman stage IIIA, n = 10; stage IIIB, n = 8) who received VBG between 1996 and 2001 and were followed up for at least 10 years. Eleven patients received transplantation from the metacarpal base and 7 patients from the distal radius. Radial shortening and capitate shortening were performed in 5 and 2 stage IIIB patients, respectively.

RESULTS

The mean follow-up period was 12 years, 3 months. Based on the Mayo Modified Wrist Score, clinical results were excellent in 8 patients, good in 7 patients, and fair in 3 patients. The Stahl index and carpal height ratio were not improved in stage IIIA patients who received bone graft alone, whereas significant improvement was observed in stage IIIB patients who received shortening, as well.

CONCLUSIONS

Vascularized bone grafting for stage III Kienböck disease demonstrated favorable long-term results and is recommended as a surgical treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Clinical and radiological results following radial osteotomy in patients with Kienböck’s disease

Radial osteotomy is currently advocated for patients with Lichtman’s stages II and IIIA of Kienböck’s disease; its place in the treatment of patients with stage IIIB disease remains controversial. The purpose of this study was to evaluate the medium-term results of this procedure and to compare the outcome in patients with stage IIIB disease and those with earlier stages (II and IIIA). A total of 18 patients (18 osteotomies) were evaluated both clinically and radiologically at a mean follow-up of 10.3 years (4 to 18). Range of movement, grip strength and pain improved significantly in all patients; the functional score (Nakamura Scoring System (NSSK)) was high and self-reported disability (Disabilities of Arm, Shoulder and Hand questionnaire) was low at the final follow-up in all patients evaluated. Patients with stage IIIB disease, however, had a significantly lower grip strength, lower NSSK scores and higher disability than those in less advanced stages. Radiological progression of the disease was not noted in either group, despite the stage. Radial osteotomy seems effective in halting the progression of disease and improving symptoms in stages II, IIIA and IIIB. Patients with less advanced disease should be expected to have better clinical results.

CLINICAL OUTCOMES OF EXCISION ARTHROPLASTY FOR KIENBOCK'S DISEASE

We have carried out a replacement of the lunate in 12 patients with advanced Kienböck's disease, with excision of the lunate and insertion of an iliac bone flap wrapped into palmaris longus. The aims of this study were to determine the effect of this procedure for advanced Kienböck's disease. At a mean follow-up period of 45.3 months, the mean clinical score was excellent in all cases. Radiographically, progression of osteoarthritis (OA) in the radiocarpal joint was found in two patients. At follow-up, the X-ray findings indicated a reduced of osseous core in four patients. On the other hand, carpal height ratio showed no significant change at follow-up. Excision arthroplasty using a tendon ball with osseous core for advanced Kienböck's disease leads to OA progression in some cases. However, clinical results were excellent in all cases. Therefore, this current study provides effective therapeutic procedure for advanced Kienböck's disease.

Treatment of Kienböck disease by lunate core decompression

PURPOSE

Kienböck disease is characterized by avascular necrosis of the lunate bone, which is usually progressive without treatment. This study examined lunate core decompression for its treatment potential.

METHODS

We surgically treated 20 patients with stage 1 to 3b Kienböck disease with lunate core decompression. We evaluated pain, range of motion, functional disability, and radiographic indices in these patients at baseline and 5 years after surgery.

RESULTS

The mean age of the patients was 29 years; 16 were men. Ten patients had Lichtman stage 1 disease, 6 had stage 2 disease, 3 had stage 3a, and 1 had stage 3b disease. Range of motion scores showed meaningful improvement. Two patients did not improve with this technique and were revised with radial shortening procedures.

CONCLUSIONS

Lunate core decompression is a simple surgical procedure that is effective in the treatment of Kienböck disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Computed tomography osteoabsorptiometry alterations in stress distribution patterns through the wrist after radial shortening osteotomy for Kienböck disease

PURPOSE

The distribution pattern of subchondral bone density is considered to closely reflect the stress distribution across a joint under physiological loading conditions. Our purpose was to determine alterations in the distribution pattern of subchondral bone density across the distal articular surfaces of the radius and the ulna in patients with Kienböck disease after radial shortening.

