Is There a Correlation between the Radiological and Clinical Outcome after Core Decompression of the Radius for Kienböck Disease?

Background: Despite the good clinical results in the treatment of Kienböck disease with distal radius core decompression, a radiological progression to a certain degree in the long-term follow-up is possible. Is there a negative correlation between the clinical improvement of the patients and the radiological progression? Methods: We retrospectively reviewed the radiological and clinical results of 24 patients (mean age: 38 years; 10 women) treated with core decompression for Kienböck disease. The mean follow-up was 10 years. Results: A radiologic progression in the Lichtman classification was seen in nine patients. The Spearman correlation did not show any correlation between this radiological progression and the clinical outcome. Namely -0.06 between Mayo and Lichtman classification and 0.16 between VAS and Lichtman classification. Conclusions: We found that the clinical outcomes do not deteriorate despite a radiological progression of patients treated with core decompression for Kienböck disease Level of Evidence: Level IV (Therapeutic).

[Three-dimensional finite element model construction and biomechanical analysis of customized titanium alloy lunate prosthesis]

Objective

To design customized titanium alloy lunate prosthesis, construct three-dimensional finite element model of wrist joint before and after replacement by finite element analysis, and observe the biomechanical changes of wrist joint after replacement, providing biomechanical basis for clinical application of prosthesis.

Methods

One fresh frozen human forearm was collected, and the maximum range of motions in flexion, extension, ulnar deviation, and radialis deviation tested by cortex motion capture system were 48.42°, 38.04°, 35.68°, and 26.41°, respectively. The wrist joint data was obtained by CT scan and imported into Mimics21.0 software and Magics21.0 software to construct a wrist joint three-dimensional model and design customized titanium alloy lunate prosthesis. Then Geomagic Studio 2017 software and Solidworks 2017 software were used to construct the three-dimensional finite element models of a normal wrist joint (normal model) and a wrist joint with lunate prosthesis after replacement (replacement model). The stress distribution and deformation of the wrist joint before and after replacement were analyzed for flexion at and 15°, 30°, 48.42°, extension at 15°, 30°, and 38.04°, ulnar deviation at 10°, 20°, and 35.68°, and radial deviation at 5°, 15°, and 26.41° by the ANSYS 17.0 finite element analysis software. And the stress distribution of lunate bone and lunate prosthesis were also observed.

Results

The three-dimensional finite element models of wrist joint before and after replacement were successfully constructed. At different range of motion of flexion, extension, ulnar deviation, and radial deviation, there were some differences in the number of nodes and units in the grid models. In the four directions of flexion, extension, ulnar deviation, and radial deviation, the maximum deformation of wrist joint in normal model and replacement model occurred in the radial side, and the values increased gradually with the increase of the range of motion. The maximum stress of the wrist joint increased gradually with the increase of the range of motion, and at maximum range of motion, the stress was concentrated on the proximal radius, showing an overall trend of moving from the radial wrist to the proximal radius. The maximum stress of normal lunate bone increased gradually with the increase of range of motion in different directions, and the stress position also changed. The maximum stress of lunate prosthesis was concentrated on the ulnar side of the prosthesis, which increased gradually with the increase of the range of motion in flexion, and decreased gradually with the increase of the range of motion in extension, ulnar deviation, and radialis deviation. The stress on prosthesis increased significantly when compared with that on normal lunate bone.

Conclusion

The customized titanium alloy lunate prosthesis does not change the wrist joint load transfer mode, which provided data support for the clinical application of the prosthesis.

Clinical and Radiological Outcomes of Scaphocapitate Fusion in Kienböck Disease: A Systematic Review and Meta-Analysis

Purpose

To report the functional and radiological outcomes of scaphocapitate (SC) arthrodesis in the treatment of Kienböck disease.

Methods

This meta-analysis was conducted with adherence to PRISMA guidelines. Google Scholar, PubMed, Cochrane and Virtual Health Library were searched from inception until November 2022. All original studies that investigated the outcomes of scaphocapitate fusion in Kienböck disease were included. Exclusion criteria were arthroscopically performed fusions, concomitant radial shortening, traumatic or other etiologies of lunate avascular necrosis, and studies published in languages other than English. Outcomes of interest were pre- and post-operative wrist range of motion, VAS score, functional scores, radiological outcomes, surgical technique, complication rate and reoperation rate.

Results

The total number of included participants was 203 from 11 articles. The results showed no significant differences pre- and post-operatively in terms of wrist flexion, extension and ulnar deviation. However, there was a significant reduction in radial deviation after the surgery (WMD -2.30; 95% CI, -4.26 to -0.33). Moreover, a significant increase was noticed in grip strength in Kg (WMD 13.29; 95% CI, 3.21-23.37) and mmHg post-operatively (WMD 23.75; 95% CI, 17.56-29.94). In addition, the models demonstrated significant decrease in carpal height (WMD -0.01; 95% CI, -0.02 to 0.00), scapholunate angle (WMD -12.11; 95% CI, -20.46 to -3.77) and radioscaphoid angle after the surgery (WMD -12.09; 95% CI, -15.51 to -8.67). The pooled overall rate of complication and reoperation rates were 24% (95% CI, 6%-47%) and 14% (95% CI, 3%-31%), respectively.

Conclusions

Scaphocapitate arthrodesis is an effective procedure for treatment of Kienböck disease. This procedure is associated with satisfactory functional outcomes and significant improvement in pain scores and grip strength. Further studies with larger sample sizes and reduced heterogeneity are needed for a better evaluation of the results.

Clinical relevance

Scaphocapitate arthrodesis is a recommended surgery for Kienböck disease with satisfactory functional and radiological outcomes. However, patients should be counseled on the possible complications and reoperation rate.

Arthroscopic Treatment of Kienböck Disease: Mid-Term Outcome of Arthroscopic Lunate Core Decompression

PURPOSE

This study evaluated the mid-term functional and radiological results of arthroscopic lunate core decompression for treating Kienböck disease.

METHODS

In a prospective cohort study, 40 patients with a confirmed diagnosis of Kienböck disease (Lichtman stages II to IIIb) underwent arthroscopic core decompression of the lunate bone. A cutting bur was used through the trans-4 portal with visualization from the 3-4 portal after synovectomy and debridement of radiocarpal joint using a shaver from the 6R portal. Disabilities of Arm, Shoulder, and Hand and visual analog scale scores, wrist range of motion, grip strength, radiological changes of Lichtman classification, carpal height ratio, and scapholunate angle were evaluated before and two years after the surgery.

