Lichtman Stage Research Articles

Outcomes of wrist denervation and core decompression of the radius for Kienbock's disease

BackgroundThe definitive treatment of Kienbock's disease has yet to be determined. Wrist denervation combined with core decompression of the radius has not been previously studied as a combined treatment for Kienbock's disease. PurposeThe purpose of this study was to assess the efficacy of simultaneous wrist denervation and core decompression of the radius in the treatment of Kienbock's disease. MethodsAll patients with Kienbock's disease who were treated with simultaneous core decompression of the radius and wrist denervation by a single surgeon at a single institution from 2012 to 2022 were contacted for this study. Demographic, clinical and radiographic data were collected retrospectively. Quick DASH and Upper Extremity PROMIS scores were collected prospectively. ResultsTen patients met inclusion criteria. Mean age at time of surgery was 31 years old. One patient was Lichtman stage 2, 5 patients were stage 3a, and 4 patients were stage 3 b. Patient reported outcomes were collected at a mean of 5.1 years since surgery (7 month-10.3 years). The mean Upper Extremity Promise T-score was 49 (median 52; age >/ = 40, normal 51.2 ± 8.2; age <40, normal 55.9 ± 6.6) and the mean Quick DASH score was 13 (median 7; normal 0–20). Nine of 10 patients reported they were satisfied with the procedure, and 100 % of patients said they would choose to have the procedure again. ConclusionsPatients with Lichtman stage 2, 3a and 3 b Kienbock's disease treated with simultaneous core decompression and wrist denervation reported minimal to no disability at 5 years after surgery. All patients in this study reported they would choose to have the surgery again to treat their Kienbock's disease.

Treatment of Kienböck's Disease Using Fourth and Fifth Extensor Compartmental Artery Vascularized Bone Grafts.

This study evaluated the radiological and clinical outcomes of bone grafts using fourth and fifth extensor compartmental arteries (4+5 ECAs) for the treatment of Kienböck's disease. In total, 21 patients (12 men and 9 women; mean age, 41 years; range, 19-59 years) were followed for a mean of 33 months. Radiological images were analyzed for the Lichtman stage, carpal height ratio, radioscaphoid angle, and Stahl's index. Clinical evaluation included range of motion, visual analog scale (VAS) score, grip strength, modified Mayo wrist score (MMWS), Lichtman outcome score, and Disabilities of the Arm, Shoulder and Hand (DASH) score. At the time of surgery, 6, 14, and 1 patients had Lichtman stages II, IIIA, and IIIB, respectively. At the final follow-up visit, grip strength had improved from 65.4% to 79.7%, wrist extension had improved from 43° to 57°, and flexion had improved from 42° to 50°. There were no significant changes in the carpal height ratio, Stahl's index, or radioscaphoid angle. The mean VAS score was 1.7, and the mean DASH score was 6.9. The mean MMWS was 87.9, with excellent and good outcomes in 6 and 11 patients, respectively. Satisfactory Lichtman outcome scores were observed in 81%. Body mass index had a strong correlation and age had a weak correlation with MMWS (coefficient=-0.534, P=.013, and coefficient=-0.393, P=.078, respectively). The 4+5 ECA bone graft is effective for the treatment of Kienböck's disease in young patients with low body mass index. [Orthopedics. 202x;4x(x)xx-xx.].

The Effect of Radial Inclination on the Stage of Kienbock Disease at the Time of Initial Diagnosis.

Negative ulnar variance is a widely accepted risk factor for the development of Kienbock disease (KD). Variation in radial inclination has been proposed as a risk factor, but evidence thus far has been inconclusive. We aim to clarify the relationship between radial inclination and KD. A retrospective analysis of all KD patients from a single institution from 2007 to 2021 was conducted. Radiographs were reviewed to measure anatomic parameters and stage of disease. An exploratory multinomial regression model was created to examine the association of patient age, radial height, ulnar variance, radial inclination, volar tilt, scapholunate angle, duration of symptoms prior to evaluation, history of wrist trauma, and diagnosis of diabetes with stage of disease. Fifty-seven cases of KD were identified, with a mean duration of disease of 33.3 months. A history of trauma to the wrist was common (53%) and significantly associated with stage of disease at initial presentation. Twenty-seven cases (47%) were stage IIIB or greater. The average initial radial inclination, radial height, and ulnar variance was 21.9°, 10.7 mm, and -1.23 mm, respectively. A multinominal logistic regression model revealed decreased initial radial inclination is associated with Lichtman stage IIIB or greater at the time of initial patient presentation. A correlation exists between decreased radial inclination and more advanced KD at presentation, suggesting this may be a risk factor for disease progression. This correlation is strengthened by our finding of decreased ulnar variance being associated with later stage at presentation, which is one of the most widely accepted proposed risk factors for development and progression of disease. IV.

