Radial recession osteotomy for Kienböck's disease

Comparing the Radiologic and Functional Outcome of Radial Shortening Versus Capitate Shortening in Management of Kienböck's Disease

BACKGROUND

Kienböck's disease is the avascular necrosis of the lunate bone. There is no consensus on the treatment strategy to avoid joint deterioration. This trial is conducted to compare the functional and radiological outcomes of radial shortening and capitate shortening techniques, in patients with avascular necrosis of lunate.

METHODS

Patients with a confirmed diagnosis of Kienböck's disease who met the inclusion criteria were randomly divided into radial shortening and capitate shortening groups and treated by allocated technique. Physical examination and radiologic evaluations were performed before and 6 and 12 months after the operation.

RESULTS

A total of 52 patients (52 wrists) of stage II or III Kienböck's disease were assessed for eligibility, 12 patients in the radial shortening group, and 17 patients remained until the end of the study. Patients in both groups achieved a satisfactory outcome, with no report of postoperative complications. None of the outcome measures, ranges of motion, grip, and pinch strengths were significantly different between the groups. The outcome was not considerably different in patients with positive or negative ulnar variances who were treated by capitate shortening technique.

CONCLUSIONS

The capitate shortening technique which is performed through a smaller incision, and takes less time as compared with radial shortening can be advantageous for patients with stage II or III Kienböck's disease regardless of the ulnar variance. This method can be as effective as classical methods such as radial shortening in improving clinical and functional symptoms after surgery while causing fewer complications.

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

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

Recent Advances in Assessment and Treatment in Kienböck's Disease

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

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

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.

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

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

Treatment of Advanced Kienbock's Disease (Lichtman Stage IIIB with Carpal Collapse) by a Shortening Osteotomy of the Radius: 21 Cases

Purpose  To review the results of shortening osteotomies of the radius in our stage IIIB Kienbock's disease patients. Materials and Methods  In the past 30 years, we treated 52 cases of Kienbock's disease by a shortening osteotomy of the radius, of which 21 already had carpal collapse. All patient charts and X-rays were reviewed, but only the cases already with carpal collapse (stage IIIB) are presented here. Results  All patients improved after surgery. Pain, on a scale of 0 to 3, generally 2 or 3 before surgery (median: 2.3), was normally 1 or 0 afterward (median: 0.9); median flexion-extension of the wrist improved from 77 to 99 degrees; and grip strength of the other hand improved from 26 to 76%. The last clinical and radiological review was performed 1 to 23 years after surgery (median: 8 years). Conclusion  Advanced Kienbock's disease with carpal collapse is not a contraindication for carpal-sparing surgery radial shortening osteotomy.

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 Grafts from the Dorsal Wrist for the Treatment of Kienböck Disease

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

Kienböck disease

Kienböck disease, or osteonecrosis of the lunate, most often affects patients between the ages of 20 and 40 years. There are 4 major stages of the disease, and treatment is based on the stage of disease. Advancements are still being made with regards to the cause, pathophysiology, and preferred method of treatment of each stage. Although the goals of pain relief, motion preservation, strength maintenance, and function outcomes are paramount to success, no 1 procedure consistently and reliably achieves these outcomes. Further advancements in treatment and results of long-term outcome studies should resolve some of these topics.

