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Graner's procedure in Kienböck disease: A series of four cases with 25years of follow-up
Abstract
Advanced stages of Kienböck's disease are treated by several techniques, one of which is Graner's procedure, nearly abandoned nowadays. The results of long-term follow-up of a series of four cases Graner's procedure are presented. Four patients were reviewed with a follow-up of 25years. There were two women and two men mean aged 37years at the time of surgery. Two of them were manual workers. Graner's procedure was the first surgery in three cases and secondary to failure of radius shortening in one case of Stage IIIa. Three patients underwent bone healing and the fourth benefited secondarily from radiocarpal arthrodesis. At maximal follow-up, the mean DASH score was 36.6 and pain assessed by visual analogic scale was 3.25 out of 10; the range of movement was half of the opposite side; the wrist strength was 80.9% of the opposite side. In the three consolidated cases, a spontaneous remodeling of the radiocarpal articular surfaces was noted. Graner's procedure is logical as it aims at creating a new radiocarpal articulation, either by the fusion of the lunate with the capitate (Graner I) or by replacing the lunate with the head of the capitate (Graner II and III). However, this old procedure should no longer be one of the surgical procedures for Kienböck disease due to its drawbacks: necrosis or non-union of the head of the capitate, necessity to perform a wrist fusion in the long-term and side effects of bone graft harvesting.
II. Retrospective study.
... Graner's procedure is logical as it aims at creating a new radiocarpal articulation, either by the fusion of the lunate with all carpus except trapezium (Graner I) or by replacing the lunate with the head of the capitate with pancarpal fusion except trapezium (Graner II) or replacing the lunate with the head of the capitate with just capitohamate fusion (Graner III). 8 We suppose that the creation of a new radiocapitate articulation as in Graner II and III procedure may decrease overloading of the radioscaphoid joint following STT or scaphocapitate (SC) arthrodesis in Kienböck disease. ...
... In our study, mean VAS was 1.2 at final follow-up. In the study of Facca et al, 8 Graner II procedure was conducted on four patients with late stage Kienböck disease. The patients were followed up for 25 years. ...
... Regarding ROM, flexion decreased to 44% and extension to 63% of contralateral side. In the study of Facca et al, 8 the range of movement was half of the opposite side. In the study of Takase and Imakiire, 9 there was moderate limitation of wrist ROM that did not affect the usual level of activity. ...
Background Intercarpal fusions are used to treat stage IIIb Kienböck disease. They increase force transfer across the radioscaphoid articulation with predisposition to arthritis.
Description of Technique This technique is excision of lunate followed by proximal transfer of capitate, with scaphocapitate and triquetrocapitate fusion to increase area of load transfer mimicking wrist hemiarthroplasty. Our purpose is to evaluate mid-term results of this technique.
Patients and Methods A prospective case series study was conducted on 11 patients with stage IIIb and IIIc. In seven cases, transfer of the capitate was performed by osteotomizing the capitate just distal to its waist, proximal migration to replace the excised lunate then bone grafting. In four cases, proximal transfer of vascularized pedicled capitate was done. Clinical outcome measures included pain (visual analog scale), grip strength, range of motion, and functional evaluation by modified Mayo wrist score and scoring system of Evans. Radiological outcome measures included healing of fusion mass, progression of the disease, and occurrence of avascular necrosis to the capitate.
Results Follow-up period averaged 54 months. Scaphocapitate fusion healing averaged 11 weeks. Union of the lengthened capitate occurred in 10 patients only. There was postoperative improvement in pain scores, grip, Evans, and modified Mayo wrist score. There was postoperative decrease in wrist flexion and extension. One patient showed resorption of the capitate head with progressive radioscaphoid arthritis-necessitated wrist fusion.
Conclusion The mid-term results of this technique may be satisfactory due to low incidence of degenerative arthritis in the radioscaphoid joint. However, longer follow-up with recruiting larger number of patients is needed.
... The basic idea of this technique was described by Graner et al. (1966). Since that report, there have been several publications regarding this technique, its modifications, and their mid-term as well as long-term results (Bartelmann et al., 1998;Braun et al., 1988;Ehall et al., 1989;Facca et al., 2013;Hierner and Wilhelm, 2010;Nonnenmacher et al., 1982;Takase and Imakiire, 2001). Graner et al. (1966) used this technique not only for lunate malacia (Kienböck's disease), but also for painful scaphoid nonunions and old carpal bone fractures with dislocation. ...
