Lichtman Stage Research Articles

Long-Term Clinical and Radiological Outcomes of Radial Shortening Osteotomy and Vascularized Bone Graft in Kienböck Disease

To evaluate the long-term (> 5 y) outcomes of radial shortening osteotomy and vascularized bone graft in Kienböck disease patients. In a retrospective study of 16 patients with early stage Kienböck disease, 9 patients with average follow-up of 6.4 years had radial shortening osteotomy (group 1), and 7 with average follow-up of 6.5 years had pedicled vascularized bone graft based on the distal radius 4 + 5 extensor compartmental artery (group 2). The 2 groups were similar in age, sex, operated side, initial Lichtman stage, and follow-up duration. There were significant differences in ulnar variance between the 2 groups. At the last follow-up, the patients were evaluated for pain, wrist motion, grip strength, functional status, and radiographic assessment. The overall results were evaluated by Cooney wrist function score and Nakamura scoring system for Kienböck disease. The 2 groups had no significant difference in pain, motion, grip strength, and radiologic assessment; however, grip strength percentage was better in group 2. There was no significant difference between the radiographic changes of the 2 groups. In group I, 7 out of 9 patients had satisfactory Nakamura scores, and 5 out of 9 patients had satisfactory Cooney scores. All of the patients in group 2 had satisfactory Cooney and Nakamura scores. The difference in the mean Cooney wrist function score in the 2 groups was significant. The difference of Nakamura scores in the 2 groups was not significant. Both groups had reasonable long-term outcomes. We were unable to recognize a substantial clinical or radiological difference between the 2 surgical treatments in long-term outcome. Therapeutic III.

Scaphotrapeziotrapezoid Arthrodesis and Lunate Excision for Advanced Kienböck Disease

To analyze the outcomes of lunate excision combined with scaphotrapeziotrapezoid arthrodesis for the treatment of advanced Kienböck disease. Sixteen patients with Lichtman stage IIIB Kienböck disease were treated with scaphotrapeziotrapezoid arthrodesis and lunate excision and were followed for a mean of 67 months (range, 49 to 108 mo). The indications for lunate excision included pain and limited motion associated with a collapsed lunate. Clinical evaluation included range of motion, grip strength, and modified Mayo wrist score. Based on plain radiographs, the carpal height ratio, ulnar carpal distance ratio, scaphoid translation ratio, and radioscaphoid angle were measured and any presence of degenerative changes was assessed. To investigate the effects of lunate excision on the radiologic results, we compared 12 patients with stage IIIB Kienböck disease who had only scaphotrapeziotrapezoid arthrodesis as the control group. Range of motion tended to be preserved, with a trend toward an increase in extension after surgery. Grip strength and modified Mayo score improved significantly. Fourteen patients with lunate excision demonstrated radiographic ulnar translation of the scaphoid beyond the scapholunate ridge, and radioscaphoid arthritis was observed in 4 patients. Compared to initial postoperative radiographs, the scaphoid translation ratio was significantly decreased, but neither ulnar carpal distance ratio nor radioscaphoid angle showed significant differences. In the control group, neither ulnar translation of the scaphoid nor significant changes of radiologic parameters was found between initial postoperative and final radiographs. Scaphotrapeziotrapezoid arthrodesis with lunate excision for advanced Kienböck disease provided favorable clinical results in terms of pain relief and functional improvement. With the absence of the lunate, however, the scaphoid had a tendency to shift toward the lunate fossa. This study suggests the risk of early development of radioscaphoid arthritis as a negative effect of lunate excision.

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienböck’s disease: first results of an ongoing observational study

Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienböck's disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienböck's disease. Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients. In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39 % of the opposite hand. Grip strength improved from 52.9 to 62.1 %. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0 % of the opposite hand. Grip strength improved from 38.6 to 69.0 %, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0. One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.