RESULTS

The mean of Disabilities of Arm, Shoulder, and Hand score improved from 52.5 ± 13 to 29.2 ± 16.3. The visual analog scale score also improved from 7.6 ± 1.8 to 2.7 ± 1.9. There was also an improvement in hand grip strength from 6.6 ± 2.7 kg to 12.3 ± 3.1 kg. Wrist range of motion in flexion, extension, ulnar deviation, and radial deviation improved significantly. Lichtman classification remained the same in 36 (90%) patients. Carpal height did not change. Intergroup evaluation showed no functional difference in response to surgery for different radiological Lichtman stages. More improvement was observed in patients with Lichtman stage II, but was not statistically significant.

CONCLUSIONS

Arthroscopic lunate core decompression appears to be an effective and safe surgery for treating Kienböck disease on the basis of mid-term follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Modified Graner's Technique with\without Vascularized Capitate Lengthening for Kienböck Disease Stage IIIb-A Pilot Study

Background  Intercarpal fusions are used to treat stage IIIb Kienböck disease. They increase force transfer across the radioscaphoid articulation with predisposition to arthritis. Description of Technique  This technique is excision of lunate followed by proximal transfer of capitate, with scaphocapitate and triquetrocapitate fusion to increase area of load transfer mimicking wrist hemiarthroplasty. Our purpose is to evaluate mid-term results of this technique. Patients and Methods  A prospective case series study was conducted on 11 patients with stage IIIb and IIIc. In seven cases, transfer of the capitate was performed by osteotomizing the capitate just distal to its waist, proximal migration to replace the excised lunate then bone grafting. In four cases, proximal transfer of vascularized pedicled capitate was done. Clinical outcome measures included pain (visual analog scale), grip strength, range of motion, and functional evaluation by modified Mayo wrist score and scoring system of Evans. Radiological outcome measures included healing of fusion mass, progression of the disease, and occurrence of avascular necrosis to the capitate. Results  Follow-up period averaged 54 months. Scaphocapitate fusion healing averaged 11 weeks. Union of the lengthened capitate occurred in 10 patients only. There was postoperative improvement in pain scores, grip, Evans, and modified Mayo wrist score. There was postoperative decrease in wrist flexion and extension. One patient showed resorption of the capitate head with progressive radioscaphoid arthritis-necessitated wrist fusion. Conclusion  The mid-term results of this technique may be satisfactory due to low incidence of degenerative arthritis in the radioscaphoid joint. However, longer follow-up with recruiting larger number of patients is needed.

Pyrocarbon Lunate Replacements Perform Well at Two Years: A Retrospective Case Series and Technique from Two UK Tertiary Centres

Background: We report medium-term results in our case series of patients with Kienböck disease receiving a pyrocarbon lunate replacement (Integra, Smith and Nephew, Watford, UK). Methods: Patients with Kienböck receiving a pyrocarbon lunate between September 2012 and November 2020, with stage 3b and above were included. Patients were staged preoperatively with radiographs and MRIs. Pre- and postoperative visual analogue scores and movement were documented. Postoperative radiographs were obtained at 6 weeks, 6 months and 1 year. Results: Seven patients were identified, all female, with a median age of 28.0 years. All but one had 3b disease and the median follow-up was 2 years (range 13-112 months). A mean 9/10 preoperative VAS score improved to 1/10 by 3 months postoperatively (p < 0.001, paired t-test). No major complications were seen, and implants were stable radiologically. Conclusions: A semi-constrained pyrocarbon lunate can provide good results for patients with advanced Kienböck's disease, offering an alternative to proximal row carpectomy salvage surgery. Level of Evidence: Level IV (Therapeutic).

The Pathoanatomy and Biomechanics of Kienböck Disease

Kienböck disease (KD) involves osseous, vascular, and chondral aspects of the lunate and wrist. We present our theories on the etiology and pathogenesis of the condition based on basic science models, seminal literature, personal case experience, and kinematic observations of the Kienböck wrist. Three phenotypes of Kienböck disease occur, and each tends to have different morphology, rates of progression, and disease pattern. The lunate fracture in KD is well-recognized but different fracture types can occur. Dynamic assessment of the Kienböck wrist allows assessment of the complex kinematics of KD. Disease onset and progression require a "perfect storm" of risk factors.

Osteotomies, Core Decompression, and Denervation for the Treatment of Kienböck Disease

Various osteotomies, core decompression, and denervation all have demonstrated favorable outcomes in treatment of Kienböck disease. Given the rarity of this disease, there is a dearth of high-level comparative studies to direct treatment. In this article, the authors review the current literature surrounding these techniques, and provide summary recommendations for the procedure choice.

An Algorithmic Approach to the Treatment of Kienböck Disease

The algorithm and rationale described is a reflection of our own surgical experience for this challenging disorder and can be compared with other publications. Our algorithm has evolved from treatment of a large volume of patients with Kienböck disease in a referral practice. However, it is limited to the management that we have found logical, effective, and within our scope of experience. The treatment guidelines for our specialty as a whole will evolve as our understanding of the etiology and our ability to quantify efficacy improves.

Arthroscopic Management of Kienböck Disease

Wrist arthroscopy represents the most recent development in the diagnosis and treatment of Kienböck disease. Through direct visualization of lunate and adjacent carpal articulations, a more accurate diagnosis can be obtained and, ultimately, a more precise treatment decision. Treatments that are based on bypassing, fusing, or excising "nonfunctional" articulations can be done with less morbidity than traditional open techniques by using arthroscopy. Given the minimal capsular and soft tissue scarring, this potentially improves early pain and functional recovery. Although technically demanding, long-term outcomes studies have shown that the benefits of an arthroscopic approach may be worth the learning curve.

Kienböck Disease: Clinical Presentation, Epidemiology, and Historical Perspective

In the now 110 years that have passed since Kienböck first published his seminal description of lunate osteonecrosis, improvements in imaging technology and surgical technique have provided a better understanding of Kienböck disease pathogenesis and treatment. However, the precise etiology, natural history, and optimal treatment remain controversial. Future studies examining the genetics behind the disease and large-scale prospective studies comparing treatment options represent the next step in improving our understanding of this rare and complex phenomenon.

Vascularized Bone Flaps for the Treatment of Kienböck Disease

Of the many treatments for Kienböck disease, only lunate revascularization procedures provide a direct mechanism for reversing the process of osteonecrosis. Owing to the redundant blood supply of the distal radius and carpus, pedicled flaps are versatile solutions for patients with bone loss but intact cartilage. With the advent of free vascularized flaps, the indications for lunate revascularization procedures are expanding. These flaps can be used when the articular cartilage has been compromised and are suitable options to restore native anatomy in patients previously thought to have unreconstructible disease.

