Pronator quadratus pedicled bone graft in the treatment of Kienböck disease: follow-up 2 to 12 years

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Clinical Outcomes of Patients with Stage II and IIIA Kienböck's Disease After Undergoing Conservative Management

PURPOSE

The current study aimed to demonstrate the outcomes of patients with Lichtman stage II and IIIA Kienböck's disease with mild pain and good range of motion (ROM) after conservative management. We hypothesized that we can conservatively manage patients with early-stage Kienböck's disease including those with stage IIIA.

PATIENTS AND METHODS

This study is a retrospective case series. Between January 2012 and December 2017, 38 patients were enrolled in this study. The mean follow-up period of conservatively managed group was 49.1 months. The flexion-extension (FE) arc, grip strength, Pain Visual Analog Scale (pVAS), Modified Mayo Wrist Score (MMWS), and disabilities of the arm, shoulder, and hand (DASH) score were determined for functional evaluation. The radiographic parameters were assessed using the Stahl's index and carpal height ratio. The morphological changes in the lunate were also evaluated with plain radiographs.

RESULTS

A total of 31 of 38 patients (81.6%) showed favorable outcomes after conservative treatment. The mean pVAS score, MMWS, and DASH score showed statistically significant improvement, as well as the morphology of lunates on the plain radiograph. The mean FE arc was slightly decreased without statistical significance. The grip strength showed improvement with statistical significance. One patient showed the same radiographic morphology, but did not manifest any pain. A total of five (13.2%) patients who experienced aggravated pain and decreased ROM underwent surgical treatment. The other patient required surgical intervention but was provided conservative treatment due to her circumstances.

CONCLUSION

Favorable outcomes can be expected in patients with Lichtman stages II and IIIA avascular necrosis of the lunate (Kienböck's disease) with mild pain and good ROM who undergo conservative management.

LEVEL OF EVIDENCE

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.

Improvement in lunate perfusion after radial closing-wedge osteotomy in patients with Kienböck's disease

Radial closing-wedge osteotomy is a widely accepted treatment for Kienböck's disease. However, despite favorable long-term clinical outcomes, its impact on lunate perfusion has not been documented. The purpose of this study was to determine whether radial closing wedge osteotomy improved lunate perfusion on gadolinium (Gd)-enhanced magnetic resonance imaging (MRI). We conducted a retrospective review of 12 patients with Kienböck's disease who received radial closing wedge osteotomy. Mean age at surgery was 25 years. Preoperative Gd-enhanced MRI was performed in 7 patients. After bone union, implants were removed and MRI was repeated. Two patients were classified as Lichtman stage IIIA, and 5 as stage IIIB. Percentage pre- to post-operative perfused lunate volume was compared on MRI. At last follow-up, mean QuickDASH score improved from 43.7 to 6.2. Pre- to post-operative lunate fragmentation, collapse and perfusion were compared qualitatively on MRI. On quantitative analysis, perfusion increased from 24% to 54% (p = 0.018) using our method of measuring percentage perfused lunate volume. The method showed satisfactory reproducibility. Investigation using Gd-enhanced MRI suggested that radial closing wedge osteotomy increases lunate perfusion.

Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.