Distal Radius Joint Surface Reconstruction Using a Pedicle Pisiform Osteochondral Transfer.

Treatment of a large articular cartilage defect in the distal radius poses a significant challenge to hand surgeons. To reduce the development of secondary degenerative arthritis, restoration of the articular surface is preferable. Pedicle pisiform transfer has been reported as a useful treatment option for Kienböck's disease. We describe a surgical technique involving vascularized pisiform transfer for large cartilage defects after intra-articular distal radius fractures and highlight the vascular supply of the pisiform.

[Os Pisiforme transposition in the treatment of Kienböck's disease - long term results]. / Transpozice os pisiforme pri resení rozvinutých stadií morbus Kienböck - dlouhodobé výsledky.

PURPOSE OF THE STUDY: One of the methods used for treatment of Kienböck's disease is based on transposition of the pisiform bone into free space created by removal of the lunate bone. It is performed in patients with stage IIIB to IV, as assessed by Lichtmann's score. However, this operative procedure has so far lacked an unequivocal assessment of its therapeutic value. The aim of our work was to assess the therapeutic effect of the Kuhlmann method in the treatment of advanced stages of Kienböck's disease. MATERIAL: From January 1996, eighteen patients (18 wrists) diagnosed with Kienböck's disease were operated on, using the Kuhlmann method, and the group of these patients was included in this follow-up study. The average follow-up time was 7.6 +/- 2.3 years. METHODS: The results were evaluated on the basis of subjective (VAS) and functional criteria (ROM, grip force, DASH questionnaire and combined Cooney score questionnaires) and radiological assessment (arthritis evaluation, C.H.I., Natrass index, RSA). RESULTS: All patients experienced pain relief. The average pain assessment by VAS (10-point scale) before and after the procedure was 8.76 +/- 0.9 and 2.94 +/- 1.59, respectively. The range of motion was reduced on the operated extremity (70% compared to non-operated) as well as the grip test (57%). The average DASH score at the time of study was 20.9 +/- 12.2 and the average Cooney score was 67.6 +/- 17.4. Before the operation, eleven wrists showed signs of osteoarthritis. At the follow-up evaluation, arthritis was present in fifteen patients.We found a significant difference in average radiological parameters characterizing a carpal collapse deformity (C.H.I., Natrass index, RSA) - all parameters showed deteriorating tendencies. DISCUSSION: In nine patients, necrotic changes of the lunate occurred. In the patients whose pisiforme was not affected, a moderate retardation of carpal collapse occurred. However, the discrepancy between relevant indicators (C.H.I, Natrass index, RSA) was not statistically significant when comparing both groups. Therefore, we cannot conclude as to whether or not a vital transposed pisiforme bone impedes the development of carpal collapse. The only proved difference between these two groups was in pain evaluation, measured by VAS, after the procedure CONCLUSION: Although there was a good subjective assessment of the operation results, we are of the opinion that this method should not be used as a routine surgical procedure for advanced Kienböck disease. In view of a large number of failed cases we believe that this method should be considered very carefully.

[Long-term results after lunate replacement by the vascularised os pisiform for treatment of Kienböck's disease III b]. / Langzeitergebnisse nach Transposition des gestielten Os pisiforme zur Behandlung der Mondbeinnekrose Stadium III b.

Saffar's procedure is used only rarely today. In order to assess the value of this operation in the treatment of advanced Kienböck's disease, after a mean follow-up period of 19 years we could review 7 of 12 patients who had had their lunate replaced by the vascularised pisiform. At the time of follow-up all patients were fully employed without restrictions, and no patient had had to change his job. The mean DASH score was 5.9. The average pain level by VAS was 0.9 and four patients were totally free of pain. Grip strength of the affected arm was reduced to 77% of the opposite side, the active range of motion (extension/flection) was 97 degrees, which was 72% of that of the not affected side. All patients reported high satisfaction with the results of the operation. Although the clinical results were very good, we found substantial radiographical alterations: In 5 patients we found an advanced intercarpal osteoarthritis. Four patients presented a spontaneous synostosis between the pisiform and the triquetrum. The average CHR (carpal height ratio) was 0.43. The presented long-term results after lunate replacement by the vascularised pisiform indicate a high patient satisfaction and very good functional results in spite of significant radiological changes.

Long-term results of vascularized os pisiform transfer for advanced Kienböck disease after follow-up for at least 15 years: A case series.

No surgical procedure perfectly treats advanced Kienböck disease. Although vascularized os pisiform transferring (VOPT) is one of the main therapeutic approaches, reports on long-term follow-up and case series for this technique are scarce.We collected postoperative results in 11 patients with advanced Kienböck disease who underwent VOPT between 1986 and 2001 in our Hospital. Follow-up durations ranged from 15 to 26 years.At the last follow-up, excellent and good results were found in 81.8% according to the Modified Green and O'Brien score. Postoperative imaging revealed significantly reduced pisiform bone; carpal height ratio and Nattrass index were decreased, while the radioscaphoid angle was increscent, compared with preoperative and mid-term follow-up results.The favorable long-term results demonstrated that VOPT is a dependable and durable procedure for the treatment of advanced Kienböck disease, with pain relief and functional improvement despite some radiographic findings such as wrist osteoarthritis occurrence.