METHODS

We collected preoperative and postoperative computed tomography (CT) image data from 7 wrists of 7 patients who had undergone radial shortening for Kienböck disease. We measured the distribution of subchondral bone density through the distal articular surface of the radius and the ulna using a CT osteoabsorptiometry method. The obtained data were quantitatively assessed by calculating the high-density area ratio of the entire radiocarpal joint surface, scaphoid fossa, lunate fossa, and distal ulnar surface.

RESULTS

At the mean postoperative period of 27 months, the mean high-density area ratio in the entire distal articular surface of the radius significantly decreased from 0.413 preoperatively to 0.141 postoperatively. The postoperative value in each fossa demonstrated a significant reduction from 0.253 to 0.096 in the scaphoid fossa and from 0.160 to 0.045 in the lunate fossa. No significant alteration in the value was found in the distal ulna at follow-up.

CONCLUSIONS

Our CT osteoabsorptiometry analysis suggests that the distribution of subchondral bone density in both scaphoid and lunate fossae notably decreases after radial shortening. This indicates that radial shortening unloads the lunate by reducing the actual stress across the distal articular surface of the radius in subjects with Kienböck disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Joint leveling for advanced Kienböck's disease

PURPOSE

The use of joint leveling procedures to treat Kienböck's disease have been limited by the degree of disease advancement. This study was designed to compare clinical and radiographic outcomes of wrists with more advanced (stage IIIB) Kienböck's disease with those of wrists with less advanced (stage II/IIIA) disease following radius-shortening osteotomy.

METHODS

This retrospective study enrolled 31 adult wrists (30 patients; mean age, 39 y), treated with radius-shortening osteotomy at 2 institutions for either stage IIIB (n = 14) or stage II/IIIA (n = 17) disease. Evaluation was performed at a mean of 74 months (IIIB, 77 mo; II/IIIA, 72 mo). Radiographic assessment determined disease progression. Clinical outcomes were determined by validated patient-based and objective measures.

RESULTS

Patient-based outcome ratings of wrists treated for stage IIIB were similar to those with stage II/IIIA (shortened Disabilities of the Arm, Shoulder, and Hand score, 15 vs 12; modified Mayo wrist score, 84 vs 87; visual analog scale pain score, 1.2 vs 1.7; visual analog scale function score, 2.6 vs 2.1). The average flexion/extension arc was 102° for wrists with stage IIIB and 106° for wrists with stage II/IIIA Kienbock's. Grip strength was 77% of the opposite side for stage IIIB wrists versus 85% for stage II/IIIA. Postoperative carpal height ratio and radioscaphoid angle were worse for wrists treated for stage IIIB (0.46 and 65°, respectively) than stage II/IIIA (0.53 and 53°, respectively) disease. Radiographic disease progression occurred in 7 wrists (6 stage II/IIIA, 1 stage IIIB). The one stage IIIB wrist that progressed underwent wrist arthrodesis.

CONCLUSIONS

In this limited series, clinical outcomes of radius shortening using validated, patient-based assessment instruments and objective measures failed to demonstrate predicted clinically relevant differences between stage II/IIIA and IIIB Kienböck's disease. Given the high percentage of successful clinical outcomes in this case series of 14 stage IIIB wrists, we believe that static carpal malalignment does not preclude radius-shortening osteotomy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Radial overgrowth after radial shortening osteotomies for skeletally immature patients with Kienböck's disease

PURPOSE

We hypothesized that radial shortening osteotomy (radial shortening) for skeletally immature patients with Kienböck's disease would induce overgrowth of the radius. The purpose of this study was to determine the effect of radial shortening on radial growth in skeletally immature patients with Kienböck's disease and to clarify the relationship between the postoperative growth alterations and the clinical results.

