Clinical and Radiographic Outcomes of Simple Curettage and Graft Using Allogenic Bone or Bone Substitute for Enchondroma Involving Short Tubular Bone of the Hand and Foot / 대한정형외과학회잡지

PURPOSE: We analyzed outcomes after management of enchondroma involving short tubular bones of the hand and foot by curettage and grafting using allogenic bone or bone substitutes. MATERIALS AND METHODS: Twenty-two patients (allogenic bone 15 and bone substitutes 7 patients) were recruited. Clinical results were assessed by pain, cosmetic problem, range of motion of joint and the power of grasp. Radiographic outcomes were analyzed by degree of bone defect. RESULTS: Clinically, 19 patients were classified as excellent and 3 patients as good. Three patients with K-wire fixation had pain with local irritation, which was easily controlled by removal of the K-wires. There were no complications including deep infection, delayed or nonunion, refracture. Radiographically, 20 cases were classified as group 1 (bone defect smaller than 3 mm) and the 2 remaining cases were classified as group 2 (bone defect 4-10 mm). CONCLUSION: Curettage and graft using allogenic bone or bone substitute is an effective modality of treatment for enchondroma involving short tubular bones of the hand and foot. When combined with pathologic fracture, early surgical management could shorten duration of immobilization. Surgical management might be considered for the lesion involving the foot when discovered because of high incidence of pathologic fracture.

Risk Factors and the Clinical Course of Acute Kidney Injury in Patients with a Femoral Fracture / 대한내과학회지

BACKGROUND/AIMS: Femoral fracture occurs most often in elderly patients and is highly associated with medical problems such as acute kidney injury (AKI); however no reports of AKI in femoral fracture patients have been published. This study was performed to identify risk factors and the clinical course of AKI in patients with femoral fracture. METHODS: We retrospectively evaluated the medical records of 110 patients with femoral fracture between November 2006 and December 2011 at Uijeongbu St. Mary's Hospital. We investigated the incidence and clinical course of AKI in femoral fracture patients and compared the clinical findings between AKI and normal kidney function (NKF) groups. RESULTS: Of the 110 femoral fracture patients, AKI was observed in 19 (17.3%). The peak serum creatinine level in patients with AKI was 2.59 +/- 1.57 mg/dL. Two of 19 patients with AKI died and two progressed to chronic kidney disease. When compared to the NKF group, the AKI group had a higher incidence of elevated lactate dehydrogenase (LDH) (63.2% vs. 34.1%, p = 0.020), erythrocyte sedimentation rate (ESR) (31.6% vs. 6.6%, p = 0.008), and C-reactive protein (57.9% vs. 46.2%, p = 0.042). The AKI group also had a longer hospitalization duration, and more patients were prescribed an angiotensin-converting-enzyme (ACE) inhibitor than in the NKF group. Multivariate analysis demonstrated elevated LDH, ESR and ACE inhibitor prescriptions as independent risk factors for AKI in patients with a femoral fracture. CONCLUSIONS: The incidence of AKI in patients with a femoral fracture was 17.3%, and AKI was associated with a longer clinical course. We recommend monitoring of laboratory findings and medications and early management to reduce the morbidity of patients with AKI.

Oncologic Outcome of Chondrosarcomas / 대한골관절종양학회지

PURPOSE: We evaluated oncologic outcomes of chondrosarcomas and analyzed the disease-free survival rate of chondrosarcomas according to the various factors. MATERIALS AND METHODS: We performed a retrospective study for the disease-free survival rate of 48 chondrosarcomas, 44 of which underwent surgical treatment and followed up more than 18 months since 1993, and in the remaining 4 cases, the patients died before 18 months after surgery. The vsariables were location, tumor volume, histologic grade, stage, age at presentation and treatment performed. The mean follow up period was 43.8 months (1-196 months). RESULTS: The overall disease-free survival rate was 77.1% at mean 43.8 month follow up. The 5 year- and 10 year disease-free survival rates were 64% and 58% respectively. The histologic grade, stage, age at presentation revealed statistical significance on disease-free survival. All 9 patients treated with extended curettage for grade 1 central chondrosarcomas revealed disease-free survival with excellent functional outcome. CONCLUSION: The disease-free survival rate of chondrosarcomas mainly depended on histologic grade, stage and age at presentation. Local recurrence and distant metastasis also revealed statistically significant differences of disease-free survival rate. Comparing to wide resection, extended curettage for low-grade central chondrosarcomas in extremities were efficient methods with similar survival rate and less functional losses and complications.

