Rehabilitation Protocol for Lunate Fracture in a Clinical Case Report.

A carpal injury called a lunate fracture can cause severe carpal instability if treatment is not received. After the scaphoid, triquetrum, and trapezium, the lunate is the fourth most frequently fractured carpal bone. Due to lunate fracture, the functional prognosis is uncertain, and conservative treatment frequently results in surgery. Lunate fracture may be caused by anatomical features such as ulnar and radial variation, although necrosis is not commonly one of them. Vascularization in the lunate is unstable and dependent on the capsular arterioles. High shear stresses are frequently applied to the lunate, which rubs against the triangular fibrocartilage complex and the radius. This could lead to a fracture. Intraosseous compartment syndrome is most likely caused by the inflammatory condition Kienböck's disease. In order to protect the lunate against shear and compression loads, surgery entails decompressing the lunate. The consequences of current osteotomy techniques on biomechanics will be discussed. While some osteotomies may lessen the stresses conveyed to the lunate, they may also put too much strain on the ulnar side of the lunate. Techniques for treating wrist degeneration comprise extra-articular methods that keep the mid-carpal joint's architecture and vascularization intact. Bone grafting or repair may be indicated if lunate destruction is extensive. In the last phases, palliative methods are employed. For Kienböck's disease, there are currently no efficient biological therapies. The lunate is prevented from collapsing by decompression osteotomies, giving time for natural healing. The patient came to Acharya Vinoba Bhave Rural Hospital Outpatient Department of Orthopedics with a complaint of pain in her right wrist. At a private hospital in Amravati, the patient had gone through a proximal row carpectomy on the right side. After undergoing post-operative physiotherapy, the patient showed good improvement in her functional activities and quality of life. Physiotherapy helps in gaining back the functional activities for the post-operated lunate fracture patient.

Scaphocapitate arthrodesis with lunate preservation for Kienböck's disease: prospective outcomes study.

PURPOSE: The study evaluated the efficacy of SC arthrodesis with lunate preservation for treating patients diagnosed with stage IIIB or IIIC Kienböck's disease, who also exhibit neutral ulnar variance. The study further aimed to explore potential variations in outcomes between patients diagnosed with stage IIIB and IIIC Kienböck's disease. METHODS: Thirty-two patients diagnosed with stage IIIB (n = 19) and stage IIIC (n = 13) Kienböck's disease underwent SC arthrodesis with distal radius bone grafting stabilised by Herbert compression screws. All participants underwent pre- and post-operative assessments including VAS score for pain, ROM, grip strength, MMWS, and the Quick DASH score. Additionally, RS angle, LHI ratio, and CHI ratio were assessed. RESULTS: For all patients, the mean operative time was 73 min, follow-up was 45.6 months, time to union was 14 weeks, and time to full return to work was 24 weeks. The rate of union at the arthrodesis site was 91% (29 out of 32 patients) whilst the incidence of postoperative degenerative arthritis was 36% (8 out of 32 patients). Regarding changes in the means of outcomes from pre- to post-operatively, the VAS score decreased from 8.2 to 1.3 and grip strength improved from 36 to 79%. The RS angle was corrected from 59° to 50°. Significant improvements were noted in the mean MMWS from 45 to 75 and QuickDASH score from 78 to 21. However, no significant changes were observed in ROM, LHI, and CHI. There were no significant differences between patients with stage IIIB and stage IIIC in terms of these parameters, except for differences observed in the RS angle, LHI, and CHI preoperatively and in LHI and CHI postoperatively. CONCLUSION: Evidence level: II. Our research demonstrates that SC arthrodesis is a valuable approach for reducing pain, improving grip strength, and enhancing overall function in individuals with advanced Kienböck's disease. Importantly, our results indicate no notable differences in outcomes between patients diagnosed with stage IIIB or IIIC Kienböck's disease.

Simplifying the Decision-Making Process in the Treatment of Kienböck's Disease.

Background In recent years, the classification and treatment algorithm for adult Kienböck's disease (KD) has expanded. However, the priority of the investigations done in determining its management has not been discussed, as not every patient with KD requires magnetic resonance imaging (MRI) or wrist arthroscopy. Materials and Methods We discuss the role of these investigations and emphasize the importance of computed tomography (CT) imaging in evaluating the cortical integrity of the lunate and its role in the decision-making process and management of KD. Results We put forward an investigative algorithm that places into context the investigative roles of MRI, arthroscopy, and CT. Conclusion KD is a rare condition, and there is a lack of comparative studies to help us choose the preferred treatment. The decision on the management options in adult KD may be made by determining the integrity of the lunate cortex and deciding whether the lunate is salvageable or not by CT scan. MRI may provide useful information on the vascular status if the lunate cortex is intact, and the lunate is salvageable. If the lunate is fragmented, it is not salvageable, and MRI does not provide useful information. Arthroscopy has a role in selective cases.

