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

Comparison of Long-term Outcomes between Nonoperative Treatment and Vascularized Bone Graft for Kienböck Disease: A Systematic Review and Single-Arm Meta-Analysis

Background

This systematic literature review compared long-term outcomes between nonoperative treatment and vascularized bone graft (VBG) in patients with Kienböck disease.

Methods

We systematically reviewed studies on nonoperative treatment and VBG for Kienböck disease with a mean follow-up of ≥ 5 years. A systematic search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Embase databases to select relevant articles. Data on patient demographics, treatment details, and outcomes were extracted.

Results

Twelve studies (6 for nonoperative treatment and 6 for VBG) were included. The proportion of wrists showing worsening Lichtman stages after treatment was 40.2% (95% confidence interval [CI], 25.7-56.6) and 17.0% (95% CI, 10.2%-26.9%) in the nonoperative treatment group and VBG group, respectively. No change in the stage was observed in 52.4% (95% CI, 25.5%-78.0%) and 77.8% (95% CI, 66.7%-86.0%) of the wrists in the nonoperative treatment group and VBG group, respectively. The proportion of wrists without pain at the final follow-up was 29.2% (95% CI, 16.6%-46.1%) and 35.9% (95% CI, 22.6%-52.0%) in the nonoperative treatment group and VBG group, respectively. The proportion of wrists with more than a moderate degree was 30.4% (95% CI, 22.7%-39.4%) and 12.9% (95% CI, 5.5%-27.4%) in the nonoperative treatment group and VBG group, respectively. The 95% CIs of the mean wrist range of motion and mean grip strength ratio of the affected side to the contralateral side substantially overlapped in the two groups.

Conclusions

The VBG group showed greater improvement in the radiographic stage and wrist pain than did the nonoperative treatment group after treatment, but meaningful differences in parameters were not observed. Further well-designed studies are needed to confirm the superiority of VBG to nonoperative treatment regarding radiographic and clinical outcomes.

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.

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.

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.

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.

Radial shortening, bone grafting and vascular pedicle implantation versus radial shortening alone in Kienböck's disease

We prospectively compared outcomes of two surgical procedures for Stage II and IIIa Kienböck's disease with negative ulnar variance. Group I (13 wrists) was treated with radial shortening alone, and Group II (14 wrists) with combined radial shortening, bone grafting and implantation of a vascular pedicle. At follow-up 3 to 7 years (mean 4.5) after operation, scores by the Quick version of the Disability of Arm, Shoulder and Hand questionnaire and scores for pain and grip strength were significantly better in Group II, but the differences were rather small. On MRI all patients in Group II had revascularization, but 11 patients in Group I had not. We conclude that combining radial shortening with the revascularization procedure improved revascularization. Clinically, both treatments were efficient, and the additional bone grafting and vascular pedicle insertion did not greatly improve function, although statistically there were differences in several follow-up variables. This study also could not identify the independent role of the three procedures (drilling, grafting and artery insertion) in Group II, because decompression or bone grafting alone may be effective.Level of evidence: II.

Treatment of Stages IIIA and IIIB in Kienbock's Disease: A Systematic Review

Background  Despite numerous proposed surgical interventions, there is a lack of consensus in the optimal treatment of advanced Kienbock's disease. Purpose  This study aims to perform a systematic review of the current evidence in the management of Lichtman's stages IIIA and IIIB of the disease. Methods  A literature search was performed using the MEDLINE, EMBASE, and COCHRANE databases to identify studies between 2008 and 2018 evaluating stage-specific outcomes in Lichtman's stages IIIA and IIIB. The quality of each included paper was evaluated using the Structured Effectiveness Quality Evaluation Scale (SEQES). Data extracted were stage-specificity, clinical and functional outcomes, and radiographic progression of Lichtman's staging. Results  A total of 1,489 titles were identified. Eighty-three papers were fully reviewed, and 30 articles met eligibility criteria for inclusion. There were 3 low-quality and 27 moderate-quality papers. Surgical techniques reported included decompression surgeries, joint-levelling, and radial wedge osteotomies, revascularization techniques, intracarpal arthrodesis, proximal row carpectomy, arthroplasty, and balloon kyphoplasty. All treatment modalities offered pain relief and improvement in functional outcomes. Compared with proximal row carpectomy, intracarpal arthrodesis, and arthroplasty, nonsalvage procedures provided similar clinical and functional outcomes in both stages, with joint-levelling and radial wedge osteotomies preserving greater range of motion. Conclusion  In this systematic review of Kienbock's disease stages IIIA and IIIB, all treatment modalities provided positive outcomes. In stage IIIB, there is evidence to support nonsalvage procedures, as they produced similar clinical outcomes to salvage procedures that have the advantage of not precluding future treatment options if needed and preserving greater range of motion.

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.

