Kienböck disease

Comparing the Radiologic and Functional Outcome of Radial Shortening Versus Capitate Shortening in Management of Kienböck's Disease

BACKGROUND

Kienböck's disease is the avascular necrosis of the lunate bone. There is no consensus on the treatment strategy to avoid joint deterioration. This trial is conducted to compare the functional and radiological outcomes of radial shortening and capitate shortening techniques, in patients with avascular necrosis of lunate.

METHODS

Patients with a confirmed diagnosis of Kienböck's disease who met the inclusion criteria were randomly divided into radial shortening and capitate shortening groups and treated by allocated technique. Physical examination and radiologic evaluations were performed before and 6 and 12 months after the operation.

RESULTS

A total of 52 patients (52 wrists) of stage II or III Kienböck's disease were assessed for eligibility, 12 patients in the radial shortening group, and 17 patients remained until the end of the study. Patients in both groups achieved a satisfactory outcome, with no report of postoperative complications. None of the outcome measures, ranges of motion, grip, and pinch strengths were significantly different between the groups. The outcome was not considerably different in patients with positive or negative ulnar variances who were treated by capitate shortening technique.

CONCLUSIONS

The capitate shortening technique which is performed through a smaller incision, and takes less time as compared with radial shortening can be advantageous for patients with stage II or III Kienböck's disease regardless of the ulnar variance. This method can be as effective as classical methods such as radial shortening in improving clinical and functional symptoms after surgery while causing fewer complications.

Wrist Salvage Procedures for the Treatment of Kienbock's Disease

Kienbock's disease is a progressive condition characterized by lunate collapse, carpal instability, and eventually perilunate arthritis. Etiology is likely multifactorial, including vascular and anatomic or osseus causes. In cases of advanced disease, disabling pain, limited motion, and decreased grip strength may be present. The preferred treatment options for the nonreconstructable wrist are proximal row carpectomy (PRC), total wrist arthrodesis, and total wrist arthroplasty (TWA). In the following chapter, we will discuss various surgical options for patients with advanced Kienbock's disease.

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

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

Kienböck Disease: Clinical Presentation, Epidemiology, and Historical Perspective

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

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.

Functional and Radiographic Disease Progression in Nonoperatively Managed Kienböck Disease

BACKGROUND

The purpose of this study was to describe the natural history of Kienböck disease among patients who elected to proceed with nonoperative treatment.

METHODS

The authors performed a retrospective study of all patients treated nonoperatively for Kienböck disease within their institution from January 1, 1999, to December 31, 2014. Inclusion criteria included follow-up greater than 1 year, serial posteroanterior and lateral wrist radiographs, and clinical examination. Posteroanterior/lateral radiographs were independently reviewed at initial presentation and at final follow-up, including Lichtman stage, carpal index, Stahl index, ulnar variance, and intercarpal angles.

RESULTS

Twenty-five patients with 25 wrists were included (mean age, 50.2 years), with an average length of clinical follow-up of 3.9 years and a mean length of radiographic follow-up of 5.2 years. There was no significant difference in range of motion; however, patient-reported pain was significantly decreased, and modified Mayo wrist scores and grip strength were increased. Lichtman stage, scapholunate angle, and radioscaphoid angle were increased; and carpal index, posteroanterior lunate ratio, and Stahl index were decreased across the study period. The mean progression in Lichtman stage was 0.5 stage/year with a range of 0 to 1.6 stages/year throughout the study period. There was no significant difference in Lichtman stage progression based on stage at presentation. A history of smoking was associated with increased radiographic disease progression.

CONCLUSION

The present study demonstrates that among patients with Kienböck disease managed nonoperatively, the majority of patients significantly improve over time with respect to pain, grip strength, and Mayo wrist score, despite radiographic progression of disease.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Radial shortening osteotomy vs partial capitate shortening osteotomy in Kienböck's disease: Medium-term radiological and clinical results