Allogeneic Inlay Cortical Strut Grafts for Large Cysts or Post-curettage Cavitary Bony Defects / 대한골관절종양학회지

PURPOSE: This study was aimed to evaluate the result of inlay cortical strut bone grafts for large cysts or cavitary bone lesions in long bones. MATERIALS AND METHODS: Seven patients with large cyst or cavitary bony lesions were managed with curettage, allogeneic inlay cortical strut and cancellous bone grafts. Additional plate and screw fixations were performed in 6 patients. There were three SBCs, two FDs with secondary ABC changes, one FD and one post-cement spacer removal state. Three of them had pathologic fractures. Progression of bone healing and mechanical support and functional result were evaluated. The mean follow-up period was 25.4 months. RESULTS: Incorporations into host bones were progressed in all, average 4.2 months in six metaphyseal regions and 5.8 months in five diaphyseal regions respectively. Full structural supports were achieved in all except one patient without any additional procedures. No allograft-related complication was developed. Mean functional score according to the MSTS criteria was 29.6 at last follow up. CONCLUSION: Inlay cortical strut graft provided additional mechanical stability and bone stock for screw purchase in large cyst or cavitary defects of long bones, which allow early mobilization and excellent functional outcome.

Prognostic Factors in Liposarcomas: A Retrospective Study of 52 Patients / 대한골관절종양학회지

PURPOSE: To investigate prognostic factors influencing on local recurrence, distant metastasis and event-free survival of liposarcomas. MATERIALS AND METHODS: Fifty-two patients managed for liposarcomas since 1993 were analyzed respectively in the view of prognostic influence of patient age, tumor size, location, histologic type, histologic grade, resection type, surgical margin, chemotherapy and radiation therapy on local recurrence, distant metastasis and event-free survival. The mean follow up period was 39 months. The univariate and multivariate regression analysis were performed for statistical evaluation. RESULTS: The local recurrences occurred in 11 patients (21.2%) and distant metastasis in 4 patients (8%), Event-free survival rate at 4 year follow up was 67%. In univariate analysis, histologic grade, surgical margin, chemotherapy and radiation therapy were significant prognostic factors on local recurrence (p<0.05). However, histologic grade lost its significance in muitivariate analysis. Trunk location revealed higher rate of distant metastasis than extremity location. In univariate analysis on event-free survival. histologic grade and chemotherapy were significant factors (p<0.05). No factor remained significant in multivariate analysis. CONCLUSION: Considering selection bias, positive surgical margin was negative prognostic factor on local recurrence. Liposarcomas arisen in trunk revealed higher rate of distant metastasis. There was no independent prognostic factor on event-free survival of patients with liposarcomas.

Secondary Chondrosarcoma Arising from Osteochondroma(tosis) / 대한골관절종양학회지

PURPOSE: To analyze clinical, radiological and pathological features as well as clinical outcome after surgical treatment of patients with secondary chondrosarcoma arising from osteochondroma(tosis). MATERIALS AND METHODS: We retrospectively reviewed clinical records, radiographs, pathologic slides of 14 patients. Nine patients were male and five were female. The mean age was 34 years. The mean follow-up period was 54 months. RESULTS: All patients had a history of previous mass since childhood or puberty. Preexisted osteochondroma was single in 3 patients and multiple in 10. Remaining 1 patient had multiple osteochondromatosis with enchondromatosis. MRI clearly provided thickness of cartilage cap, which was over 2 cm except in 2 cases. Chondrosarcoma was grade 1 in all except 1 case, which was grade 2. Wide excision was performed in 10 patients, marginal excision in 3 and amputation in 1. Twelve patients were doing very well without evidence of disease. Among 3 patients with marginal excision, 1 patient had local recurrence and 1 patient died of disease. CONCLUSION: Comprehensive understanding of clinical, radiological and pathological features of secondary chondrosarcoma is warranted for accurate diagnosis. The best result can be expected with early recognition of malignant change of osteohcondroma(tosis) and wide excision.

