Radial osteotomy is currently advocated for patients with Lichtman’s stages II and IIIA of Kienböck’s disease; its place in the treatment of patients with stage IIIB disease remains controversial. The purpose of this study was to evaluate the medium-term results of this procedure and to compare the outcome in patients with stage IIIB disease and those with earlier stages (II and IIIA). A total of 18 patients (18 osteotomies) were evaluated both clinically and radiologically at a mean follow-up of 10.3 years (4 to 18). Range of movement, grip strength and pain improved significantly in all patients; the functional score (Nakamura Scoring System (NSSK)) was high and self-reported disability (Disabilities of Arm, Shoulder and Hand questionnaire) was low at the final follow-up in all patients evaluated. Patients with stage IIIB disease, however, had a significantly lower grip strength, lower NSSK scores and higher disability than those in less advanced stages. Radiological progression of the disease was not noted in either group, despite the stage. Radial osteotomy seems effective in halting the progression of disease and improving symptoms in stages II, IIIA and IIIB. Patients with less advanced disease should be expected to have better clinical results

Kienböck’s disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck’s disease and negative ulnar variance. Many other forms of surgical treatment have been described

We have performed a form of lunate replacement arthroplasty, which included excision of the lunate and insertion of a vascularised radial bone flap wrapped in pronator quadratus, for stage IIIB or stage IV Kienböck’s disease, in 41 patients who have been followed up for more than three years. All patients reported an improvement in their symptoms, and 20 of the 41 became free of pain after the operation. Extension and flexion of the wrist were increased by a mean of 9° and 6°, respectively (p < 0.05). The radioscaphoid angle and the carpal height ratio were not significantly changed and only minimal deterioration was observed due to degenerative change. The size, density or location of the inserted bone did not change with time. A vascularised radial bone flap wrapped in pronator quadratus can be a reliable treatment option for advanced Kienböck’s disease, when the pedicled bone and muscle envelope acts as a stable spacer for the excised lunate

We have examined whether the rotatory subluxation of the scaphoid which is seen in patients with advanced Kienböck’s disease is associated with scapholunate advanced collapse (SLAC) wrist. We studied 16 patients (11 men, 5 women) who had stage-IV Kienböck’s disease with chronic subluxation of the scaphoid. All had received conservative treatment. The mean period of affection with Kienböck’s disease was 30 years (14 to 49). No wrist had SLAC. In eight patients, 24 years or more after the onset of the disease, the articular surface of the radius had been remodelled by the subluxed scaphoid with maintenance of the joint space. The wrists of six patients were considered to be excellent, nine good, and one fair according to the clinical criteria of Dornan. Our findings have shown that rotatory subluxation of the scaphoid in Kienböck’s disease is not a cause of SLAC wrist and therefore that scaphotrapezio-trapezoid arthrodesis is not required for the management of these patients

We have reviewed 20 patients stage-IIIB and stage-IV Kienböck’s disease in order to examine the efficacy of two forms of radial osteotomy, namely radial wedge osteotomy and radial shortening. Lateral closing wedge osteotomies and radial shortenings were carried out on 11 and nine patients, respectively. There were no preoperative differences with respect to age, gender, and radiological stage. After a mean follow-up of 29 months, all patients, in both groups, had either a good or an excellent outcome. After the lateral closing wedge osteotomy, the radioscaphoid angle significantly increased and the St̊hl index significantly decreased. Progression of the degenerative changes at the radioscaphoid joint was found in two patients in this group. By contrast, there were no significant changes in any radiological parameters after radial shortening. Both procedures gave acceptable clinical results in stage-IIIB and stage-IV Kienböck’s disease

Introduction and purpose: Kienböck’s disease was described by R. Kienbock in 1910. From that date onwards, multiple surgical techniques for its treatment have been described. Amongst these techniques is the one we have used: a radial osteotomy with Nakamura effect; this is a radial osteotomy with a wedge-shaped base and minimum dorsal width with subsequent osteoclasia carried out distally to the distal radioulnar joint to prevent any alterations in joint congruence. The aim of this study is to assess the results of this technique and compare them with those described in the literature using other surgical techniques. Materials and methods: We selected patients with Kien-böck’s disease stage II and IIIA that underwent surgery using the technique described and we subsequently assessed clinical and radiological parameters both pre and postoperatively. Results: Of the 17 patients diagnosed with Kienböck’s disease in our department, only 11 were operated using the technique described above. In these patients it was possible to see that a greater number had their dominant arm affected, there was a greater percentage of ulnar plus variants, the radial inclination angle was higher and the main symptom was pain. At this time, having undergone surgery, the patients are stable both clinically and radiologically, with the exception of 1 case that required rescue surgery. Satisfactory union was seen in 100% of cases after osteotomy. Conclusions: During the initial stages, surgical treatment is preferable, and osteotomies are the techniques most frequently used. Radial osteotomy with Nakamura effect is a technique with excellent results, comparable to those seen with other techniques applied used during the initial stage

