Advanced Kienbock Research Articles

Tendon ball arthroplasty and proximal carpal stabilization with tendon graft for advanced Kienbock's disease.

This study reports the surgical technique and outcomes of tendon ball arthroplasty combined with proximal carpal stabilization using the extensor carpi radialis longus tendon for treating advanced Kienbock's disease. The collapsed lunate is excised and a tendon ball inserted as a spacer. A distally based extensor carpi radials longus graft is passed through the scaphoid, tendon ball and triquetrum, reconstructing the proximal carpal row. In total, 16 patients were included and the mean follow-up was 25 months. Pain improved from 5.6 preoperatively to 1.3 postoperatively on a 10-point visual analogue scale. Mean wrist motion improved by 17.8° and grip strength compared with the non-operative side increased by 22.1% on average. Radiographic outcomes demonstrated correction of scaphoid flexion and carpal height ratio. The modified tendon ball arthroplasty may be an alternative wrist salvage procedure for the treatment of advanced Kienbock's disease.Level of evidence: IV.

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

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. 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. 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. 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.

Wrist Salvage Procedures for the Treatment of Kienbock's Disease.

Kienbock's disease is a progressive condition characterized by lunate collapse, carpal instability, and eventually perilunate arthritis. Etiology is likely multifactorial, including vascular and anatomic or osseus causes. In cases of advanced disease, disabling pain, limited motion, and decreased grip strength may be present. The preferred treatment options for the nonreconstructable wrist are proximal row carpectomy (PRC), total wrist arthrodesis, and total wrist arthroplasty (TWA). In the following chapter, we will discuss various surgical options for patients with advanced Kienbock's disease.

Management of type 3 Kienbock's disease in manual workers by scaphocapitate fusion with minimum 7-year follow-up

BackgroundKienbock's disease results in altered wrist biomechanics producing debilitating pain at the wrist. The disease is staged according to radiological and clinical findings and the stage guides the treatment. Various treatment options have been described for stage 3, however, there is a lack of consensus over these treatment methods. Scaphocapitate fusion is the preferred surgical option for advanced Kienbock's disease. Previous studies had heterogeneous cohorts with a short duration of follow-up and a lack of uniform surgical technique. The purpose of the study was to show the long-term functional and radiological outcome of scaphocapitate arthrodesis (SCA) by using Herbert screw for the treatment of Kienbock's disease in manual workers. MethodsFor this single-centre, retrospective study, all consecutive patients who were manual workers and managed by SCA between January 2010 and Jan 2014 for Lichtman stage IIIA and IIIB with at least 7 years of follow-up were included. Patients were assessed using clinical and radiological parameters preoperatively and in the follow-up period. Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Related Wrist Evaluation (PRWE), and VAS for pain were assessed. ResultsOut of 27 patients, 4 lost to follow-up, therefore, 23 patients (14 women and 9 men) with 30 years of median age at the time of the surgery were included. DASH scores, PRWE scores, and VAS for pain significantly improved (p < 0.5) after surgery. Wrist range of motion and grip strength also improved significantly (p < 0.5). Postoperative radiological parameters were found to be within a normal range. ConclusionScaphocapitate fusion by Herbert screws gives good functional, clinical, and radiological outcomes, in stage 3 of Kienbock's disease with excellent rates of fusion with low complications. Even, in manual workers, scaphocapitate fusion can reliably provide good outcomes and this is maintained in the mid to long-term follow-up. Therefore, it should be considered as one of the procedures of choice. Level of evidenceRetrospective, Level 4.