Treatment of Kienböck Disease by Lunate Core Decompression

Kienböck disease is characterized by avascular necrosis of the lunate bone, which is usually progressive without treatment. This study examined lunate core decompression for its treatment potential. We surgically treated 20 patients with stage 1 to 3b Kienböck disease with lunate core decompression. We evaluated pain, range of motion, functional disability, and radiographic indices in these patients at baseline and 5 years after surgery. The mean age of the patients was 29 years; 16 were men. Ten patients had Lichtman stage 1 disease, 6 had stage 2 disease, 3 had stage 3a, and 1 had stage 3b disease. Range of motion scores showed meaningful improvement. Two patients did not improve with this technique and were revised with radial shortening procedures. Lunate core decompression is a simple surgical procedure that is effective in the treatment of Kienböck disease. Therapeutic IV.

Long-term effects of vascularized pisiform transfer for Kienb(o)ck's disease

Objective To evaluate the long-term efficacy of vascularized pisiform transfer for patients with Kienb(o)ck's disease in Lichtman stages Ⅲ-Ⅳ. Methods Eleven patients were reviewed to analyze results after lunate resection and vascularized pisiform transfer for Lichtman stages Ⅲ and Ⅳ. There were six men and five women. Age ranged from 20 to 67 years with a average of 41.0±14.3 years. According to Lichtman stage. There were 4 cases in stage Ⅲa, 5 cases in stage Ⅲb, and 2 cases in stage Ⅳ. Assessment criteria included subjective assessment of pain, visual analogue scale (VAS), range of motion (ROM), grip power,Cooney wrist score and radiographic changes on each follow-up visit. The radiographic changes including pis iform bone location, shape, sclerosis change, osteoarthritis, carpal height ratio, Nattrass index, Radioscaphoid angle and ulnar variance were recorded. Results The follow-up periods of all of cases were 61-202 months,with an average of 104.1 months. Pain had improved in 10 patients and disappeared in 7 cases. The VAS score was 2.2±1.9 at follow-up visit. Range of motion of injured wristw as only 65.3% of opposite side. Grip power was 84.3% of the contralateral hand. According to Cooney score, the results were excellent in 1 case, good in 7cases, fair in 2 cases and poor in 1 case, with the excellent and good rate of 72.7%. Radiologically, 8 cases had normal position of the pisiform bone, 2 had volar displacement and 1 had ulnar displacement which leaded to widen scaphopisiform space. Six pisiform bones had normal trabecular structure, three had degenerative changes. Bone sclerosis was seen in 2 cases and osteoarthritis was found in 3 patients. Compared with radiographic parameter before surgery, carpal height ratio and Nattrass index significantly lowered and radioscaphoid angle significantly increased. Conclusion Lunate resection and vascularized pisiform transfer is an effective method for Kienb(o)k′s disease in stages Ⅲ-Ⅳ. Although carpal collapse appeared postoperatively,the results show high patient satisfaction and good function after vascularized bone transplantation. Key words: Lunate bone; Pisiform bone; Osteonecrosis; Bone transplantation

Lunate Revascularization After Capitate Shortening Osteotomy in Kienböck's Disease

The aim of surgical treatment in the early stages of Kienböck's disease is to decrease compressive loading of the lunate to promote revascularization. Capitate shortening osteotomy is one technique that has been advocated in Kienböck's disease with ulnar neutral or positive variance and Lichtman stage I to IIIA. The purpose of this study was to examine the revascularization process of the lunate after capitate shortening osteotomy. This was a retrospective study of 9 patients with Kienböck's disease with Lichtman stage II or IIIA and ulnar neutral or positive variance. I confirmed avascular necrosis of the lunate in all the patients by magnetic resonance imaging preoperatively. Capitate shortening osteotomy was performed through a dorsal approach and fixed with K-wires. I used magnetic resonance images with fat suppression to detect the revascularization of the lunate after surgery. The mean follow-up was 12 months (range, 8-16 mo). All patients demonstrated partial revascularization of the lunate and the mean revascularization time was 4.7 months (range, 3-7 mo), which was interpreted as the beginning of the revascularization process. Capitate shortening osteotomy is an efficient technique to induce the revascularization process in the early stages of Kienböck's disease. Therapeutic IV.

