A novel classification of Kienbock's disease based on magnetic resonance imaging.

PURPOSE: We devised a classification system for Kienbock's disease using magnetic resonance imaging (MRI). Moreover, we compared it with the modified Lichtman classification and evaluated the inter-observer reliability. METHODS: Eighty-eight patients diagnosed with Kienbock's disease were included. All patients were classified using the modified Lichtman and MRI classifications. MRI staging was based on factors including partial marrow oedema, cortical integrity of the lunate, and dorsal subluxation of the scaphoid. The inter-observer reliability was evaluated. We also evaluated the presence of a displaced coronal fracture of the lunate and investigated its association with the presence of a dorsal subluxation of the scaphoid. RESULTS: Seven patients were categorized into stage I, 13 into II, 33 into IIIA, 33 into IIIB, and two into IV using the modified Lichtman classification. Six patients were categorized into stage I, 12 into II, 56 into IIIA, ten into IIIB, and four into IV using the MRI classification. The greatest shift between the stages was observed in stages IIIA and IIIB when the results of the two classification systems were compared. The inter-observer reliability of the MRI classification was greater than that of the modified Lichtman classification. Fifteen cases with a displaced coronal fracture of the lunate were identified, and a dorsal subluxation of the scaphoid was significantly more present in these patients. CONCLUSION: The MRI classification system is more reliable than is the modified Lichtman classification. MRI classification reflects carpal misalignment with higher fidelity and is more appropriate for classification into stages IIIA and IIIB.

Facet Inclinations and Interfacet Angle of the Distal Radius on Posteroanterior Radiographs: Clinical Associations With 3 Carpal Pathologies.

PURPOSE: The radiographic interfacet angle (IFA), scaphoid facet inclination (SFI), and lunate facet inclination (LFI) of the distal radius were measured in patients with 3 distinct wrist pathologies to determine whether there is an association between these radiographic measurements and these conditions. METHODS: Posteroanterior wrist radiographs were compiled from patients with 3 types of common wrist pathologies (scaphoid waist fracture [n = 54], scapholunate [SL] dissociation [n = 23], and dorsal ganglion [n = 51]). The patients were all Caucasians aged 20 to 45 years who met strict radiographic criteria. The IFA, SFI, and LFI values of these patients were compared with those obtained from 400 normal wrist radiographs of subjects who met the same selection criteria. RESULTS: In men with a scaphoid waist fracture, the IFA and SFI were significantly greater than in normal men, whereas the LFI was significantly lower. In the SL dissociation group, for all patients and for subgroups stratified according to sex, the IFA and SFI were significantly lower than in the normal matched groups. In the dorsal ganglion group, differences were found in the IFA and SFI for women, but not for men. CONCLUSIONS: The facet orientations of the distal radius in patients with scaphoid fracture, SL dissociation, and dorsal ganglion differed from those in the normal population. The IFA alone is most likely to be associated with all 3 pathologies. The SFI and LFI are less likely to be associated with patients with carpal pathologies. CLINICAL RELEVANCE: Patients with a greater IFA may be susceptible to scaphoid fractures when they fall on an overstretched hand. Patients with a smaller IFA may be susceptible to SL dissociation when they fall on an overstretched hand.

Arthroscopic Capsulodesis for the Treatment of Dynamic Scapholunate Dissociations.

Management of scapholunate dissociations remains a significant challenge. Open approaches suffer from a disadvantageous further impairment of the stabilizing local structures. The minimally invasive arthroscopic technique described provides reliable stability of the scapholunate interosseous ligament complex in dynamic lesions. The anatomic key structure is the dorsal capsuloligamentous scapholunate septum, which provides a mechanical connection between the scaphoid, lunate, and dorsal capsule of the wrist. Arthroscopic capsuloplasty aims to tighten and stabilize this complex structure in long term. This approach preserves the adjacent structures, namely the secondary wrist stabilizers and their neuromuscular feedback loops. With a certain degree of experience in wrist arthroscopy, the technique is reliably adaptable and reproducible.

Osteonecrosis of the trapezium: a case report and review of the literature.

