Three-dimensional finite element model construction and biomechanical analysis of customized titanium alloy lunate prosthesis / 中国修复重建外科杂志

OBJECTIVE@#To design customized titanium alloy lunate prosthesis, construct three-dimensional finite element model of wrist joint before and after replacement by finite element analysis, and observe the biomechanical changes of wrist joint after replacement, providing biomechanical basis for clinical application of prosthesis.@*METHODS@#One fresh frozen human forearm was collected, and the maximum range of motions in flexion, extension, ulnar deviation, and radialis deviation tested by cortex motion capture system were 48.42°, 38.04°, 35.68°, and 26.41°, respectively. The wrist joint data was obtained by CT scan and imported into Mimics21.0 software and Magics21.0 software to construct a wrist joint three-dimensional model and design customized titanium alloy lunate prosthesis. Then Geomagic Studio 2017 software and Solidworks 2017 software were used to construct the three-dimensional finite element models of a normal wrist joint (normal model) and a wrist joint with lunate prosthesis after replacement (replacement model). The stress distribution and deformation of the wrist joint before and after replacement were analyzed for flexion at and 15°, 30°, 48.42°, extension at 15°, 30°, and 38.04°, ulnar deviation at 10°, 20°, and 35.68°, and radial deviation at 5°, 15°, and 26.41° by the ANSYS 17.0 finite element analysis software. And the stress distribution of lunate bone and lunate prosthesis were also observed.@*RESULTS@#The three-dimensional finite element models of wrist joint before and after replacement were successfully constructed. At different range of motion of flexion, extension, ulnar deviation, and radial deviation, there were some differences in the number of nodes and units in the grid models. In the four directions of flexion, extension, ulnar deviation, and radial deviation, the maximum deformation of wrist joint in normal model and replacement model occurred in the radial side, and the values increased gradually with the increase of the range of motion. The maximum stress of the wrist joint increased gradually with the increase of the range of motion, and at maximum range of motion, the stress was concentrated on the proximal radius, showing an overall trend of moving from the radial wrist to the proximal radius. The maximum stress of normal lunate bone increased gradually with the increase of range of motion in different directions, and the stress position also changed. The maximum stress of lunate prosthesis was concentrated on the ulnar side of the prosthesis, which increased gradually with the increase of the range of motion in flexion, and decreased gradually with the increase of the range of motion in extension, ulnar deviation, and radialis deviation. The stress on prosthesis increased significantly when compared with that on normal lunate bone.@*CONCLUSION@#The customized titanium alloy lunate prosthesis does not change the wrist joint load transfer mode, which provided data support for the clinical application of the prosthesis.

Pathogenesis and clinical treatment progress of Kienbock’s disease / 中国组织工程研究

BACKGROUND: Kienbock’s disease is aseptic necrosis of the lunate bone due to various causes, and its pathogenesis is unknown. Because the soft tissue around the wrist articular surface is small, so it leads to poor blood supply, and the progressive necrosis is irreversible. Early specificity is poor, clinical diagnosis rate is low, and late teratogenicity and disability rate is high. The clinical diagnosis and treatment are complicated, and there are many procedures, but there is no accurate guidance. OBJECTIVE: To review the current research status of mechanism, stage and clinical diagnosis of Kienbock’s disease, to summarize the clinical treatment of Kienbock’s disease in recent years, so as to discuss the clinical efficacy of various programs and provide guidance for clinical diagnosis and treatment. METHODS: A computer-based online search of PubMed and CNKI databases from 1970 to 2019 was conducted. Key words were “Kienbock’s disease, lunate bone, necrosis, mechanism, treatment” in English and Chinese, respectively. About 900 articles were retrieved, and 52 articles eligible for the inclusion and exclusion criteria were included for review. RESULTS AND CONCLUSION: (1) The pathogenesis of Kienbock’s disease is unknown, its etiology is complex, and researchers believe that anatomy and biomechanics, and individual factors are main causes, which still need further research. (2) The Lichtman stage is widely used in Kienbock’s disease classification. The latest breakthrough in arthroscopy is expected to form a new classification standard, which can be diagnosed by X-ray, CT or MRI combined with “triple sign”. It has poor early specificity, so the rate of misdiagnosis is high, and it should be identified with wrist diseases. (3) Early-stage Kienbock’s disease usually receive conservative treatment, and advanced stage tends to undergo surgical programs, including free vascularized bone graft, the lumate resection + tendon tamponade, radial wedge and shortening osteotomy, scaphotrapeziotrapezoid fusion, proximal row carpectomy, and bone cement prosthesis replacement, and the follow-up outcomes are different, so there is still no perfect treatment program.

