Results of a prospective clinical study on the diagnostic performance of standard magnetic resonance imaging in comparison to a combination of 3T MRI and additional CT imaging in Kienböck's disease.

PURPOSE: This prospective clinical study examined standard wrist magnetic resonance imaging (MRI) examinations and the incremental value of computed tomography (CT) in the diagnosis of Kienböck's disease (KD) with regard to reliability and precision in the different diagnostic steps during diagnostic work-up. MATERIALS AND METHODS: Sixty-four consecutive patients referred between January 2009 and January 2014 with positive initial suspicion of KD according to external standard wrist MRI were prospectively included (step one). Institutional review board approval was obtained. Clinical examination by two handsurgeons were followed by wrist radiographs (step two), ultrathin-section CT, and 3T contrast-enhanced MRI (step three). Final diagnosis was established in a consensus conference involving all examiners and all examinations results available from step three. RESULTS: In 12/64 patients, initial suspicion was discarded at step two and in 34/64 patients, the initial suspicion of KD was finally discarded at step three. The final external MRI positive predictive value was 47%. The most common differential diagnoses at step three were intraosseous cysts (n=15), lunate pseudarthrosis (n=13), and ulnar impaction syndrome (n=5). A correlation between radiograph-based diagnoses (step two) with final diagnosis (step three) showed that initial suspicion of stage I KD had the lowest sensitivity for correct diagnosis (2/11). Technical factors associated with a false positive external MRI KD diagnosis were not found. CONCLUSION: Standard wrist MRI should be complemented with thin-section CT, and interdisciplinary interpretation of images and clinical data, to increase diagnostic accuracy in patients with suspected KD.

Do prophylactic antibiotics in gynecologic surgery prevent postoperative inflammatory complications? A systematic review.

PURPOSE: The aim of this study was to systematically review the literature on antibiotic prophylaxis in gynaecologic surgeries to prevent inflammatory complications after gynaecological operations. The study was carried out as a systematic review. METHODS: Only randomised controlled trials of women undergoing gynaecological surgery were included. The Medline and the Cochrane library databases were searched from 1966 to 2016. The trials must have investigated an antibiotic intervention to prevent an inflammatory complication after gynaecological surgery. Trials were excluded if they were not randomised, uncontrolled or included obstetrical surgery. RESULTS: Prophylactic antibiotics prevent inflammatory complications after gynaecological surgery. Prophylactic antibiotics are more effective in surgery requiring access to the peritoneal cavity or the vagina. Cefotetan appears to be more capable in preventing the overall inflammatory complication rate than cefoxitin or cefazolin. No benefit has been shown for the combination of antibiotics as prophylaxis. No difference has been shown between the long-term and short-term use of antibiotics. There is no need for the primary use of an anaerobic antibacterial agent. CONCLUSION: Antibiotics help to prevent postoperative inflammatory complications after major gynecologic surgeries.

Comparison of clinical and radiologic treatment outcomes of Kienböck's disease.

PURPOSE: The clinical outcomes of scaphotrapeziotrapezoid (STT) arthrodesis were compared to radial shortening osteotomy (RSO) to determine if any of the treatment methods was superior. The impact of RSO and vascularized bone grafts (VBG) on disease progression were measured based on X-rays to evaluate if a difference in Kienböck's disease (KD) progression exists. METHODS: Out of 98 consecutive patients treated between 1991 and 2013, 46 had STT arthrodesis, 21 had RSO, 7 had VBG, and 3 had VBG and RSO. Patients treated with STT arthrodesis were compared to RSO regarding post-operative range of motion (ROM), wrist pain on the Numeric Rating Scale (NRS), grip strength, duration of incapacity for work, the Disabilities of the Arm, Shoulder, and Hand (DASH), and the Modified Mayo Wrist scores (MMWS). Radiographic assessment (Nattrass index, radioscaphoid angle, and Ståhl index) was performed to determine disease progression following RSO or VBG. Baseline patient characteristics were comparable in all treatment groups. RESULTS: There were no significant differences in post-operative ROM, wrist pain, grip strength, duration of incapacity, DASH score, or MMWS score following STT arthrodesis (n = 27) or RSO (n = 14). The Ståhl index, the Nattrass index, and the radioscaphoid angle suggested disease progression following RSO (n = 14) and/or VBG (n = 6) although the changes were not significant. CONCLUSIONS: The study failed to demonstrate clinically relevant differences between STT arthrodesis compared to RSO. No evidence was found that decompression or revascularization, or the combination of the two, can reverse or halt the course of the disease. LEVEL OF EVIDENCE: Therapy, level III, retrospective comparative study with prospectively collected data.

Characteristic features and natural evolution of Kienböck's disease: five years' results of a prospective case series and retrospective case series of 106 patients.