METHODS

Eight wrists of 8 skeletally immature patients with Kienböck's disease were treated with radial shortening. There were 3 boys and 5 girls, ranging in age from 11 to 18 (mean, 14) years old. All patients presented with open physis and negative ulnar variance. The length of the radial shortening equaled the amount of negative ulnar variance. Clinical assessment was based on the modified Nakamura scoring system. Radiographic assessment, including Lichtman's stages, ulnar variance, carpal height ratio, radial inclination, and volar tilt, was performed before surgery, immediately after surgery, and at follow-up. A difference in ulnar variance of more than 2 mm between these 3 measurements was considered to be overgrowth. Statistical comparisons were performed using paired t-tests.

RESULTS

At a mean follow-up period of 69 months, the mean clinical score was 19.7 of 21 maximum points, with all wrists rated as excellent. Radiographically, no progression of Lichtman stage was found in any patient. At follow-up, the x-ray and magnetic resonance imaging findings indicated lunate revascularization in all patients. Four of the 8 had overgrowth in the operated radius. On the other hand, other radiographic parameters showed no significant changes at follow-up. The occurrence of postoperative radial overgrowth did not notably affect the clinical scores.

CONCLUSIONS

The current results suggest the probability of overgrowth of the radius in skeletally immature patients with Kienböck's disease treated with radial shortening. The postoperative radial overgrowth after this osteotomy had no effect on clinical and other radiographic outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Double V-shaped cancellous osteotomy of the distal radius for Kienböck's disease

Treatments of Kienböck's disease range from conservative measures-usually immobilization during the acute phase-to such procedures as joint leveling by radial shortening or ulnar lengthening, intercarpal fusion, silastic arthroplasty, and vascularized bone grafts. Joint-leveling procedures have many complications such as nonunion, hardware problems, and pain. In this study, 34 patients with Kienböck's disease, stage 1 through 3B in Lichtman's classification, were treated with a new technique: a double V-shaped metaphyseal osteotomy of the distal radius and dorsal tilt of the distal radius. The patients were evaluated clinically regarding pain, which decreased in 88% of patients; range of motion, which improved in all patients; and grip strength, which improved by 90%. Progression of the disease was assessed radiologically by determining the carpal height ratio and the carpal ulnar distance ratio. There were no cases with nonunion of the radial osteotomy at follow-up. This procedure is an effective treatment method for Kienböck's disease in wrists that do not have degenerative changes in the adjacent carpal joints.

Distraction histiogenesis for treatment of Kienbock's disease: A 2- to 8-year follow-up

BACKGROUND

Distraction histiogenesis is known to enhance vascularity and stimulate new tissue formation. Its use in Kienbock's disease is not reported in the literature, so we proposed to study the outcome after distraction histiogenesis in treating this condition.

MATERIALS AND METHODS

This prospective study comprised of six patients (two male and four female) with mean age 18.16 years (range 21-35 years) with clinicoradiologically diagnosed Lichtman stage II (n = 3) and stage III (n = 3) Kienbock's disease with a mean duration of symptoms 6.67 months. The ulnar variance was neutral in two and was negative in four patients treated with the application of Joshi external stabilization system (JESS) across the wrist. The gradual distraction was done at a rate of 0.5 mm/day. After the distraction of 5-7 mm, the distractors were kept static for 3 weeks. The wrist was mobilized by using hinged distractors for next 3 weeks. Later short cockup splint was used for further 4 weeks. At the end of minimum 2 years, an assessment was done on the basis of relief of symptoms, ability to perform activities of daily living, range of movement at wrist, grip strength, and on radiology (change in the density of bone and C:MC ratio i.e ratio of carpal height to third metacarpal height).