Kienböck's Disease Following a Hypersupination Injury: A Case Report.

Wrist pain is a common presentation in primary care clinics. Chronic pain after trauma with non-acute radiographs requires careful physical examination and a case-specific workup. We present a case of a 32-year-old female evaluated at the primary care clinic with two months of left wrist pain after a hypersupination injury that was found to be secondary to avascular necrosis of the lunate on the left wrist with no radiographic signs of fracture or focal sclerosis on plain films. This case demonstrates the importance of identifying less common chronic wrist pain etiologies.

Medial Femoral Trochlea Osteochondral Flap Reconstruction of the Previously Unsalvageable Kienbock-Associated Lunate With a Coronal Split.

PURPOSE: Patients with Kienbock disease can present with coronal fracture and collapse of the proximal lunate (Unified B2/Bain grade 1, 2B). Traditionally, this was considered unsalvageable. However, medial femoral trochlea (MFT) osteochondral reconstruction, used to recreate the proximal lunate surface, can be paired with reduction and repair of the coronal plane fracture, thus restoring midcarpal congruity. The purpose of this study was to report radiographic and clinical outcomes following lunate coronal fracture fixation at the time of MFT osteochondral reconstruction. METHODS: This was a retrospective study performed at a single institution. We identified patients with Kienbock disease who underwent MFT osteochondral reconstruction from 2014 to 2023. Patients were included if they had a coronal fracture of the lunate distal articular surface fixed at the time of surgery. Radiographic and clinical parameters were evaluated, including carpal height ratio, union rate, presence of heterotopic ossification, need for revision surgery, and patient-reported outcome measures. RESULTS: Thirty-three patients were included, with a mean age of 27.5 years (range: 15-41); 19 (58%) were women. Mean radiographic follow-up time was 5.8 months, and mean clinical follow-up time was 22.6 months. Union was achieved in 30/33 patients (91%). Carpal height ratio improved from 1.32 to 1.4. Two patients (6%) required reoperation, one for removal of heterotopic ossification and another for conversion to proximal row carpectomy. Patients demonstrated meaningful improvement in brief Michigan Hand Questionnaire and Patient-Reported Outcomes Measurement Information Upper Extremity scores. Range of motion before and after surgery was similar. CONCLUSIONS: Lunate coronal fracture fixation with MFT osteochondral reconstruction represents an additional management option in select patients with Kienbock disease. This technique restores the midcarpal joint during lunate reconstruction and may allow patients to avoid salvage procedures. Early radiographic and clinical outcomes are promising. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pyrocarbon Lunate Arthroplasty: An Option for the Young Patient with Advanced Kienbock Disease.

Kienbock disease, or avascular necrosis of the lunate, is an uncommon cause of a painful and stiff wrist. Management options range from conservative treatment in the form of immobilization and corticosteroid injections to a wide variety of surgical treatments that depend on the structural integrity of the lunate, intercarpal relationships, and the condition of the articular cartilage of the wrist. A particularly difficult problem lies in the management of young patient in whom vascularized bone grafting of the lunate has failed but in whom arthritis has not yet developed. Pyrocarbon lunate implant arthroplasty is a newer treatment option for such a patient, and allows the preservation of the remainder of the proximal carpal row while directly addressing the degenerative lunate. This article describes the evidence and surgical technique for lunate implant arthroplasty and presents an illustrative case example.

Tendon ball arthroplasty and proximal carpal stabilization with tendon graft for advanced Kienbock's disease.

This study reports the surgical technique and outcomes of tendon ball arthroplasty combined with proximal carpal stabilization using the extensor carpi radialis longus tendon for treating advanced Kienbock's disease. The collapsed lunate is excised and a tendon ball inserted as a spacer. A distally based extensor carpi radials longus graft is passed through the scaphoid, tendon ball and triquetrum, reconstructing the proximal carpal row. In total, 16 patients were included and the mean follow-up was 25 months. Pain improved from 5.6 preoperatively to 1.3 postoperatively on a 10-point visual analogue scale. Mean wrist motion improved by 17.8° and grip strength compared with the non-operative side increased by 22.1% on average. Radiographic outcomes demonstrated correction of scaphoid flexion and carpal height ratio. The modified tendon ball arthroplasty may be an alternative wrist salvage procedure for the treatment of advanced Kienbock's disease.Level of evidence: IV.

