Operative treatment with radial shortening in Kienböck's disease

Precision Medicine for Kienböck Disease in the 21st Century

One of the most popular treatment algorithms for Kienböck disease is based on a progression of successive radiographic changes that was developed in the 1970s. Since then, 2 other important classifications systems have been introduced. One is centered on contrasted magnetic resonance imaging findings and the other, articular cartilage degeneration. All 3 systems have been used, in isolation, to recommend specific treatment modalities. To coordinate all available clinical data and to simplify the treatment selection process, we combined the 3 classification systems into 1 unified classification and treatment algorithm. With the added consideration of some recently introduced surgical options and further knowledge of how Kienböck disease affects children and the elderly, we anticipate that this unified classification system will allow for a more precise and individualized treatment plan.

Outcomes of Arthroscopic Lunate Core Decompression Versus Radial Osteotomy in Treatment of Kienböck Disease

PURPOSE

The purpose of the study was to evaluate the functional and radiographic outcomes of arthroscopic lunate decompression versus radial osteotomy in the treatment of Kienböck disease (KD).

METHODS

In a prospective cohort design, we enrolled 82 patients with KD with Lichtman stages I to IIIb. Participants assigned themselves to groups by choosing either arthroscopic lunate core decompression and synovectomy (group A; n = 54) or radial osteotomy (group B; n = 28). For radial osteotomy, a distal radius volar approach was used and a shortening osteotomy (in negative and neutral ulnar variance) or lateral closing wedge osteotomy (in positive ulnar variance) was performed. Arthroscopic lunate core decompression was performed under direct visualization from the 3-4 portal using a shaver (through the 6R portal) and a cutting burr (through the trans-4 portal). The shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, visual analog scale (VAS) score for pain, wrist passive flexion/extension, grip strength, and radiographic assessments (Lichtman classification, radioscaphoid angle, carpal height ratio) were recorded before surgery and at the final follow-up.

RESULTS

Sixty-four patients were included in the final analysis (44 in group A and 20 in group B). The mean ages of participants were 33 ± 11 years in group A and 31 ± 8 years in group B. The mean follow-up periods were 44 ± 20 months in group A and 37 ± 23 months in group B. The QuickDASH score, VAS score, and passive wrist movements significantly improved in both groups. Grip strength showed a significant increase in group A only. The postoperative functional analysis between the 2 groups showed no significant difference, except for the wrist passive extension, which was higher in group A. Lichtman staging remained the same in 79.5% and 73.6% of patients in groups A and B, respectively.

CONCLUSIONS

An arthroscopic lunate core decompression and wrist synovectomy has comparable midterm results to radial shortening osteotomy in the treatment of KD.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.

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

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

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.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Range of movement in the wrist as a diagnostic tool in radial-sided wrist pain

Kienböck disease is diagnosed by imaging studies, and is often difficult to diagnose in its early stages. Our clinical impression is that wrist movement is more limited in Kienböck disease than when radial-sided wrist pain is caused by other conditions. The purpose of this study was to determine the use of wrist movement in differentiating between early Kienböck disease and radial-sided sprained wrist. We retrospectively reviewed 62 cases of Kienböck disease and 49 patients with radial-sided wrist sprain. Wrist movement at presentation was recorded. The two groups differed significantly in flexion and extension (p<0.001). The ability of movement of the affected wrist relative to the normal side to distinguish between the groups was excellent (AUC = 0.96, 0.97, respectively). The ability of wrist movement measurements to differentiate between early Kienböck disease and radial-sided wrist sprain emphasises that wrist movement should be measured prior to invasive or expensive testing.