Evaluation of Kienböck's Disease Treated by Camembert Osteotomy at Seven Years

In Kienböck's disease, radius shortening osteotomy is the most common treatment. The Camembert procedure is a wedge osteotomy that shortens only the radius facing the lunate. Its aim is to offload the lunate by redirecting the compression stress of the grip forces toward the scaphoid. The purpose of this study was to determine if the Camembert osteotomy is effective in improving clinical symptoms and limits lunate collapse. The series include 10 patients who underwent a Camembert osteotomy for Kienböck's disease between 2002 and 2012 (one bilaterally). They are six men and four women, aged 40.6 years. Five patients had an additional ulnar shortening osteotomy if ulnar variance was neutral or positive. The mean follow-up is 7 years. Preoperatively, range of motion, grip strength, pain, and functional scores were poor. All osteotomies healed within 3 months. Extension, ulnar deviation, grip, functional scores improved significantly. In 10 cases, there were improvement in the T1 and T2 signals on the magnetic resonance imaging (MRI). There was no lunate collapse. This series shows good results with no worsening of the lunate shape. There was no ulnocarpal impingement. The Camembert osteotomy proposes to offload the lunate and redirect strains toward the scaphoid. The supposed interest is to protect the lunate from collapse. In this small series, the Camembert osteotomy improved function in patients with early stage Kienböck's disease. MRI aspects improve in most cases and no patients collapsed. Camembert can be used in combination with a Sennwald's ulnar shortening when ulnar variance is neutral or positive. Authors propose this procedure for Lichtman's stages 1-2-3A if there are no cartilage or ligament lesions. This is a Level IV, case series study.

Partial Capitate Shortening Osteotomy and Its Impact on Lunate Revascularization: Mid-Term Results

Background

Treatment of Kienböck disease is still a clinical challenge. The treatment used in each instance is decided according to stage of the disease at presentation. Good clinical and radiological results could be obtained with partial capitate shortening osteotomy. However, mid-term results of this technique and its effect on lunate revascularization are not well known.

Objectives

The aim of this study was to report our results of partial capitate shortening osteotomy in the treatment of stage II and IIIA Kienböck disease.

Methods

Ten patients were enrolled in the study with a mean age of 37.7 years old (standard deviation [SD] = 9.6). Patients were evaluated clinically in terms of range of motion, DASH and VAS scores, satisfaction with the outcome, and grip/tip/palmar/key pinch strength compared to the contralateral side. Radiological evaluation consisted of Lichtman staging on plain radiographs and lunate revascularization on magnetic resonance imaging (MRI) at both preoperative and postoperative evaluations.

Results

The mean duration of follow-up was 55.2 (SD = 24) months. The mean DASH and VAS scores were 14.3 (SD = 6.7) and 1.5 (SD = 1.3), respectively. For patient satisfaction, the mean score was 3.6 (SD = 0.6). The Lichtman stage of 7 patients remained unchanged. Lunate revascularization was detected with MRI in 6 patients.

Conclusions

Although the number of patients in the study prevents more strict conclusions, our results are promising, and the technique presented offers minimally but observable lunate revascularization and high success rates in preventing the progression of the disease.

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.

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.

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.

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.

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.

Vascularized Bone Grafts from the Dorsal Wrist for the Treatment of Kienböck Disease

Purpose The objective of this article is to evaluate functional and radiological outcomes of vascularized bone grafts for stage 2 and 3 Kienböck disease. The outcomes of three different donor sites via dorsal approach of the wrist were compared. Pearls and pitfalls in surgical technique were discussed. Methods There were 28 patients who underwent vascularized bone grafts, including the extensor fourth and fifth compartmental artery graft of distal radius in 8 patients, the first and second supraretinacular intercompartmental artery graft of distal radius in 12 patients, and the second dorsal metacarpal neck graft in 8 patients. Average age was 32 years, and radiological grading according to Lichtman classification was stage 2 in 8 patients, stage 3A in 10 patients, and stage 3B in 10 patients. Temporary pinning fixing the midcarpal joint was conducted for 10 weeks postoperatively. Results Follow-up periods averaged 70 months. Pain reduced in 27 patients, and visual analog scale for pain of pre- and postoperative level averaged 59 and 18. Range of wrist flexion and extension motion improved from 87 to 117 degrees, and average grip strength improved from 21 kg preoperatively to 33 kg postoperatively. Carpal height ratio had almost no change from 0.52 to 0.53. Fragmentation of necrotic bone healed in 7 of the 14 cases. Comparative analyses of functional and radiological outcomes between three donor sites found no significant difference. Conclusion Three different vascularized bone grafts from the dorsal wrist and hand area demonstrated favorable and comparable functional outcomes. It was technically important to elevate vascular bundle with surrounding retinaculum or fascia, to include sufficient periosteum, and to insert the vascularized bone as the cortex aligned longitudinally.

Comparison of clinical and radiologic treatment outcomes of Kienböck's disease

Purpose

The clinical outcomes of scaphotrapeziotrapezoid (STT) arthrodesis were compared to radial shortening osteotomy (RSO) to determine if any of the treatment methods was superior. The impact of RSO and vascularized bone grafts (VBG) on disease progression were measured based on X-rays to evaluate if a difference in Kienböck’s disease (KD) progression exists.

