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

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.

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

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

Vascularized Bone Graft to the Lunate Combined with Shortening of the Capitate and Radius for Treatment of Advanced Kienböck Disease After a Follow-Up for More Than 10 Years

Purpose

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

Methods

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

Results

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

Conclusions

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

Type of study/level of evidence

Therapeutic Ⅳ.

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

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

Vascularized 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.

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

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

Intracarpal shortening osteotomy for Kienböck's disease: A retrospective study of 28 cases

INTRODUCTION

Kienböck's disease is rare in patients with a neutral or positive ulnar variance. In these situations, treatment is challenging and controversial. Various intracarpal shortening osteotomy (ICSO) procedures have been proposed.

OBJECTIVE

Study the effect of the type of ICSO (isolated capitate osteotomy or combined with hamate osteotomy) on the clinical and radiological outcomes in a retrospective series.

METHODS

Patients with Kienböck's disease were treated with ICSO. A dorsal approach centered over the capitate was used. The transverse osteotomy was located 5mm below the capitate's proximal chondral boundary. The osteotomy cut was 2mm thick. In some patients, a hamate osteotomy was done at the same level as that of the capitate. The osteotomy site was fixed with staples. Cases were classified as with or without a vascularized bone graft was added to the ICSO.

RESULTS

There were 28 cases and the average follow-up was 43 months. Three patients required surgical revision. Pain relief at rest was achieved in all patients. The flexion/extension range of motion was 84°. Strength was 75% of the opposite side. The mean QuickDASH was 32.5 and the PRWE (Patient Related Wrist Evaluation) was 30.2. Isolated capitate osteotomy resulted in better satisfaction and improved ulnar/radial deviation and flexion range of motion. There was no difference in terms of pain, strength and functional scores. However, it triggered a significant increase in the radioscaphoid angle. Adding a vascularized bone graft did not impact the outcomes.

DISCUSSION

Isolated capitate osteotomy provides better outcomes than combined capitate/hamate osteotomy (satisfaction and wrist range of motion) and should be done as the primary procedure. However, since it increases the radioscaphoid angle more than combined capitate/hamate osteotomy, the latter procedure should be used when a large radioscaphoid angle exists preoperatively. We found no benefit of using a vascularized graft.

LEVEL OF EVIDENCE

IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic/IV.

J, Strauch RJ. The Management of Kienböck Disease: A Survey of the ASSH Membership

Background The purpose of this study was to determine the current trends and common practices for the treatment of Kienböck disease at different stages. Question/Purpose To determine the current trends and common practices by hand surgeons for the treatment of Kienböck disease. Methods A survey with hypothetical Kienböck disease cases stratified by the Lichtman staging system was distributed to the American Society for Surgery of the Hand (ASSH) members. Questions and responses reflected common treatment strategies. Results Of a total of 375 worldwide respondents, preferred treatments of Kienböck disease were as follows: for Stage I disease, an initial trial of splinting was favored (74%), followed by radial shortening osteotomy for continued symptoms. For Stage II disease, 63% of surgeons preferred surgical intervention, particularly radial shortening osteotomy. For Stage IIIa with negative ulnar variance, 69% chose radial shortening osteotomy. Responses were heterogeneous for Stage IIIa Kienböck with positive variance, and capitate shortening osteotomy and vascularized bone grafting were preferred. Salvage procedures predominated for Stage IIIb disease, including proximal row carpectomy (PRC; 42%), intracarpal arthrodesis (21%), and total wrist fusion (10.7%). Similarly, Stage IV disease was treated by 87% of respondents by either PRC or wrist fusion. Without regard to stage of disease, 90% of participants reported using the same Lichtman staging to guide treatment and would also alter treatment strategy based upon ulnar variance. Conclusions Most respondents used Lichtman staging and ulnar variance to guide treatment decisions. Results indicate that the most common surgical treatments were radial shortening osteotomy for early disease and PRC in later stages. Level of Evidence Level IV, Economic/Decision Analysis.

Distal capitate shortening with capitometacarpal fusion for management of the early stages of Kienböck's disease with neutral ulnar variance: case series

Background

The aim of surgical management of Kienböck’s disease has been proposed to slow the progressive osteonecrosis and secondary carpal damage. The aim of this case series was to evaluate the results of a new technique, combining distal capitate shortening with capitometacarpal fusion for the treatment of Kienböck’s disease (Lichtman stage II or stage IIIA) in neutral ulnar variance patients.

Methods

From 2009 to 2012, 12 patients (mean age: 25 ± 7.6 years) were enrolled in this series. Radiological and clinical evaluations using the modified Mayo wrist scoring system were performed both pre-operatively and 12 months post-operatively. In addition, values of the scapho-capitate angle were evaluated both pre-operatively and 12 months post-operatively. The mean follow-up was 20.7 ± 11.2 months. Statistical analysis was performed for comparisons between pre-operative and post-operative findings with the use of paired sample T test, Pearson’s correlation, independent sample T test, and Spearman’s rho correlation. Statistical significance was determined to be present at p <0.05.

Results

All patients achieved bony union at the fusion site within a mean period of 11.5 ± 2.4 weeks. Regarding wrist pain, grip strength, total wrist arc of motion, practicing daily activities in a normal pattern, and the total modified Mayo wrist score, there were statistically significant differences between the pre-operative and post-operative results. For the differential arc of motion, the only non-significant results were at the ulnar/radial deviation range (p = 0.262). The mean pre-operative scapho-capitate angle was 29.75 ± 3.44 while the mean post-operative value was 33.67 ± 4.77 (p < 0.001). Both pre-operative and post-operative scapho-capitate angle values were positively correlated to post-operative pain, ulnar/radial deviation, and final score (p = 0.001, 0.027, 0.021 and p = 0.001, 0.004, 0.002, respectively). Other parameters had no correlation to this angle.

Post-operative MRI (at 12 months follow-up) demonstrated better lunate revascularization in four patients; one of them was diagnosed as having Lichtman stage IIIA Kienböck’s disease. There were no patient-reported complications at the end of follow-up.

Conclusions

Distal capitate shortening combined with capitometacarpal fusion represents a new reliable method in the treatment of early stages of Kienböck’s disease with neutral ulnar variance.

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.

The treatment of Kienböck disease with vascularized bone graft from dorsal radius

INTRODUCTION

Numerous surgical treatment options are proposed for the Kienböck disease but there has not been a consensus on the most appropriate method yet. The aim of this study is to present our experience and preliminary results of the use of vascularized bone graft from dorsal radius.

MATERIALS AND METHODS

Second and third intercompartmental supraretinacular artery pedicled bone graft has been used to treat 11 patients with Kienböck disease between 2001 and 2006. The average follow-up period was 37 months (range 19-77 months). Pre- and post-operative range of motion, pain and grip strength, radiologic parameters such as carpal height ratio, Stahl index and scapholunate angle were evaluated.

RESULTS

Eleven patients were composed of two stage II, one stage IIIA and eight stage IIIB patients according to Lichtmann classification. At the end of the observation period, five excellent, four good, one fair and one poor results were observed. There were no or little changes in carpal height ratio and Stahl index. Pain has diminished considerably.

DISCUSSION

We believe that the treatment of Kienböck disease with vascularized bone graft from the dorsum of the radius has encouraging results and need no other additional procedures.

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.

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 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.