Application of 3 dimension-printed injection-molded polyether ether ketone lunate prosthesis in the treatment of stage III Kienböck’s disease: A case report

BACKGROUND

Polyether ether ketone (PEEK) is a high-performance medical polymer, and there are some clinical cases of PEEK prosthesis implantation. However, application of 3D-printed injection-molded PEEK lunate prosthesis for treatment of stage III Kienböck’s disease has not been reported. This study’s purpose was to analyze the clinical efficacy of 3D-printed injection-molded PEEK lunate prosthesis in the treatment of stage III Kienböck’s disease and thus provide a good therapeutic choice for Kienböck’s disease.

CASE SUMMARY

We report a patient with stage III Kienböck’s disease. With the healthy lunate bone as reference, 3D lunate reconstruction was performed using a mirroring technique. A PEEK lunate prosthesis was prepared by 3D printing and injection molding, and then it was inserted into the original anatomical position after removing the necrotic lunate bone. Wrist pain and function, anatomical suitability of the lunate prosthesis, and complications were evaluated and analyzed postoperatively. At the last visit (one year after surgery), the range of motion, grasp force, visual analog scale score and Cooney score of the affected wrist were significantly improved, and postoperative X-ray examination indicated that the lunate prosthesis had good anatomical suitability for adjacent bony structures.

CONCLUSION

The 3D-printed injection-molded PEEK lunate prosthesis demonstrated definite efficacy in treating stage III Kienböck’s disease.

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.

Association of the Interfacet Angle and the Lunate Facet Inclination Angle With Kienböck Disease

PURPOSE

The etiology of Kienböck disease remains unclear, although mechanical, vascular, and metabolic risk factors have been suggested. We aimed to investigate the association of the angle between the curvatures of the distal radius and the development of Kienböck disease.

METHODS

The lunate facet inclination (LFI), scaphoid facet inclination, and interfacet angle (IFA) values were measured using posteroanterior plain radiographs of 82 patients diagnosed with Kienböck disease. The results were compared with normative angular reference values published based on an analysis of 400 wrists of Caucasian patients aged between 20 and 45 years. The posteroanterior radiographs were divided into 3 categories: negative, neutral, and positive based on ulnar variance, and the relationship between ulnar variance and facet angles was evaluated.

RESULTS

The IFA value was significantly higher than the normative angular reference value in the patients with Kienböck disease. Conversely, the LFI values were significantly lower in the Kienböck patient group. There were no statistically significant differences in the IFA and LFI values among the ulnar variance groups.

CONCLUSIONS

Measuring IFA and LFI allows the evaluation of the bifacet curvature of the distal radius articular surface in the coronal plane. Steep IFA and shallow LFI are associated with Kienböck disease. Increased IFA may lead to abnormal load transmission to the intermediate column, which might eventually lead to increased stress on the lunate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Potential Role for Non-Salvage Procedures in the Treatment of Kienböck Disease Stage IV: A Systematic Review

BACKGROUND

The purpose of this systematic review is to identify whether non-salvage procedures can provide satisfactory and acceptable outcomes in Lichtman stage IV disease.

METHODS

The MEDLINE, Embase, and Cochrane databases were systematically searched for English publications between 1989 and 2019 that reported stage IV-specific primary treatment outcomes. Revisions and skeletally immature patients were excluded. Data extracted were patient demographics, pain scores, range of motion (ROM), grip strength, and patient-reported outcome measures (PROMs). The results were pooled into 3 categories: conservative management, non-salvage, and salvage procedures.

RESULTS

Data from 24 studies (n = 114 patients) were extracted. Compared with conservative management and non-salvage treatment (joint-leveling radial osteotomies, lunate reconstruction), salvage procedures (intercarpal and radiocarpal arthrodesis, proximal row carpectomy, total wrist arthroplasty) showed significantly decreased ROM in flexion-extension arc of motion (89° vs 95° vs 73°, respectively, P = .0001) and no significant differences in grip strength as a percentage of the contralateral side (83% vs 86% vs 79%, respectively, P = .28). All reported treatments provided pain relief, ability to return to previous occupations, and variable PROMs.

CONCLUSIONS

In young, active, and labor-intensive patients, motion-preserving, non-salvage options may be worth trialing as they do not preclude future salvage options.

Does Age Affect the Outcomes of Core Decompression for the Treatment of Kienböck Disease?

Background: Core decompression of the distal radius is a minimally invasive technique that has demonstrated good clinical outcomes in the treatment of Kienböck disease. However, the effectiveness of core decompression has not been compared in different age groups. The aim of this study is to compare the outcomes of core decompression in patients <45 years of age to those ≥45 years of age. Methods: This retrospective study included 36 patients with Kienböck disease who were treated with core decompression over a 20-year period. The mean follow-up was 7 years. Outcome measures included visual analogue scale pain score (VAS), active range of flexion/extension at the wrist, grip strength, and modified Mayo wrist score. The patients were divided into two age groups namely <45 years (younger group; n = 22) and ≥45 years (older group; n = 12) and the outcome measures were compared between the two age groups. Results: There were no statistically significant differences between the outcomes of the two age groups. Conclusion: The outcomes of core decompression of the distal radius for Kienböck disease in older patients (≥45 years) are favorable and similar to those seen in younger patients (<45 years). Level of Evidence: Level III (Therapeutic).

Kienböck Disease in a 66-Year-Old Man after Distal Ulna Fracture

Kienböck disease after fracture-dislocations around the wrist is a rare occurrence. This case report presents a case of a 66-year-old man who developed Kienböck disease 18 months after his distal ulnar fracture. The patient developed negative ulnar variance after union of the distal ulnar fracture. Nonsurgical treatment was not effective in relieving his pain. Radial shortening osteotomy was performed based on the negative ulnar variance that developed. One year postoperatively, visual analog scale improved to 0, grip strength improved to 25 kg, and flexion-extension arc improved to 150 degrees. The patient achieved satisfactory clinical outcomes. This is a therapeutic level IV study.

Influence of carpal-ulnar translation on clinical outcome after scaphocapitate arthrodesis for the treatment of late-stage Kienböck disease

BACKGROUND

This study sought to compare postoperative outcomes after scaphocapitate arthrodesis (SCA) for the treatment of late-stage Kienböck disease according to the amount of ulnar translation of the carpus and to identify surgical factors associated with carpal-ulnar translation.

METHODS

Thirty-nine patients diagnosed with Kienböck disease (Lichtman stages III-IV) and treated with SCA were retrospectively reviewed. They were divided into the translated group (n=28) and untranslated group (n=11) according to the presence of carpal-ulnar translation. The following surgical factors in the patients were assessed: excision of the lunate, postoperative carpal height ratio, and radioscaphoid angle (RSA). Pain Visual Analog scale (VAS) score, wrist range of motion, grip strength, modified Mayo wrist score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and progression of radioscaphoid osteoarthritis were also assessed.