... The outcomes of this procedures performed by other surgeons were not as good as Graner et al. (1966) reported. However, some surgeons did not publish their outcomes on this technique (Facca et al., 2013). Graner et al. (1966) removed the lunate and cut and moved the proximal fragment of the capitate proximally, supported by cancellous bone graft, when the lunate was not viable. ...
... Nonnenmacher et al. (1982) described how their own previously good results obtained at 2 years postoperative declined with time over 25 years follow-up. This procedure is no longer preferred in Germany and France because of the declining long-term outcome (Facca et al., 2013). As far as I know, this method is not used in Europe any longer. ...
... With the same principle of balancing axial load transmission through radio-lunate and radio-scaphoid joints, the Graner II procedure included complete lunate excision and its replacement with the head of the capitate through capitate lengthening so that the articular surface of the head of the capitate articulated with the lunate surface of the radius. To prevent intercarpal instability following the lunate excision, intercarpal fusion between all carpal bones except the trapezium and pisiform was done [28,29]. However, this procedure had several reported complications, including osteonecrosis and nonunion of the head of the capitate, and long-term arthritis [29][30][31][32]. ...
... To prevent intercarpal instability following the lunate excision, intercarpal fusion between all carpal bones except the trapezium and pisiform was done [28,29]. However, this procedure had several reported complications, including osteonecrosis and nonunion of the head of the capitate, and long-term arthritis [29][30][31][32]. ...
Background:
Kienböck's disease is idiopathic lunate avascular necrosis, which may lead to lunate collapse, abnormal carpal motion and wrist arthritis. The current study aimed to assess the outcomes of treating stage IIIA Kienböck's disease by a novel technique of limited carpal fusion via partial lunate excision with preservation of the proximal lunate surface and scapho-luno-capitate (SLC) fusion.
Materials and methods:
We conducted a prospective study of patients with grade IIIA Kienböck's disease managed with a novel technique of limited carpal fusion comprising SLC fusion with preservation of the proximal lunate articular cartilage. Autologous iliac crest bone grafting and K-wires fixation were used to enhance the osteosynthesis of the SLC fusion. The minimum follow-up period was 1 year. A visual analog scale (VAS) and the Mayo Wrist Score were utilized for the evaluation of patient residual pain and functional assessment, respectively. A digital Smedley dynamometer was used to measure the grip strength. The modified carpal height ratio (MCHR) was used for monitoring carpal collapse. The radioscaphoid angle, scapholunate angle, and the modified carpal-ulnar distance ratio were used for the assessment of carpal bones alignment and ulnar translocation of carpal bones.
Results:
This study included 20 patients with a mean age of 27.9 ± 5.5 years. At the last follow-up, the mean range of flexion/extension range of motion (% of normal side) improved from 52.8 ± 5.4% to 65.7 ± 11.1%, P = 0.002, the mean grip strength (% of normal side) improved from 54.6 ± 11.8% to 88.3 ± 12.4%, P = 0.001, the mean Mayo Wrist Score improved from 41.5 ± 8.2 to 81 ± 9.2, P = 0.002, and the mean VAS score reduced from 6.1 ± 1.6 to 0.6 ± 0.4, P = 0.004. The mean follow-up MCHR improved from 1.46 ± 0.11 to 1.59 ± 0.34, P = 0.112. The mean radioscaphoid angle improved from 63 ± 10º to 49 ± 6º, P = 0.011. The mean scapholunate angle increased from 32 ± 6º to 47 ± 8º, P = 0.004. The mean modified carpal-ulnar distance ratio was preserved and none of the patients developed ulnar translocation of the carpal bones. Radiological union was achieved in all patients.
Conclusions:
Scapho-luno-capitate fusion with partial lunate excision and preservation of the proximal lunate surface is a valuable option for treating stage IIIA Kienböck's disease, with satisfactory outcomes. Level of evidence Level IV. Trial registration Not applicable.
... The avascular osteonecrosis of the lunate is a rare disease and its prevalence is about 7 per 100000 (10,11). It shows, as in our study, a male predominance with a peak incidence between 20-40 years (12). ...
