Scaphotrapeziotrapezoid (STT)-Arthrodesis in Kienböck’s Disease

Long-term Outcomes for Late-Phase Kienböck's Tenoarthroplasty

BACKGROUND

In late Kienbӧck's, the lunate is fully fragmented and nonreconstructible. Replacing the lunate with a pyrocarbon prosthesis preserves load distribution and avoids carpectomy or fusion, but leaves the wrist intrinsically unstable, requiring additional soft-tissue stabilization techniques.

METHODS

Five men and 7 women with a mean age of 43 (±15) years underwent prosthetic replacement of the lunate with dual bundle scaphoid-triquetrum tenodesis for carpal stabilization. The mean follow-up interval from initial surgery was 9.1 (±1.7) years. Outcomes were Disabilities of Arm, Shoulder, and Hand (DASH) score, revision or conversion surgery, and wrist range of motion.

RESULTS

The mean DASH score was 8.9 (±7.1). No patients reported any additional revision or conversion surgery. The mean wrist flexion was 60° (±14°); wrist extension was 45° (±21°).

CONCLUSIONS

Clinical outcomes proved more favorable than anticipated, particularly the self-rated outcomes scores and the absence of any revision or conversion surgery.

Carpal bone replacement using personalized 3D printed tantalum prosthesis

Objective: Scaphoid and lunate fractures have a relatively high incidence rate. Traditional carpectomy and carpal arthrodesis in the treatment of carpal osteonecrosis will lead to many complications. Three-dimensional (3D) printed tantalum has good biocompatibility and can be designed to match the patient's personalized anatomical carpal structure. This study aims to investigate carpal function and prosthesis-related conditions after carpal bone replacement using 3D printed tantalum prostheses. Methods: From July 2020 to January 2022 at our center, seven patients with osteonecrosis of the carpus received carpal bone replacement using 3D printed tantalum prosthesis. The Disability of the Arm, Shoulder and Hand (DASH) score and patient satisfaction, as well as the Mayo Wrist Scores (Cooney method, modified Green, and O'Brien wrist score), were used to evaluate the preoperative and postoperative wrist function of patients. The Visual Analog Scale (VAS) pain scores were also recorded before and after surgery. The angles of flexion, dorsiflexion, ulnar deviation, and radial deviation were measured using an arthrometer. The grip strength and pinch strength of the operated hand after carpal bone replacement and the contralateral healthy carpus were measured using a dynamometer. Radiographs were taken to confirm the condition and complications of the tantalum prosthesis. Results: All seven patients were followed for 19.6 ± 2.7 months. At the last follow-up, the grip strength of the operated wrist joint after carpal bone replacement was 33.4 ± 2.3 kg, the pinch strength was 8.9 ± 0.7 kg, the flexion was 54.6° ± 0.8°, the dorsiflexion was 54.7° ± 1.7°, the ulnar deviation was 34.6° ± 1.9°, and the radial deviation was 25.9° ± 0.8°, all of which showed no statistically significant difference with the contralateral healthy carpus (p > 0.05). There were significant differences in the VAS, DASH, and MAYO scores between the preoperative and the last follow-up (p < 0.01). Patients had reduced postoperative pain and improved wrist function and range of motion (ROM), and the tantalum prostheses were stable. Conclusion: The 3D printed tantalum brings us new hope, not only for hip or knee replacement, but also for joint replacement of other complex anatomical structures, and patients with other irregular bone defects such as bone tumors and deformity, which could realize personalized treatment and precise medicine.

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.

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.

Scaphotrapeziotrapezoid Arthrodesis: A 10-Year Follow-up Study of Complications in 58 Wrists

BACKGROUND

Scaphotrapeziotrapezoid (STT) arthrodesis is a procedure used for specific degenerative arthritis and instability patterns of the wrist. This study evaluates nonunion rate and risk factors for reoperation after STT arthrodesis in the Veterans Affairs Department patient population. The purpose of our study was to assess the long-term nonunion rate following STT arthrodesis and to identify factors associated with reoperation.

METHODS

The national Veterans Health Administration Corporate Data Warehouse and Current Procedural Terminology codes identified STT arthrodesis procedures from 1995 to 2016. Frequencies of total wrist arthrodesis (TWA) and secondary operations were determined. Univariate analyses provided odds ratios for risk factors associated with complications.