RESULTS

All patients showed functional improvement after a mean postoperative follow-up period of 40 months (VAS: 4.1 vs. 1.1, p <0.001; grip strength, 42.3 vs. 51.2 lb., p = 0.002; MMWS, 52.6 vs. 69.5, p <0.001; QuickDASH, 33.7 vs. 21.5, p <0.001). No statistically significant differences were found between the two groups in terms of outcome measures. Among the assessed surgical factors, the mean postoperative RSA was significantly smaller in the translated group than in the untranslated group (34.8° vs. 46.8°, p = 0.008). The proportion of patients with postoperative RSA <30° was significantly higher in the translated group than in the untranslated group (54.5% vs. 0%, p<0.001).

CONCLUSION

These results suggest that sufficient pain relief and functional improvement can be achieved after SCA for the treatment of late-stage Kienböck disease disregarding the occurrence of carpal-ulnar translation. In this study, overcorrection to RSA <30° induced more frequent carpal-ulnar translation after SCA.

Radial Osteotomy for Kienböck Disease: Clinical and Radiological Comparison between Younger and Older Patients

Background: The usefulness of radial osteotomy for older patients remains unclear. The purpose of this study was to compare the clinical and radiological outcomes of radial osteotomy with volar locking plate between younger and older patients with Kienböck disease stages II to IIIB. Methods: This was a retrospective comparative study of 21 consecutive patients treated at our department. Lichtman's classification was used for staging, and four patients had stage II, six patients had stage IIIA, and 11 patients had stage IIIB disease. We divided them into two groups to compare the radiological and clinical results between younger (younger than 40 years) and older patients. The mean follow-up periods in the younger and older groups were 4 and 3.6 years, respectively. For radiological assessment, we evaluated the carpal height ratio (CHR), Stahl index, and union of the fractured lunate. For clinical assessment, we examined the range of motion of the wrist, grip strength, numeric rating scale (NRS) for pain, and the patient-reported Hand20 score preoperatively and at the final follow-up. Results: There were 12 patients in the younger group with a mean age of 23 years (range, 12-37 years), and 9 in the older group with a mean age of 56 years (range, 40-74 years). There were no intra- and post-operative complications in either group. Radiological improvement, including CHR, Stahl index, and union of the fractured lunate, was more common in the younger group than in the older one, as was the case for clinical improvement. However, even in the older group, significant clinical improvement, including the range of motion of the wrist, NRS for pain, and the Hand20 score, was seen postoperatively. Conclusions: Radial osteotomy appears to be a safe and reliable option in older symptomatic patients with Kienböck disease stages II to IIIB.

Long-Term Outcome of Surgical Treatment for Kienböck Disease Using an Articular-Based Classification

PURPOSE

The aim of this study was to report the outcomes of surgery using the Bain and Begg articular-based classification for the treatment of Kienböck disease.

METHODS

We identified and followed patients who had surgery for Kienböck disease between 1995 and 2014. Assessment included functional scoring using a modification of the Gartland and Werley score, pain levels, and grip strength.

RESULTS

Thirty-one patients were operated on for Kienböck disease between 1995 and 2014. Twenty-seven patients were assessed (12 men and 15 women). Mean age at the index procedure was 45.1 years (range, 20-82 years). Median follow-up after the index procedure was 10 years (range, 2-18 years). On the Bain and Begg classification, 5 patients had grade 0, 4 had grade 1, 5 had grade 2a, 10 had grade 2b, 1 had grade 3, and 1 had grade 4. The median pain visual analog scale improved from a preoperative score of 5 (interquartile range [IQR], 5-6) to a postoperative score of 2 (IQR, 0-3). The median functional scores from the modified Gartland and Werley score improved from 67 (IQR, 57.0-78.5) to 97 (IQR, 90.0-97.0). Eighteen out of 20 working patients returned to the same level of work. There was a significant improvement in power grip and tip pinch following surgery. One patient required a secondary salvage procedure. No patient required a full wrist fusion or arthroplasty.

CONCLUSIONS

This study confirms that the Bain and Begg arthroscopic classification and an articular-based approach to Kienböck disease provide a high probability of good long-term relief of pain and a minimal chance of requiring a salvage procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Vascularized Capitate Transposition for the Treatment of Stage IIIB Kienböck Disease

PURPOSE

The treatment of Kienböck disease (KD) continues to be controversial. In this study, we report the long-term follow-up outcomes of patients who were diagnosed with stage IIIB KD treated with vascularized capitate transposition.

METHODS

A total of 16 patients were retrospectively reviewed. Baseline clinical information was extracted from medical records, and wrist function was clinically evaluated, including x-ray images.

RESULTS

At the final follow-up, wrist pain was severe in 0 patients, moderate in 2 patients, mild in 5 patients, and absent in 9 patients. The mean postoperative active flexion and extension of the affected wrist was significantly improved after surgery compared with before surgery. The postoperative and preoperative mean grip strength was 35 kg and 27 kg, respectively. The Disabilities of the Arm, Shoulder, and Hand score was significantly improved after surgery compared with before surgery.

CONCLUSIONS

Vascularized capitate transposition for the treatment of Lichtman stage IIIB KD is feasible and associated with improvements in wrist function and pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Preliminary Clinical, Radiographic, and Patient-Reported Outcomes of the Medial Femoral Trochlea Osteochondral Free Flap for Lunate Reconstruction in Advanced Kienböck Disease

PURPOSE

We aimed to describe the radiographic, functional, and patient-reported outcomes (PROs) of medial femoral trochlea osteochondral free flap reconstruction of the proximal lunate in stage IIIA and IIIB Kienböck disease.

METHODS

Eighteen adult patients underwent medial femoral trochlea reconstruction of the proximal lunate for advanced Kienböck disease by a single surgeon. Eight of these patients returned for clinical examination, radiographs, and completion of PRO questionnaires. An additional 4 patients completed PRO questionnaires remotely.

RESULTS

The mean patient age was 28.4 years. The mean radiographic and physical examination follow-up was 1.4 and 2.2 years, respectively. The mean PRO follow-up was 2.1 years. Radiographic measurements (carpal height ratio, radioscaphoid angle) demonstrated that carpal collapse was halted, and carpal alignment was maintained, after surgery. Wrist flexion (38.3°) and extension (37.3°) were unchanged by this operation, and postoperative pinch and grip strength were 90% and 68% of the uninjured side, respectively. The mean postoperative Disabilities of the Arm, Shoulder, and Hand score was 10.8, and the Patient-Rated Wrist Evaluation score was 18.1. Knee Injury and Osteoarthritis Outcomes Score subscales, International Knee Documentation Committee, and Kujala lower extremity PRO scores ranged from 83.1 to 96.8. The Patient-Reported Outcomes Measurement Information System Global Health, Physical Function, Pain Intensity, Pain Interference, and Pain Behavior scores reflected good postoperative patient health and function and low pain levels.