Kienböck’s disease is a rare condition. It affects young adults who are mostly manual workers. Radiology allows diagnosis and classification of the disease using the Lichtman classification which will guide the therapeutic strategy. The aim of the present work is to review the clinical data, recent advances in assessment methods (MRI and arthroscopy) and our therapeutic results compared to the literature. Material and methods: This is a retrospective study of fifteen cases of Kienböck’s disease, collected in the Traumatology-Orthopaedics Department I of the Mohamed V Military Hospital in Rabat, Morocco, over a 20 years period, from 2001 to 2020. This study included 10 men and 5 women, with an average age of 29 years. All of our patients underwent plain radiographs that allowed diagnosis and staging. Only 6 patients benefited from MR imaging and none of them had cartilage arthroscopic assessment. Radial shortening osteotomy were performed for 14 patients and lunate decompression by forage for one patient with good results in 53% and 14% of poor results. Discussion: Comparing the results of our study with those of the literature, we found concordance regarding clinical, radiological and therapeutic methods. However, this study has shown insufficient use of MRI for viability evaluation of the lunate and cartilage arthroscopic assessment, due in first place to their high cost for developing countries as ours. Thus, treatment choices weren’t accurate enough, which explains our 47% poor to fair results. Conclusion: Kienböck’s disease is a rare condition that should be early diagnosed with accurate staging using recent advances in assessment methods which allows proper treatment choices to prevent its evolution toward total destruction of the wrist. However, patient’s desires and needs, surgeon’s experience and capabilities of their facilities precondition the final decision.
... A técnica utilizada neste trabalho visa a criação de uma nova articulação radiocárpica, seja pela fusão do semilunar com o capitato ou pela substituição do semilunar pela cabeça do capitato. Existem relatos de que a técnica pode trazer alguns inconvenientes, como a necrose ou não-união da cabeça do capitato, obrigando a realização de uma fusão do punho em longo prazo, além do surgimento de efeitos colaterais no local de coleta do enxerto (FACCA et al., 2013). Todavia, nenhuma das complicações relatadas foram observadas no caso aqui relatado. ...
Introdução: A osteomalácia do semilunar é o resultado de uma interrupção traumática do suprimento sanguíneo para o referido osso, com uma perturbação subsequente de sua nutrição, caracterizando a Doença de Kienböck (DK). A etiologia da doença ainda é controversa, e dentre as principais teorias sobre o mecanismo para o desenvolvimento da osteonecrose do semilunar inclui-se fratura de compressão primária, ruptura traumática do suprimento sanguíneo extra-ósseo do semilunar e carga repetitiva do osso, além da presença de êmbolos. Objetivo: Descrever um caso de DK tratado cirurgicamente em nosso Serviço através da ressecção da fileira proximal do punho seguida de artrodese. Método: Trata-se do relato do caso único de um paciente atendido no Serviço de Ortopedia e Traumatologia do Hospital Ana Costa, localizado na cidade de Santos – SP. Relato do Caso: Paciente do sexo masculino, 40 anos de idade e caucasiano, trabalhador rural, foi admitido em nosso Serviço com relato de dores no punho direito, mão dominante do paciente, e limitação funcional. Relatou história de trauma prévio em punho, todavia sem tratamento cirúrgico. Após avaliação clínica e com o advento de imagens radiográficas, a equipe chegou ao diagnóstico de DK. Foi realizado então tratamento cirúrgico, que consistiu em uma grande ressecção da fileira proximal do punho associada a uma artrodese do punho. Conclusão: A técnica utilizada demonstrou sucesso para tratamento da DK no paciente aqui relatado, sem a ocorrência de complicações ou quaisquer intercorrências que desabonem sua utilização.
... Kienböck's disease or osteonecrosis of the lunate, described in 1910 by Robert Kienbock, remains a rare condition, the pathophysiology of which is not completely elucidated despite the development of imaging technics [2] . It is an avascular necrosis of the lunate that progressively evolves to carpal collapse [1] . ...
Kienböck's disease is a condition characterized by avascular necrosis of the lunate. It is also known as lunatomalacia and aseptic or ischemic necrosis of the lunate.
The aim of this work is to summarize and illustrate, through a case diagnosed in our institution, the radiological aspects of this rare entity, which occupy a prominent place in the diagnosis.
A better understanding of this recently described nosological entity and a wide dissemination of its diagnostic criteria, especially by radiologists, should facilitate the diagnosis and treatment of patients.
... Personal factors include age and gender, the associated diseases, the trauma-related factors, the social and environmental factors, and the association with osteonecrosis of other carpal bones [2]. Kienböck's disease is classified as rare and its prevalence is about 7 per 100,000 [3,4]. Kienböck's disease shows male predominance, with a peak incidence in patients aged 20-40 years [5]. ...