RESULTS

The mean follow-up was of 4.5 years (range 2-8 years). The average duration of treatment was 5.3 months (range 4.5-6 months), and the duration of distraction (both static and hinged) was 8 weeks. Clinically all the patients were relieved of the symptoms with an increase in the range of wrist movement (ulnar deviation increased from 20.8 degrees to 29.5 degrees , radial deviation from 17.5 degrees to 21 degrees , dorsiflexion from 37.5 degrees to 52.5 degrees , and palmer flexion from 38.3 degrees to 47.5 degrees ). At the last follow-up, activities of daily living were not affected, and all the patients were on their previous jobs without any fresh complaints. The average grip strength increased to 73-86% of normal. Radiologically the C:MC ratio (ratio of carpal height to third metacarpal height) did not show any significant improvement, but the density of lunate decreased.

CONCLUSION

Distraction histiogenesis when used in Lichtman stage II and III with negative or neutral ulnar variance gives good symptomatic relief, allowing return to normal activities. This study has also shown that reparative process is possible in avascular bone by distraction. The authors recommend further research in this modality of treatment.

[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.

Kienböck’s disease

Kienböck’s disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck’s disease and negative ulnar variance. Many other forms of surgical treatment have been described.

Outcome of Kienböck's disease 22 years after distal radius shortening osteotomy

Loading of the lunate in patients with Kienböck's disease and a negative ulnar variance provide the rationale for a radial shortening osteotomy. This osteotomy decreases forces transmitted from the radius to the lunate. We retrospectively reviewed 12 patients with Kienböck's disease who had 13 radial shortening osteotomies to ascertain whether the reported short- and medium-term results endured in the long-term. We evaluated nine osteotomies in nine of the 12 patients with a minimum of 16 years followup (average, 22 years; range, 16-31 years). Three patients died and one was lost to followup. For the nine patients, the range of motion was impaired compared with the normal side. Grip strength was on average 90% of the unaffected side. The average visual analog scale score for pain was 2.4 and the average Disabilities of the Arm, Shoulder, and Hand score was 14 at latest followup. In eight patients, the Lichtman classification of Kienböck's disease did not change at followup, but in three patients there was radiographic progression of the disease, which occurred during the first 10 years postoperatively. The medium- and long-term results therefore were comparable. We recommend radial shortening in stable wrists (Stage 3A or less) with a negative ulnar variance. The radius should be shortened to the level of the ulna, normally 4 to 6 mm, after which stable (plate) fixation should be performed under compression.

Overgrowth after radial shortening for Kienböck's disease in a teenager: case report

A 16-year-old boy was treated by a radial-shortening procedure for symptomatic stage IIIB Kienböck's disease with 4 mm negative ulnar variance. The osteotomy corrected the ulnar variance to negative 1 mm after surgery, but further negative ulnar variance of 9 mm occurred at follow-up evaluation as a result of radial overgrowth. The functional outcome was excellent with remodeling of the lunate. The possibility of overgrowth should be considered when contemplating a radial-shortening osteotomy for Kienböck's disease in skeletally immature patients.

Radial osteotomies for teenage patients with Kienböck disease

Age seems to affect the efficacy of radial osteotomies for Kienböck disease. We questioned whether an osteotomy would produce acceptable results in teenagers. We retrospectively identified 11 patients (six males and five females) between 11-19 years of age who were treated with radial osteotomies for Kienböck disease. Preoperatively, three patients had Lichtman Stage II disease, two patients had Stage IIIA disease, and six patients had Stage IIIB disease. Two patients with zero or positive ulnar variance had lateral closing wedge osteotomies, and nine patients with negative ulnar variance had radial shortenings. All patients were evaluated clinically and radiographically. At a mean followup of 50 months, 10 of 11 patients were free from pain, and the remaining one patient had moderate wrist pain during strenuous activity. All patients except one, who had Stage IIIB disease, had an excellent clinical outcome. Radiographic improvement, indicating lunate revascularization, was seen for eight patients. Despite Stage IIIB disease, radial osteotomies produced excellent clinical results in five of six teenage patients. The current results indicate that radial osteotomies are effective in improving not only short-term clinical outcomes, but also radiographic findings in teenage patients with Kienböck disease.

