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Dolan JD, Shiver L, Wallace D, Whitehead J, Wood M, Fulcher SM. Isolated Osseous Excision in the Adult Carpus: A Narrative Review. J Hand Microsurg 2024; 16:100041. [PMID: 38855507 PMCID: PMC11144647 DOI: 10.1055/s-0043-1769748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024] Open
Abstract
Various pathologies of the adult carpus result in clinical scenarios where excision can be considered and even recommended. In the appropriate patient population, isolated carpal excision can alleviate pain and improve mobility. Excisions of the pisiform, trapezium, and trapezoid have abundant literature evidence to support positive long-term functional outcomes. In contrast, isolated excision of the capitate, hamate, and triquetrum has limited support in the literature secondary to compromise of carpal mechanics and lead to recurrent pain. Additionally, isolated scaphoid and lunate excision are best avoided secondary to carpal collapse and should be paired with concomitant stabilizing procedures in the carpus. This article provides a comprehensive literature review of isolated excision of each osseous carpal bone, their indications, and previously assessed outcomes.
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Affiliation(s)
- Joshua D. Dolan
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia, United States
| | - Luke Shiver
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia, United States
| | - Doyle Wallace
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia, United States
| | - Jonathon Whitehead
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia, United States
| | - Matthew Wood
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia, United States
| | - S. Mark Fulcher
- Department of Orthopaedic Surgery, Medical College of Georgia, Augusta, Georgia, United States
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Chojnowski K, Opiełka M, Piotrowicz M, Sobocki BK, Napora J, Dąbrowski F, Piotrowski M, Mazurek T. Recent Advances in Assessment and Treatment in Kienböck's Disease. J Clin Med 2022; 11:jcm11030664. [PMID: 35160115 PMCID: PMC8836398 DOI: 10.3390/jcm11030664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/09/2022] [Accepted: 01/21/2022] [Indexed: 12/17/2022] Open
Abstract
Kienböck’s disease is a rare disease described as progressive avascular osteonecrosis of the lunate. The typical manifestations include a unilateral reduction in wrist motion with accompanying pain and swelling. Besides recent advances in treatment options, the etiology and pathophysiology of the disease remain poorly understood. Common risk factors include anatomical features including ulnar variance, differences in blood supply, increased intraosseous pressure along with direct trauma, and environmental influence. The staging of Kienböck’s disease depends mainly on radiographic characteristics assessed according to the modified Lichtman scale. The selection of treatment options is often challenging, as radiographic features may not correspond directly to initial clinical symptoms and differ among age groups. At the earliest stages of Kienböck disease, the nonoperative, unloading management is generally preferred. Patients with negative ulnar variance are usually treated with radial shortening osteotomy. For patients with positive or neutral ulnar variance, a capitate shortening osteotomy is a recommended option. One of the most recent surgical techniques used in Stage III Kienböck cases is vascularized bone grafting. One of the most promising procedures is a vascularized, pedicled, scaphoid graft combined with partial radioscaphoid arthrodesis. This technique provides excellent pain management and prevents carpal collapse. In stage IV, salvage procedures including total wrist fusion or total wrist arthroplasty are often required.
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Cerezal L, Llopis E, Canga A, Piñal FD. Postoperative Imaging of Ulnar Wrist Pain. Semin Musculoskelet Radiol 2021; 25:329-345. [PMID: 34374067 DOI: 10.1055/s-0041-1731331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Ulnar wrist pain, caused by a broad spectrum of bone and soft tissue injuries, is the most common clinical condition of the wrist. Multiple surgical techniques and their variants in the treatment of these injuries are constantly evolving. Postoperative evaluation of the wrist for many surgeons is limited to serial clinical and radiographic monitoring. However, imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and arthrographic techniques (arthrographic CT and arthrographic MRI) play a fundamental role in diagnosing and managing postsurgical complications.The several critical aspects in evaluating the postsurgical wrist imaging spectrum are familiarity with the surgical techniques, knowledge of the original clinical problem, understanding the strength and limitations of the different radiologic modalities, and effective communication between surgeon and radiologist.