RESULTS

Fifty-eight STT arthrodeses were performed in 54 patients with a mean follow-up of 120 months. Kirschner wires (K-wires) were the most common fixation method (69%). Six wrists (10%) required secondary procedures: 5 TWAs and 1 revision STT arthrodesis. Four patients underwent additional procedures for nonunion (7%). Twenty-four patients required K-wire removal, 8 (14%) of these in the operating room, which were not included in regression analysis. Every increase in 1 year of age resulted in a 15% decrease in likelihood of reoperation (95% confidence interval: 0.77-0.93; P < .0001). Opioid use within 90 days before surgery (P = 1.00), positive smoking history (P = 1.00), race (P = .30), comorbidity count (P = .25), and body mass index (P = .19) were not associated with increased risk of reoperation.

CONCLUSIONS

At a mean follow-up of 10 years, patients undergoing STT arthrodesis have a 10% risk of reoperation, and this risk decreases with older patient age. There was a symptomatic nonunion rate of 7%, similar to prior published rates. Patient demographics, comorbidity, smoking history, and opioid use did not appear to increase risk of reoperation.

Management of type 3 Kienbock's disease in manual workers by scaphocapitate fusion with minimum 7-year follow-up

BACKGROUND

Kienbock's disease results in altered wrist biomechanics producing debilitating pain at the wrist. The disease is staged according to radiological and clinical findings and the stage guides the treatment. Various treatment options have been described for stage 3, however, there is a lack of consensus over these treatment methods. Scaphocapitate fusion is the preferred surgical option for advanced Kienbock's disease. Previous studies had heterogeneous cohorts with a short duration of follow-up and a lack of uniform surgical technique. The purpose of the study was to show the long-term functional and radiological outcome of scaphocapitate arthrodesis (SCA) by using Herbert screw for the treatment of Kienbock's disease in manual workers.

METHODS

For this single-centre, retrospective study, all consecutive patients who were manual workers and managed by SCA between January 2010 and Jan 2014 for Lichtman stage IIIA and IIIB with at least 7 years of follow-up were included. Patients were assessed using clinical and radiological parameters preoperatively and in the follow-up period. Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Related Wrist Evaluation (PRWE), and VAS for pain were assessed.

RESULTS

Out of 27 patients, 4 lost to follow-up, therefore, 23 patients (14 women and 9 men) with 30 years of median age at the time of the surgery were included. DASH scores, PRWE scores, and VAS for pain significantly improved (p < 0.5) after surgery. Wrist range of motion and grip strength also improved significantly (p < 0.5). Postoperative radiological parameters were found to be within a normal range.

CONCLUSION

Scaphocapitate fusion by Herbert screws gives good functional, clinical, and radiological outcomes, in stage 3 of Kienbock's disease with excellent rates of fusion with low complications. Even, in manual workers, scaphocapitate fusion can reliably provide good outcomes and this is maintained in the mid to long-term follow-up. Therefore, it should be considered as one of the procedures of choice.

LEVEL OF EVIDENCE

Retrospective, Level 4.

Scaphotrapeziotrapezoid Arthrodesis: Systematic Review

PURPOSE

Scaphotrapeziotrapezoid (STT) arthrodesis surgery is used for various types of wrist pathologies. The objective of our study was to perform a systematic review of complications and outcomes after STT arthrodesis.

METHODS

Several major databases were used to perform a systematic literature review in order to obtain articles reporting complications and outcomes following STT arthrodesis. The primary purpose was to identify rates of nonunion and conversion to total wrist arthrodesis. Secondary outcomes included wrist range of motion, grip strength, and Disabilities of the Arm Shoulder and Hand scores. A multivariable analysis was performed to evaluate factors associated with the primary and secondary outcomes of interest.

RESULTS

Out of the 854 records identified in the primary literature search, 30 studies were included in the analysis. A total of 1,429 procedures were performed for 1,404 patients. The pooled nonunion rate was 6.3% (95% CI, 3.5-9.9) and the rate of conversion to total wrist arthrodesis following the index STT was 4.2% (95% CI, 2.2-6.7). The mean pooled wrist flexion was 40.7° (95% CI, 30.8-50.5) and extension was 49.7° (95% CI, 43.5-55.8). At final follow-up, the mean pooled grip strength was 75.9% (95% CI, 69.3-82.5) of the nonsurgical contralateral hand. Compared with all other known indications, Kienbock disease had a statistically significant lower nonunion rate (14.1% vs 3.3%, respectively). Mixed-effects linear regression using patient-level data revealed that increasing age was significantly associated with complications, independent of occupation and diagnosis.

