Osteotomy of the radius without shortening for Kienböck disease: a 10-year follow-up

Novel Descriptions of the Radial Osteotomy in Kienböck's Disease: A Systematic Review

Purpose

Kienböck's disease consists of intrinsic and extrinsic characteristics that coalesce into a pathology with multifactorial etiology. Mechanical, morphological, and vascular factors have been identified as contributory. Radial osteotomy is one of the most commonly used surgical treatment for late-stage Kienböck's disease. Despite its frequent use and reported value, the specifics of radial osteotomy have not been described in aggregate. Our objective was to review the recent literature for descriptions of the radial osteotomy techniques used for treatment of Kienböck's disease.

Methods

The inclusion criteria for the systematic review were as follows: (1) patients aged >18 years, (2) a publication date no older than 2012, and (3) a complete description of the distal radius osteotomy technique, including verbiage that specified numeric dimensions of bony resection or verbiage that detailed a goal in terms of a radiographic parameter that would guide the bony resection.

Results

The studies were grouped according to the stated description of radial osteotomy. This process yielded the following three main groups: (1) studies that used radial shortening, (2) studies that used lateral closing wedge osteotomy or combined lateral closing wedge with radial shortening, and (3) novel osteotomy descriptions.

Conclusions

The Kienböck's disease literature predominantly describes an osteotomy to shorten the radius by 2-3 mm. In some studies, the degree of radial shortening corresponded to the value necessary to achieve near-neutral ulnar variance. The common goal in using lateral closing wedge osteotomy was to achieve a radial inclination of 5° to 15°. Unique wedge resections, some with multiplanar corrections, have been recently described with each purporting specific advantages.

Clinical relevance

Our findings support the premise of mechanical and biologic efficacy for radial osteotomy, with satisfactory results being reported across a wide spectrum of osteotomy techniques.

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.

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.

Improvement in lunate perfusion after radial closing-wedge osteotomy in patients with Kienböck's disease

Radial closing-wedge osteotomy is a widely accepted treatment for Kienböck's disease. However, despite favorable long-term clinical outcomes, its impact on lunate perfusion has not been documented. The purpose of this study was to determine whether radial closing wedge osteotomy improved lunate perfusion on gadolinium (Gd)-enhanced magnetic resonance imaging (MRI). We conducted a retrospective review of 12 patients with Kienböck's disease who received radial closing wedge osteotomy. Mean age at surgery was 25 years. Preoperative Gd-enhanced MRI was performed in 7 patients. After bone union, implants were removed and MRI was repeated. Two patients were classified as Lichtman stage IIIA, and 5 as stage IIIB. Percentage pre- to post-operative perfused lunate volume was compared on MRI. At last follow-up, mean QuickDASH score improved from 43.7 to 6.2. Pre- to post-operative lunate fragmentation, collapse and perfusion were compared qualitatively on MRI. On quantitative analysis, perfusion increased from 24% to 54% (p = 0.018) using our method of measuring percentage perfused lunate volume. The method showed satisfactory reproducibility. Investigation using Gd-enhanced MRI suggested that radial closing wedge osteotomy increases lunate perfusion.

Evaluation of a shape memory staple (Qual®) in radial shortening osteotomy in Kienböck's disease: A retrospective study of 30 cases

The QUAL^® (Memometal, Stryker) device is a shape memory staple used for bone fixation during distal radius shortening osteotomy in the context of Kienböck's disease. The present study is a retrospective, single-center and multisurgeon study of 30 patients with a mean follow-up of 8 years. Clinical criteria (range of motion (ROM), strength, pain and functional score) and radiographic data (ulnar variance, distal radius articular surface inclination, Lichtman stage, carpal height and bone healing) were evaluated pre- and post-operatively. We found satisfactory results with the mean grip strength of 22 kg/F before surgery and 24 kg/F after surgery. The mean ROM was 88° preoperatively and 82° postoperatively and the mean ulnar deviation was 23° preoperatively and 21° post-operatively. There was no change in radial deviation and pronation-supination after surgery. The average ulnar variance was 1 mm before surgery and 0.2 mm after surgery. The inclination of the distal radius articular surface on lateral and anteroposterior views and the mean carpal height were similar to the pre-operative ones. There was no delay in bone healing. The mean pain score was 2 at rest on a visual analogue scale after surgery. Seven patients experienced an increase in their Lichtman stage at the follow-up, and two patients were waiting for conversion to a non-conservative surgical treatment. Seven staples were removed postoperatively. Seventy-eight percent of patients returned to work after 3 months on average. Seventy-five percent of patients were at least satisfied with the outcome of their surgery. The QUAL^® staple is a reliable option for fixation during shortening osteotomy of the radius in Kienböck's disease.

Long-term results of vascularized os pisiform transfer for advanced Kienböck disease after follow-up for at least 15 years: A case series

No surgical procedure perfectly treats advanced Kienböck disease. Although vascularized os pisiform transferring (VOPT) is one of the main therapeutic approaches, reports on long-term follow-up and case series for this technique are scarce.We collected postoperative results in 11 patients with advanced Kienböck disease who underwent VOPT between 1986 and 2001 in our Hospital. Follow-up durations ranged from 15 to 26 years.At the last follow-up, excellent and good results were found in 81.8% according to the Modified Green and O'Brien score. Postoperative imaging revealed significantly reduced pisiform bone; carpal height ratio and Nattrass index were decreased, while the radioscaphoid angle was increscent, compared with preoperative and mid-term follow-up results.The favorable long-term results demonstrated that VOPT is a dependable and durable procedure for the treatment of advanced Kienböck disease, with pain relief and functional improvement despite some radiographic findings such as wrist osteoarthritis occurrence.