Detecting Avascular Necrosis of the Lunate from Radiographs Using a Deep-Learning Model.

Deep-learning (DL) algorithms have the potential to change medical image classification and diagnostics in the coming decade. Delayed diagnosis and treatment of avascular necrosis (AVN) of the lunate may have a detrimental effect on patient hand function. The aim of this study was to use a segmentation-based DL model to diagnose AVN of the lunate from wrist postero-anterior radiographs. A total of 319 radiographs of the diseased lunate and 1228 control radiographs were gathered from Helsinki University Central Hospital database. Of these, 10% were separated to form a test set for model validation. MRI confirmed the absence of disease. In cases of AVN of the lunate, a hand surgeon at Helsinki University Hospital validated the accurate diagnosis using either MRI or radiography. For detection of AVN, the model had a sensitivity of 93.33% (95% confidence interval (CI) 77.93-99.18%), specificity of 93.28% (95% CI 87.18-97.05%), and accuracy of 93.28% (95% CI 87.99-96.73%). The area under the receiver operating characteristic curve was 0.94 (95% CI 0.88-0.99). Compared to three clinical experts, the DL model had better AUC than one clinical expert and only one expert had higher accuracy than the DL model. The results were otherwise similar between the model and clinical experts. Our DL model performed well and may be a future beneficial tool for screening of AVN of the lunate.

Is There a Correlation between the Radiological and Clinical Outcome after Core Decompression of the Radius for Kienböck Disease?

Background: Despite the good clinical results in the treatment of Kienböck disease with distal radius core decompression, a radiological progression to a certain degree in the long-term follow-up is possible. Is there a negative correlation between the clinical improvement of the patients and the radiological progression? Methods: We retrospectively reviewed the radiological and clinical results of 24 patients (mean age: 38 years; 10 women) treated with core decompression for Kienböck disease. The mean follow-up was 10 years. Results: A radiologic progression in the Lichtman classification was seen in nine patients. The Spearman correlation did not show any correlation between this radiological progression and the clinical outcome. Namely -0.06 between Mayo and Lichtman classification and 0.16 between VAS and Lichtman classification. Conclusions: We found that the clinical outcomes do not deteriorate despite a radiological progression of patients treated with core decompression for Kienböck disease Level of Evidence: Level IV (Therapeutic).

Clinical and radiographic results of lunate resection and vascularized os pisiform transfer for Kienböck's disease.

Although various treatments for advanced stages of Kienböck's disease have been reported, clinical evidence demonstrating the efficacy of lunate resection and vascularized os pisiform transfer for Kienböck's disease is limited. Herein, we investigated the clinical and radiographic results of this procedure. We retrospectively investigated eight patients who were followed up for ≥1 year. The mean age at the time of surgery was 52 years. The mean follow-up period was 3.4 years. The preoperative and postoperative mean wrist flexion-extension ranges were 84° and 111°, respectively, and grip strengths were 18.5 and 26.3 kg, respectively. Pain decreased in five patients postoperatively. The mean preoperative and postoperative carpal height ratios were 0.47 and 0.46, respectively, and radio scaphoid angles were 63° and 65°, respectively. Osteoarthritic changes were observed in or around the transferred pisiform in all five patients who were surveyed using radiographs. Most patients demonstrated satisfactory clinical results, including pain relief and improved wrist motion and grip strength, regardless of osteoarthritic wrist changes on postoperative radiographs. In summary, this procedure was effective for treating Kienböck's disease, especially in the advanced stages. Level of evidence: Ⅳ.

The Effect of Radial Inclination on the Stage of Kienbock Disease at the Time of Initial Diagnosis.