We describe the case of a 58-year-old woman with AVN of the left trapezium which was treated surgically. This paper aims to review the etiologies leading to the pathology and the different therapeutic options. Avascular necrosis (AVN) of the carpal bones most commonly involves the lunate and the scaphoid . AVN of the trapezium is extremely rare. To our knowledge only 3 cases have been published in the literature so far and they were all treated differently.

The Epidemiology of Scapholunate Advanced Collapse.

Background: Scapholunate advanced collapse (SLAC) is the most common pattern of wrist arthritis. Sparse data exist regarding the SLAC wrist pattern of arthritis. This study aimed to document the epidemiology of advanced SLAC in terms of patients' sociodemographics and possible association with trauma. Methods: Sixty-one patients with severe SLAC wrist were included. Baseline sociodemographic characteristics were reviewed. To evaluate the relationship to injury, this group of cases was compared with a control group of 61 patients with first carpometacarpal osteoarthritis (CMC OA). The following data were collected for both groups: age, gender, history of traumatic injury, history of manual labor, duration of symptoms, and dominant hand involvement. Pearson chi-square tests for categorical variables and independent samples t test for continuous variables were performed to determine differences between groups. Results: Patients with SLAC wrist were more likely to be male (80.3% vs 31.1%; p<0.001), have a history of a traumatic injury (69.5% vs 25.9%, P < .001), have longer symptom duration (10.3 ± 13.3 vs 3.5 ± 2.5 years, P = .001), be involved in a manual labor job (49.0% vs 20.0%, P = .002), and be younger (53.1 ± 10.4 vs 58.3 ± 9.8; P = .006) compared with patients with CMC OA. There was no difference in dominant hand involvement (49.2% vs 53.3%; P = .571) between the groups. Conclusions: This study identified the characteristics of patients with advanced SLAC wrist. Compared with a control cohort of CMC OA, patients with SLAC wrist were more likely to be male, have a history of a traumatic injury, and be younger.

Current Techniques in Scapholunate Ligament Reconstruction.

Scapholunate ligament injuries are common and can lead to a predictable pattern of arthritis (scaphoid lunate advanced collapse wrist) if unrecognized or untreated. This article describes the relevant anatomy, biomechanics, and classification system, and provides an up-to-date literature-based review of treatment options, including acute repair and various reconstruction techniques. It also helps guide surgeons in making decisions regarding a systematic treatment algorithm for these injuries.

Dysplasia Epiphysealis Hemimelica/Trevor Disease: Report of a Lesion Solely Involving the Lunate Bone: A Case Report.

CASE: We describe the case of a dysplasia epiphysealis hemimelica (DEH) lesion affecting uniquely the lunate bone in a 16-year-old boy causing pain, stiffness, and decreased range of motion. Surgical excision was performed, leading to resolution of primary symptoms with residual limitations in terminal wrist extension. CONCLUSIONS: From our review of the literature, we believe this case to be the first report of a DEH lesion affecting solely the lunate bone. Although conservative and surgical management have both been described with DEH cases, we report a positive outcome following the excision of a symptomatic lesion.

Metaphyseal Core Decompression of the Distal Radius for Early Lunate Necrosis.

Background: Metaphyseal core decompression of the distal radius (MCD) is clinically effective in early lunate necrosis without changing individual wrist mechanics. Its concept is based on the induction of physiologic mechanisms known as physiologic fracture healing response. However, this biological concept does not yet have its place in the historically developed mechanical concepts about Kienböck's disease and requires more detailed clarifications to understand when a change of individual wrist mechanics might be unnecessary. Methods: Thirteen consecutive cases, Lichtman stage I (n = 1) or II (n = 12), confirmed by conventional MRI, were treated by MCD. Time off work, changes in magnetic resonance imaging of the lunate, as well as clinical outcome using modified Mayo wrist score were evaluated at final follow-up. Results: Return to work was at six (1-10) weeks after surgery. MRI controls at short-term generally demonstrated stop of progression and signs of bone healing. Independently from ulna variance complete signal normalization was observed in six and a distinct, yet incomplete decrease of lunate bone marrow edema and zones of fat necrosis was confirmed in further six cases after a mean of 21 (13-51) weeks. One patient had radiographic controls only, stating normal healing at 56 months. After a mean follow-up of 37 (12-70) months the clinical outcomes were excellent in eleven and good in two cases (mean 95% in modified Mayo wrist score). Conclusions: In stage I and II lunate necrosis MCD stops disease progression, it improves clinical symptoms and induces normalization of lunate bone signal alterations in MRI. Findings suggest that stage I and II lunate necrosis can be effectively treated without alterations of individual wrist mechanics. Future studies are necessary to readjust common concepts regarding Kienböck's disease, especially focusing on conservative therapy.