Aim: Although several surgical procedures have been proposed for advancedstage Kienböck’s disease, it still remains a difficult therapeutic problem. This study documents the clinical, radiographic and MRI outcomes of ten patients, who underwent lateral closing wedge osteotomy of the distal radius by the same surgeon, after MRI confirmation of advanced Kienböck’s disease. Methods: Ten patients (6 men and 4 women) with a mean age of 28,7 years (range 21–66) were included in this study. Seven had Lichtman stage III-B and three stage IV disease. The lateral closing wedge osteotomy was performed at the distal metaphysis of the radius through a palmar approach and was fixed with a 3,5mm titanium T-plate. The average follow up period was 52 months (range 36–60 months). Results: Substantial pain relief, increase in grip strength and range of wrist flexion and extension were achieved. Clinical results were excellent in two patients, good in five, fair in two patients and poor in one patient according to Nakamura’s postoperative scoring system. Gadolinium enhanced MRI at the latest follow up revealed signs of revascularization of the lunate in 6 cases. Conclusions: Lateral closing osteotomy decreases radial inclination and pressure at the radiolunate joint, thus improving lunate coverage. It is a reliable extra-articular procedure for advanced Kienbock’s disease that provides pain relief while there is evidence that it may improve lunate vascularization

1. Twenty-four cases of excision of the lunate bone in Kienböck's disease have been reviewed. 2. In general, the results have been favourable, with 88 per cent excellent or good and 12 per cent fair or poor. 3. Abnormal contact between the triquetrum and the styloid process of the ulna appeared in many cases, but this contact did not appear to prejudice the results. 4. Excision after prolonged symptoms of the disease gave disappointing results

Introduction: We report on our experience of using a vascularised bone graft harvested from the volar face of the radius in the treatment of Kienböck’s disease, with an average follow up of 79 months and a minimum of 5 years. Materials: We treated 22 patients with Kienböck’s disease. There were 8 women and 14 men whose average age was 31.4 years old (range 18–63 years). Pain was always present and incapacitating in 19 cases. All patients underwent pre-operative tomodensitometry and an MRI, based on LICHTMAN’s classification there were 8 stage II, 10 stage IIIA and 4 stage IIIB. Methods: The volar carpal artery of the carpus originates from the radial artery and vascularises medial part of the radial epiphysis. Using the same anterior surgical approach it was possible to harvest the pedicled bone graft from this artery and to place it into the lunate for revascularisation. Shortening of the radius was carried out in all cases, as was immobilisation until union of the radius. Results: Our average follow up is 79 months (range 60–138 months). Pain disappeared completely in 20 cases, and was moderate and tolerable in 2 cases. The average active range of motion was higher than 71°. The average period for return to work was 3.5 months. Post-operative MRI at an average of more than 8 months showed 16 complete revascularisations of the lunate, 5 stabilizations of lesions and one failure which necessitated secondary palliative treatment. There were 4 delayed unions of the radius and one Südeck’s dystrophy. There was a clear correlation between the stage of Kienböck’s disease and the final outcome of surgery. Discussion: The use of a vascularised bone graft harvested from the anterior face of the radius for the revascularisation of the lunate associated with shortening of the radius has given encouraging results. A longer-term study is necessary

A vascular necrosis of the lunate, first described by Kienböck, can be treated either conservatively or by various surgical procedures. We compared the results of 18 conservatively treated patients, all of whom had stage-2 or stage-3 disease, with those of 15 who underwent a radial shortening procedure. We evaluated pain, range of movement, grip strength and functional disability, and determined the progression of the disease by assessing radiologically carpal height, the width and flattening of the lunate, the radioscaphoid angle, the pattern of the fracture and sclerosis and cysts. The mean follow-up was for 3.6 years (1.5 to 9).

Patients treated by radial shortening had less pain and better grip strength than those managed conservatively. In some patients with stage-3 disease treated conservatively there was rapid deterioration to carpal collapse. Although radial shortening did not reverse or prevent carpal collapse, it slowed down the process in patients with stage-3 disease.