Vascularized bone grafts for the treatment of carpal bone pathology

Primary bone healing fails to occur in 5-15 % of scaphoid bones that undergo fracture fixation. Untreated, occult fractures result in nonunion up to 12 % of the time. Conventional bone grafting is the accepted management in the treatment algorithm of scaphoid nonunion if the proximal pole is vascularized. Osteonecrosis of the proximal scaphoid pole intuitively suggests a need for transfer of the vascularized bone to the nonunion site. Scaphoid nonunion treatment aims to prevent biological and mechanical subsidence of the involved bone, destabilization of the carpus, and early degenerative changes associated with scaphoid nonunion advanced collapse. Pedicled distal radius and free vascularized bone grafts (VBGs) offer hand surgeons an alternative treatment option in the management of carpal bone nonunion. VBGs are also indicated in the treatment of avascular necrosis of the scaphoid (Preiser's disease), lunate (Kienböck's disease), and capitate. Relative contraindications to pedicled dorsal radius vascularized bone grafting include humpback deformity, carpal instability, or collapse. The free medial femoral condyle bone graft has offered a novel treatment option for the humpback deformity to restore geometry of the carpus, otherwise not provided by pedicled grafts. In general, VBGs are contraindicated in the setting of a carpal bone without an intact cartilaginous shell, in advanced carpal collapse with degenerative changes, and in attempts to salvage small or collapsed bone fragments. Wrist salvage procedures are generally accepted as the more definitive treatment option under such circumstances. This manuscript offers a current review of the techniques and outcomes of VBGs to the carpal bones.

Arthroscopic assessment of avascular necrosis

Avascular necrosis of the lunate is a process that is not well understood. The cause is uncertain, but a common theory persists that it is caused by disruption of the vascular supply to the lunate. This article discusses an approach to assessment that respects the articular cartilage and places at the front of the decision-making process the pathoanatomic components of the articular cartilage. It primarily respects the articular cartilage in the patient with avascular necrosis. This approach was developed for avascular necrosis of the lunate, but in principle applies to other joints with avascular necrosis as well.

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.

Lunate revascularization after capitate shortening osteotomy in Kienböck's disease

PURPOSE

The aim of surgical treatment in the early stages of Kienböck's disease is to decrease compressive loading of the lunate to promote revascularization. Capitate shortening osteotomy is one technique that has been advocated in Kienböck's disease with ulnar neutral or positive variance and Lichtman stage I to IIIA. The purpose of this study was to examine the revascularization process of the lunate after capitate shortening osteotomy.

METHODS

This was a retrospective study of 9 patients with Kienböck's disease with Lichtman stage II or IIIA and ulnar neutral or positive variance. I confirmed avascular necrosis of the lunate in all the patients by magnetic resonance imaging preoperatively. Capitate shortening osteotomy was performed through a dorsal approach and fixed with K-wires. I used magnetic resonance images with fat suppression to detect the revascularization of the lunate after surgery.

RESULTS

The mean follow-up was 12 months (range, 8-16 mo). All patients demonstrated partial revascularization of the lunate and the mean revascularization time was 4.7 months (range, 3-7 mo), which was interpreted as the beginning of the revascularization process.

CONCLUSIONS

Capitate shortening osteotomy is an efficient technique to induce the revascularization process in the early stages of Kienböck's disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Pedicled vascularized bone grafts for scaphoid and lunate reconstruction

Conventional bone grafts have some osteogenic potential, whereas vascularized bone grafts retain live, functional osteocytes and osteoblasts. High rates of scaphoid union have been achieved with conventional bone grafting in the absence of osteonecrosis or prior surgery. Vascularized bone grafting is valuable in the management of wrist disorders with compromised bone vascularity (eg, scaphoid nonunion with proximal pole necrosis, Preiser disease, Kienböck disease) or when previous grafting has failed. Improved understanding of the vascular anatomy of the wrist has allowed the use of an array of vascularized bone grafts that do not require microsurgical anastomosis. Successful outcome depends on careful patient selection and appropriate surgical technique.

Capitate shortening osteotomy with vascularized bone grafting for the treatment of Kienböck's disease in the ulnar positive wrist

PURPOSE

Decompression surgery combined with revascularization surgery may provide better results than either alone in the treatment of Kienböck's disease. This study describes our experience with capitate shortening combined with vascularized bone grafting for the treatment of Kienböck's disease in ulnar neutral and ulnar positive variant patients.