Der Stellenwert der Arthroskopie bei der Lunatumnekrose

The integrity of the articular surfaces is of major importance for the prognosis and treatment of lunate necrosis (Kienböck's disease). Though arthroscopy is the most reliable method in the diagnosis of intraarticular pathology it is rarely applied in this condition. The purpose of this study was to evaluate the value of arthroscopy in Kienböck's disease. 20 prospectively evaluated patients underwent arthroscopy for Kienböck's disease. Initial diagnosis was performed by enhanced magnet resonance images, standard radiographies and computed tomography. Preoperative staging was performed according to the MRI-adapted classification of Lichtman and Ross . The arthroscopical measures followed standard procedures. Cartilage lesions were rated by an own modified classification. The wrists were further staged according to an arthroscopical classification system for Kienböck's disease (Bain and Begg ). The posterior and anterior interosseus nerves were resected in all patients and, if necessary, an arthroscopical debridement of the lunate performed. No clinical or statistical correlation was found between the Lichtman-stages and the distribution and severity of the cartilage lesions. In selected cases severe cartilage lesions (3 degrees and 4 degrees ) were already found in Lichtman-stage IIIA and IIIB, while less severe lesions than expected were observed in Lichtman-stage IV. There was no correlation between the Lichtman-stages and the classification according to Bain and Begg. In selected cases without cartilage lesions carpal collapse (Lichtman stage IIIB) was found. The individual response was unequivocal: Four patients reported minimal, five patients remarkable improvement but all did not demand further procedures. Four patients reported complete relieve. Seven patients demanded further operations (3 proximal row carpectomies, 4 STT fusions). In three of these seven cases the arthroscopical evaluation guided the further operative therapy to appropriate procedures. In Kienböck's disease arthroscopy more precisely detected alterations of the articular surfaces than radiological diagnostics. Radiological staging over- but also underestimated the cartilage damage. Arthroscopic results strongly influenced the further surgical treatment. Therefore in Kienböck's disease arthroscopy is of high value and recommended.

Der osteochondrale Ersatz der Fossa lunata bei der Entfernung der proximalen Handwurzelreihe im frühen Stadium IV der Lunatumnekrose

An osteochondral transfer of a scaphoid segment into the lunate fossa in proximal row carpectomy was performed in two female patients in stage IV of Kienböck's disease. Clinical and radiological follow-up at 18 and 6 months, respectively, showed results comparable to those of PRC in Lichtman stage III. This technique may serve as another option for salvage operations on the wrist.

Systematic Review of the Treatment of Kienböck's Disease in Its Early and Late Stages

To perform a systematic review of the treatment of Kienböck's disease to test the hypothesis that none of the reported treatments for Kienböck's disease is superior with respect to outcomes of pain, motion, grip strength, and radiographic measures. We searched PubMed, Medline, and the Cochrane Review for articles published between 1998 and 2008 reporting outcomes of treatment for Kienböck's disease. Patients were grouped by stage of disease. Early stages were defined as Lichtman stage I, II, and IIIa, and 'late' stages as IIIb and IV. The groups were then analyzed on the basis of treatment; procedures performed on subjects in the early group included vascularized bone grafting (VBG), metaphyseal core decompression, and radial osteotomy, whereas the procedures performed on subjects in the late group included VBG, radial osteotomy, partial arthrodesis, proximal row carpectomy, tendon ball arthroplasty, and nonsurgical treatment. We found no statistically significant difference between any of the treatment groups for subjective pain outcomes. In terms of objective measures, statistically significant improvement (p<.05) was seen in range of motion after radial osteotomy and VBG in early-stage patients and after all interventions, except partial arthrodesis and nonsurgical treatment, for late-stage patients. Grip strength was significantly improved in early-stage patients after radial osteotomy and VBG and for all late-stage patients, except among those managed nonsurgically. Changes in Stahl and carpal height index scores were not statistically significant regardless of intervention, except after radial osteotomy in the early group, where they statistically worsened. Based on retrospective data from uncontrolled studies, no active treatment is superior in the treatment of Kienböck's disease and there are insufficient data to determine whether the outcomes of any intervention are superior to placebo or the natural history of the disease.