Arthroscopic Treatment of Kienböck Disease: Mid-Term Outcome of Arthroscopic Lunate Core Decompression

This study evaluated the mid-term functional and radiological results of arthroscopic lunate core decompression for treating Kienböck disease. In a prospective cohort study, 40 patients with a confirmed diagnosis of Kienböck disease (Lichtman stages II to IIIb) underwent arthroscopic core decompression of the lunate bone. A cutting bur was used through the trans-4 portal with visualization from the 3-4 portal after synovectomy and debridement of radiocarpal joint using a shaver from the 6R portal. Disabilities of Arm, Shoulder, and Hand and visual analog scale scores, wrist range of motion, grip strength, radiological changes of Lichtman classification, carpal height ratio, and scapholunate angle were evaluated before and two years after the surgery. The mean of Disabilities of Arm, Shoulder, and Hand score improved from 52.5 ± 13 to 29.2 ± 16.3. The visual analog scale score also improved from 7.6 ± 1.8 to 2.7 ± 1.9. There was also an improvement in hand grip strength from 6.6 ± 2.7 kg to 12.3 ± 3.1 kg. Wrist range of motion in flexion, extension, ulnar deviation, and radial deviation improved significantly. Lichtman classification remained the same in 36 (90%) patients. Carpal height did not change. Intergroup evaluation showed no functional difference in response to surgery for different radiological Lichtman stages. More improvement was observed in patients with Lichtman stage II, but was not statistically significant. Arthroscopic lunate core decompression appears to be an effective and safe surgery for treating Kienböck disease on the basis of mid-term follow-up. Therapeutic IV.

Diagnostic performance of traditional radiographic indices in detection of carpal collapse in Kienböck's disease.

Correctly identifying carpal collapse is important for adequate treatment of Kienböck's disease. This study aimed to assess the accuracy of traditional radiographic indices in detecting carpal collapse to differentiate between Lichtman stages IIIa and IIIb. In 301 patients, carpal height ratio, revised carpal height ratio, Ståhl index and radioscaphoid angle were measured on plain radiographs by two blinded observers. As a reference standard, Lichtman stages were determined by an expert radiologist using CT and MR imaging. The interobserver agreement was excellent. In the differentiation between Lichtman stages IIIa and IIIb, measurements of indices showed moderate to good sensitivity (0.60-0.95) and low specificity (0.09-0.69) using normal cut-off values from the literature, while receiver operating curve analysis revealed poor area under the curve (58-66%). Traditional radiographic indices showed poor diagnostic performance in detecting carpal collapse in Kienböck's disease and did not reach sufficient accuracy in the differentiation between Lichtman stages IIIa and IIIb.Level of evidence: III.

A CASE REPORT ON TREATMENT OF KIENBOCK'S DISEASE BY IMPLANTATION OF VASCULAR PEDICLE AND BONE GRAFTING

Numerous literatures have described various procedures in the treatment of Kienbock's disease depending upon the severity of the symptoms, patient characteristics and radiological staging. These range from conservative management to surgical procedures. The case under study had Lichtman stage ** disease. Vascularised bone grafts provide improved blood flow, osteocyte preservation, and accelerated healing rates. We inserted pronator quadratus pedicled bone graft into our case of lunate osteonecrosis and temporarily fixed the graft. Clinically, the patient reported pain subsidence with improvement in range of motion and grip strength. Vascularised pedicle and bone grafting is an effective way for treatment of early and middle stages of osteonecrosis of lunate

Mid-term follow-up results of gradual capitate lengthening for the treatment of stage IIIA Kienbock's disease.