CONCLUSIONS

Our study demonstrated a low failure rate and conversion to total wrist arthrodesis after STT arthrodesis and acceptable postoperative wrist range of motion and strength when compared to the contralateral hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Limited Carpal Fusion in Kienböck's Disease: Early Results following Scaphocapitate Arthrodesis

Background  Kienböck's disease leading to progressive carpal collapse alters the wrist biomechanics leading to early arthritis and degenerative changes. Out of multiple surgical procedures present, no gold standard has been described. Scaphocapitate arthrodesis (SCA) is limited carpal fusion which shifts the loading axis toward radioscaphoid joint. This study presents the midterm clinical and radiological results of SCA in Kienböck's disease. Materials and Methods  The data were reviewed from January 2016 to December 2017. Lichtman's classification used to stage the disease. Clinical variables were noted for wrist range of motion, grip strength, visual analog scale (VAS) score, quick disabilities of the arm, shoulder, and hand (quickDASH), and patient-rated wrist evaluation (PRWE) scores. Radiographs were evaluated for union, ulnar variance, carpal height ratio, radioscaphoid angle, and scapholunate angle. Results  A total of 11 patients of Stage IIIA and IIIB Kienböck's disease with mean age of 24 years were included in the study with a minimum of 18 months of clinical follow-up. The procedure resulted in decreased ranges of motion but improved grip strength (26.09 ± 4.76 from 19.54 ± 4.63 kgf) and reduced pain with VAS score decreased from 7.36 ± 0.8 to 2 ± 1. Radiographic analysis showed union in all patients, reduced carpal height with a corrected radioscaphoid angle (from 62.12 to 48.3 degrees), and scapholunate angle (from 34 to 26.27 degrees). Discussion  SCA has advantage of technical ease of orientation of the scaphoid and osteosynthesis of only one intercarpal joint with a large contact surface. Coupling the distal and proximal carpal rows results in significant loss of mean wrist range of motion but with improved grip strength, shifting the load away from the radiolunate joint. However, long-term studies are needed for clinical benefits and radiographic signs of radioscaphoid arthritis for the treatment of advanced-stage Kienböck's disease. Level of Evidence  This is a Level IV, retrospective observational study.

The effect of surgery for basal osteoarthritis of the thumb on dart thrower's motion

This study aimed to identify the effects of basal thumb surgery on the range of dart thrower's motion. Thirteen fresh-frozen cadaveric specimens were placed in a customized jig. Simulated scaphotrapeziotrapezoid joint fusion was carried out on all specimens. Half the specimens then underwent trapeziectomy and the rest had excision of the distal pole of the scaphoid. Simulated scaphotrapeziotrapezoid fusion reduced the range of dart thrower's motion to 89% of the range in the intact wrists, from a mean of 117° to 104°. Although this reduction is not large, it was statistically significant. Simulated trapeziectomy caused a very small increase in dart thrower's motion range compared with the range in the intact wrists. Simulated distal pole of scaphoid excision did not change the range of dart thrower's motion. These results may inform preoperative decisions for surgical management of basal osteoarthritis of the thumb.

Scaphotrapeziotrapezoid Arthrodesis Using Limited Wrist Fusion Plates in Kienböck's Disease

PURPOSE

The purpose of this study was to evaluate the clinical and radiological results of scaphotrapeziotrapezoid (STT) arthrodesis with a limited wrist fusion plate in patients with Stage IIIB Kienböck's disease (KD).

MATERIALS AND METHODS

A retrospective review was performed on nine patients with Stage IIIB KD who underwent STT arthrodesis between 2014 and 2017 at our institution. Clinical evaluations of the patients were made using the shortened quick version of the Disabilities of the Arm, Shoulder, and Hand (Q-DASH) Outcome Measure score (Institute for Work and Health, Toronto, ON, Canada) and grip strength measurements before surgery and at the final follow-up examination. All patients underwent computed tomography (CT) scan to confirm the union of the arthrodesis.

RESULTS

A complete union was obtained in all patients. The Q-DASH score was changed from 57.8 ± 8.2 points (range: 47.7 - 70.5) to 32.3 ± 17.3 points (range: 13.6 - 54.5) (p = 0.008). Similarly, the grip strength was improved significantly (p = 0.007).

CONCLUSIONS

The use of limited wrist fusion plates for STT arthrodesis in KD is a safe and effective treatment method that provides a high rate union and acceptable functional results.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

Osteotomía de acortamiento del hueso grande en la enfermedad de Kienböck asociada a varianza ulnar positiva o neutra

Objetivos: La enfermedad de Kienböck se asocia generalmente a cubitus minus y la descompresión quirúrgica más común es a nivel radial. El objetivo es conocer los efectos de realizarla en el hueso grande cuando se encuentra asociada a varianza cubital normal o positiva.

