Comparison of Long-Term Outcomes of Radial Osteotomy and Nonoperative Treatment for Kienböck Disease: A Systematic Review

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.

Novel Descriptions of the Radial Osteotomy in Kienböck's Disease: A Systematic Review

Purpose

Kienböck's disease consists of intrinsic and extrinsic characteristics that coalesce into a pathology with multifactorial etiology. Mechanical, morphological, and vascular factors have been identified as contributory. Radial osteotomy is one of the most commonly used surgical treatment for late-stage Kienböck's disease. Despite its frequent use and reported value, the specifics of radial osteotomy have not been described in aggregate. Our objective was to review the recent literature for descriptions of the radial osteotomy techniques used for treatment of Kienböck's disease.

Methods

The inclusion criteria for the systematic review were as follows: (1) patients aged >18 years, (2) a publication date no older than 2012, and (3) a complete description of the distal radius osteotomy technique, including verbiage that specified numeric dimensions of bony resection or verbiage that detailed a goal in terms of a radiographic parameter that would guide the bony resection.

Results

The studies were grouped according to the stated description of radial osteotomy. This process yielded the following three main groups: (1) studies that used radial shortening, (2) studies that used lateral closing wedge osteotomy or combined lateral closing wedge with radial shortening, and (3) novel osteotomy descriptions.

Conclusions

The Kienböck's disease literature predominantly describes an osteotomy to shorten the radius by 2-3 mm. In some studies, the degree of radial shortening corresponded to the value necessary to achieve near-neutral ulnar variance. The common goal in using lateral closing wedge osteotomy was to achieve a radial inclination of 5° to 15°. Unique wedge resections, some with multiplanar corrections, have been recently described with each purporting specific advantages.

Clinical relevance

Our findings support the premise of mechanical and biologic efficacy for radial osteotomy, with satisfactory results being reported across a wide spectrum of osteotomy techniques.

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.

Kienböck's disease: preventing disease progression in early-stage disease

Currently Kienböck's disease remains an 'unsolved' problem in hand surgery. Different factors have been associated with the avascular necrosis of the lunate. Mechanical, vascular and biological factors, alone or in combination, may have an influence in the aetiopathogenesis and determine the progress of the disease and even the results of the treatment. This is especially relevant in the early stages, in which conservative or surgical treatment may modify the natural history of the disease, maintaining the lunate structure and thus preserving the joint surfaces. There are multiple surgical treatments for Kienböck's disease in the early stages, before lunate collapse; each one is based on one of the possible factors that can cause avascular necrosis of the lunate. The objective is not only to treat symptoms but to prevent progression. This article is a review of the most frequent treatments used in the early stages and a personal view of the authors.Level of evidence: V.

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.

The association of three anatomical factors with ulnar-sided wrist pain: a radiological study

BACKGROUND

Ulnar-sided wrist pain is associated with the development of multiple wrist pathologies. But the anatomical etiologies have not been fully understood.

PURPOSE

To determine the association of three anatomical factors with ulnar-sided wrist pain, including ulnar variance (UV), distal ulnar volar angle (DUVA), and pisiform-ulnar distance (PUD).

MATERIAL AND METHODS

A total of 64 patients who had ulnar-sided wrist pain associated with training injuries were retrospectively studied. A control group included 64 healthy athletes from the same unit. The UV, DUVA, and PUD of each individual was measured on radiographs.

RESULTS

The average UV and DUVA of those in the ulnar-sided pain group were 0.84 mm and 174.65°, respectively; the control group values were 0.39 mm and 175.11°. The differences between the two groups had no statistical significance (P > 0.05). The average PUD of the ulnar-sided wrist pain group was shorter than that of the control group (2.37 cm vs. 2.65 cm); the difference had statistical significance (P < 0.05). PUD had a negative correlation with ulnar-sided pain; it was an anatomical protective factor (odds ratio = 0.01; P < 0.00; 95% confidence interval=0.00-0.05). Both UV and DUVA had no significant correlations with ulnar-sided wrist pain (P > 0.05).

CONCLUSION

PUD has a significant correlation with ulnar-sided wrist pain. It is the anatomical protective factor. Both the UV and DUVA have no statistical association with ulnar-sided wrist pain, but we cannot ignore their potential pathogenic effects on wrists, and further studies are needed to confirm the results.

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.

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.

Treatment of Stages IIIA and IIIB in Kienbock's Disease: A Systematic Review

Background  Despite numerous proposed surgical interventions, there is a lack of consensus in the optimal treatment of advanced Kienbock's disease. Purpose  This study aims to perform a systematic review of the current evidence in the management of Lichtman's stages IIIA and IIIB of the disease. Methods  A literature search was performed using the MEDLINE, EMBASE, and COCHRANE databases to identify studies between 2008 and 2018 evaluating stage-specific outcomes in Lichtman's stages IIIA and IIIB. The quality of each included paper was evaluated using the Structured Effectiveness Quality Evaluation Scale (SEQES). Data extracted were stage-specificity, clinical and functional outcomes, and radiographic progression of Lichtman's staging. Results  A total of 1,489 titles were identified. Eighty-three papers were fully reviewed, and 30 articles met eligibility criteria for inclusion. There were 3 low-quality and 27 moderate-quality papers. Surgical techniques reported included decompression surgeries, joint-levelling, and radial wedge osteotomies, revascularization techniques, intracarpal arthrodesis, proximal row carpectomy, arthroplasty, and balloon kyphoplasty. All treatment modalities offered pain relief and improvement in functional outcomes. Compared with proximal row carpectomy, intracarpal arthrodesis, and arthroplasty, nonsalvage procedures provided similar clinical and functional outcomes in both stages, with joint-levelling and radial wedge osteotomies preserving greater range of motion. Conclusion  In this systematic review of Kienbock's disease stages IIIA and IIIB, all treatment modalities provided positive outcomes. In stage IIIB, there is evidence to support nonsalvage procedures, as they produced similar clinical outcomes to salvage procedures that have the advantage of not precluding future treatment options if needed and preserving greater range of motion.

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

We inserted a pronator quadratus pedicled bone graft into the avascular lunate with preservation of its corticocartilaginous portion for the treatment of Kienböck disease. Twenty-seven patients (14 men, 13 women; mean age, 42 years (range 17-66 years)) were treated between September 2005 and July 2014 and followed up from 2 to 12 years. Three patients had Lichtman stage II disease, 13 had stage IIIA, and 11 had stage IIIB. Among them, 18 patients showed radiological improvement in lunate morphology. The Lichtman stage was unchanged in 23 patients and aggravated in four patients. The Stahl index was significantly decreased, but grip strength was significantly improved and 18 patients did not have any wrist pain during daily activities. Although our technique did not restore the already changed carpal malalignment, it improved lunate morphology. Clinically, it provided satisfactory pain levels in two-thirds of the patients and grip strength was improved. Level of evidence: IV.

Kienböck's disease: Where do we stand?

Avascular necrosis of the lunate, commonly known as Kienböck's disease is a disorder that can lead to carpal collapse and the need for surgeries, which can stabilize the wrist. There are different associations with the disease but the exact etiology is unknown. Kienböck's disease is believed to result from mechanical and vascular factors in genetically predisposed individuals. The newer classification based on advanced wrist arthroscopy and MRI help in a better understanding of the disease, early diagnosis, and treatment. A review of recent literature regarding newer treatment options has shown good results in the early stages of osteonecrosis. This article intends to review an update on the etiopathogenesis, classification, and the current advanced treatment options.