Anatomy of pisiform blood supply and feasibility of vascularized pisiform transfer for avascular necrosis of lunate based on digital technique / 中国修复重建外科杂志

Objective: To provide anatomical basis for vascularized pisiform transfer in the treatment of advanced avascular necrosis of the lunate (Kienböck's disease) by studying its morphology and blood supply pattern based on digital technique. Methods: Twelve adult fresh wrist joint specimens were selected and treated with gelatin-lead oxide solution from ulnar or radial artery. Then the three-dimensional (3D) images of the pisiform and lunate were reconstructed by micro-CT scanning and Mimics software. The morphologies of pisiform and lunate were observed and the longitudinal diameter, transverse diameter, and thickness of pisiform and lunate were measured. The main blood supply sources of pisiform were observed. The number, diameter, and distribution of nutrient foramina at proximal, distal, radial, and ulnar sides of pisiform were recorded. The anatomic parameters of the pedicles (branch of trunk of ulnar artery, carpal epithelial branch, descending branch of carpal epithelial branch, recurrent branch of deep palmar branch) were measured, including the outer diameter of pedicle initiation, distance of pedicle from pisiform, and distance of pedicle from lunate. Results: There were significant differences in the longitudinal and transverse diameters between pisiform and lunate ( t=6.653, P=0.000; t=6.265, P=0.000), but there was no significant difference in thickness ( t= 1.269, P=0.109). The distal, proximal, radial, and ulnar sides of pisiform had nutrient vessels. The nutrient foramina at proximal side were significantly more than that at distal side ( P0.05). The outer diameter of pedicle initiation of the recurrent branch of deep palmar branch was significantly smaller than the carpal epithelial branch and descending branch of carpal epithelial branch ( P0.05), and between carpal epithelial branch and descending branch of carpal epithelial branch ( P>0.05). But the differences between the other vascular pedicles were significant ( P<0.05). Conclusion: There are abundant nutrient vessels at the proximal and ulnar sides of pisiform, so excessive stripping of the proximal and ulnar soft tissues should be avoided during the vascularized pisiform transfer. It is feasible to treat advanced Kienböck's disease by pisiform transfer with the carpal epithelial branch of ulnar artery and the descending branch.

Advanced Pediatric Kienbock's Disease / 대한정형외과학회잡지

Kienbock's disease is very rare in pediatrics. The treatment of Kienbock's disease is controversial and depends on an understanding of the natural history of the disease. The methods proposed vary from conservative treatment to surgical treatment such as radial shortening or scaphotrapezoidal joint fixation, but there are few therapeutic guidelines for paediatric Kienbock's disease. We encountered a 14-year-old male with Lichtman stage IIIB disease and treated him with conservative management. We report this rare case of advanced paediatric Kienbock's disease with good clinical results at the 2-year follow-up along with a review of the relevant literature.

Clinical Outcome of Lateral Wedge Osteotomy of the Radius in Advanced Stages of Kienböck's Disease

BACKGROUND: Radius osteotomies showed favorable clinical outcome in Kienböck's disease. However, few articles have been published on the long-term outcome of lateral wedge osteotomy of the radius in patients with advanced stage Kienböck's disease. METHODS: Eleven patients with Lichtman stage IIIB/IV Kienböck's disease (group A; mean follow-up period, 86.1 months; range, 48 to 163 months) and 14 patients with Lichtman stage IIIA Kienböck's disease (group B; mean follow-up period, 85.1 months; range, 49 to 144 months) underwent radial wedge osteotomy between August 2004 and August 2012. Radiological changes of the lunate and radiocarpal joint were compared between two groups after osteotomy. The wrist flexion/extension angle, grip strength, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were evaluated preoperatively and at the final follow-up. The Nakamura Scoring System (NSSK) was used for comprehensive understanding of radiological and clinical outcomes. RESULTS: Nine patients of group A and 11 patients of group B showed radiological improvement in the lunate regarding sclerosis, cystic changes, or fragmentation. No patients showed progression of arthritic changes in radiocarpal and midcarpal joints. The wrist flexion/extension angle, grip strength, and DASH score were significantly improved in both groups after operation, but intergroup difference was not statistically significant at the final follow-up (p = 0.149, p = 0.267, and p = 0.536, respectively). The mean NSSK was 21.6 (range, 15 to 27) in group A and 21.8 (range, 15 to 26) in group B. CONCLUSIONS: Radial wedge osteotomy yielded excellent radiological and functional outcomes in advanced stages of Kienböck's disease and these results were comparable to those of Lichtman stage IIIA disease. This technique could be a useful alternative to salvage procedures in the treatment of Lichtman stage IIIB/IV Kienböck's disease without severe radiocarpal arthritis.