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Affiliation(s)
- Luis Cerezal
- Department of Radiology, Diagnóstico Médico Cantabria (DMC), Santander, Spain
| | - Eva Llopis
- Department of Radiology, Hospital de la Ribera, Valencia, Spain
| | - Ana Canga
- Department of Radiology, Marqués de Valdecilla University Hospital, Santander, Spain
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Goyal N, Singh V, Barik S, Behera S. Limited Carpal Fusion in Kienböck's Disease: Early Results following Scaphocapitate Arthrodesis. J Wrist Surg 2020; 9:404-410. [PMID: 33042643 PMCID: PMC7540655 DOI: 10.1055/s-0040-1712517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Nikhil Goyal
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Vivek Singh
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sitanshu Barik
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Santosh Behera
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Botelheiro JC, Silverio S, Neto AL. Treatment of Advanced Kienbock's Disease (Lichtman Stage IIIB with Carpal Collapse) by a Shortening Osteotomy of the Radius: 21 Cases. J Wrist Surg 2019; 8:264-267. [PMID: 31404372 PMCID: PMC6685728 DOI: 10.1055/s-0039-1688947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Abstract
Purpose To review the results of shortening osteotomies of the radius in our stage IIIB Kienbock's disease patients. Materials and Methods In the past 30 years, we treated 52 cases of Kienbock's disease by a shortening osteotomy of the radius, of which 21 already had carpal collapse. All patient charts and X-rays were reviewed, but only the cases already with carpal collapse (stage IIIB) are presented here. Results All patients improved after surgery. Pain, on a scale of 0 to 3, generally 2 or 3 before surgery (median: 2.3), was normally 1 or 0 afterward (median: 0.9); median flexion-extension of the wrist improved from 77 to 99 degrees; and grip strength of the other hand improved from 26 to 76%. The last clinical and radiological review was performed 1 to 23 years after surgery (median: 8 years). Conclusion Advanced Kienbock's disease with carpal collapse is not a contraindication for carpal-sparing surgery radial shortening osteotomy.
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Affiliation(s)
- J. C. Botelheiro
- Department of Orthopaedics, Hospital dos Lusiadas, Lisbon, Portugal
| | - Silvia Silverio
- Department of Orthopaedics, Hospital de Sant’Ana, Parede, Portugal
| | - Ana Luísa Neto
- Department of Orthopaedics, Hospital de Sant’Ana, Parede, Portugal
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Barrera-Ochoa S, Campillo-Recio D, Muñoz-Perdomo T, Esteban-Feliu I, Mendez-Sanchez G, Mir-Bullo X. Dorsolateral Biplane Closing Radial Osteotomy and Lunate Fixation for Stage IIIC Kienböck Disease: A New Surgical Approach. Tech Hand Up Extrem Surg 2018; 22:74-80. [PMID: 29894391 DOI: 10.1097/bth.0000000000000197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The treatment of advanced-stage Kienböck disease (KD) remains highly controversial. Particularly important is stage IIIC KD, which includes patients with a lunate coronal fracture. The purpose of this paper was to describe a new approach to KD in patients with Lichtman stage IIIC KD, and our results using it. The procedure combines a dorsolateral biplane closing radial osteotomy and lunate fixation. A total of 11 patients from January 2002 through December 2016 with documented KD who underwent this technique were included. The patients were assessed before surgery, then postoperatively at 1 and 10 days, 3 and 6 weeks, 3 and 6 months, and annually. Wrist range of motion, grip and pinch strength, the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, a Modified Mayo Wrist Score (MMWS), 10-point visual analog scale, radiologic measurements, and data related to consolidation were collected. All statistical analyses were performed using the statistical software package SPSS. Some degree of pain relief, improvements in the QuickDASH score, MMWS score, grip strength, and the degrees of flexion and extension were observed, the results being statistically significant (P<0.05). After surgery, the values for radial and sagittal tilt were statistically different than those measured before surgery. Carpal collapse was not evident either before or after surgery. In conclusion, combining a dorsolateral radial osteotomy and a lunate compression screw may expand the options for patients with Lichtman stage IIIC KD. Our experience indicates that it is a viable option in challenging clinical scenarios.
