Ultrasound-Guided Axillary Brachial Plexus Block, Performed by Orthopedic Surgeons / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to assess the effectiveness and complications of an ultrasound-guided axillary brachial plexus block performed by orthopedic surgeons. MATERIALS AND METHODS: From March to May 2017, an ultrasound-guided axillary brachial plexus block was performed on a total of 103 cases of surgery. A VF13-5 transducer from Siemens Acuson X300 was used. The surgical site was included in the range of the anatomic sensory distribution of the blocked nerve, except for the case where an operation time of more than 2 hours was expected due to multiple injuries and the operation of the upper arm. The procedure was performed by 2 orthopedic surgeons in the same method using 50 ml of solution (20 ml of lidocaine HCl in 2%, 20 ml of ropivacaine in 0.75%, 10 ml of normal saline in 0.9%). The success rate of anesthesia induction during surgery, anesthetic induction time, anatomical range of operation, duration of postoperative analgesia and complications were investigated. RESULTS: The results from the 2 practices were similar. The anesthesia was successful in 100 out of 103 patients (97.1%). In these patients, the average needling time was 5.5 minutes (2.5–13.2 minutes), the average induction time to complete anesthesia was 18.4 minutes (5–40 minutes), and the average duration of postoperative analgesia was 402.8 minutes (141–540 minutes). The post-anesthesia immediate complications were dizziness in 1 case, nausea and vomiting in 4 cases, and peri-oral numbness in 2 cases, but surgery was performed without problems. All these 7 cases with complications recovered on the same day. A total of 3 cases failed with anesthesia, and they were treated by an injection with local anesthesia in the operation room in 2 cases and switched to general anesthesia in 1 case. CONCLUSION: An ultrasound-guided axillary brachial plexus block, which was performed by orthopedic surgeons allows anesthesia in a brief period and the high success rates of anesthesia for certain surgeries of the elbow and surgeries on forearm, wrist and hand. Therefore, it can reduce the waiting time to the operating room. This technique is a relatively safe procedure and dose selective anesthesia is possible.

Treatment of Wide Gap Non-Unions in Lower Extremities

PURPOSE: To analyze the end results of the treatment for patients with wide gap non-unions of the long bones in the lower extremities. MATERIALS AND METHODS: A total of 62 cases of wide gap unions, with a mean age of 38 years, were included for analysis. Study cohort included six children under the age of seven years. The average size of established bone defect was 7 cm (4-23 cm). Bone defects under 7 cm were treated with plating and various bone grafts, and those over 7 cm were managed with vascularized fibular graft (VFG), distraction-osteogenesis, tibial strut, plating and etc. Two boys with a defect of the whole tibia but with an intact fibula were treated with tibialization of intact fibula and with rotation-plasty of the leg. Their end results were evaluated by the time of bony union in accordance with the treatment of defect size of the long bone as well as their age. RESULTS: Bony unions were obtained for an average period of at least 27 months. Fifty-one cases showed an average leg-length discrepancy of 2.8 cm, and 11 cases showed no leg-length discrepancy. The VFG, distraction-osteogenesis, and tibial cortical-strut graft and plating were the most effective methods for non-unions of wide, long bone defections (>7 cm). The prognosis was more favorable in children, muscular femur, and in cases with tibial defect but intact fí bula. CONCLUSION: Various bone union techniques should be considered carefully, considering the ages of patients and the size of bone defects. Due to severe physical and mental disabilities of patients during the long-treatment period, specialized orthopedic doctors for trauma and mental care were necessary.