Langerhans' Cell Histiocytosis in Patients Younger than 2 Years / 대한정형외과학회잡지

PURPOSE: To analyze the clinical characteristics and outcome of Langerhans' cell histiocytosis that developed in patients younger than 2 years and to compare them with those of older patients. MATERIALS AND METHODS: The chief complaint, age of onset, site and number of bone involvements, systemic organ involvement, treatment and final outcome of fourteen cases of histologically proven Langerhans' cell histiocytosis that developed in patients younger than 2 years were analyzed retrospectively and compared with the results from those of fourteen older patients. The Fisher Exact test was used for statistical analysis. RESULTS: Langerhans' cell histiocytosis that developed in patients younger than 2 years had a more advanced stage (2.5/1.1), multiple bone involvement (2.7/1.7 sites) and a higher rate of systemic organ involvement (29%/0%). It required chemotherapy more often (9/2 patients). There was also a trend of frequent relapse and a lower rate of complete healing, but this was not statistically significant. Among the 62 bone lesions, 47 were healed by simple observation or systemic chemotherapy without the need for surgical intervention. CONCLUSION: Langerhans' cell histiocytosis that developed in patients younger than 2 years showed multiple bone involvement, more systemic involvement and a high recurrence rate. It also required systemic chemotherapy more often. However most bone lesions were managed successfully without the need for surgical intervention.

Preventive and Mitigative Effects of Alendronate on Osteolysis induced by Particulate Debris: Quantitative and Comparative Analysis Using Mouse Calvarial Model / 대한정형외과학회잡지

PURPOSE: Wear particle induced osteolysis is a serious complication in total joint arthroplasty. The purpose of this study was to compare the preventive and mitigative effects of alendronate on particle induced osteolysis among particles using mouse calvarial model. MATERIALS AND METHODS: Seventy-two mice were randomized into sham group, Ti6Al4V group, CoCr- Mo group and Ultra High Molecular Weight Polyethylene (UHMWPE) group according to the particles treated to the calvarial tissues. Each group was divided into control subgroup which received no alendronate, preventive subgroup which received alendronate for 4 weeks after particle distribution and therapeutic subgroup which received alendronate for 3 weeks after 1 week delay from particle distribution. We evaluated the effects quantitatively using histomorphometry. Number of osteoclast, fibrous thickness, eroded bone surface area, bone thickness and bone volume were measured and compared. RESULTS: Alendronate showed significant preventive and mitigative effects on osteolysis induced by Ti6Al4V particles and showed significant preventive and somewhat less mitigative effect on osteolysis by CoCrMo particles. On UHMWPE particles, alendronate showed no preventive and mitigative effects. CONCLUSION: Alendronate may be useful in preventing osteolysis induced by metal particles but had no effect on ostelysis induced by UHMWPE particles.

Bone Formation of Cultured Osteoblasts in Bone Defect of Radial Shaft of Rabbit / 대한정형외과학회잡지

PURPOSE: To evaluate the osteogenic potential of an autologous cultured osteoblast transplant to the bone defects. MATERIALS AND METHODS: Radial bone defects over 15 mm were made in 20 New Zealand white rabbits using the anterior approach. There were 10 rabbits in the control group, which underwent an iliac bone graft to the preformed bone defect 3 weeks from the initial operation. There were 10 rabbits in the experimental group that underwent an autologous cultured osteoblasts injection. After 9 weeks, both groups were compared radiologically and histologically. RESULTS: The osteogenesis in both groups were progressed similarly and there was no difference in terms of the amount of bone formation and the duration of the bone union. CONCLUSION: An autologous cultured osteoblast transplant to the bone defect produces bone efficiently.In addition, it can be applied to a wide field, which requires a bone grafting operation.

Clinical Applications of Autologous Cultured Osteoblasts: Case Report

We treated 3 cases of fracture and 1 case of avascular necrosis of femoral head using autologous cultured osteoblasts injection. The stromal cells from the bone marrow were cultured to differentiate to osteoblasts for 4 weeks. The fracture sites of each patients were right ulnar shaft, left radial shaft, and left 5th metatarsal base. All of the fractures showed callus formations after 1 week of osteoblasts injection to the fracture site. After 4 weeks, callus formations were progressed. Avascular necrosis of femoral head was bilateral and both were Ficat stage II. Core decompression and allograft impaction were performed to the left, and core decompression and autologous cultured osteoblasts injection percutaneously after 4 weeks of the decompression operation were done to the right femoral head. CT images of 1 year from the operations showed trabecular bone formation and well maintained femoral head contour of the right femur, but resorption of the grafted bone for the left.