Comparison of Long-Term Outcomes of Radial Osteotomy and Nonoperative Treatment for Kienböck Disease: A Systematic Review

BACKGROUND

Radial osteotomy has shown favorable clinical results for early to advanced stages of Kienböck disease. However, it is not clear whether this technique could change the natural course of the disease, or whether its clinical results are actually superior to those of nonoperative treatment. The purpose of this study was to compare radial osteotomy with nonoperative treatment in terms of long-term radiographic and clinical outcomes in patients with Kienböck disease.

METHODS

We systematically reviewed retrospective studies of radial osteotomy and nonoperative treatment for Kienböck disease with long-term follow-up (mean of ≥10 years). A systematic search was conducted across 3 databases (CENTRAL, PubMed, and Embase) and relevant articles were selected. Data regarding patient demographics, treatment details, and radiographic and clinical outcomes were abstracted from the selected studies.

RESULTS

Seventeen studies (5 of nonoperative treatment and 12 of radial osteotomy) were included. Before treatment, the mean age of patients and mean proportion of wrists with Lichtman stage III or higher were not significantly different between the 2 groups. Neither the mean proportion of wrists that showed worsening of the Lichtman stage after treatment nor the proportion that showed no change in the stage were significantly different between the 2 groups. However, the mean proportion of wrists that had more than moderate pain at the time of final follow-up was significantly lower in the radial osteotomy group (5.7%; range, 0% to 18.2%) than in the nonoperative treatment group (23.2%; range, 17.4% to 35.3%). In addition, the total arc of wrist motion at the time of final follow-up was significantly greater in the radial osteotomy group (107.4° ± 10.0°; range, 93.0° to 126.0°) than in the nonoperative treatment group (88.8° ± 13.2°; range, 68.5° to 103.5°).

CONCLUSIONS

Systematic review of long-term follow-up studies showed that radial osteotomy was not superior to nonoperative treatment in terms of disease progression according to the Lichtman stage. Nevertheless, radial osteotomy was reported to have better outcomes with respect to the extent of pain and range of wrist motion.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Treatment of necrosis of the lunate bone]

BACKGROUND

There still is no standard therapy that predictably results in healing of avascular necrosis of the lunate bone. Nevertheless, there exists a wide spectrum of operative treatment options for different stages.

OBJECTIVE

This article reviews the treatment options for necrosis of the lunate bone and proposes algorithms based on the age of the patient and condition of the lunate bone and the wrist.

METHODS

Surgical treatment options for necrosis of the lunate bone can be divided into relieving or revascularization procedures and salvage procedures.

RECOMMENDATIONS

For patients under 20 years old the treatment of choice is prolonged immobilization, in cases of non-response or progression, minimally invasive and relieving procedures are used. In adult patients with limited affection of the lunate bone the first therapeutic approach should also be immobilization. If in progressive disease or advanced stages only the lunate bone is compromised but reconstructable, restoration should be considered. In progressive collapse of a non-reconstructable lunate bone the therapeutic efforts shift to mobility-preserving procedures utilizing still functional articulations of the wrist. If all functional articulations are lost only classical salvage procedures are feasible.

CONCLUSION

According to the presented algorithms a stage-dependent therapy of necrosis of the lunate bone is possible. It should not be ignored that there are still no scientific and evidence-based arguments for some of these treatment options. This is also true for maximally invasive procedures, where superiority to more simple procedures have not been proven. Therefore, their application should be restricted and based on an individual decision.

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.

Radiologic Guide to Surgical Treatment of Kienbock's Disease

Kienbock's disease, or avascular necrosis of the lunate, is a progressive disease ultimately resulting in end-stage arthrosis of the wrist. Various surgical treatments are available for different Lichtman stages of disease. We review the surgical options and indications, expected radiologic post-operative appearance, as well as detail potential surgical complications, as they relate to Kienbock's disease.

Radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease

We carried out a retrospective study to analyse the long-term outcome of 36 patients after radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease at a mean follow-up of 12.1 years (range 5.4-17.5). At review, seven wrists had progressed to Stage IIIB, eight wrists to Stage IV and 21 remained in Stage IIIA. Motion and grip strength were significantly improved. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score at review was 12 points (range 0-52), and patient satisfaction was high. Apart from plate removals in 14 patients and one wrist denervation, no subsequent surgical procedures were done. Radial shortening yields good long-term clinical results, but does not prevent radiographic progression of disease in some patients.

LEVEL OF EVIDENCE

Therapeutic IV.

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.

Treatments for Kienböck disease: what the radiologist needs to know

The etiology of Kienböck disease, or avascular necrosis of the lunate, is controversial, and there are a myriad of treatments aimed at correcting the various hypothesized pathologies. Interventions to reduce mechanical stress on the lunate have been used for decades, including radial osteotomy with or without radial shortening, ulnar lengthening and metaphyseal core decompression procedures. However, these procedures require preservation of lunate architecture. Newer procedures to revascularize the lunate bone have emerged in the last 10 years, such as pedicled corticoperiosteal vascularized bone grafting. Once there is collapse of the radiocarpal joint or midcarpal arthrosis, the conventional treatments have included proximal row carpectomy and complete or partial wrist joint arthrodesis. Newer salvage procedures such as lunate excision with autologous or synthetic interposition grafts are now being used when possible. As this disease is relatively rare, radiologists may not be familiar with the expected post-operative radiologic findings and complications, especially of the newer treatments. The goals of this paper are to review the available treatment options and their expected appearance on postoperative imaging, with discussion of possible complications when appropriate.

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.

Vascularized bone grafting and distal radius osteotomy for scaphoid nonunion advanced collapse

PURPOSE

To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction.

METHODS

Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closing-wedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores.

RESULTS

Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected.

CONCLUSIONS

Scaphoid reconstruction with vascularized bone graft combined with closing-wedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.