This study aimed to evaluate the mid-term radiological and clinical results of gradual lengthening of capitate for the treatment of stage IIIA Kienbock's disease. We retrospectively reviewed nine patients (five females, four males) with Lichtman stage IIIA Kienbock's disease who underwent gradual capitate lengthening at our hospital. Their clinical (range of motion (ROM), grip strength, visual analogue scale (VAS) value for pain, and Mayo wrist score (MWS)) and radiological outcomes (in terms of progression of arthritis and carpal height ratio) at the last follow-up were compared to the preoperative values. The mean age of the nine patients was 30years (range: 20-38years). The mean follow-up period was 73.8 (60-83) months. The average grip strength increased from 14.3kg preoperatively to 22.3kg at the last follow-up. The mean MWS increased from 58.8 preoperatively to 79.4 postoperatively. The mean VAS values decreased from the preoperative values: from 1.9 to 0.36 at rest, from 3.75 to 1.6 during mild effort, and from 5.35 to 3 during severe effort. The average carpal height ratio changed from 0.38 preoperatively to 0.53 postoperatively. None of the patients had any arthritic changes in their wrists. Gradual lengthening of capitate offers satisfactory mid-term results for treating stage IIIA Kienbock's disease.

Combined radial wedge and shortening osteotomy versus scaphocapitate arthrodesis in advanced Kienböck’s disease

Although various surgical techniques have been reported for the treatment of advanced Kienböck's disease (Lichtman stage IIIB and above), the ap- propriate operative treatment is still being debated. This study compared the clinical and radiological outcomes of combined radial wedge and shortening osteotomy (CRWSO) and scaphocapitate arthrodesis (SCA) in the treatment of advanced Kienböck's disease (above type IIIB) with a minimum of 3 years of follow-up. We analyzed the data from 16 and 13 patients who underwent CRWSO and SCA, respectively. The average follow-up period was 48.6±12.8 months. Clinical outcomes were evaluated using the flexion-extension arc, grip strength, Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), and Visual Analogue Scale (VAS) for pain. The following radiological parameters were measured: ulnar variance (UV), carpal height ratio (CHR), radioscaphoid angle (RSA), and Stahl index (SI). Osteoarthritic changes in the radiocarpal and midcarpal joints were evaluated using computed tomography (CT). Clinically, both groups showed significant improvements in the grip strength, DASH, and VAS at final follow-up. However, regarding the flexion-extension arc, the CRWSO group showed a significant improvement, while the SCA group did not. Radiologically, compared to the preoperative values, the CHR results improved at final follow-up in the CRWSO and SCA groups. There was no statistically significant difference in the degree of CHR correction between the 2 groups. By the final follow-up visit, none of the patients in either group had progressed from Lichtman stage IIIB to stage IV. Considering restoration of wrist joint range of motion, CRWSO may be a good alternative for limited carpal arthrodesis for advanced Kienböck's disease.

Comparison of Clinical Outcomes in Open and Arthroscopically-Assisted Mini Open Proximal Row Carpectomy for Lichtman Stage IIIB and IIIC Kienböck Disease

Proximal row carpectomy (PRC) can be performed in the late stages of Kienböck disease using the traditional open technique or arthroscopically. In this study, we describe the arthroscopically-assisted mini-open PRC technique. The aim of the study was to compare the functional results with the open PRC technique in advanced-stage Kienböck disease. The medical records of patients with Kienböck disease who underwent open PRC between 2006-2010 (Cohort A) and arthroscopically-assisted PRC (AAPRC) between 2010-2018 (Cohort B) were analyzed. The Quick Disabilities of the Arm, Shoulder, and Hand scores, visual analog scale, and Modified Mayo Wrist Scores were compared, which were obtained at the early postoperative (third month) and final follow-up. Cohort A had 14 and Cohort B 21 patients. The preoperative, early, and final mean visual analog scale scores were 7, 3, and 0.3, respectively, for Cohort A, and 7, 0.3, and 0.1, respectively, for Cohort B. The preoperative mean Quick Disabilities of the Arm, Shoulder, and Hand scores decreased from 69 to 34 at the third-month and 6.1 on the final follow-up visit for Cohort A and from 77 to 18, and 5 for Cohort B. The final Mayo wrist scores were excellent in 4, good in 4, and moderate in 6 of the Cohort A patients, and excellent in 11, good in 8, and moderate in 2 of the Cohort B patients. Mean flexion increased to 52° from 43° for Cohort A and to 62° from 41° for Cohort B. AAPRC, compared to the open PRC, resulted in increased wrist motion and increased Mayo wrist scores in the long-term. Also, the third-month patient-related outcomes revealed favorable results in the AAPRC group. We attribute these findings to the earlier initiation of postoperative wrist motion and the less invasive character of the AAPRC procedure. Therapeutic IV.