CONCLUSIONS

Following medial femoral trochlea reconstruction of the proximal lunate for advanced Kienböck disease, we observed a cessation of radiocarpal collapse. After surgery, patients demonstrated acceptable levels of function, pain, and wrist range of motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Kienböck Disease: Quality, Accuracy, and Readability of Online Information

Background: Patients with limited health literacy require online educational materials to be written below a sixth grade level for optimal understanding. We assessed the quality, accuracy, and readability of online materials for Kienböck disease (KD). Methods: "Kienbock's Disease" and "Lunate Avacular Necrosis" were entered into 3 search engines. The first 25 Web sites from each search were collected. Quality was assessed via a custom grading rubric, accuracy by 2 residents and a fellow, and readability by Flesch-Kincaid grade level (FKGL) and New Dale-Chall test. Web sites were stratified according to the search term, FKGL, order of appearance, and authorship type. Results: A total of 38 unique Web sites were included, of which 22 were assigned to "KD" and 16 to "Lunate Avascular Necrosis." The average quality score out of 30, accuracy score out of 12, and FKGL for all Web sites were 13.3 ± 7.3, 10.4 ± 1.9, and 10.5 ± 1.4, respectively. Web sites assigned to the term "Kienbock's Disease" had a significantly higher FKGL. Web sites of higher FKGL had significantly worse accuracy scores. Order of appearance had no influence. Physician specialty societies (PSS) had a significantly lower FKGL than Web sites of other authorship types. Conclusions: Despite concerted efforts by national organizations, the readability of online patient materials is above the recommended level for KD. Patients with limited health literacy will be most affected by this reality. Until readability improves, patients should continue to consult their physicians when uncertain and prioritize Web sites that are easier to read and produced by PSS.

Relationship of Plasminogen Activator Inhibitor 1 4G/5G Gene Polymorphism and Nontraumatic Lunatum Avascular Necrosis

PURPOSE

Plasminogen activator inhibitor 1 (PAI-1) is a critical enzyme that regulates coagulation and fibrinolytic systems. The aim of this study was to determine the role of PAI-1 4G/5G polymorphism in nontraumatic avascular necrosis of the lunate.

METHODS

The study included 45 patients with Kienböck disease and 45 healthy individuals as a control group. In both groups, genomic DNA was extracted from peripheral blood samples to determine the distributions of PAI-1 4G/5G polymorphism using allele-specific polymerase chain reaction and sequencing.

RESULTS

No statistically significant difference was determined in the distribution of the gene polymorphism between the patient and control groups. We found the 5G/5G genotype to be 1.7 times higher in the control group compared with the patient group. A 1.6-fold increase in the 4G homozygote genotype was identified in the patient group. The patient and control groups were also evaluated for 4G/4G plus 4G/5G and 5G/5G in terms of genotype distribution. No statistically significant difference was found.

CONCLUSIONS

The findings suggest that the PAI-1 4G/4G polymorphism is not a genetic risk for Kienböck disease.

CLINICAL RELEVANCE

This study aimed to reveal the genetic etiology of Kienböck disease.

Pronator quadratus pedicled bone graft in the treatment of Kienböck disease: follow-up 2 to 12 years

We inserted a pronator quadratus pedicled bone graft into the avascular lunate with preservation of its corticocartilaginous portion for the treatment of Kienböck disease. Twenty-seven patients (14 men, 13 women; mean age, 42 years (range 17-66 years)) were treated between September 2005 and July 2014 and followed up from 2 to 12 years. Three patients had Lichtman stage II disease, 13 had stage IIIA, and 11 had stage IIIB. Among them, 18 patients showed radiological improvement in lunate morphology. The Lichtman stage was unchanged in 23 patients and aggravated in four patients. The Stahl index was significantly decreased, but grip strength was significantly improved and 18 patients did not have any wrist pain during daily activities. Although our technique did not restore the already changed carpal malalignment, it improved lunate morphology. Clinically, it provided satisfactory pain levels in two-thirds of the patients and grip strength was improved. Level of evidence: IV.

Evaluation for Kienböck Disease Familial Clustering: A Population-Based Cohort Study

PURPOSE

Kienböck disease (KD) is rare and its etiology remains unknown. As a result, the ideal treatment is also in question. Our primary purpose was to test the hypothesis that KD would demonstrate familial clustering in a large statewide population with comprehensive genealogical records, possibly suggesting a genetic etiologic contribution. Our secondary purpose was to evaluate for associations between KD and known risk factors for avascular necrosis.

METHODS

Patients diagnosed with KD were identified by searching medical records from a comprehensive statewide database, the Utah Population Database. This database contains pedigrees dating back to the early 1800s, which are linked to 31 million medical records for 11 million patients from 1996 to the present. Affected individuals were then mapped to pedigrees to identify high-risk families with an increased incidence of KD relative to control pedigrees. The magnitude of familial risk of KD in related individuals was calculated using Cox regression models. Association of risk factors related to KD was analyzed using conditional logistic regression.

RESULTS

We identified 394 affected individuals linked to 194 unrelated high-risk pedigrees with increased incidence of KD. The relative risk of developing KD was significantly elevated in first-degree relatives. There was a significant correlation between alcohol, glucocorticoid, and tobacco use and a history of diabetes, and the diagnosis of KD.

CONCLUSIONS

Familial clustering of KD observed in the Utah Population Database cohort indicates a potential genetic contribution to the etiology of the disease. Identification of causal gene variants in these high-risk families may provide insight into the genes and pathways that contribute to the onset and progression of KD.

CLINICAL RELEVANCE

This study suggests that there is a potential genetic contribution to the etiology of KD and that the disease has a significant association with several risk factors.

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.

Fixation of the Fractured Lunate in Kienböck Disease

PURPOSE

To describe an uncommon subset of fractured lunates in Kienböck disease that is salvageable by internal fixation.

METHODS

We performed a retrospective review for patients with Kienböck disease treated by internal fixation. Demographic data, objective and radiographic measurements, patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and pain (visual analog scale) scores were collected.

RESULTS

Of the 7 patients treated, 5 were available for review. At an average follow-up of 7.1 years (range, 1.5-15 years), all patients had activity-related wrist pain but were pain-free at rest. Radiographic assessment showed union in all lunates and a normal radioscaphoid angle and Stahl index. The modified carpal height ratio was reduced in 4 patients and normal in one. There was no observed narrowing or irregularity of the radiocarpal or midcarpal joints. Patient-reported outcome measures in 2 patients were unsatisfactory.