Enfermedad de Kienböck: conceptos actuales

La osteonecrosis del semilunar o enfermedad de Kienböck es un cuadro progresivo y debilitante que puede llevar al dolor crónico y la pérdida de la función. Pese a que se conoce hace más de 100 años, la etiología todavía es incierta, si bien se la ha relacionado con factores mecánicos, vasculares y traumáticos. Su evolución natural está pobremente definida y los hallazgos radiográficos no siempre se correlacionan con los hallazgos clínicos. Se han logrado avances para identificar y entender la progresión del proceso avascular y sus efectos nocivos sobre la mecánica de la muñeca. El tratamiento inicial es no quirúrgico. El perfeccionamiento de la técnica quirúrgica utilizando injertos óseos vascularizados de radio distal puede mejorar los resultados en los pacientes que cursan etapas tempranas de la enfermedad, aunque resta mucho trabajo para determinar si este tratamiento quirúrgico representa una mejor opción que los tratamientos tradicionales. Reportes recientes de resultados a largo plazo de la osteotomía de acortamiento del radio para estadios tempranos de la enfermedad y la resección de la primera fila del carpo para estadios avanzados revelan que estos procedimientos son una opción válida para el tratamiento a largo plazo de este cuadro de difícil manejo.

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.

Treatment of Advanced Kienbock's Disease (Lichtman Stage IIIB with Carpal Collapse) by a Shortening Osteotomy of the Radius: 21 Cases.

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.

Surgical interventions for Kienbock's disease: An update

Numerous surgical interventions have been reported for the treatment of Kienbock's disease. However, there is no consensus on the appropriate surgical interventions for the different stages of Kienbock's disease. The present review aims to evaluate and summarise the various surgical interventions and their outcomes in Kienbock's disease. Various electronic databases were searched to identify articles related to surgical interventions. Based on the stage of disease, various surgical options are available that can provide a successful outcome. These surgical procedures include proximal row carpectomy, total wrist arthrodesis, scapho-trapezio-trapezoid arthrodesis, excisional arthroplasty, vascularised bone grafting (VBG), radial shortening osteotomy, radial corrective osteotomy, capitate shortening osteotomy combined with or without VBG and tendon ball arthroplasty and are commonly utilised. Majority of surgical procedures had shown good results in selected patients with advanced Kienbock's disease. In this review, the surgical interventions at an early and late stage of Kienbock's disease will be discussed.

Limited intercarpal fusion as a salvage procedure for advanced Kienbock disease.

With progressive lunate collapse, salvage procedures in advanced Kienbock disease attempt to provide pain relief and maintain motion. Scaphocapitate arthrodesis may provide a durable option with comparable outcomes to proximal row carpectomy in the well-selected patient. We performed a retrospective chart review of all consecutive patients with Lichtman stage IIIA or IIIB Kienbock's disease who underwent either scaphocapitate or scaphotrapeziotrapezoid-capitate arthrodesis from January 2004 to December 2013. Twelve patients were included with a mean age of 41.6years. Ten patients underwent scaphocapitate arthrodesis, while two patients underwent scaphotrapezio-trapezoid-capitate arthrodesis with an average clinical follow-up of 13.1months. All patients achieved fusion. The average postoperative flexion-extension arc was 53° (range 20-110°). The average ulnar deviation was 9° (range 5-15°), and the average radial deviation was 13° (range 5-25°). Postoperative pain scores were significantly improved, having changed from an average of 6.6 preoperatively to 2.8 on a 10-point scale (W = 18, P < 0.05). Despite a mean flexion-extension arc that is reduced from that of a normal individual, the postoperative range of motion following a midcarpal arthrodesis was not significantly different than that reported in a recent systematic review of proximal row carpectomy (73.5° compared with 53°, respectively) (P = 0.05). Additionally, given the significant postoperative reduction in associated pain symptoms at the time of follow-up, scaphocapitate arthrodesis should be considered as a treatment option for wrist salvage in the patient with advanced Kienbock's disease.