Material y métodos: Realizamos un estudio retrospectivo de los resultados de la osteotomía de acortamiento del hueso grande en la enfermedad de Kienböck sin cubitus minus. Hemos revisado a 6 pacientes, intervenidos entre 2006 y 2013 en el Hospital Universitario Ramón y Cajal (Madrid). El seguimiento medio fue 36 meses (12-93). Se registraron: escala de valoración del dolor (EVA), rango de movimiento de la muñeca, fuerza de prensión palmary de la pinza, valoración funcional (DASH, Mayo Score), así como estudio radiológico y con RM.

Resultados: Se obtuvo una mejoría clínica y funcional de los parámetros estudiados, pero no de los radiológicos. En un caso la enfermedad evolucionó y el resto mantuvo los estadios radiológico (Lichtman) iniciales, consiguiendo la consolidación de la osteotomía en todos los casos. No se apreciaron complicaciones destacables.

Conclusión: La osteotomía de acortamiento del hueso grande es una técnica que oferta buenos y duraderos resultados en pacientes con enfermedad de Kienböck sin cubitus minus ni cambios degenerativos carpianos.

Intercarpal fusions: indications, treatment options and techniques

Partial wrist fusion is a useful technique for the treatment of such specific carpal disorders as arthritis, Kienböck's disease, midcarpal instability, scaphoid nonunion, etc.Many techniques have been described by removing arthritic joint surfaces and transfering load, using, for bone fixation, K-wires, screws, staples, and more recently dedicated plates.The goal of this procedure is to maximise wrist motion and strength while minimizing or eliminating pain.The purpose of this article is to discuss the most commonly used combination of intercarpal arthrodeses, to clarify the indications for each fusion, to describe the appropriate surgical technique for each fusion, and to provide an overview of results and current concepts. Cite this article: Houvet, P. Intercarpal fusions: indications, treatment options and techniques. EFORT Open Rev 2016;1:45-51. DOI: 10.1302/2058-5241.1.000019.

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.

Load distribution on the radio-carpal joint for carpal arthrodesis

BACKGROUND AND OBJECTIVE

Carpal fusions are useful for treating specific carpal disorders, maximizing postoperative wrist motion, hand strength, reducing pain and instability of the joint. The surgeon selects the appropriate treatment by considering the degree of stability, the chronicity of the injury, functional demands of the patient and former patient's outcomes as well. However there are not many studies regarding the load distribution provided by the treatment. So, the purpose of this study is to analyze the load distribution through the wrist joint with an arthrodesis treatment and compare the results with a normal wrist.

METHOD

To this end the rigid body spring model (RBSM) method was used on a three-dimensional model of the wrist joint. The cartilage and ligaments were simulated as springs acting under compression and tension, respectively, while the bones were considered as rigid bodies. To simulate the arthrodesis, the fused bones were considered as a single rigid body.

RESULTS

The changes on the load distribution for each arthrodesis agree with the treatment objective, reducing load transmission through a specific articular surface. For example, for SLAC/SNAC II most of the treatments reduced the load transmitted through the radioscaphoid fossae, almost by 8%. However, the capitolunate (CL) arthrodesis was the treatment that managed to keep the load transmitted through the radiolunate joint closer to normal conditions. Also, in treatments where the scaphoid was excised (3-corner, 4-corner and capitolunate arthrodesis), the joint surface between the lunate surface compensates by doubling the transmitted force to the radius.

CONCLUSIONS

The common arthrodesis for treating SLAC/SNAC II-III, reduces, in fact, the load on the radioscaphoid joint. Alternative treatments that reduce load distribution on the radiocarpal joint should be three corner and capitolunate arthrodesis for treating SLAC/SNAC-II; and for SLAC/SNAC-III four corners with scaphoid excision. On Kienbock's disease. Scaphocapitate (SC) arthrodesis is more effective on reducing the load transmission through the radiolunate and ulnolunate joints. All arthrodesis treatment should consider changes on the load transmission, and also bones' fusion rates and pain reduction on patient's outcomes.