This study aimed to compare medium-term results for partial capitate shortening (PCS) and radial shortening (RS) osteotomies on lunate bone revascularization and disease progression in patients with stage II or IIIA Kienböck's disease. Patients who underwent surgery for Kienböck's disease between March 2010 and July 2020 were retrospectively evaluated. Clinical evaluation included assessment of pain, joint range of motion, strength, DASH, visual analog scale (VAS) for pain, Modified Mayo Wrist Score (MMWS), satisfaction and time to return to work, with comparison as appropriate to the contralateral side. Preoperative and postoperative plain radiographs and magnetic resonance imaging (MRI) were used for radiological evaluation. Lichtman staging and signal changes in the lunate were evaluated using MRI. Group 1 (PCS) included 14 patients and Group 2 (RS) 14. Mean follow-up was 57.8 months (range 24-102) in Group 1 and 49.4 months (range 36-73) in Group 2. Clinical evaluation included pain on VAS, DASH score, MMWS, range of motion, and grip, palmar and key pinch strength. Regarding lunate bone vascularization, increased signal on final follow-up MRI was observed in 10 of the 14 patients in Group 1 and 7 of the 14 patients in Group 2. There was a positive correlation between revascularization and final follow-up MMWS (p = 0.006). The present study thus showed that functional scores were improved by revascularization in Kienböck's disease. Both osteotomies had clinically and radiologically satisfactory results. However, we believe that PCS osteotomy is preferable, as it leads to higher revascularization rates without increasing ulnolunate load.

Varisized 3D-Printed Lunate for Kienböck's Disease in Different Stages: Preliminary Results

Objective

To evaluate the feasibility of arthroplasty with varisized three‐dimensional(3D) printing lunate prosthesis for the treatment of advanced Kienböck's disease (KD).

Methods

From 2016 November to 2018 September, a retrospective study was performed for the patients of KD in our hospital. Five patients (two males, three females) were included in this study. The mean age of the patients at the time of surgery was 51.6 years (range, 37–64 years). Varisized prosthesis identical to the live model in a ratio of 1:0.85, 1:1, and 1:1.1 were fabricated by 3D printing. All patients (one in Lichtman IIIA stage, two in Lichtman IIIB stage, one in Lichtman IIIC stage, and one in Lichtman IV stage) were treated with lunate excision and 3D printing prosthetic arthroplasty. Visual analog scale score (VAS), the active movement of wrist (extension, flexion) and strength were assessed preoperatively and postoperatively. The Mayo Modified Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) Score, and patient's satisfaction were evaluated during the follow‐up.

Results

Prosthesis identical to the live model in a ratio of 1:0.85 or 1:1 were chosen for arthroplasty. The mean operation time (range, 45 to 56 min) was 51.8 ± 4.44 min. Follow‐up time ranged from 11 months to 33 months with the mean value of 19.4 months. The mean extension range of the wrist significantly increased from preoperative 44° ± 9.6° to postoperative 60° ± 3.5° (P < 0.05). The mean flexion range of the wrist significantly increased from preoperative 40° ± 10.6° to postoperative 51° ± 6.5° (P < 0.05). The active movement of wrist and strength were improved significantly in all patients. VAS was significantly reduced from 7.3 preoperatively to 0.2 at the follow‐up visit (P < 0.05). The mean DASH score was 10 (range, 7.2–14.2), and the mean MMWS was 79 (range, 70–90). There were no incision infection. All patients were satisfied with the treatment.

Conclusions

For patients suffering advanced Kienböck's disease, lunate excision followed by 3D printing prosthetic arthroplasty can reconstruct the anatomical structure of the carpal tunnel, alleviate pain, and improve wrist movement.

Use of 4+5 extensor compartmental vascularized bone graft and K-wire fixation for treating stage II-IIIA Kienböck's disease

Vascularized bone grafts have shown favorable outcomes in Kienböck's disease, preventing the progression of lunate collapse and avascular necrosis. Here we describe our experience using a 4+5 extensor compartmental artery (ECA) vascularized bone graft combined with K-wire fixation. Between September 2010 and June 2013, 9 patients with Lichtman stage II-IIIA disease underwent arthroscopy prior to 4+5 ECA graft placement combined with temporary fixation (scaphocapitate and triquetrum-capitate joints). The average follow-up was 69 months (range, 51-92 months). Changes in pain, range of motion, grip strength, and pinch strength were analyzed. All patients had satisfactory recovery, especially pain relief and grip strength improvement (both P<0.01). Furthermore, magnetic resonance imaging follow-up was critical for monitoring lunate revascularization, especially in the early postoperative period.