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Affiliation(s)
- Sergi Barrera-Ochoa
- Hand and Microsurgery Unit
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
- ICATME, Hospital Universitari Quiron-Dexeus
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Lunate excision with capitohamate fusion in the treatment of stage IIIB and IIIC Kienböck's disease. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:211-215. [PMID: 29506904 PMCID: PMC6136328 DOI: 10.1016/j.aott.2018.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/28/2018] [Accepted: 02/11/2018] [Indexed: 12/04/2022]
Abstract
Objective The aim of this study was to report our results of lunate excision combined with capitohamate fusion in the treatment of Kienböck's stage IIIB/IIIC disease. Methods A total of 7 patients with a mean age 35.2 (SD 11.5) years were enrolled in the study. Pain was the principal reason for surgery. All operations were carried out by the same senior surgeon. Patients were evaluated in terms of range of motion, DASH and VAS scores, satisfaction, and grip/tip/palmar/key pinch strength compared with contralateral sides. Preoperative carpal height indexes and findings of osteoarthritis were determined radiographically and compared with postoperative evaluations. Results Mean duration of follow up was 15.2 months. Mean DASH and VAS scores were 13.8 2.7 and 2 1.1 respectively. The mean patient satisfaction score was 3.2 0.4 over 4 points. The mean grip strength in the operated hands was 66.4%, palmar pinch was 75.1%, tip pinch was 71.8% and key pinch was 70.4% when compared to the contralateral unaffected sides. The mean flexion range in the operated hands was 58.8%, extension range was 60.3%, radial deviation range was 65.2% and ulnar deviation range was 65.7% when compared to the contralateral sides. There was no significant difference between preoperative and postoperative carpal height ratios (p = 0.086). Conclusions Our early term results indicate that lunate excision combined with capitohamate fusion may be an alternative treatment option in patients with stage IIIB and IIIC Kienböck's disease. Level of Evidence Level IV, Therapeutic study.
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Parwaiz H, Elnikety S. More than 40 years' follow-up of an unconstrained metal lunate replacement for the treatment of Kienböck's disease. BMJ Case Rep 2018; 2018:bcr-2017-223546. [PMID: 29545435 DOI: 10.1136/bcr-2017-223546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Kienböck's disease is characterised by avascular necrosis of the lunate bone, and over the years it has been a challenging disease to manage, with differing opinions on the best intervention. We present an interesting case of a metallic unconstrained lunate replacement that is still functioning well in a patient 40 years after surgery. This case report represents the longest follow-up of any such prosthesis.
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Affiliation(s)
- Hammad Parwaiz
- Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Bath, UK
| | - Sherif Elnikety
- Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Bath, UK
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Havulinna J, Jokihaara J, Paavilainen P, Leppänen OV. Keyhole Revascularization for Treatment of Coronal Plane Fracture of the Lunate in Kienböck Disease. J Hand Surg Am 2016; 41:e441-e445. [PMID: 27663052 DOI: 10.1016/j.jhsa.2016.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/19/2016] [Indexed: 02/06/2023]
Abstract
Coronal plane fracture of lunate in Kienböck disease is a challenging problem with no proven treatment. We present a technique for the treatment. A vascularized bone graft from the distal radius employing the fourth and fifth extracompartmental artery pedicles is used as a mechanical support in order to enable fracture union. The technical pearls and pitfalls are described and a clinical case is presented.