Treatment of Wide Gap Non-Unions in Lower Extremities

PURPOSE: To analyze the end results of the treatment for patients with wide gap non-unions of the long bones in the lower extremities. MATERIALS AND METHODS: A total of 62 cases of wide gap unions, with a mean age of 38 years, were included for analysis. Study cohort included six children under the age of seven years. The average size of established bone defect was 7 cm (4-23 cm). Bone defects under 7 cm were treated with plating and various bone grafts, and those over 7 cm were managed with vascularized fibular graft (VFG), distraction-osteogenesis, tibial strut, plating and etc. Two boys with a defect of the whole tibia but with an intact fibula were treated with tibialization of intact fibula and with rotation-plasty of the leg. Their end results were evaluated by the time of bony union in accordance with the treatment of defect size of the long bone as well as their age. RESULTS: Bony unions were obtained for an average period of at least 27 months. Fifty-one cases showed an average leg-length discrepancy of 2.8 cm, and 11 cases showed no leg-length discrepancy. The VFG, distraction-osteogenesis, and tibial cortical-strut graft and plating were the most effective methods for non-unions of wide, long bone defections (>7 cm). The prognosis was more favorable in children, muscular femur, and in cases with tibial defect but intact fí bula. CONCLUSION: Various bone union techniques should be considered carefully, considering the ages of patients and the size of bone defects. Due to severe physical and mental disabilities of patients during the long-treatment period, specialized orthopedic doctors for trauma and mental care were necessary.

An Anterior Approach to Entire Length of Humerus and to Distal Shaft for Fracture Fixation

BACKGROUND: The aim of study was to confirm the clinical effectiveness and results of wide and single anterior approach for fractures occurring along length of humerus. METHODS: A total of 23 patients with humeral fracture were enrolled into our study who were able to participate in at least one year of follow-up. Seven patients had segmental comminuted humeral fractures and 16 patients had distal humeral fractures. We made various tractions of the muscles to expose the proximal and the middle third humerus between the biceps and brachialis and the distal humerus by partial splitting of lateral side of biceps through a single incision. Postoperatively, we measured the Mayo elbow performance index (MEPI). RESULTS: we achieved bone union in all 23 patients. Solid union of the bone was achieved at an average 13.9 weeks. Postoperatively, two complications were observed screw loosening and nonunion. Revision surgery was performed in both patients. The patient with bone nonunion was treated using bone grafts. No postoperative infections or peripheral neuropathies were observed. At the final follow-up (average 20 months), we found that the average MEPI functional score of the patients was 91.7 points regardless of the fracture site. CONCLUSIONS: Our whole humerus with a single incision was effective for the treatment of segmental comminuted and distal fractures. we believe it is a useful alternative to preexisting methods of fracture fixation.

An Anterior Approach to Entire Length of Humerus and to Distal Shaft for Fracture Fixation

BACKGROUND: The aim of study was to confirm the clinical effectiveness and results of wide and single anterior approach for fractures occurring along length of humerus. METHODS: A total of 23 patients with humeral fracture were enrolled into our study who were able to participate in at least one year of follow-up. Seven patients had segmental comminuted humeral fractures and 16 patients had distal humeral fractures. We made various tractions of the muscles to expose the proximal and the middle third humerus between the biceps and brachialis and the distal humerus by partial splitting of lateral side of biceps through a single incision. Postoperatively, we measured the Mayo elbow performance index (MEPI). RESULTS: we achieved bone union in all 23 patients. Solid union of the bone was achieved at an average 13.9 weeks. Postoperatively, two complications were observed screw loosening and nonunion. Revision surgery was performed in both patients. The patient with bone nonunion was treated using bone grafts. No postoperative infections or peripheral neuropathies were observed. At the final follow-up (average 20 months), we found that the average MEPI functional score of the patients was 91.7 points regardless of the fracture site. CONCLUSIONS: Our whole humerus with a single incision was effective for the treatment of segmental comminuted and distal fractures. we believe it is a useful alternative to preexisting methods of fracture fixation.