Kienböck's disease is a rare disease described as progressive avascular osteonecrosis of the lunate. The typical manifestations include a unilateral reduction in wrist motion with accompanying pain and swelling. Besides recent advances in treatment options, the etiology and pathophysiology of the disease remain poorly understood. Common risk factors include anatomical features including ulnar variance, differences in blood supply, increased intraosseous pressure along with direct trauma, and environmental influence. The staging of Kienböck's disease depends mainly on radiographic characteristics assessed according to the modified Lichtman scale. The selection of treatment options is often challenging, as radiographic features may not correspond directly to initial clinical symptoms and differ among age groups. At the earliest stages of Kienböck disease, the nonoperative, unloading management is generally preferred. Patients with negative ulnar variance are usually treated with radial shortening osteotomy. For patients with positive or neutral ulnar variance, a capitate shortening osteotomy is a recommended option. One of the most recent surgical techniques used in Stage III Kienböck cases is vascularized bone grafting. One of the most promising procedures is a vascularized, pedicled, scaphoid graft combined with partial radioscaphoid arthrodesis. This technique provides excellent pain management and prevents carpal collapse. In stage IV, salvage procedures including total wrist fusion or total wrist arthroplasty are often required.
... Following which several options arise depending on whether the lunate will be preserved or not: the decision to preserve it depends on the radiological appearance of this ossicle, the evolutionary stage of the disease and the local anatomy. Kienböck's disease are treated by several techniques, one of which is Graner's procedure, an almost forgotten technique nowadays [8]. Graner's procedure is logical as its purpose is to create a new radiocarpal articulation. ...
Kienbock's disease is an avascular necrosis of the lunate bone of the hand, which manifests itself by pain in the wrist associated with a certain stiffness and above all a loss of clenching strength. If left untreated, the natural course of this disease is towards the progressive aggravation and destruction of the lunate and then the whole wrist. In the advanced stages of the disease, the lunate becomes too damaged to be preserved. Several surgical techniques can be considered, including the placement of an implant. In this perspective, the present paper deals with the modelling and the realization of a lunate implant. To do this, we first used scanner images provided by the Cheikh Zaid International University Hospital in Rabat (Morocco) in order to obtain a 3D reconstruction of the semilunar bone. The measurements carried out on this reconstruction allowed us to determine the parameters necessary for its modelling. In a second step, we proceeded to the choice of the material taking into account several criteria such as biocompatibility, elastic limit, cost, ... Finally, we proceeded to the 3D printing of a prototype. The results obtained are satisfactory and could contribute to a better management of patients suffering from Kienbock disease.
... Décrite depuis 1910, la maladie de Kienböck ou ostéonécrose du lunatum reste une affection rare, mystérieuse malgré le développement de l´imagerie [4]. C´est une nécrose avasculaire du lunatum qui évolue progressivement vers un collapsus du carpe [1]. ...
Décrite en 1910 par un radiologue autrichien, Robert Kienböck, la maladie de Kienböck ou ostéonécrose aseptique du lunatum est une affection rare dont l´histoire naturelle évolue vers un collapsus progressif du carpe avec évolution dégénérative secondaire. La négativité de l´index radio ulnaire inférieur et sa vascularisation précaire sont les principaux facteurs prédisposants. Elle peut être asymptomatique ou se manifester par la douleur et l´impotence fonctionnelle. L´imagerie confirme le diagnostic, détermine le stade évolutif permettant ainsi un choix thérapeutique adéquat. Nous rapportons les observations de quatre patients chez qui le diagnostic de maladie de Kienböck a été porté. Nous discuterons du rôle de l´imagerie dans le diagnostic et la prise en charge.
Background
Kienböck’s disease is described as avascular osteonecrosis of the lunate. The capitate-hamate fusion is another means of relieving pressure on the lunate. This procedure is designed for patients with Kienböck’s disease.
Aim
To evaluate clinical and radiological outcomes of the surgical technique capitate-hamate fusion for the treatment of stages II, III A of Kienböck’s disease with neutral ulnar variance and whether this technique resulted in pain relief, improvement in wrist motion, or changes in the radiographic evaluation.
Patients and methods
This randomized controlled clinical trial included 20 patients with early stages (stages II and IIIA) of Kienböck’s disease with neutral ulnar variance. The study was carried out in the orthopedic unit of Al-Helal Hospital during the period from March 1st to July 31, 2023.
Results
Postoperatively, pain, grip strength, range of motion, and the modified Mayo wrist score all increased significantly. There was a significant decrease in carpal height index and lunate height index postoperatively. 65% of patients had stage II Kienböck’s disease, and 35% had stage IIIA Kienböck’s disease. 12 (60%) of patients were excellent, and five (25%) of patients were good. While two patients were fair, and one patient was poor.