Commentary: Terms That Accurately Reflect Current Best Evidence

NSTEAD OF BOLSTERING OUR confidence, systematic reviews and meta-analyses often demonstrate the limited scientific basis for many of our treatments. With respect to Kienbock’s disease (idiopathic osteonecrosis of the lunate), the science is poor, largely because the disease is uncommon and therefore difficult to study. The more limited the science, the more likely that our understanding of the disease will change as we perform more experiments. The etiology and pathophysiology of Kienbock’s disease and our ability to modify its course are open to debate. We do not know when or how the disease arrests, but we do know that the natural history is not inevitable progressive collapse and arthritis. With or without treatment, the disease often stops at one of the lower Lichtman stages. In a specific patient, we have no way of knowing when the disease started and whether or not it will progress. We meet patients with currently or previously asymptomatic Kienbock’s, so one should not assume that the disease started at the onset of symptoms. To gauge the importance of these considerations, consider the possibility that we might sometimes perform unnecessary surgery to try to modify the course of Kienbock’s that has already resolved or arrested. Because we currently cannot know the evolution of Kienbock’s disease in specific patients, I think it is time to reconsider the concepts of early and late stages of the illness as used by the authors. 1 I contend that we should judge our treatments according to their goals: to modify the course of mild or moderate disease or to salvage advanced disease. The term early implies that, if the disease does not progress, our intervention should get the credit—an assumption that goes beyond current best evidence. To learn more about Kienbock’s disease, we need to perform experiments that compare the ability of different treatments to modify the course of the disease or to relieve symptoms (palliate)—uncontrolled case series leave us with too many questions. As the authors of this systematic review confirmed, whether considered according to an early/late or disease modifying/salvage paradigm, we have yet to establish that our treatments make a meaningful difference in the course of Kienbock’s disease.

Freies gefäßgestieltes Beckenkamm-Transplantat bei aseptischer Mondbeinnekrose im Stadium III

The aim of this retrospective study is to report the clinical and radiological long-term results (follow-up >10 years) after revascularisation of the lunate in Kienböck's disease using a free vascularised iliac bone graft in patients with Lichtman stage III disease. 23 patients (14 male, 9 female) aged between 17 and 43 years were treated with a free vascularised iliac bone graft. The average follow-up time was 13 (10-15) years. Assessment included active range of wrist motion, grip strength, level of pain, patient disability and functional outcome measured by the DASH questionnaire as well as the Green and O'Brien score. Radiological evaluation included Ståhl index, Youm carpal height index, radioscaphoidal angle, radiolunate angle and integration of the free vascularised bone graft. All long-term results were compared to the preoperative state. In 20 of 23 patients definite osteointegration of the vascularised bone graft was achieved. The average extension-flexion arc increased from 75 degrees to 100 degrees postoperatively and the average ulnar-radial deviation arc increased from 35 degrees to 45 degrees . The grip strength improved from 45 kg to 65 kg postoperatively and the pain level decreased from 65 to 6. Radiologically the average Ståhl index improved to 0.44 (preoperative 0.33), the average Youm index to 0.54 (preoperative 0.51) and the average radioscaphoidal angle to 50 degrees (preoperative 46 degrees ). The mean DASH score was 14.2. The Green and O'Brien score showed 11 (48%) excellent, 5 (22%) good, 4 (17%) fair und 3 (13%) bad results. 3 patients presented with a resorption of the bone graft with ongoing radiological progression of Lichtman stage, reduced range of motion and high pain level. Free vascularised iliac bone grafts for Kienböck's disease is a reasonable treatment option and the clinical and radiological improvements last for a long period of time. Long-term restoration of carpal height was demonstrated. Progression of disease was prevented in 87% (20 of 23) of patients over a mean time of 13 years. In our hands this technique remains the best option for the treatment of Kienböck's disease stage III.