Long-term outcome of radial shortening with or without ulnar shortening for treatment of Kienbock's disease: a 13-25 year follow-up

Fourteen of 35 patients who underwent radial shortening with or without ulnar shortening for the treatment of Kienbock's disease were followed up for a median of 19 (range, 13-25) years. Radial shortening was performed for patients with ulnar negative or neutral variance, and combined shortening of radius and ulna for those with ulnar positive variance. Overall the clinical situation was significantly improved at the final follow-up. There was no significant advanced collapse of the wrists and Lichtman's stage of disease increased in only three cases. Although osteoarthritic changes in the distal radio-ulnar joint progressed in five patients, this may have little influence on clinical outcome. Radial shortening osteotomy is a reliable method for treatment of Kienbock's disease.

Surgical outcome of radial osteotomy for Kienböck's disease-minimum 10 years of follow-up

PURPOSE

Long-term results of radial osteotomy for Kienböck's disease seldom are seen in the literature. The purpose of this study was to report the minimum 10-year results and to compare them with the 5-year results to determine whether the favorable intermediate-term results were maintained.

METHODS

Twenty-five patients who underwent radial osteotomy were followed-up for a mean period of 14.5 years. They were examined for pain, grip strength, and wrist range of motion (ROM). Through a review of clinical records, 5-year postoperative results were collected. The carpal height ratio and Ståhl's index were measured and the x-rays were inspected for osteoarthritic changes. We devised an original lunate grade to evaluate radiologic improvement of the ischemic lunate. Overall results were evaluated using Cooney's wrist function score and Nakamura's scoring system for Kienböck's disease. The long-term results were compared with both the preoperative status and the 5-year results.

RESULTS

Pain, ROM, and grip strength were improved significantly after surgery, and the results were maintained for a long period. Carpal height ratio and Ståhl's index did not show significant improvements but ischemic lunate showed certain radiologic improvements with time by the lunate grade system. Osteoarthritic changes were observed in 54% of patients at 5 years and in 73% of patients at the final follow-up evaluation, but the arthrosis generally was mild and did not affect the clinical results. Cooney's wrist function score was excellent or good in 96% of the patients, and the results with Nakamura's scoring system for Kienböck's disease were excellent or good in 68% of the patients at the final follow-up evaluation. The percentages were the same 5 years after surgery.

CONCLUSIONS

Radial osteotomy for Kienböck's disease is a reasonable treatment option and clinical improvement lasts for a long period of time. Although radiologic improvement was not drastic, the inner structure such as sclerotic change or bone cysts of the lunate improved with time, indicating healing of the ischemic lunate. Severe osteoarthritic change or proximal migration of the capitate can be avoided.

Predictors of clinical results of radial osteotomies for Kienböck's disease

The factors affecting the clinical results after radial osteotomies for Kienböck's disease are unknown. In the current study, we reviewed the data of 41 patients treated with radial osteotomies for Kienböck's disease and analyzed which preoperative factors significantly affected the clinical results of these procedures. Lateral closing wedge osteotomies of the radius were done for 22 patients (six patients with Lichtman Stage II disease, three patients with Lichtman Stage IIIA disease, 12 patients with Lichtman Stage IIIB disease, and one patient with Lichtman Stage IV disease) with zero or positive ulnar variance, and radial shortenings were done for 19 patients (four patients with Stage II disease, two patients with Stage IIIA disease, 12 patients with Stage IIIB disease, and one patient with Stage IV disease) with negative ulnar variance. The mean age of the patients at surgery was 36 years and the average followup was 38 months. To statistically assess the prognostic factors, multiple regression analysis focused on the postoperative clinical score as a dependent variable and preoperative patient data as independent variables. In the current analysis, patient age was the preoperative factor most clearly predictive of clinical results after radial osteotomies for Kienböck's disease. We think that the lower effectiveness of radial osteotomies must be considered in doing these procedures for elderly patients.

Pediatric Kienböck's disease: case report and review of the literature

A 13-year-old boy with symptomatic Stage III Kienböck's disease was treated successfully with a radial shortening procedure. A comparison of the preoperative and postoperative radiographs and magnetic resonance imaging studies showed evidence of lunate revascularization and remodeling after a radial shortening osteotomy.