Performance Characteristics of the Verbal QuickDASH

To quantify the performance of the verbally administered Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire by assessing its replication of self-administered scores, its test-retest reliability, and its rate of scorable completion compared with its self-administered, written administration. Fifty patients presenting for initial visits to a hand clinic were enrolled regardless of diagnosis. All patients completed a written and a verbal QuickDASH 1 day apart (25 patients written first; 25 patients verbal first). Intraclass correlation coefficients quantified the verbal questionnaire's ability to reproduce written scores. Participants verbally completed the questionnaire a final time, 5 months later, to assess test-retest reliability. To quantify the usability of survey data, we compared percentages of scorable surveys between written and verbally administered QuickDASH questionnaires in this study and in prior studies within our division. The intraclass correlation coefficient between the 2 QuickDASH administration types for the entire sample was 0.91. Across all participants, there was a minimal change in mean score from a patient's written QuickDASH to that patient's first verbal QuickDASH score. Scoring consistency between QuickDASH administrations was similar for each administration sequence (phone followed by written vs. written followed by phone) and by diagnosis. Test-retest reliability between the 2 verbal administrations demonstrated good reliability and a minimal difference between scores. In this study, no written or verbal surveys were incomplete. Reviewing our practice, 17% of 258 written questionnaires produced unscorable data compared with 0% of 239 verbally administered surveys. Our results indicate that verbal administration of the QuickDASH replicates clinically relevant scores of the written QuickDASH, has good test-retest performance, andmay minimize unusable data. These data allow researchers greater flexibility in gatheringpatient outcome data in both retrospective and prospective studies. Diagnostic II.

Management of Wrist Arthritis Secondary to Advanced Kienbock Disease

Summary: This review will discuss various surgical options available to the hand surgeon treating advanced Kienbock disease. Development of the extensive wrist arthritis changes seen in stage IV Kienbock disease is a contraindication to techniques which focus on lunate unloading or revasuclarization. Instead, the focus must be on salvage procedures, such as total wrist arthrodesis, proximal row carpectomy, total wrist arthroplasty, or lunate arthroplasty (excision alone, or with various implants).

Outcomes of advanced Kienbock' s diseases treated by vascularized pedicled distal radius bone graft

Objective To investigate the outcomes of advanced Kienbock' s diseases treated by vascularized pedicled distal radius bone flap transfer.Method Two patients with advanced Kienbock's diseases ( type Ⅴ) underwent distal radius bone flap transfer pedicled by dorsal branches of the radial artery.The observations included pain evaluation,radiography,function assessment of the wrist ( range of motion and Krimmer scale),and quality of life ( DASH questionnaire).Results Pain disappeared after surgery in both patients at rest,and reduced in intensity to a mild level during wrist motion.In one patient,X-ray showed the high density image of the lunate had disappered and now bone had formed.In the other patient,there was no aggravation in X-ray or MRI.According to the assessment of hand function,the Krimmer score and DASH score were higher comparing with that assessed before the operation.Conclusion Distal radius bone flap transfer pedicled by dorsal branches of the radial artery is a feasible procedure to treat advanced Kienbock's diseases,with favorable preliminary results. Key words: Kienbock' s disease; Surgical procdures,operative; Bone flaps

Retrospective Study of Clinical Results of Anthovy's Technique with Scaphocapitate and Hamatocapitate Arthrodesis in Advanced Kienbock's Disease

Purpose : A retrograde analysis of the clinical results of 11 cases of Kienbock's disease (Lichtman stage III), who underwent surgery for scaphocapitate or hamatocapitate arthrodesis followed by a rolled palmaris tendon replacement after a collapsed lunate excision. Materials and Methods : This study followed-up 11 patients diagnosed with advanced Kienbock's disease for more than 5 years from January 1989 through May 2000. The patient’s age ranged from 25 to 65 years old. Among the 11 patients, 7 patients received hamatocapitate arthrodesis, and the remainder received scaphocapitate arthrodesis. The Evans’ scoring system was used for the clinical evaluation. Results : After surgery, all patients showed complete radiologic fusion and an increase in grip strength, and most patients showed an increase in the ROM of a wrist joint, particularly in the group who received hamatocapitate arthrodesis. Conclusion : In advanced Kienbock’s disease, a lunate excision followed by rolled tendon replacement with limited intercarpal arthrodesis showed relatively good results during the follow-up period, and had a particularly better ROM of the wrist joint in hamatocapitate arthrodesis, than the scaphocapitate arthrodesis because of the arthrodesis between the proximal and distal carpal row in the biomechanical aspect of the carpal bone.

