Open treatment of stage III Kienböck's disease with lunate revascularization compared with arthroscopic treatment without revascularization

Examining the Efficacy of Arthroscopic Scaphocapitate Arthrodesis for Advanced Kienbock's Disease: Clinical and Radiological Outcomes

Background

Altering wrist biomechanics, Kienbock's disease leads to progressive carpal collapse that results in early arthritis and degenerative changes. By shifting the loading axis toward the radioscaphoid joint, scaphocapitate arthrodesis (SCA) has been reported as a salvage procedure effective in treating symptomatic patients with advanced Kienbock's disease. In this study, we aimed to evaluate the clinical and radiological outcomes of arthroscopic SCA in symptomatic patients with advanced stages of Kienbock's disease.

Methods

Between March 2010 and February 2021, we included 15 patients with symptomatic stage IIIA (n=2) and stage IIIB (n=13) Kienbock's disease who were followed up for a minimum of 24 months after arthroscopic SCA with or without lunate excision. The lunate was excised in 6 patients and retained in 9. Visual analog scale (VAS) pain score, grip strength, range of motion (ROM), active flexion-extension arc, and modified Mayo wrist score (MMWS) were measured preoperatively and at each follow-up examination after surgery. Operation-related complications and radiographic changes were also assessed.

Results

There were 13 women and 2 men, with a mean age of 57.6 years (range, 21-74 years) at the time of undergoing arthroscopic SCA. Follow-up ranged from 24 to 116 months, with an average of 56.9 ± 32.3 months. Bony union was achieved in all patients. At preoperative examination, wrist ROM (67%) and grip strength (48%) significantly decreased, compared to the contralateral wrist. At the final follow-up, there were significant improvements in VAS, grip strength, and MMWS, whereas the active wrist ROM showed no significant change. Radioscaphoid angle recovered after surgery, while radiographic carpal collapse and ulnar translation of the carpus occurred. In subgroup analysis according to excision of the lunate, there were no significant differences in VAS, MMWS, grip strength, or total ROM. However, increased ulnar translation and decreased radial deviation were noted in the lunate excision group.

Conclusions

Arthroscopic SCA achieved significant improvements in pain and wrist function in patients with advanced Kienbock's disease without any complications. Excision of the lunate when performing arthroscopic SCA seemed to induce progressive carpal ulnar translation, with no apparent clinical benefits over retaining it.

Precision Medicine for Kienböck Disease in the 21st Century

One of the most popular treatment algorithms for Kienböck disease is based on a progression of successive radiographic changes that was developed in the 1970s. Since then, 2 other important classifications systems have been introduced. One is centered on contrasted magnetic resonance imaging findings and the other, articular cartilage degeneration. All 3 systems have been used, in isolation, to recommend specific treatment modalities. To coordinate all available clinical data and to simplify the treatment selection process, we combined the 3 classification systems into 1 unified classification and treatment algorithm. With the added consideration of some recently introduced surgical options and further knowledge of how Kienböck disease affects children and the elderly, we anticipate that this unified classification system will allow for a more precise and individualized treatment plan.

Update on the Use of Arthroscopy in Kienböck's Disease Management

Kienböck's disease is a clinical-radiological condition that can permanently affect wrist functionality and the patient's quality of life. Proper, pertinent diagnosis and treatment are required to avoid salvage procedures. Arthroscopic techniques have emerged as an important tool for the treatment of certain stages of the disease.

We present a review of the literature and propose a treatment algorithm according to the stage of the disease, including arthroscopic techniques. We detail the surgical technique of arthroscopic scaphocapitate arthrodesis, and the functional outcomes obtained by our group.

Lower nationwide rates of arthroscopic procedures in 2016 compared with 1997 (634925 total arthroscopic procedures): has the tide turned?

Objectives

To assess the rates and secular trends of different joint arthroscopies—shoulder, elbow, wrist, hip, knee and ankle—in Finland between 1997 and 2016.

Design

Retrospective nationwide registry study.

Participants

All adults in Finland with any arthroscopic intervention procedure code for knee, shoulder, ankle, wrist, elbow or hip arthroscopy between 1 January 1997 and 31 December 2016 were included.

Main outcome measures

Incidence rate of arthroscopic surgery per 100 000 person-years.

Results

The rate of knee and shoulder arthroscopies declined after reaching a peak in 2006 and 2007, respectively. The rates of wrist, elbow and hip joint arthroscopies declined after their 2014 peak. At the same time, the median age of patients who had knee, ankle and hip arthroscopy decreased, whereas the age of patients who had shoulder arthroscopy increased.