L’ostéotomie du capitatum dans la maladie de Kienböck. Résultats cliniques et radiologiques à cinq ans de recul moyen. À propos de 12 cas

Kienböck's disease could occur pain and reduce wrist's range of motion despite of an early radiologic staging. Usual surgical procedures unload the lunate. Radial shortening is the common procedure in negative ulnar variance. For wrists with neutral or positive ulnar variance, this procedure could produce a distal radio-ulnar discrepancy and an ulnocarpal impingement. We perform, in these cases, a capitate shortening. The goal of this study is to relate the wrist functional outcome and the radiological result in 12 cases. It was a consecutive retrospective study of 12 patients (nine male, three female). Eight Lichtman's stage II and four stage III A with neutral or positive ulnar variance. The wrists were painful and with a reduce range of motion. The surgical procedure consisted in a dorsal approach and a 2 -mm shortening osteotomy in the capitate's waist. Bone clips were used for fixation. The follow-up average period was 65.8 months. All patients had pain relief. The wrist's range of motion improved in all cases. Any single complication was noted. The patients recovered their professional or usual occupation with an average of 3.6 months. Lunate's vascularization improved in all cases. Any intracarpal complication or capitate non-union occured. The capitate shortening is a simple and low aggressive procedure. Wrist's functional outcome has good results. We recommend this procedure for symptomatic patients in early Kienböck's disease with neutral or positive ulnar variance.

Treatment of Kienböck's Disease Using the 4+5 Extensor Compartmental Vascularized Bone Grafting Procedure: Early Experience

Purpose: Kienbck's disease can be treated with a vascularized bone graft to provide relief of wrist joint symptoms and prevent collapse of the lunate. We evaluated the functional outcome and subjective satisfaction in patients with Kienbck's disease treated with the 4+5 extensor compartmental vascularized bone graft. Materials and Methods: We included 6 patients in the study. 3 males and 3 females with an average age of 37.5 years (range 21-49). Kienbck's disease was staged by Lichtman classification based on plain radiography. Three patients were in stage II and three in stage IIIA. Cooney's wrist function score was used to evaluate changes in severity of pain, functional status, range of motion, and grip strength. We also assessed subjective patient satisfaction, carpal height ratio and bone union on the radiographs, and the occurence of complications. The mean follow-up period was 30 months. Results: Four patients had excellent and two had good outcomes of wrist function. Three patients showed excellent subjective satisfaction, and three were good. All patients showed radiographic bone union and no further progression of lunate necrosis. The presurgical carpal height ratio was similar to the value at last follow-up, and there was no radiographic carpal bone collapse. For two cases of Lichtman stage IIIA, the slight degenerative arthritis at the lunocapitate joint observed preoperatively did not change. Skin necrosis and pin track infection were not observed. Conclusion: The 4+5 extensor compartmental vascularized bone graft is a reliable procedure for Lichtman stage II and IIIA patients with Kienbck's disease, as it achieved not only pain relief and improvement of range of motion but also maintenance of the intercarpal bone relationship on radiographs, with relatively few complications.

Limited Wrist Fusion for Kienböck's Disease

Purpose: To evaluate clinical outcomes of triscaphe (STT), scapho-capitate (SC) and scapho-capito-hamato-triquetral (SCHT) fusion in advanced Kienbck's disease. Materials and Methods: Forty patients with Lichtman stage III and IV disease were treated with limited wrist fusion. STT & SC fusion for stage IIIa and IIIb, and SCHT fusion for IIIb and IV were done according to preoperative radiologic and intraoperative articular surface findings. The mean follow-up period was 31.6 months (range 13-108) and the mean age at the time of their surgery was 44.7 years (range 22-71). There were 13 cases of STT fusion, 19 cases of SC fusion and 8 cases of SCHT fusion. For assessment of treatment results, wrist range of motion, grip strength, VAS (visual analog pain score) and any radiologic changes of the wrist were checked at last follow-up. Results: VAS score was 4.7 for STT, 3.0 for SC, 4.5 for SCHT. Grip strength, compared with the contralateral side, was 72% for STT, 78% for SC, and 54% for SCHT. Pain was more improved for the SC fusion group than for the other two groups (p=0.007). Grip strength was decreased more in the SCHT fusion group than in the other two groups (p=0.009). There were no statistically significant differences in range of motion between any of the three groups. The bone achieved union in all cases except one SC fusion. Conclusion: Limited wrist fusion in advanced Kienbck's disease has been regarded as a valuable method. However, SC fusion has been thought of as a more favorable technique than STT fusion with respect to pain relief. SCHT fusion is thought to be a possible salvage procedure with a limited indication for Stage IV Kienbck's disease.