Bilateral scapholunate widening may have a nontraumatic aetiology and progress to carpal instability and osteoarthritis with advancing age

It was hypothesized that bilateral widening of the scapholunate gap is relatively common in the absence of trauma and that it progresses to radiological carpal instability and scapholunate advanced collapse. Electronic files of 1000 patients with bilateral X-rays were studied in retrospect. Wide scapholunate gaps were bilaterally present in 67 and unilaterally in 51 patients. Scapholunate advanced collapse was observed in 26 patients; in nine it was in both wrists. A trauma was recorded in less than half of the patients with a bilateral wide scapholunate gap. Patients with bilateral wide gaps were younger if signs of carpal instability or osteoarthritis were absent. Bilateral scapholunate widening may not be caused by an acute trauma, but may lead to carpal instability and degenerative changes with advancing age.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical manual assessment of the wrist

Although hand therapists often evaluate patients with wrist pain, novice and experienced clinicians alike would benefit from a systematic assessment to efficiently identify the source of dysfunction and initiate an appropriate treatment plan. This article proposes a systematic approach for clinical evaluation of the wrist by describing the basic clinical examination (BCE) process and interpreting the findings in terms of common pathology. The BCE will enable the hand therapist to identify conditions that are contraindicated for conservative care and require further physician intervention, determine a working diagnosis for most musculoskeletal problems, and determine the appropriate extra tests to confirm the working diagnosis and/or rule out differential diagnoses. By combining findings from the patient's history, BCE, and special testing, hand therapists can efficiently determine the underlying pathology and provide appropriate treatment that can optimize clinical outcomes.

Microstructural study of the lunate in stage III Kienböck's disease with micro-computed tomography imaging

Seventeen fresh lunates with stage III Kienböck's disease were scanned with micro-computed tomography. Four regions of interest were selected to measure trabecular parameters, which were compared with those from normal lunates. Within the three regions in the distal surface, there was more compact trabecular bone in the middle region when compared with the palmar and dorsal regions. In the central part, the trabeculae of the Kienböck's lunates were much thicker than those in normal lunates. The diameters of the palmar nutrient foramina of the Kienböck's lunates were significantly smaller than those in normal lunates. In affected lunates, the bony disruptions were mostly located in the palmar or dorsal areas, which were shown from trabecular bone structure analysis to be structurally weaker. This leads to separation of the distal part of the fractured bone, disruption of the blood supply, poor bone remodelling and proneness to secondary fracture and eventual collapse.

Idiopathic bilateral lunate and triquetrum avascular necrosis: A case report

We report on the case of bilateral avascular osteonecrosis (AVN) of the lunate and triquetrum in a 45-year-old woman without any relevant medical history for which the cause could not be established. She was treated conservatively with splinting and analgesics. The patient was able to pursue her work and hobbies with subnormal range of motion at 1-year follow-up. AVN of the triquetrum is very rare, as it is a richly vascularized bone. The presence of AVN in multiple carpal bones has only been described in patients receiving high doses of corticosteroids. To our knowledge, there are no other cases of idiopathic AVN of multiple carpal bones in the literature.

Partial capitate shortening for Kienböck's disease

The purpose of this study was to report our experience of partial capitate shortening in seven patients with a median 38 months follow-up. Staging was made by the Lichtman classification system and stage II and III-A patients were included in the study. The mean age was 34 years (range 22-52). Patients were assessed for pain, range of motion, grip and pinch strength, and satisfaction was recorded using a scale between 0 and 4. All these parameters showed improvement after surgery. The Lichtman stage, lunate height index and carpal height index were determined radiographically. Magnetic resonance images of the wrist were studied for lunate revascularization at the final follow-up and occurred in all patients. According to our study, partial capitate shortening seems an effective treatment for Lichtman stage II and III-A patients.Level IV case series study.

Needle Curette Technique for Hand Surgery

Curettage of lesions in the hand often requires fine instruments of varying angles for a thorough debridement. This can be seen with debridement of enchondromas of the phalanges when minimizing the size of the cortical window is desired. In this technical note, the authors describe the modification of an 18-G needle so that it may be used as a small curette when standard small curettes are not available or optimal.

(99m)Tc-MDP SPECT/CT as the one-stop imaging modality for the diagnosis of early setting of Kienbock's disease

(99m)Tc-Methylene diphosphonate (MDP) triple phase bone scintigraphy (BS) has a role in early diagnosis of Kienbock's disease, especially when the X-ray is negative. Early diagnosis can result in prompt management of the patient since wrist pain in older individuals due to aging may go unnoticed or be due to other diagnoses with the production of greater damage and eventually a worse prognosis. Herein, we present a case report of a 29-year-old female with Kienbock's disease in whom the X-ray was negative and MRI incorrect. The (99m)Tc-MDP SPECT/CT BS helped the diagnosis of the disease in an early stage (stage 1) and had a clinical impact on the patient's management.

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.