OBJECTIVES: Scientific databases index numerous references related to the treatment of Kienböck's disease; yet little is known about the nature of the disease and its pathognomonic features. This study provides a cross-sectional analysis of the pattern and extent of osteonecrosis in a large cohort and a longitudinal analysis to determine the spontaneous disease progression in single patients who have not had surgical management until fragmentation of the lunate. METHODS: In a prospective case series, the pattern and extent of osteonecrosis were correlated with the duration of symptoms in all patients with Kienböck's disease confirmed using high-resolution 3-T magnetic resonance imaging (MRI) and ultra-thin section computed tomographic (CT) scan since 2009. Furthermore, a retrospective consecutive case series study was conducted to determine the rate of spontaneous evolution in all consecutive patients treated conservatively in our university hospital since 1990. RESULTS: Among the 35 consecutive patients with Kienböck's disease diagnosed in high-resolution 3-T MRI and ultra-thin section CT, 46% (16/35) presented degeneration of lunate cartilage on CT scan in the first 12 months following the onset of symptoms. Median wrist pain duration of patients presenting a fracture of the lunate was 14 months. Thirty-one percent (11/35) of the patients had arthritis of the lunate, yet no fractures at the time of examination. Of 106 consecutive patients with Kienböck's disease and complete records, who did not have surgical intervention until fragmentation of the lunate, three cases were identified with well-documented spontaneous courses from apparently intact lunate morphology until fragmentation within 6 months. CONCLUSIONS: Kienböck's disease progresses substantially faster than previously described and, contrary to current classifications, the articular cartilage of the lunate degenerates in early stages. LEVEL OF EVIDENCE: Diagnostic accuracy, Level IV.

Prospective case-control study on the etiopathology of Kienböck disease.

BACKGROUND: Multiple hypotheses regarding the cause of Kienböck disease have been proposed in seemingly contradictory small case series and cohort studies with inadequate statistical power. A prospective case-control study was conducted to analyze frequently discussed risk and causal factors. METHODS: Eighty-one consecutive patients with Kienböck disease and 198 patients with wrist ganglia were referred to the authors' clinic between 1990 and 2012, and 2003 and 2011, respectively. Patients with wrist ganglia were chosen as a control group because of the similar age distribution compared with the general population and because the common etiopathologic features of wrist ganglia and Kienböck disease can be excluded. Demographic, occupational, and medical information, including age, sex, handedness, ethnicity, education, occupation and employment status, prior treatment, and medical history were collected. Associated conditions and medication were assessed at a follow-up examination. RESULTS: Sixty-five of 81 patients with Kienböck disease and 70 of 198 controls were included in the study. Both groups were comparable with respect to age distribution and handedness. Employment status and job characteristics were similar in both groups. Hand-arm vibration during work or leisure activity over a period of 2 years was present in 23 percent with Kienböck disease and in 24 percent of 70 controls. Cortisone was used in six of 65 cases with Kienböck disease [controls, zero of 70] for an average duration of 46 months. CONCLUSIONS: Trauma, hand-arm vibration, heavy manual labor, and comorbidities were not associated with Kienböck disease. Steroid-associated Kienböck disease in six of 65 cases is consistent with the findings reported for osteonecrosis of other parts of the skeleton. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Critical analysis of causality between negative ulnar variance and Kienböck disease.

BACKGROUND: Negative ulnar variance has been associated with Kienböck disease, both supporting a causal link and providing a basis for therapeutic recommendations. The aim of this study was to determine whether there is a causal relationship between Kienböck disease and negative ulnar variance. METHODS: The causal relationship between Kienböck disease and negative ulnar variance was assessed using three methodologies: (1) an analysis of the quantitative and qualitative distribution of ulnar variance in a case-control study of 81 patients with Kienböck disease and a control group of 212 healthy wrists; (2) a systematic literature review and meta-analysis of six case-control studies (including the case-control study presented in this article) to test for an association between Kienböck disease and negative ulnar variance; and (3) a determination of causal relationship by using the Bradford Hill criteria. RESULTS: The case-control study indicated that when Kienböck disease is associated with negative ulnar variance (59 of 81), in 75 percent of the cases negative ulnar variance was equal (29 of 59) or less (15 of 59) pronounced on the contralateral healthy side. The odds ratio generated from the meta-analysis demonstrated a significant association between Kienböck disease and negative ulnar variance (OR, 3.58; 95 percent CI, 1.59 to 8.06; p = 0.002, random effects method). Six of nine Bradford Hill criteria do not support a causal relationship. CONCLUSIONS: The significant association between Kienböck disease and negative ulnar variance can be well explained by selection bias because magnetic resonance imaging, which may detect and allow exclusion of a potential ulnar impaction syndrome, was performed in only the Kienböck disease group in all six case-control studies. The application of the Bradford Hill criteria does not provide sufficient scientific evidence to support a causal relationship between Kienböck disease and negative ulnar variance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.