Conclusions

Numerous randomised controlled trials point to lack of efficacy of the most common knee and shoulder arthroscopic procedures. It should not be assumed that this has contributed to decreased rates of arthroscopic surgery. The concurrent decrease in most of the other joint arthroscopic procedures was unexpected.

Results of scaphocapitate arthrodesis with lunate excision in advanced Kienböck disease at 10.7-year mean follow-up

Scaphocapitate arthrodesis with lunate excision was performed for treatment of advanced Kienböck disease in 17 patients (18 wrists). Ten were women and seven men. Five were Lichtmann Stage IIIA, 12 Stage IIIB, and one Stage IV. Minimum follow-up period was 24 months; mean follow-up was 10.7 years (range 2.3 to 22 years, SD 7.1). At the latest follow-up, six patients were very satisfied, nine were satisfied and two were disappointed. Pain was significantly decreased in all cases. Wrist mobility was unchanged. Grip strength was significantly increased. Consolidation of the arthrodesis was confirmed in 17 wrists. We encountered a scaphocapitate nonunion at 12 years follow-up and two cases of styloscaphoid arthritis at 17 and 22 years. Scaphocapitate arthrodesis with lunate excision performed in an advanced stage of Kienböck disease significantly alleviates pain, while preserving functional mobility and satisfactory grip strength in the long term.

LEVEL OF EVIDENCE

IV.

Kienböck Disease: A New Algorithm for the 21st Century

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

Lunatum excision and scaphocapitate arthrodesis in Kienböck's disease

PURPOSE

The aim of this study was to compare functional results before and after lunatum excision and scaphocapitate arthrodesis (SCA) using an angular stable circular plate in patients with Lichtman's stage IIIB Kienböck's disease.

METHODS

The study included nine patients (six females and three males) with a mean age of 33.2 ± 11 years (range: 18-54 years). Clinical and radiological assessment before and after surgery included wrist extension and flexion, range of motion and grip strength, visual analogue scale (VAS) score to assess pain, modified Mayo wrist scores, and measurements of the scapholunate (SL) angle and modified carpal height ratio.

RESULTS

The mean follow-up period was 17.33 ± 4.69 months (range: 12-24 months), mean operation time was 56.67 ± 12.5 min (range: 45-75 min) and mean hospitalization time was 3.44 ± 1.13 days (range: 2-6 days). Preoperative mean wrist extension was 23.89° ± 4.17°, mean wrist flexion was 32.22° ± 5.07°, mean grip strength compared to the healthy side was 34% (range: 28-37%) and mean VAS score was 7.6 (range: 7-8). Modified Mayo wrist scores were poor in all of the nine patients. Post-operative mean wrist extension was 27.78° ± 4.41°, mean wrist flexion was 40.56° ± 4.64°, mean grip strength compared to the healthy side was 71% (range: 63-81%) and mean VAS score was recorded as 1.4 (range: 1-2). Modified Mayo wrist scores were good in five and moderate in four patients. No patients had non-union or additional surgery.

CONCLUSION

Lunatum excision and SCA using angular stable circular plate fixation provide pain relief with acceptable preservation of the range of motion.

Kienböck Disease: Moving Forward

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

The treatment of Kienböck disease with vascularized bone graft from dorsal radius

INTRODUCTION

Numerous surgical treatment options are proposed for the Kienböck disease but there has not been a consensus on the most appropriate method yet. The aim of this study is to present our experience and preliminary results of the use of vascularized bone graft from dorsal radius.

MATERIALS AND METHODS

Second and third intercompartmental supraretinacular artery pedicled bone graft has been used to treat 11 patients with Kienböck disease between 2001 and 2006. The average follow-up period was 37 months (range 19-77 months). Pre- and post-operative range of motion, pain and grip strength, radiologic parameters such as carpal height ratio, Stahl index and scapholunate angle were evaluated.

RESULTS

Eleven patients were composed of two stage II, one stage IIIA and eight stage IIIB patients according to Lichtmann classification. At the end of the observation period, five excellent, four good, one fair and one poor results were observed. There were no or little changes in carpal height ratio and Stahl index. Pain has diminished considerably.

DISCUSSION

We believe that the treatment of Kienböck disease with vascularized bone graft from the dorsum of the radius has encouraging results and need no other additional procedures.

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.