Artrodesis intercarpiana como tratamiento de salvamento en pacientes con enfermedad de Kienböck / Intercarpal fusion as a salvage procedure in Kienböck disease

Resumen: Introducción: Se analizaron los resultados funcionales de cuatro técnicas quirúrgicas de salvamento para resolver la etapa IIIB-IV de Litchman de la enfermedad de Kienböck. Observamos la evolución de los procedimientos quirúrgicos de salvamento realizados del 2000 al 2015. Material y métodos: Estudio retrospectivo transversal de 33 pacientes tratados con cuatro técnicas quirúrgicas distintas a quienes se les realizó la escala Quick-DASH, dinamometría y EVA. Resultados: Se encontró menor limitación funcional al año postquirúrgico en los individuos a los cuales se les realizó la artrodesis intercarpiana con o sin neurotomía del nervio interóseo posterior, con una media de 16.4, una mediana de 16.35, una moda de 15.3 y una p < 0.05. Discusión: Se demostró que una cirugía poco agresiva es suficiente para evolucionar a un aumento sintomatológico y un descenso de la función y fuerza, por lo que la artrodesis intercarpiana logra mejores resultados que otros procedimientos usados con anterioridad y avalados por las grandes asociaciones internacionales. Conclusiones: La técnica quirúrgica de salvamento de elección en nuestra serie, que sugiere evitar la progresión de la enfermedad de Kienböck, es la artrodesis intercarpiana más neurotomía del nervio interóseo posterior, ya que presenta menor número de complicaciones.

Abstract: Introduction: Functional results of four surgical techniques to resolve the IIIB-IV Litchman`s stage of the Kienböck disease were analyzed. We observed the evolution from 2000 to 2015. aterial and methods: Transversal retrospective study of 33 patients treated with different surgical techniques and evaluated with Quick-DASH scale, dynamometer and EVA. Results: Less functional limitation was found in the patients who underwent the intercarpal fusion with or without neurotomy of the posterior interosseous. Discussion: It was shown that the fact of making a less aggressive surgery is enough to evolve into an increase in symptoms and a decrease in function and strength; therefore, the intercarpal fusion performed at the right time of the natural history of the disease can achieve better results than other methods used previously and endorsed by international associations. Conclusions: The surgical technique of choice in our series to prevent disease progression was the intercarpal fusion and neurotomy of the posterior interosseous nerve.

Lunate Excision and Tendon Ball Implantation in Lichtman Stage IIIB Kienbock's Disease in Middle-Aged Patients

PURPOSE: Our purpose was to assess the results of lunate excision and tendon ball implantation with temporary scaphocapitate fixation for Lichtman stage IIIB Kienbockos disease in middle-aged patients. METHODS: Ten patients with Lichtman stage IIIB Kienbock's disease who underwent lunate excision and tendon ball implantation and followed up at least 24 months were analyzed. There were 4 males and 6 females. The mean age at the time of surgery was 55.4 years (range, 48-67 years), and follow-up period ranged from 24 to 68 months (mean, 46 months). Radiocarpal joint pain, grip strength, return to daily living activity, range of motion were evaluated and radiologic findings of preoperative, postoperative and last follow-up were evaluated. RESULTS: All patients returned to daily living activity after 6 months of surgery. At the last follow up, 8 patients had no pain and 2 patients experienced mild pain occasionally. The mean improvement of extension arc was 14.5degrees, and the mean flexion arc improved 8.5degrees. The mean grip strength was 88% of unaffected side. The mean carpal height ratio was 0.49 preoperatively, 0.47 at final follow-up. No patients showed osteoarthritis change at the last follow-up. The mean Cooney's wrist function were 83, 4 patients had excellent, 4 had good, and 2 had fair. CONCLUSION: Lunate excision and tendon ball implantation with temporary scaphocapitate fixation for Lichtman stage IIIB Kienbock's disease in middle-aged patients showed satisfactory clinical, functional and radiological results. So this can be a reasonable treatment option.