We recommend a radial shortening procedure for patients with severe pain and radiological signs of progressive carpal collapse.

Purpose: We report our experience with vascularised bone grafts harvested from the anterior aspect of the radius for the treatment of Kienböck disease. We reviewed our patients at minimum three years, average 67 months. Material and methods: We treated 22 patients with Kienböck disease, eight women and fourteen men, mean age 31.4 years (18–63). Pain was present in all cases and was disabling in nineteen. After systematic computed tomography and magnetic resonance imagine (MRI), the Büchler classification was stage II=8, stage IIA=10 and stage IIIB=4. The transverse anterior artery of the carpus arises from the radial artery and supplies blood to the medial part of the radial epiphysis. The pediculated bone graft fed by this artery can be harvested via the same anterior approach as used to position it in the semilunate for revascularisation. Radial shortening was performed in all cases. The patients were immobilised until the radius healed. Results: Mean follow-up was 67 months (36–104). Pain resolved completely in all twenty patients. Two patients nevertheless reported moderate pain occasionally. Mean active motion was greater than 71°. Mean time to resumption of former activities was 3.5 months. Postoperative MRI, performed at mean 8 months, demonstrated complete revascularisation of the semilunate in six cases, stable lesions in five, and one failure requiring secondary palliation. There were four cases of late healing of the radial osteotomy and one reflex dystrophy. There was a direct correlation between Kienböck disease stage and final outcome. Conclusion: Use of a vascularised graft harvested from the anterior aspect of the radius for revascularisation of the semilunate associated with radial shortening has provided encouraging results. Long-term follow-up is needed to verify these results

Summary. Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease. Introduction. The purpose of this study was to investigate the outcomes of patients suffering from avascular necrosis of the lunate, or Kienböck's Disease, who received arthroscopic decompression to treat the ischemic lunate. Previous studies have demonstrated an elevated intraosseus pressure in the ischemic lunate, and it has been hypothesised that ischemia in the lunate is secondary to this elevated pressure and subsequent venous congestion, as opposed to diminished arterial supply. Based on this work we have used decompression of the lunate to prevent progression of the disease. Patients and Methods. 21 patients, (22 wrists), reported to a single surgeon with a chief complaint of unremitting wrist pain and the subsequent diagnosis was Kienböck's disease, stages I, II, IIIA or IIIB. Range of motion measurement and grip strength, as well as self-reported outcome measures such as Disabilities of the Arm, Shoulder and Hand (DASH) and Modified Mayo, were obtained preoperatively and post operatively at 2, 7 and 12 months. The patients were treated operatively with arthroscopic decompression of the lunate. The lunate was approached dorsally at the interosseous lunotriquetral and the scapholunate ligament areas with an arthroscopic shaver until brisk bleeding was achieved upon deflating the tourniquet. In some cases, the core of the lunate had to be penetrated with a 45 k-wire until bleeding was obtained. Of the 22 wrists treated arthroscopically with lunate decompression, 18 had both pre-surgical and post-surgical follow-up evaluations. Results. The patients who underwent lunate arthroscopic decompression surgery demonstrated a statistically significant improvement in DASH score at 7 and 12 months postoperatively (p<0.05). The preoperative DASH score average for this cohort was 51, while post-operative DASH scores averaged 23 and 17 at 7 and 12 months, respectively. The patients also demonstrated some overall improvement in pain, functionality, range of motion, and grip strength as demonstrated by the Modified Mayo wrist score. Notably, the patients demonstrated statistically significant improvement in grip strength post-operatively at 7-months (p<0.05) and 12-months (p<0.01). In addition, there was noted to be improvement in supination and ulnar deviation measurements post-operatively at 7 months and 12 months, respectively. Conclusion. This study demonstrates the clinical outcome of arthroscopic decompression of the lunate in patients suffering from Kienböck's Disease using the patient's subjective evaluations as well as range of motion and grip strength measurements. Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease using a less invasive surgical intervention