Tuberculosis of lunate as an isolated intraosseous osteolytic lesion in an adult: a diagnostic challenge.

In an endemic zone of tuberculosis (TB), osseous involvement is a relatively common presentation. Spine and long bones are the the most common nidus of TB. Smaller bones and joints are relatively less involved. Thorough clinical examination and history of typical constitutional symptoms like weight loss, fever and loss of appetite are the diagnostic aids for initiating early treatment. Wrist and hand involvement is a rare occurrence and often presents atypically without any obvious symptoms or signs. This results in delayed diagnosis and worse outcome. TB of lunate without articular involvement is a very rare subset and we present such an isolated case of TB involving the lunate, without any typical symptoms, with the patient complaining of vague pain without any restriction of joint mobility. TB was diagnosed with the aid of radiology, haematology and histopathology. 18 months of multidrug antitubercular treatment was given, to which the patient responded well.

Superselective angiography of the wrist in patients with Kienböck's disease.

BACKGROUND: Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck's disease. We examined if wrist position modifies the blood flow in the nutrient vessels. METHODS: Retrospective analysis of 17 patients with Kienböck's disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher's exact and Wilcoxon-test. RESULTS: We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position. CONCLUSION: The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

Comparison of Radiographic and Intraoperative Visual Assessment of Scaphotrapezoid Joint Arthritis in Patients With End-Stage Carpometacarpal Arthritis of the Thumb Base.

Background: The purpose of this investigation is to compare the radiographic and intraoperative assessment of scaphotrapezoid (ST) joint arthritis in patients with end-stage carpometacarpal (CMC) arthritis of the thumb base. We aim to define the incidence of ST arthritis in this population and determine whether radiographic features such as lunate morphology, dorsal intercalated segment instability (DISI), and scapholunate (SL) diastasis are associated with the incidence of ST arthritis. Methods: We retrospectively reviewed consecutive patients with end-stage CMC arthritis of the thumb treated operatively with trapeziectomy. Preoperative wrist radiographs were reviewed, and the presence of ST arthritis was determined using the Sodha classification. Lunate morphology, DISI, and SL diastasis were noted. Intraoperative grading of ST arthritis was assessed using a modified Brown classification. The specificity and sensitivity of radiographic assessment was compared with the gold standard of intraoperative direct visualization. Results: In total, 302 thumbs met inclusion criteria. End-stage ST joint arthritis determined by intraoperative visual inspection was noted in 31% of cases. No radiographic or demographic variables were found to be risk factors for ST arthritis. Plain radiographs were 47% sensitive and 94% specific in their ability to detect end-stage ST joint arthritis. Conclusions: We report a 31% incidence of end-stage ST joint arthritis in surgically treated patients with CMC arthritis based on visual inspection which is lower than previous literature. Wrist radiographs demonstrate a 47% sensitivity and 94% specificity in predicting end-stage ST joint arthritis. It is imperative to directly visualize the ST joint after trapeziectomy, as radiographs demonstrate poor sensitivity.

Kienböck's disease in an 11-year-old girl: a case report.

Kienböck disease is a pathology that remains uncommon in children, therefore the number of published cases of Kienböck's disease before skeletal maturity is limited. The etiology of Kienböck's disease is still controversial. Although many therapeutic methods are described in the literature. There is no consensus treatment for this pathology. We describe a case of Kienböck's disease of an 11-year-old girl who presented with avascular necrosis of the lunate bone confirmed by the radiologic pattern. And who was treated with 10 weeks of splinting with satisfying clinical outcome. Wrist pain and other symptoms resolved after 2 months. A magnetic resonance imaging (MRI) confirmed partial revascularization of the lunate. After 18 months of follow-up the patient remains asymptomatic.