BACKGROUND: Negative ulnar variance is a widely accepted risk factor for the development of Kienbock disease (KD). Variation in radial inclination has been proposed as a risk factor, but evidence thus far has been inconclusive. We aim to clarify the relationship between radial inclination and KD. METHODS: A retrospective analysis of all KD patients from a single institution from 2007 to 2021 was conducted. Radiographs were reviewed to measure anatomic parameters and stage of disease. An exploratory multinomial regression model was created to examine the association of patient age, radial height, ulnar variance, radial inclination, volar tilt, scapholunate angle, duration of symptoms prior to evaluation, history of wrist trauma, and diagnosis of diabetes with stage of disease. RESULTS: Fifty-seven cases of KD were identified, with a mean duration of disease of 33.3 months. A history of trauma to the wrist was common (53%) and significantly associated with stage of disease at initial presentation. Twenty-seven cases (47%) were stage IIIB or greater. The average initial radial inclination, radial height, and ulnar variance was 21.9°, 10.7 mm, and -1.23 mm, respectively. A multinominal logistic regression model revealed decreased initial radial inclination is associated with Lichtman stage IIIB or greater at the time of initial patient presentation. CONCLUSIONS: A correlation exists between decreased radial inclination and more advanced KD at presentation, suggesting this may be a risk factor for disease progression. This correlation is strengthened by our finding of decreased ulnar variance being associated with later stage at presentation, which is one of the most widely accepted proposed risk factors for development and progression of disease. LEVEL OF EVIDENCE: IV.

Pediatric Kienböck's Disease in an 11-Year-Old Boy: A Case Report.

Kienböck's disease is a rare condition in the pediatric age group, with little agreement on its natural history and the best treatment option. Typically, these patients present with vague wrist pain and a variable degree of joint motion restriction. Diagnosis is mainly based on clinical suspicion and MRI findings, as radiographs do not show significant changes in the early stages of the disease. Prognosis is better in children than in adults due to the good healing capacity in this age group. This study will report on an 11-year-old boy diagnosed with Kienböck's disease who underwent surgical treatment to temporarily offload the diseased lunate. Clinical and radiographic recovery was observed at the six-month follow-up.

Dorsal Subluxation of The Proximal Carpal Row with the Use of a Bridge Plate.

Background Spanning bridge plates were first popularized for fixation of complex distal radius fractures. However, indications for their use have expanded including the surgical treatment algorithm for treating conditions such as Kienböck's disease. Traditionally, initial surgical treatment of Lichtman Stages II to III Kienböck's disease included lunate decompression, unloading, and revascularization procedures. The addition of a dorsal spanning bridge plate further facilitates lunate offloading and may improve bone revascularization. Case Description We report a complication of proximal carpal row dorsal subluxation secondary to dorsal spanning plate fixation in a patient with Stage IIIb Kienböck's disease. The patient had undergone wrist arthroscopy, lunate forage, radius core decompression, and spanning plate fixation. At 6 weeks after surgery, radiographic imaging demonstrated dorsal subluxation of the proximal carpal row that was corrected upon bridge plate removal. Serial radiographs during follow-up showed no further carpal subluxation without Kienböck's disease progression at 12 months postremoval of hardware. Patient remains pain free and has returned to elite level sport. Literature Review To our knowledge no previous cases of proximal carpal row subluxation with the use of dorsal bridge plate has been reported in the literature. Clinical Relevance Proximal row carpal subluxation can occur with dorsal bridge plate fixation.

Conservative Management of Kienbock's Disease in a 7-year Old: A Case Report.

Background Kienbock's disease is primarily seen in young adult males but has been recognized in skeletally immature populations as well. Traditional treatment strategies recommend operative treatment but high remodeling potential in children may allow conservative management. Case Description We present the case of a 7-year-old female with 2 months of atraumatic right wrist pain who was found to have edematous signal change within the lunate on wrist magnetic resonance imaging (MRI) consistent with Kienbock's disease. She was treated with rigid immobilization for 12 weeks and transitioned to custom orthotic splint for another 3 months during activities. At her 6 month follow-up, she reported minimal wrist pain with repeat MRI demonstrating the resolution of lunate edema. Literature Review Available literature shows a significant portion of patients treated conservatively subsequently require surgical intervention due to unresolved symptoms or progressive disease. Only three cases are reported in the literature where skeletally immature patients were successfully treated with conservative management alone Clinical Relevance We report the youngest case of Lichtman stage I Kienbock's disease successfully treated with conservative management resulting in clinical and imaging resolution. Younger patients may be able to successfully remodel and recover from Kienbock disease with extended time in conservative management.

Comparison of Long-term Outcomes between Nonoperative Treatment and Vascularized Bone Graft for Kienböck Disease: A Systematic Review and Single-Arm Meta-Analysis.