Long-Term Follow-up of Radial Shortening Osteotomy for Kienböck Disease

Three previous studies have investigated the long-term outcome of radial osteotomy in the treatment of Kienböck disease. However, none used patient-based assessment. The purpose of this study was to investigate the long-term clinical and radiographic outcomes of this osteotomy, including the subjective evaluation of the patient with use of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. A DASH questionnaire was sent to nineteen patients with Kienböck disease who had undergone a radial shortening osteotomy, and thirteen replied. The mean age at the time of surgery was thirty-nine years. On the basis of the Lichtman classification, six patients had stage-II, four had stage-IIIA, and three had stage-IIIB disease. Prior to surgery, ulnar variance was positive in six patients, neutral in four, and negative in three. The mean duration of follow-up was twenty-one years. Clinical evaluation, including calculation of the modified Mayo wrist score, and radiographic evaluation were also performed on twelve of the thirteen patients. The mean DASH score was 8 points (range, 0 to 23 points), and patient satisfaction was high. Compared with the findings in the contralateral wrist, the mean range of motion was 81% in flexion and 82% in extension and mean grip strength was 88%. The mean modified Mayo wrist score was 83 points, and the clinical results were excellent in six patients, good in five, and moderate in one. The DASH scores tended to be worse in patients with Lichtman stage-IIIB disease. Follow-up radiographs revealed that the Lichtman stage had progressed in six of the twelve patients. Although most patients had mild wrist pain, patient satisfaction and the clinical results were satisfactory following a radial shortening osteotomy. This procedure is a reliable long-term treatment for Lichtman stage-II and IIIA disease and may be a reasonable option for patients with stage-IIIB disease.

Radial oblique osteotomy for treatment of Kienböck disease

Background The association of ulnar minus variance with Kienbock disorder led to interest in joint-levelling surgical procedures. In this study, long-term results of an oblique radial osteotomy in Kienbock stage II and III-A, without consideration of ulnar variance, either before or after osteotomy, were analyzed. Methods We retrospectively reviewed eight patients who were treated with an oblique radial osteotomy without consideration of ulnar variance. All eight patients had their index surgery for symptomatic Kienbock disease. Six patients had Lichtman stage II and two had stage III-A. Outcome parameters included pain, range of motion, grip-strength, radiographic results in terms of Stahl-index, Lichtman-classification and ulnar variance. Results The average follow-up was 8.3 years. No postoperative infections, delayed unions or soft-tissue problems were found. The plate was removed in three patients. Pain and function improved in all patients. A difference from minus 0.76 mm to 1.86 mm positive in mean ulnar variance was found. The Stahl-index remained the same. Radiographically, no deterioration was seen in the lunate or Lichtman classification. Conclusions An oblique radial shaft osteotomy seems a successful treatment option for Kienbock disease.

Radial Overgrowth After Radial Shortening Osteotomies for Skeletally Immature Patients With Kienböck's Disease

We hypothesized that radial shortening osteotomy (radial shortening) for skeletally immature patients with Kienböck's disease would induce overgrowth of the radius. The purpose of this study was to determine the effect of radial shortening on radial growth in skeletally immature patients with Kienböck's disease and to clarify the relationship between the postoperative growth alterations and the clinical results. Eight wrists of 8 skeletally immature patients with Kienböck's disease were treated with radial shortening. There were 3 boys and 5 girls, ranging in age from 11 to 18 (mean, 14) years old. All patients presented with open physis and negative ulnar variance. The length of the radial shortening equaled the amount of negative ulnar variance. Clinical assessment was based on the modified Nakamura scoring system. Radiographic assessment, including Lichtman's stages, ulnar variance, carpal height ratio, radial inclination, and volar tilt, was performed before surgery, immediately after surgery, and at follow-up. A difference in ulnar variance of more than 2 mm between these 3 measurements was considered to be overgrowth. Statistical comparisons were performed using paired t-tests. At a mean follow-up period of 69 months, the mean clinical score was 19.7 of 21 maximum points, with all wrists rated as excellent. Radiographically, no progression of Lichtman stage was found in any patient. At follow-up, the x-ray and magnetic resonance imaging findings indicated lunate revascularization in all patients. Four of the 8 had overgrowth in the operated radius. On the other hand, other radiographic parameters showed no significant changes at follow-up. The occurrence of postoperative radial overgrowth did not notably affect the clinical scores. The current results suggest the probability of overgrowth of the radius in skeletally immature patients with Kienböck's disease treated with radial shortening. The postoperative radial overgrowth after this osteotomy had no effect on clinical and other radiographic outcomes. Therapeutic IV.