Purpose: This retrospective analysis was performed to determine the long-term usefulness of carpectomy and to define prognostic factors. Material and methods: Forty-four patients were operated. There mean age was 39.2 years, and mean follow-up was 17 years (10–35 years). Twenty-two patients had osteoarthritis, one STT, thirteen SNAC-wrist, two SLAC-wrist, and three radiocarpal osteoarthritis. The wrists were free of degenerative lesions in 22 cases: eight Kienböck disease, five longstanding perilunar dislocations, six fracture sequelae, and one rheumatoid polyarthritis. Seventeen patients had had several procedures before the present operation. The dorsal approach was used for all patients except five. Complementary styloidectomy was associated in two cases. clinical and radiological outcome was assessed at one, five and fifteen years. Factors predictie of outcome were analysed with the Student test and the Man and Whitney test. Results: The pain score (Cooney scale 1 to 4) was 3.19 preoperatively and 1.56, 1.88 and < 2 at one, five and fifteen years respectively. Flexion amplitude improved from 44° preoperatively to 61°, 68° and 62° at one, five and fifteen years respectively. Mean grip force, compared with the other wrist was 57.5%, 75% and 64% at one, five and fifteen years. Radiographically, at fifteen years 80% of the patients had a centred capitatum on the AP view of the lunar facet. On the lateral view, 56% of the patients exhibited anterior translation of the apitatum and 37% were centred. There was a degradation of the radiocapitum space requiring revision for arthrodesis in five cases. Discussion, conclusion: This study confirms the long-term preservation of outcome after proximal carpectomy: 89% of the patients were satisfied at fifteen years. These findings also indicate that reconstruction of recent trauma (fracture-dislocation) produces variable results. For patients with grade II or II osteoarthritis (SNAC or SLAC-wrist) carpectomy should be reserved for selected patients with occupational or sports activities not requiring grip force. For grade III wrists, carpectomy can be proposed for elderly patients with limited activity. Grade IV is a contraindication for carpectomy. We do not recommend this procedure for patients with rheumatoid arthritis or Kienböck disease

Introduction. Kienböck's disease is generally defined as the collapse of the lunate bone, and this may lead to early wrist osteoarthritis. Replacing the collapsed lunate with an implant has regained renewed interest with the advancing technology of additive manufacturing, enabling the design of patient-specific implants. The aims of this project are (1) to determine how accurate it is to use the contralateral lunate shape as a template for patient-specific lunate implants, and (2) to study the effects of shape variations wrist kinematics using 4D-computed tomography (CT) scanning. Methods. A 3D statistical shape model (SSM) of the lunate was built based on bilateral CT scans of 54 individuals. Using SMM, shape variations of the lunate were identified and the intra- and inter-subject shape variations were compared by performing an intraclass correlation analysis. A radiolucent motor-controlled wrist-holder was designed to guide flexion/extension and radial/ulnar deviation of ex vivo wrist specimens under 4D-CT scanning. In this pilot, three shape mode variations were tested per specimen in two specimens were. After post-processing each CT, the scapholunate angle (SLA) and capitolunate angle (CLA) were measured. Results. The shape of the lunate was not symmetrical, defined as exceeding the intra-subject variation in five different shape modes. The FE tests show a generalized increase in scapholunate and capitolunate angle when using lunate implants, and comparing variation of shape modes showed that shape mode 3 has a significant effect on the measured angles (p<0.05). Discussion. The design of patient-specific lunate implants may prove to be challenging using a ‘mirror’-design as it will lead to a degree of shape asymmetry. The pilot study, to determine the effects of those shape variations on wrist kinematics suggest that the degree of shape variation observed indeed may alter the wrist kinematics, although this needs to be further investigated in study using more specimens

The August 2012 Wrist & Hand Roundup. 360. looks at: the Herbert ulnar head prosthesis; the five-year outcome for wrist arthroscopic surgery; four-corner arthrodesis with headless screws; balloon kyphoplasty for Kienböck's disease; Mason Type 2 radial head fractures; local infiltration and intravenous regional anaesthesia for endoscopic carpal tunnel release; perilunate injuries; and replanting the amputated fingertip

We assessed carpal collapse by measuring the capitate-radius (CR) distance on standard plain radiographs. This new method required validation of diagnostic accuracy, so we compared it with the method of Nattrass et al. 1. known as revised carpal height (RCH). We studied wrist radiographs from 16 normal subjects and 11 patients with unilateral Kienböck’s disease. We found that there was a significant difference in the left/right CR index between the normal wrists and those with Kienböck’s disease (p < 0.001). The use of left/right RCH index showed no significant difference (p = 0.30). Diagnostic accuracy was shown to be higher for the CR index using ROC curves. We then assessed 40 normal wrists and found the mean CR index to be 0.999 ± 0.034, and suggest that values less than 0.92 are abnormal. The CR index can be used for diagnosis in unilateral carpal collapse, and for monitoring progress where the condition is bilateral

The June 2012 Wrist & Hand Roundup. 360. looks at; radial osteotomy and advanced Kienböck's disease; fixing the Bennett fracture; PEEK plates and four-corner arthrodesis,;carpal tunnel release and haemodialysis; degloved digits and the reverse radial forearm flap; occupational hand injuries; trapeziometacarpal osteoarthritis; fixing the fractured metacarpal neck and pyrocarbon implants for the destroyed PIPJ

Aims

The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes.