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.

The Natural History of Kienböck's Disease Diagnosed at More than 50 Years of Age.

BackgroundPrevious literatures suggest that the prognosis of Kienböck’s disease might be favorable despite no surgery if it is diagnosed in late age, but the evidence is not clear. The aim of this study was to determine the radiographic and clinical progression of Kienböck’s disease diagnosed at more than 50 years of age.MethodsData of 27 patients diagnosed with Kienböck’s disease at more than 50 years of age between 2000 and 2016 were investigated. During the study period, no treatment, either surgical or nonsurgical, was applied. We explained to the patients that the affected lunate was not expected to collapse further if found late in age. Annual visits were recommended, through which radiographic and clinical observation was made. We assessed changes in Stahl index and radioscaphoid angle between the initial assessment and the final follow-up, and clinical assessment was made using pain in visual analog scale (VAS) and Dornan’s criteria.ResultsInitially, 2 patients were in Lichtman stage 1, 6 in stage 2, 5 in stage 3A, 11 in stage 3B, and 3 in stage 4. Radiographic follow-up of at least 5 years (mean, 7.8 years) was made in 14 patients, whose Stahl index and radioscaphoid angle did not differ significantly from their initial measurements. Arthritic appearance was not found, and progression in the Lichtman stage was detected in 1 lunate, from 3A to 3B. Despite no surgical treatment for an average of 7.5 years (range, 5.0–15.7 years) of observation period in the 27 patients, average pain in VAS improved from 3.5 (range, 1–7) to 0.8 (range, 0–2), with excellent or good clinical status by Dornan’s criteria.ConclusionsOur study suggests that Kienböck’s disease diagnosed at more than 50 years of age can follow a benign natural course in radiographic and clinical aspects. Therefore, surgical interventions should be considered carefully in this age group.

Evaluation of the efficacy of wrist arthroscopic surgery for aseptic necrosis of lunate bone.

ObjectiveTo explore the use of wrist arthroscopy for treatment of aseptic necrosis of lunate bone and its curative effect.MethodsFrom March 2012 to January 2016, 12 patients with aseptic necrosis of lunate bone underwent necrotic lunate bone extirpation assisted by wrist arthroscopy, and the scaphocapitate joint treated with fusion‐stabilization were selected. Among these patients, 10 patients were male and two patients were female. The age of these patients ranged from 25 to 42 years old, with an average age of 32 years old. These lesions were located in the right hand in eight patients, and in the left hand in four patients. Lichtman stage: stage IIIA in two patients, and stage IIIB in 10 patients. All patients were diagnosed by anterior lateral radiographs and magnetic resonance imaging (MRI). From the second day after the surgery, patients underwent active motion for the metacarpophalangeal joint and interphalangeal joints. When the X‐ray film indicated that the fracture had healed, patients began to resume their daily activities and work. After surgery, the plain films of all planes, including the axial plane of the scaphoid, were taken every month, until fracture healing. All patients were followed up for a mean duration of 8 months, and the Mayo wrist score was used to assess the range of motion of the wrist joint and grip force during the follow‐ups for objective function evaluation.ResultsFracture healing was obtained in all patients within 9–12 weeks after the operation, and average healing time was 10 weeks. The duration of follow‐up ranged between 6–14 months, and the mean duration was 8 months. According to the modified Mayo wrist score, the objective function of the wrist joint was evaluated as follows: flexion and extension range of the wrist joint was 40°–110°, with an average of 105°, which was 80% of that of the unaffected side. Radioulnar deviation was 45°‐80°, with an average of 55°, which was 82% of that of the unaffected side. Grip force was 25–48 kg, with an average of 40 kg, which was 84% of that of the unaffected side. The modified Mayo wrist score was good in eight patients, acceptable in three patients, and poor in one patient.ConclusionsWrist arthroscopy is an effective and feasible tool for the treatment of aseptic necrosis of the lunate bone, and the right kind of surgical procedure should be selected for different stages of the disease, and wrist arthroscopy is applied timely, in order to achieve the desired therapeutic effect.