Treatment of Aseptic Necrosis of the Lunate Bone (Kienböck Disease) Using a Nickel-Titanium Memory Alloy Arthrodesis Concentrator: A Series of 24 Cases

Avascular necrosis of the lunate bone (Kienböck disease) is caused by loss of blood supply of the bone. This study aimed to evaluate the efficacy and safety of a novel nickel-titanium (Ni-Ti) memory alloy arthrodesis concentrator in the treatment of this disease.A consecutive 24 patients with stage IIIb aseptic lunate necrosis were treated with scapho-trapezio-trapezoeid (STT) arthrodesis using a Ni-Ti arthrodesis concentrator from August 2008 to December 2012. Wrist pain, grip strength, carpal height, and scapholunate angle were measured and compared before and after the surgery. The wrist functions were evaluated using the Mayo scale.Patients were followed up for a mean of 12 months (range, 6-24 months). Grip strength of the affected side was significantly improved after the surgery (18 ± 4.74 kg vs. 30.21 ± 7.14 kg, P < 0.0001). Wrist pain score was significantly decreased from 5.88 ± 0.9 to 0.5 ± 0.51 (P < 0.0001). Carpal height and Mayo score were also significantly increased after the surgery (P < 0.0001). Scapholunate angle was significantly decreased after the surgery (68.38 ± 7.28° vs. 49.91 ± 4.28°, P < 0.0001). No implant breakage, loose implant, wound infection, or nonunion occurred.STT arthrodesis is effective for the treatment of stage IIIb lunate necrosis. The Ni-Ti memory alloy arthrodesis concentrator is a convenient tool for STT arthrodesis with excellent and reliable results.

Management of complications of wrist arthroplasty and wrist fusion

The human wrist joint is unique from functional and anatomic standpoints. Numerous articulations exist within the wrist that allow for many options for partial wrist fusion and arthroplasty. In cases of pancarpal disease, fusion or arthroplasty of the entire wrist joint can be performed. Because of the high functional demand of the wrist, many of these surgical options can fail, leading to devastating complications. This article addresses the types of fusions and arthroplasties available for the wrist and discusses the potential complications associated with each. Methods to prevent these complications are presented and those to treat them once they have occurred are discussed.

Outcomes assessment of lunate replacement arthroplasty with intrinsic carpal ligament reconstruction in Kienböck's disease

BACKGROUND

With advanced Kienböck's disease, hyaline cartilage delamination or bone fragmentation render the lunate unsalvageable. Common surgical options are proximal row carpectomy, scaphotrapeziotrapezoid fusion, scaphocapitate fusion, or total wrist fusion. The purpose of this study was to prospectively evaluate the clinical and radiographic outcomes of one alternative: lunate prosthetic replacement arthroplasty combined with reconstruction of the scapholunate and lunotriquetral interosseous ligaments using the flexor carpi radialis tendon.

METHODS

Eligible patients with advanced Kienböck's disease and an unsalvageable lunate were included in this prospective study on a self-selected basis, forming a study group of 13 consecutive patients, 6 males and 7 females with a mean age of 40. Clinical and radiographic measurements were compared at a mean follow-up of 30.3 months from surgery with a paired, single-tailed, Student's t test using a p value of 0.05 as statistically significant.

RESULTS

Mean preoperative/postoperative clinical measurements were as follows: wrist flexion 29.2°/43.3°, wrist extension 24.2°/53.3°, absolute value grip strength 12.3/31.5 kg, grip strength vs. contralateral 36.5/85.2 %, and DASH scores 39.1/7.7. Mean initial/immediate postoperative/final radiographic measurements were the following: scapholunate angle 64.2°/46.7°/46.4°, radioscaphoid angle 64.6°/42.1°/45°, and modified carpal height ratio 1.20/1.62/1.59. Preoperative to postoperative differences were all statistically significant.

CONCLUSIONS

Although these subjective and objective results reflect substantial improvement, there remain recognizable deficiencies in both prosthetic design and surgical strategy that require further modification.

Scaphocapitate arthrodesis for treatment of late stage Kienbock disease

Symptomatic lunate collapse owing to Kienböck disease is difficult to treat. To define the potential role of scaphocapitate arthrodesis, we reviewed ten patients who underwent scaphocapitate arthrodesis for stage IIIB-IV Kienböck disease at a mean follow-up of 8.75 years (range 1.3-18.6). Clinical variables included ranges of motion, grip strength, pain, return to work, and QuickDASH (disabilities of the arm, shoulder and hand) scores. Radiographs were evaluated for union, carpal height, alignment, ulnar translation, and radiocarpal arthritis. The procedure resulted in functional ranges of motion and good grip strengths. Pain was substantially reduced. The mean QuickDASH score was 27 (range 9.1-56.3). Radiographic analysis showed union in nine patients, maintenance of carpal height with a corrected radioscaphoid angle, and no evidence of ulnar translation. The long-term clinical benefits of scaphocapitate arthrodesis for treatment of collapsed Kienböck disease are demonstrated. However, radiographic signs of radioscaphoid arthritis were often observed in patients with follow-up greater than 10 years.