Purpose: Necrosis of the navicular bone, described by Müller then Weiss in 1927, is an uncommon finding, unlike talonavicular degeneration which is a rather frequent complication of talipes planovalgus. Between 1985 and 2000, we cared for 25 patients with this condition. The purpose of this retrospective analysis was to describe the clinical and radiological presentation and attempt to reconstruct its natural history with the aim of determining therapeutic indications. Material and methods: We analysed 25 cases of navicular bone necrosis observed in 14 women and 3 men (eight bilateral cases). Mean age of the patients was 39 years (range 16–59). The diagnosis of necrosis was established on the basis of structural alterations (densification, bone defects) and in the more advanced cases, flattening and “expulsion” of the navicular bone. We looked for clinical signs and described the radiological aspect of the necrotic zone. A computed tomography was available in 14 cases and magnetic resonance imaging in the five most recent cases. Results: Pain was the major sign in all cases. One-third of the cases occurred in a foot with prior planovalgus. History taking revealed elements suggestive of an aetiology in three cases: probable Köhler-Mouchet disease in a 16-year-old boy, sickle cell disease in a 35-year-old man, and prolonged walking with signs suggesting stress fracture in a 40-year-old woman. In the other 19 cases (11 women and 1 man, 7 bilateral cases), necrosis was considered idiopathic. Radiologically, we used the Ficat classification (described for hips): stage 0 with normal x-ray and strong uptake on scintigram (n=1), stage 1 with a normally shaped navicular bone but condensation or bone defect, stage 2 with modification of the shape of the bone without signs of degeneration, stage 3 where changes in the shape of the bone are associated with narrowing of the talonavicular then cuneonavicular space. Computed tomography included frontal and horizontal slices as well as lateral reconstructions indispensable to assess the posterior part of the interarticular spaces. Treatment was surgical in 12 cases and medical in 13. Well tolerated forms were treated with plantar ortheses with regular surveillance. Surgical procedures included triple arthrodesis (early in our experience), mediotarsal arthrodesis (n=2), talonavicular arthrodesis (n=7) and talocuneate arthrodesis with replacement of the scaphoid by an iliac graft (n=2). The natural course of necrosis was studied in the cases without surgery. The first sign was medial mediotarsal pain. At this stage scin-tigraphy or MRI was required for positive diagnosis. At stage 0 condensation of the navicular bone, confirmed by computed tomography, preceded bone flattening then expulsion upwardly and medially, sometimes with fragmentation and onset of talonavicular degeneration. Cuneonavicular degeneration appeared to occur later (except in one case). Long-term results of surgery were good with pain relief and renewed activity. Discussion: The clinical presentation initially described as Müller-Weiss disease or scaphoiditis, which concerns a bilateral condition generally occurring after trauma and sometimes with a favouring factor (alcoholism, osteoporosis), appears somewhat different from our description. Mechanical factors predominated in our patients and the aetiologies were quite similar to those observed in Kienböck syndrome. Excessive pressure on the navicular bone, which leads to avascular necrosis, flattening, and expulsion, is undoubtedly the essential cause of this condition. It is well tolerated in some individuals and can lead to spontaneous fusion. In this situation, treatment can be limited to surveillance or orthopaedic care. If the functional impact is important, surgical treatment can be proposed, generally limited to talonavicular arthrodesis. If the navicular bone is sclerosed and flat, the remaining fragment can be replaced by an iliac graft to achieve talocuneate fusion. Conclusion: Necrosis of the navicular bone appears to be less uncommon than in the classical description, particularly in black women aged 25–50 years. A more precise study of favouring anatomic factors (length of the medial ray, size of the talar neck, depression of the medial arch) could provide further information concerning the aetiology which appears to be similar to that of Kienböck disease

1. Excision of the proximal row of the carpus is a useful procedure, with a limited application in patients with ununited fractures of the scaphoid, Kienböck's disease, dislocation of the lunate bone, unreduced mid-carpal dislocations and similar injuries which do not respond to conservative management. 2. It is an acceptable alternative to arthrodesis, even when the wrist is likely to be subjected to heavy use. 3. In the event of failure arthrodesis can still be carried out. 4. Advanced degenerative changes are a contra-indication but mild to moderate changes do not appear to affect the results