[Vascularized pisiform transfer in place of lunatum for Kienböck's disease]. / Transfert du pisiforme vascularisé à la place du lunatum dans la maladie de Kienböck.

There is a specific vascularization of the pisiform bone depending on the cubito-dorsal artery, branch of the ulnar artery. The vascularized pisiform bone may be transferred in place of the excised lunatum. The aims are to decrease pain when keeping the mobility, to replace a dead bone, to maintain the distance between scaphoid and triquetrum and radius and capitatum, by preventing the carpal collapse. X-rays and a MRI are performed. The vascularized transfer is indicated at stage III of the usual classifications. The technique is described, insisting on the transferred bone stabilization using ligament reconstructions. Radial shortening or scapho-capitate limited arthrodesis may be combined to reduce the stress on the transferred bone. Fifty-one cases have been performed at stage IIIa or IIIb and sometimes IV of the disease. The maximum follow-up is 15 years. The pain has decreased constantly. Motion in flexion-extension has an increase of more than 35°, radial and ulnar deviation of more than 14°. Strength has been slightly modified to more than 10%. The complications are: one case of "complex regional pain syndrome", one infection reoperated and one infection cured by antibiotics; one reoperation for a proximal row carpectomy. Results of this technique have been published in the literature. This technique provides regularly good results with a long follow-up. A precise technique is mandatory.

[Kienböck's disease in paediatric and juvenile patients]. / Die Lunatumnekrose im Kindes- und Jugendalter.

PURPOSE/BACKGROUND: Kienböck's disease is a rare condition in children or juvenile patients with unique features. This article presents a review of the literature on this topic and an evaluation of our own patients to help to establish therapeutic guidelines. PATIENTS/MATERIAL AND METHOD: From 1994-2005 we treated 23 patients. The 2 paediatric patients could be followed - one for 102 months after vascularised transposition of the pisiform and the other one for 24 months after conservative treatment. 15 out of the 21 juvenile patients could be followed: 9 patients on average for 47 months after radial shortening osteotomy, 5 patients on average for 94 months after partial wrist fusion and one for 24 months after arthroscopic debridement. Beginning in 2006 our therapeutic strategy has been changed. Since then one paediatric and one juvenile patient could be followed after temporary transfixation of the scaphotrapezoidal joint as well as one juvenile patient after spontaneous healing of the lunate bone. We measured motion, grip strength and pain level in rest and under load using the visual analogue scale, as well as the DASH score. Furthermore, standard X-rays of the wrist were performed. RESULTS: The 3 paediatric patients demonstrated good clinical and radiological results with healing of the lunate bone. The juvenile patients with radial shortening osteotomy had a better motion than those with partial wrist fusion. Reduction of pain level was similar in both groups. Radiologically we found no progression of lunate disease in these patients. In spite of a temporary ST transfixation the 17-year-old boy with advanced Kienböck's disease developed symptomatic progression of the disease. CONCLUSION: In paediatric and juvenile patients with Kienböck's disease we find an age-related potential for spontaneous remodelling and revascularisation. Therefore in paediatric and in juvenile patients not older than 14 years our method of choice is an immobilisation with regular gadolinium-enhanced MRI studies. In those who do not improve and in older juvenile patients we prefer temporary transfixation of the scaphotrapezoidal joint. Alternatively, in cases of the ulnar minus variant, radial shortening osteotomy or a combination of these 2 methods is indicated as the primary approach. In our opinion there is no longer an indication for partial wrist fusions as a primary procedure in these patients.

Vascularized os pisiform for reinforcement of the lunate in Kienböck's Disease: an average of 12 years of follow-up study.

PURPOSE: Little is known about the long-term results of vascularized bone transplantation for Kienböck's disease. This retrospective study investigated the long-term results of vascularized pisiform transfer. METHODS: We reviewed 23 patients to analyze results after vascularized pisiform transposition to a cored-out lunate for Lichtman stages II and III. Patients with ulnar-minus variance received additional radial shortening. RESULTS: Pain improved in 20 of 23 patients. Range of motion increased significantly relative to preoperative values but was only 80% that of opposite side. Grip power was 84% of the contralateral hand. At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15.3 +/- 17.9 and the mean Cooney score was 82.4 +/- 10.0. Radiologically, out of 20 patients with preoperative x-rays Lichtman stage was unchanged in 11, improved in 3, and progressed in 6 patients. No patient showed radiologic signs of arthritis before surgery. At follow-up evaluation osteoarthritis was found in 7 of 22 patients. The majority of degenerative changes were of low grade and were seen at the radiocarpal joint. CONCLUSIONS: The results show high patient satisfaction and good function after vascularized bone transplantation for Kienböck's disease. In the long term vascularized pisiform transfer prevented lunate collapse in 16 of 22 patients.