The 4+5th Extensor Compartmental Artery- Pedicled Vascularized Bone Graft in Lichtman Stage III Kienbock's Disease

PURPOSE: The purpose of this study was to evaluate the clinical results of the 4+5th extensor compartmental artery pedicled vascularized bone graft in advanced Lichtman stage III Kienbock's disease. MATERIALS AND METHODS: Eight patients with advanced Lichtman stage III Kienbock's disease who underwent the 4+5th extensor compartmental artery pedicled vascularized bone graft and followed up more than 1 year were analyzed retrospectively. There were 3 men and 5 women. The mean age was 43.6 years old. Two patients were Lichtman stage IIIA and six patients were IIIB. The clinical outcomes were evaluated with radiocarpal joint pain, range of motion, grip strength, carpal-height ratio, radioscaphoid angle, return to daily living activity and/or work. The mean follow up period was 38.5 months (range from 12 to 86 months). RESULTS: On last follow up, the pain was disappeared in 6 patients, and mild occasional pain was remained in 2 patients. Mean radiocarpal joint flexion and extension were 55 degrees and 60 degrees, 87% and 88% of the normal side, respectively. The carpal-height ratio was maintained or improved in 6 patients and slightly decreased in 2 patients. Radioscaphoid angle were improved or maintained in 7 patients. Mean grip strength was 67 lb, 93% of the normal side. All 8 patients returned to daily living activities and/or their previous works. CONCLUSION: The 4+5th extensor compartmental artery pedicled vascularized bone graft prevented the progression of disease and provided clinical improvement even in advanced Lichtman stage III Kienbock's disease.

Rupture of the Extensor Tendon Secondary to Advanced Kienbock's Disease / 대한정형외과학회잡지

Rupture of the extensor tendon caused by a posteriorly displaced lunate fragment is an uncommon complication of Kienbock's disease. Thirteen cases have been reported in the English literatures, but it has never been reported in the Korean literatures. We report a case of rupture of the third and fourth extensor tendons secondary to advanced Kienbock's disease that was successfully treated by excision of the lunate and a tendon transfer.

The Treatment for Kienbock's Disease using the Fourth Extensor Compartment Artery Vascularized Bone Graft: Preliminary Results

Lunate revascularization with the vascularized bone grafts is a current concept in the treatment of Kienbock disease. The aim of this study is to present our experience and preliminary results of the treatment using the fourth extensor compartment artery (4 ECA) vascularized bone graft for Kienbock disease. Between May 2009 and June 2010, five patients (3 men and 2 women) with Kienbock disease were treated with 4 ECA vascularized bone grafts. The mean age was 32.8 years and mean follow-up time was 13 months. The patients were composed of two patients in stage II and three patients in stage IIIa according to Lichtman's classification. Modified Mayo wrist score including pain, grip strength, range of motion and functional status and radiographic parameters such as carpal height ratio and radioscaphoid angle were evaluated at a final follow-up. Pain was markedly diminished and modified Mayo wrist score was 82 at last follow up period. There were no or little changes in carpal height ratio and radioscaphoid angle. All patients showed satisfactory bony union and no further lunate collapse on follow-up radiographs. The 4 ECA vascularized bone graft is a reliable alternative procedures among revascularization procedures for treatment of Kienbock's disease. It is less invasive and has low risk of kinking of pedicle compared to the 4+5 ECA vascularized bone graft. However, long term follow-up and MRI evaluation at follow up period should be needed for the future.

Limited Wrist Fusion for Kienbock's Disease / 대한정형외과학회잡지

PURPOSE: To evaluate clinical outcomes of triscaphe (STT), scapho-capitate (SC) and scapho-capito-hamato-triquetral (SCHT) fusion in advanced Kienbock's disease. MATERIALS AND METHODS: Forty patients with Lichtman stage III and IV disease were treated with limited wrist fusion. STT & SC fusion for stage IIIa and IIIb, and SCHT fusion for IIIb and IV were done according to preoperative radiologic and intraoperative articular surface findings. The mean follow-up period was 31.6 months (range 13-108) and the mean age at the time of their surgery was 44.7 years (range 22-71). There were 13 cases of STT fusion, 19 cases of SC fusion and 8 cases of SCHT fusion. For assessment of treatment results, wrist range of motion, grip strength, VAS (visual analog pain score) and any radiologic changes of the wrist were checked at last follow-up. RESULTS: VAS score was 4.7 for STT, 3.0 for SC, 4.5 for SCHT. Grip strength, compared with the contralateral side, was 72% for STT, 78% for SC, and 54% for SCHT. Pain was more improved for the SC fusion group than for the other two groups (p=0.007). Grip strength was decreased more in the SCHT fusion group than in the other two groups (p=0.009). There were no statistically significant differences in range of motion between any of the three groups. The bone achieved union in all cases except one SC fusion. CONCLUSION: Limited wrist fusion in advanced Kienbock's disease has been regarded as a valuable method. However, SC fusion has been thought of as a more favorable technique than STT fusion with respect to pain relief. SCHT fusion is thought to be a possible salvage procedure with a limited indication for Stage IV Kienbock's disease.