Conclusion
The current study showed that surgical treatment of stages II and IIIA of Kienböck’s disease with neutral ulnar variance by capitate-hamate fusion technique resulted in significant pain relief, improvement in wrist motion, and a significant decrease in carpal height index and lunate height index, with high patient satisfaction.
La maladie de Kienbock est une entite rare caracterisee par une necrose avasculaire de los semi-lunaire. Nous rapportons lobservation clinico-radiologique dune patiente âgee de 52 ans chez qui le diagnostic de maladie de Kienbock a ete porte. Lexamen clinique objectivait une douleur avec diminution de la force de prehension de la main droite. La radiographie du poignet et en particulier limagerie par resonnance magnetique ont permis de faire le diagnostic de certitude.
Background Despite numerous proposed surgical interventions, there is a lack of consensus in the optimal treatment of advanced Kienbock's disease.
Purpose This study aims to perform a systematic review of the current evidence in the management of Lichtman's stages IIIA and IIIB of the disease.
Methods A literature search was performed using the MEDLINE, EMBASE, and COCHRANE databases to identify studies between 2008 and 2018 evaluating stage-specific outcomes in Lichtman's stages IIIA and IIIB. The quality of each included paper was evaluated using the Structured Effectiveness Quality Evaluation Scale (SEQES). Data extracted were stage-specificity, clinical and functional outcomes, and radiographic progression of Lichtman's staging.
Results A total of 1,489 titles were identified. Eighty-three papers were fully reviewed, and 30 articles met eligibility criteria for inclusion. There were 3 low-quality and 27 moderate-quality papers. Surgical techniques reported included decompression surgeries, joint-levelling, and radial wedge osteotomies, revascularization techniques, intracarpal arthrodesis, proximal row carpectomy, arthroplasty, and balloon kyphoplasty. All treatment modalities offered pain relief and improvement in functional outcomes. Compared with proximal row carpectomy, intracarpal arthrodesis, and arthroplasty, nonsalvage procedures provided similar clinical and functional outcomes in both stages, with joint-levelling and radial wedge osteotomies preserving greater range of motion.
Conclusion In this systematic review of Kienbock's disease stages IIIA and IIIB, all treatment modalities provided positive outcomes. In stage IIIB, there is evidence to support nonsalvage procedures, as they produced similar clinical outcomes to salvage procedures that have the advantage of not precluding future treatment options if needed and preserving greater range of motion.
The Graner–Wilhelm procedure, indicated in selected stage III Kienböck’s cases with preserved hyaline cartilage at the distal radius lunate fossa and capitate head (Bain–Begg Kienböck’s grade 0 or 1), consists of resection of the necrotic lunate, transverse osteotomy of the distal corpus of the capitate, implantation of an external minifixator, followed—after 7–10 days—by progressive lengthening of the capitate until the carpal height is restored. Bone healing under distraction osteogenesis is relatively quick. After rehabilitation the patient regains acceptable wrist joint motion and strength. Contrary to what is observed after first carpal row resection, no degenerative osteo-arthrosis seems to affect the radio-capitate joint.
The etiology of Kienböck disease, or avascular necrosis of the lunate, is controversial, and there are a myriad of treatments aimed at correcting the various hypothesized pathologies. Interventions to reduce mechanical stress on the lunate have been used for decades, including radial osteotomy with or without radial shortening, ulnar lengthening and metaphyseal core decompression procedures. However, these procedures require preservation of lunate architecture. Newer procedures to revascularize the lunate bone have emerged in the last 10 years, such as pedicled corticoperiosteal vascularized bone grafting. Once there is collapse of the radiocarpal joint or midcarpal arthrosis, the conventional treatments have included proximal row carpectomy and complete or partial wrist joint arthrodesis. Newer salvage procedures such as lunate excision with autologous or synthetic interposition grafts are now being used when possible. As this disease is relatively rare, radiologists may not be familiar with the expected post-operative radiologic findings and complications, especially of the newer treatments. The goals of this paper are to review the available treatment options and their expected appearance on postoperative imaging, with discussion of possible complications when appropriate.
The pathophysiology of Kienböck's disease is not well understood: factors that were previously considered as potentially being responsible for the disease are now only seen as predisposing factors that contribute to discovering pre-existing disease. The natural history of the disease is also not well known. The arthroscopic classification proposed by Bain and Begg is now an essential supplement to the well-known Lichtman radiographic classification system. Various treatment options exist and some are better suited to each stage of the disease. This review will explore the advantages and disadvantages of these treatment options and match them with the best indications.