METHODS

Between 1996 and 2004, patients diagnosed with Lichtman stage II or stage IIIA Kienböck's disease with ulnar neutral or ulnar positive wrists were enrolled in this prospective study and had capitate shortening osteotomy with concurrent vascularized bone grafting. Preoperative and postoperative clinical evaluation included wrist arc of motion, grip strength, and overall satisfaction score. Preoperative and postoperative wrist radiographs and preoperative magnetic resonance imaging were performed. Radiographic measurements of preoperative and postoperative ulnar variance and carpal height ratio were also evaluated. The average follow-up period was 41 months (range, 26-65 months).

RESULTS

Fourteen patients with an average age of 25 years (range, 16-39 years) were studied. The results show significant improvement in grip strength (58% to 78% of the normal side), satisfaction score, and satisfactory arc of motion. The average carpal height ratio was maintained. Average time to osteotomy healing was 48 days.

CONCLUSIONS

Capitate shortening osteotomy combined with vascularized bone graft is effective in the treatment of ulnar-positive Kienböck's disease prior to the onset of radiocarpal arthrosis.

Vascularized bone grafts and their applications in the treatment of carpal pathology

Vascularized bone grafts (VBGs) are techniques in the management of certain types of carpal pathology. VBGs have traditionally been advocated for conditions including delayed and nonunion of fractures and avascular necrosis. The most common indications for VBG have been for scaphoid nonunion, lunatomalacia (Kienböck's disease), and osteonecrosis of the scaphoid (Preiser's disease). Advantages over NVBG have been established. VBGs provide improved blood flow, osteocyte preservation, and accelerated healing rates. Local pedicled VBGs are the most commonly used methods. They are technically less demanding than are free VBGs and are associated with less morbidity. Commonly used donor grafts arise from the dorsal vasculature of the wrist and include the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), the 2,3 ICSRA, the fourth extensor compartment artery (fourth ECA), and the fifth ECA. A 4 + 5 ECA combination graft has been described to provide a longer pedicle. In managing osteonecrosis, most surgeons would agree that VBG should be reserved for carpal bones with an intact cartilaginous shell and no collapse. In treating scaphoid pathology, indications for VBG include fractures/nonunions with proximal pole avascular necrosis and/or small proximal pole fragments.

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.

Distraction osteogenesis for ulnar lengthening in Kienbock's disease

Ulnar lengthening is an accepted modality of treatment to achieve joint levelling in Kienbock's disease. The conventional method of ulnar lengthening with a plate and bone graft is fraught with complications including graft site morbidity, non-union, hardware removal and difficulty in the achievement of a proper length. We used a Umex distractor to achieve distraction osteogenesis in a group of 12 patients and assessed them over an average follow-up period of 29.5 months. We had one excellent, ten good and one fair result. We conclude that distraction osteogenesis addresses all the complications of coventional lengthening in addition to providing an increase in the local blood supply, which might be beneficial in a disease that is primarily an avascular necrosis. This procedure addresses both the biomechanical and the biological aspects of this disease.

Vascularized bone grafting for the treatment of carpal pathology

Vascularized bone graft procedures have been applied to several maladies of the carpus including proximal pole fractures of the scaphoid, Preiser's disease, and Kienböck's disease. Vascularized bone grafts are capable of primary bony healing without creeping substitution and can thus accelerate fracture healing, replace deficient bone, and revascularize ischemic bone. Long-term data are now available to evaluate the benefits and deficiencies of vascularized grafts in the treatment of many carpal maladies. This article reviews the pertinent literature and provides some treatment algorithms for the use of vascularized bone grafting in cases of carpal pathology.

Vascularized os pisiform for reinforcement of the lunate in Kienböck's Disease: an average of 12 years of follow-up study

PURPOSE

Little is known about the long-term results of vascularized bone transplantation for Kienböck's disease. This retrospective study investigated the long-term results of vascularized pisiform transfer.

METHODS

We reviewed 23 patients to analyze results after vascularized pisiform transposition to a cored-out lunate for Lichtman stages II and III. Patients with ulnar-minus variance received additional radial shortening.