Trigger Wrist

Trigger wrist is a relatively rare disease compared to trigger finger, which is the most common disorder found in hands. Patients with trigger wrist usually complain about the following symptoms: snapping and clicking or triggering around carpal tunnel with or without mild to moderate median neuropathy. There are a total of five cases of trigger wrist: three cases of anomalous muscle belly of flexor digitorum superficialis and two cases of fibroma around flexor tendon sheath within carpal tunnel. This study reports on two of those cases: one with anomalous muscle and the other with fibroma of flexor tendon sheath. Accurate examination and proper diagnosis are mandatory to obviate improper and time-wasting treatment for patients with trigger wrist.

Clinical Features and Treatments of Carpal Bone Cysts

PURPOSE: A total of 27 carpal bone cysts were analyzed for their sites, relations of other wrist soft tissue ganglions and their results of treatment were evaluated. METHODS: Twenty-seven carpal bone cysts in 20 patients (bilateral 5, multiple 2) from February 2002 to June 2013 were evaluated. Mean follow-up period was 16.6 months. We investigated etiological classification, the site of carpal bone cyst, and their relationship with soft tissue ganglion in same wrist. Pain, range of motion, radiographic changes, and their satisfaction after treatment were assessed postoperatively. RESULTS: The carpal bone cysts occurred mainly at the radial wrist axial ray on the lunate (12 cases), scaphoid (6 cases), and triquetrum (5 cases), trapezium (2 cases), and capitate (2 cases). Based on the magnetic resonance imaging (MRI) findings in 25 cases, we classified carpal bone cysts into 4 distinct types; type I with purely intraosseous lesion (16 cases), type II with bone cyst associated cortical perforations (6 cases), type III with coexisting soft tissue ganglion communicating with intra-osseous lesion (2 cases), and type IV with coexisting soft tissue ganglion non-communicating intraosseous lesions (1 case). CONCLUSION: The carpal bone cysts can be classified by MRI into 4 distinct types. The purely intraosseous type is most common, suggesting the intrinsic cause in the development of carpal bone cyst.

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.

Compartment Syndrome of Forearm Caused by Extravasation of CT Contrast Media: A Case Report

A contrast media is essential for the diagnostic accuracy of vascular structure or soft tissue imaging study. The incidence of extravasation of contrast media is very low (0.03% to 0.17%), but higher (0.25% to 0.9%) when using mechanical infuser. We report a case of 64-year-old female patient suffered from acute compartment syndrome, such as pain, skin discoloration in forearm and limitation of finger movement associated with extravasation of contrast media during the coronary angio-computed tomography.

Treatment of Distal Radioulnar Joint Injuries Associated with a Distal Radius Fracture

PURPOSE: Distal radius fractures involving distal radioulnar joint (DRUJ) are common. After the fracture treatment, pain on the ulnar side of wrist, limitation of forearm rotation and instabilities can be remained. The purpose of this study was to address the importance of anatomical reduction for DRUJ injuries. METHODS: Of 115 cases with a distal radius fracture involving DRUJ, 61 cases involving sigmoid notch of the radius or having a ulnar styloid process base fracture were evaluated. At an average of six months follow-up, their final outcomes were investigated using radiologic findings, functional disabilities of the arm, shoulder and hand (DASH) and visual analogue scale (VAS) pain scores and wrist motion of pronation/supination. RESULTS: Satisfied radiologic reduction rate was 73.8%(45/61) in average, which was most favorable in external fixator group (82.4%, 28/34). The mean functional DASH score was 29.0 points and mean VAS for pain was 5.0. The mean range of wrist motions for pronation/supination was 59.5degrees/55.7degrees. CONCLUSION: Distal radius fractures involving DRUJ should be classified into the basic categories of unstable distal radius fracture, and immediate anatomical reduction is needed by operative treatment to avoid painful forearm rotation.