Necrosis of the lunate requires surgery when it is painful and disabling. Decoulx's stage III is too often beyond reconstructive surgery (lengthening of the ulna, shortening of the radius), while such disbling procedures as wrist arthrodesis are not indicated yet. The intracarpal revascularizing arthrodesis with transposition of the capitate (described by Graner in 1966) is to be considered at this stage. The creation of a new condylar arch coated with cartilage, resembling the psysiologic arch, and the preservation of the radio-carpal mobility, allows the return of sufficient motion and strength for everyday needs. The wrist often gets painfree; this procedure should thus be considered as a palliative salvage operation, none the less useful in young manual workers.
Treatment of advanced Kienböck's disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböck's disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32–51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6–36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.
The main accepted principle to treat Kienböck disease is to decompress the lunate. Radius shortening is the most used technique. Three transverse osteotomies of the radius are described: neutral shortening osteotomy, lateral closing wedge osteotomy, and medial closing wedge osteotomy. Shortening the radius decompress the lunate and more or less the scaphoid. This deviates axial constraints toward ulna and triangular fibrocartilage complex. But the ulnar wrist is not able to support important axial constraints. The authors propose a solution to decompress only the lunate and not the scaphoid. This solution deviates axial constraints toward the scaphoid, which is naturally the most capable bone to support it. The authors describe a new radial nontransverse decompression wedge osteotomy. It allows to shorten the radius in front of the lunate. The fixation is done with a dorsal staple. To complete lunate decompression, authors propose to associate a metaphysal ulnar oblique shortening, essentially if ulnar variance is neutral or positive. The preliminar results on 10 cases are presented.
Treatment of advanced Kienböck's disease (Lichtmann IV) is commonly proximal row carpectomy or partial arthrodesis. The purpose of this study is to evaluate a more conservative treatment of advanced Kienböck's disease for young people: replacement of the lunate with a costochondral autograft. Between 2007 and 2009, four patients of mean age 40 years (32-51) were operated by two surgeons using this technique. This is a prospective study with a final follow-up by an independent operator. Mean follow-up was 27 months (6-36). Surgery is in two stages: excision of lunate and replacement with costochondral autograft taken from the ninth rib. Patients were evaluated with DASH and Cooney scores, pain, satisfaction, mobility and strength. Results show disappearance of pain at rest and during daily activities for all patients and a mean DASH of 6. Flexion-extension was 108° and grip strength 83% compared with the opposite side. Radiological evaluation showed no disease evolution. No complication was noted. Functional improvement was significant with good results compared to conventional techniques. Alternative techniques have been proposed for the replacement of the lunate, each with its specific problems. Lunate replacement by a costochondral graft is possible because studies showed vitality of this free graft up to five years. It also allows subsequent surgery. The absence of carpal collapse and good functional results are encouraging but the follow up is short. A long-term study is needed to confirm findings.
Copyright © 2011 Elsevier Masson SAS. All rights reserved.
The goals of surgical procedures in Kienböck's disease are to preserve wrist function, revascularize the necrotic lunate and maintain normal wrist kinematics when possible. Of the various treatment options, pedicled vascularized bone grafts from the dorsal distal radius permit the transfer of vascularized osseous tissue to the necrotic lunate in order to revascularize it. Vascularized bone grafting is an attractive alternative to conventional bone grafting by improving the local biological environment and thereby promoting revascularization. Recent advances in the anatomy and physiology of vascularized pedicled bone grafts have increased our ability to apply them to the treatment of Kienböck's disease. The purpose of this article is to describe the detailed vascular anatomy of the dorsal distal radius, the surgical technique, indications as well as contraindications of our preferred method of pedicled vascularized bone grafts of Kienböck's disease.
The callotasis lengthening technique was used to gradually lengthen the capitate after resection of the lunate in stage IIIa necrosis in 23 patients. Results of ten patients with a follow-up of at least 5 years showed rapid and sufficient callus formation in every patient regardless of age. The callotasis lengthening modification of the Graner II operation provides all advantages and avoids the major inconvenience of the traditional Graner II operation. There was no increased rate of disturbed fracture healing. Results of the DTPA-gadolinium MRI study did not show any significant impairment of vascularization within the region of the capitate bone. With the "intrinsic bone formation," contrary to every other intercarpal arthrodesis at the wrist, there is no need for an additional bone graft.
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.