Avascular Necrosis of the Lunate Following Reconstruction of the Scapholunate Ligament Using the Scapholunate Axis Method (SLAM).

Various surgical treatment options have been described to address chronic scapholunate dissociation. The Scapholunate Axis Method (SLAM) is a new technique used to reconstruct the scapholunate interosseous ligament. It is biomechanically advantageous compared with other ligament reconstruction techniques but clinical studies are lacking. We describe a previously unreported complication of avascular necrosis of the lunate after the SLAM procedure.

Existing or Worsening Symptoms of Kienböck's Disease after Distal Radius Fracture: Two Case Reports.

We report two rare cases of existing or worsening symptoms due to Kienböck's disease after distal radius fracture (DRF). During examination, radiographs show changes in the lunate bone; there was persistent wrist pain after treatment for DRF. In each case, surgeries were performed: A combined therapy (bone marrow transfusion, bone peg graft, external fixation, and low intensity pulsed ultrasound) for one, as well as carpal coalition for another. The etiology of these case presentations suggest that a compression fracture of the lunate due to a DRF resulted in softening and sclerosis.

[Proximal Row Carpectomy - Five-Year Results]. / Proximální karpektomie ­ petileté výsledky.

PURPOSE OF THE STUDY This study aims to evaluate the results of patients treated by proximal row carpectomy at a follow-up of at least 5 years after the surgery. MATERIAL AND METHODS A total of 25 patients were treated by proximal row carpectomy for degenerative changes of the wrist as a consequence of the previous trauma or avascular necrosis of the lunate bone, of whom 21 patients underwent a follow-up examination at least 5 years postoperatively. Proximal row carpectomy was indicated in 15 patients for SLAC wrist, in 4 patients for avascular necrosis of the lunate bone, in 1 patient for SNAC wrist, and in 1 patient for inveterate dislocation of the wrist. The follow-up clinical and radiological examinations were performed at least 5 years after the surgery. The range of wrist motion, grip strength, presence of pain at rest or pain under loads, total clinical score according to the Green and O'Brien scoring system, patient satisfaction with the outcome of surgery were assessed. By fluoroscopy the range of wrist motion, degenerative changes of the radiocapitate joint, and translation of the capitate bone with respect to the distal radius were evaluated. RESULTS Postoperative improvements in the range of motion and grip strength were confirmed. Also, the pain relief at rest and under loads was achieved. Five years after the surgery, most of the patients (85.6%) reported an overall improvement. The total clinical score according to the Green and O'Brien scoring system improved from 35.8 preoperatively to 63.1 postoperatively. DISCUSSION The advantage of this procedure is a low percentage of complications, relative technical simplicity, maintenance of functional motion of the wrist, satisfactory grip strength, and pain relief. There are no complications related to the implant, no risk of a non-union. CONCLUSIONS As shown by our results obtained 5 years after the surgery as well as the published data, in the indicated cases the proximal row carpectomy is an appropriate surgical technique to treat the degenerative changes of the wrist. In most of the patients, favourable functional results and pain relief can be expected. Key words:proximal row carpectomy, SLAC wrist, SNAC wrist, avascular necrosis of the lunate bone, dislocation of the wrist.

Stage III Kienböck's disease treated with hyperbaric oxygen: the role of an unusual approach to a rare condition.

Kienböck's disease is a rare condition characterised by avascular necrosis of the lunate bone. Its natural history and aetiopathogenesis have not yet been clarified, nor are its triggering factors identified. We present a case of a 17-year-old male gymnast, without relevant medical/family history, with stage IIIA Kienböck's disease diagnosed in 2016. Initially, submitted to conservative treatment that proved to be insufficient. Consequently, surgical treatment was proposed, but refused. The patient instead underwent experimental treatment with hyperbaric oxygen (120 sessions, 100% oxygen at 2.5 atm, for 70 min periods, once daily, five times per week). In April 2018, a favourable clinical and radiological evolution was observed, with an improvement in the patterns of pain, motion and strength and an almost complete involution of the process of aseptic necrosis of the semilunar. To the best of our knowledge, this is the first report of Kienböck's disease treated with hyperbaric oxygen.

