Tendon ball arthroplasty and proximal carpal stabilization with tendon graft for advanced Kienbock's disease

This study reports the surgical technique and outcomes of tendon ball arthroplasty combined with proximal carpal stabilization using the extensor carpi radialis longus tendon for treating advanced Kienbock's disease. The collapsed lunate is excised and a tendon ball inserted as a spacer. A distally based extensor carpi radials longus graft is passed through the scaphoid, tendon ball and triquetrum, reconstructing the proximal carpal row. In total, 16 patients were included and the mean follow-up was 25 months. Pain improved from 5.6 preoperatively to 1.3 postoperatively on a 10-point visual analogue scale. Mean wrist motion improved by 17.8° and grip strength compared with the non-operative side increased by 22.1% on average. Radiographic outcomes demonstrated correction of scaphoid flexion and carpal height ratio. The modified tendon ball arthroplasty may be an alternative wrist salvage procedure for the treatment of advanced Kienbock's disease.Level of evidence: IV.

Mid-term follow-up results of gradual capitate lengthening for the treatment of stage IIIA Kienbock's disease

PURPOSE

This study aimed to evaluate the mid-term radiological and clinical results of gradual lengthening of capitate for the treatment of stage IIIA Kienbock's disease.

METHODS

We retrospectively reviewed nine patients (five females, four males) with Lichtman stage IIIA Kienbock's disease who underwent gradual capitate lengthening at our hospital. Their clinical (range of motion (ROM), grip strength, visual analogue scale (VAS) value for pain, and Mayo wrist score (MWS)) and radiological outcomes (in terms of progression of arthritis and carpal height ratio) at the last follow-up were compared to the preoperative values.

RESULTS

The mean age of the nine patients was 30 years (range: 20-38 years). The mean follow-up period was 73.8 (60-83) months. The average grip strength increased from 14.3 kg preoperatively to 22.3 kg at the last follow-up. The mean MWS increased from 58.8 preoperatively to 79.4 postoperatively. The mean VAS values decreased from the preoperative values: from 1.9 to 0.36 at rest, from 3.75 to 1.6 during mild effort, and from 5.35 to 3 during severe effort. The average carpal height ratio changed from 0.38 preoperatively to 0.53 postoperatively. None of the patients had any arthritic changes in their wrists.

CONCLUSION

Gradual lengthening of capitate offers satisfactory mid-term results for treating stage IIIA Kienbock's disease.

Biomechanical effect of isolated capitate shortening in Kienbock's disease: an anatomical study

Multiple operations have been proposed to slow the progression of osteonecrosis and secondary carpal damage in Kienböck's disease. To assess the biomechanical changes after capitate shorting, we inserted pressure-testing devices into the carpal and radiocarpal joints in an anatomical study. Pressure sensors were placed into eight thawed non-fixated human cadaver arms to measure the forces transmitted in physiological loading. Longitudinal 9.8 N and 19.6 N forces were applied before and after capitate shortening. After capitate shortening, significant load reduction on the lunate was evident in all specimens. An average decrease of 49% was seen under a 9.8 N load and 56% under a 19.6 N load. The load was transferred to the radial and ulnar intercarpal joints. More relief of pressure on the lunate after isolated capitate shortening is achieved with a shallow angle between the scaphoid and capitate in the posteroanterior radiograph.

A systematic review of the etiopathogenesis of Kienböck's disease and a critical appraisal of its recognition as an occupational disease related to hand-arm vibration

BACKGROUND

We systematically reviewed etiological factors of Kienböck's disease (osteonecrosis of the lunate) discussed in the literature in order to examine the justification for including Kienböck's disease (KD) in the European Listing of Occupational Diseases.

METHODS

We searched the Ovid/Medline and the Cochrane Library for articles discussing the etiology of osteonecrosis of the lunate published since the first description of KD in 1910 and up until July 2012 in English, French or German. Literature was classified by the level of evidence presented, the etiopathological hypothesis discussed, and the author's conclusion about the role of the etiopathological hypothesis. The causal relationship between KD and hand-arm vibration was elucidated by the Bradford Hill criteria.

RESULTS

A total of 220 references was found. Of the included 152 articles, 140 (92%) reached the evidence level IV (case series). The four most frequently discussed factors were negative ulnar variance (n=72; 47%), primary arterial ischemia of the lunate (n=63; 41%), trauma (n=63; 41%) and hand-arm vibration (n=53; 35%). The quality of the cohort studies on hand-arm vibration did not permit a meta-analysis to evaluate the strength of an association to KD. Evidence for the lack of consistency, plausibility and coherence of the 4 most frequently discussed etiopathologies was found. No evidence was found to support any of the nine Bradford Hill criteria for a causal relationship between KD and hand-arm vibration.

CONCLUSIONS

A systematic review of 220 articles on the etiopathology of KD and the application of the Bradford Hill criteria does not provide sufficient scientific evidence to confirm or refute a causal relationship between KD and hand-arm vibration. This currently suggests that, KD does not comply with the criteria of the International Labour Organization determining occupational diseases. However, research with a higher level of evidence is required to further determine if hand-arm vibration is a risk factor for KD.