The Incidence of Asymptomatic Kienböck’s Disease

The aim of this study was to determine the incidence of asymptomatic Kienböck's disease in patients who attended the Dr George Mukhari Hospital (formerly Ga-Rankuwa Hospital), as well as the relevance of ulnar variance on the disease. This was a retrospective study. In a 12 month period we reviewed postero-anterior radiographs of 1287 patients seen at our radiology department, with complaints unrelated to the upper limb including the wrist and hand. We identified 23 cases (1.9%) of asymptomatic Lichtman stage II-IV Kienböck's disease in our African population. The majority (63%) were male with an average age of 49 years, and 37% were female with an average age of 46.5 years. All cases were unilateral and all were in the dominant hand. Thirteen cases (57%) had an ulnar neutral wrist and the remaining ten (43%) had an ulnar negative variance. The vast majority (83%) were unemployed. Analysis of the data shed no further light on the aetiology. The relevance of ulnar variance as an aetiological factor is questioned.

Distraction histiogenesis for treatment of Kienbock′s disease: A 2- to 8-year follow-up

Background:Distraction histiogenesis is known to enhance vascularity and stimulate new tissue formation. Its use in Kienbock's disease is not reported in the literature, so we proposed to study the outcome after distraction histiogenesis in treating this condition.Materials and Methods:This prospective study comprised of six patients (two male and four female) with mean age 18.16 years (range 21-35 years) with clinicoradiologically diagnosed Lichtman stage II (n = 3) and stage III (n = 3) Kienbock's disease with a mean duration of symptoms 6.67 months. The ulnar variance was neutral in two and was negative in four patients treated with the application of Joshi external stabilization system (JESS) across the wrist. The gradual distraction was done at a rate of 0.5 mm/day. After the distraction of 5-7 mm, the distractors were kept static for 3 weeks. The wrist was mobilized by using hinged distractors for next 3 weeks. Later short cockup splint was used for further 4 weeks. At the end of minimum 2 years, an assessment was done on the basis of relief of symptoms, ability to perform activities of daily living, range of movement at wrist, grip strength, and on radiology (change in the density of bone and C:MC ratio i.e ratio of carpal height to third metacarpal height).Results:The mean follow-up was of 4.5 years (range 2-8 years). The average duration of treatment was 5.3 months (range 4.5-6 months), and the duration of distraction (both static and hinged) was 8 weeks. Clinically all the patients were relieved of the symptoms with an increase in the range of wrist movement (ulnar deviation increased from 20.8° to 29.5°, radial deviation from 17.5° to 21°, dorsiflexion from 37.5° to 52.5°, and palmer flexion from 38.3° to 47.5°). At the last follow-up, activities of daily living were not affected, and all the patients were on their previous jobs without any fresh complaints. The average grip strength increased to 73-86% of normal. Radiologically the C:MC ratio (ratio of carpal height to third metacarpal height) did not show any significant improvement, but the density of lunate decreased.Conclusion:Distraction histiogenesis when used in Lichtman stage II and III with negative or neutral ulnar variance gives good symptomatic relief, allowing return to normal activities. This study has also shown that reparative process is possible in avascular bone by distraction. The authors recommend further research in this modality of treatment.

Lunate Revascularization With Artery Implantation and Bone Grafting

Treatment of Kienböck's disease encompasses a wide array of options. Proper staging is the first step to successful treatment. Revascularization of the lunate remains a viable option for the treatment of Lichtman stage II or IIIA Kienböck's disease. In this article, we review the indications for and the surgical technique used with a modified Hori procedure (vascular pedicle insertion with structural distal radius graft) for revascularization of the lunate.