CONCLUSIONS

Computed tomography of the lunate in Kienböck disease is an important investigative tool. A coronal split fracture of these lunates can be salvageable by internal fixation. Revascularization of the lunate can be performed when the fragment is of sufficient size.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Long-Term Clinical Outcome After Titanium Lunate Arthroplasty for Kienböck Disease

PURPOSE

Titanium lunate arthroplasty (TLA) for Kienböck disease was introduced in 1984 to address the silicone-wear particle problem common to silicone lunate implants. We sought to study the outcome of TLA.

METHODS

We identified 11 patients from our hospital database who had undergone TLA between 2001 and 2010. We evaluated pain, range of motion (ROM), function, and radiological outcome at a mean 11 years after surgery. We compared preoperative ROM and radiological findings with final follow-up in the ipsilateral wrist and also made comparisons with the contralateral wrists.

RESULTS

No implants were removed, and no wrist joints were fused. Pain on the visual analog scale averaged 0.5 at rest, 0.3 at night, and 2.7 during heavy exertion. Seven patients had no pain at rest and 9 had no pain at night. Range of motion reached 70% of that of the contralateral wrist, and strength reached 81%. The Disabilities of the Arm, Shoulder, and Hand (DASH) score averaged 9.6, optional DASH 9.7, and Mayo wrist score 67.7. Radiologically, only Ståhl and arthrosis indexes differed significantly between affected and unaffected wrists. Two patients had a dorsally dislocated implant, meaning that around 20% of our cases probably meet the criteria for failure.

CONCLUSIONS

The longer-term results of TLA for stage III Kienböck disease are promising.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Kienböck Disease in the Skeletally Immature Patient

Kienböck disease is uncommon in skeletally immature patients. Although there is no gold standard treatment for Kienböck disease in the skeletally immature patient, surgical and nonsurgical treatment options have been shown to be effective. Initial immobilization with a cast, protection with an orthosis, and avoidance of repetitive forceful activities have been shown to be effective in some cases. Surgery may be offered to the skeletally immature patient when nonsurgical treatment is ineffective. Among several surgical techniques used for treatment in the skeletally immature patient with Kienböck disease, distal radial osteotomies have been the most frequently performed surgery; however, radial overgrowth is a concern. There is a great potential for revascularization and remodeling of the lunate in the skeletally immature patients with Kienböck disease. Good and excellent clinical and radiological outcomes can be achieved with both nonsurgical and surgical treatments.

Results of scaphocapitate arthrodesis with lunate excision in advanced Kienböck disease at 10.7-year mean follow-up

Scaphocapitate arthrodesis with lunate excision was performed for treatment of advanced Kienböck disease in 17 patients (18 wrists). Ten were women and seven men. Five were Lichtmann Stage IIIA, 12 Stage IIIB, and one Stage IV. Minimum follow-up period was 24 months; mean follow-up was 10.7 years (range 2.3 to 22 years, SD 7.1). At the latest follow-up, six patients were very satisfied, nine were satisfied and two were disappointed. Pain was significantly decreased in all cases. Wrist mobility was unchanged. Grip strength was significantly increased. Consolidation of the arthrodesis was confirmed in 17 wrists. We encountered a scaphocapitate nonunion at 12 years follow-up and two cases of styloscaphoid arthritis at 17 and 22 years. Scaphocapitate arthrodesis with lunate excision performed in an advanced stage of Kienböck disease significantly alleviates pain, while preserving functional mobility and satisfactory grip strength in the long term.

LEVEL OF EVIDENCE

IV.

Risk Factors of Lunate Collapse in Kienböck Disease

PURPOSE

Not all patients with Kienböck disease progress to collapse of the lunate and carpal malalignment, but it is difficult to determine which patients are at risk. We aimed to identify demographic or anatomical factors associated with more advanced stages of Kienböck disease.

METHODS

We included all 195 eligible patients with Kienböck disease and available preoperative posteroanterior and lateral radiographs. We compared the mean age, sex distribution, mean ulnar variance, radial height, radial (ulnarward) inclination, palmar tilt, anteroposterior distance, and lunate type among the different Lichtman stages of Kienböck disease and performed ordinal logistic regression analysis.

RESULTS

We found that patients with more negative ulnar variance had more advanced stages of Kienböck disease (adjusted odds ratio, 1.4). An increase in age was also independently associated with a higher Lichtman stage of Kienböck disease (adjusted odds ratio, 1.02).

CONCLUSIONS

Our findings suggest that more negative ulnar variance may be related to a greater magnitude of lunate collapse in Kienböck disease. Additional long-term study is needed to confirm the longitudinal relationship of negative ulnar variance with progressive Kienböck disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Interobserver Agreement in Diagnosing Early-Stage Kienböck Disease on Radiographs and Magnetic Resonance Imaging

BACKGROUND

The appearance of early Kienböck disease on radiographs and magnetic resonance imaging (MRI) may be difficult to distinguish from other conditions that affect the lunate. We aimed to assess the interobserver agreement in the diagnosis of early Kienböck disease when evaluated on different imaging modalities.

METHODS

Forty-three hand surgeon members of the Science of Variation Group were randomized to evaluate radiographs and 35 hand surgeons to evaluate radiographs and MRI scans of 26 patients for the presence of Kienböck disease, the lunate type, and the ulnar variance. We used Fleiss' kappa analysis to assess the interobserver agreement for categorical variables and compared the κ values between the 2 groups.

RESULTS

We found that agreement on the diagnosis of early Kienböck disease was fair (κ, 0.36) among observers who evaluated radiographs alone and moderate (κ, 0.58) among observers who evaluated MRI scans in addition to radiographs, and that the difference in κ values was not statistically significant ( P = .057). Agreement did not differ between observers based on imaging modality with regard to the assessment of the lunate type ( P = .75) and ulnar variance ( P = .15).

CONCLUSIONS

We found, with the numbers evaluated, a notable but nonsignificant difference in agreement in favor of observers who evaluated MRI scans in addition to radiographs compared with radiographs alone. Surgeons should be aware that the diagnosis of Kienböck disease in the precollapse stages is not well defined, as evidenced by the substantial interobserver variability.

Radius Core Decompression for Kienböck Disease Stage IIIA: Outcomes at 13 Years Follow-Up

PURPOSE

This study was designed to analyze the long-term clinical and radiological outcomes of a series of patients with Kienböck disease stage IIIA treated with radius core decompression.

METHODS

This retrospective study included 15 patients with Kienböck disease (Lichtman stage IIIA) who underwent distal radius metaphyseal core decompression between 1998 and 2005 and who were followed-up for at least 10 years. At the last follow-up, the patients were evaluated for wrist range of motion and grip strength. The overall results were evaluated by the modified Mayo wrist score and visual analog scale pain score. We also compared the radiological changes between the preoperative and the final follow-up in their Lichtman classification and the modified carpal height ratio.

