Treatment of Kienböck disease by lunate core decompression

Simplifying the Decision-Making Process in the Treatment of Kienböck's Disease

Background  In recent years, the classification and treatment algorithm for adult Kienböck's disease (KD) has expanded. However, the priority of the investigations done in determining its management has not been discussed, as not every patient with KD requires magnetic resonance imaging (MRI) or wrist arthroscopy. Materials and Methods  We discuss the role of these investigations and emphasize the importance of computed tomography (CT) imaging in evaluating the cortical integrity of the lunate and its role in the decision-making process and management of KD. Results  We put forward an investigative algorithm that places into context the investigative roles of MRI, arthroscopy, and CT. Conclusion  KD is a rare condition, and there is a lack of comparative studies to help us choose the preferred treatment. The decision on the management options in adult KD may be made by determining the integrity of the lunate cortex and deciding whether the lunate is salvageable or not by CT scan. MRI may provide useful information on the vascular status if the lunate cortex is intact, and the lunate is salvageable. If the lunate is fragmented, it is not salvageable, and MRI does not provide useful information. Arthroscopy has a role in selective cases.

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.

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.

Pathophysiology of Avascular Necrosis

Avascular necrosis is a complicated, multifactorial disease with potentially devastating consequences. Although the underlying root cause is a lack of appropriate vascular perfusion to affected bone, there are often varying patient-specific, anatomic-specific, and injury-specific predispositions. These factors generally fall into 3 categories: direct vascular disruption, intravascular obliteration, or extravascular compression. The initial stages of disease can be insidiously symptomatic because edematous bone marrow progresses to subchondral collapse and subsequent degenerative arthritis. Although much of the current literature focuses on the femoral head, other common areas of occurrence include the proximal humerus, knee, and the carpus. The low-incidence rate of carpal avascular necrosis poses a challenge in establishing adequately powered, control-based validated treatment options, and therefore, optimal surgical management remains a continued debate among hand surgeons. Appreciation for expectant fracture healing physiology may help guide future investigation into carpal-specific causes of avascular necrosis.

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.

Pediatric Ulnar-sided Wrist Pain: A Review of the Current Literature

Patients presenting with ulnar-sided wrist pain can pose a diagnostic and therapeutic challenge to physicians because there are several pathologies with similar signs and symptoms. In comparison with adult patients, other etiologies must be considered in the pediatric patient, given the skeletal immaturity and potential for known or unrecognized syndromes. In addition, these patients may not be able to articulate their symptoms as clearly as an adult patient, further stressing the importance of obtaining a pertinent history and performing a focused physical examination. Having a thorough understanding of the anatomy, the varying pathologies, and the indications for surgical and nonsurgical management will assist in improved patient outcomes.

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.

Recent Advances in Assessment and Treatment in Kienböck's Disease

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

Matching Kienböck's Treatment Options to Specific Features of Each Case

Kienböck's disease is best understood as a continuous interaction between compromised perfusion and structural deterioration that transitions from an early phase to a late phase. Existing literature has failed to identify any one superior treatment for Kienböck's; many studies even demonstrate no advantage for surgery compared with the natural history. Surgical interventions for early and transitional Kienböck's are designed to preserve or reconstruct the lunate. However, in most studies, the only tool used to assess the lunate itself has been plain radiography that neither reveals critical architectural details (demonstrated by computed tomographic scan) nor the vascular status (demonstrated by magnetic resonance imaging). Most articles, therefore, do not adequately define the preoperative status of the lunate or its alteration through surgical intervention. Critical preoperative features that are best demonstrated by these advanced imaging studies have specific anatomic and physiologic relationships that better correspond with certain surgical interventions, which also pair better with specific patient characteristics. This review explains how to identify, analyze, and strategically match these variables with the treatment interventions available for Kienböck's patients through the early, transitional, and late phases of the disease.

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.

Osteonecrosis of the Lunate: Kienböck Disease

Kienböck disease, osteonecrosis of the lunate, is a well-known but poorly understood complication seen by hand surgeons. This review presents the background and important patient-specific parameters of the disease and reviews the numerous treatment options that exist for the disease.

Kienböck's disease: Where do we stand?