Open treatment of stage III Kienböck's disease with lunate revascularization compared with arthroscopic treatment without revascularization

PURPOSE

The goal of this study was to compare the results of open scaphocapitate fusion and revascularization with the results of arthroscopic scaphocapitate fusion and capitate pole excision.

TYPE OF STUDY

Prospective randomized study.

METHODS

Between April 1997 and January 2000, 16 consecutive patients (5 men and 11 women with a mean age of 31 years [range, 18 to 61]) presenting with Kienböck's disease stage IIIA and stage IIIB were randomized to either open scaphocapitate fusion and lunate revascularization (group I) or fully arthroscopic scaphocapitate fusion and capitate pole excision (group II) groups. Cannulated 3.5-mm ASIF screws were used for the purpose of scaphocapitate fixation in both groups. Operation time, hospital stay, time to fusion, range of wrist motion at final follow-up, grip strength, and return to unrestricted activities of daily living were evaluated at 33 months' follow-up.

RESULTS

The mean operating time (153 v 99 minutes), hospital stay (3.6 v 2.3 days), and return to unrestricted daily activities (15 v 5.8 weeks) were shorter in group II. Average time to radiographically evident fusion was shorter in group I (7.25 weeks v 9 weeks). There was a significant increase in grip strength and in range of motion at final follow-up in both groups, and the final grip strength and range of motion was not different between the groups. There were no major complications in either group.

CONCLUSIONS

Although the number of patients was small and the follow-up period was short, arthroscopic scaphocapitate fusion and capitate pole excision in stage IIIA and IIIB Kienböck's disease resulted in shorter operating time, shorter hospital stay, earlier return to unrestricted daily activities, and equal range of motion and grip strength as compared with open scaphocapitate fusion and lunate revascularization. Determination of specific surgical indications for the benefits of arthroscopic treatment of Kienböck's disease must be analyzed in larger studies.

Stage 3 Kienböck's disease: reconstruction of the fractured lunate using a free vascularized iliac bone graft and external fixation

Eighteen patients with stage 3 Kienböck's disease were treated by débridement of the necrotic core of the lunate and implantation of a free vascularized corticocancellous iliac bone. The wrist was stabilized with an external fixator during healing. The efficiency of the procedure for restoring the structure of the fractured lunate, preventing carpal collapse and improving the clinical outcome was assessed at a mean follow-up of 5 years. The graft became incorporated in the lunate in 16 of the 18 patients and no fracture of the reconstructed lunate or carpal collapse occurred in these cases. The graft did not integrate and was resorbed in the other two patients.

Radial closing wedge osteotomy for Kienböck's disease: an over 10 year clinical and radiographic follow-up

Thirteen patients with Kienböck's disease who had undergone a radial closing wedge osteotomy were reviewed clinically and radiologically at a follow-up mean of 14 years. Good long-term results were obtained in all patients. Their levels of pain were improved, and significant increases were seen in the range of motion and grip strength. Radiographic stage, as assessed by Lichtman's classification, improved in one, did not change in four, and advanced in eight patients. The radial inclination angle significantly decreased and the carpal-ulnar distance and lunate covering ratios both increased, demonstrating that radial shift in the alignment of the carpal bones occurs and that the joint contact area of the lunate increases in proportion to the decrease in radial inclination. The preoperative radiolunate and radioscaphoid angles, which were significantly larger than those of the unaffected wrist, did not change postoperatively which shows that this technique was not able to correct the flexion deformity of the lunate and the scaphoid.