Kienböck's disease: Role of cross-sectional imaging in treatment choice and patient follow-up.

The management of Kienböck's disease is complex and constantly evolving in parallel with progress in the understanding of the pathophysiological mechanisms of this condition. Cross-sectional imaging techniques have an essential role in the diagnosis and prognostic assessment of this disease. CT allows the optimal study of the morpho-structure of lunate bone. MRI makes it possible to study bone marrow viability. As for CT arthrography, it allows to evaluate accurately articular cartilage of the different carpal joints. The evaluation of these different aspects of Kienböck's disease is essential for optimal treatment selection. Cross-sectional imaging also has an interest in post-treatment follow-up, by having a prognostic value and allowing the identification of post-operative complications. The purpose of this article is to review the contribution of cross-sectional imaging in the assessment of Kienböck's disease before and after treatment according to the most common surgical procedures. Pathophysiological mechanisms, predisposing factors, the different classifications and their interests will be discussed.

Dorsolateral Biplane Closing Radial Osteotomy and Lunate Fixation for Stage IIIC Kienböck Disease: A New Surgical Approach.

The treatment of advanced-stage Kienböck disease (KD) remains highly controversial. Particularly important is stage IIIC KD, which includes patients with a lunate coronal fracture. The purpose of this paper was to describe a new approach to KD in patients with Lichtman stage IIIC KD, and our results using it. The procedure combines a dorsolateral biplane closing radial osteotomy and lunate fixation. A total of 11 patients from January 2002 through December 2016 with documented KD who underwent this technique were included. The patients were assessed before surgery, then postoperatively at 1 and 10 days, 3 and 6 weeks, 3 and 6 months, and annually. Wrist range of motion, grip and pinch strength, the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, a Modified Mayo Wrist Score (MMWS), 10-point visual analog scale, radiologic measurements, and data related to consolidation were collected. All statistical analyses were performed using the statistical software package SPSS. Some degree of pain relief, improvements in the QuickDASH score, MMWS score, grip strength, and the degrees of flexion and extension were observed, the results being statistically significant (P<0.05). After surgery, the values for radial and sagittal tilt were statistically different than those measured before surgery. Carpal collapse was not evident either before or after surgery. In conclusion, combining a dorsolateral radial osteotomy and a lunate compression screw may expand the options for patients with Lichtman stage IIIC KD. Our experience indicates that it is a viable option in challenging clinical scenarios.

Lunate excision with capitohamate fusion in the treatment of stage IIIB and IIIC Kienböck's disease.

OBJECTIVE: The aim of this study was to report our results of lunate excision combined with capitohamate fusion in the treatment of Kienböck's stage IIIB/IIIC disease. METHODS: A total of 7 patients with a mean age 35.2 (SD 11.5) years were enrolled in the study. Pain was the principal reason for surgery. All operations were carried out by the same senior surgeon. Patients were evaluated in terms of range of motion, DASH and VAS scores, satisfaction, and grip/tip/palmar/key pinch strength compared with contralateral sides. Preoperative carpal height indexes and findings of osteoarthritis were determined radiographically and compared with postoperative evaluations. RESULTS: Mean duration of follow up was 15.2 months. Mean DASH and VAS scores were 13.8 2.7 and 2 1.1 respectively. The mean patient satisfaction score was 3.2 0.4 over 4 points. The mean grip strength in the operated hands was 66.4%, palmar pinch was 75.1%, tip pinch was 71.8% and key pinch was 70.4% when compared to the contralateral unaffected sides. The mean flexion range in the operated hands was 58.8%, extension range was 60.3%, radial deviation range was 65.2% and ulnar deviation range was 65.7% when compared to the contralateral sides. There was no significant difference between preoperative and postoperative carpal height ratios (p = 0.086). CONCLUSIONS: Our early term results indicate that lunate excision combined with capitohamate fusion may be an alternative treatment option in patients with stage IIIB and IIIC Kienböck's disease. LEVEL OF EVIDENCE: Level IV, Therapeutic study.