New surgical approach to advanced Kienböck disease: lunate replacement with pedicled vascularized scaphoid graft and radioscaphoidal partial arthrodesis

Reconstructive procedures such as proximal row carpectomy or partial arthrodesis have been commonly proposed for advanced Kienböck disease (Lichtmann IIIB to IV). The purpose of this study is to evaluate an alternative surgical technique to advanced Kienböck disease: lunate excision and replacement with pedicled vascularized scaphoid graft and partial radioscaphoidal arthrodesis. The main advantage of the proposed intervention is to preserve mobility while not jeopardizing prime clinical outcomes such as pain. By replacing the devitalized lunate we aim at maintaining midcarpal range of motion, and preventing disease progression with carpal collapse and osteoarthritis of the wrist. Between 2002 and 2008, 13 patients of mean age 41 years (range, 25 to 57 y) were operated using this technique. The surgical act included 3 key steps. First, we excised the lunate, then, filled the generated gap with the rotated scaphoid, using it as a pedicled vascularized autograft. Finally, we performed a partial radioscaphoid arthrodesis. At the final follow-up, none of the intervened patients had pain at rest, and 6 patients could perform nonrestricted daily activities. The average postoperative range of motion in flexion/extension was 70 degrees (range, 55 to 90 degrees), 44% (range, 38% to 54%) of what could be achieved by the contralateral arm, and only 16% (range, 14% to 19%) or 25 degrees (range, 18 to 30 degrees) less than the preoperative range of motion of the same wrist. Grip strength improved by more than 30% (range, 24% to 36%). At an average follow-up of 4 years after surgery, 12 of 13 patients had no radiographic evidence of osteoarthritis or collapse of subchondral bone at the level of the new scaphocapitate joint. At follow-up evaluation, the average DASH score was 14 points (range, 6 to 20). The patients experienced a significant improvement in their functional abilities, achieving good results compared with the conventional techniques. The absence of carpal collapse and good functional results are encouraging.

Long-term outcomes for Kienböck's disease

BACKGROUND

The precise etiology of Kienböck's disease is unclear. Controversy exists regarding the appropriate treatment modality. The present study sought to investigate and compare surgical and nonsurgical treatment outcomes of patients suffering from Kienböck's disease in the province of Newfoundland and Labrador (NL), Canada.

METHODS

The present study was a retrospective analysis of 66 patients. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Student's t test was used to assess differences in outcomes between treatment groups. One-way ANOVA was used to assess differences in primary outcome in time since first assessed in an effort to examine progression over time. Pearson correlation was used to assess for correlation between primary outcome and age at diagnosis.

RESULTS

The average age was 38.6 ± 11.4 (18-70) years; Four patients were excluded due to inaccessible imaging. Of the remaining patients, 44 were treated conservatively, while 18 were treated surgically. The DASH scores for the surgical group were 23.7 ± 24.5 (0.9-82.8) and nonsurgical group were 20.0 ± 20.1 (1.7-81). As expected, the surgical group was mainly comprised of late-stage Kienböck's. When both groups were compared, there was no significant difference in the DASH scores. There were no difference in DASH scores within groups according to time since first diagnosed (<5 years; between 5 and 10 years; and >10 years). A positive correlation was found between age at diagnosis and DASH score (r = 0.42, p = 0.007), despite treatment modality. This finding remained significant after accounting for confounding factors (p = 0.029).

CONCLUSION

The DASH score for the surgical group was 23.7 ± 24.5 (0.9-82.8) and nonsurgical group was 20.0 ± 20.1 (1.7-81). No significant difference in DASH scores was found between surgically and nonsurgically treated patients. A positive association was found between the age at diagnosis of Kienböck's and DASH score, which suggests that patients diagnosed and treated later in life tend not to do as well.

Scaphotrapeziotrapezoid arthrodesis and lunate excision for advanced Kienböck disease

PURPOSE

To analyze the outcomes of lunate excision combined with scaphotrapeziotrapezoid arthrodesis for the treatment of advanced Kienböck disease.

METHODS

Sixteen patients with Lichtman stage IIIB Kienböck disease were treated with scaphotrapeziotrapezoid arthrodesis and lunate excision and were followed for a mean of 67 months (range, 49 to 108 mo). The indications for lunate excision included pain and limited motion associated with a collapsed lunate. Clinical evaluation included range of motion, grip strength, and modified Mayo wrist score. Based on plain radiographs, the carpal height ratio, ulnar carpal distance ratio, scaphoid translation ratio, and radioscaphoid angle were measured and any presence of degenerative changes was assessed. To investigate the effects of lunate excision on the radiologic results, we compared 12 patients with stage IIIB Kienböck disease who had only scaphotrapeziotrapezoid arthrodesis as the control group.

