Long-Term Outcomes of Distal Radius Metaphyseal Core Decompression for Kienböck Disease Stage IIIa

Abstract

Background: Stage IIIa of the Lichtman classification is characterized by collapse of the lunate, with preservation of carpal height and intercarpal alignment. Although joint-leveling procedures and revascularization techniques have become the standard treatment during the past decade, these procedures have not been able to reverse Kienböck disease, and as many as 25% of patients have reported complications including infection, nonunion, and ulnar impingement. Core decompression techniques for the treatment of Kienböck disease stage I and II had demonstrated similar benefits as joint-leveling procedures (reduction in pain, improvement in functional activity, and improvement of motion) but a much simpler technique with almost no complications. The purpose of this study is to analyze the long-term clinical and radiological outcomes of a series of patients with Kienböck disease stage IIIa of the Lichtman classification treated with distal radius core decompression. Material and Methods: This retrospective study included 14 patients with Kienböck disease (Lichtman stage IIIa) who received distal radius metaphyseal core decompression between 1998 and 2005 and were followed-up for at least 10 years. Exclusion criteria were patients with previous surgery of the wrist, presence of osteoarthritis, and a history of major wrist trauma. At the last follow-up, the patients were evaluated for pain, comparative wrist range of motion and grip strength, and wrist functional status. The overall results were evaluated by the modified Mayo wrist score and visual analogue scale (VAS) pain score. We also compared the radiological changes preoperatively and postoperatively in their Lichtman classification and the modified carpal height ratio. Results: The mean follow-up period was 13 years (range, 10-18). The mean age of the patients was 42 years old (range, 28-64); 9 were men. Based on the modified Mayo wrist Score, clinical results were excellent in 6 patients, good in 7 patients, and poor in 1 patient who require a proximal row carpectomy as revision surgery. The mean postoperative pain was VAS 1.5 (range, 0-7). Moreover, at the final follow-up, 10 of the 14 patients had VAS either 0 or 1. Compared with the opposite side, the average flexion/extension arc was 76% and the grip strength was 78%. All patients, except one, returned to their original employment. Radiographic disease progression according to the Lichtman classification to stage IIIb to IV occurred in one wrist, while the other patients remained in the same stage as preoperatively. The average preoperative modified carpal height ratio was 1.38 (range, 1.5-1.28) and the postoperative was 1.34 (range, 1.42-1.25). There were no complications related to the metaphyseal core decompression. Summary Points: (1) In this limited series, distal radius metaphyseal core decompression demonstrated favorable long-term results and is recommended as a surgical alternative for stage IIIa of the Kienböck disease. (2) This procedure may be a reasonable option for patients who prefer a simpler operation that may have a good result and allows to perform a more complex alternative if needed.