Avascular necrosis of the lunate, commonly known as Kienböck's disease is a disorder that can lead to carpal collapse and the need for surgeries, which can stabilize the wrist. There are different associations with the disease but the exact etiology is unknown. Kienböck's disease is believed to result from mechanical and vascular factors in genetically predisposed individuals. The newer classification based on advanced wrist arthroscopy and MRI help in a better understanding of the disease, early diagnosis, and treatment. A review of recent literature regarding newer treatment options has shown good results in the early stages of osteonecrosis. This article intends to review an update on the etiopathogenesis, classification, and the current advanced treatment options.

Kienböck Disease: A New Algorithm for the 21st Century

Background It has been over 100 years since the initial description of avascular necrosis of the lunate. Over the last two decades, there has been the introduction of advanced information regarding the etiology, natural history, classification, and treatment options for lunate osteonecrosis. There have been new classifications developed based on advanced imaging, perfusion studies of lunate viability, and arthroscopic assessment of the articular cartilage. Purpose This article brings together a new treatment algorithm, incorporating the traditional osseous classification system (Lichtman) with the perfusion/viability classification (Schmitt) and the articular cartilage classification (Bain). Methods We have developed a new algorithm to manage Kienböck avascular necrosis of the lunate. This new algorithm incorporates the current concepts of the diseased lunate and its effects on the remainder of the wrist. Conclusion For patients with a good prognosis and in the earliest stages, the "intact lunate" is initially protected utilizing nonoperative measures. If this fails, then appropriate lunate unloading procedures should be considered. If the lunate is "compromised" then it can be reconstructed with a medial femoral condyle graft or proximal row carpectomy (PRC). With the further collapse of the lunate, the wrist is then also compromised, with the development of secondary degeneration of the central column articulation. The "compromised wrist" will have functional articulations, which allows motion-preserving procedures to be utilized to maintain a functional wrist. With advanced disease (Kienböck disease advanced collapse), the wrist is not reconstructable, so only a salvage procedure can be performed. Other than these objective pathoanatomical factors, the final decision must accommodate the various patient factors (e.g., age, general health, lifestyle, financial constraints, and future demands on the wrist) and surgeon factors (skill set, equipment, and work environment).

Trans-4 Portal as a New Portal for Accessing the Lunate in Wrist Arthroscopy: a Cadaveric Study

Background

Evolving wrist arthroscopy requires creating new portals, and creating portals reciprocally leads to increased indications for arthroscopic wrist procedures. To facilitate access to the lunate bone and fossa for new arthroscopic procedures, a new portal was used. This is a cadaveric study of this portal.

Objectives

In this cadaveric study, we evaluated a portal in wrist arthroscopy for procedures involving the lunate bone and lunate fossa.

Materials and Methods

Seventeen wrists from 10 fresh cadavers were included in this study. After diagnostic arthroscopy, a portal (Trans-4) was made through the fourth extensor compartment, exactly along the lunate’s long axis under direct visualization from the 3-4 portal. Strand retractors were used to protect the extensor tendons and posterior capsule. Lunate bone core decompression and osteoscopy were done through the portal. At the end of the procedure, the position of the decompression hole in the lunate and any possible injury to the extensor tendons, distal radius cartilage, lunate cartilage, and perilunate ligaments were investigated.

Results

Lunate bone decompression was performed successfully in all cases using the trans-4 portal. In 15 wrists, the lunate hole was located in the middle third. In the other two wrists, it was located slightly radial in one case and slightly on the ulnar side in the other case. There was no cortical penetration during decompression, and no extensor tendon, superficial nerve branches, or peri-lunate ligament injuries were observed.

Conclusions

The trans-4 portal could be a safe working portal in wrist arthroscopy that enables access to the lunate bone and lunate fossa.

Kienböck Disease: Moving Forward

Over the past decade, a plethora of new information has been reported regarding etiology, natural history, classification, and treatment options for lunate osteonecrosis. New disease classifications have been described based on advanced imaging determination of lunate viability as well as a cartilage-based arthroscopic classification. Here we review the newest literature regarding Kienböck disease and present a new treatment algorithm that incorporates the traditional osseous classification system with a perfusion/viability classification and an articular cartilage-based classification.

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.

Outcome of Kienböck's disease in twelve cases: a mid-term follow-up study

INTRODUCTION

No single study has established the superiority of one treatment of Kienböck's disease over the other. Pooled outcome data is presently considered the best way to add to the knowledge and understanding of Kienböck's disease.