RESULTS

The mean follow-up period was 13 years (range, 10-18 years). Based on the modified Mayo wrist score, clinical results were excellent in 6 patients, good in 8 patients, and poor in 1 patient who required a proximal row carpectomy as revision surgery. The mean preoperative pain according to the visual analog scale was 7 (range, 6-10) and was 1.2 (range, 0-6) at the final follow-up. Compared with the opposite side, the average flexion/extension arc was 77% and the grip strength was 80%. All patients, except 1, returned to their original employment. At the final follow-up, 3 patients had decreased modified carpal height ratio, 12 remained unchanged. Radiographic disease progression according to the Lichtman classification to stages IIIB to IV occurred in only 2 wrists. There were no complications related to the core decompression.

CONCLUSIONS

In this limited series, the radius core decompression demonstrated favorable long-term results and could be considered as a surgical alternative for stage IIIA of Kienböck disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Biologic Approaches to Problems of the Hand and Wrist

Orthobiologics are not used as frequently in the hand and wrist as in other sites. The most frequently reported is the use of bone morphogenetic protein for the treatment of Kienböck disease. Animal studies have described improved tendon healing with the use of platelet-rich plasma (PRP), but no clinical studies have confirmed these results. PRP has been reported to produce improvements in the outcomes of distal radial fractures and osteoarthritis of the trapeziometacarpal in small numbers of patients. The use of orthobiologics in the hand and wrist are promising, but clinical trials are necessary to establish efficacy and safety.

Flexor Tendon Rupture Due to Previously Undiagnosed Kienböck Disease: A Case Report

BACKGROUND

Spontaneous flexor tendon rupture is rare and most common in the little finger. The pathogenesis of spontaneous tendon ruptures is unclear but may occur through attrition or mechanical abrasion over a bony prominence. Kienböck disease is avascular necrosis of the lunate, with an unknown etiology.

METHODS

We present a case of spontaneous rupture of flexor digitorum profundus due to Kienböck disease, which we believe is the first recorded case of flexor tendon rupture attributable to osteonecrosis of the lunate.

RESULTS

The patient underwent single-stage reconstruction of FDP and regained a good range of motion at the affected DIPJ.

CONCLUSIONS

This case illustrates the the importance of plain radiographs in the assessment of a patient presenting with spontaneous flexor tendon rupture in the hand to exclude bony pathology as a cause.

Percutaneous Cementoplasty for Kienbock's Disease

Kienböck disease typically presents with wrist pain, swelling, restricted range of motion, and difficulty in performing activities of daily living. Because the etiology and evolution of disease remain unclear, broad ranges of treatments have been designed. Percutaneous cementoplasty is expanding its role for managing painful bone metastases outside the spine. We can draw a parallel between lytic tumoral lesions and Kienbock's disease. Increasing the strength and rigidity of lunate with cementoplasty can prevent it from collapse, relieve the symptoms associated with the process of avascular necrosis, and increase the wrist range of motion. We report the case of 30-year-old man with a painful stage IIIA Kienböck disease who underwent percutaneous cementoplasty and experienced immediate effective pain relief and recovery of wrist mobility.

The Etiology and Pathogenesis of Kienböck Disease

Kienböck disease is a condition that typically occurs in the "at-risk" patient, in the "at-risk" aspect of the proximal condyle of the "at-risk" lunate. In the active male, repetitive loading causes the stress fracture that commences in the single layer proximal subchondral bone plate. The lunate fracture commences at the point the lunate cantilevers over the edge of the distal radius, and then takes on the shape of the radius. We postulate that the stress fracture violates the parallel veins of the venous subarticular plexus-leading to localized venous hypertension and subsequent ischemia and edema of the fatty marrow. The increased osseous compartment pressure further potentiates the venous obstruction, producing avascular necrosis. If the fracture remains localized, it can heal or settle into a stable configuration, so that the wrist remains functional. Fractures of the subchondral bone plate produce irregularity of the lunate articular surfaces and secondary "kissing lesions" of the lunate facet and capitate, and subsequent degeneration. The lunate collapses when the fracture is comminuted, or there is disruption of the spanning trabeculae or a coronal fracture. The secondary effect of the lunate collapse is proximal migration of the capitate between the volar and dorsal fragments, producing collapse of the entire central column. The proximal carpal row is now unstable, and is similar to scapholunate instability, where the capitate migrates between the scaphoid and lunate. The scaphoid is forced into flexion by the trapezium, however, degeneration of the scaphoid and scaphoid facet only occurs in late disease or following failed surgery. In Kienböck disease, the secondary effects of the collapsing lunate are a "compromised" wrist, including: deformity and collapse of the central column, degeneration of the central column (perilunate) articulations, proximal row instability (i.e., between the central and radial columns), and degeneration of the radial column.

[Intercarpal fusion as a salvage procedure in Kienböck disease]

INTRODUCTION

Functional results of four surgical techniques to resolve the IIIB-IV Litchman's stage of the Kienböck disease were analyzed. We observed the evolution from 2000 to 2015.

MATERIAL AND METHODS

Transversal retrospective study of 33 patients treated with different surgical techniques and evaluated with Quick-DASH scale, dynamometer and EVA.

RESULTS

Less functional limitation was found in the patients who underwent the intercarpal fusion with or without neurotomy of the posterior interosseous.

DISCUSSION

It was shown that the fact of making a less aggressive surgery is enough to evolve into an increase in symptoms and a decrease in function and strength; therefore, the intercarpal fusion performed at the right time of the natural history of the disease can achieve better results than other methods used previously and endorsed by international associations.

CONCLUSIONS

The surgical technique of choice in our series to prevent disease progression was the intercarpal fusion and neurotomy of the posterior interosseous nerve.

Kienböck Disease and Arthroscopy: Assessment, Classification, and Treatment

The assessment and management of Kienböck Disease (KD) has always been a conundrum. The Lichtman classification has traditionally been used to guide treatment based on imaging. Arthroscopy provides a direct visualization of the articular surface, allows probing of the surfaces, and enables minimally invasive techniques to be performed. The Lichtman-Bain classification is a new classification that takes into account the osseous, vascular, and cartilage aspects of the lunate and the secondary effects on the wrist. It identifies the important prognostic factors including age, the status of the lunate, and the status of the wrist. With arthroscopy, the articular surfaces of the lunate can be assessed to better understand the status of the lunate. The lunate can be defined as intact, compromised, or not reconstructable. If the lunate is intact then lunate decompression (forage) and arthroscopic assisted bone grafting can be performed. If the lunate facet and capitate are functional, then a proximal carpectomy can be performed. This can be performed as an arthroscopic procedure. Assessment of the wrist includes assessment of the adjacent articular surfaces of the central column articulations (radiocarpal and midcarpal articulations). Instability of the proximal carpal row can also be assessed. The radioscaphoid articulation is often preserved except in late KD, which allows the scaphocapitate fusion to be a good surgical option. This can now be performed as an arthroscopic procedure. Once the radioscaphoid articulation is degenerate, a salvage procedure is required.