Treatment of Kienbock's Disease Using the 4+5 Extensor Compartmental Vascularized Bone Grafting Procedure: Early Experience / 대한정형외과학회잡지

PURPOSE: Kienbock's disease can be treated with a vascularized bone graft to provide relief of wrist joint symptoms and prevent collapse of the lunate. We evaluated the functional outcome and subjective satisfaction in patients with Kienbock's disease treated with the 4+5 extensor compartmental vascularized bone graft. MATERIALS AND METHODS: We included 6 patients in the study. 3 males and 3 females with an average age of 37.5 years (range 21-49). Kienbock's disease was staged by Lichtman classifi cation based on plain radiography. Three patients were in stage II and three in stage IIIA. Cooney's wrist function score was used to evaluate changes in severity of pain, functional status, range of motion, and grip strength. We also assessed subjective patient satisfaction, carpal height ratio and bone union on the radiographs, and the occurence of complications. The mean follow-up period was 30 months. RESULTS: Four patients had excellent and two had good outcomes of wrist function. Three patients showed excellent subjective satisfaction, and three were good. All patients showed radiographic bone union and no further progression of lunate necrosis. The presurgical carpal height ratio was similar to the value at last follow-up, and there was no radiographic carpal bone collapse. For two cases of Lichtman stage IIIA, the slight degenerative arthritis at the lunocapitate joint observed preoperatively did not change. Skin necrosis and pin track infection were not observed. CONCLUSION: The 4+5 extensor compartmental vascularized bone graft is a reliable procedure for Lichtman stage II and IIIA patients with Kienbock's disease, as it achieved not only pain relief and improvement of range of motion but also maintenance of the intercarpal bone relationship on radiographs, with relatively few complications.

4+5 Extensor Compartmental Vascularized Bone Graft for Stage III Kienbock's Disease : Preliminary Results

PURPOSE: The aim of this study was to evaluate the preliminary results using the 4+5 extensor compartmental vascularized bone graft for the treatment of stage III Kienbock's disease and to report the usefulness of this procedure. METHODS: A retrospective study was carried out on five patients who had undergone 4+5 extensor compartmental vascularized bone graft for stage III Kienbock's disease between Jan. 2005 and Aug. 2006. All patients were composed of two patients in stage IIIA and three patients in stage IIIB according to Lichtman classification. The radiographic findings were evaluated by carpal height ratio, Stahl's index, ulnar variance and scapholunate angle. The clinical outcome was assessed using the Mayo wrist score. RESULTS: The mean age of 43.4 years(range, 21-61) and the mean follow up of 23.6 months(range, 14-31) were presented. All patients were satisfied and the mean Mayo wrist score was 78(range, 70-85). Two patients showed further lunate collapse on follow-up radiographs. Four patients had no pain in the activity of daily living, one patient had a mild occasional pain. CONCLUSION: The 4+5 extensor compartmental vascularized bone graft for the surgical treatment of stage III Kienbock's disease is the effective treatment showing satisfactory clinical results, but a lunate collapse proceeds. Before this operation, the possibility of lunate collapse should be considered.