Background: This systematic literature review compared long-term outcomes between nonoperative treatment and vascularized bone graft (VBG) in patients with Kienböck disease. Methods: We systematically reviewed studies on nonoperative treatment and VBG for Kienböck disease with a mean follow-up of ≥ 5 years. A systematic search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Embase databases to select relevant articles. Data on patient demographics, treatment details, and outcomes were extracted. Results: Twelve studies (6 for nonoperative treatment and 6 for VBG) were included. The proportion of wrists showing worsening Lichtman stages after treatment was 40.2% (95% confidence interval [CI], 25.7-56.6) and 17.0% (95% CI, 10.2%-26.9%) in the nonoperative treatment group and VBG group, respectively. No change in the stage was observed in 52.4% (95% CI, 25.5%-78.0%) and 77.8% (95% CI, 66.7%-86.0%) of the wrists in the nonoperative treatment group and VBG group, respectively. The proportion of wrists without pain at the final follow-up was 29.2% (95% CI, 16.6%-46.1%) and 35.9% (95% CI, 22.6%-52.0%) in the nonoperative treatment group and VBG group, respectively. The proportion of wrists with more than a moderate degree was 30.4% (95% CI, 22.7%-39.4%) and 12.9% (95% CI, 5.5%-27.4%) in the nonoperative treatment group and VBG group, respectively. The 95% CIs of the mean wrist range of motion and mean grip strength ratio of the affected side to the contralateral side substantially overlapped in the two groups. Conclusions: The VBG group showed greater improvement in the radiographic stage and wrist pain than did the nonoperative treatment group after treatment, but meaningful differences in parameters were not observed. Further well-designed studies are needed to confirm the superiority of VBG to nonoperative treatment regarding radiographic and clinical outcomes.

Novel Descriptions of the Radial Osteotomy in Kienböck's Disease: A Systematic Review.

Purpose: Kienböck's disease consists of intrinsic and extrinsic characteristics that coalesce into a pathology with multifactorial etiology. Mechanical, morphological, and vascular factors have been identified as contributory. Radial osteotomy is one of the most commonly used surgical treatment for late-stage Kienböck's disease. Despite its frequent use and reported value, the specifics of radial osteotomy have not been described in aggregate. Our objective was to review the recent literature for descriptions of the radial osteotomy techniques used for treatment of Kienböck's disease. Methods: The inclusion criteria for the systematic review were as follows: (1) patients aged >18 years, (2) a publication date no older than 2012, and (3) a complete description of the distal radius osteotomy technique, including verbiage that specified numeric dimensions of bony resection or verbiage that detailed a goal in terms of a radiographic parameter that would guide the bony resection. Results: The studies were grouped according to the stated description of radial osteotomy. This process yielded the following three main groups: (1) studies that used radial shortening, (2) studies that used lateral closing wedge osteotomy or combined lateral closing wedge with radial shortening, and (3) novel osteotomy descriptions. Conclusions: The Kienböck's disease literature predominantly describes an osteotomy to shorten the radius by 2-3 mm. In some studies, the degree of radial shortening corresponded to the value necessary to achieve near-neutral ulnar variance. The common goal in using lateral closing wedge osteotomy was to achieve a radial inclination of 5° to 15°. Unique wedge resections, some with multiplanar corrections, have been recently described with each purporting specific advantages. Clinical relevance: Our findings support the premise of mechanical and biologic efficacy for radial osteotomy, with satisfactory results being reported across a wide spectrum of osteotomy techniques.

Clinical and Radiological Outcomes of Scaphocapitate Fusion in Kienböck Disease: A Systematic Review and Meta-Analysis.