Kienböck Disease and Carpal Coalitions: A Potential Correlation

Kienböck disease, or lunate avascular necrosis, can lead to chronic wrist pain and instability. Its etiology appears to be multifactorial including variations in adjacent anatomical structures, interrupted blood supply, and trauma. Capitate-hamate fusion is the second most commonly diagnosed carpal coalition and not treated unless symptomatic. Coalitions may alter the wrist mechanics depending on their extent. No prior reports have associated Kienböck disease with capitate-hamate coalition. We present 2 cases with congenital capitate-hamate fusion and lunate AVN.

Carpal tunnel syndrome associated with Kienböck disease

We retrospectively reviewed 12 patients (3 men and 9 women, with a mean age of 72 years) who were surgically treated for carpal tunnel syndrome associated with Kienböck disease. All patients except 1 were incidentally diagnosed with Kienböck disease and had little or no wrist pain. Radiographic tests revealed advanced Kienböck disease in all patients. Intraoperative findings indicated that the site of maximum compression on the median nerve was located at the level of the carpal tunnel inlet in 11 patients, and the volar dislocated fragment of the lunate was located proximally adjacent to the floor of the carpal tunnel inlet. This disorder is most prevalent in elderly women, and even advanced Kienböck disease can present without wrist pain. Our findings suggest that palmar protrusion of the lunate may be the primary cause of carpal tunnel syndrome associated with Kienböck disease.

Radiographic Progression of Kienböck Disease: Radial Shortening Versus No Surgery

PURPOSE

The natural course of the pathophysiology of Kienböck disease is uncertain. Shortening of the radius is believed to modify the pathophysiology by addressing mechanical influences on the lunate. The aim of this study was to compare the radiographic progression of Kienböck disease among patients who had radial shortening osteotomy and patients who had no surgical treatment, with a minimum 1-year interval between radiographs.

METHODS

Among 207 patients with Kienböck disease, we included all 48 eligible patients who had either radial shortening osteotomy or nonsurgical treatment and 2 sets of wrist radiographs available a minimum of 1 year apart. We compared changes in carpal height ratio, Stahl index, and carpal angles between the 2 sets of radiographs and between radial shortening osteotomy and nonsurgical treatment.

RESULTS

We found, on average, a small decrease in the carpal height ratio and the Stahl index in patients who did and did not have surgery, with no differences between the 2 groups. Nearly half of the patients had no decrease in the carpal height ratio and/or the Stahl index.

CONCLUSIONS

Radiographic progression of Kienböck over 1 year or more seems slight on average regardless of treatment. Future research might address the probability of and factors associated with radiographic progression of Kienböck disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Radiological Prevalence of Incidental Kienböck Disease

BACKGROUND

To determine the prevalence of incidental Kienböck disease.

METHODS

A retrospective analysis of 150,912 radiological reports or images obtained over a five year period was performed of 76,174 patients who underwent a radiograph or computed tomography scan which included the wrist, in Edinburgh and Lothian, UK.

RESULTS

There were 5 cases of incidental Kienböck disease and 13 cases of symptomatic Kienböck disease. There were no significant differences in age, sex, ethnicity, comorbidities, smoking status, excess alcohol use or Lichtman stage between the incidental and symptomatic Kienböck groups.

CONCLUSION

The radiological prevalence of incidental Kienböck disease was 0.0066% or 7 in 100,000 patients.

Kuhlmann vascularized bone grafting for treatment of Kienböck's disease: a case report

Treatment of Kienböck's disease has historically been determined by staging, ulnar variance, and presence or absence of arthritic changes. With the advent of newer techniques of vascularized bone grafting, the status of the cartilage shell of the lunate has become another factor that can influence the procedure performed. The purpose of this article is to describe the technique of Kuhlmann vascularized bone graft for Kienböck's disease. In addition, the indications, contraindications, and outcomes are described.

In Vivo High-Resolution Trabecular Microstructure of Kienböck Lunate before and after Radial Shortening: A Case Report

We report a patient with stage IIIB Kienböck disease treated with radial shortening where preoperative and sequential postoperative imaging were done using in vivo high-resolution peripheral quantitative micro-computed tomography (micro-CT) scan. Sequential in vivo micro-CT scan analysis of a target zone of the Kienböck lunate of this patient demonstrated early signs of lunate remodeling (bone trabecular densification) at 5-month follow-up suggesting an ongoing healing process. These early remodeling micro-CT scan signs were confirmed at 5 years' follow-up as well.

Kienböck Disease: Postoperative Radiographs at Long-Term Follow-Up

We present the radiographic results of four patients with Kienböck disease who had undergone a simple lunate excision at 26, 30, 35, and 43 years after surgery.

Long-Term Outcomes of Radial Osteotomy for the Treatment of Kienböck Disease

Background Kienböck disease is an aseptic necrosis of the lunate of unknown etiology, prevalent in young adults. Treatment aims to lower forces on the lunate, decrease pain and improve function. We conducted a retrospective evaluation of the 10-year clinical and radiological outcomes of radial osteotomy as a treatment for Kienböck disease. Materials and Methods We analyzed pain, grip strength, wrist range of motion (ROM), radiological carpal geometry, and staging of osteoarthritic changes over a 10-year period, postosteotomy, for 18 patients. The Mayo wrist score was used as an overall measure of outcome. Technique Outcomes for two types of osteotomies were included, a step-cut osteotomy with fixed screws and an updated technique of two linear transverse osteotomies with volar locking plates. For cases with negative ulnar variance, resection of the radius was included to obtain a final ulnar variance of -1 to 0 mm. For positive ulnar variance, the goal was to obtain a correction of radial inclination of 10 to 15 degrees. Results Improvements in pain, ROM, and grip strength were maintained over the 10-year follow-up, without radiological improvement in geometry (carpal height ratio and Stahl index). Mild osteoarthritic changes were identified in 33% of patients, with no effect on clinical results. Degree of cartilage damage determined postoperative grip strength improvement. The Mayo wrist score at the final follow-up was excellent in one patient, good in nine, and fair in eight. Conclusions Radial osteotomy provides reasonable and long-term clinical benefits. Preoperative arthroscopic evaluation of cartilage damage can inform treatment decisions.