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Affiliation(s)
| | - Jarkko Jokihaara
- Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland
| | - Pasi Paavilainen
- Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland
| | - Olli V Leppänen
- Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland; Medical School, University of Tampere, Tampere, Finland.
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White C, Benhaim P, Plotkin B. Treatments for Kienböck disease: what the radiologist needs to know. Skeletal Radiol 2016; 45:531-40. [PMID: 26802001 DOI: 10.1007/s00256-016-2332-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/12/2015] [Accepted: 01/06/2016] [Indexed: 02/02/2023]
Abstract
The etiology of Kienböck disease, or avascular necrosis of the lunate, is controversial, and there are a myriad of treatments aimed at correcting the various hypothesized pathologies. Interventions to reduce mechanical stress on the lunate have been used for decades, including radial osteotomy with or without radial shortening, ulnar lengthening and metaphyseal core decompression procedures. However, these procedures require preservation of lunate architecture. Newer procedures to revascularize the lunate bone have emerged in the last 10 years, such as pedicled corticoperiosteal vascularized bone grafting. Once there is collapse of the radiocarpal joint or midcarpal arthrosis, the conventional treatments have included proximal row carpectomy and complete or partial wrist joint arthrodesis. Newer salvage procedures such as lunate excision with autologous or synthetic interposition grafts are now being used when possible. As this disease is relatively rare, radiologists may not be familiar with the expected post-operative radiologic findings and complications, especially of the newer treatments. The goals of this paper are to review the available treatment options and their expected appearance on postoperative imaging, with discussion of possible complications when appropriate.
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Affiliation(s)
- Carissa White
- Department of Radiology, University of California, Los Angeles, 757 Westwood Blvd. Suite 1638, Los Angeles, CA, 90095, USA.
| | - Prosper Benhaim
- Department of Orthopaedic Surgery, University of California, Los Angeles, 10945 Le Conte Ave, Room 33-55 PVUB, Box 957326, Los Angeles, CA, 90095, USA
| | - Benjamin Plotkin
- Department of Radiology, University of California, Los Angeles, 1250 Sixteenth Street, Box 957036, Santa Monica, CA, 90404, USA
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Li C, Su YY, Xu XS, Zhou TH, Fan XY, Xu YQ. Biomechanical Comparison of Two Surgical Methods in Treating Stage IIIb Lunate Necrosis. J HARD TISSUE BIOL 2016. [DOI: 10.2485/jhtb.25.213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Chuan Li
- Department of Orthopedic Surgery, Kunming General Hospital
| | - Yong-Yue Su
- Department of Orthopedic Surgery, Kunming General Hospital
| | - Xiao-Shan Xu
- Department of Orthopedic Surgery, Kunming General Hospital
| | - Tian-Hua Zhou
- Department of Orthopedic Surgery, Kunming General Hospital
| | - Xin-Yu Fan
- Department of Orthopedic Surgery, Kunming General Hospital
| | - Yong-Qing Xu
- Department of Orthopedic Surgery, Kunming General Hospital
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Xu Y, Li C, Zhou T, Su Y, He X, Fan X, Zhu Y. Treatment of Aseptic Necrosis of the Lunate Bone (Kienböck Disease) Using a Nickel-Titanium Memory Alloy Arthrodesis Concentrator: A Series of 24 Cases. Medicine (Baltimore) 2015; 94:e1760. [PMID: 26496298 PMCID: PMC4620833 DOI: 10.1097/md.0000000000001760] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Yongqing Xu
- From the Department of Orthopedic Surgery, Kunming General Hospital, Kunming, Yunnan, China (YX, CL, TZ, YS, XH, XF, YZ)
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Outcomes assessment of lunate replacement arthroplasty with intrinsic carpal ligament reconstruction in Kienböck's disease. Hand (N Y) 2014; 9:364-9. [PMID: 25191169 PMCID: PMC4152445 DOI: 10.1007/s11552-014-9624-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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