The Results of Radial Shortening Osteotomy for Kienbock Disease Stage III

PURPOSE: Radial shortening osteotomy and ulnar lengthening osteotomy for decreasing axial loading have been known to treatment for avascular necrosis of lunate bone. The purpose of this study was to evaluate the clinical outcomes of radial shortening osteotomy for Lichtman stage III Kienbock disease. MATERIALS AND METHODS: Between December 2001 and October 2008, thirteen patients with Kienbock disease underwent a radial shortening osteotomy at our institution. On the basis of Lichtman classification, six had stage IIIA and seven had stage IIIB. Radiographic measurement of the ulnar variance and the carpal height ratio were assessed preoperatively and at the follow-up. Patients were examined for wrist pain, range of motion at flexion and extension and grip strength both preoperatively and postoperatively. The clinical outcomes was evaluated through the modification of Evans scoring system. RESULTS: All thirteen had maintained the preoperative stage at the follow-up. In ulnar variance, negative variance was seven. The carpal height ratio was increased mean 0.018 at the follw-up. Pain in VAS was improved mean 3.6 at the follow-up. In range of motion of wrist flexion-extension, in the eleven which had limitation of motion preoperatively, all eleven showed improvement. In grip strength, among the ten which had decreased preoperatively, eight showed improvement and two showed no change at the follw-up. The clinical outcomes were good in eight, fair in three and poor in two. Among the five, negative ulnar variance of stage IIIB, three had good, two had fair clinical outcomes. CONCLUSIONS: We found that radial shortening osteotomy can prevent disease progression, also show good clinical results for stage IIIB Kienbock disease as well as stage IIIA.

Scaphoid-capitate-hamate-triquetrum Fusion in the Advanced Kienbock's Disease

PURPOSE: To evaluate clinical and radiological results of SCHT(scapho-capito-hamato-triquetral) fusion in Lichtman stage IIIB or IV Kienbock's disease. MATERIALS AND METHODS: The result of eight cases, operated and followed since December 2002, were analyzed retrospectively. The indication of SCHT fusion was the advanced Kienbock's disease, in Lichtman stage IIIB or IV, with severe fragmentation of lunate. The fragmented lunate was excised and the intercarpal joint between scaphoid and capitate, capitate and hamate, hamate and triquetrum were fused with joint resection, bone graft and multiple K-wires, to make an horse-shoeshaped carpal bone block. The clinical results were evaluated by wrist pain, ROM, any radiologic changes of wrist at last follow-up and Kuschner's method. RESULTS: There were 3 cases of Stage IIIB and 5 cases of stage IV. Mean follow-up period was 28.9 (range 15-53) months, and mean age at the time of operation was 49.4 (range 33~66) years. Two cases were minus ulnar variance, 4 cases were positive and 2 cases were neutral. The wrist range of motion was decreased from 121.8degreesto 90.6degrees(25%). Carpal height ratio was decreased in 1 case. The last follow-up results according to Kuschner's method revealed 4 excellent, 3 good and 1 fair. CONCLUSIONS: SCHT fustion was considered as one of the favorable salvage procedure for the advanced Kienbock's disease. However, biomechanical study using cadaver, long-term follow-up & accumulation of more cases would be needed to confirm its definitive usefulness in the future.

Lunate Excision and Vascularized Os Pisiform Transfer in Advanced Kienbock's Disease

PURPOSE: There are many controversies concerning therapeutic guidelines for the treatment of Kienbock's disease. The purpose of this study is to evaluate the clinical and radiological result of lunate replacement by vascularized os pisiform transfer in advanced Kienbock's disease. MATERIALS & METHODS: There were two men and three women. The mean age was 55 years, ranging from 41 to 70. According to Lichtman's classification, three cases were stage IIIb and two cases were stage IV. RESULTS: At the period of follow up, pain during motion was markedly diminished in all patients, the arc of motion ranged on average from 49 degrees of flexion to 53 degrees of extension and the grip power of the affected hand reached on average 83% compared with the contralateral side. Clinical results assessed by DASH and modified Mayo score showed 8 and 90. On plain X-rays, carpal height ratio and radioscaphoid angle were not changed postoperatively. CONCLUSION: Lunate excision and vascularized os pisiform transfer is a reliable alternative method for the treatment of advanced Kienbock's disease.

Pathologic Rupture of Flexor Pollicis Longus Tendon Secondaryto Kienbock's Disease: A Case Report / 대한정형외과학회잡지

A pathologic rupture of the flexor pollicis longus tendon secondary to Kienbock disease is extremely rare with only three cases being reported in the literature. We encountered a case of a pathological rupture of the flexor pollicis longus tendon secondary to longstanding Kienbock disease. The treatment included tendon ball insertion after excising the collapsed lunate and a flexor pollicis longus tendon reconstruction with autogenous palmaris longus tendons. Satisfactory results with a restoration of the active motion of the interphalangeal joint of the thumb, maintenance of the preoperative active range of motion of the wrist and markedly reduced pain was achieved after a one year follow up. We describe this case with a review of the relevant literature.