Wedge osteotomies of the radius for Kienböck's disease: a biomechanical analysis

We compared changes in lunate cortical strain with an applied physiologic load by altering radial inclination to simulate opening and closing wedge osteotomies of the distal radius. Nineteen fresh-frozen cadaver arms were mounted in neutral position and tested under axial compression at a physiologic load by means of a repeated-measures design. Principal compressive strains were measured with rosette strain gauges mounted on the lunate's palmar and dorsal cortices. Distal radius osteotomy and custom external fixator allowed for altering radial inclination in progressive 3 degrees increments both by increasing and decreasing radial inclination in each specimen. Maximum principal strain was recorded for each inclination increment and compared with control. Comparison of all data showed a 26% decrease on lunate cortical strain for the radial opening wedge osteotomy and a 24% increase for the radial closing wedge osteotomy. This difference was statistically significant. No significant differences were found between individual angular increments (3 degrees to 15 degrees). The radial opening wedge osteotomy was more effective than the radial closing wedge osteotomy at diminishing lunate strain. The results validate the biomechanical effectiveness of this extra-articular osteotomy, which is intended to minimize alteration of ulnar variation.

Lunate plasty for Kienböck's disease: use of a pedicled vascularised radial bone graft combined with shortening of the capitate and radius

We treated eight patients with Kienböck's disease (two patients each with stage 1, 2, 3a and 3b disease by Lichtman's classification) by removing a pedicled, vascularised bone segment from the dorsal aspect of the distal radius and engrafting it into the lunate. Additional shortening of the radius was performed in patients with the ulna-minus or null variant. Shortening of the capitate and capito-hamate fusion were also performed in patients with stage 3 disease. All patients were relieved of their wrist pain at rest and during movement, and the mean grip strength increased from 37% of that in the contralateral hand before surgery to 80% after surgery. The mean post-operative range of motion in the affected wrist was 92% of that in the opposite wrist in patients with stage 1 and 2 disease, and 53% in patients with stage 3 disease. Post-operative assessment revealed that four patients had excellent results, three had good results, and one had a fair result.

Effects of forearm rotation on the clinical evaluation of ulnar variance

Neutral rotation radiographs of the wrist are recommended to standardize the measurement of ulnar variance because it is known that changes in forearm rotation result in changes of this measurement. The purpose of this study was to examine whether there are clinically measurable differences in ulnar variance between radiographs in various degrees of forearm rotation in human subjects. Forty-five wrist radiographs of 15 normal adults were obtained in 3 positions: maximum forearm pronation, neutral rotation, and maximum supination. The ulnar variance on each view was measured by 3 independent observers using a standard millimeter ruler. The average absolute difference in ulnar variance was 0.4 mm between pronation, 0.6 mm between pronation and supination, and 0.2 mm between neutral and supination. Although we found a statistically significant difference in ulnar variance between the pronated and neutral positions, this difference may not be clinically significant and may not justify concerns of forearm position during the radiographic evaluation of ulnar variance.

Operative treatment with radial shortening in Kienböck's disease

Eighty-eight patients underwent radial shortening for Kienböck's disease. Prerequisites for surgery were radiographic studies positive for Kienböck's disease without evidence of radiocarpal arthritis and wrist pain unrelieved by conservative management. Thirty-nine patients were evaluated by subjective questionnaire at a mean postoperative follow-up of 86 months (range: 24-188 months). Following surgery, a significant decrease was noted in pain severity, frequency, and duration. Functional status improved postoperatively, with the most significant gains noted in the following activities: opening jars, opening car doors, carrying bags, and shoveling. Only 3 of 34 patients employed outside the home were unable to return to their original occupations due to their wrist problems. Seventy-six patients were evaluated by physical examination at a mean postoperative follow-up of 31 months (range: 3-87 months). Objective evaluation by physical examination revealed a significant improvement in wrist motion and grip strength. Seventy-seven patients underwent radiographic evaluation at a mean postoperative follow-up of 31 months (range: 3-180 months). A significant progression in Lichtman stage of Kienböck's disease was noted despite the favorable subjective findings and high satisfaction ratings. Thirty-six of 39 patients stated they would undergo the surgery again. The long-term data demonstrate radial shortening in patients with stage II-IIIA Kienböck's disease provides substantial improvement over preoperative status.