Triscaphe Fusion in the Treatment of Kienbock's Disease: Comparison of Lunate Preservation and Excision

Purpose : To evaluate the necessity and effectiveness of a lunate excision in triscaphe fusion for the treatment of advanced Kienbock's disease. Materials and Methods : Twenty-six patients who underwent a triscaphe fusion for Kienbock's disease (IIIb) were analyzed. Fifteen patients received triscaphe fusion only and 11 patients received triscaphe fusion and a lunate excision. The indication for a lunate excision included pain and limited motion due to posterior impingement associated with a severely collapsed lunate. The range of motion and modified Mayo wrist score in the two groups were compared. The carpal height ratio, ulnocarpal distance ratio and radioscaphoid angle were measured on the plain radiographs, and the presence of degenerative change was evaluated. Results : The mean extension range was more preserved in the lunate excision group than in the lunate preserving group. Several radiology indices were similar in the two groups, but a degenerative change in the radioscaphoid joint was observed in 45.5% of the lunate excision group and in 13% of the lunate preserving group. Conclusion : When performing the triscaphe fusion in advanced Kienbock's disease, excision of the lunate can relieve the symptoms of posterior impingement. However, this procedure should be carried out carefully because degenerative changes in the radioscaphoid joint are frequently observed.

Wrist fusion versus limited carpal fusion in advanced kienbock's disease

We treated 18 patients with advanced Kienbock's disease surgically. Six had total wrist fusions and 12 had limited carpal fusions. The average age was 39.6 yrs and the average follow up was 61.8 months and 66.8 months respectively. The visual analogue pain scores, the patient satisfaction scores and the SF 12 were better in the total wrist fusion group. The DASH (Disabilities of the Arm, Shoulder and Hand) scores, the range of movement and the grip strengths were better in the limited carpal fusions group but this was not statistically significant. Four patients with limited carpal fusions had a non-union that required revising. We believe that total wrist fusion should be offered earlier to patients with advanced stages of the disease, as there are less surgical failures, more satisfied patients, better post operative pain scores and consistent long-term results with less potential for further deterioration with time as compared to other treatment methods.

Proximal row carpectomy in advanced kienbock's disease

This retrospective study assessed the outcomes of 21 patients (16 male and 5 female, mean age 39 years) with advanced Kienbock's disease treated by resection of the proximal carpal row. They were clinically reviewed. The mean follow-up was 67 months, with all but two patients having had a follow-up of 2 years. No or mild pain was being experienced by 13 patients, moderate pain by 3 and severe pain by 5. Grip strength increased from 19 kg pre-operatively to 26 kg postoperatively (or 65% of the normal contralateral side). There was a slight increase of mobility. The DASH score was 22 points (range 0-78) and the Patient Rated Wrist Score (PRWS) was 30 points (range 0-84). Two patients developed Complex Regional Pain Syndrome which was ongoing at the time of review and one developed a superficial wound infection. Proximal carpal row resection arthroplasty gave satisfactory results in patients with advanced Kienbock's disease.

進行期Ｋｉｅｎｂｏｅｃｋ病に対するとう骨骨切り術の検討 Ｘ線学的解析

Radial osteotomy has been recommended for stages II and III-a of Kienbock's disease because of it's load decreasing effect on the lunate. Recently usefullness of this procedure in the tratment of advanced stage Kienbock's disease has been demonstrated clinically by several authors. In contrast, the effects of this procedure on the biomechanics of the degenerative arthritis of wrist advanced Kienbock's disease are unclear. In this study, we studied 17 patients with stage III and IV Kienbock's disease to analyse the precise radiographic consequence of radial wedge osteotomy for progressive stage Kienbock's disease.12 patients who underwent the radial closing wedge osteotomy and 5 patients who underwent radial shortening osteotomy for the treatment of advanced Kienbock's disease were reviewed clinically and radiographically. There were 7 males and 10 females, whose average age was 51 years. 5 were stage III-a, 10 were III-b and 2 were stage IV. The average follow-up period was 2 years and 3 months. The following measurements were made for radiographic assessment: the angle of radial inclination, ulnar variance, carpal height ratio, Stahl index, radio-lunate angle, radio-scaphoid angle, scapho-lunate angle, carpal-ulnar distance ratio, lunate covering ratio, and ring to proximal pole distance.The radial inclination decreased from 26.8° to 15.7 in the wedge osteotomy group. The ulnar variance increased 2mm in the radial shorening group. The carpal height ratio decreased from 0.509 to 0.504 and Stahl index increased from 36% to 37%, both without statistical significance (p<0.01) in the wedge osteotomy group. In addition, the radio-scaphoid angle increased significantly (p<0.01) in the wedge osteotomy group.The increased lunate covering ratio is believed to increase the area of distribution of the axial load through the lunate by increasing the contact area with the radius. In addition, the increased radio-scaphoid angle is believed to correct the radio-carpal malalignment in patients with advanced stage Kienbock's disease. The satisfactory clinical outcome of radial closing wedge osteotomy is believed to be due to both these effects on carpal alignment.