Avulsion Fracture of the Calcaneal Tuberosity: Classification and Its Characteristics

BACKGROUND: Not much is known regarding avulsion fractures of the calcaneal tuberosity. We propose a modified classification scheme that presents the four types of calcaneal avulsion fracture as described by surgical and magnetic resonance imaging (MRI) findings, and evaluation of their specific features. METHODS: Out of 764 cases of calcaneal fractures, we examined 20 cases (2.6%) that involved the tuberosity of the calcaneus. Each case was classified depending on the avulsed fracture patterns as follows; type I is a 'simple extra-articular avulsion' fracture, type II is the 'beak' fracture, type III is an infrabursal avulsion fracture from the middle third of the posterior tuberosity, and finally in type IV there is the 'beak', but a small triangular fragment is separated from the upper border of the tuberosity. We examined the features of each avulsed type according to several criteria including patient age, gender, anatomical variances of the Achilles tendon, the fibers involved and the mechanism of injury. RESULTS: The type I fracture (8/20 cases) was the most common and likely to occur in elderly women. However, in other types, they were more common in relatively younger male patients. Type I were usually caused due to an accidental trip causing a fall by the patient. However, the dominant cause of type II (5/20 cases) fractures a direct blow or hit directly to the bone. Type III (4/20 cases) and IV (3/20 cases) fractures were likely to occur due to falling. All fibers within the Achilles tendon are involved in both type I and II fractures. However, only the superficial fibers are involved in type III fractures, whereas the deep fibers are involved in type IV fractures. CONCLUSIONS: The avulsion patterns of the calcaneal tuberosity fractures are the result of several factors including the bony density level, the mechanism of injury and the fibers of the Achilles tendon that transmit the force. Accurate diagnosis of type III and IV is dependant on MRI technology to confirm the specific location of the injury and provide proper patient treatment therapeutics.

Risk Factors of Nonunion after Surgical Fixation of Acute Scaphoid Fractures

PURPOSE: The aim of this study was to assess the risk factors of nonunion after surgical treatment of acute scaphoid fractures. MATERIALS AND METHODS: Predictable risk factors were investigated retrospectively in 70 patients with an acute scaphoid fracture. The risk factors involved sex, age, profession, smoking, fracture location, fracture gap distance, type of lunate, ulnar variance, fixation method, and surgical approach. At twelve months after surgery, analysis was conducted to identify the factors for prognosis toward bone healing or failure. RESULTS: Sixty-four patients (91%) demonstrated radiological union after a mean time of 2.8 months. The average scapholunate angle was 52degrees at the final follow up. Professional heavy work, smoking, fracture of proximal pole were associated with a significantly decreased likelihood of healing. CONCLUSION: The patients who have the risk factors of nonunion such as heave work, smoking and fracture of proximal pole should be treated carefully.

Long Term Results of Congenital Pseudarthrosis of the Clavicle: A Case Report of 22 Years Follow-up

Congenital pseudarthrosis of the clavicle is a rare condition, which rarely produces functional disabilities except for cosmetic problems. Surgical treatment involves autogenous iliac bone grafts and internal fixation. Few studies have reported long-term results of surgical treatment or morphological changes of the clavicle. We report a patient with a congenital pseudarthrosis of the clavicle, who demonstrated a near normal radiographic appearance of the clavicle and an excellent result 22 years after the operation performed at 4 years of age.