Limited Intercarpal Arthrodesis in Kienbock's Disease / 대한정형외과학회잡지

PURPOSE: To compare the treatment results of triscaphe and scaphocapitate arthrodesis in Lichtman's stage III Kienbock's disease. MATERIALS AND METHODS: Among 25 cases of Kienbock's disease (Lichtman's stage III), who were followed up more than 1 year after surgery from 1997 March to 2005 March, 15 cases of scaphocapitate and 10 cases of triscaphe arthrodesis were reviewed. The average age was 42.6 and the mean follow-up period was 33 months. The clinical and radiology results were analyzed before surgery and at the last follow-up. RESULTS: In the clinical assessments, there was good pain relief after each procedure and there was a similar limitation of the carpal range of motion before and after surgery. The radiology assessments revealed no difference between the two arthrodeses according to the carpal height ratio and lunate index. Regarding complications, there were 4 cases with a scaphocapitate including 1 nonunion and 4 cases with triscaphe arthrodesis including 2 superficial infections. CONCLUSION: The scaphocapitate arthrodesis is a technically simple, easy reducible to the anatomical position and produces similar clinical and radiology results to triscaphe arthrodesis. Overall, scaphocapitate arthrodesis appears to be an effective method for treating Lichtman's stage III Kienbock's disease.

Retrospective Study of Clinical Results of Anthovy's Technique with Scaphocapitate and Hamatocapitate Arthrodesis in Advanced Kienbock's Disease / 대한정형외과학회잡지

PURPOSE: A retrograde analysis of the clinical results of 11 cases of Kienbock's disease (Lichtman stage III), who underwent surgery for scaphocapitate or hamatocapitate arthrodesis followed by a rolled palmaris tendon replacement after a collapsed lunate excision. MATERIALS AND METHODS: This study followed-up 11 patients diagnosed with advanced Kienbock's disease for more than 5 years from January 1989 through May 2000. The patient's age ranged from 25 to 65 years old. Among the 11 patients, 7 patients received hamatocapitate arthrodesis, and the remainder received scaphocapitate arthrodesis. The Evans' scoring system was used for the clinical evaluation. RESULTS: After surgery, all patients showed complete radiologic fusion and an increase in grip strength, and most patients showed an increase in the ROM of a wrist joint, particularly in the group who received hamatocapitate arthrodesis. CONCLUSION: In advanced Kienbock's disease, a lunate excision followed by rolled tendon replacement with limited intercarpal arthrodesis showed relatively good results during the follow-up period, and had a particularly better ROM of the wrist joint in hamatocapitate arthrodesis, than the scaphocapitate arthrodesis because of the arthrodesis between the proximal and distal carpal row in the biomechanical aspect of the carpal bone.

The Use of Second Metacarpal Vascular Pedicle Graft and Temporary Scaphotrapeziotrapezoid Fixation for the Treatment of Kienbock's Disease / 대한정형외과학회잡지

PURPOSE: Revascularization is a useful method for treating Kienbock's disease. The aim of this study was to evaluate the use of the second dorsal metacarpal vascular pedicle to treat Kienbock's disease. MATERIALS AND METHODS: A retrospective study was carried out on 9 patients who had undergone vascular pedicle graft for Kienbock's disease between 1999 and 2003. The mean follow up period was 35 months. At the time of surgery, 2 patients were graded as stage II, 6 as IIIa and 1 as IIIb. The ulnar variance was neutral in all cases. A vascular pedicle graft using second dorsal metacarpal vessel were performed and temporary scaphotrapeziotrapezoid (STT) fixation were applied for 6 months. RESULTS: Wrist motion except for the radial deviation and grip strength had improved significantly. The patients returned to work after an average of 22 weeks. Resorption of the sclerosis was observed in 7 cases, but lunate collapse was observed in the simple radiograph in 6 cases. According to Lichtman's criteria, 7 cases were satisfactory but 2 cases with a relative old age were unsatisfactory. According to Nakamura's classification, 5 cases were good, 3 cases were fair and 1 case was poor. CONCLUSION: In Kienbock's disease with neutral ulnar variance, a revascularization procedure of vascular pedicle graft with temporary STT fixation is a good treatment method but the patient's age should be considered when determining the revascularization procedure. A prospective study will be needed to determine the optimal duration of temporary STT fixation.