Common Peroneal Nerve Palsy Caused by a Ganglion: Case Report / 대한정형외과학회잡지

A common peroneal nerve palsy caused by a ganglion has been rarely reported. A Ganglion may arise from joint, tendon sheath or sheath of peripheral nerve. They may also be intraosseous and intraneural but relatively rare entities. Although intraneural ganglion is a well recognized entity, few reports in the literature describe motor weakness and sensory change as a primary clinical manifestation. The pathogenesis of intraneural ganglion cyst remains controversial. We describe the case of 42-year-old male manual worker with a 2 month history of weakness of the right ankle and foot drop and paresthesia of the anterolateral aspect of the lower leg, as a result of compression of the common peroneal nerve by a ganglion, in both intraneural and intramuscular forms.

Anterior Cruciate Ligament Reconstruction Using a Contralateral Hamstring Tendon Graft in Combined Anterior Cruciate and Medial Collateral Ligament Injury / 대한정형외과학회잡지

PURPOSE: We reviewed the results of a series of patients with combined anterior cruciate ligament and medial collateral ligament injury who received nonoperative management of medial collateral ligament with anterior cruciate ligament reconstruction using a contralateral hamstring tendon graft. MATERIALS AND METHODS: From May 2000 to June 2001, 12 cases (20-46 years; mean, 35 years) were available for follow-up (12-23months; mean, 16.7 months) with combined anterior cruciate ligament and medial collateral ligament injury that underwent anterior cruciate ligament reconstruction alone using a contralateral hamstring tendon graft. Follow-up evaluation involved; KT-2000 arthrometer testing, valgus stress testing and the International Knee Documentation Committee (IKDC) evaluation form. RESULTS: Mean side to side difference of manual maximum anterior displacement using the KT-2000 arthrometer was 1.75 mm. All cases showed a firm end point by the valgus stress test. At the final IKDC evaluation, 2 cases were graded as normal, 8 nearly normal, 1 abnormal and 1 severely abnormal. The donor site result of the IKDC evaluation form showed normal in 8, nearly normal in 3 and abnormal in 1. CONCLUSION: These results demonstrate the effectiveness of ACL reconstruction alone using the contralateral hamstring tendon graft as an autograft in combined ACL and MCL injury, which was found to restore satisfactory stability with minimal complications at both injured and donor sites.

Cross Pin Femoral Fixation for Posterior Cruciate Ligament Reconstruction Using Quadruple Hamstring Tendon

PURPOSE: The purpose of this study is to introduce new fixation technique for posterior cruciate ligament (PCL) reconstruction using quadruple hamstring tendon autograft. MATERIALS AND METHODS: From September 2001 to March 2002, eight patients received PCL reconstruction using quadruple hamstring autograft for PCL injury without associated procedures for posterolateral complex injures. All femoral tunnels were fixed with cross pins and all tibial tunnels were fixed with Intrafix(Mitek , USA). Clinical assessments consisted of Lysholm knee scores, International Knee Documentation Committee(IKDC) evaluation form and manual maximal side to side difference using KT-2000 arthrometer. RESULTS: The average Lysholm knee score improved from 54 preoperatively to 89 postoperatively. At the final IKDC evaluation, 2 cases were graded as normal, 5 nearly normal, 1 abnormal. Mean side to side difference of manual maximum posterior displacement with knee in 70 degrees flexion using the KT-2000 arthrometer was 3.7mm. CONCLUSION: In PCL reconstruction using quadruple hamstring autograft, cross pins are good fixation method with high strength and stiffness.

Surgical Treatment of Monostotic Fibrous Dysplasia of the Proximal Part of the Femur / 대한정형외과학회잡지

PURPOSE: To clarify the clinical behavior and radiological features and to evaluate the effectiveness of curettage, bone graft and/or internal fixation of monostotic fibrous dysplasia involving the proximal part of the femur without deformity. MATERIALS AND METHOD: We reviewed the medical records and plain radiographs of patients who were proven to have monostotic fibrous dysplasia involving the proximal part of the femur by biopsy and who were treated between January 1994 and December 1998. Among those treated with curettage, bone graft and/or internal fixation, patients were selected for study after minimun of one year had elapsed. Fifteen patients were eligible for this study. RESULT: Although no lesion had completely disappeared at the point of the last follow-up evaluation, clinical results judged by the method described by Guille et al. was satisfactory in all patients. CONCLUSION: The authors believe that curettage and bone grafting with or without internal fixation is a clinically adequate treatment for monostotic fibrous dysplasia of the proximal part of the femur without deformity. Longer periods of follow-up evaluation is warranted because the treatments are not completely effective in eradicating the lesion despite the satisfactory preliminary clinical result.

