Proximal row carpectomy for treatment of stage III ulna neutral variant of kienbock's disease

ABSTRACT

Kienbock's disease is a painful disorder of the wrist of unknown cause in which roentgenograms show a vascular necrosis of the carpal lunate. Treatment options depend widely on classification of the disease stage and are not standardized in literature. Proximal Row carpectomy [PRC] is a motion preservation option for patients with kienbock's disease in late stages where carpal collapse has already happened and when no arthritic changes has affected the lower radial articular cartilage nor proximal pole of capitate especially in ulna neutral variant when leveling procedures have no role. This prospective study was conducted in Am Shams University Hospitals and Hospitals of the Ministry of Health between April of 2001 and January of 2006. [Diagnosis, management and follow-ups were done during that period] Seven patients, stage III, ulna neutral variant, Kienbock's disease with no evidence of arthritis of neither the upper pole of capitate nor lunate fossa [lower radial articular cartilage] were treated by Proximal Row Carpectomy [PRC] by the two surgeon authors via dorsal approach. The study included four males and three females. Age ranged from 28-47 years with a mean age of 37.6 +/- 12.3 years. Range of time passed from the beginning of symptoms and diagnosis was 3-7 months with mean of 5.2 +/- 1.4 months. Patients were followed-up for a minimum of 30[Thirty] months postoperatively. Range of follow up was from 30-57 months with a mean of 43.29 +/- 12.3 months and we considered the follow up at 30 months postoperative as the end of follow up for the current work. Six of seven patients [86%] had complete pain relief' at the end of follow-up. Only one patient had mild pain on moderate exertion with intermittent use of NSAIDs. Range of motion improved for all patients at the end of follow-up Flexion range improved from a median of 29 to79° Extension from 25 to 75°, radial deviation from 25 to 50°, ulnar deviation from 25 to 66.7° [% of normal side movement]. Improvement of each movement was found to be statistically significant [P value < 0.05]. DASH score decreased from a median of 82.5 to 44.2. This indicated that patients got less disabled at the end of follow-up and this improvement was found to be statistically significant [P value < 0.05]. Grip strength improved from a mean of 25 to 50 [As% of normal side] and this improvement was found to be statistically significant [P value < 0.05]. Patients' working ability improved as indicated by decrease of DASH optional work module score from 100 to 50 and this improvement was found to be statistically significant. [P value < 0.05]. Patient's satisfaction rate was 100%. Results of this study were comparable to results of PRC in other series in literature. Table [1] Lichtman and Degnan's classification Stage I Normal architecture with evidence of a linear or compression fracture. Stage II Normal outline but definite density changes within the lunate. Stage III Collapse or fragmentation of the lunate and proximal migration of the capitate [carpal height ratio is less than 0.54 +/- 0.03]. Stage IV Generalized degenerative changes within the carpus. We found this procedure of PRC to be an effective motion preservation method for treatment of stage III Kienbock's disease in ulna neutral variant where leveling procedures are not indicated and when preservation of wrist motion is possible i.e. when there is no degenerative arthritis involving the Lunate fossa nor the proximal pole of capitate