Purpose: To report the functional and radiological outcomes of scaphocapitate (SC) arthrodesis in the treatment of Kienböck disease. Methods: This meta-analysis was conducted with adherence to PRISMA guidelines. Google Scholar, PubMed, Cochrane and Virtual Health Library were searched from inception until November 2022. All original studies that investigated the outcomes of scaphocapitate fusion in Kienböck disease were included. Exclusion criteria were arthroscopically performed fusions, concomitant radial shortening, traumatic or other etiologies of lunate avascular necrosis, and studies published in languages other than English. Outcomes of interest were pre- and post-operative wrist range of motion, VAS score, functional scores, radiological outcomes, surgical technique, complication rate and reoperation rate. Results: The total number of included participants was 203 from 11 articles. The results showed no significant differences pre- and post-operatively in terms of wrist flexion, extension and ulnar deviation. However, there was a significant reduction in radial deviation after the surgery (WMD -2.30; 95% CI, -4.26 to -0.33). Moreover, a significant increase was noticed in grip strength in Kg (WMD 13.29; 95% CI, 3.21-23.37) and mmHg post-operatively (WMD 23.75; 95% CI, 17.56-29.94). In addition, the models demonstrated significant decrease in carpal height (WMD -0.01; 95% CI, -0.02 to 0.00), scapholunate angle (WMD -12.11; 95% CI, -20.46 to -3.77) and radioscaphoid angle after the surgery (WMD -12.09; 95% CI, -15.51 to -8.67). The pooled overall rate of complication and reoperation rates were 24% (95% CI, 6%-47%) and 14% (95% CI, 3%-31%), respectively. Conclusions: Scaphocapitate arthrodesis is an effective procedure for treatment of Kienböck disease. This procedure is associated with satisfactory functional outcomes and significant improvement in pain scores and grip strength. Further studies with larger sample sizes and reduced heterogeneity are needed for a better evaluation of the results. Clinical relevance: Scaphocapitate arthrodesis is a recommended surgery for Kienböck disease with satisfactory functional and radiological outcomes. However, patients should be counseled on the possible complications and reoperation rate.

[Three-dimensional finite element model construction and biomechanical analysis of customized titanium alloy lunate prosthesis].

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.

Vascularized Bone Grafts from the Lateral Femoral Condyle for the Treatment of Avascular Lunate Necrosis (Kienböck's).

Background: Avascular necrosis of the lunate (Kienböck's disease) is rare and one of the main causes of progressive painful arthritis, requiring surgical intervention. Various approaches have shown benefits in treating Kienbock's disease but with limitations. The article aims to analyze the functional outcome using lateral femoral condyle free vascularized bone grafts (VBGs) as the first choice of treatment for Kienböck`s. Materials and methods: This was a retrospective analysis of 31 patients with Kienbock's who had microsurgical revascularization or reconstruction of the lunate between 2016 and 2021 using either corticocancellous or osteochondral VBGs from the lateral femoral condyle. The characteristics of lunate necrosis, choice of VBG and postoperative functional outcome were reviewed. Results: Corticocancellous VBGs were used in 20 patients (64.5%), while osteochondral VBGs in 11 patients (35.4%). The lunate was reconstructed in 11 patients, revascularized in 19 patients, and one patient received augmentation of a luno-capitate arthrodesis with a corticocancellous graft. We noted postoperative irritation of the median nerve (n = 3) and screw loosening requiring removal (n = 1) as minor complications. All patients had complete graft healing at eight-month follow-up and acceptable functional outcomes. Conclusions: Free VBG from the lateral femoral condyle represent a reliable method of lunate revascularisation or reconstruction in advanced Kienböck's. Their main advantages are the constant vascular anatomy, straightforward graft harvesting technique and possibility to harvest several graft types according to the requirements at the donor site. Postoperatively, the patients become pain-free and have an acceptable functional outcome.

Results after open lunate excision alone or in combination with palmaris longus tendon ball arthroplasty for the treatment of Kienböck's disease.

PURPOSE: This study aims to compare results after open lunate excision alone and in combination with palmaris longus tendon ball arthroplasty for the treatment of late-staged Kienböck's disease (KD). METHODS: This is a retrospective study using the prospectively collected data, and patients who had a discharge diagnosis of KD (stage IIIB based on Lichtman staging criteria) and underwent surgical treatment by lunate excision alone or in combination with palmaris longus tendon ball arthroplasty between January 2011 and December 2020 were included in this study. Variables of interest involved demographics, disease condition, operative procedure, and the outcomes evaluated at the last follow-up. Within and between comparisons were performed. RESULTS: Thirty-five patients underwent lunate excision alone, and 40 patients underwent the combination procedure. At the final follow-up, patients in both groups exhibited significant improvements compared to pre-operation, such as wrist flexion, wrist extension, carpal height ratio, PRWE score, Cooney score, and grip strength (all P < 0.05). Compared to the excision group, combination procedure group had significantly longer surgical time (P < 0.001), more blood loss (P < 0.001) and exhibited better wrist flexion (P = 0.001), PRWE score (P = 0.001), Cooney score (P = 0.0034), and grip strength (P = 0.017). The excellent or good rate based on Cooney wrist score was not significantly different (87.5% vs 71.4%, P = 0.083). CONCLUSION: Lunate excision in combination with palmaris longus tendon ball arthroplasty is a better option than lunate excision alone for the treatment of stage III KD and can be considered as an operative option.