METHODS

A total of 12 patients (9 male and 3 female) with Kienböck's disease were included in the present case series. The mean age of the 12 patients was 28 years. One patient presented in Lichtman stage I, five in Lichtman stage II, five in Lichtman stage IIIa, and one in Lichtman stage IV. Univariate and multivariate analyses of the obtained data were performed to identify any correlations.

RESULTS

The mean follow-up time was 62 months, and the mean modified Mayo wrist score improved from the preoperative value of 29.5 to the final value of 89.6. Lichtman stage at presentation showed moderate positive correlation with the duration of symptoms (r = 0.56), and a strong negative correlation with the preoperative and final modified Mayo scores (r = -0.89 and r = -0.77, respectively). The final modified Mayo score showed moderate negative correlation with the duration of the symptoms (r = -0.55). There was a significant difference in the preoperative modified Mayo scores of patients who presented in stage II and those of patients who presented in stage IIIa (p = 0.03). However, the difference in the final modified Mayo scores of the patients in these stages was not significant (p = 0.14).

CONCLUSION

Lichtman's stage is moderately related to the duration of symptoms, suggesting natural progression of the disease. The final outcomes of stages II and IIIa were the same irrespective of the surgical treatment (radial shortening and/or vascularised bone grafting).

Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement to assess reporting of observational trials in hand surgery

PURPOSE

To use the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist to critically evaluate the change in quality of observational trial reporting in the Journal of Hand Surgery American between 2005 and 2011.

METHODS

A cross-sectional analysis of observational studies published in the Journal of Hand Surgery American was designed to sample 2 6-month periods of publication (March 2005 to August 2005 and June 2011 to November 2011). Fifty-one items were extracted from the STROBE statement for evaluation. Overall STROBE compliance rates for articles and specific checklist items were determined. Final compliance percentages from each period were compared by Student t-testing. Changes in item compliance over time were quantified.

RESULTS

Overall compliance with the STROBE statement was 38% (range, 10%-54%) in 2005 and 58% (range, 39%-85%) for 2011 manuscripts representing a significant improvement. Seventy-five percent or greater of articles (2005/2011) provided the explicit reporting of background (100%/97%), follow-up time (85%/94%), overall interpretation of data (100%/94%), and results of similar studies (95%/89%). Twenty-five percent or less of articles provided the study design in the abstract (10%/20%), a clear description of the study's setting (10%/23%), the handling of missing data (0%/6%), the potential directions of bias (5%/11%), and the use of a power analysis (0%/17%). Eighty-six percent (44/51) of items were more frequently satisfied in 2011 articles than in 2005 publications. Absolute increases in compliance rates of 40% or greater were noted in 10 items (20%) with no worsening in compliance for an individual item over 6%.

CONCLUSIONS

The overall quality of the reporting of observational trials in the Journal of Hand Surgery American improved from 2005 to 2011. Current observational trials in hand surgery could still benefit from increased reporting of methodological details including the use of power analyses, the handling of missing data, and consideration of potential bias.

LEVEL OF EVIDENCE

Diagnostic III.

The Proposal and Early Results of Capitate Forage as a New Treatment Method for Kienböck's Disease

Kienböck's disease is a type of avascular necrosis which disrupts the biomechanics of the wrist as a result of the changes it creates in the lunate bone. Its treatment generally consists of osteotomies intended to relieve the pressure on the bone, pedicle bone grafting applications aiming to increase bone blood supply, and salvage procedures. Capitate forage is a safe and simple-to-apply surgical treatment method which is intended to enhance neovascularization of the lunate much like a radius osteotomy or core decompression.