RESULTS

Range of motion tended to be preserved, with a trend toward an increase in extension after surgery. Grip strength and modified Mayo score improved significantly. Fourteen patients with lunate excision demonstrated radiographic ulnar translation of the scaphoid beyond the scapholunate ridge, and radioscaphoid arthritis was observed in 4 patients. Compared to initial postoperative radiographs, the scaphoid translation ratio was significantly decreased, but neither ulnar carpal distance ratio nor radioscaphoid angle showed significant differences. In the control group, neither ulnar translation of the scaphoid nor significant changes of radiologic parameters was found between initial postoperative and final radiographs.

CONCLUSIONS

Scaphotrapeziotrapezoid arthrodesis with lunate excision for advanced Kienböck disease provided favorable clinical results in terms of pain relief and functional improvement. With the absence of the lunate, however, the scaphoid had a tendency to shift toward the lunate fossa. This study suggests the risk of early development of radioscaphoid arthritis as a negative effect of lunate excision.

The current state of imaging the articular cartilage of the upper extremity

MR imaging has increasingly been used to image joints since its inception. Historically, there has been more emphasis on the evaluation of internal derangement rather than cartilaginous disease. This article reviews cartilaginous diseases of the upper extremity emphasizing those that can be assessed using current clinical MR imaging protocols and addresses the limitations of current imaging techniques in evaluating the articular cartilage of smaller joints. It also provides a brief overview of novel techniques that may be instituted in the future to improve the diagnostic performance of MR imaging in the evaluation of the articular cartilage of the upper extremity.

[New treatment of advanced Kienböck disease: replacement of lunate with costochondral autograft]

Treatment of advanced Kienböck's disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböck's disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32-51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6-36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.

Complications of limited and total wrist arthrodesis

Partial and total wrist arthrodeses have become common procedures for treating degenerative diseases arising from numerous conditions, including posttraumatic arthrosis, intercalated segment instability, inflammatory arthropathy, and carpal osteonecrosis. The goals of these two procedures are to provide pain relief and improved function by fusing arthritic or unstable joints. A thorough understanding of the complications and the best practices to avoid them is critical for the surgeon in the preoperative, intraoperative, and postoperative management of candidates for total or limited wrist arthrodesis.

Proximal row carpectomy for advanced Kienböck's disease: average 10-year follow-up

PURPOSE

To evaluate the clinical and radiographic results after a proximal row carpectomy for Lichtman stage III and IV Kienböck's disease at an average 10-year follow-up.

METHODS

Twenty-one patients with either Lichtman stage IIIA, IIIB, or IV Kienböck's disease were treated surgically at an average age of 38 years. At follow-up evaluation, each patient was evaluated subjectively with the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Related Wrist Evaluation questionnaires (both are validated, patient-reported questionnaires assessing pain and function) and objectively with an assessment of range of motion and grip strength. Radiographs were obtained to assess the radiocapitate articulation.

RESULTS

Three patients had persistent pain after a proximal row carpectomy requiring a radiocapitate arthrodesis at a mean of 23 months (range, 5-53 months). Two of these 3 patients had preoperative stage IV disease. The remaining 18 patients were evaluated at an average follow-up of 10 years (range, 4-17 years). The average wrist flexion-extension arc was 105 degrees, which averaged 78% of that of the contralateral wrist. Average maximal grip strength was 35 kg, which averaged 87% of that of the contralateral wrist. Average Quick Disabilities of the Arm, Shoulder, and Hand score was 12 points and average Patient-Related Wrist Evaluation score was 17 points, each representing minimal functional limitation. Radiographic analysis at final follow-up demonstrated degeneration of the radiocapitate articulation in 16 patients. Narrowing of the joint space was rated as none in 2 wrists, partial in 10 wrists, and complete in 4 wrists. There was no significant association between the radiographic findings and the subjective and objective outcome.

CONCLUSIONS

At an average follow-up of 10 years, proximal row carpectomy is a reliable and durable procedure for patients with Lichtman stage IIIA or IIIB Kienböck's disease. Caution should be exercised in performing the procedure in patients with stage IV disease because of risk of early symptomatic radiocapitate degeneration.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-term follow-up of radial shortening osteotomy for Kienbock disease

BACKGROUND

Three previous studies have investigated the long-term outcome of radial osteotomy in the treatment of Kienböck disease. However, none used patient-based assessment. The purpose of this study was to investigate the long-term clinical and radiographic outcomes of this osteotomy, including the subjective evaluation of the patient with use of the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire.