Kienböck, a German radiologist, described avascular necrosis of the lunate (Kienböck's disease) in 1910. The epidemiology and etiology are not well-known and always has been debated. A negative ulnar variance is considered as a predisposing factor for Kienböck's disease by the majority of the authors. The treatment depends upon the stage of the disease at the time of presentation and diagnosis. Radial shortening and lengthening of the ulna are biomechanically satisfactory procedures because they increase the load sharing of the ulna and result in decompression of the lunate. Revascularization of the lunate by shortening of the radius may appear to be a very bold and ambitious technique. In very advanced cases, palliative procedures like wrist denervation, resection of the proximal carpal row, or wrist arthrodesis are the techniques resorted to. We report our experience of a series of 22 operated cases between 1994 and 2000 with a minimum follow up of 5 years. All cases were treated with an anterior vascularized bone graft based on the volar carpal artery associated to an osteotomy of the radius.
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.
Since 1978 eighteen patients were treated for Kienböck's disease by the Graner procedure. The satisfactory long-term results can be explained by the preservation of the radiocarpal joint. By restoring fairly congruent joint surfaces, secondary radiocarpal joint arthrosis, which affects long-term results, may be avoided. Employing Graner's procedure, the authors observed two cases with pseudarthrosis within the intercarpal arthrodesis. They interpret this complication to be a result of micro-movements with the new bone block in the former midcarpal joint level. These movements may be avoided by careful removal of all the cartilage from all joint parts which are to be fused.
In capitate interpositional arthroplasty (Graner II) the necrotic lunate bone is removed and the congruity of the proximal carpal row is restored by interposition of the proximal half of the capitate. The carpal bones are fused except for the scaphotrapezial joint. In this fashion carpal instability can be safely treated. Good results are achieved for both grip strength and relief of pain. Motion is restricted but with a useful range of motion remaining. The arc of remaining motion can be shifted into extension through the use of an opening wedge osteotomy of the capitate. Capitate interpositional arthroplasty without an intercarpal arthrodesis has poor result because of remaining carpal instability.
Necrosis of the lunate requires surgery when it is painful and disabling. Decoulx's stage III is too often beyond reconstructive surgery (lengthening of the ulna, shortening of the radius), while such disabling procedures as wrist arthrodesis are not indicated yet. The intracarpal revascularizing arthrodesis with transposition of the capitate (described by Graner in 1966) is to be considered at this stage. The creation of a new condylar arch coated with cartilage, resembling the physiologic arch, and the preservation of the radio-carpal mobility, allows the return of sufficient motion and strength for everyday needs. The wrist often gets painfree; this procedure should thus be considered as a palliative salvage operation, none the less useful in young manual workers.
Intercarpal arthrodesis with interposition of the capitate osteotomized in Graner's technique is performed in the treatment of stage III Kienböck's disease. Although clinical results are satisfactory, there are complications such as necrosis of the capitate, pseudarthrosis of the capitate, and arthrosis of the radiocarpal joint. From 1992 to 1995, twenty patients were treated for Kienböck's disease by Graner's technique in the Clinic of Hand Surgery II in Bad Neustadt/Saale. Seventeen patients were submitted to follow-up studies. The range of motion (extension/flexion) of the wrist was 55 degree. The grip strength was 67% of the other hand. Four patients continued to complain of pain. Necrosis of the capitate was found in four cases, pseudarthrosis in two cases, and arthrosis of the radiocarpal joint in five cases. Based on the poor X-ray results found in this review, the authors feels there is no indication for Graner's technique. They favor STT arthrodesis in stage III of Kienböck's disease.
Kienböck disease is caused by aseptic necrosis of the lunate. In the advanced stages of the disease, carpal collapse, joint incongruity, and osteoarthritis develop. We performed lunate excision, capitate osteotomy, and intercarpal arthrodesis (the modified procedure of Graner et al.) on fifteen patients with stage-IIIB or IV Kienböck disease. This report is a review of the findings in these patients.
The subjects ranged in age from twenty-six to fifty-four years (mean, 39.2 years) at the time of surgery. We evaluated the results more than five years postoperatively (range, sixty-two to 145 months postoperatively; mean, 79.3 months postoperatively). Therapeutic results were evaluated according to the scoring system of Evans et al.
Pain disappeared after surgery in most patients. Others had a reduction in the intensity of the pain to a mild level. The grip strength on the affected side had recovered to about 80% of that on the unaffected side twelve months after surgery. The long-term results were graded as good in eleven of the patients, as fair in two, and as poor in two. Postoperative radiographs showed that the carpal bone parameters (carpal height index and radioscaphoid angle) had improved. Radiographic osteoarthritic changes occurred in all of the patients; however, except for moderate limitation of the range of motion at the wrist joint, these findings did not affect the level of pain, grip strength, or activities of daily living.