The Treatment of Thoracic Outlet Syndrome

PURPOSE: As clinical manifestations of thoracic outlet syndrome are vague pain or symptoms in upper extremity, the diagnosis of the disease is delayed or misdiagnosed as cervical HNP, shoulder pathologies, or peripheral neuropathies. In that reason, many patients spend time for unnecessary or ineffective treatments. We report the results of our thoracic outlet syndrome cases, which were treated by conservative care or surgical treatment. MATERIALS & METHODS: Twenty five cases, diagnosed as thoracic outlet syndrome since 1999, were reviewed retrospectively. Physical examinations including Adson's and reverse Adson's test, hyperabduction test, costoclavicular maneuver, and Roo's test, plain radiography of shoulder and cervical spine, MRI of neck or brachial plexus, and EMG were checked. If subjective symptoms were not improved after conservative treatments over three months, surgical treatment were performed. Nine patients were performed operative treatment and the others had conservative treatment in outpatient clinic. Postoperative improvement of symptoms and the follow up period, and the results of conservative care were reviewed. RESULTS: Among five physical examinations, mean 1.75 tests were positive, and EMG has little diagnostic value. MRI were performed in twenty cases and compression of brachial plexus were found in 6 cases (30%). Ten patients out of 16 conservative treatment group had excellent improvement of symptoms, and 5 had good results. Eight patients out of 9 operative treatment group had excellent improvement with mean 5.1 months of follow-up period. CONCLUSION: Diagnosis of thoracic outlet syndrome is difficult due to bizarre and vague symptoms. However if the diagnosis is suspected by careful physical examinations, radiologic studies, or nerve conduction studies, conservative care should be done as initial treatment and at least after three months, reassess the patient's condition. If the results of conservative treatment is not satisfactory and still the thoracic outlet syndrome is suspected, surgical treatment should be considered. Conservative treatment and operative technique are the valuable for the treatment of this disease.

Malignant Tumors of the Hand

PURPOSE: Malignant tumors of the hand occurred very rarely and optical surgical treatment and prognosis are not clearly established. We report the clinical characteristics and treatment outcomes of primary and metastatic bone and soft tissue tumors during last twenty years with a review of literatures. MATERIALS AND METHODS: We reviewed 20 cases of malignant tumors in the hand (7 cases of acrometastasis, 9 cases of malignant melanoma, 2 cases of chondrosarcoma and 2 cases of squamous cell carcinoma) retrospectively. RESULTS: Patients of early Clark stage (I to III) of malignant melanoma survived after wide resection or ray amputation. But patients with late Clark stage (IV to V) expired associated with distant metastasis. All seven patients with acrometastasis expired in 6.3 months after diagnosis of metastasis. Two patients with chondrosarcoma survived without recurrence. Among patients with squamous cell carcinoma, one patient is free of disease after wide resection, but the other was dead due to metastasis. CONCLUSION: Good results might be attained after surgical treatment of malignant tumors of the hand by proper surgical technique to minimize loss of hand function and systemic evaluation of metastasis.

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.

Ankle Deformity Secondary to Acquired Fibular Segmental Defect in Children

BACKGROUND: The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold's supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children. METHODS: Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold's operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs. RESULTS: In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2degrees (range, 5degrees to 35degrees) and 10degrees (range, 5degrees to 12degrees), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times. CONCLUSIONS: A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiold supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.

Follow-up Result in Repairing a Type II Superior Labrum Anterior and Posterior (SLAP) Lesion when Associated with Shoulder Impingement Syndrome / 대한정형외과학회잡지

PURPOSE: Type II superior labral anterior posterior (SLAP) lesions can occur in the setting of impingement syndrome. The authors compared the clinical results of patients who had undergone either an isolated acromioplasty or a combined type II SLAP repair and acromioplasty. MATERIALS AND METHODS: Between 2003 and 2008, a total of 75 cases of SLAP II lesions associated with impingement syndrome were recruited. In 39 patients, the type II SLAP lesion was repaired and acromioplasty was performed. In the other 35 patients, acromioplasty was performed alone. All patients were evaluated using the American Shoulder and Elbow Surgeons (ASES) questionnaire and range of motion. RESULTS: At an average of 33 months postoperatively, the ASES scores significantly increased in both groups (p<0.001) but the ASES score was similar in the 2 groups (p=0.278). However, there was a significant difference in the ASES scores when the competitive sports activity of the 2 groups of patients postoperatively were compared (p=0.014). The SLAP repair patients showed limited external rotation motion compared to the acromioplasty alone patients (p=0.026). CONCLUSION: There are no advantages in repairing a type II SLAP lesion when associated with impingement syndrome. However, type II SLAP lesions should be repaired in patients involved with competitive sports activity but the competitive sports activity should be limited for a better result.

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.