TREATMENT OF ADVANCED KIENBOCK’S WITH SCAPHOCAPITATE FUSION.

Abstract

Treatment of advanced Kienbock’s disease is challenging, and controversial. Palliative procedures should be chosen.

The goal of this study was to analyse the results of scaphocapitate arthrodesis with lunarectomy in advanced cases. Fourteen consecutive wrists in 13 patients were re-examined at a ranged follow-up of 31,7 months (range 3 to 103). Preoperative radiographs showed Lichtman stage 3a disease in 4 patients, stage 3b in 9 patients, and stage 4 in the last patient. Eight patients were women, and the involved wrist was the dominant in 8 cases. The age at operation averaged 36,6 years (range 24 to 55). Symptoms consisted in pain or pain with stiffness. Operative techniques consisted through a dorsal approach in excision of the dorsal interosseus nerve, lunarectomy, and scaphocapitate arthrodesis. Autologous bone graft was used in 8 cases, and osteosynthesis used K wires or staples. The wrists were immobilized in arm cast during 6 weeks, and rehabilitation was started. Postoperatively, one patient developed a complex regional pain syndrome.

At longest follow-up, patients were very satisfied in 8 cases, satisfied in 4, and poorly or not satisfied in 2 cases. Three wrists were painless, and only one wrist had no improvement. One wrist had no improvement. All the employed patients returned to their original work. Mean wrist motion increased slightly. Flexion increased from 33.3 to 33.9°, extension from 39.6 to 39.3°, ulnar deviation from 20 to 23.7°, and radial deviation from 18.8 to 17°. The arc of motion was useful (Flexion- Extension: 73.7° range, Pronation-Supination: 172.7°) Grip strength increased and reached 64.5% of the controlateral wrist. The mean gain was 5.6 Kg (+199%). The improvement was slow and very progressive over one year. On radiographs the arthrodeseses were consolidated in all cases, but the union seemed partial but asymptomatic in two wrists. Correction of scaphoid in flexion was difficult to obtain. No arthritis or degenerative changes were observed, but the distal radial epiphysis seemed to be reshuffled to the new joint and articular surfaces, with progressive disappearance of the radial lunar notch

Scaphocapitate arthrodesis associated with lunarectomy allows getting a painful and functional wrist. This simple procedure theoretically decreases load across the radiolunate joint, prevents further carpal collapse, and stabilizes the midcarpal joint.