進行期キーンベック病に対するとう骨くさび状骨切り術の治療成績とＸ線解析の検討

The treatment of advanced stages of Kienbock's disease (stage III-B and IV according to Lichtman's classification) consists of several methods. We performed radial closing wedge osteotomy for eleven patients with advanced stages of Kienbock's disease from 1990 to 1998. Seven patients were followed up for more than 6 months. All patients were female with an average age of 50.1 years. Five were stage III-B and 2 were stage IV. All patients underwent radial wedge osteotomy. The average follow-up was 3.5 years. Pain in the wrist, grip strength and wrist range of motion were assessed preand post operatively and Nakamura's scoring system was applied as postoperative clinical status. The following measurements were made pre-and postoperatively for radiographic assessment: the carpal height ratio, Stahl's index, carpal-ulnar distance ratio, lunate covering ratio, radio-lunate angle, scapho-lunate angle, and radio-scaphoid angle. All patients were relieved from pain of the wrist and returned to their original jobs. Grip strength improved from 54% to 95% of the opposite wrist. Wrist motion also improved, with the flexion-extion arc, from 60% to 83% of the opposite side. Clinical results were good in 4, fair in 2 and poor in 1 patients using the Nakamura's scoring system. The carpal height ratio and Stahl'S index decreased from 0.48 to 0.45 and from 33% to 27%, respectively, both without statistical significance. The carpal-ulnar distance ratio and the lunate covering ratio increased significantly (p<0.002), from 0.29 to 0.39 and from 68% to 84%, respectively. In addition, the radio-scaphoid angle was improved from 75.1° to 67.1° with statistical significance (p<0.01). Furthermore, the improvement of the radio-scaphoid angle and Nakamura's postoperative clinical score correlated significantly (p<0.001). Our study demonstrates that radial closing wedge osteotomy offers the advantage of improving not only wrist symptoms but also scaphoid rotation in patients with advanced Kienbock's disease.

A comparative study of the surgical procedures to treat advanced Kienbock's disease

We have treated a total of 16 cases of advanced Kienböck's disease, stage III and IV by Lichtman's classification, with triscaphe fusion, tendon ball replacement arthroplasty after excision of lunate, proximal row carpectomy as a salvage procedure and limited wrist fusion, since 1985. All cases were followed for minimal 16 months after each operation. Tendon ball replacement arthroplasty after excision of lunate could not prevent further carpal collapse with persistent chronic wrist pain. The triscaphe fusion or radio-lunate fusion induced a marked limited wrist motion later, and the triscaphe fusion alone was not fit for the treatment of advanced one because of progressive proximal migration of capitate and continuous wrist pain due to ligamentous carpal instability in follow-up. So we tried to simultaneously combine tendon ball replacement arthroplasty after excision of lunate with triscaphe fusion in far advanced Kienböck's disease, and their end results was favorable. Proximal row carpectomy could be done in far advanced Kienböck's disease with reasonably painless wrist motions. The overall end results of proximal row carpectomy are much better than any form of carpal arthrodesis. Conclusively the proper way to treat advanced Kienböck's disease seems to depend on the patient's age, their job and sex, and the stage of disease. And the cause of wrist pain in advanced Kienböck's disease seems due to ligamentous carpal instability rather than osteoarthritis on radio-lunate joint.