RESULTS

Pain improved in 20 of 23 patients. Range of motion increased significantly relative to preoperative values but was only 80% that of opposite side. Grip power was 84% of the contralateral hand. At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15.3 +/- 17.9 and the mean Cooney score was 82.4 +/- 10.0. Radiologically, out of 20 patients with preoperative x-rays Lichtman stage was unchanged in 11, improved in 3, and progressed in 6 patients. No patient showed radiologic signs of arthritis before surgery. At follow-up evaluation osteoarthritis was found in 7 of 22 patients. The majority of degenerative changes were of low grade and were seen at the radiocarpal joint.

CONCLUSIONS

The results show high patient satisfaction and good function after vascularized bone transplantation for Kienböck's disease. In the long term vascularized pisiform transfer prevented lunate collapse in 16 of 22 patients.

The biomechanical effect of radial shortening on the radiocapitellar articulation

Repeated trauma to the radial head may be one of the causative factors in the genesis of osteochondritis dissecans of the capitellum. We measured the force, contact area and pressure across the radiocapitellar articulation of the elbow before and after radial shortening osteotomy in five fresh-frozen cadaver upper limbs with loads of 45, 90 and 135 N, respectively. Measurements were made on pressure-sensitive film placed in the radiocapitellar articulation with the forearm in the supinated, neutral and pronated positions before and after radial shortening. Radial shortening significantly reduced the mean force and contact area across the radiocapitellar articulation in all positions of the forearm.

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

PURPOSE

The use of vascularized bone grafts for the treatment of Kienböck's disease may prevent ongoing lunate collapse and provide relief of wrist symptomatology. This study examines our experience with the use of the 4 + 5 extensor compartmental artery (ECA) bone graft for the treatment of Kienböck's disease.

METHODS

A retrospective review was performed of all patients having pedicled vascularized bone grafts for Kienböck's disease between 1991 and 2002. Only those patients who had reconstruction with a 4 + 5 ECA graft were included in the study. Presurgical and postsurgical measurements included range of motion, grip strength, and pain evaluation. Measurements of the radiolunate angle, radioscaphoid angle, Stahl's index, and carpal height ratio were taken from presurgical and final follow-up radiographs. Postsurgical magnetic resonance imaging scans were also examined to verify revascularization of the lunate. Statistical analysis was performed using Student's t test. A chi-square test was used to evaluate the effects of lunate revascularization on radiographic progression of disease. Twenty-six 4 + 5 ECA vascularized bone grafts were performed as treatment for Kienböck's disease. The average patient age was 32 years. At the time of surgery 12 patients were graded as stage II, 10 as IIIA, and 4 as IIIB. Mean follow-up time was 31 months.

RESULTS

At a mean follow-up of 3 months, motion improved from 68% to 71% of the unaffected side, grip strength improved from 50% to 89% of the unaffected side, and 92% of patients had significant improvement in their pain. Satisfactory results were seen in 85% of patients based on the Lichtman outcome score. Seventy-seven percent of patients showed no further collapse on postsurgical radiographs. Sixty-five percent of patients had follow-up magnetic resonance imaging scans at a mean of 20 months after surgery. Seventy-one percent of patients showed evidence of revascularization with improvement in the T2 and/or T1 signal.

CONCLUSIONS

The 4 + 5 ECA bone graft provides a reliable alternative for the treatment of Kienböck's disease and may aid in lunate revascularization.

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.

Ulnar variance and the role of joint levelling procedure for Kienböck's disease

Forty patients with Kienböck's disease were reviewed to determine the relationship between ulnar variance and the development of Kienböck's disease in a Japanese cohort. The joint levelling procedures designed to correct ulnar variance were evaluated in 11 patients after a mean of 9.7 years following surgery. The mean ulnar variance was 0.50+/-1.67 in patients with Kienböck's disease and 0.56+/-1.76 in a control group. The onset of wrist symptoms in a younger age group was noticed after sports injuries, whereas older patients had no distinct history of trauma. Joint levelling procedures produced good clinical results, but carpal height ratio, Stahl's index and radioscaphoid angle were not improved, as evidenced radiographically. Our study suggests that in a Japanese cohort ulnar minus variance is not an important factor in the aetiology of Kienböck's disease. Although joint levelling procedures improved the clinical results, they did not reverse lunate collapse or carpal alignment.