Long-term results after vascularised bone graft as treatment of Kienböck disease

The aim of this study was to present the long-term results in a small series of patients with Kienböck disease treated with a pedicled vascularised bone graft from the 4/5 extensor compartment of the distal radius as the only surgical treatment. In the period 2002-2006, five patients, three men and two women, mean age 41 years (22-54) were operated on using a pedicled vascularised bone graft from the 4/5 extensor compartment of the distal radius as described by Sheetz et al. Four patients were staged as Lichtman stage 2 and one as Lichtman stage 3. At the follow-up examination with radiographs and clinical examination at a mean of 7.4 years (5-9) after the operation, they all stated that they were satisfied with the operation. None of the patients had any further surgery in the observation period. Four patients were fully employed, and only one had changed employment due to his hand. The last patient was on a medical pension due to other medical causes. In all patients, no sign of progression was found of the radiological changes in the lunate and in all patients the arches of Gilula were unchanged without signs of carpal collapse. So, in this small series, a pedicled vascularised bone graft from the 4/5 extensor compartment of the distal radius as the only surgical treatment provided good long-term results in patients with stage 2 and 3 Kienböck disease.

Long-term clinical and radiological outcomes of radial shortening osteotomy and vascularized bone graft in Kienböck disease

PURPOSE

To evaluate the long-term (> 5 y) outcomes of radial shortening osteotomy and vascularized bone graft in Kienböck disease patients.

METHODS

In a retrospective study of 16 patients with early stage Kienböck disease, 9 patients with average follow-up of 6.4 years had radial shortening osteotomy (group 1), and 7 with average follow-up of 6.5 years had pedicled vascularized bone graft based on the distal radius 4 + 5 extensor compartmental artery (group 2). The 2 groups were similar in age, sex, operated side, initial Lichtman stage, and follow-up duration. There were significant differences in ulnar variance between the 2 groups. At the last follow-up, the patients were evaluated for pain, wrist motion, grip strength, functional status, and radiographic assessment. The overall results were evaluated by Cooney wrist function score and Nakamura scoring system for Kienböck disease.

RESULTS

The 2 groups had no significant difference in pain, motion, grip strength, and radiologic assessment; however, grip strength percentage was better in group 2. There was no significant difference between the radiographic changes of the 2 groups. In group I, 7 out of 9 patients had satisfactory Nakamura scores, and 5 out of 9 patients had satisfactory Cooney scores. All of the patients in group 2 had satisfactory Cooney and Nakamura scores. The difference in the mean Cooney wrist function score in the 2 groups was significant. The difference of Nakamura scores in the 2 groups was not significant.

CONCLUSIONS

Both groups had reasonable long-term outcomes. We were unable to recognize a substantial clinical or radiological difference between the 2 surgical treatments in long-term outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienböck's disease: first results of an ongoing observational study

INTRODUCTION

Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienböck's disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienböck's disease.

MATERIALS AND METHODS

Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients.

RESULTS

In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39 % of the opposite hand. Grip strength improved from 52.9 to 62.1 %. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0 % of the opposite hand. Grip strength improved from 38.6 to 69.0 %, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0.

CONCLUSION

One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.

Primary results of Kienböck's disease treated using balloon kyphoplasty system

OBJECTIVE

Kienböck's disease is difficult to treat and optimal treatments for stages II to III continue to elude investigators. We hypothesized that impacting the ischemic cancellous trabeculae and increasing the strength and rigidity of the lunate with balloon kyphoplasty can prevent lunate collapse, relieve the symptoms, and increase wrist range of motion. The purpose of this study was to demonstrate the feasibility of percutaneous balloon kyphoplasty for treatment of stage II to III Kienböck's disease.

METHODS

The study group comprised five patients (two in stage II, three in stage III). All were treated with balloon kyphoplasty. Pain, strength, and wrist flexion/extension range of motion were evaluated preoperatively and postoperatively. The Mayo Wrist Score and the Disabilities of the Arm, Shoulder and Hand (DASH) Score were used to evaluate outcomes. Patient satisfaction was also assessed. Comparisons between preoperative and postoperative data were made with SPSS software.

RESULTS

Clinical data were collected at a mean of 26.6 months (range 24-28 months) postoperatively. Pain was significantly reduced from 6.8 ± 0.8 in the visual analog scale preoperatively to 0.6 ± 0.9 at the 24-month follow-up. Strength and range of motion were improved postoperatively in all patients. The mean DASH score was 11.3 (range 6.7-18.3), and the mean Mayo Wrist Score was 78 (range 75-80). All five patients returned to their previous occupations.

CONCLUSIONS

Balloon kyphoplasty can prevent lunate collapse, reduce pain, and improve wrist function of patients with stage II to III Kienböck's disease. Further studies regarding the feasibility of this new approach are warranted.