Methods

Out of 98 consecutive patients treated between 1991 and 2013, 46 had STT arthrodesis, 21 had RSO, 7 had VBG, and 3 had VBG and RSO. Patients treated with STT arthrodesis were compared to RSO regarding post-operative range of motion (ROM), wrist pain on the Numeric Rating Scale (NRS), grip strength, duration of incapacity for work, the Disabilities of the Arm, Shoulder, and Hand (DASH), and the Modified Mayo Wrist scores (MMWS). Radiographic assessment (Nattrass index, radioscaphoid angle, and Ståhl index) was performed to determine disease progression following RSO or VBG. Baseline patient characteristics were comparable in all treatment groups.

Results

There were no significant differences in post-operative ROM, wrist pain, grip strength, duration of incapacity, DASH score, or MMWS score following STT arthrodesis (n = 27) or RSO (n = 14). The Ståhl index, the Nattrass index, and the radioscaphoid angle suggested disease progression following RSO (n = 14) and/or VBG (n = 6) although the changes were not significant.

Conclusions

The study failed to demonstrate clinically relevant differences between STT arthrodesis compared to RSO. No evidence was found that decompression or revascularization, or the combination of the two, can reverse or halt the course of the disease.

Level of evidence

Therapy, level III, retrospective comparative study with prospectively collected data.

The quality of control groups in nonrandomized studies published in the Journal of Hand Surgery

PURPOSE

To evaluate control group selection in nonrandomized studies published in the Journal of Hand Surgery American (JHS).

METHODS

We reviewed all papers published in JHS in 2013 to identify studies that used nonrandomized control groups. Data collected included type of study design and control group characteristics. We then appraised studies to determine whether authors discussed confounding and selection bias and how they controlled for confounding.

RESULTS

Thirty-seven nonrandomized studies were published in JHS in 2013. The source of control was either the same institution as the study group, a different institution, a database, or not provided in the manuscript. Twenty-nine (78%) studies statistically compared key characteristics between control and study group. Confounding was controlled with matching, exclusion criteria, or regression analysis. Twenty-two (59%) papers explicitly discussed the threat of confounding and 18 (49%) identified sources of selection bias.

CONCLUSIONS

In our review of nonrandomized studies published in JHS, papers had well-defined controls that were similar to the study group, allowing for reasonable comparisons. However, we identified substantial confounding and bias that were not addressed as explicit limitations, which might lead the reader to overestimate the scientific validity of the data.

CLINICAL RELEVANCE

Incorporating a brief discussion of control group selection in scientific manuscripts should help readers interpret the study more appropriately. Authors, reviewers, and editors should strive to address this component of clinical importance.

Does dorsal capsule interposition improve the results of proximal row carpectomy in Kienböck's disease? One year randomized trial

Introduction: Proximal row carpectomy (PRC) is an option as a salvage procedure in late stage Kienböck’s disease. In this study, we hypothesize that interposition of a dorsal capsular flap following PRC improves functional outcomes. No comparative study is available to assess whether interposition is effective from the functional perspective. This study aims to determine whether the addition of this procedure may improve functional outcomes at a one year assessment.

Methods: Thirty adult patients with IIIA and IIIB Lichtman stages, aged 18–54 years, were randomized into two study groups. Fourteen patients were allocated to the “no interposition group” and 16 to the “interposition” group. DASH questionnaire was used to evaluate quality of life. Cooney’s system was used to assess pain, functional state, range of motion, and grip strength. Complications were also assessed. Final followup and clinical assessment occurred after 12 months.

Results: After 12 months and no patient losses, outcomes were similar in both groups. DASH scores (41.9 (7.5) vs. 42.9 (12.8), p = 0.79)), Cooney’s system (poor results, 0.6 vs. 0.14, p = 0.54), and complications were similar between groups. In conclusion, the inclusion of a dorsal capsular flap does not improve functional outcomes in PRC. Low rates of complications were found in both groups.

Clinical Outcomes of Radial Shortening Osteotomy and Vascularized Bone Graft in Kienböck's Disease

The aim of this study was to compare two surgery methods including radial shortening and radial shortening combined with vascularized bone graft for treatment of stage II or IIIa of Kienböck's disease. It is a randomized, controlled clinical trial, which was carried out in 2011–2013. Twenty-four patients were assigned equally to radial shortening group (A) or radial shortening combined with vascularized bone graft group (B). The outcome was assessed by Mayo Wrist score before and 9 months after surgery. The mean Mayo Wrist score (SD) was 27.1 (15.4) and 32.5 (18.3) before surgery and 74.6 (5.4) and 85.8 (5.1) after surgery for groups A and B, respectively. The mean score increased in both groups, and it was higher in group B significantly. Radial shortening combined with vascularized bone graft is a valuable method which can be more effective than radial shortening alone, in early stages of Kienböck's disease. This trial is registered with IRCT201404127841N5.