Lunate excision followed by capitate osteotomy and intercarpal arthrodesis (the modified procedure of Graner et al.) is a reliable form of treatment for advanced Kienböck disease, with favorable results for at least five years postoperatively.
A technique of partial intercarpal fusion used in the treatment of Kienbock's disease and paintul non-union of fractures of the carpal navicular bone with avascular necrosis is described. The results are presented for twenty-seven patients followed from one to four years after operation. The advantages of the method are that the wrist need be immobilized for only two months and the patient can resume normal activity three to four months after operation. Although motion of the wrist after operation was limited in all patients, pain was relieved in all but two instances, and a strong grip was restored in all but on patient. During the time covered by this study, only four patients showed roentgenographic evidence of arthrosis of the radiocarpal joint after intercarpal fusion.
To investigate the long-term results of lunate replacement by vascularized bone transfer in advanced Kienböck's disease.
Twenty-one patients were reviewed (mean follow-up period +/- SD, 9.9 +/- 3.5 y) to analyze results after lunate replacement by vascularized pisiform transposition (Saffar's procedure) for Lichtman stages III and IV.
Pain was improved in 16 of 21 patients but range of motion did not improve after surgery. Range of motion was reduced to 68% and grip power to 80% of that of the opposite hand. At follow-up evaluation the mean score on the Disabilities of the Arm, Shoulder, and Hand Questionnaire was 22.3 +/- 17.9 and the mean Cooney score was 75.4 +/- 13.2. Radiologically, Lichtman stage persisted in 8, improved in 1, progressed in 8, and could not be evaluated in 3 patients. Two patients had radiologic signs of arthritis before surgery. At follow-up examination osteoarthritis was found in 50% of patients. The majority of degenerative changes were associated with carpal collapse.
The replacement of the lunate by vascularized pisiform transposition maintained preoperative ranges of motion. At follow-up examination both patient satisfaction and wrist function were high. In the long term, however, Saffar's procedure can restore alignment of the carpus only partly and also results in osteoarthritis in half of all patients.
This retrospective study assessed the outcomes of 21 patients (16 male and 5 female, mean age 39 years) with advanced Kienbock's disease treated by resection of the proximal carpal row. They were clinically reviewed. The mean follow-up was 67 months, with all but two patients having had a follow-up of 2 years. No or mild pain was being experienced by 13 patients, moderate pain by 3 and severe pain by 5. Grip strength increased from 19 kg pre-operatively to 26 kg postoperatively (or 65% of the normal contralateral side). There was a slight increase of mobility. The DASH score was 22 points (range 0-78) and the Patient Rated Wrist Score (PRWS) was 30 points (range 0-84). Two patients developed Complex Regional Pain Syndrome which was ongoing at the time of review and one developed a superficial wound infection. Proximal carpal row resection arthroplasty gave satisfactory results in patients with advanced Kienbock's disease.
The purpose of this study was to evaluate the long-term clinical results of a proximal row carpectomy with an average 15-year follow-up for the primary treatment of advanced-stage (Lichtman IIIA and IIIB) Kienböck's disease. This study is a follow-up to a paper by the senior author in a similar cohort of patients where the clinical results of a proximal row carpectomy were evaluated for the treatment of advanced-stage Kienböck's disease at an average 3-year follow-up.
Seventeen patients with a minimum of 10 years of follow-up were identified who met criteria for inclusion. Thirteen of these patients were located and agreed to participate. Patients were seen, examined, and queried regarding their wrists. Range of motion, grip strength, and subjective patient satisfaction were all obtained and quantified using a clinical outcomes scale.
Twelve of 13 patients demonstrated excellent or good results based on the clinical outcomes scale used (5 excellent, 7 good, 1 fair, and none poor). Total arc of motion averaged 73% of the uninvolved side. Grip strength averaged 92% of the uninvolved side. Compared with preoperative values, range of motion improved an average of 16% and grip strength improved an average of 129%, an overall average improvement of 12 degrees and 18 kg, respectively. At the most recent follow-up, all patients remained employed. Seven patients held manual labor positions, 2 were nurses, and 4 were employed in sedentary vocations. All patients demonstrated some degree of degenerative changes, usually localized to the radiocapitate articulation in the lunate fossa. Clinical results did not correlate with radiographic degeneration.
This study demonstrates proximal row carpectomy to be a reliable motion-preserving procedure with good clinical results maintained out to an average of 15 years postoperatively.