Outcomes of Arthroscopic Lunate Core Decompression Versus Radial Osteotomy in Treatment of Kienböck Disease

The purpose of the study was to evaluate the functional and radiographic outcomes of arthroscopic lunate decompression versus radial osteotomy in the treatment of Kienböck disease (KD). In a prospective cohort design, we enrolled 82 patients with KD with Lichtman stages I to IIIb. Participants assigned themselves to groups by choosing either arthroscopic lunate core decompression and synovectomy (group A; n= 54) or radial osteotomy (group B; n= 28). For radial osteotomy, a distal radius volar approach was used and a shortening osteotomy (in negative and neutral ulnar variance) or lateral closing wedge osteotomy (in positive ulnar variance) was performed. Arthroscopic lunate core decompression was performed under direct visualization from the 3-4 portal using a shaver (through the 6R portal) and a cutting burr (through the trans-4 portal). The shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, visual analog scale (VAS) score for pain, wrist passive flexion/extension, grip strength, and radiographic assessments (Lichtman classification, radioscaphoid angle, carpal height ratio) were recorded before surgery and at the final follow-up. Sixty-four patients were included in the final analysis (44 in group A and 20 in group B). The mean ages of participants were 33 ± 11 years in group A and 31 ± 8 years in group B. The mean follow-up periods were 44 ± 20 months in group A and 37 ± 23 months in group B. The QuickDASH score, VAS score, and passive wrist movements significantly improved in both groups. Grip strength showed a significant increase in group A only. The postoperative functional analysis between the 2 groups showed no significant difference, except for the wrist passive extension, which was higher in group A. Lichtman staging remained the same in 79.5% and 73.6% of patients in groups A and B, respectively. An arthroscopic lunate core decompression and wrist synovectomy has comparable midterm results to radial shortening osteotomy in the treatment of KD. Therapeutic II.

Influence of carpal–ulnar translation on clinical outcome after scaphocapitate arthrodesis for the treatment of late-stage Kienböck disease

This study sought to compare postoperative outcomes after scaphocapitate arthrodesis (SCA) for the treatment of late-stage Kienböck disease according to the amount of ulnar translation of the carpus and to identify surgical factors associated with carpal-ulnar translation. Thirty-nine patients diagnosed with Kienböck disease (Lichtman stages III-IV) and treated with SCA were retrospectively reviewed. They were divided into the translated group (n=28) and untranslated group (n=11) according to the presence of carpal-ulnar translation. The following surgical factors in the patients were assessed: excision of the lunate, postoperative carpal height ratio, and radioscaphoid angle (RSA). Pain Visual Analog scale (VAS) score, wrist range of motion, grip strength, modified Mayo wrist score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and progression of radioscaphoid osteoarthritis were also assessed. All patients showed functional improvement after a mean postoperative follow-up period of 40 months (VAS: 4.1 vs. 1.1, p <0.001; grip strength, 42.3 vs. 51.2 lb., p=0.002; MMWS, 52.6 vs. 69.5, p <0.001; QuickDASH, 33.7 vs. 21.5, p <0.001). No statistically significant differences were found between the two groups in terms of outcome measures. Among the assessed surgical factors, the mean postoperative RSA was significantly smaller in the translated group than in the untranslated group (34.8° vs. 46.8°, p=0.008). The proportion of patients with postoperative RSA <30° was significantly higher in the translated group than in the untranslated group (54.5% vs. 0%, p<0.001). These results suggest that sufficient pain relief and functional improvement can be achieved after SCA for the treatment of late-stage Kienböck disease disregarding the occurrence of carpal-ulnar translation. In this study, overcorrection to RSA <30° induced more frequent carpal-ulnar translation after SCA.

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

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. 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 49.1months. 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. 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. 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. 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.

The free vascularized lateral femoral trochlea osteochondral graft: a reliable alternative for Stage III Kienböck's disease.

Lunate reconstruction using a lateral femoral trochlea osteochondral graft was carried out in 27 patients with Stage III Kienböck's disease from 2012 to 2019. Twenty-three of these patients could be followed-up in this retrospective study. Ten were women and 13 men. Nine were Lichtman Stage IIIA, seven Stage IIIB and seven Stage IIIC. The mean follow-up was 39months (range 12-86). Bony consolidation was found in 18 of the 23 patients, with no graft loss. The mean Disabilities of the Arm, Shoulder and Hand score (DASH score) was 11 and the Modified Mayo Wrist Score was 83. There were only two radiological deteriorations, with the same or improved Lichtman classifications in the other patients and a significant reduction in pain. Postoperative extension of the wrist (52°) and flexion (48°) were comparable with preoperative values and, respectively, 81% and 72% of the contralateral side. Grip strength and pinch grip were 32 kg and 12 kg, 88% and 94% of the other hand, respectively, and an insignificant increase compared with the preoperative values. The vascularized lateral femoral trochlea osteochondral graft yields good short- and mid-term results in Grade III Kienböck's disease.Level of evidence: IV.