METHODS

A DASH questionnaire was sent to nineteen patients with Kienböck disease who had undergone a radial shortening osteotomy, and thirteen replied. The mean age at the time of surgery was thirty-nine years. On the basis of the Lichtman classification, six patients had stage-II, four had stage-IIIA, and three had stage-IIIB disease. Prior to surgery, ulnar variance was positive in six patients, neutral in four, and negative in three. The mean duration of follow-up was twenty-one years. Clinical evaluation, including calculation of the modified Mayo wrist score, and radiographic evaluation were also performed on twelve of the thirteen patients.

RESULTS

The mean DASH score was 8 points (range, 0 to 23 points), and patient satisfaction was high. Compared with the findings in the contralateral wrist, the mean range of motion was 81% in flexion and 82% in extension and mean grip strength was 88%. The mean modified Mayo wrist score was 83 points, and the clinical results were excellent in six patients, good in five, and moderate in one. The DASH scores tended to be worse in patients with Lichtman stage-IIIB disease. Follow-up radiographs revealed that the Lichtman stage had progressed in six of the twelve patients.

CONCLUSIONS

Although most patients had mild wrist pain, patient satisfaction and the clinical results were satisfactory following a radial shortening osteotomy. This procedure is a reliable long-term treatment for Lichtman stage-II and IIIA disease and may be a reasonable option for patients with stage-IIIB disease.

Treatment of scaphotrapezio-trapezoid arthritis

Arthritis of the scaphotrapeziotrapezoid (STT) joint presents with deep thenar eminence and thumb basilar pain and is often coexistent with carpometacarpal arthritis of the thumb. Conservative treatment includes splinting and corticosteroid injections. Operative treatment consists primarily of fusion of the STT joint, although alternatives include trapeziectomy, fibrous arthroplasty, and prosthetic replacements. When STT arthritis is coexistent with carpometacarpal arthritis, excision of the trapezium and proximal 2 mm of trapezoid has been recommended. Complications of surgery include pericarpal arthrosis, superficial radial nerve injury, and nonunion.

Comparison of MRI and wrist arthroscopy for assessment of wrist cartilage

In order to perform motion-preserving procedures for wrist arthritis rather than total joint fusion, it is important to determine the integrity of specific areas of wrist cartilage. This is generally performed using a wrist arthroscope and by directly visualising the cartilage. Twenty patients with wrist pain were investigated over a 1-year period with both MRI and wrist arthroscopy. Kappa analysis was used to compare the two methods of cartilage assessment. There is only a fair correlation (K = 0.38) between the two methods. With only a fair correlation between arthroscopy and MRI, it cannot be concluded that the two methods are equivalent for assessing wrist cartilage and, as such, wrist arthroscopy still has an important role to play in the assessment of a painful degenerative wrist.

Kienböck's disease: an approach to treatment

Since its description in 1910, Kienböck's disease has continued to be a difficult problem for clinicians as well as patients. An incomplete understanding of the etiology as well as the natural history of the disease has led to an assortment of surgical treatment options. The authors present a review of Kienböck's disease and the theories behind different surgical interventions, as well as their current approach to treatment of patients with Kienböck's disease.

Time course of magnetic resonance images in an adolescent patient with Kienböck's disease treated by temporary scaphotrapezoidal joint fixation: a case report

Kienböck's disease in a 15-year-old girl was treated successfully by temporary scaphotrapezoidal joint fixation using longitudinal K-wires. Repeated magnetic resonance imaging begun 3 months after surgery showed progressive increases in signal intensity on T1-weighted sequences of the lunate and was almost normal 6 months after surgery. The K-wires used for the temporary joint fixation were removed 6 months after surgery. The signal intensity of the lunate on magnetic resonance images remained normal 2 years after surgery. At that time plain x-ray showed no sign of lunate sclerosis and there was no cystic shadow or sign of advanced collapse. At 2 years after surgery the patient does not complain of wrist pain, can lead a normal daily life, and plays sports without difficulty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Scaphotrapeziotrapezoid arthrodesis for arthritis

The main indications for scaphotrapeziotrapezoid (STT) fusion are STT arthritis, rotary subluxation of the scaphoid, and Kienbock disease. The results of this procedure in the literature for each indication are discussed, as are the advantages, disadvantages,and alternative procedures. This article discusses the authors' surgical technique and results. The authors believe this procedure is a viable one in specific clinical scenarios.