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.

Vascularized bone graft from the index metacarpal for Kienböck's disease: a case report

A vascularized bone graft from the head and neck of the index metacarpal bone was used for the treatment of stage IIIA Kienböck's disease in a 20-year-old woman. Three months after surgery pain had disappeared and wrist range of motion improved. Postoperative radiographs and magnetic resonance imaging revealed revascularization and fracture healing of the lunate bone. This technique has not been used in the treatment of Kienböck's disease; it may be useful in selected cases.

Kienbock's disease: diagnosis and treatment

Kienbock's disease, or osteonecrosis of the lunate, can lead to chronic, debilitating wrist pain. Etiologic factors include vascular and skeletal variations combined with trauma or repetitive loading. In stage I Kienbock's disease, plain radiographs appear normal, and bone scintigraphy or magnetic resonance imaging is required for diagnosis. Initial treatment is nonoperative. In stage II, sclerosis of the lunate, compression fracture, and/or early collapse of the radial border of the lunate may appear. In stage IIIA, there is more severe lunate collapse. Because the remainder of the carpus is still uninvolved, treatment in stages II and IIIA involves attempts at revascularization of the lunate-either directly (with vascularized bone grafting) or indirectly (by unloading the lunate). Radial shortening in wrists with negative ulnar variance and capitate shortening or radial-wedge osteotomy in wrists with neutral or positive ulnar variance can be performed alone or with vascularized bone grafting. In stage IIIB, palmar rotation of the scaphoid and proximal migration of the capitate occur, and treatment addresses the carpal collapse. Surgical options include scaphotrapeziotrapezoid or scaphocapitate arthrodesis to correct scaphoid hyperflexion. In stage IV, degenerative changes are present at the midcarpal joint, the radiocarpal joint, or both. Treatment options include proximal-row carpectomy and wrist arthrodesis.

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.

Dorsolateral biplane closing radial osteotomy in zero variant cases of Kienböck's disease

Twenty-six patients with Lichtman stages II and III Kienböck's disease had biplane dorsolateral radial closing osteotomy to reduce the radial inclination and dorsal angles on the sagittal plane. The effects of the procedure were studied clinically, radiologically, and by magnetic resonance imaging in a 2- to 6-year follow-up study (average follow-up period, 3.5 years). The signal intensity on T1- and T2-weighted images of the lunate increased after surgery in all patients, suggesting revascularization. The comparative advantages of this technique are discussed with regard to others currently used.

Arthroscopic debridement for the treatment of Kienbock's disease

The treatment results of seven patients (age range, 37 to 74 years, male:female ratio, 1:6) with Kienbock's disease (Lichtman stage IIIA-IIIB) who underwent arthroscopic debridement of the necrotic lunate bone and degenerative intrinsic ligaments were studied retrospectively. Osteoarthritic changes of the articular cartilage were documented in all cases. Partial (n = 2) and complete (n = 5) ruptures of the lunotriquetral and scapholunate ligaments, local synovitis (n = 5), and loose fragments (n = 6) occurred most commonly in the radiocarpal joint. All patients were available for an average of 19 months of follow-up (range, 6 to 42 months), physical examination, and radiographic evaluation. All patients reported significant improvement in pain relief and complete relief of mechanical symptoms. Radiographs showed progression of the disease in three cases; two of these were followed-up for more than 2 years. Arthroscopy in Kienbock's disease allows direct visualization and assessment of the exact pathology of the radiocarpal and midcarpal joint and the lunate cartilage. Arthroscopic debridement of the necrotic lunate increased wrist functional range of motion, provided excellent pain relief, and improved health-related quality of life in all patients.