Functional and Radiographic Disease Progression in Nonoperatively Managed Kienböck Disease.

The purpose of this study was to describe the natural history of Kienböck disease among patients who elected to proceed with nonoperative treatment. The authors performed a retrospective study of all patients treated nonoperatively for Kienböck disease within their institution from January 1, 1999, to December 31, 2014. Inclusion criteria included follow-up greater than 1 year, serial posteroanterior and lateral wrist radiographs, and clinical examination. Posteroanterior/lateral radiographs were independently reviewed at initial presentation and at final follow-up, including Lichtman stage, carpal index, Stahl index, ulnar variance, and intercarpal angles. Twenty-five patients with 25 wrists were included (mean age, 50.2 years), with an average length of clinical follow-up of 3.9 years and a mean length of radiographic follow-up of 5.2 years. There was no significant difference in range of motion; however, patient-reported pain was significantly decreased, and modified Mayo wrist scores and grip strength were increased. Lichtman stage, scapholunate angle, and radioscaphoid angle were increased; and carpal index, posteroanterior lunate ratio, and Stahl index were decreased across the study period. The mean progression in Lichtman stage was 0.5 stage/year with a range of 0 to 1.6 stages/year throughout the study period. There was no significant difference in Lichtman stage progression based on stage at presentation. A history of smoking was associated with increased radiographic disease progression. The present study demonstrates that among patients with Kienböck disease managed nonoperatively, the majority of patients significantly improve over time with respect to pain, grip strength, and Mayo wrist score, despite radiographic progression of disease. Risk, IV.

Lunate Revascularization With Temporary Internal Radiocarpal Spanning Fixation for Kienböck Disease.

The goal in the treatment of stages II and III Kienböck disease is to restore lunate vascularity and halt the progression of avascular necrosis. We report the outcomes for patients with stages II and III Kienböck disease treated with fourth extensor compartment artery vascularized bone grafting and temporary radiocarpal spanning internal fixation. Nine patients with a mean age of 28.8 years were included. Mean clinical and radiographic follow-up were 4.9 and 1.9 years, respectively. Six patients had no change in Lichtman stage, 2 patients regressed 1 stage, and 1 patient progressed 1 stage. Mean postoperative quick disabilities of the arm, shoulder, and hand (QuickDASH) was 17.4. Mean postoperative visual analogue pain scale (VAS) was 1.8. Patients under age 25 trended toward improved clinical outcomes compared with patients over age 25. Two patients, aged 33 and 65, underwent proximal row carpectomy at a mean 30.5 months postoperatively. In conclusion, the use of local vascularized bone graft with temporary internal radiocarpal spanning fixation provides a treatment option with outcomes comparable to existing literature with benefits inherent to internal immobilization.

Capitate shortening osteotomy and vascularized bone grafting for Kienböck's disease in ulnar positive or neutral wrists.

We report the short- to medium-term outcomes for patients with Kienböck's disease and ulnar positive or neutral wrists treated by capitate shortening osteotomy combined with a 4 + 5 extensor compartmental artery vascularized bone graft placed in the lunate. This is a retrospective study of seven consecutive patients with Lichtman Stage 2 to 3B. Radiological and clinical outcomes were evaluated. Six patients maintained their Lichtman stage, one progressed. Mean time to union of the capitate was 10weeks. Five of six lunates were completely revascularized on MRI scans, with one partial revascularization. Mean follow-up for functional scores was 40months (range 15 to 62). Mean pain score improved significantly from 7.4/10 preoperatively to 1.9/10 postoperatively, and patient satisfaction was 9.2/10. Mean postoperative Quick Disabilities of Arm, Shoulder and Hand, Patient Evaluation Measure and Patient-Rated Wrist Evaluation scores were improved. All patients returned to their previous work. We conclude that this procedure has good short- to medium-term outcomes.Level of evidence: IV.