The surgical treatment of Kienböck's disease by radius and ulna metaphyseal core decompression

We present a new surgical procedure, metaphyseal core decompression, to treat Kienböck's disease. Twenty-two patients were treated between 1976 and 1988 and were retrospectively reviewed. Sixteen were male and 6 female with an average age of 36 years (range, 18-64 years). The surgical technique involved curettage of the distal radius and ulna metaphyseal bone through small cortical windows. The average follow-up period was 10 years (range, 6-16 years). No postoperative complications were noted and no patient underwent additional surgical procedure. Sixteen patients were pain-free; 4 noted occasional pain. Twenty returned to their prior occupation. One patient had moderate pain and altered his occupation. Another had increasing pain and had x-ray evidence of advanced intercarpal arthritis. The average arc of wrist extension and flexion was 77% of the opposite wrist and the average grip strength was 75%. Long-term follow-up monitoring indicates that the metaphyseal core decompression produces results at least as good as other surgical procedures without any postoperative complications.

Force distribution through the wrist joint in patients with different stages of Kienböck's disease: using computed tomography osteoabsorptiometry

The pattern of subchondral bone density has been considered to reflect the stress distribution that occurs under physiologic loading conditions. To determine the force distribution through the wrist joint with Kienböck's disease in living subjects, we applied a computed tomography osteoabsorptiometry and investigated the subchondral bone density pattern across the radio-carpal joint of 6 normal subjects and 10 patients suffering from Kienböck's disease (Lichtman's stage IIIA, 5 patients; stage IIIB, 5 patients). A single density maximum was found in each scaphoid and lunate fossa in all normal subjects. Among the subjects with Kienböck's disease, the current analysis demonstrated that the density maximum area significantly increased in the scaphoid fossa and decreased in the lunate fossa from stage IIIA to IIIB group. These findings indicate that the load is shifted away from the lunate to the scaphoid with the progression of Kienböck's disease in living subjects.

Lateral closing wedge osteotomy for treatment of Kienböck's disease. A clinical and biomechanical study of the optimum correcting angle

A retrospective clinical analysis of 20 patients who underwent a lateral closing wedge osteotomy of the radius as an adjuvant procedure to a radial recession in the treatment of Kienböck's disease is reported. The functional outcome is compared to the results of a simplified two-dimensional articulating force analysis (Rigid Body Spring Model) based on radiographs of the wrist of the same patients taken before and after surgery. At an average follow-up of 39 months, wrist function was excellent in 4 patients, good in 9, moderate in 6, and poor in one patient. A significant positive correlation between functional improvement and percent reduction of the calculated peak pressure at the radiolunate interval was found. This was maximal in patients with wedge osteotomies between 5 and 10 degrees.

Kienböck's disease and multiple hereditary osteochondromata: a case report

A case of bilateral forearm localization of multiple hereditary osteochondromata and unilateral Kienböck's disease is reported. Ulnar minus variance is frequent in both diseases. Carpal slip is often found in multiple hereditary osteochondromata. In this case, the extremity having both multiple hereditary osteochondromata and Kienböck's disease had no carpal slip. This might have produced an excess load on the lunate, which might have provoked Kienböck's disease.

Arthroscopic evaluation of radial osteotomy for Kienböck's disease

To determine whether osteoarthritic changes of the perilunate articular cartilage improve following radial osteotomy for Kienböck's disease and correlate with clinical results, arthroscopic examination was performed in 18 patients concurrently with radial osteotomy and at the time of removal of implants after an average of 21 months. Clinical results were satisfactory. All patients improved the preoperative level of pain. Wrist function was improved in range of motion and grip strength. Radiographic findings also demonstrated prevention of further collapse of the lunate. However, follow-up arthroscopic examination revealed progression of osteoarthritis in the area of the lunate in two thirds of the cases. There was no correlation between arthroscopic observations and clinical results. A long-term follow-up period is therefore advocated for evaluation of radial osteotomy because of the possibility of additional progression of osteoarthritic changes.