The LDH to AST ratio as an indicator of pancreatic necrosis in acute biliary and alcoholic pancreatitis / 대한내과학회지

BACKGROUND: Lactate dehydrogenase (LDH) has been reported to be a sensitive indicator of pancreatic necrosis (PN), and some studies suggested that an elevation of the ratio of LDH to AST (LDH/AST ratio) woud be more accurate indicator of PN in acute biliary pncreatitis (BP). However, there were no studies in alcoholic pancreatitis (AP). The aim of this study was to assess the clinical usefulness of LDH/AST ratio in alcoholic pancreatitis (AP) as a indicator of PN. METHODS: On the basis of CT scan findings, the patients were categorized into two groups as having PN or non-PN. The plasma levels of the LDH, AST and LDH/AST ratio over two weeks postadmission period were evaluated and compared with in two groups of patients with BP (consiting of 12 PN and 34 non-PN patients), and with AP (consisting of 14 PN and 38 non-PN patients). RESULTS: In acute BP, on post-admission days 1 and 2, the LDH/AST ratio were low in both groups without significant difference. In the group with PN, thereafter, the LDH/AST ratio increased gradually, reached peak values at the 7th days and decreased. In the non-PN patients, the LDH/AST ratio increased gradually, but remained below the control range. The LDH/AST ratios were significantly higher from post-admission day 3 in the group with PN than in the non-PN group. In acute AP, the LDH levels were significantly higher over two weeks from admission day in the PN patients. The LDH/AST ratios were remained within or below the control range in both groups, though with statistically significnat difference. CONCLUSION: The LDH/AST ratio could be used as an indicator of PN in acute BP. In acute AP, however, LDH was a more useful indicator from the early stage in the course.

Salmonella osteomyelitis with osteonecrosis in a patient with systemic lupus erythematosus / 대한내과학회지

Although infectious diseases are frequent in systemic lupus erythematosus, salmonella osteomyelitis is rarely reported. We here report an unusual case of salmonella osteomyelitis with osteonecrosis in a patient with systemic lupus erythematosus. A 29-year old woman with systemic lupus erythematosus was admitted to our hospital because of a painful swelling of right knee joint. She had been taking steroid and cyclophosphamide for 4 months because of diffuse membranous proliferative lupus nephritis. MRI showed both osteonecrosis of the right distal femur and osteomyelitis of the right proximal tibia. The abscess culture demonstrated almonella species (non typhoidal). The infection was treated successfully by a combination of surgical drainage and intravenous ceftriaxone.

Synovial Cyst of Transverse Ligament of Axis in a Patient with Os Odontoideum and Atlantoaxial Instability: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case report and review of the literature. OBJECTIVES: To describe the diagnosis and successful treatment of the synovial cyst arising from the transverse ligament in a patient with Os odontoideum and atlantoaxial instability. SUMMARY OF LITERATURE REVIEW: Synovial cyst arising from the transverse ligament of the axis is extremely rare and thought to be attributed to degenerative changes of the C1-C2 facet joints or microtraumas. Direct excision of the cyst is the only treatment method described in previous reports. MATERIALS AND METHODS: A case of synovial cyst arising from the transverse ligament of the axis in a 45-year-old man with Os odontoideum and atlantoaxial instability was managed with posterior atlantoaxial fusion alone. The characteristic MRI findings and surgical treatment, and related literature are reviewed. RESULTS: MRI of the cervical spine showed a large cystic mass located at the transverse ligament of the axis which was com-pressing the spinal cord near the C1-C2 junction: the images showed a low signal intensity on T1WI; high signal intensity on T2WI; and rim enhancement with no internal enhancement on Gadolinium enhanced T1WI. The spontaneous resolution of the cyst was identified on the follow-up MRI taken at 3 months after operation and clinical improvement was achieved. CONCLUSIONS: The MRI findings of spontaneous resolution of synovial cyst arising from the transverse ligament of the axis after posterior atlantoaxial fusion alone suggest that stable fusion rather than direct excision of the cyst should be considered over the surgical option when the location of the cyst is difficult or dangerous to approach surgically.

Anterior Interbody Fusion and Posterior Instrumentation for Degenerative Lumbar Spondylolisthesis / 대한정형외과학회잡지

Degenerative lumbar spondylolisthesis requires fusion of the involved segments and decompression laminectomy because it is mechanically unstahle and usually associated with stenosis of the spinal canal. Transabdominal retroperitoneal approach through small longitudinal pararectal skin incision provides easy and safe access to L3-4 and L4-5 disc spaces with less bleeding. We thought that anterior interbody fusion enable us to restore the disc space and to reduce partially the listhesis with less hleeding and less harvest of graft hone compared to posterolateral fusion, and also without the risk of neural or dural damage which could he occurred in posterior lumbar interbody fusion 4.15.16.17). Thus, authors performed the same-day anterior and posterior spinal surgery (APSS) in 28 patients (30 disc spaces) from 1992 to 1996 and analyzed the clinical and radiological results. The most common site of involvement was L4-5 level (82.1%). The mean follow-up period was 2 years and 2 months (from l2 months to 4 years). Fusion was ohtained at 29 disc spaces (96.7%) within 24 weeks (average, I 6 weeks). The anterior displacement was corrected up to the average of 65.4% (5.8mm) postoperatively and the average of 60.7% (5.2mm) correction remained at last follow-up. The intervertebral disc space was restored up to the average of 96.9% (7.5mm) postoperatively and the average of 86.0% (6.2mm) restoration remained at last follow-up. Twenty-five out of 28 patients (89.2%) showed excellent or good clinical results hy the criteria of Kim, et al6). In conclusion, the same-day procedure of successive anterior interbody fusion, decompression laminectomy and posterior pedicular instrumentation for the degenerative lumbar spondylolisthesis associated with spinal stenosis was thought to be a good method of treatment.

Rationale for the Combined Front and Back Surgery in the Treatment of Cervical Spondylotic Myeloradiculopathy / 대한정형외과학회잡지

We have retrospectively analyzed the clinical and radiological outcome in 22 cervical spondylotic myeloradiculopathy patients who underwent combined front anterior decompression and fusion) and back (open door laminoplasty) surgery between Mar. 1991 and Jan. 1995. Clinical symptoms were evaluated by Japanese Orthopaedic Association(JOA) score and the recovery rate. Plain radiogram and MIR were taken before and after surgery, and then the cervical curvature, change of body to canal ratio and the A-P compression ratio of the cord were measured and compared to the clinical symptoms. Results : The mean JOA score increased from 10.1±3.3 preoperatively to 14.7±1.4 at the final follow-up with a mean recovery rate of 64.4%. No patients deteriorated as a result of the combined procedure. Post-op. radiograms showed an increasement of body to ratios (average 0.69±0.09 pre-op. to 1.0±0.13 post-op.) and maintenance or recovery of cervical Lordosis. On MRI, the A-P compression ratios of the cord were increased with recovery of subarachnoid space after the operation in most cases (average 38.4±7.6 pre-op. to 55.7±7.2 post-op.). Conclusion : This combined procedure safely and effectively resulted in decompression of the spinal cord and good functional recovery in patients with 1) anterior and posterior pathology, 2) narrow spinal canal and large spondylotic bar or herniated disc encroaching the spinal canal more than 5mm, 3) narrow spinal canal and kyphotic deformity, 4) narrow spinal canal and segmental instability, 5) multisegmental cord compression and severe radiculopathy.

A comparative study of the surgical procedures to treat advanced Kienbock's disease

We have treated a total of 16 cases of advanced Kienbock's disease, stage III and IV by Lichtman's classification, with triscaphe fusion, tendon ball replacement arthroplasty after excision of lunate, proximal row carpectomy as a salvage procedure and limited wrist fusion, since 1985. All cases were followed for minimal 16 months after each operation. Tendon ball replacement arthroplasty after excision of lunate could not prevent further carpal collapse with persistent chronic wrist pain. The triscaphe fusion or radio-lunate fusion induced a marked limited wrist motion later, and the triscaphe fusion alone was not fit for the treatment of advanced one because of progressive proximal migration of capitate and continuous wrist pain due to ligamentous carpal instability in follow-up. So we tried to simultaneously combine tendon ball replacement arthroplasty after excision of lunate with triscaphe fusion in far advanced Kienbock's disease, and their end results was favorable. Proximal row carpectomy could be done in far advanced Kienbock's disease with reasonably painless wrist motions. The overall end results of proximal row carpectomy are much better than any form of carpal arthrodesis. Conclusively the proper way to treat advanced Kienbock's disease seems to depend on the patient's age, their job and sex, and the stage of disease. And the cause of wrist pain in advanced Kienbock's disease seems due to ligamentous carpal instability rather than osteoarthritis on radio-lunate joint.